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Contraintes de doses aux organes à risque en radiothérapie conformationnelle et stéréotaxique : intestin grêle et duodénum. Cancer Radiother 2017; 21:613-618. [DOI: 10.1016/j.canrad.2017.07.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 07/02/2017] [Indexed: 12/25/2022]
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Ling A, Furhang E, Ryemon SN, Ennis RD. Late small bowel toxicity after aggressive abdominopelvic intensity modulated radiation therapy. Adv Radiat Oncol 2017; 2:615-623. [PMID: 29204529 PMCID: PMC5707426 DOI: 10.1016/j.adro.2017.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 08/17/2017] [Accepted: 09/06/2017] [Indexed: 12/24/2022] Open
Abstract
Purpose We retrospectively analyzed late small bowel toxicity in patients who received abdominal or pelvic intensity modulated radiation therapy (IMRT) to the small bowel with a maximum dose greater than the generally accepted maximal tolerable dose of 45 Gy. Methods and materials All patients (N = 94) who received IMRT with a point dose of at least 45 Gy to tightly contoured small bowel between 2005 and 2014 at our institution were included. The median prescribed treatment dose was 70.2 Gy. The median follow-up was 20.1 months. Late small bowel toxicity was assessed using the Common Terminology Criteria for Adverse Events Version 3.0. Dosimetric variables and clinical factors were assessed for their relationship to small bowel toxicity. Results The median maximal small bowel point dose (Dmax) was 6546.5 cGy. The estimated 5-year rates of freedom from at least grade 1, at least grade 2, and at least grade 3 late small bowel toxicity were 72.4% (95% confidence interval [CI], 60.7%-86.5%), 91.9% (95% CI, 84.1%-100%), and 93.6% (95% CI, 86.2%-100%), respectively. One patient (1.1%) developed grade 3 late toxicity, and 2 patients (2.1%) developed grade 4 late toxicity. Use of capecitabine/5-fluorouracil treatment was a significant predictor (P < 0.001) of at least grade 1 and at least grade 2 small bowel toxicity. No other clinical factors were associated with toxicity. None of the dose-volume parameters were significant predictors of small bowel toxicity. Conclusion It may be possible with IMRT to deliver high doses to small volumes of small bowel with low rates of significant long-term complications. Further studies should explore tolerable dose-volume relationships in cases in which aggressive abdominal or pelvic treatment may be warranted to treat the underlying malignancy.
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Affiliation(s)
- Andrew Ling
- Department of Radiation Oncology, Mount Sinai West Hospital, New York, New York
| | - Eli Furhang
- Department of Radiation Oncology, Mount Sinai West Hospital, New York, New York
| | - Shannon N Ryemon
- Department of Radiation Oncology, Mount Sinai West Hospital, New York, New York
| | - Ronald D Ennis
- Department of Radiation Oncology, Mount Sinai West Hospital, New York, New York.,Icahn School of Medicine at Mount Sinai, New York, New York
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Kwak YK, Lee SW, Kay CS, Park HH. Intensity-modulated radiotherapy reduces gastrointestinal toxicity in pelvic radiation therapy with moderate dose. PLoS One 2017; 12:e0183339. [PMID: 28846718 PMCID: PMC5573121 DOI: 10.1371/journal.pone.0183339] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 08/02/2017] [Indexed: 12/25/2022] Open
Abstract
This retrospective study was performed to evaluate and compare gastrointestinal (GI) toxicities caused by conventional radiotherapy (cRT) and intensity modulated radiotherapy (IMRT) in 136 cancer patients treated with pelvic radiotherapy (RT) with moderate radiation dose in a single institution. A matched-pair analysis of the two groups was performed; each group included 68 patients. Conventional RT was delivered using the four-field box technique and IMRT was delivered with helical tomotherapy. The median daily dose was 1.8 Gy and the median total dose was 50.4 Gy (range 25.2–56 Gy). Primary end point was GI toxicity during and after RT. Secondary end point was factors that affect toxicity. Patients treated with IMRT had lower incidence of grade ≥ 2 acute GI toxicity compared to the patients treated with cRT (p = 0.003). The difference remained significant in multivariate analysis (p = 0.01). The incidence of chronic GI toxicity was not statistically different between the two groups, but the cRT group had higher incidence of grade 3 chronic GI toxicity. Based on our results, IMRT can reduce GI toxicity compared to cRT in the treatment of pelvic radiotherapy even with moderate radiation dose and this will enhance patients’ quality of life and treatment compliance.
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Affiliation(s)
- Yoo-Kang Kwak
- Department of Radiation Oncology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sea-Won Lee
- Department of Radiation Oncology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chul Seung Kay
- Department of Radiation Oncology, Incheon St. Mary’s Hospital, College of Medicine, the Catholic University of Korea, Seoul, Republic of Korea
- * E-mail:
| | - Hee Hyun Park
- Department of Radiation Oncology, Incheon St. Mary’s Hospital, College of Medicine, the Catholic University of Korea, Seoul, Republic of Korea
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Sini C, Noris Chiorda B, Gabriele P, Sanguineti G, Morlino S, Badenchini F, Cante D, Carillo V, Gaetano M, Giandini T, Landoni V, Maggio A, Perna L, Petrucci E, Sacco V, Valdagni R, Rancati T, Fiorino C, Cozzarini C. Patient-reported intestinal toxicity from whole pelvis intensity-modulated radiotherapy: First quantification of bowel dose-volume effects. Radiother Oncol 2017; 124:296-301. [PMID: 28739383 DOI: 10.1016/j.radonc.2017.07.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 06/06/2017] [Accepted: 07/06/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND PURPOSE Intestinal toxicity is commonly experienced during whole-pelvis intensity-modulated radiotherapy (WPRT) for prostate cancer. The aim of the current study was to assess bowel dose-volume relationships for acute patient-reported intestinal symptoms of patients treated with WPRT for prostate cancer. MATERIALS AND METHODS Complete data of 206 patients were available; the median dose to pelvic nodes was 51.8Gy (range 50.4-54.4, 1.7-2Gy/fr). Intestinal symptoms were assessed as changes in the Inflammatory Bowel Disease Questionnaire scores relative to the Bowel Domain (IBDQ-B) between baseline and radiotherapy mid-point/end. The 25th percentiles of the most severe worsening from baseline (ΔIBDQ-B) were set as end-points. The impact of bowel loops and sigmoid colon dose-volume/surface parameters as well as selected clinical parameters were investigated using multivariate logistic regression. RESULTS Analyses were focused on the four questions showing a median ΔIBDQ-B>0. No dose volume/surface parameters were predictive, other than ΔIBDQ5≥3 (loose stools): when grouping patients according to bowel DVHs (high risk: V20>470cc, V30>245cc, V42>110cc; low risk: all the remaining patients), a two-variable model including high-risk DVH-shape (OR: 9.3) and age (protective, OR: 0.94) was assessed. The model showed good calibration (slope: 1.003, R2=0.92) and was found to be robust after bootstrap-based internal validation. CONCLUSIONS Constraining the bowel loops may reduce the risk of loose stools. The risk is higher for younger patients.
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Affiliation(s)
- Carla Sini
- Medical Physics, San Raffaele Scientific Institute, Milano, Italy
| | | | - Pietro Gabriele
- Radiotherapy Department, Candiolo Cancer Institute - FPO, IRCCS, Italy
| | - Giuseppe Sanguineti
- Department of Radiotherapy, Regina Elena National Cancer Institute, Rome, Italy
| | - Sara Morlino
- Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - Fabio Badenchini
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | | | - Viviana Carillo
- Radiotherapy, Centro AKTIS Diagnostica e terapia, Napoli, Italy
| | | | - Tommaso Giandini
- Medical Physics, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - Valeria Landoni
- Department of Physics, Regina Elena National Cancer Institute, Rome, Italy
| | - Angelo Maggio
- Medical Physics Department, Candiolo Cancer Institute - FPO, IRCCS, Italy
| | - Lucia Perna
- Medical Physics, San Raffaele Scientific Institute, Milano, Italy
| | | | - Vincenzo Sacco
- Radiotherapy, San Raffaele Scientific Institute, Milano, Italy
| | - Riccardo Valdagni
- Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy; Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy; UNIV Hematology and Hemato-Oncology, Università degli Studi di Milano, Italy
| | - Tiziana Rancati
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - Claudio Fiorino
- Medical Physics, San Raffaele Scientific Institute, Milano, Italy.
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Gamelon-Bénichou C, Oldrini S, Charra-Brunaud C, Vogin G, Salleron J, Peiffert D. [Comparison of survival and chronic gastrointestinal toxicities in patients with locally advanced cervical cancer, treated by conventional or intensity-modulated radiation technique]. Cancer Radiother 2017; 21:171-179. [PMID: 28457817 DOI: 10.1016/j.canrad.2016.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Revised: 10/28/2016] [Accepted: 11/23/2016] [Indexed: 11/17/2022]
Abstract
PURPOSE To evaluate prospectively chronic gastrointestinal toxicity in patients with cervical cancer treated with conventional irradiation or with intensity-modulated irradiation (IMRT). PATIENTS AND METHODS Between June 2005 and September 2013, 109 patients underwent external radiotherapy followed by brachytherapy for cervical cancer at the "Institut de Cancérologie de Lorraine". Each patient receiving IMRT was paired with a patient receiving conventional radiotherapy on the following criteria: concomitant chemotherapy, additional nodal dose, treatment of para-aortic lymph node area, age. The toxicity collection was prospective using the RTOG scale. The main objective was to compare the incidence of gastrointestinal toxicity chronic between the two groups. In a second time, the influence of dosimetric parameters on chronic GI toxicity was investigated. Comparisons of acute toxicity, chronic genitourinary toxicities, overall survival, disease-free survival were secondary objectives. RESULTS Sixty-six patients were able to be matched. Overall survival at 36 months was 71% in the conventional radiotherapy group against 73% in the IMRT group (P=0.54). There was no significant difference between the two groups in terms of digestive chronic toxicity (P=0.17), nor in terms acute gastrointestinal toxicities (P=0.6445) and genitourinary (P=0.5724). IMRT spared significantly small bowel (P=0.0006) and rectum (P=0.0046) from 30Gy dose, and bladder from 45Gy (P<0.001). The incidence of genitourinary toxicity was significantly different between the two groups (P=0.03) in favor of conventional radiotherapy. CONCLUSION Our study does not seem to show significant difference in the occurrence of chronic gastrointestinal toxicities between the two groups. Clinical efficacy seems comparable. Larger studies with longer follow-up period should be conducted.
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Affiliation(s)
- C Gamelon-Bénichou
- Département universitaire de radiothérapie, institut de cancérologie de Lorraine-Alexis-Vautrin, 6, avenue de Bourgogne, CS 30 519, 54511 Vandœuvre-lès-Nancy cedex, France.
| | - S Oldrini
- Département universitaire de radiothérapie, institut de cancérologie de Lorraine-Alexis-Vautrin, 6, avenue de Bourgogne, CS 30 519, 54511 Vandœuvre-lès-Nancy cedex, France
| | - C Charra-Brunaud
- Département universitaire de radiothérapie, institut de cancérologie de Lorraine-Alexis-Vautrin, 6, avenue de Bourgogne, CS 30 519, 54511 Vandœuvre-lès-Nancy cedex, France
| | - G Vogin
- Département universitaire de radiothérapie, institut de cancérologie de Lorraine-Alexis-Vautrin, 6, avenue de Bourgogne, CS 30 519, 54511 Vandœuvre-lès-Nancy cedex, France
| | - J Salleron
- Cellule data biostatistique, institut de cancérologie de Lorraine-Alexis-Vautrin, 6, avenue de Bourgogne, CS 30 519, 54511 Vandœuvre-lès-Nancy cedex, France
| | - D Peiffert
- Département universitaire de radiothérapie, institut de cancérologie de Lorraine-Alexis-Vautrin, 6, avenue de Bourgogne, CS 30 519, 54511 Vandœuvre-lès-Nancy cedex, France
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Eminowicz G, Rompokos V, Stacey C, Hall L, McCormack M. Understanding the impact of pelvic organ motion on dose delivered to target volumes during IMRT for cervical cancer. Radiother Oncol 2017; 122:116-121. [DOI: 10.1016/j.radonc.2016.10.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 10/12/2016] [Accepted: 10/23/2016] [Indexed: 10/20/2022]
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Sharfo AWM, Breedveld S, Voet PWJ, Heijkoop ST, Mens JWM, Hoogeman MS, Heijmen BJM. Validation of Fully Automated VMAT Plan Generation for Library-Based Plan-of-the-Day Cervical Cancer Radiotherapy. PLoS One 2016; 11:e0169202. [PMID: 28033342 PMCID: PMC5199117 DOI: 10.1371/journal.pone.0169202] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 12/13/2016] [Indexed: 11/21/2022] Open
Abstract
Purpose To develop and validate fully automated generation of VMAT plan-libraries for plan-of-the-day adaptive radiotherapy in locally-advanced cervical cancer. Material and Methods Our framework for fully automated treatment plan generation (Erasmus-iCycle) was adapted to create dual-arc VMAT treatment plan libraries for cervical cancer patients. For each of 34 patients, automatically generated VMAT plans (autoVMAT) were compared to manually generated, clinically delivered 9-beam IMRT plans (CLINICAL), and to dual-arc VMAT plans generated manually by an expert planner (manVMAT). Furthermore, all plans were benchmarked against 20-beam equi-angular IMRT plans (autoIMRT). For all plans, a PTV coverage of 99.5% by at least 95% of the prescribed dose (46 Gy) had the highest planning priority, followed by minimization of V45Gy for small bowel (SB). Other OARs considered were bladder, rectum, and sigmoid. Results All plans had a highly similar PTV coverage, within the clinical constraints (above). After plan normalizations for exactly equal median PTV doses in corresponding plans, all evaluated OAR parameters in autoVMAT plans were on average lower than in the CLINICAL plans with an average reduction in SB V45Gy of 34.6% (p<0.001). For 41/44 autoVMAT plans, SB V45Gy was lower than for manVMAT (p<0.001, average reduction 30.3%), while SB V15Gy increased by 2.3% (p = 0.011). AutoIMRT reduced SB V45Gy by another 2.7% compared to autoVMAT, while also resulting in a 9.0% reduction in SB V15Gy (p<0.001), but with a prolonged delivery time. Differences between manVMAT and autoVMAT in bladder, rectal and sigmoid doses were ≤ 1%. Improvements in SB dose delivery with autoVMAT instead of manVMAT were higher for empty bladder PTVs compared to full bladder PTVs, due to differences in concavity of the PTVs. Conclusions Quality of automatically generated VMAT plans was superior to manually generated plans. Automatic VMAT plan generation for cervical cancer has been implemented in our clinical routine. Due to the achieved workload reduction, extension of plan libraries has become feasible.
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Affiliation(s)
- Abdul Wahab M. Sharfo
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
- * E-mail:
| | - Sebastiaan Breedveld
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Peter W. J. Voet
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Sabrina T. Heijkoop
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Jan-Willem M. Mens
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Mischa S. Hoogeman
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Ben J. M. Heijmen
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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Heijkoop ST, Westerveld H, Bijker N, Feije R, Sharfo AW, van Wieringen N, Mens JWM, Stalpers LJ, Hoogeman MS. Optimal Patient Positioning (Prone Versus Supine) for VMAT in Gynecologic Cancer: A Dosimetric Study on the Effect of Different Margins. Int J Radiat Oncol Biol Phys 2016; 96:432-439. [DOI: 10.1016/j.ijrobp.2016.05.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 05/13/2016] [Accepted: 05/23/2016] [Indexed: 11/27/2022]
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Eminowicz G, Motlib J, Khan S, Perna C, McCormack M. Pelvic Organ Motion during Radiotherapy for Cervical Cancer: Understanding Patterns and Recommended Patient Preparation. Clin Oncol (R Coll Radiol) 2016; 28:e85-91. [DOI: 10.1016/j.clon.2016.04.044] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/11/2016] [Accepted: 04/14/2016] [Indexed: 10/21/2022]
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Eminowicz G, Hall-Craggs M, Diez P, McCormack M. Improving target volume delineation in intact cervical carcinoma: Literature review and step-by-step pictorial atlas to aid contouring. Pract Radiat Oncol 2016; 6:e203-e213. [DOI: 10.1016/j.prro.2016.01.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Revised: 12/21/2015] [Accepted: 01/08/2016] [Indexed: 10/22/2022]
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61
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Mak KS, Phillips JG, Barysauskas CM, Lee LK, Mannarino EG, Van Benthuysen L, Raut CP, Mullen JT, Fairweather M, DeLaney TF, Baldini EH. Acute gastrointestinal toxicity and bowel bag dose-volume parameters for preoperative radiation therapy for retroperitoneal sarcoma. Pract Radiat Oncol 2016; 6:360-366. [DOI: 10.1016/j.prro.2015.12.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 12/13/2015] [Accepted: 12/15/2015] [Indexed: 10/22/2022]
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Canlas R, McVicar N, Nakano S, Sahota H, Mahajan P, Tyldesley S. Assessment of Adaptive Margins Using a Single Planning Computed Tomography Scan for Bladder Radiotherapy. J Med Imaging Radiat Sci 2016; 47:227-234. [DOI: 10.1016/j.jmir.2016.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 04/28/2016] [Accepted: 05/04/2016] [Indexed: 11/29/2022]
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63
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Noël G, Antoni D, Barillot I, Chauvet B. Délinéation des organes à risque et contraintes dosimétriques. Cancer Radiother 2016; 20 Suppl:S36-60. [DOI: 10.1016/j.canrad.2016.07.032] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Sargos P, Stoeckle E, Henriques de Figueiredo B, Antoine M, Delannes M, Mervoyer A, Kantor G. [Radiotherapy for retroperitoneal sarcomas]. Cancer Radiother 2016; 20:677-84. [PMID: 27568294 DOI: 10.1016/j.canrad.2016.07.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 06/27/2016] [Accepted: 07/02/2016] [Indexed: 10/21/2022]
Abstract
The management of retroperitoneal sarcoma can be very challenging, and the quality of initial treatment strategy appears to be a crucial prognostic factor. En bloc surgery is currently the standard of care for these rare tumours and perioperative treatments such as chemotherapy or radiotherapy have not been validated yet. However, local-regional relapse constitutes the most common disease course. While adjuvant radiotherapy is less and less common due to gastrointestinal toxicities, preoperative radiation therapy offers numerous advantages and is being evaluated as part of a national multicentre phase II study (TOMOREP trial) and is the subject of a European randomized phase III study (STRASS trial). The objective of this article is to present data on preoperative irradiation in terms of dose, volumes and optimal radiotherapy techniques for the treatment of this rare disease.
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Affiliation(s)
- P Sargos
- Département de radiothérapie, institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France.
| | - E Stoeckle
- Département de chirurgie, institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France
| | - B Henriques de Figueiredo
- Département de radiothérapie, institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France
| | - M Antoine
- Unité de physique médicale, institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France
| | - M Delannes
- Département de radiothérapie, institut Claudius-Regaud, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex 9, France
| | - A Mervoyer
- Département de radiothérapie, institut de cancérologie de l'Ouest René-Gauducheau, boulevard Jacques-Monod, 44805 Saint-Herblain, France
| | - G Kantor
- Département de radiothérapie, institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France
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Perna L, Sini C, Cozzarini C, Agnello G, Cattaneo G, Hysing L, Muren L, Fiorino C, Calandrino R. Deformable registration-based segmentation of the bowel on Megavoltage CT during pelvic radiotherapy. Phys Med 2016; 32:898-904. [DOI: 10.1016/j.ejmp.2016.06.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 05/24/2016] [Accepted: 06/17/2016] [Indexed: 11/15/2022] Open
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Xu MJ, Kirk M, Zhai H, Lin LL. Bag and loop small bowel contouring strategies differentially estimate small bowel dose for post-hysterectomy women receiving pencil beam scanning proton therapy. Acta Oncol 2016; 55:900-8. [PMID: 26927612 DOI: 10.3109/0284186x.2016.1142114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background Small bowel (SB) dose-volume relationships established during initial computed tomography (CT) simulations may change throughout therapy due to organ displacement and motion. We investigated the impact of organ motion on SB dose-volume histograms (DVHs) in women with gynecologic malignancies treated with pencil beam scanning (PBS) proton therapy and compared PBS SB DVHs to intensity-modulated radiation therapy (IMRT). Material and methods Post-hysterectomy patients (n = 11) treated for gynecologic cancers were enrolled on an image-guided proton therapy protocol involving CT simulation with full (CTF) and empty (CTE) bladders and weekly/biweekly on-treatment scans. IMRT plans were generated for comparative analysis. SB was contoured as bowel loops or bowel bag. Wilcoxon signed-rank tests were used for matched-pair comparisons of SB, bladder, and rectum dose-volumes between CT scans and between PBS and IMRT plans. Results In PBS loops analysis, on-treatment DVH was significantly higher than CTF for doses <45 Gy (p < 0.05), and not significantly different than CTE. Specifically, V15 for loops was higher on-treatment (median 240 cm(3)) compared to CTF (median 169 cm(3), p = 0.03). In PBS bag analysis, on-treatment DVH was not significantly different from CTF across all dose ranges. Bowel bag V45 was not significantly different between on-treatment (median 540 cm(3)) and CTF (median 499 cm(3), p = 0.53). Decreasing bladder volume was associated with increasing V15 for loops and V45 for bowel bag (p < 0.005, both). Comparing PBS and IMRT, PBS resulted in significantly lower DVHs at low dose regions (<38 Gy) and higher DVHs at high dose regions (42.5-45.5 Gy) in both loops and bag analysis. IMRT plans demonstrated higher on-treatment SB loop DVHs and only minimal differences in bowel bag DVHs compared to CTF. Conclusions SB DVHs were well estimated by CTF bowel bag and underestimated by CTF loops in the setting of inconsistent bladder filling. Verifying bladder filling prior to treatment or using CTE for planning may more conservatively estimate SB dose-volume relationships.
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Affiliation(s)
- Melody J. Xu
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maura Kirk
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Huifang Zhai
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lilie L. Lin
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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van de Schoot AJAJ, de Boer P, Crama KF, Visser J, Stalpers LJA, Rasch CRN, Bel A. Dosimetric advantages of proton therapy compared with photon therapy using an adaptive strategy in cervical cancer. Acta Oncol 2016; 55:892-9. [PMID: 26934821 DOI: 10.3109/0284186x.2016.1139179] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background Image-guided adaptive proton therapy (IGAPT) can potentially be applied to take into account interfraction motion while limiting organ at risk (OAR) dose in cervical cancer radiation therapy (RT). In this study, the potential dosimetric advantages of IGAPT compared with photon-based image-guided adaptive RT (IGART) were investigated. Material and methods For 13 cervical cancer patients, full and empty bladder planning computed tomography (CT) images and weekly CTs were acquired. Based on both primary clinical target volumes (pCTVs) [i.e. gross tumor volume (GTV), cervix, corpus-uterus and upper part of the vagina] on planning CTs, the pretreatment observed full range primary internal target volume (pITV) was interpolated to derive pITV subranges. Given corresponding ITVs (i.e. pITVs including lymph nodes), patient-specific photon and proton plan libraries were generated. Using all weekly CTs, IGART and IGAPT treatments were simulated by selecting library plans and recalculating the dose. For each recalculated IGART and IGAPT fraction, CTV (i.e. pCTV including lymph nodes) coverage was assessed and differences in fractionated substitutes of dose-volume histogram (DVH) parameters (V15Gy, V30Gy, V45Gy, Dmean, D2cc) for bladder, bowel and rectum were tested for significance (Wilcoxon signed-rank test). Also, differences in toxicity-related DVH parameters (rectum V30Gy, bowel V45Gy) were approximated based on accumulated dose distributions. Results In 92% (96%) of all recalculated IGAPT (IGART) fractions adequate CTV coverage (V95% >98%) was obtained. All dose parameters for bladder, bowel and rectum, except the fractionated substitute for rectum V45Gy, were improved using IGAPT. Also, IGAPT reduced the mean dose to bowel, bladder and rectum significantly (p < 0.01). In addition, an average decrease of rectum V30Gy and bowel V45Gy indicated reductions in toxicity probabilities when using IGAPT. Conclusion This study demonstrates the feasibility of IGAPT in cervical cancer using a plan-library based plan-of-the-day approach. Compared to photon-based IGART, IGAPT maintains target coverage while significant dose reductions for the bladder, bowel and rectum can be achieved.
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Affiliation(s)
| | - Peter de Boer
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Koen F. Crama
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jorrit Visser
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Lukas J. A. Stalpers
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Coen R. N. Rasch
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Arjan Bel
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Initial Report of Pencil Beam Scanning Proton Therapy for Posthysterectomy Patients With Gynecologic Cancer. Int J Radiat Oncol Biol Phys 2016; 95:181-189. [DOI: 10.1016/j.ijrobp.2015.07.2205] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 06/30/2015] [Accepted: 07/07/2015] [Indexed: 11/16/2022]
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Landoni V, Fiorino C, Cozzarini C, Sanguineti G, Valdagni R, Rancati T. Predicting toxicity in radiotherapy for prostate cancer. Phys Med 2016; 32:521-32. [PMID: 27068274 DOI: 10.1016/j.ejmp.2016.03.003] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 02/15/2016] [Accepted: 03/02/2016] [Indexed: 02/08/2023] Open
Abstract
This comprehensive review addresses most organs at risk involved in planning optimization for prostate cancer. It can be considered an update of a previous educational review that was published in 2009 (Fiorino et al., 2009). The literature was reviewed based on PubMed and MEDLINE database searches (from January 2009 up to September 2015), including papers in press; for each section/subsection, key title words were used and possibly combined with other more general key-words (such as radiotherapy, dose-volume effects, NTCP, DVH, and predictive model). Publications generally dealing with toxicity without any association with dose-volume effects or correlations with clinical risk factors were disregarded, being outside the aim of the review. A focus was on external beam radiotherapy, including post-prostatectomy, with conventional fractionation or moderate hypofractionation (<4Gy/fraction); extreme hypofractionation is the topic of another paper in this special issue. Gastrointestinal and urinary toxicity are the most investigated endpoints, with quantitative data published in the last 5years suggesting both a dose-response relationship and the existence of a number of clinical/patient related risk factors acting as dose-response modifiers. Some results on erectile dysfunction, bowel toxicity and hematological toxicity are also presented.
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Affiliation(s)
- Valeria Landoni
- Medical Physics, Istituto Nazionale Tumori Regina Elena, Rome, Italy
| | - Claudio Fiorino
- Medical Physics, Raffaele Scientific Institute IRCCS, Milan, Italy
| | | | | | - Riccardo Valdagni
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Tiziana Rancati
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
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Feuerstein MA, Goenka A. Quality of Life Outcomes for Bladder Cancer Patients Undergoing Bladder Preservation with Radiotherapy. Curr Urol Rep 2016; 16:75. [PMID: 26343030 DOI: 10.1007/s11934-015-0547-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
For patients with muscle-invasive bladder cancer, the decision to undergo radical cystectomy or bladder preservation treatment must incorporate survival differences, toxicity, and quality of life. Our objective was to review patient-reported outcomes for bladder preservation treatment with a focus on patients eligible for radical cystectomy, for whom a comparison of patient-reported outcomes is most relevant. Peer-reviewed, English-language manuscripts in MEDLINE and PubMed databases were examined from 1996 through 2014. Subject headings included quality of life, bladder cancer, bladder sparing, bladder preservation, radiation, and radiotherapy. Prospective and retrospective studies of patient-reported outcomes in patients undergoing bladder preservation with radiotherapy for muscle-invasive bladder cancer were included. Two prospective studies and four retrospective studies were identified. Several weaknesses from these studies were identified including small sample sizes, variable time points of assessment, variation in treatment regimens, and failure to use validated or condition-specific questionnaires. From the available data, bladder preservation appears to result to similar or better general quality of life compared to radical cystectomy with satisfactory urinary and sexual function reported in most series. In general, bladder preservation resulted in more gastrointestinal symptoms than radical cystectomy. This is one of the first reviews on the subject of patient-reported outcomes for bladder preservation in muscle-invasive bladder cancer. Although the data are limited, this review may provide a framework for developing well-designed, prospective comparisons of treatment for this patient cohort.
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Affiliation(s)
- Michael A Feuerstein
- Department of Urology, Lenox Hill Hospital, Hofstra-North Shore LIJ School of Medicine, 170 East 77th Street, New York, NY, 10075, USA,
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Rattan R, Kapoor R, Bahl A, Gupta R, Oinam AS, Kaur S. Comparison of bone marrow sparing intensity modulated radiotherapy (IMRT) and three-dimensional conformal radiotherapy (3DCRT) in carcinoma of anal canal: a prospective study. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:70. [PMID: 27004217 DOI: 10.3978/j.issn.2305-5839.2016.01.37] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Chemoradiation (CRT) is the standard of care in anal canal carcinoma. CRT leads to suppression of iliac bone marrow (BM) leading to hematological toxicity. Intensity modulated radiation therapy (IMRT) technique can be used to decrease radiation dose to iliac BM and thus decrease haematological toxicity. This study aims to compare the haematological and gastrointestinal toxicity in BM sparing IMRT with three-dimensional conformal radiation therapy (3DCRT) in anal carcinoma patients. METHODS Twenty untreated, biopsy proven anal canal carcinoma (stages I-III) patients were randomized into IMRT and 3DCRT arm. All patients received CRT with 45 Gy in 25 fractions at 1.8 Gy/fraction and weekly concurrent inj. cisplatin and 5-FU. Patients were evaluated for acute haematological and gastrointestinal toxicity during treatment. Additional dosimetric comparison was made between the two groups. RESULTS Incidence of worst hematological toxicity grade II (GII) and GIII was seen in 40% [4] vs. 30% [3] and 20% [2] vs. 0% [0] respectively, in 3DCRT and IMRT group. However these did not come as statistically significant (P=0.228). Incidence of worst gastrointestinal toxicity during treatment in terms of GII was 30% [3] vs. 50% [5] and GIII was 60% [6] vs. 0% [0] in 3DCRT and IMRT group respectively (P=0.010). Other parameters indicating better tolerance of treatment with IMRT arm than 3DCRT arm were lesser need for administration of parenteral fluid 10% [1] vs. 60% [6] (P=0.019); lesser need for blood transfusion 0% [0] vs. 20% [2] (P=0.060) in IMRT arm than in 3DCRT arm respectively. Patient requiring supportive care during treatment like need for anti-motility drugs and WHO. Step II analgesics also favored IMRT arm. Overall treatment time for Arm B (33.40 days) was less than what was seen in Arm A patients (36.8 days), although difference was not statistically significant (P=0.569). In terms of dosimetric analysis, arm B with the use of IMRT showed superiority over arm A with 3DCRT. The mean volume of bladder receiving ≥30 and 40 Gy respectively was 100% and 96% for group A (3DCRT) as compared to 68% and 31% for the group B (IMRT) (P<0.05). For bowel, although, the V30 and V40 for 3DCRT versus IMRT respectively were 51% and 27% vs. 27% and 13%, statistical significance was not reached (P>0.05). There was also less mean BM receiving ≥10 Gy (80.4%) and ≥20 Gy (65.6%) for group B using IMRT, than in 3DCRT (group A) were it was 91% and 73% respectively. Although for V10 it was significant (P=0.04), it did not reach statistical significance for the V20 (P=0.550). CONCLUSIONS Preliminary outcomes suggest that BM sparing IMRT for anal canal cancers can decrease both haematological and gastrointestinal toxicity as compared to 3DCRT and thus CRT course can be completed effectively without treatment breaks.
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Affiliation(s)
- Rajit Rattan
- 1 Department of Radiotherapy, 2 Department of Surgery, Postgraduate Institute of Medical Sciences and Research, Chandigarh, India
| | - Rakesh Kapoor
- 1 Department of Radiotherapy, 2 Department of Surgery, Postgraduate Institute of Medical Sciences and Research, Chandigarh, India
| | - Amit Bahl
- 1 Department of Radiotherapy, 2 Department of Surgery, Postgraduate Institute of Medical Sciences and Research, Chandigarh, India
| | - Rajesh Gupta
- 1 Department of Radiotherapy, 2 Department of Surgery, Postgraduate Institute of Medical Sciences and Research, Chandigarh, India
| | - Arun S Oinam
- 1 Department of Radiotherapy, 2 Department of Surgery, Postgraduate Institute of Medical Sciences and Research, Chandigarh, India
| | - Satinder Kaur
- 1 Department of Radiotherapy, 2 Department of Surgery, Postgraduate Institute of Medical Sciences and Research, Chandigarh, India
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Treatment Guidelines for Preoperative Radiation Therapy for Retroperitoneal Sarcoma: Preliminary Consensus of an International Expert Panel. Int J Radiat Oncol Biol Phys 2015; 92:602-12. [DOI: 10.1016/j.ijrobp.2015.02.013] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 01/12/2015] [Accepted: 02/06/2015] [Indexed: 12/25/2022]
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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] [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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Sharfo AWM, Voet PWJ, Breedveld S, Mens JWM, Hoogeman MS, Heijmen BJM. Comparison of VMAT and IMRT strategies for cervical cancer patients using automated planning. Radiother Oncol 2015; 114:395-401. [PMID: 25725503 DOI: 10.1016/j.radonc.2015.02.006] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 02/04/2015] [Accepted: 02/09/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE In a published study on cervical cancer, 5-beam IMRT was inferior to single arc VMAT. Here we compare 9, 12, and 20 beam IMRT with single and dual arc VMAT. MATERIAL AND METHODS For each of 10 patients, automated plan generation with the in-house Erasmus-iCycle optimizer was used to assist an expert planner in generating the five plans with the clinical TPS. RESULTS For each patient, all plans were clinically acceptable with a high and similar PTV coverage. OAR sparing increased when going from 9 to 12 to 20 IMRT beams, and from single to dual arc VMAT. For all patients, 12 and 20 beam IMRT were superior to single and dual arc VMAT, with substantial variations in gain among the study patients. As expected, delivery of VMAT plans was significantly faster than delivery of IMRT plans. CONCLUSIONS Often reported increased plan quality for VMAT compared to IMRT has not been observed for cervical cancer. Twenty and 12 beam IMRT plans had a higher quality than single and dual arc VMAT. For individual patients, the optimal delivery technique depends on a complex trade-off between plan quality and treatment time that may change with introduction of faster delivery systems.
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Affiliation(s)
- Abdul Wahab M Sharfo
- Department of Radiation Oncology, Erasmus MC-Cancer Institute, Rotterdam, The Netherlands.
| | - Peter W J Voet
- Department of Radiation Oncology, Erasmus MC-Cancer Institute, Rotterdam, The Netherlands
| | - Sebastiaan Breedveld
- Department of Radiation Oncology, Erasmus MC-Cancer Institute, Rotterdam, The Netherlands
| | - Jan Willem M Mens
- Department of Radiation Oncology, Erasmus MC-Cancer Institute, Rotterdam, The Netherlands
| | - Mischa S Hoogeman
- Department of Radiation Oncology, Erasmus MC-Cancer Institute, Rotterdam, The Netherlands
| | - Ben J M Heijmen
- Department of Radiation Oncology, Erasmus MC-Cancer Institute, Rotterdam, The Netherlands
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Søndergaard J, Holmberg M, Jakobsen AR, Agerbæk M, Muren LP, Høyer M. A comparison of morbidity following conformal versus intensity-modulated radiotherapy for urinary bladder cancer. Acta Oncol 2014; 53:1321-8. [PMID: 24980045 DOI: 10.3109/0284186x.2014.928418] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND In radiotherapy (RT) of urinary bladder cancer, the use of intensity-modulated RT (IMRT) opens for sparing of considerable intestinal volumes. The purpose of the present study was to investigate the acute and late toxicities following either conformal RT (CRT) or IMRT for bladder cancer, and to correlate the toxicities to dose-volume parameters. MATERIAL AND METHODS The study included 116 consecutively treated patients with muscle-invasive bladder cancer who received either CRT (n = 66) or IMRT (n = 50) during 2007-2010. Acute side effects were retrospectively collected whereas late effects were assessed by a cross-sectional evaluation by telephone interview of 44 recurrence-free patients. Acute and late toxicities were scored according to the Common Terminology Criteria for Adverse Event (CTCAE) version 3.0. RESULTS Acute diarrhoea grade ≥ 2 was more frequent in patients treated by CRT (56%) compared to IMRT (30%) (p = 0.008). Logistic regression analysis showed a correlation between acute diarrhoea and bowel cavity dose-volume parameters in the 10-50 Gy range. Severe late toxicity (grade ≥ 3) was recorded in 10% of the total cohort, with no statistical difference between the IMRT and CRT groups. CONCLUSION Patients treated with IMRT for bladder cancer had significantly less acute diarrhoea compared to those treated with CRT, but there was no significant difference in late morbidity between the groups. The risk of acute diarrhoea was related to the volume of bowel irradiated.
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Affiliation(s)
- Jimmi Søndergaard
- Department of Oncology, Aarhus University Hospital , Aarhus , Denmark
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Evaluating QUANTEC Small Bowel Dose-Volume Guidelines for Rectal Cancer Patients Treated Using a Couch Top Inclined Belly Board. J Med Imaging Radiat Sci 2014; 45:218-222. [PMID: 31051972 DOI: 10.1016/j.jmir.2014.03.093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Revised: 03/12/2014] [Accepted: 03/14/2014] [Indexed: 01/19/2023]
Abstract
PURPOSE The goal of this work was to analyse small bowel (SB) dose-volume following the Quantitative Analyses of Normal Tissue Effects in the Clinic (QUANTEC) guidelines for rectal cancer patients treated using a couch top inclined belly board (iBB). As part of this, the consistency in SB displacement was evaluated using on-treatment cone-beam computed tomographic (CBCT) imaging. METHODS Twenty-four patients with rectal cancer were treated on a commercially available iBB. All patients went through the standard radiochemotherapy protocol in either a pre- or postoperative setup. All patients underwent weekly CBCT imaging during the course of radiation treatment. The planning computed tomographic data sets were used to analyze the quality of SB displacement, and the CBCT data sets were used to assess the reproducibility in SB displacement during treatment. The SB dose volume was evaluated and compared with QUANTEC-recommended dose limitations. Similarly, the impact of body mass index on dose volume and SB displacement was evaluated. RESULTS The SB displacement was assessed respectively as "good" and "very good" by both independent evaluating radiation oncologists. The consistency of SB displacement through the course of radiation treatment was scored as "excellent" for 22 of 24 and 23 of 24 patients by both radiation oncologists, respectively. The QUANTEC recommendation was met for all patients without bowel adhesions; however, the most benefit was observed for patients with body mass index > 23 kg/m2. CONCLUSIONS Our study has shown that QUANTEC recommendations for SB dose during rectal cancer treatment can easily be met by treating patients on a couch top iBB. This technique is robust and produces consistent SB displacement.
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Huang B, Fang Z, Huang Y, Lin P, Chen Z. A dosimetric analysis of volumetric-modulated arc radiotherapy with jaw width restriction vs 7 field intensity-modulated radiotherapy for definitive treatment of cervical cancer. Br J Radiol 2014; 87:20140183. [PMID: 24834477 PMCID: PMC4075592 DOI: 10.1259/bjr.20140183] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 05/03/2014] [Accepted: 05/14/2014] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE Radiation therapy treatment planning was performed to compare the dosimetric difference between volumetric-modulated arc radiotherapy (RapidArc™ v. 10; Varian® Medical Systems, Palo Alto, CA) and 7-field intensity-modulated radiotherapy (7f-IMRT) in the definitive treatment of cervical cancer. METHODS 13 patients with cervical cancer were enrolled in this study. Planning target volume (PTV) 50 and PTV60 were prescribed at a dose of 50 and 60 Gy in 28 fractions, respectively. The dose to the PTV60 was delivered as a simultaneous integrated boost to the pelvic lymph nodes. Owing to the mechanical limitation of the multileaf collimator in which the maximum displacement was limited to 15 cm, two types of RapidArc with different jaw width restrictions (15 and 20-23 cm) were investigated to evaluate their dosimetric differences. The RapidArc plan type with dosimetric superiority was then compared against the 7f-IMRT on the target coverage, sparing of the organs at risk (OARs), monitor units, treatment time and delivery accuracy to determine whether RapidArc is beneficial for the treatment of cervical cancer. RESULTS The 15-cm jaw width restriction had better performance compared with the restrictions that were longer than 15 cm in the sparing of the OARs. The 15-cm RapidArc spared the OARs, that is, the bladder, rectum, small intestine, femoral heads and bones, and improved treatment efficiency compared with 7f-IMRT. Both techniques delivered a high quality-assurance passing rate (>90%) according to the Γ3mm,3% criterion. CONCLUSION RapidArc with a 15-cm jaw width restriction spares the OARs and improves treatment efficiency in cervical cancer compared with 7f-IMRT. ADVANCES IN KNOWLEDGE This study describes the dosimetric superiority of RapidArc with a 15-cm jaw width restriction and explores the feasibility of using RapidArc for the definitive treatment of cervical cancer.
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Affiliation(s)
- B Huang
- 1 Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, Shantou, China
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Scher ED, Ahmed I, Yue NJ, Jabbour SK. Technical aspects of radiation therapy for anal cancer. J Gastrointest Oncol 2014; 5:198-211. [PMID: 24982768 DOI: 10.3978/j.issn.2078-6891.2014.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 05/22/2014] [Indexed: 01/26/2023] Open
Abstract
Historically treated with surgery, current practice recommends anal carcinoma to be treated with a combination of chemotherapy and radiation. This review will examine the anatomy, modes of disease spread and recurrence, and evaluate the existing evidence for treatment options for these tumors. An in-depth examination of specific radiation therapy (RT) techniques-such as conventional 3D-conformal RT and intensity-modulated RT-will be discussed along with modern dose constraints. RT field arrangement, patient setup, and recommended gross and clinical target volume (CTV) contours will be considered. Areas in need of further investigation, such as the role in treatment for positron emission tomography (PET) will be explored.
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Affiliation(s)
- Eli D Scher
- 1 Rowan University School of Osteopathic Medicine, Stratford, NJ 08084, USA ; 2 Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08903, USA
| | - Inaya Ahmed
- 1 Rowan University School of Osteopathic Medicine, Stratford, NJ 08084, USA ; 2 Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08903, USA
| | - Ning J Yue
- 1 Rowan University School of Osteopathic Medicine, Stratford, NJ 08084, USA ; 2 Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08903, USA
| | - Salma K Jabbour
- 1 Rowan University School of Osteopathic Medicine, Stratford, NJ 08084, USA ; 2 Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08903, USA
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Impact of post operative intensity modulated radiotherapy on acute gastro-intestinal toxicity for patients with endometrial cancer: Results of the phase II RTCMIENDOMETRE French multicentre trial. Radiother Oncol 2014; 111:138-43. [DOI: 10.1016/j.radonc.2014.01.018] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 01/23/2014] [Accepted: 01/26/2014] [Indexed: 11/19/2022]
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XIE XIAOXUE, OUYANG SHUYU, WANG HUI, YANG WENJUAN, JIN HEKUN, HU BINGQIANG, SHEN LIANGFANG. Dosimetric comparison of left-sided whole breast irradiation with 3D-CRT, IP-IMRT and hybrid IMRT. Oncol Rep 2014; 31:2195-205. [DOI: 10.3892/or.2014.3058] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Accepted: 09/30/2013] [Indexed: 11/06/2022] Open
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Predictors of Grade 3 or Higher Late Bowel Toxicity in Patients Undergoing Pelvic Radiation for Cervical Cancer: Results From a Prospective Study. Int J Radiat Oncol Biol Phys 2014; 88:630-5. [DOI: 10.1016/j.ijrobp.2013.11.214] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 09/19/2013] [Accepted: 11/08/2013] [Indexed: 11/22/2022]
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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] [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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Adaptive plan selection vs. re-optimisation in radiotherapy for bladder cancer: A dose accumulation comparison. Radiother Oncol 2013; 109:457-62. [DOI: 10.1016/j.radonc.2013.08.045] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 08/30/2013] [Accepted: 08/31/2013] [Indexed: 11/22/2022]
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Gandhi AK, Sharma DN, Rath GK, Julka PK, Subramani V, Sharma S, Manigandan D, Laviraj MA, Kumar S, Thulkar S. Early clinical outcomes and toxicity of intensity modulated versus conventional pelvic radiation therapy for locally advanced cervix carcinoma: a prospective randomized study. Int J Radiat Oncol Biol Phys 2013; 87:542-8. [PMID: 24074927 DOI: 10.1016/j.ijrobp.2013.06.2059] [Citation(s) in RCA: 160] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 06/09/2013] [Accepted: 06/27/2013] [Indexed: 12/14/2022]
Abstract
PURPOSE To evaluate the toxicity and clinical outcome in patients with locally advanced cervical cancer (LACC) treated with whole pelvic conventional radiation therapy (WP-CRT) versus intensity modulated radiation therapy (WP-IMRT). METHODS AND MATERIALS Between January 2010 and January 2012, 44 patients with International Federation of Gynecology and Obstetrics (FIGO 2009) stage IIB-IIIB squamous cell carcinoma of the cervix were randomized to receive 50.4 Gy in 28 fractions delivered via either WP-CRT or WP-IMRT with concurrent weekly cisplatin 40 mg/m(2). Acute toxicity was graded according to the Common Terminology Criteria for Adverse Events, version 3.0, and late toxicity was graded according to the Radiation Therapy Oncology Group system. The primary and secondary endpoints were acute gastrointestinal toxicity and disease-free survival, respectively. RESULTS Of 44 patients, 22 patients received WP-CRT and 22 received WP-IMRT. In the WP-CRT arm, 13 patients had stage IIB disease and 9 had stage IIIB disease; in the IMRT arm, 12 patients had stage IIB disease and 10 had stage IIIB disease. The median follow-up time in the WP-CRT arm was 21.7 months (range, 10.7-37.4 months), and in the WP-IMRT arm it was 21.6 months (range, 7.7-34.4 months). At 27 months, disease-free survival was 79.4% in the WP-CRT group versus 60% in the WP-IMRT group (P=.651), and overall survival was 76% in the WP-CRT group versus 85.7% in the WP-IMRT group (P=.645). Patients in the WP-IMRT arm experienced significantly fewer grade ≥2 acute gastrointestinal toxicities (31.8% vs 63.6%, P=.034) and grade ≥3 gastrointestinal toxicities (4.5% vs 27.3%, P=.047) than did patients receiving WP-CRT and had less chronic gastrointestinal toxicity (13.6% vs 50%, P=.011). CONCLUSION WP-IMRT is associated with significantly less toxicity compared with WP-CRT and has a comparable clinical outcome. Further studies with larger sample sizes and longer follow-up times are warranted to justify its use in routine clinical practice.
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Affiliation(s)
- Ajeet Kumar Gandhi
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India.
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85
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Wang S, Ai P, Xie L, Xu Q, Bai S, Lu Y, Li P, Chen N. Dosimetric comparison of different multileaf collimator leaves in treatment planning of intensity-modulated radiotherapy for cervical cancer. Med Dosim 2013; 38:454-9. [PMID: 24099965 DOI: 10.1016/j.meddos.2013.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2012] [Revised: 06/28/2013] [Accepted: 08/14/2013] [Indexed: 02/05/2023]
Abstract
To study the effect of multileaf collimator (MLC) leaf widths (standard MLC [sMLC] width of 10mm and micro-MLC [mMLC] width of 4mm) on intensity-modulated radiotherapy (IMRT) for cervical cancer. Between January 2010 and August 2010, a retrospective analysis was conducted on 12 patients with cervical cancer. The treatment plans for all patients were generated with the same machine setup parameters and optimization methods in a treatment planning system (TPS) based on 2 commercial Elekta MLC devices. The dose distribution for the planning tumor volume (PTV), the dose sparing for organs at risk (OARs), the monitor units (MUs), and the number of IMRT segments were evaluated. For the delivery efficiency, the MUs were significantly higher in the sMLC-IMRT plan than in the mMLC-IMRT plan (802 ± 56.9 vs 702 ± 56.7; p < 0.05). The number of segments in the plans were 58.75 ± 1.8 and 59 ± 1.04 (p > 0.05). For the planning quality, the conformity index (CI) between the 2 paired IMRT plans with the mMLC and the sMLC did not differ significantly (average: 0.817 ± 0.024 vs 0.810 ± 0.028; p > 0.05). The differences of the homogeneity index (HI) between the 2 paired plans were statistically significant (average: 1.122 ± 0.010 vs 1.132 ± 0.014; p < 0.01). For OARs, the rectum, bladder, small intestine, and bony pelvis were evaluated in terms of V10, V20, V30, and V40, percentage of contoured OAR volumes receiving 10, 20, 30, and 40Gy, respectively, and the mean dose (Dmean) received. The IMRT plans with the mMLC protected the OARs better than the plans with the sMLC. There were significant differences (p < 0.05) in evaluated parameters between the 2 paired IMRT plans, except for V30 and V40 of the rectum and V10, V20, V40, and Dmean of the bladder. IMRT plans with the mMLC showed advantages over the plans with the sMLC in dose homogeneity for targets, dose sparing of OARs, and fewer MUs in cervical cancer.
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Affiliation(s)
- Shichao Wang
- Radiation and Physics Center, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China; State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
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86
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Warren S, Partridge M, Fokas E, Eccles CL, Brunner TB. Comparing dose-volume histogram and radiobiological endpoints for ranking intensity-modulated arc therapy and 3D-radiotherapy treatment plans for locally-advanced pancreatic cancer. Acta Oncol 2013; 52:1573-8. [PMID: 23957620 DOI: 10.3109/0284186x.2013.813072] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Samantha Warren
- The Gray Institute of Radiation Oncology and Biology, Department of Oncology, University of Oxford , Old Road Campus Research Building, Oxford , UK
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87
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Ahmad R, Bondar L, Voet P, Mens JW, Quint S, Dhawtal G, Heijmen B, Hoogeman M. A margin-of-the-day online adaptive intensity-modulated radiotherapy strategy for cervical cancer provides superior treatment accuracy compared to clinically recommended margins: a dosimetric evaluation. Acta Oncol 2013; 52:1430-6. [PMID: 23902275 DOI: 10.3109/0284186x.2013.813640] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To dosimetrically evaluate a margin-of-the-day (MoD) online adaptive intensity-modulated radiotherapy (IMRT) strategy for cervical cancer patients. The strategy is based on a single planning computed tomography (CT) scan and a pretreatment constructed IMRT plan library with incremental clinical target volumes (CTV)-to-planning target volumes (PTV) margins. MATERIAL AND METHODS For 14 patients, 9-10 variable bladder filling CT scans acquired at pretreatment and after 40 Gy were available. Bladder volume variability during the treatment course was recorded by twice-weekly US bladder-volume measurements. A MoD strategy that selects the best IMRT plan of the day from a library of plans with incremental margins in steps of 5 mm was compared with a clinically recommended population-based margin (15 mm). To compare the strategies, for each fraction that had a recorded US bladder-volume measurement, the CT scan with the nearest bladder volume was selected from the pretreatment CT series and from the CT series acquired after 40 Gy. A frequency-weighted average of the dose-volume histograms (DVH) parameters calculated for the two selected CT scans was used to estimate the DVH parameters of the fraction of interest. RESULTS The 15-mm recommended margin resulted in cervix-uterus underdosage in six of 14 patients. Compared with the 15-mm margin, the MoD strategy resulted in significantly better cervix-uterus coverage (p = 0.008) without a significant difference in the sparing of rectum, bladder, and small bowel. For each patient, 3-8 (median 5) plans were needed in the library of plans for the MoD strategy. The required range of the MoD was 5-45 mm (median 15 mm). Twenty-five percent of all fractions could be treated with a MoD of 5 mm and 81% of all fractions could be treated with a MoD up to 25 mm. CONCLUSIONS Compared with a clinically recommended margin, a simple online adaptive strategy resulted in better cervix-uterus coverage without compromising organs at risk sparing.
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Affiliation(s)
- Rozilawati Ahmad
- Department of Radiation Oncology, Erasmus MC-Daniel den Hoed Cancer Center , Rotterdam , The Netherlands
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Schneider RA, Vitolo V, Albertini F, Koch T, Ares C, Lomax A, Goitein G, Hug EB. Small bowel toxicity after high dose spot scanning-based proton beam therapy for paraspinal/retroperitoneal neoplasms. Strahlenther Onkol 2013; 189:1020-5. [PMID: 24052010 DOI: 10.1007/s00066-013-0432-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 07/18/2013] [Indexed: 12/25/2022]
Abstract
PURPOSE Mesenchymal tumours require high-dose radiation therapy (RT). Small bowel (SB) dose constraints have historically limited dose delivery to paraspinal and retroperitoneal targets. This retrospective study correlated SB dose-volume histograms with side-effects after proton radiation therapy (PT). PATIENTS AND METHODS Between 1997 and 2008, 31 patients (mean age 52.1 years) underwent spot scanning-based PT for paraspinal/retroperitoneal chordomas (81%), sarcomas (16%) and meningiom (3%). Mean total prescribed dose was 72.3 Gy (relative biologic effectiveness, RBE) delivered in 1.8-2 Gy (RBE) fractions. Mean follow-up was 3.8 years. Based on the pretreatment planning CT, SB dose distributions were reanalysed. RESULTS Planning target volume (PTV) was defined as gross tumour volume (GTV) plus 5-7 mm margins. Mean PTV was 560.22 cm(3). A mean of 93.2% of the PTV was covered by at least 90% of the prescribed dose. SB volumes (cm(3)) receiving doses of 5, 20, 30, 40, 50, 60, 70, 75 and 80 Gy (RBE) were calculated to give V5, V20, V30, V40, V50, V60, V70, V75 and V80 respectively. In 7/31 patients, PT was accomplished without any significant SB irradiation (V5=0). In 24/31 patients, mean maximum dose (Dmax) to SB was 64.1 Gy (RBE). Despite target doses of >70 Gy (RBE), SB received >50 and >60 Gy (RBE) in only 61 and 54% of patients, respectively. Mean SB volumes (cm(3)) covered by different dose levels (Gy, RBE) were: V20 (n=24): 45.1, V50 (n=19): 17.7, V60 (n=17): 7.6 and V70 (n=12): 2.4. No acute toxicity ≥ grade 2 or late SB sequelae were observed. CONCLUSION Small noncircumferential volumes of SB tolerated doses in excess of 60 Gy (RBE) without any clinically-significant late adverse effects. This small retrospective study has limited statistical power but encourages further efforts with higher patient numbers to define and establish high-dose threshold models for SB toxicity in modern radiation oncology.
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Affiliation(s)
- R A Schneider
- Center for Proton Therapy, Paul Scherrer Institute, 5232, Villigen PSI, Germany,
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89
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Does initial 45Gy of pelvic intensity-modulated radiotherapy reduce late complications in patients with locally advanced cervical cancer? A cohort control study using definitive chemoradiotherapy with high-dose rate brachytherapy. Radiol Oncol 2013; 47:176-84. [PMID: 23801915 PMCID: PMC3691093 DOI: 10.2478/raon-2013-0011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2012] [Accepted: 12/24/2012] [Indexed: 11/20/2022] Open
Abstract
Background Comparing initial 45 Gy of pelvic intensity-modulated radiation therapy (IMRT) and non-IMRT in terms of the late toxicities associated with advanced cervical cancer that has also been treated with definitive concurrent chemoradiotherapy and high-dose rate intracavitary brachytherapy (HDRICB). Patients and methods This retrospective study included 320 stage IB2-IIIB cervical cancer patients treated with CCRT (83 IMRT and 237 non-IMRT). The two groups had similar stage and HDRICB ratings. Following 45 Gy to the pelvis, HDRICB of 24 Gy in four courses was prescribed. Late toxicities, including rectal complications (RC), bladder complications (BC) and non-rectal intestinal injury (NRRII), were scored by the Common Terminology Criteria for Adverse Events. A logistic regression was used to estimate the odds ratio (OR) of the complications. Results With a median follow-up duration of 33 and 77 months for IMRT and non-IMRT, 33 patients had Grade 2 or higher late RC (7.2% IMRT, 11.4% non-IMRT), whereas that for BC was 40 (9.6% IMRT, 13.5% non-IMRT) and for NRRII was 48 (12.0% IMRT, 16.0% non-IMRT). The cumulative rate for total grade 3 or higher gastrointestinal or genitourinary toxicities was 8.4% and 11.8% (p = 0.33). IMRT did not reduce the OR for all endpoints; however, the ORs for rectum and bladder reference doses to Point A were associated with RC and BC. Conclusions Locally advanced cervical cancer patients treated with initial 45Gy of pelvic IMRT and HDRICB have similar treatment-related late toxicities as those treated with non-IMRT. Optimization of the brachytherapy scheme is essential to minimize late toxicities.
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91
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Radu C, Norrlid O, Brændengen M, Hansson K, Isacsson U, Glimelius B. Integrated peripheral boost in preoperative radiotherapy for the locally most advanced non-resectable rectal cancer patients. Acta Oncol 2013; 52:528-37. [PMID: 23113591 DOI: 10.3109/0284186x.2012.737022] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Few studies have explored the potential clinical advantages of dose escalation and integrated boosts for patients with non-resectable locally advanced rectal cancer. The possibility of escalating dose to non-resectable regions in these patients was the aim of this study. PATIENTS AND METHODS Seven patients with locally very advanced rectal tumours (sacrum overgrowth or growth into pelvic side walls) were evaluated. Intensity modulated photon and pencil beam scanning proton plans with simultaneously integrated boosts (45 Gy to elective lymph nodes, 50 Gy to tumour and 62.5 Gy to boost area in 25 fractions) were compared. RESULTS Target coverage was achieved with both photon and proton plans. Estimated risks of acute side effects put the two patients with the largest tumours at unacceptable risk for intestinal toxicity, regardless of modality. The remaining five patients had beneficial sparing of dose to the small intestine with protons. CONCLUSIONS Adding boost to areas where rectal tumours infiltrate adjacent non-resectable organs is an attractive option which appears possible using both photon and proton irradiation. Proton plans reduced dose to organs at risk. Integrated peripheral boosts should be considered more frequently in these very advanced tumours.
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Affiliation(s)
- Calin Radu
- Department of Radiology, Oncology and Radiation Science, Uppsala University,
Uppsala, Sweden
| | - Ola Norrlid
- Department of Radiology, Oncology and Radiation Science, Uppsala University,
Uppsala, Sweden
| | - Morten Brændengen
- Department of Oncology and Pathology, Karolinska Institutet,
Stockholm, Sweden
- Department of Oncology, Oslo University Hospital,
Oslo, Norway
| | - Karl Hansson
- Department of Diagnostic Radiology, Karolinska University Hospital,
Solna, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet,
Stockholm, Sweden
| | - Ulf Isacsson
- Department of Radiology, Oncology and Radiation Science, Uppsala University,
Uppsala, Sweden
| | - Bengt Glimelius
- Department of Radiology, Oncology and Radiation Science, Uppsala University,
Uppsala, Sweden
- Department of Oncology and Pathology, Karolinska Institutet,
Stockholm, Sweden
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92
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Duodenal and Other Gastrointestinal Toxicity in Cervical and Endometrial Cancer Treated With Extended-Field Intensity Modulated Radiation Therapy to Paraaortic Lymph Nodes. Int J Radiat Oncol Biol Phys 2013. [DOI: 10.1016/j.ijrobp.2012.10.004] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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93
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Uptake and outcomes of intensity-modulated radiation therapy for uterine cancer. Gynecol Oncol 2013; 130:43-8. [PMID: 23500087 DOI: 10.1016/j.ygyno.2013.03.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 03/02/2013] [Accepted: 03/06/2013] [Indexed: 11/21/2022]
Abstract
OBJECTIVE While intensity-modulated radiation therapy (IMRT) allows more precise radiation planning, the technology is substantially more costly than conformal radiation and, to date, the benefits of IMRT for uterine cancer are not well defined. We examined the use of IMRT and its effect on late toxicity for uterine cancer. METHODS Women with uterine cancer treated from 2001 to 2007 and registered in the SEER-Medicare database were examined. We investigated the extent and predictors of IMRT administration. The incidence of acute and late-radiation toxicities was compared for IMRT and conformal radiation. RESULTS We identified a total of 3555 patients including 328 (9.2%) who received IMRT. Use of IMRT increased rapidly and reached 23.2% by 2007. In a multivariable model, residence in the western U.S. and receipt of chemotherapy were associated with receipt of IMRT. Women who received IMRT had a higher rate of bowel obstruction (rate ratio=1.41; 95% CI, 1.03-1.93), but other late gastrointestinal and genitourinary toxicities as well as hip fracture rates were similar between the cohorts. After accounting for other characteristics, the cost of IMRT was $14,706 (95% CI, $12,073 to $17,339) greater than conformal radiation. CONCLUSION The use of IMRT for uterine cancer is increasing rapidly. IMRT was not associated with a reduction in radiation toxicity, but was more costly.
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Jhingran A, Ramondetta LM, Bodurka DC, Slomovitz BM, Brown J, Levy LB, Garcia ME, Eifel PJ, Lu KH, Burke TW. A prospective phase II study of chemoradiation followed by adjuvant chemotherapy for FIGO stage I-IIIA (1988) uterine papillary serous carcinoma of the endometrium. Gynecol Oncol 2013; 129:304-9. [PMID: 23385150 DOI: 10.1016/j.ygyno.2013.01.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Revised: 01/24/2013] [Accepted: 01/26/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To prospectively evaluate tumor control, survival, and toxic effects in patients with International Federation of Gynecology and Obstetrics (1988) stage I-IIIA papillary serous carcinoma of the endometrium treated with concurrent chemoradiation and adjuvant chemotherapy. METHODS Thirty-two patients were enrolled from October 2001 through July 2009. Patients underwent full surgical disease staging and postoperative concurrent weekly paclitaxel (50 mg/m2) and pelvic RT to 45 Gy plus a vaginal cuff boost followed by 4 cycles of adjuvant paclitaxel (135 mg/m2). RESULTS Thirty patients (94%) were evaluable (3 with stage IA disease, 11 IB, 3 IC, 1 IIB, and 12 IIIA). Eighteen patients (60%) received all 5 planned courses of concurrent chemotherapy, 10 (33%) received 4 courses, and 2 (7%) received 3 courses. All 30 patients received RT; 27 (90%) received the full dose, 2 received 43.2 Gy, and 1 received 39.6 Gy owing to toxic effects. Twenty-three patients (77%) completed all 4 cycles of adjuvant paclitaxel, 3 (10%) completed 3 cycles, 2 (7%) completed 2 cycles, and 2 received no adjuvant therapy. Overall survival (OS), progression-free survival (PFS), and local control rates for all patients were 93%, 87%, and 87%, respectively, at 2 years and 85%, 83%, and 87%, respectively, at 5years. Six patients developed (20%) grade 3/4 toxicities from the treatment. Four patients (13%) had grade 3 or more severe bowel complications and two patients developed symptomatic pelvic fractures. CONCLUSIONS Treatment with concurrent paclitaxel and pelvic RT followed by 4 courses of systemic paclitaxel produced favorable results in patients with surgically staged I-III UPSC.
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Affiliation(s)
- Anuja Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
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95
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DeFoe SG, Kabolizadeh P, Heron DE, Beriwal S. Dosimetric Parameters Predictive of Acute Gastrointestinal Toxicity in Patients with Anal Carcinoma Treated with Concurrent Chemotherapy and Intensity-Modulated Radiation Therapy. Oncology 2013; 85:1-7. [DOI: 10.1159/000348387] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 01/22/2013] [Indexed: 11/19/2022]
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Yang B, Zhu L, Cheng H, Li Q, Zhang Y, Zhao Y. Dosimetric comparison of intensity modulated radiotherapy and three-dimensional conformal radiotherapy in patients with gynecologic malignancies: a systematic review and meta-analysis. Radiat Oncol 2012; 7:197. [PMID: 23176540 PMCID: PMC3539899 DOI: 10.1186/1748-717x-7-197] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Accepted: 09/16/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To quantitatively evaluate the safety and related-toxicities of intensity modulated radiotherapy (IMRT) dose-volume histograms (DVHs), as compared to the conventional three-dimensional conformal radiotherapy (3D-CRT), in gynecologic malignancy patients by systematic review of the related publications and meta-analysis. METHODS Relevant articles were retrieved from the PubMed, Embase, and Cochrane Library databases up to August 2011. Two independent reviewers assessed the included studies and extracted data. Pooled average percent irradiated volumes of adjacent non-cancerous tissues were calculated and compared between IMRT and 3D-CRT for a range of common radiation doses (5-45 Gy). RESULTS In total, 13 articles comprised of 222 IMRT-treated and 233 3D-CRT-treated patients were included. For rectum receiving doses ≥30 Gy, the IMRT pooled average irradiated volumes were less than those from 3D-CRT by 26.40% (30 Gy, p = 0.004), 27.00% (35 Gy, p = 0.040), 37.30% (40 Gy, p = 0.006), and 39.50% (45 Gy, p = 0.002). Reduction in irradiated small bowel was also observed for IMRT-delivered 40 Gy and 45 Gy (by 17.80% (p = 0.043) and 17.30% (p = 0.012), respectively), as compared with 3D-CRT. However, there were no significant differences in the IMRT and 3D-CRT pooled average percent volumes of irradiated small bowel or rectum from lower doses, or in the bladder or bone marrow from any of the doses. IMRT-treated patients did not experience more severe acute or chronic toxicities than 3D-CRT-treated patients. CONCLUSIONS IMRT-delivered high radiation dose produced significantly less average percent volumes of irradiated rectum and small bowel than 3D-CRT, but did not differentially affect the average percent volumes in the bladder and bone marrow.
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Affiliation(s)
- Baojuan Yang
- Department of Gynecologic Oncology, Cancer Hospital of Harbin Medical University, 150 Haping Street, Nangang District, Harbin, Heilongjiang Province, PR China
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Small bowel dose parameters predicting grade ≥ 3 acute toxicity in rectal cancer patients treated with neoadjuvant chemoradiation: an independent validation study comparing peritoneal space versus small bowel loop contouring techniques. Int J Radiat Oncol Biol Phys 2012. [PMID: 23182394 DOI: 10.1016/j.ijrobp.2012.09.036] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE To determine whether volumes based on contours of the peritoneal space can be used instead of individual small bowel loops to predict for grade ≥3 acute small bowel toxicity in patients with rectal cancer treated with neoadjuvant chemoradiation therapy. METHODS AND MATERIALS A standardized contouring method was developed for the peritoneal space and retrospectively applied to the radiation treatment plans of 67 patients treated with neoadjuvant chemoradiation therapy for rectal cancer. Dose-volume histogram (DVH) data were extracted and analyzed against patient toxicity. Receiver operating characteristic analysis and logistic regression were carried out for both contouring methods. RESULTS Grade ≥3 small bowel toxicity occurred in 16% (11/67) of patients in the study. A highly significant dose-volume relationship between small bowel irradiation and acute small bowel toxicity was supported by the use of both small bowel loop and peritoneal space contouring techniques. Receiver operating characteristic analysis demonstrated that, for both contouring methods, the greatest sensitivity for predicting toxicity was associated with the volume receiving between 15 and 25 Gy. CONCLUSION DVH analysis of peritoneal space volumes accurately predicts grade ≥3 small bowel toxicity in patients with rectal cancer receiving neoadjuvant chemoradiation therapy, suggesting that the contours of the peritoneal space provide a reasonable surrogate for the contours of individual small bowel loops. The study finds that a small bowel V15 less than 275 cc and a peritoneal space V15 less than 830 cc are associated with a less than 10% risk of grade ≥3 acute toxicity.
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98
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Shih KK, Milgrom SA, Abu-Rustum NR, Kollmeier MA, Gardner GJ, Tew WP, Barakat RR, Alektiar KM. Postoperative pelvic intensity-modulated radiotherapy in high risk endometrial cancer. Gynecol Oncol 2012; 128:535-9. [PMID: 23174538 DOI: 10.1016/j.ygyno.2012.11.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 11/12/2012] [Accepted: 11/13/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE According to national surveys, the use of intensity-modulated radiation therapy (IMRT) in gynecologic cancers is on the rise, yet there is still some reluctance to adopt adjuvant IMRT as standard practice. The purpose of this study is to report a single-institution experience using postoperative pelvic IMRT with or without chemotherapy in high-risk endometrial cancer. METHODS From 11/2004 to 12/2009, 46 patients underwent hysterectomy/bilateral salpingo-oophorectomy for stage I-III (22% stage I/II and 78% stage III) endometrial cancer. Median IMRT dose was 50.4Gy. Adjuvant chemotherapy was given to 30 (65%) patients. RESULTS With a median follow-up of 52months, 4 patients recurred: 1 vaginal plus lung metastasis, 2 isolated para-aortic recurrences, and 1 lungs and liver metastasis. Five-year relapse rate was 9% (95% CI, 0-13.6%). Five-year disease-free survival (DFS) was 88% (95% CI, 77-98%) and overall survival (OS) was 97% (95% CI, 90-100%). There were 2 patients with non-hematological grade 3 toxicity: 1 (2%) acute and 1 (2%) chronic gastrointestinal toxicity. In patients treated with IMRT and chemotherapy (n=30), 5 had grade 3 leukopenia, 8 grade 2 anemia, and 2 grade 2 thrombocytopenia. CONCLUSIONS Oncologic outcomes with postoperative IMRT were very good, with DFS and OS rates of >88% at median follow-up of 52months, despite a preponderance (78%) of stage III disease. Toxicity was minimal even in the setting of an aggressive trimodality (65% of patients) approach. Data from this study and emerging data from RTOG trial 0418 demonstrate the advantages of IMRT in high-risk endometrial cancer.
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Affiliation(s)
- Karin K Shih
- Departments of Surgery, Memorial-Sloan-Kettering Cancer Center, New York, NY 10065, USA
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99
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Folkert MR, Shih KK, Abu-Rustum NR, Jewell E, Kollmeier MA, Makker V, Barakat RR, Alektiar KM. Postoperative pelvic intensity-modulated radiotherapy and concurrent chemotherapy in intermediate- and high-risk cervical cancer. Gynecol Oncol 2012; 128:288-93. [PMID: 23159818 DOI: 10.1016/j.ygyno.2012.11.012] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Revised: 11/07/2012] [Accepted: 11/09/2012] [Indexed: 11/15/2022]
Abstract
OBJECTIVE According to national surveys, the use of intensity-modulated radiation therapy (IMRT) in gynecologic cancers is on the rise, yet there is still some reluctance to adopt adjuvant IMRT as standard practice. The purpose of this study is to report a single-institution experience using postoperative pelvic IMRT with concurrent chemotherapy in intermediate- and high-risk early stage cervical cancer. METHODS From 1/2004 to 12/2009, 34 patients underwent radical hysterectomy and pelvic lymph node dissection (28 median nodes were removed) for early stage cervical cancer. Median dose of postoperative pelvic IMRT was 50.4 Gy (range, 45-50.4). All patients received concurrent cisplatin. RESULTS With a median follow-up of 44 months, 3 patients have recurred; 1 vaginal recurrence, 1 regional and distant, and 1 distant. The 3- and 5-year disease-free survival (DFS) was 91.2% (95% CI, 81.4-100%) and overall survival (OS) was 91.1% (95% CI, 81.3-100%). All failures and all deaths were in the high-risk group (n=3/26). There was 32.3% G3-4 hematologic toxicity, 2.9% acute G3 gastrointestinal toxicity, and no acute G3 or higher genitourinary toxicity. There were no chronic G3 or higher toxicities. CONCLUSIONS Oncologic outcomes with postoperative IMRT were very good, with DFS and OS rates of >90% at median follow-up of 44 months, despite a preponderance (76.5%) of high-risk features. Toxicity was minimal even in the setting of an aggressive trimodality approach. Data from this study and emerging data from the Phase II RTOG study (0418) demonstrate the advantages of postoperative IMRT in early stage cervical cancer.
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Affiliation(s)
- Michael R Folkert
- Department of Radiation Oncology, Memorial-Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
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A Phase II Study of Intensity Modulated Radiation Therapy to the Pelvis for Postoperative Patients With Endometrial Carcinoma: Radiation Therapy Oncology Group Trial 0418. Int J Radiat Oncol Biol Phys 2012; 84:e23-8. [DOI: 10.1016/j.ijrobp.2012.02.044] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Revised: 02/07/2012] [Accepted: 02/20/2012] [Indexed: 11/21/2022]
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