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Guthier CV, Damato AL, Viswanathan AN, Hesser JW, Cormack RA. A fast multitarget inverse treatment planning strategy optimizing dosimetric measures for high-dose-rate (HDR) brachytherapy. Med Phys 2017. [DOI: 10.1002/mp.12410] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Christian V. Guthier
- Department of Radiation Oncology; Brigham and Womens Hospital and Dana-Faber Cancer Institute; Boston MA 02215 USA
- Harvard Medical School; Boston MA 02215 USA
| | - Antonio L. Damato
- Department of Radiation Oncology; Brigham and Womens Hospital and Dana-Faber Cancer Institute; Boston MA 02215 USA
- Harvard Medical School; Boston MA 02215 USA
| | - Akila N. Viswanathan
- Department of Radiation Oncology; Brigham and Womens Hospital and Dana-Faber Cancer Institute; Boston MA 02215 USA
- Harvard Medical School; Boston MA 02215 USA
| | - Juergen W. Hesser
- Department of Experimental Radiation Oncology; Medical Faculty of Mannheim, Heidelberg University; 68167 Mannheim Germany
- IWR, Heidelberg University; 69126 Heidelberg Germany
| | - Robert A. Cormack
- Department of Radiation Oncology; Brigham and Womens Hospital and Dana-Faber Cancer Institute; Boston MA 02215 USA
- Harvard Medical School; Boston MA 02215 USA
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Small W, Bacon MA, Bajaj A, Chuang LT, Fisher BJ, Harkenrider MM, Jhingran A, Kitchener HC, Mileshkin LR, Viswanathan AN, Gaffney DK. Cervical cancer: A global health crisis. Cancer 2017; 123:2404-2412. [PMID: 28464289 DOI: 10.1002/cncr.30667] [Citation(s) in RCA: 660] [Impact Index Per Article: 94.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 02/13/2017] [Accepted: 02/15/2017] [Indexed: 01/03/2023]
Abstract
Cervical cancer is the fourth most common malignancy diagnosed in women worldwide. Nearly all cases of cervical cancer result from infection with the human papillomavirus, and the prevention of cervical cancer includes screening and vaccination. Primary treatment options for patients with cervical cancer may include surgery or a concurrent chemoradiotherapy regimen consisting of cisplatin-based chemotherapy with external beam radiotherapy and brachytherapy. Cervical cancer causes more than one quarter of a million deaths per year as a result of grossly deficient treatments in many developing countries. This warrants a concerted global effort to counter the shocking loss of life and suffering that largely goes unreported. This article provides a review of the biology, prevention, and treatment of cervical cancer, and discusses the global cervical cancer crisis and efforts to improve the prevention and treatment of the disease in underdeveloped countries. Cancer 2017;123:2404-12. © 2017 American Cancer Society.
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Affiliation(s)
- William Small
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University, Chicago, Illinois
| | - Monica A Bacon
- Gynecological Cancer InterGroup, Kingston, Ontario, Canada
| | - Amishi Bajaj
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University, Chicago, Illinois
| | - Linus T Chuang
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Matthew M Harkenrider
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University, Chicago, Illinois
| | - Anuja Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Henry C Kitchener
- Department of Obstetrics and Gynecology, University of Manchester, Manchester, United Kingdom
| | - Linda R Mileshkin
- Division of Hematology and Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Akila N Viswanathan
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David K Gaffney
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
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53
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Damato AL, Buzurovic I, Bhagwat MS, Cormack RA, Devlin PM, Friesen S, Hansen J, Lee LJ, Manuel MM, Cho LP, O'Farrell D, Viswanathan AN. The value of systematic contouring of the bowel for treatment plan optimization in image-guided cervical cancer high-dose-rate brachytherapy. Brachytherapy 2017; 16:579-585. [PMID: 28256433 DOI: 10.1016/j.brachy.2017.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 09/23/2016] [Revised: 01/17/2017] [Accepted: 01/18/2017] [Indexed: 11/24/2022]
Abstract
PURPOSE To investigate the dose-volume histogram metrics and optimization results of the contoured bowel in cervical cancer brachytherapy. METHODS AND MATERIALS Treatment plans of cervical cancer patients treated with image-guided high dose rate were retrospectively analyzed with institutional review board approval. In addition to the clinical target volume, rectum, bladder, and sigmoid, the bowel was contoured at the time of planning (Group 1) or at the time of this analysis (Group 2). RESULTS Thirty-two patients treated with 145 insertions were included. Before optimization, mean ± 1 standard deviation overall bowel minimum dose to the most irradiated 2 cm3 volume of an organ (D2cc) was 67.8 Gyα/β3 ± 13.7 Gyα/β3 (Group 1: 72.6 ± 13.2 Gyα/β3; Group 2: 57.3 ± 8.0 Gyα/β3). Before optimization, one patient in Group 1 presented a bowel D2cc metric exceeding 100 Gyα/β3. After optimization, bowel D2cc mean ± 1 standard deviation was 59.4 ± 6.7 Gyα/β3 (Group 1: 61.4 ± 6.0 Gyα/β3, p < 0.001; Group 2: 55.2 ± 6.5 Gyα/β3, p = 0.026). CONCLUSIONS Given the potentially high doses and the benefit of optimization in reducing dose to the organs at risk, we recommend consideration of systematic contouring of the bowel when bowel is present in the pelvis.
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Affiliation(s)
- Antonio L Damato
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY.
| | - Ivan Buzurovic
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - Mandar S Bhagwat
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - Robert A Cormack
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - Phillip M Devlin
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - Scott Friesen
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - Jorgen Hansen
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - Larissa J Lee
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - Matthias M Manuel
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - Linda P Cho
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - Desmond O'Farrell
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA
| | - Akila N Viswanathan
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins Medicine, Baltimore, MD
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Driver JA, Viswanathan AN. Frailty measure is more predictive of outcomes after curative therapy for endometrial cancer than traditional risk factors in women 60 and older. Gynecol Oncol 2017; 145:526-530. [PMID: 28359689 DOI: 10.1016/j.ygyno.2017.03.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 03/13/2017] [Accepted: 03/15/2017] [Indexed: 01/28/2023]
Abstract
OBJECTIVES To determine if readily obtainable markers of frailty predict disease-free survival (DFS) in elderly women with endometrial cancer treated with curative intent. METHODS 88 consecutive women≥age 60 treated with surgery, chemotherapy and radiation for stage I-IV endometrial cancer were included. We considered the following health deficits as markers of "frailty": albumin <3.5mg/dL, hemoglobin <10mg/dL, BMI<20kg/m,2 unintentional weight loss, ECOG performance status ≥2, history of osteopenia or osteoporosis and Charlson comorbidity score. Kaplan-Meier estimates and Cox proportional hazards models of DFS were calculated. RESULTS The median age was 68.5 (range 60-88years). The majority of women (65/88) had at least one frailty factor at baseline and 23/88 had two or more. All women received radiation and chemotherapy. Treatment was delayed, modified or truncated in 46% (40/88) of women due to treatment-related toxicity. Age (< 70 vs. ≥70 y) did not independently predict toxicity or recurrence risk. Women with at least one baseline frailty factor had twice the risk of disease recurrence (HR=2.21;95% CI:1.02-4.80) when adjusted for age, stage, grade and Charlson score. The 3-year DFS was 77% in those with no frailty markers and 48% in those with at least one (p=0.02). The presence of a frailty marker also predicted shortened overall survival (HR=2.34;95% CI:1.08-5.03) irrespective of treatment administered and stage of disease. CONCLUSIONS A combined frailty measure was a more robust predictor of DFS and OS than patient age, tumor characteristics and comorbidities in this cohort of older women with very good functional status.
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Affiliation(s)
- Jane A Driver
- Geriatric Research Education and Clinical Center, VA Boston Medical Center, Boston, MA, United States; Brigham and Women's Hospital, Boston, MA, United States; Dana-Farber Cancer Institute, Boston, MA, United States.
| | - Akila N Viswanathan
- Brigham and Women's Hospital, Boston, MA, United States; Dana-Farber Cancer Institute, Boston, MA, United States; Johns Hopkins School of Medicine, Baltimore, MD, United States
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55
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Kamran SC, Harshman LC, Bhagwat MS, Muralidhar V, Nguyen PL, Martin NE, La Follette S, Faso S, Viswanathan AN, Efstathiou JA, Beard CJ. Characterization of efficacy and toxicity after high-dose pelvic reirradiation with palliative intent for genitourinary second malignant neoplasms or local recurrences after full-dose radiation therapy in the pelvis: A high-volume cancer center experience. Adv Radiat Oncol 2017; 2:140-147. [PMID: 28740925 PMCID: PMC5514247 DOI: 10.1016/j.adro.2017.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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: 12/15/2022] Open
Abstract
Purpose The use of large-field external beam reirradiation (re-RT) after pelvic radiation therapy (RT) for genitourinary (GU) cancers has not been reported. We report the results of such treatment in patients with either symptomatic GU second malignant neoplasms or locally recurrent pelvic tumors after initial RT for whom surgery or further systemic therapy was not an option. Methods and materials The records of 28 consecutive patients with advanced, bulky GU malignancies treated with high-dose, large-field re-RT with palliative intent between 2008 and 2014 were retrospectively reviewed. Descriptive outcome analyses focused on toxicities and symptom control, and responses were evaluated by 2 independent observers. Results Twenty-seven male patients (96%) were included. Median initial external beam RT dose was 64 Gy (range, 30-75.6 Gy). The median time between initial RT and re-RT was 9.5 years (range, 0.2-32 years). At the time of re-RT, there were 16 local recurrences and 12 second malignant neoplasms together comprising 16 bladder, 10 prostate, 1 ureteral, and 1 penile cancer. Indications for re-RT were pain and bleeding/hemorrhage. The median equivalent sphere diameter planning target volume for re-RT was 8.6 cm (range, 4.7-16.3 cm). Given the severity of the symptoms and the bulk of the disease at the time of re-RT, a higher dose of RT was administered. The median re-RT dose was 50 Gy (range, 27.5-66 Gy). For patients who received <60 Gy, hypofractionation of 250 cGy was used. The median cumulative dose was 113.9 Gy (range, 81.5-132.8 Gy). Re-RT was well tolerated with no Radiation Therapy Oncology Group grade 3-4 toxicities. Twenty-four patients (92%) had complete resolution of symptoms, and relief was durable in 67% of patients. The median overall survival was 5.8 months (range, 0.3-38.9 months). Of those patients who are still alive, 100% remain free of initial symptoms. Conclusion This small series suggests that aggressive re-RT of inoperable and symptomatic GU malignancies that is undertaken with meticulous treatment planning is well tolerated and provides excellent, durable relief without undue short-term toxicity. Validation in a larger prospective cohort is required.
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Affiliation(s)
| | - Lauren C Harshman
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, Massachusetts
| | - Mandar S Bhagwat
- Brigham and Women's Hospital, Department of Radiation Oncology, Boston, Massachusetts
| | | | - Paul L Nguyen
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Radiation Oncology, Boston, Massachusetts
| | - Neil E Martin
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Radiation Oncology, Boston, Massachusetts
| | - Stephanie La Follette
- Brigham and Women's Hospital, Department of Radiation Oncology, Boston, Massachusetts
| | - Sarah Faso
- Brigham and Women's Hospital, Department of Radiation Oncology, Boston, Massachusetts
| | - Akila N Viswanathan
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Radiation Oncology, Boston, Massachusetts
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Clair J Beard
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Radiation Oncology, Boston, Massachusetts
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Harkenrider MM, Block AM, Alektiar KM, Gaffney DK, Jones E, Klopp A, Viswanathan AN, Small W. American Brachytherapy Task Group Report: Adjuvant vaginal brachytherapy for early-stage endometrial cancer: A comprehensive review. Brachytherapy 2017; 16:95-108. [PMID: 27260082 PMCID: PMC5612425 DOI: 10.1016/j.brachy.2016.04.005] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [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: 01/06/2016] [Revised: 03/30/2016] [Accepted: 04/08/2016] [Indexed: 11/29/2022]
Abstract
This article aims to review the risk stratification of endometrial cancer, treatment rationale, outcomes, treatment planning, and treatment recommendations of vaginal brachytherapy (VBT) in the postoperative management of endometrial cancer patients. The authors performed a thorough review of the literature and reference pertinent articles pertaining to the aims of this review. Adjuvant VBT for early-stage endometrial cancer patients results in very low rates of vaginal recurrence (0-3.1%) with low rates of late toxicity which are primarily vaginal in nature. Post-Operative Radiation Therapy in Endometrial Cancer 2 (PORTEC-2) supports that VBT results in noninferior rates of vaginal recurrence compared to external beam radiotherapy for the treatment of high-intermediate risk patients. VBT as a boost after external beam radiotherapy, in combination with chemotherapy, and for high-risk histologies have shown excellent results as well though randomized data do not exist supporting VBT boost. There are many different applicators, dose-fractionation schedules, and treatment planning techniques which all result in favorable clinical outcomes and low rates of toxicity. Recommendations have been published by the American Brachytherapy Society and the American Society of Radiation Oncology to help guide practitioners in the use of VBT. Data support that patients and physicians prefer joint decision making regarding the use of VBT, and patients often desire additional treatment for a marginal benefit in risk of recurrence. Discussions regarding adjuvant therapy for endometrial cancer are best performed in a multidisciplinary setting, and patients should be counseled properly regarding the risks and benefits of adjuvant therapy.
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MESH Headings
- Adenocarcinoma, Clear Cell/pathology
- Adenocarcinoma, Clear Cell/radiotherapy
- Advisory Committees
- Brachytherapy/methods
- Carcinoma, Endometrioid/pathology
- Carcinoma, Endometrioid/radiotherapy
- Carcinosarcoma/pathology
- Carcinosarcoma/radiotherapy
- Combined Modality Therapy
- Endometrial Neoplasms/pathology
- Endometrial Neoplasms/radiotherapy
- Female
- Humans
- Hysterectomy
- Neoplasm Recurrence, Local
- Neoplasm Staging
- Neoplasms, Cystic, Mucinous, and Serous/pathology
- Neoplasms, Cystic, Mucinous, and Serous/radiotherapy
- Radiotherapy, Adjuvant/methods
- Societies, Medical
- United States
- Vagina
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Affiliation(s)
- Matthew M Harkenrider
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL.
| | - Alec M Block
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL
| | - Kaled M Alektiar
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David K Gaffney
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Ellen Jones
- Department of Radiation Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Ann Klopp
- Department of Radiation Oncology, MD Anderson Cancer Center, University of Texas, Houston, TX
| | - Akila N Viswanathan
- Department of Radiation Oncology, Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, MA
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL
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57
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Chapman BV, Gill BS, Viswanathan AN, Balasubramani GK, Sukumvanich P, Beriwal S. Adjuvant Radiation Therapy for Margin-Positive Vulvar Squamous Cell Carcinoma: Defining the Ideal Dose-Response Using the National Cancer Data Base. Int J Radiat Oncol Biol Phys 2017; 97:107-117. [DOI: 10.1016/j.ijrobp.2016.09.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 09/10/2016] [Accepted: 09/19/2016] [Indexed: 01/22/2023]
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58
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Viswanathan AN, Erickson BA, Ibbott GS, Small W, Eifel PJ. The American College of Radiology and the American Brachytherapy Society practice parameter for the performance of low-dose-rate brachytherapy. Brachytherapy 2017; 16:68-74. [DOI: 10.1016/j.brachy.2016.06.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 06/15/2016] [Indexed: 12/01/2022]
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59
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Suneja G, Brown D, Chang A, Erickson B, Fidarova E, Grover S, Mahantshetty U, Nag S, Narayan K, Bvochora-Nsingo M, Viegas C, Viswanathan AN, Lin MY, Gaffney D. American Brachytherapy Society: Brachytherapy treatment recommendations for locally advanced cervix cancer for low-income and middle-income countries. Brachytherapy 2016; 16:85-94. [PMID: 27919654 DOI: 10.1016/j.brachy.2016.10.007] [Citation(s) in RCA: 28] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 09/06/2016] [Accepted: 10/21/2016] [Indexed: 01/17/2023]
Abstract
PURPOSE Most cervix cancer cases occur in low-income and middle-income countries (LMIC), and outcomes are suboptimal, even for early stage disease. Brachytherapy plays a central role in the treatment paradigm, improving both local control and overall survival. The American Brachytherapy Society (ABS) aims to provide guidelines for brachytherapy delivery in resource-limited settings. METHODS AND MATERIALS A panel of clinicians and physicists with expertise in brachytherapy administration in LMIC was convened. A survey was developed to identify practice patterns at the authors' institutions and was also extended to participants of the Cervix Cancer Research Network. The scientific literature was reviewed to identify consensus papers or review articles with a focus on treatment of locally advanced, unresected cervical cancer in LMIC. RESULTS Of the 40 participants invited to respond to the survey, 32 responded (response rate 80%). Participants were practicing in 14 different countries including both high-income (China, Singapore, Taiwan, United Kingdom, and United States) and low-income or middle-income countries (Bangladesh, Botswana, Brazil, India, Malaysia, Pakistan, Philippines, Thailand, and Vietnam). Recommendations for modifications to existing ABS guidelines were reviewed by the panel members and are highlighted in this article. CONCLUSIONS Recommendations for treatment of locally advanced, unresectable cervical cancer in LMIC are presented. The guidelines comment on staging, external beam radiotherapy, use of concurrent chemotherapy, overall treatment duration, use of anesthesia, applicator choice and placement verification, brachytherapy treatment planning including dose and prescription point, recommended reporting and documentation, physics support, and follow-up.
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Affiliation(s)
| | - Derek Brown
- University of California San Diego, San Diego, CA
| | - Amy Chang
- Pamela Youde Nethersole Eastern Hospital, Hong Kong
| | | | | | - Surbhi Grover
- University of Pennsylvania, Philadelphia, PA; Princess Marina Hospital, Gaborone, Botswana
| | | | | | | | | | - Celia Viegas
- Instituto Nacional de Cancer- INCA, Rio de Janeiro, Brazil
| | | | - Ming Yin Lin
- Peter MacCallum Cancer Centre, Melbourne, Australia
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Cho LP, Manuel M, Catalano P, Lee L, Damato AL, Cormack RA, Buzurovic I, Bhagwat M, O'Farrell D, Devlin PM, Viswanathan AN. Outcomes with volume-based dose specification in CT-planned high-dose-rate brachytherapy for stage I-II cervical carcinoma: A 10-year institutional experience. Gynecol Oncol 2016; 143:545-551. [PMID: 27720445 DOI: 10.1016/j.ygyno.2016.09.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [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: 07/26/2016] [Revised: 09/13/2016] [Accepted: 09/16/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine prognostic factors for progression-free survival (PFS) and overall survival (OS) for stage I-II cervical-cancer patients treated using computed-tomography (CT)-planned high-dose-rate (HDR) intracavitary brachytherapy (BT). METHODS A total of 150 patients were treated for Stage I-II cervical cancer using CT-planned BT between 4/2004 and 10/2014. Of these, 128 were eligible for inclusion. Kaplan-Meier local control (LC), pelvic control (PC), overall survival (OS), and PFS estimates were calculated. RESULTS After a median follow-up of 30months, the 2-year LC rate was 96%, PFS was 88%, and OS was 88%. Overall, 18 patients (14%) experienced any recurrence (AR), 8 had distant recurrence only and 10 had a combination of local, pelvic, regional, and distant recurrence. No patients had LR only. A prognostic factor for AR was tumor size >4cm (p=0.01). Patients with tumors >4cm were 3.3 times more likely to have AR than those with tumors ≤4cm (hazard ratio [HR]=3.3; 95% confidence interval [CI] 1.28-9.47). Point A was 85% of prescription for tumors < 4 cm and decreased approximately 3% over 5 fractions compared to 90% of prescription for tumors > 4 cm that decreased approximately 4% over 5 fractions. Two patients (2%) experienced grade≥2 late toxicity. There were no acute or late grade≥3 toxicities. CONCLUSION CT-planned BT resulted in excellent local control and survival. Large tumor size was associated with an increased risk of recurrence outside the radiation field and worse PFS and OS. A volume-optimized plan treated a smaller area than a point A standard plan for patients with Stage I-II cervical cancer that have received chemoradiation. Given the outstanding LC achieved with modern therapy including chemoradiation, HDR, and image-based BT, further efforts to combat spread outside the radiation field with novel therapies are warranted.
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Affiliation(s)
- Linda P Cho
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, United States.
| | - Matthias Manuel
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, United States
| | - Paul Catalano
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, United States; Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Larissa Lee
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Antonio L Damato
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Robert A Cormack
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Ivan Buzurovic
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Mandar Bhagwat
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, United States
| | - Desmond O'Farrell
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, United States
| | - Phillip M Devlin
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Akila N Viswanathan
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
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61
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Grover S, Gudi S, Gandhi AK, Puri PM, Olson AC, Rodin D, Balogun O, Dhillon PK, Sharma DN, Rath GK, Shrivastava SK, Viswanathan AN, Mahantshetty U. Radiation Oncology in India: Challenges and Opportunities. Semin Radiat Oncol 2016; 27:158-163. [PMID: 28325242 DOI: 10.1016/j.semradonc.2016.11.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [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]
Abstract
Rising cancer incidence and mortality in India emphasize the need to address the increasing burden of this disease and the stark inequities in access to radiotherapy and other essential medical treatments. State-of-the-art technology is available within the private sector and a few hospitals in the public sector, but 75% of patients in the public sector in India do not have access to timely radiotherapy. This inequity in access to radiotherapy in the public sector is amplified in rural areas, where most of India׳s population lives. A long-term government commitment to machine purchase and human resource development in the public sector is needed to improve access. A number of innovative initiatives to improve cancer treatment and access have emerged that could support such an investment. These include local production of equipment, twinning programs between institutions in high- and low-income countries to exchange knowledge and expertise, and nongovernmental and state-sponsored schemes to sponsor and support patients in their cancer journey. Strengthening of cancer registries and regulatory bodies with authority to enforce minimum standards is also required to improve care. The more uniform and frequent availability of high-quality radiotherapy can improve cancer outcomes and may be regarded as a marker of a comprehensive and equitable system of health care delivery.
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Affiliation(s)
- Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA.
| | | | - Ajeet Kumar Gandhi
- Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | - Priya M Puri
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Adam C Olson
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC; Hubert Yeargan Center for Global Health, Duke University, Durham, NC
| | - Danielle Rodin
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Onyi Balogun
- Department of Radiation Oncology, Weill Cornell Medical College, NY
| | - Preet K Dhillon
- Public Health Foundation of India, National Capital Region, India
| | | | | | | | - Akila N Viswanathan
- Johns Hopkins Radiation Oncology and Molecular Radiation Sciences, Baltimore, MD
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Wang W, Viswanathan AN, Damato AL, Chen Y, Tse Z, Pan L, Tokuda J, Seethamraju RT, Dumoulin CL, Schmidt EJ, Cormack RA. Evaluation of an active magnetic resonance tracking system for interstitial brachytherapy. Med Phys 2016; 42:7114-21. [PMID: 26632065 DOI: 10.1118/1.4935535] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE In gynecologic cancers, magnetic resonance (MR) imaging is the modality of choice for visualizing tumors and their surroundings because of superior soft-tissue contrast. Real-time MR guidance of catheter placement in interstitial brachytherapy facilitates target coverage, and would be further improved by providing intraprocedural estimates of dosimetric coverage. A major obstacle to intraprocedural dosimetry is the time needed for catheter trajectory reconstruction. Herein the authors evaluate an active MR tracking (MRTR) system which provides rapid catheter tip localization and trajectory reconstruction. The authors assess the reliability and spatial accuracy of the MRTR system in comparison to standard catheter digitization using magnetic resonance imaging (MRI) and CT. METHODS The MRTR system includes a stylet with microcoils mounted on its shaft, which can be inserted into brachytherapy catheters and tracked by a dedicated MRTR sequence. Catheter tip localization errors of the MRTR system and their dependence on catheter locations and orientation inside the MR scanner were quantified with a water phantom. The distances between the tracked tip positions of the MRTR stylet and the predefined ground-truth tip positions were calculated for measurements performed at seven locations and with nine orientations. To evaluate catheter trajectory reconstruction, fifteen brachytherapy catheters were placed into a gel phantom with an embedded catheter fixation framework, with parallel or crossed paths. The MRTR stylet was then inserted sequentially into each catheter. During the removal of the MRTR stylet from within each catheter, a MRTR measurement was performed at 40 Hz to acquire the instantaneous stylet tip position, resulting in a series of three-dimensional (3D) positions along the catheter's trajectory. A 3D polynomial curve was fit to the tracked positions for each catheter, and equally spaced dwell points were then generated along the curve. High-resolution 3D MRI of the phantom was performed followed by catheter digitization based on the catheter's imaging artifacts. The catheter trajectory error was characterized in terms of the mean distance between corresponding dwell points in MRTR-generated catheter trajectory and MRI-based catheter digitization. The MRTR-based catheter trajectory reconstruction process was also performed on three gynecologic cancer patients, and then compared with catheter digitization based on MRI and CT. RESULTS The catheter tip localization error increased as the MRTR stylet moved further off-center and as the stylet's orientation deviated from the main magnetic field direction. Fifteen catheters' trajectories were reconstructed by MRTR. Compared with MRI-based digitization, the mean 3D error of MRTR-generated trajectories was 1.5 ± 0.5 mm with an in-plane error of 0.7 ± 0.2 mm and a tip error of 1.7 ± 0.5 mm. MRTR resolved ambiguity in catheter assignment due to crossed catheter paths, which is a common problem in image-based catheter digitization. In the patient studies, the MRTR-generated catheter trajectory was consistent with digitization based on both MRI and CT. CONCLUSIONS The MRTR system provides accurate catheter tip localization and trajectory reconstruction in the MR environment. Relative to the image-based methods, it improves the speed, safety, and reliability of the catheter trajectory reconstruction in interstitial brachytherapy. MRTR may enable in-procedural dosimetric evaluation of implant target coverage.
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Affiliation(s)
- Wei Wang
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts 02115 and Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts 02115
| | - Akila N Viswanathan
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts 02115
| | - Antonio L Damato
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts 02115
| | - Yue Chen
- Department of Engineering, The University of Georgia, Athens, Georgia 30602
| | - Zion Tse
- Department of Engineering, The University of Georgia, Athens, Georgia 30602
| | - Li Pan
- Siemens Healthcare USA, Baltimore, Maryland 21287
| | - Junichi Tokuda
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts 02115
| | | | - Charles L Dumoulin
- Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229
| | - Ehud J Schmidt
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts 02115
| | - Robert A Cormack
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts 02115
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Manuel MM, Cho LP, Catalano PJ, Damato AL, Miyamoto DT, Tempany CM, Schmidt EJ, Viswanathan AN. Outcomes with image-based interstitial brachytherapy for vaginal cancer. Radiother Oncol 2016; 120:486-492. [PMID: 27321150 DOI: 10.1016/j.radonc.2016.05.019] [Citation(s) in RCA: 28] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 05/17/2016] [Accepted: 05/17/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE To compare clinical outcomes of image-based versus non-image-based interstitial brachytherapy (IBBT) for vaginal cancer. METHODS AND MATERIALS Of 72 patients with vaginal cancer treated with brachytherapy (BT), 47 had image guidance (CT=31, MRI=16) and 25 did not. Kaplan-Meier (KM) estimates were generated for any recurrence, local control (LC), disease-free interval (DFI), and overall survival (OS) and Cox models were used to assess prognostic factors. RESULTS Median age was 66 and median follow-up time was 24months. Median cumulative EQD2 dose was 80.8Gy in the non-IBBT group and 77Gy in the IBBT group. For non-IBBT versus IBBT, the 2-year KM LC was 71% vs. 93% (p=0.03); DFI was 54% vs. 86% (p=0.04); and OS 52% vs. 82% (p=0.35). On multivariate analysis, IBBT was associated with better DFI (HR 0.24, 95% CI 0.07-0.73). Having any 2 or more of chemotherapy, high-dose-rate (HDR) BT or IBBT (temporally correlated variables) significantly reduced risk of relapse (HR=0.33, 95% CI=0.13-0.83), compared to having none of these factors. CONCLUSION Over time, the use of chemotherapy, HDR, and IBBT has increased in vaginal cancer. The combination of these factors resulted in the highest rates of disease control. Image-guided brachytherapy for vaginal cancer patients maximizes disease control.
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Affiliation(s)
- Matthias M Manuel
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - Linda P Cho
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - Paul J Catalano
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute and Department of Biostatistics, Harvard School of Public Health, Boston, USA
| | - Antonio L Damato
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - David T Miyamoto
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Clare M Tempany
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Ehud J Schmidt
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Akila N Viswanathan
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA.
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Grover S, Bvochora-Nsingo MF, MacDuffie E, Ratcliffe S, Wileyto EP, Bhatia R, Yeager A, Chiyapo SP, Gaolebale PA, Russell AH, Makufa R, Karunmekayi T, Balang D, Kayembe M, Ramogola-Masire D, Dryden-Peterson S, Viswanathan AN, Robertson E, Zetola NM, Lin LL. Treatment completion and tolerability of women with cervical cancer with and without HIV in Botswana. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.5526] [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] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Emily MacDuffie
- Warren Alpert Medical School of Brown University, Providence, RI
| | | | | | | | | | | | | | | | | | | | - Dawn Balang
- Gaborone Private Hospital, Gaborone, Botswana
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Buzurovic IM, Damato AL, Bhagwat MS, O'Farrel DA, Friesen S, Hansen JL, Lee LJ, Cormack RA, Devlin PM, Viswanathan AN. Redesign of the Intracavitary Ring and Tandem Applicator for Improved Dosimetry in High Dose-Rate Brachytherapy. Brachytherapy 2016. [DOI: 10.1016/j.brachy.2016.04.213] [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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Cho LP, Grover S, Harkenrider MM, Small C, Small W, Erickson B, Viswanathan AN. Factors Associated with the Use of Magnetic Resonance (MR) Imaging for Cervical Brachytherapy in the United States (U.S.). Brachytherapy 2016. [DOI: 10.1016/j.brachy.2016.04.072] [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: 10/21/2022]
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67
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Cho LP, Townamchai K, Manuel M, Lee LJ, Bhagwat M, Buzurovic I, Damato A, Harris T, O'Farrell D, Viswanathan AN. Outcomes of Uterine Papillary Serous and Uterine Clear Cell Carcinoma Treated with Vaginal-Cylinder Brachytherapy Alone. Brachytherapy 2016. [DOI: 10.1016/j.brachy.2016.04.196] [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: 10/21/2022]
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68
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Chen Y, Wang W, Schmidt EJ, Kwok KW, Viswanathan AN, Cormack R, Tse ZTH. Design and Fabrication of MR-Tracked Metallic Stylet for Gynecologic Brachytherapy. IEEE ASME Trans Mechatron 2016; 21:956-962. [PMID: 28989272 PMCID: PMC5627614 DOI: 10.1109/tmech.2015.2503427] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Active magnetic resonance (MR) tracking for gynecologic brachytherapy was made possible by attaching the micro radiofrequency coils to the brachytherapy applicator. The rectangular planar micro coil was fabricated using flexible printed circuits with dimensions of 8mm×1.5mm. A 5-Fr (1.6mm) tungsten brachytherapy stylet was custom-machined to incorporate the micro coils. The finite element analysis and the phantom tissue studies show that the proposed device enables in situ, real-time guidance of access routes to the target anatomy safely and accurately. The setup was tested in a Siemens 3T MR scanner. The micro coils can be localized rapidly (up to 40 Hz) and precisely (resolution: 0.6×0.6×0.6mm3) using an MR-tracking sequence.
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Affiliation(s)
- Yue Chen
- College of Engineering, The University of Georgia, Athens, GA, 30605 USA, and is also with Department of Mechanical Engineering, The University of Hong Kong, HK, China (, )
| | - Wei Wang
- Department of Radiology, Brigham & Women's Hospital, Boston, MA, 02115 USA, and is also with the Department of Radiation Oncology, Brigham & Women's Hospital, Boston, MA, 02115 USA
| | - Ehud J Schmidt
- Department of Radiology, Brigham & Women's Hospital, Boston, MA, 02115 USA
| | - Ka-Wai Kwok
- Department of Mechanical Engineering, The University of Hong Kong, HK, China
| | - Akila N Viswanathan
- Department of Radiation Oncology, Brigham & Women's Hospital, Boston, MA, 02115
| | - Robert Cormack
- Department of Radiation Oncology, Brigham & Women's Hospital, Boston, MA, 02115
| | - Zion Tsz Ho Tse
- College of Engineering, The University of Georgia, Athens, GA, 30605 USA
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69
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Ciris PA, Balasubramanian M, Damato AL, Seethamraju RT, Tempany-Afdhal CM, Mulkern RV, Viswanathan AN. Characterizing gradient echo signal decays in gynecologic cancers at 3T using a Gaussian augmentation of the monoexponential (GAME) model. J Magn Reson Imaging 2016; 44:1020-30. [PMID: 26971387 DOI: 10.1002/jmri.25226] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [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: 07/02/2015] [Accepted: 02/23/2016] [Indexed: 12/26/2022] Open
Abstract
PURPOSE To assess whether R2* mapping with a standard Monoexponential (ME) or a Gaussian Augmentation of the Monoexponential (GAME) decay model better characterizes gradient-echo signal decays in gynecological cancers after external beam radiation therapy at 3T, and evaluate implications of modeling for noninvasive identification of intratumoral hypoxia. MATERIALS AND METHODS Multi-gradient-echo signals were acquired on 25 consecutive patients with gynecologic cancers and three healthy participants during inhalation of different oxygen concentrations at 3T. Data were fitted with both ME and GAME models. Models were compared using F-tests in tumors and muscles in patients, muscles, cervix, and uterus in healthy participants, and across oxygenation levels. RESULTS GAME significantly improved fitting over ME (P < 0.05): Improvements with GAME covered 34% of tumor regions-of-interest on average, ranging from 6% (of a vaginal tumor) to 68% (of a cervical tumor) in individual tumors. Improvements with GAME were more prominent in areas that would be assumed hypoxic based on ME alone, reaching 90% as ME R2* approached 100 Hz. Gradient echo decay parameters at different oxygenation levels were not significantly different (P = 0.81). CONCLUSION R2* may prove sensitive to hypoxia; however, inaccurate representations of underlying data may limit the success of quantitative assessments. Although the degree to which R2 or σ values correlate with hypoxia remains unknown, improved characterization with GAME increases the potential for determining any correlates of fit parameters with biomarkers, such as oxygenation status. J. MAGN. RESON. IMAGING 2016;44:1020-1030.
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Affiliation(s)
- Pelin A Ciris
- Biomedical Engineering, Akdeniz University, Antalya, Turkey. .,Harvard Medical School, Boston, Massachusetts, USA. .,Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA.
| | - Mukund Balasubramanian
- Harvard Medical School, Boston, Massachusetts, USA.,Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Antonio L Damato
- Harvard Medical School, Boston, Massachusetts, USA.,Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | - Clare M Tempany-Afdhal
- Harvard Medical School, Boston, Massachusetts, USA.,Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Robert V Mulkern
- Harvard Medical School, Boston, Massachusetts, USA.,Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Akila N Viswanathan
- Harvard Medical School, Boston, Massachusetts, USA.,Siemens Healthcare, Boston, Massachusetts, USA
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Kamran SC, Berrington de Gonzalez A, Ng A, Haas-Kogan D, Viswanathan AN. Therapeutic radiation and the potential risk of second malignancies. Cancer 2016; 122:1809-21. [DOI: 10.1002/cncr.29841] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 11/03/2015] [Accepted: 11/04/2015] [Indexed: 11/09/2022]
Affiliation(s)
- Sophia C. Kamran
- Harvard Radiation Oncology Program, Harvard Medical School; Boston Massachusetts
| | - Amy Berrington de Gonzalez
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics; National Cancer Institute; Bethesda Maryland
| | - Andrea Ng
- Department of Radiation Oncology; Brigham and Women's Hospital, Harvard Medical School; Boston Massachusetts
| | - Daphne Haas-Kogan
- Department of Radiation Oncology; Brigham and Women's Hospital, Harvard Medical School; Boston Massachusetts
| | - Akila N. Viswanathan
- Department of Radiation Oncology; Brigham and Women's Hospital, Harvard Medical School; Boston Massachusetts
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71
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Gaffney DK, King B, Viswanathan AN, Barkati M, Beriwal S, Eifel P, Erickson B, Fyles A, Goulart J, Harkenrider M, Jhingran A, Klopp A, Koh WJ, Lim K, Petersen I, Portelance L, Small W, Stewart A, Wiebe E, Wolfson A, Yashar C, Bosch W. Consensus Recommendations for Radiation Therapy Contouring and Treatment of Vulvar Carcinoma. Int J Radiat Oncol Biol Phys 2016; 95:1191-200. [PMID: 27130794 DOI: 10.1016/j.ijrobp.2016.02.043] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [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: 09/16/2015] [Revised: 01/05/2016] [Accepted: 02/11/2016] [Indexed: 11/19/2022]
Abstract
PURPOSE The purpose of this study was to develop a radiation therapy (RT) contouring atlas and recommendations for women with postoperative and locally advanced vulvar carcinoma. METHODS AND MATERIALS An international committee of 35 expert gynecologic radiation oncologists completed a survey of the treatment of vulvar carcinoma. An initial set of recommendations for contouring was discussed and generated by consensus. Two cases, 1 locally advanced and 1 postoperative, were contoured by 14 physicians. Contours were compared and analyzed using an expectation-maximization algorithm for simultaneous truth and performance level estimation (STAPLE), and a 95% confidence interval contour was developed. The level of agreement among contours was assessed using a kappa statistic. STAPLE contours underwent full committee editing to generate the final atlas consensus contours. RESULTS Analysis of the 14 contours showed substantial agreement, with kappa statistics of 0.69 and 0.64 for cases 1 and 2, respectively. There was high specificity for both cases (≥99%) and only moderate sensitivity of 71.3% and 64.9% for cases 1 and 2, respectively. Expert review and discussion generated consensus recommendations for contouring target volumes and treatment for postoperative and locally advanced vulvar cancer. CONCLUSIONS These consensus recommendations for contouring and treatment of vulvar cancer identified areas of complexity and controversy. Given the lack of clinical research evidence in vulvar cancer radiation therapy, the committee advocates a conservative and consistent approach using standardized recommendations.
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Affiliation(s)
- David K Gaffney
- Department of Radiation Oncology, Huntsman Cancer Hospital, Salt Lake City, Utah.
| | - Bronwyn King
- Department of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre and Epworth Radiation Oncology, Melbourne, Victoria, Australia
| | - Akila N Viswanathan
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Maroie Barkati
- Department of Radiation Oncology, Centre hospitalier de l'universite de Montreal, Montreal, Quebec, Canada
| | - Sushil Beriwal
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Patricia Eifel
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Beth Erickson
- Department of Radiation Oncology, Proedtert and Medical College Clinical Cancer Center, Milwaukee, Wisconsin
| | - Anthony Fyles
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Jennifer Goulart
- Department of Radiation Oncology, British Columbia Cancer Agency, Victoria, British Columbia, Canada
| | - Matthew Harkenrider
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University, Maywood, Illinois
| | - Anuja Jhingran
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Ann Klopp
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Wui-Jin Koh
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Karen Lim
- Liverpool Cancer Therapy Centre, Radiation Oncology Unit, Sydney, New South Wales, Australia
| | - Ivy Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Lorraine Portelance
- Radiation Oncology Department, Miller School of Medicine, University of Miami, Miami, Florida
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University, Maywood, Illinois
| | - Alexandra Stewart
- St. Luke's Cancer Centre, Royal Surrey Country Hospital, Surrey, United Kingdom
| | - Ericka Wiebe
- Department of Radiation Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Aaron Wolfson
- Radiation Oncology Department, Miller School of Medicine, University of Miami, Miami, Florida
| | - Catheryn Yashar
- Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, California
| | - Walter Bosch
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
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72
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Vargo JA, Viswanathan AN, Erickson BA, Beriwal S. Gynecologic Brachytherapy: Vaginal Cancer. Brachytherapy 2016. [DOI: 10.1007/978-3-319-26791-3_16] [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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73
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Vargo JA, Viswanathan AN, Erickson BA, Beriwal S. Gynecologic Brachytherapy: Cervical Cancer. Brachytherapy 2016. [DOI: 10.1007/978-3-319-26791-3_15] [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: 10/21/2022]
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74
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Grover S, Harkenrider MM, Cho LP, Erickson B, Small C, Small W, Viswanathan AN. Image Guided Cervical Brachytherapy: 2014 Survey of the American Brachytherapy Society. Int J Radiat Oncol Biol Phys 2015; 94:598-604. [PMID: 26867888 DOI: 10.1016/j.ijrobp.2015.11.024] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [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: 07/21/2015] [Indexed: 01/27/2023]
Abstract
PURPOSE To provide an update of the 2007 American brachytherapy survey on image-based brachytherapy, which showed that in the setting of treatment planning for gynecologic brachytherapy, although computed tomography (CT) was often used for treatment planning, most brachytherapists used point A for dose specification. METHODS AND MATERIALS A 45-question electronic survey on cervical cancer brachytherapy practice patterns was sent to all American Brachytherapy Society members and additional radiation oncologists and physicists based in the United States between January and September 2014. Responses from the 2007 survey and the present survey were compared using the χ(2) test. RESULTS There were 370 respondents. Of those, only respondents, not in training, who treat more than 1 cervical cancer patient per year and practice in the United States, were included in the analysis (219). For dose specification to the target (cervix and tumor), 95% always use CT, and 34% always use MRI. However, 46% use point A only for dose specification to the target. There was a lot of variation in parameters used for dose evaluation of target volume and normal tissues. Compared with the 2007 survey, use of MRI has increased from 2% to 34% (P<.0001) for dose specification to the target. Use of volume-based dose delineation to the target has increased from 14% to 52% (P<.0001). CONCLUSION Although use of image-based brachytherapy has increased in the United States since the 2007 survey, there is room for further growth, particularly with the use of MRI. This increase may be in part due to educational initiatives. However, there is still significant heterogeneity in brachytherapy practice in the United States, and future efforts should be geared toward standardizing treatment.
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Affiliation(s)
- Surbhi Grover
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Matthew M Harkenrider
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Chicago, Illinois
| | - Linda P Cho
- Department of Radiation Oncology, Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Beth Erickson
- Department Radiation Oncology, Froedtert Hospital and Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Christina Small
- Department of Public Health Sciences, Stritch School of Medicine, Loyola University Chicago, Chicago, Illinois
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Chicago, Illinois
| | - Akila N Viswanathan
- Department of Radiation Oncology, Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
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75
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Cho LP, Kim CK, Viswanathan AN. Pilot study assessing (18)F-fluorothymidine PET/CT in cervical and vaginal cancers before and after external beam radiation. Gynecol Oncol Rep 2015; 14:34-7. [PMID: 26793770 PMCID: PMC4688880 DOI: 10.1016/j.gore.2015.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 10/28/2015] [Accepted: 10/31/2015] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE The role of F-18-fluorothymidine (FLT) PET-CT imaging in the evaluation of gynecologic cancers has not been established. We sought to evaluate (FLT) PET-CT imaging in gynecologic cancers by comparing standard uptake values (SUVs) of FLT with F-18-fluorodeoxyglucose (FDG) PET in the primary tumor at diagnosis, and assess FLT uptake immediately following concurrent chemoradiotherapy (chemoRT). METHODS In this pilot study, patients treated for cervical (5) or vaginal (1) cancer underwent FLT-PET and FDG-PET scanning at diagnosis (FLT1 and FDG1). Five patients (4 cervical and 1 vaginal) also underwent FLT-PET within 1-3 weeks after chemoRT before brachytherapy (FLT2). Wilcoxon rank-sum test was used to compare the FLT1 and FDG1 parameters. RESULTS Median age at diagnosis was 61-years (range, 33-72). Cervical cancers were staged as IB2 (n = 1, 20%), IIB (n = 1, 20%), IIIB (n = 1, 20%) and IVA (n = 2, 40%) and the single vaginal cancer was staged IIIB. The most common histology was squamous cell carcinoma (n = 3, 50%) followed by adenocarcinoma (n = 2, 33%) and clear-cell adenosquamous carcinoma (n = 1, 17%). Median tumor SUVmax at diagnosis was 7.8 on FLT1-PET (3.9-14.2) versus 11.6 (5.9-23.2) on FDG1-PET (p = 0.15). Tumor SUVmax of FLT declined 54%-100% after chemoRT. CONCLUSION The tumor SUV of FLT at diagnosis was lower than that of FDG-PET. FLT uptake was markedly decreased after chemoRT. Results indicate that there may not be a significant effect of inflammation on FLT uptake in gynecologic cancers. FLT may be a useful tool when assessing the effects of chemoRT on gynecologic malignancies and planning for postchemoRT brachytherapy treatments.
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Affiliation(s)
- Linda P. Cho
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, MA, United States
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Chun K. Kim
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Akila N. Viswanathan
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, MA, United States
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- Corresponding author at: Department of Radiation Oncology, Brigham and Women's Hospital, 75 Francis Street, ASBI-L2, Boston, MA 02115, United States.Department of Radiation OncologyBrigham and Women's Hospital75 Francis Street, ASBI-L2BostonMA02115United States
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Bair RJ, Bair E, Viswanathan AN. A radiopaque polymer hydrogel used as a fiducial marker in gynecologic-cancer patients receiving brachytherapy. Brachytherapy 2015; 14:876-80. [PMID: 26481393 DOI: 10.1016/j.brachy.2015.08.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [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: 06/02/2015] [Revised: 08/12/2015] [Accepted: 08/27/2015] [Indexed: 11/30/2022]
Abstract
PURPOSE We assessed a novel Food and Drug Administration-approved hydrogel, synthesized as absorbable iodinated particles, in gynecologic-cancer patients undergoing computed tomography (CT) or magnetic resonance (MR) based brachytherapy after external beam radiation. METHODS AND MATERIALS Nineteen patients underwent CT-guided (n = 13) or MR-guided (n = 6) brachytherapy for gynecologic cancers. Seventy-seven hydrogel injections were placed. The hydrogel material was injected into gross residual disease and/or key anatomic landmarks in amounts ranging from 0.1 to 0.4 mL. The visibility of the tracer was scored on CT and on MR images using a 5-point scoring scale. A Cohen's kappa statistic was calculated to assess interobserver agreement. To assess the unadjusted effects of baseline parameters on hydrogel visibility, we modeled visibility using a linear mixed-effect model. RESULTS Injections were without complication. The kappa statistic was 0.77 (95% confidence interval [CI], 0.68-0.87). The volume of hydrogel injected was significantly associated with visibility on both CT (p = 0.032) and magnetic resonance imaging (p = 0.016). We analyzed visibility by location, controlling for amount. A 0.1-cc increase in volume injected was associated with increases of 0.54 (95% CI = 0.05-1.03) in the CT visibility score and 0.83 (95% CI = 0.17-1.49) in the MR visibility score. Injection of 0.4 cc or more was required for unequivocal visibility on CT or MR. No statistically significant correlation was found between tumor type, tumor location, or anatomical location of injection and visibility on either CT or magnetic resonance imaging. CONCLUSIONS In this first report of an injectable radiopaque hydrogel, targets were visualized to assist with three-dimensional-based brachytherapy in gynecologic malignancies. This marker has potential for several applications, is easy to inject and visualize, and caused no acute complications.
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Affiliation(s)
- Ryan J Bair
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA
| | - Eric Bair
- Department of Endodontics, University of North Carolina, Chapel Hill, NC; Department of Biostatistics, University of North Carolina, Chapel Hill, NC
| | - Akila N Viswanathan
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA.
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Mitra D, Catalano PJ, Cimbak N, Damato AL, Muto MG, Viswanathan AN. The risk of lymphedema after postoperative radiation therapy in endometrial cancer. J Gynecol Oncol 2015; 27:e4. [PMID: 26463430 PMCID: PMC4695454 DOI: 10.3802/jgo.2016.27.e4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [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: 04/17/2015] [Revised: 08/16/2015] [Accepted: 09/13/2015] [Indexed: 12/20/2022] Open
Abstract
Objective Lower extremity lymphedema adversely affects quality of life by causing discomfort, impaired mobility and increased risk of infection. The goal of this study is to investigate factors that influence the likelihood of lymphedema in patients with endometrial cancer who undergo adjuvant radiation with or without chemotherapy. Methods A retrospective chart review identified all stage I–III endometrial cancer patients who had a hysterectomy with or without complete staging lymphadenectomy and adjuvant radiation therapy between January 2006 and February 2013. Patients with new-onset lymphedema after treatment were identified. Logistic regression was used to find factors that influenced lymphedema risk. Results Of 212 patients who met inclusion criteria, 15 patients (7.1%) developed new-onset lymphedema. Lymphedema was associated with lymph-node dissection (odds ratio [OR], 5.6; 95% CI, 1.01 to 105.5; p=0.048) and with the presence of pathologically positive lymph nodes (OR, 4.1; 95% CI, 1.4 to 12.3; p=0.01). Multivariate logistic regression confirmed the association with lymph-node positivity (OR, 3.2; 95% CI, 1.0007 to 10.7; p=0.0499) when controlled for lymph-node dissection. Median time to lymphedema onset was 8 months (range, 1 to 58 months) with resolution or improvement in eight patients (53.3%) after a median of 10 months. Conclusion Lymph-node positivity was associated with an increased risk of lymphedema in endometrial cancer patients who received adjuvant radiation. Future studies are needed to explore whether node-positive patients may benefit from early lymphedema-controlling interventions.
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Affiliation(s)
- Devarati Mitra
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, MA, USA.
| | - Paul J Catalano
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA.,Department of Biostatistics, Harvard School of Public Health, Boston, MA, USA
| | - Nicole Cimbak
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, MA, USA
| | - Antonio L Damato
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, MA, USA
| | - Michael G Muto
- Department of Gynecologic Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, MA, USA
| | - Akila N Viswanathan
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham & Women's Hospital, Boston, MA, USA
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78
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Lee LJ, Damato AL, Viswanathan AN. Gynecologic Brachytherapy. Brachytherapy 2015. [DOI: 10.1891/9781617052613.0005] [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: 11/25/2022]
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Ye JC, Mohindra P, Spektor A, Krishnan MS, Chmura SJ, Howard AR, Viswanathan AN, MacDonald SM, Thaker NG, Das P, Mancini BR, Higgins SA, Braunstein S, Haas-Kogan D, Bradley KA, Hung AY, Thomas CR, Kharofa J, Wheatley M, Currey A, Parashar B, Du K, Jimenez RB, Golden DW. Medical Student Perspectives on a Multi-institutional Clerkship Curriculum: A Report From the Radiation Oncology Education Collaborative Study Group. Int J Radiat Oncol Biol Phys 2015; 92:217-9. [PMID: 25968822 DOI: 10.1016/j.ijrobp.2015.01.043] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 01/28/2015] [Indexed: 11/19/2022]
Affiliation(s)
- Jason C Ye
- Department of Radiation Oncology, Weill-Cornell Medical College, Stich Radiation Oncology Center, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Alexander Spektor
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Monica S Krishnan
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Steven J Chmura
- Department of Radiation and Cellular Oncology, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Andrew R Howard
- Department of Radiation and Cellular Oncology, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Akila N Viswanathan
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Nikhil G Thaker
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Prajnan Das
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Brandon R Mancini
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Susan A Higgins
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Steve Braunstein
- Department of Radiation Oncology, University of California-San Francisco, San Francisco, California
| | - Daphne Haas-Kogan
- Department of Radiation Oncology, University of California-San Francisco, San Francisco, California
| | - Kristin A Bradley
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Arthur Y Hung
- Department of Radiation Medicine, Knight Cancer Institute Oregon Health and Science University, Portland, Oregon
| | - Charles R Thomas
- Department of Radiation Medicine, Knight Cancer Institute Oregon Health and Science University, Portland, Oregon
| | - Jordan Kharofa
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, Ohio
| | - Matt Wheatley
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Adam Currey
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Bhupesh Parashar
- Department of Radiation Oncology, Weill-Cornell Medical College, Stich Radiation Oncology Center, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - Kevin Du
- Department of Radiation Oncology, New York University Perlmutter Cancer Center, New York, New York
| | - Rachel B Jimenez
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Daniel W Golden
- Department of Radiation and Cellular Oncology, University of Chicago Pritzker School of Medicine, Chicago, Illinois.
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Viswanathan AN, Erickson BA. Seeing is saving: The benefit of 3D imaging in gynecologic brachytherapy. Gynecol Oncol 2015; 138:207-15. [DOI: 10.1016/j.ygyno.2015.02.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 02/26/2015] [Indexed: 12/18/2022]
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Damato AL, Viswanathan AN, Don SM, Hansen JL, Cormack RA. A system to use electromagnetic tracking for the quality assurance of brachytherapy catheter digitization. Med Phys 2015; 41:101702. [PMID: 25281941 DOI: 10.1118/1.4894710] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE To investigate the use of a system using electromagnetic tracking (EMT), post-processing and an error-detection algorithm for detecting errors and resolving uncertainties in high-dose-rate brachytherapy catheter digitization for treatment planning. METHODS EMT was used to localize 15 catheters inserted into a phantom using a stepwise acquisition technique. Five distinct acquisition experiments were performed. Noise associated with the acquisition was calculated. The dwell location configuration was extracted from the EMT data. A CT scan of the phantom was performed, and five distinct catheter digitization sessions were performed. No a priori registration of the CT scan coordinate system with the EMT coordinate system was performed. CT-based digitization was automatically extracted from the brachytherapy plan DICOM files (CT), and rigid registration was performed between EMT and CT dwell positions. EMT registration error was characterized in terms of the mean and maximum distance between corresponding EMT and CT dwell positions per catheter. An algorithm for error detection and identification was presented. Three types of errors were systematically simulated: swap of two catheter numbers, partial swap of catheter number identification for parts of the catheters (mix), and catheter-tip shift. Error-detection sensitivity (number of simulated scenarios correctly identified as containing an error/number of simulated scenarios containing an error) and specificity (number of scenarios correctly identified as not containing errors/number of correct scenarios) were calculated. Catheter identification sensitivity (number of catheters correctly identified as erroneous across all scenarios/number of erroneous catheters across all scenarios) and specificity (number of catheters correctly identified as correct across all scenarios/number of correct catheters across all scenarios) were calculated. The mean detected and identified shift was calculated. RESULTS The maximum noise ±1 standard deviation associated with the EMT acquisitions was 1.0 ± 0.1 mm, and the mean noise was 0.6 ± 0.1 mm. Registration of all the EMT and CT dwell positions was associated with a mean catheter error of 0.6 ± 0.2 mm, a maximum catheter error of 0.9 ± 0.4 mm, a mean dwell error of 1.0 ± 0.3 mm, and a maximum dwell error of 1.3 ± 0.7 mm. Error detection and catheter identification sensitivity and specificity of 100% were observed for swap, mix and shift (≥2.6 mm for error detection; ≥2.7 mm for catheter identification) errors. A mean detected shift of 1.8 ± 0.4 mm and a mean identified shift of 1.9 ± 0.4 mm were observed. CONCLUSIONS Registration of the EMT dwell positions to the CT dwell positions was possible with a residual mean error per catheter of 0.6 ± 0.2 mm and a maximum error for any dwell of 1.3 ± 0.7 mm. These low residual registration errors show that quality assurance of the general characteristics of the catheters and of possible errors affecting one specific dwell position is possible. The sensitivity and specificity of the catheter digitization verification algorithm was 100% for swap and mix errors and for shifts ≥2.6 mm. On average, shifts ≥1.8 mm were detected, and shifts ≥1.9 mm were detected and identified.
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Affiliation(s)
- Antonio L Damato
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts 02115
| | - Akila N Viswanathan
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts 02115
| | - Sarah M Don
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts 02115
| | - Jorgen L Hansen
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts 02115
| | - Robert A Cormack
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts 02115
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Mitra D, Nout R, Catalano PJ, Creutzberg C, Cimbak N, Lee L, Viswanathan AN. Rectal bleeding after radiation therapy for endometrial cancer. Radiother Oncol 2015; 115:240-5. [PMID: 26003340 DOI: 10.1016/j.radonc.2015.03.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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: 01/30/2015] [Revised: 03/23/2015] [Accepted: 03/27/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND PURPOSE The goals of this study were to determine the rate and risk factors of rectal bleeding (RB) after external beam radiotherapy and vaginal brachytherapy (EBRT +VB), and to compare these data to previously unreported RB rates from PORTEC-2 patients receiving EBRT or VB alone. MATERIALS AND METHODS Retrospective chart review identified 212 endometrial cancer patients receiving adjuvant EBRT+VB between 2006 and 2013. Patient-reported RB data were also obtained from PORTEC-2 patients randomized to EBRT (n=166) or VB (n=182). The two populations were compared using an RB scale of symptom severity. RESULTS After a median 35months, 17.9% of EBRT+VB patients (n=38) experienced any RB with 1.9% (n=4) having bleeding requiring intervention. Age ⩽70years was the only predictor of RB (OR 2.8; 95% CI 1.1-8.7; p=0.027). Rates of patient-reported RB after EBRT were similar with 15.0% (n=25) having any RB and 0.6% (n=1) having "very much" bleeding. On regression analysis, any EBRT (either EBRT alone or EBRT+VB) increased the risk of RB compared to those who received VB alone (OR 3.0; p=0.0028; 95% CI 1.4-6.7). The rates of more severe RB were low and did not significantly differ between treatments. CONCLUSIONS Significant RB is rare after radiation. EBRT has higher rates of rectal bleeding than VB. The addition of VB to EBRT does not significantly alter bleeding rates.
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Affiliation(s)
- Devarati Mitra
- Department of Radiation Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, USA.
| | - Remi Nout
- Department of Radiation Oncology, Leiden University Medical Center, The Netherlands
| | - Paul J Catalano
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute and Department of Biostatistics, Harvard School of Public Health, Boston, USA
| | - Carien Creutzberg
- Department of Radiation Oncology, Leiden University Medical Center, The Netherlands
| | - Nicole Cimbak
- Department of Radiation Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, USA
| | - Larissa Lee
- Department of Radiation Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, USA
| | - Akila N Viswanathan
- Department of Radiation Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, USA
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83
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Damato A, Bhagwat MS, Buzurovic I, Cormack RA, Friesen S, Hansen J, Lee LJ, O'Farrell D, Williams CL, Devlin PM, Viswanathan AN. Balance Between Clinical Target Volume and Organs-at-Risk Optimization Goals in Cervical-Cancer Brachytherapy. Brachytherapy 2015. [DOI: 10.1016/j.brachy.2015.02.339] [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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84
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Damato AL, Bhagwat MS, Buzurovic I, Cormack RA, Friesen S, Hansen J, Lee LJ, O'Farrell D, Williams CL, Devlin PM, Viswanathan AN. Is the Systematic Contouring of the Bowel in Image-Based Cervical-Cancer HDR Brachytherapy Necessary? Brachytherapy 2015. [DOI: 10.1016/j.brachy.2015.02.326] [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: 10/23/2022]
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85
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Brown LC, Petersen IA, Haddock MG, Bakkum-Gamez JN, Lee LJ, Cimbak NC, Berkowitz RS, Viswanathan AN. Vaginal brachytherapy for early-stage carcinosarcoma of the uterus. Brachytherapy 2015; 14:433-9. [PMID: 25890795 DOI: 10.1016/j.brachy.2015.02.194] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [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: 11/10/2014] [Revised: 01/07/2015] [Accepted: 02/12/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Uterine carcinosarcoma (CS) is an aggressive malignancy and the optimal adjuvant treatment is not well-established. We report outcomes with vaginal brachytherapy (VB) for women with early-stage CS. METHODS AND MATERIALS A multi-institutional retrospective study of Stage I-II CS treated with hysterectomy, surgical staging, and adjuvant high-dose-rate VB without external-beam pelvic radiotherapy was performed. Rates of vaginal control, pelvic control, locoregional control, disease-free survival, and overall survival were determined using the Kaplan-Meier method. RESULTS 33 patients were identified. Prescribed VB dose was 21 Gy in three fractions (n = 15 [45%]) or 24 Gy in six fractions (n = 18 [55%]). Eighteen patients (55%) received chemotherapy. Median followup was 2.0 years. Twenty-seven patients (82%) underwent pelvic lymphadenectomy, 5 (15%) had nodal sampling, and 1 (3%) had no lymph node assessment. Relapse occurred in 11 patients (33%), all of whom had lymph node evaluation. Locoregional relapse was a component of failure in 6 patients (18%), of whom 3 (9%) failed in the pelvis alone. Three patients (9%) had simultaneous distant and locoregional relapse (two vaginal, one pelvic). Five additional patients (15%) had distant relapse. Six of the 11 patients (55%) with disease recurrence received chemotherapy. Two-year vaginal control and pelvic control were 94% and 87%. Two-year locoregional control, disease-free survival, and overall survival were 81%, 66%, and 79%. CONCLUSIONS Despite having early-stage disease and treatment with VB, patients in this series had relatively high rates of local and distant relapse. Patients who undergo lymphadenectomy and VB remain at risk for relapse. Novel treatment strategies are needed.
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Affiliation(s)
- Lindsay C Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Ivy A Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | | | | | - Larissa J Lee
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA
| | - Nicole C Cimbak
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA
| | - Ross S Berkowitz
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA
| | - Akila N Viswanathan
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA.
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Viswanathan AN, Moughan J, Miller BE, Xiao Y, Jhingran A, Portelance L, Bosch WR, Matulonis UA, Horowitz NS, Mannel RS, Souhami L, Erickson BA, Winter KA, Small W, Gaffney DK. NRG Oncology/RTOG 0921: A phase 2 study of postoperative intensity-modulated radiotherapy with concurrent cisplatin and bevacizumab followed by carboplatin and paclitaxel for patients with endometrial cancer. Cancer 2015; 121:2156-63. [PMID: 25847373 DOI: 10.1002/cncr.29337] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [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: 12/29/2014] [Accepted: 02/04/2015] [Indexed: 11/08/2022]
Abstract
BACKGROUND The current study was conducted to assess acute and late adverse events (AEs), overall survival (OS), pelvic failure, regional failure, distant failure, and disease-free survival in a prospective phase 2 clinical trial of bevacizumab and pelvic intensity-modulated radiotherapy (IMRT) with chemotherapy in patients with high-risk endometrial cancer. METHODS Patients underwent a hysterectomy and lymph node removal, and had ≥1 of the following high-risk factors: grade 3 carcinoma with >50% myometrial invasion, grade 2 or 3 disease with any cervical stromal invasion, or known extrauterine extension confined to the pelvis. Treatment included pelvic IMRT and concurrent cisplatin on days 1 and 29 of radiation and bevacizumab (at a dose of 5 mg/kg on days 1, 15, and 29 of radiation) followed by adjuvant carboplatin and paclitaxel for 4 cycles. The primary endpoint was grade ≥3 AEs occurring within the first 90 days (toxicity was graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events [version 4.0]). RESULTS A total of 34 patients were accrued from November 2009 through December 2011, 30 of whom were eligible and received study treatment. Seven of 30 patients (23.3%; 1-sided 95% confidence interval, 10.6%-36.0%) developed grade ≥3 treatment-related nonhematologic toxicities within 90 days; an additional 6 patients experienced grade ≥3 toxicities between 90 and 365 days after treatment. The 2-year OS rate was 96.7% and the disease-free survival rate was 79.1%. No patient developed a within-field pelvic failure and no patients with International Federation of Gynecology and Obstetrics stage I to IIIA disease developed disease recurrence after a median follow-up of 26 months. CONCLUSIONS Postoperative bevacizumab added to chemotherapy and pelvic IMRT appears to be well tolerated and results in high OS rates at 2 years for patients with high-risk endometrial carcinoma.
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Affiliation(s)
- Akila N Viswanathan
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Jennifer Moughan
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - Brigitte E Miller
- Carolinas Healthcare System NorthEast, Levine Cancer Institute, Concord, North Carolina
| | - Ying Xiao
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Anuja Jhingran
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | | | - Ursula A Matulonis
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Neil S Horowitz
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA
| | - Robert S Mannel
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | | | | | - Kathryn A Winter
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | | | - David K Gaffney
- University of Utah Health Science Center, Salt Lake City, Utah
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Aviki EM, Esselen KM, Barcia SM, Nucci MR, Horowitz NS, Feltmate CM, Berkowitz RS, Orgill DG, Viswanathan AN, Muto MG. Does plastic surgical consultation improve the outcome of patients undergoing radical vulvectomy for squamous cell carcinoma of the vulva? Gynecol Oncol 2015; 137:60-5. [DOI: 10.1016/j.ygyno.2015.02.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 02/02/2015] [Indexed: 10/24/2022]
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Affiliation(s)
| | - Steven J Frank
- University of Texas MD Anderson Cancer Center, Houston, TX
| | - Akila N Viswanathan
- Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | | | - Patricia Eifel
- University of Texas MD Anderson Cancer Center, Houston, TX
| | - Paul L Nguyen
- Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - David E Wazer
- Tufts Medical Center, Tufts University School of Medicine, Boston, MA, and Rhode Island Hospital, The Alpert Medical School of Brown University, Providence, RI
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Abstract
The application of magnetic resonance image (MRI)-guided brachytherapy has demonstrated significant growth during the past 2 decades. Clinical improvements in cervix cancer outcomes have been linked to the application of repeated MRI for identification of residual tumor volumes during radiotherapy. This has changed clinical practice in the direction of individualized dose administration, and resulted in mounting evidence of improved clinical outcome regarding local control, overall survival as well as morbidity. MRI-guided prostate high-dose-rate and low-dose-rate brachytherapies have improved the accuracy of target and organs-at-risk delineation, and the potential exists for improved dose prescription and reporting for the prostate gland and organs at risk. Furthermore, MRI-guided prostate brachytherapy has significant potential to identify prostate subvolumes and dominant lesions to allow for dose administration reflecting the differential risk of recurrence. MRI-guided brachytherapy involves advanced imaging, target concepts, and dose planning. The key issue for safe dissemination and implementation of high-quality MRI-guided brachytherapy is establishment of qualified multidisciplinary teams and strategies for training and education.
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Affiliation(s)
- Kari Tanderup
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO; Department of Oncology, Aarhus University Hospital, Aarhus, Denmark.
| | - Akila N Viswanathan
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women׳s Hospital, Boston, MA
| | - Christian Kirisits
- Department of Radiotherapy, Comprehensive Cancer Center and Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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90
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Barber LA, Damato AL, Viswanathan AN. CT- and MR-based Urethral Dosimetry and Toxicity With HDR Interstitial Brachytherapy for Gynecological Cancer. Brachytherapy 2015. [DOI: 10.1016/j.brachy.2014.08.040] [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: 11/25/2022]
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Viswanathan AN, Erickson B, Gaffney DK, Beriwal S, Bhatia SK, Lee Burnett O, D'Souza DP, Patil N, Haddock MG, Jhingran A, Jones EL, Kunos CA, Lee LJ, Lin LL, Mayr NA, Petersen I, Petric P, Portelance L, Small W, Strauss JB, Townamchai K, Wolfson AH, Yashar CM, Bosch W. Comparison and consensus guidelines for delineation of clinical target volume for CT- and MR-based brachytherapy in locally advanced cervical cancer. Int J Radiat Oncol Biol Phys 2014; 90:320-8. [PMID: 25304792 DOI: 10.1016/j.ijrobp.2014.06.005] [Citation(s) in RCA: 136] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 05/28/2014] [Accepted: 06/02/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To create and compare consensus clinical target volume (CTV) contours for computed tomography (CT) and 3-Tesla (3-T) magnetic resonance (MR) image-based cervical-cancer brachytherapy. METHODS AND MATERIALS Twenty-three experts in gynecologic radiation oncology contoured the same 3 cervical cancer brachytherapy cases: 1 stage IIB near-complete response (CR) case with a tandem and ovoid, 1 stage IIB partial response (PR) case with tandem and ovoid with needles, and 1 stage IB2 CR case with a tandem and ring applicator. The CT contours were completed before the MRI contours. These were analyzed for consistency and clarity of target delineation using an expectation maximization algorithm for simultaneous truth and performance level estimation (STAPLE), with κ statistics as a measure of agreement between participants. The conformity index was calculated for each of the 6 data sets. Dice coefficients were generated to compare the CT and MR contours of the same case. RESULTS For all 3 cases, the mean tumor volume was smaller on MR than on CT (P<.001). The κ and conformity index estimates were slightly higher for CT, indicating a higher level of agreement on CT. The Dice coefficients were 89% for the stage IB2 case with a CR, 74% for the stage IIB case with a PR, and 57% for the stage IIB case with a CR. CONCLUSION In a comparison of MR-contoured with CT-contoured CTV volumes, the higher level of agreement on CT may be due to the more distinct contrast medium visible on the images at the time of brachytherapy. MR at the time of brachytherapy may be of greatest benefit in patients with large tumors with parametrial extension that have a partial or complete response to external beam. On the basis of these results, a 95% consensus volume was generated for CT and for MR. Online contouring atlases are available for instruction at http://www.nrgoncology.org/Resources/ContouringAtlases/GYNCervicalBrachytherapy.aspx.
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Affiliation(s)
- Akila N Viswanathan
- Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts.
| | | | - David K Gaffney
- University of Utah Huntsman Cancer Hospital, Salt Lake City, Utah
| | - Sushil Beriwal
- University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | | | | | - David P D'Souza
- London Health Sciences Centre and Western University, London, Ontario, Canada
| | - Nikhilesh Patil
- London Health Sciences Centre and Western University, London, Ontario, Canada
| | | | - Anuja Jhingran
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ellen L Jones
- University of North Carolina, Chapel Hill, North Carolina
| | | | - Larissa J Lee
- Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lilie L Lin
- University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nina A Mayr
- University of Washington, Seattle, Washington
| | | | - Primoz Petric
- Division of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Department of Radiation Oncology, National Center for Cancer Care and Research, Doha, Qatar
| | | | - William Small
- Loyola University Strich School of Medicine, Chicago, Illinois
| | - Jonathan B Strauss
- The Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois
| | - Kanokpis Townamchai
- Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Aaron H Wolfson
- University of Miami Miller School of Medicine, Miami, Florida
| | - Catheryn M Yashar
- University of California, San Diego, California, Washington University, St. Louis, Missouri
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92
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Mayr NA, Hu KS, Liao Z, Viswanathan AN, Wall TJ, Amendola BE, Calaguas MJ, Palta JR, Yue NJ, Rengan R, Williams TR. International outreach: what is the responsibility of ASTRO and the major international radiation oncology societies? Int J Radiat Oncol Biol Phys 2014; 89:481-4. [PMID: 24929158 DOI: 10.1016/j.ijrobp.2013.12.052] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 12/31/2013] [Accepted: 12/31/2013] [Indexed: 11/17/2022]
Abstract
In this era of globalization and rapid advances in radiation oncology worldwide, the American Society for Radiation Oncology (ASTRO) is committed to help decrease profound regional disparities through the work of the International Education Subcommittee (IES). The IES has expanded its base, reach, and activities to foster educational advances through a variety of educational methods with broad scope, in addition to committing to the advancement of radiation oncology care for cancer patients around the world, through close collaboration with our sister radiation oncology societies and other educational, governmental, and organizational groups.
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Affiliation(s)
- Nina A Mayr
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington.
| | - Kenneth S Hu
- Department of Radiation Oncology, Beth Israel Medical Center, New York, New York
| | - Zhongxing Liao
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Akila N Viswanathan
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Terry J Wall
- St. Luke's Cancer Institute, Kansas City, Missouri
| | | | - Miriam J Calaguas
- Department of Radiation Oncology, St. Luke's Medical Center, Quezon City, Philippines
| | - Jatinder R Palta
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Ning J Yue
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Ramesh Rengan
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
| | - Timothy R Williams
- Lynn Cancer Institute, Boca Raton Regional Hospital, Boca Raton, Florida
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93
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Viswanathan AN, Lee LJ, Eswara JR, Horowitz NS, Konstantinopoulos PA, Mirabeau-Beale KL, Rose BS, von Keudell AG, Wo JY. Complications of pelvic radiation in patients treated for gynecologic malignancies. Cancer 2014; 120:3870-83. [DOI: 10.1002/cncr.28849] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 04/30/2014] [Accepted: 05/01/2014] [Indexed: 01/05/2023]
Affiliation(s)
- Akila N. Viswanathan
- Department of Radiation Oncology; Brigham and Women's Hospital and Dana-Farber Cancer Institute; Boston Massachusetts
| | - Larissa J. Lee
- Department of Radiation Oncology; Brigham and Women's Hospital and Dana-Farber Cancer Institute; Boston Massachusetts
| | - Jairam R. Eswara
- Division of Urology; Washington University School of Medicine; St. Louis Missouri
| | - Neil S. Horowitz
- Division of Gynecologic Oncology; Brigham and Women's Hospital; Boston Massachusetts
| | | | | | - Brent S. Rose
- Harvard Radiation Oncology Residency Program; Boston Massachusetts
| | | | - Jennifer Y. Wo
- Department of Radiation Oncology; Massachusetts General Hospital; Boston Massachusetts
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94
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Wang W, Dumoulin CL, Viswanathan AN, Tse ZTH, Mehrtash A, Loew W, Norton I, Tokuda J, Seethamraju RT, Kapur T, Damato AL, Cormack RA, Schmidt EJ. Real-time active MR-tracking of metallic stylets in MR-guided radiation therapy. Magn Reson Med 2014; 73:1803-11. [PMID: 24903165 DOI: 10.1002/mrm.25300] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [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: 02/25/2014] [Revised: 05/01/2014] [Accepted: 05/02/2014] [Indexed: 11/10/2022]
Abstract
PURPOSE To develop an active MR-tracking system to guide placement of metallic devices for radiation therapy. METHODS An actively tracked metallic stylet for brachytherapy was constructed by adding printed-circuit micro-coils to a commercial stylet. The coil design was optimized by electromagnetic simulation, and has a radio-frequency lobe pattern extending ∼5 mm beyond the strong B0 inhomogeneity region near the metal surface. An MR-tracking sequence with phase-field dithering was used to overcome residual effects of B0 and B1 inhomogeneities caused by the metal, as well as from inductive coupling to surrounding metallic stylets. The tracking system was integrated with a graphical workstation for real-time visualization. The 3 Tesla MRI catheter-insertion procedures were tested in phantoms and ex vivo animal tissue, and then performed in three patients during interstitial brachytherapy. RESULTS The tracking system provided high-resolution (0.6 × 0.6 × 0.6 mm(3) ) and rapid (16 to 40 frames per second, with three to one phase-field dithering directions) catheter localization in phantoms, animals, and three gynecologic cancer patients. CONCLUSION This is the first demonstration of active tracking of the shaft of metallic stylet in MR-guided brachytherapy. It holds the promise of assisting physicians to achieve better targeting and improving outcomes in interstitial brachytherapy.
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Affiliation(s)
- Wei Wang
- Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Radiation Oncology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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95
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Damato AL, Bhagwat MS, Buzurovic I, Devlin PM, Friesen S, Hansen JL, Kapur T, Lee LJ, Mehrtash A, Nguyen PL, O' Farrell D, Wang W, Viswanathan AN, Cormack RA. WE-A-17A-03: Catheter Digitization in High-Dose-Rate Brachytherapy with the Assistance of An Electromagnetic (EM) Tracking System. Med Phys 2014. [DOI: 10.1118/1.4889373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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96
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Prescott J, Bao Y, Viswanathan AN, Giovannucci EL, Hankinson SE, De Vivo I. Dietary insulin index and insulin load in relation to endometrial cancer risk in the Nurses' Health Study. Cancer Epidemiol Biomarkers Prev 2014; 23:1512-20. [PMID: 24859872 DOI: 10.1158/1055-9965.epi-14-0157] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [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
BACKGROUND Although unopposed estrogen exposure is considered the main driver of endometrial carcinogenesis, factors associated with states of insulin resistance and hyperinsulinemia are independently associated with endometrial cancer risk. We used dietary insulin load and insulin index scores to represent the estimated insulin demand of overall diets and assessed their association with endometrial cancer risk in the prospective Nurses' Health Study. METHODS We estimated incidence rate ratios (RR) and 95% confidence intervals (CI) for risk of invasive endometrial cancer using Cox proportional hazards models. Between the baseline dietary questionnaire (1980) and 2010, we identified a total of 798 incident-invasive epithelial endometrial adenocarcinomas over 1,417,167 person-years of follow-up. RESULTS Dietary insulin scores were not associated with overall risk of endometrial cancer. Comparing women in the highest with the lowest quintile, the multivariable-adjusted RRs of endometrial cancer were 1.07 (95% CI, 0.84-1.35) for cumulative average dietary insulin load and 1.03 (95% CI, 0.82-1.31) for cumulative average dietary insulin index. Findings did not vary substantially by alcohol consumption, total dietary fiber intake, or body mass index and/or physical activity (P(heterogeneity) ≥ 0.10). CONCLUSIONS Intake of a diet predicted to stimulate a high postprandial insulin response was not associated with endometrial cancer risk in this large prospective study. Considering the complex interplay of diet, lifestyle, and genetic factors contributing to the hyperinsulinemic state, dietary measures alone may not sufficiently capture absolute long-term insulin exposure. IMPACT This study is the first to investigate dietary insulin scores in relation to endometrial cancer risk.
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Affiliation(s)
- Jennifer Prescott
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School; Program in Genetic Epidemiology and Statistical Genetics, Harvard School of Public Health;
| | - Ying Bao
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School
| | - Akila N Viswanathan
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School
| | - Edward L Giovannucci
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School; Department of Nutrition and Epidemiology, Harvard School of Public Health, Boston; and
| | - Susan E Hankinson
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School; Division of Biostatistics and Epidemiology, University of Massachusetts School of Public Health and Health Sciences, Amherst, Massachusetts
| | - Immaculata De Vivo
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School; Program in Genetic Epidemiology and Statistical Genetics, Harvard School of Public Health
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97
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Damato AL, Townamchai K, Albert M, Bair RJ, Cormack RA, Jang J, Kovacs A, Lee LJ, Mak KS, Mirabeau-Beale KL, Mouw KW, Phillips JG, Pretz JL, Russo AL, Lewis JH, Viswanathan AN. Dosimetric consequences of interobserver variability in delineating the organs at risk in gynecologic interstitial brachytherapy. Int J Radiat Oncol Biol Phys 2014; 89:674-81. [PMID: 24803035 DOI: 10.1016/j.ijrobp.2014.03.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 02/26/2014] [Accepted: 03/05/2014] [Indexed: 11/16/2022]
Abstract
PURPOSE To investigate the dosimetric variability associated with interobserver organ-at-risk delineation differences on computed tomography in patients undergoing gynecologic interstitial brachytherapy. METHODS AND MATERIALS The rectum, bladder, and sigmoid of 14 patients treated with gynecologic interstitial brachytherapy were retrospectively contoured by 13 physicians. Geometric variability was calculated using κ statistics, conformity index (CIgen), and coefficient of variation (CV) of volumes contoured across physicians. Dosimetric variability of the single-fraction D0.1cc and D2cc was assessed through CV across physicians, and the standard deviation of the total EQD2 (equivalent dose in 2 Gy per fraction) brachytherapy dose (SD(TOT)) was calculated. RESULTS The population mean ± 1 standard deviation of κ, CIgen, and volume CV were, respectively: 0.77 ± 0.06, 0.70 ± 0.08, and 20% ± 6% for bladder; 0.74 ± 06, 0.67 ± 0.08, and 20% ± 5% for rectum; and 0.33 ± 0.20, 0.26 ± 0.17, and 82% ± 42% for sigmoid. Dosimetric variability was as follows: for bladder, CV = 31% ± 19% (SD(TOT) = 72 ± 64 Gy) for D0.1cc and CV = 16% ± 10% (SD(TOT) = 9 ± 6 Gy) for D2cc; for rectum, CV = 11% ± 5% (SD(TOT) = 16 ± 17 Gy) for D0.1cc and CV = 7% ± 2% (SD(TOT) = 4 ± 3 Gy) for D2cc; for sigmoid, CV = 39% ± 28% (SD(TOT) = 12 ± 18 Gy) for D0.1cc and CV = 34% ± 19% (SD(TOT) = 4 ± 4 Gy) for D2cc. CONCLUSIONS Delineation of bladder and rectum by 13 physicians demonstrated substantial geometric agreement and resulted in good dosimetric agreement for all dose-volume histogram parameters except bladder D0.1cc. Small delineation differences in high-dose regions by the posterior bladder wall may explain these results. The delineation of sigmoid showed fair geometric agreement. The higher dosimetric variability for sigmoid compared with rectum and bladder did not correlate with higher variability in the total brachytherapy dose but rather may be due to the sigmoid being positioned in low-dose regions in the cases analyzed in this study.
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Affiliation(s)
- Antonio L Damato
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts.
| | - Kanopkis Townamchai
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts
| | - Michele Albert
- Department of Radiation Oncology, Saint Anne's Hospital Regional Cancer Center, Fall River, Massachusetts
| | - Ryan J Bair
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Robert A Cormack
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts
| | - Joanne Jang
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Arpad Kovacs
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Larissa J Lee
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts
| | - Kimberley S Mak
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, Massachusetts
| | | | - Kent W Mouw
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, Massachusetts
| | - John G Phillips
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, Massachusetts
| | - Jennifer L Pretz
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, Massachusetts
| | - Andrea L Russo
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, Massachusetts
| | - John H Lewis
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts
| | - Akila N Viswanathan
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts
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98
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Klopp A, Smith BD, Alektiar K, Cabrera A, Damato AL, Erickson B, Fleming G, Gaffney D, Greven K, Lu K, Miller D, Moore D, Petereit D, Schefter T, Small W, Yashar C, Viswanathan AN. The role of postoperative radiation therapy for endometrial cancer: Executive Summary of an American Society for Radiation Oncology evidence-based guideline. Pract Radiat Oncol 2014; 4:137-144. [DOI: 10.1016/j.prro.2014.01.003] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 01/15/2014] [Indexed: 10/25/2022]
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99
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Damato AL, Viswanathan AN, Cormack RA. Validation of mathematical models for the prediction of organs-at-risk dosimetric metrics in high-dose-rate gynecologic interstitial brachytherapy. Med Phys 2014; 40:101711. [PMID: 24089901 DOI: 10.1118/1.4819946] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE Given the complicated nature of an interstitial gynecologic brachytherapy treatment plan, the use of a quantitative tool to evaluate the quality of the achieved metrics compared to clinical practice would be advantageous. For this purpose, predictive mathematical models to predict the D2cc of rectum and bladder in interstitial gynecologic brachytherapy are discussed and validated. METHODS Previous plans were used to establish the relationship between D2cc and the overlapping volume of the organ at risk with the targeted area (C0) or a 1-cm expansion of the target area (C1). Three mathematical models were evaluated: D2cc = α*C1 + β (LIN); D2cc = α - exp(-β*C0) (EXP); and a mixed approach (MIX), where both C0 and C1 were inputs of the model. The parameters of the models were optimized on a training set of patient data, and the predictive error of each model (predicted D2cc - real D2cc) was calculated on a validation set of patient data. The data of 20 patients were used to perform a K-fold cross validation analysis, with K = 2, 4, 6, 8, 10, and 20. RESULTS MIX was associated with the smallest mean prediction error <6.4% for an 18-patient training set; LIN had an error <8.5%; EXP had an error <8.3%. Best case scenario analysis shows that an error ≤ 5% can be achieved for a ten-patient training set with MIX, an error ≤ 7.4% for LIN, and an error ≤ 6.9% for EXP. The error decreases with the increase in training set size, with the most marked decrease observed for MIX. CONCLUSIONS The MIX model can predict the D2cc of the organs at risk with an error lower than 5% with a training set of ten patients or greater. The model can be used in the development of quality assurance tools to identify treatment plans with suboptimal sparing of the organs at risk. It can also be used to improve preplanning and in the development of real-time intraoperative planning tools.
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Affiliation(s)
- Antonio L Damato
- Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts 02115
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100
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Townamchai K, Poorvu PD, Damato AL, DeMaria R, Lee LJ, Berlin S, Feltmate C, Viswanathan AN. Radiation dose escalation using intensity modulated radiation therapy for gross unresected node-positive endometrial cancer. Pract Radiat Oncol 2014; 4:90-98. [DOI: 10.1016/j.prro.2013.07.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 05/30/2013] [Accepted: 07/01/2013] [Indexed: 10/26/2022]
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