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Tringale KR, Modlin LA, Sine K, Forlenza CJ, Cahlon O, Wolden SL. Vital organ sparing with proton therapy for pediatric Hodgkin lymphoma: Toxicity and outcomes in 50 patients. Radiother Oncol 2022; 168:46-52. [PMID: 35101461 PMCID: PMC9446376 DOI: 10.1016/j.radonc.2022.01.016] [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: 07/09/2021] [Revised: 12/03/2021] [Accepted: 01/19/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND PURPOSE With high survival rates for pediatric Hodgkin lymphoma (HL), attention has turned to minimizing treatment-related morbidity and mortality. Chemotherapy and dose of radiation to organs at risk (OARs) contribute to elevated risks of secondary malignancy and cardiopulmonary disease. We sought to characterize the radiation dose to OARs, toxicities, and outcomes for pediatric HL patients treated with proton therapy (PT). MATERIALS AND METHODS Fifty patients aged 11-21 with HL consecutively treated with PT were evaluated 1-2 months following completion of PT and every 6 months thereafter. Acute and late toxicities were captured retrospectively using CTCAE v5. Patterns of relapse were characterized, and survival was assessed using Kaplan-Meier method. RESULTS Most (47, 94%) patients received PT to the mediastinum. Median mean heart dose was 4.3 Gy (RBE) and median bilateral lung V20Gy was 5.8%. Median integral dose was 1.7 Gy. For the 27 female patients, a median mean dose of 0.4 and 0.3 Gy (RBE) was delivered to ipsilateral and contralateral breast tissue, respectively. No on-treatment grade 3-5 toxicities were seen. At a median follow-up of 5.3 years, no PT-related grade 3-5 toxicities or secondary malignancies developed. Five patients relapsed at a median time of 9.2 months after PT (range 2.5-24.9 months; 5-year recurrence free survival 90%). Recurrences were both in- and out-of-field in all 5 cases with no marginal failures. All relapsed patients were successfully salvaged (5-year overall survival 100%). CONCLUSION For pediatric HL patients, proton treatment resulted in marked dose sparing of OARs with low rates of toxicity, no marginal failures, and excellent 5-year survival.
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Affiliation(s)
- Kathryn R. Tringale
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Leslie A. Modlin
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA,ProCure Proton Therapy Center, Somerset, NJ, USA
| | - Kevin Sine
- ProCure Proton Therapy Center, Somerset, NJ, USA
| | | | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA,ProCure Proton Therapy Center, Somerset, NJ, USA
| | - Suzanne L. Wolden
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA,ProCure Proton Therapy Center, Somerset, NJ, USA
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2
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Rosenbrock J, Baues C, Vasquez-Torres A, Clivio A, Fogliata A, Borchmann P, Marnitz S, Cozzi L. Volumetric modulated arc therapy versus intensity-modulated proton therapy in the irradiation of infra diaphragmatic Hodgkin Lymphoma in female patients. Acta Oncol 2022; 61:81-88. [PMID: 34596491 DOI: 10.1080/0284186x.2021.1986230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To investigate the role of infra diaphragmatic intensity-modulated proton therapy (IMPT) compared to volumetric modulated arc therapy (VMAT) for female Hodgkin Lymphoma (HL) patients and to estimate the risk of secondary cancer and ovarian failure. METHODS A comparative treatment planning study was performed on 14 patients, and the results were compared according to conventional dose-volume metrics. In addition, estimates of the excess absolute risk (EAR) of secondary cancer induction were determined for the bowel, the bladder and the rectum. For the ovaries, the risk of ovarian failure was estimated. RESULTS The dosimetric findings demonstrate the equivalence between VMAT and IMPT in terms of target coverage. A statistically significant reduction of the mean and near-to-maximum doses was proven for the organs at risk. The EAR ratio estimated for IMPT to VMAT was 0.51 ± 0.32, 0.32 ± 0.35 and 0.05 ± 0.11 for the bowel, bladder and rectum, respectively. Concerning the risk of ovarian failure for the chronologic age ranging from 18 to 46 years, the expected net loss in fertility years ranged from 4.8 to 3.0 years for protons and 12.0 to 5.7 years for photons. CONCLUSION This in-silico study confirmed the beneficial role of IMPT from a dosimetric point of view. Mathematical models suggested that the use of protons might be further advantageous due to the expected reduction of the risk of secondary cancer induction and its milder impact on the reduction of fertility.
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Affiliation(s)
- Johannes Rosenbrock
- Department of Radiation Oncology, CyberKnife and Radiation Therapy, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Christian Baues
- Department of Radiation Oncology, CyberKnife and Radiation Therapy, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Andres Vasquez-Torres
- Department of Radiation Oncology, CyberKnife and Radiation Therapy, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | | | - Antonella Fogliata
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Peter Borchmann
- German Hodgkin Study Group, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Department of Biomedical Sciences, Humanitas University, Milan-Rozzano, Italy
| | - Simone Marnitz
- Department of Radiation Oncology, CyberKnife and Radiation Therapy, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Luca Cozzi
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
- Department of Hematology and Oncology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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3
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Hall MD, Terezakis SA, Lucas JT, Gallop-Evans E, Dieckmann K, Constine LS, Hodgson D, Flerlage JE, Metzger ML, Hoppe BS. Radiotherapy across pediatric Hodgkin lymphoma research group protocols: a report from the Staging, Evaluation, and Response Criteria Harmonization (SEARCH) for childhood, adolescent, and young adult Hodgkin lymphoma (CAYAHL) Group. Int J Radiat Oncol Biol Phys 2021; 112:317-334. [PMID: 34390770 PMCID: PMC8802654 DOI: 10.1016/j.ijrobp.2021.07.1716] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 07/23/2021] [Accepted: 07/31/2021] [Indexed: 01/17/2023]
Affiliation(s)
- Matthew D Hall
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA.
| | | | - John T Lucas
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Eve Gallop-Evans
- Department of Clinical Oncology, Velindre Cancer Centre, Cardiff, Wales, United Kingdom
| | - Karin Dieckmann
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Louis S Constine
- Department of Radiation Oncology and Pediatrics, University of Rochester Medical Center, Rochester, NY, USA
| | - David Hodgson
- Department of Radiation Oncology, University of Toronto, Toronto, Alberta, Canada
| | - Jamie E Flerlage
- Department of Pediatric Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Monika L Metzger
- Department of Pediatric Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
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4
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Bates JE, Terezakis S, Morris CG, Rao AD, Sehgal S, Kumar R, Mailhot Vega RB, Mendenhall NP, Hoppe BS. Comparative Effectiveness of Proton Therapy versus Photon Radiotherapy in Adolescents and Young Adults for Classical Hodgkin Lymphoma. Int J Part Ther 2021; 8:21-27. [PMID: 35127972 PMCID: PMC8768899 DOI: 10.14338/ijpt-21-00011.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/11/2021] [Indexed: 12/04/2022] Open
Abstract
Purpose Early stage (stages I-II) classical Hodgkin lymphoma (cHL) is a highly curable disease typically diagnosed in adolescents and young adults (AYAs). Proton therapy can also reduce the late toxicity burden in this population, but data on its comparative efficacy with photon radiotherapy in this population are sparse. We assessed outcomes in AYAs with cHL in a multi-institution retrospective review. Materials and Methods We identified 94 patients aged 15 to 40 years with stages I and II cHL treated with radiotherapy as part of their initial treatment between 2008 and 2017. We used Kaplan-Meier analyses and log-rank testing to evaluate survival differences between groups of patients. Results A total of 91 patients were included in the analysis. The 2-year progression-free survival (PFS) rate was 89%. Of the 12 patients who experienced progression after radiotherapy, 4 occurred out-of-field, 2 occurred in-field, and 6 experienced both in- and out-of-field progression. There was no significant difference in 2-year PFS among AYA patients by radiotherapy dose received (≥ 30 Gy, 91%; < 30 Gy, 86%; P = .82). Likewise, there was no difference in 2-year PFS among patients who received either proton or photon radiotherapy (proton, 94%; photon, 83%; P = .07). Conclusion Our cohort of AYA patients had comparable outcomes regardless of radiotherapy dose or modality used. For patients with significant risk of radiation-induced late effects, proton therapy is a reasonable treatment modality.
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Affiliation(s)
- James E. Bates
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Stephanie Terezakis
- Department of Radiation Oncology, University of Minnesota, Minneapolis, MN, USA
| | - Christopher G. Morris
- Department of Radiation Oncology, University of Florida, Gainesville, FL, USA
- University of Florida Proton Therapy Institute, Jacksonville, FL, USA
| | - Avani D. Rao
- Department of Radiation Oncology and Molecular Radiation Science, Johns Hopkins University, Baltimore, MD, USA
| | - Shuchi Sehgal
- Department of Radiation Oncology and Molecular Radiation Science, Johns Hopkins University, Baltimore, MD, USA
| | - Rahul Kumar
- School of Medical Sciences & Research, Sharda University, Greater Noida, India
| | | | - Nancy P. Mendenhall
- Department of Radiation Oncology, University of Florida, Gainesville, FL, USA
- University of Florida Proton Therapy Institute, Jacksonville, FL, USA
| | - Bradford S. Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
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5
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Lex JR, Kurisunkal V, Kaneuchi Y, Fujiwara T, Sherriff J, Wigley C, Stevenson JD, Parry MC, Jeys LM. Pelvic Ewing sarcoma: Should all patients receive pre-operative radiotherapy, or should it be delivered selectively? Eur J Surg Oncol 2021; 47:2618-2626. [PMID: 34030919 DOI: 10.1016/j.ejso.2021.05.027] [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: 02/19/2021] [Revised: 05/06/2021] [Accepted: 05/11/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Locally recurrent disease following surgical resection of Ewing sarcoma (ES) confers a poor prognosis. Limited evidence is available evaluating non-selective use of pre-operative radiotherapy (RT) for patients with pelvic ES and its effect on local control and survival. PATIENTS AND METHODS 49 consecutive patients with pelvic ES were identified retrospectively from a prospectively collated database. Patients either received non-selective pre-operative RT and surgery (n = 27), or selective post-operative RT (n = 22) (surgery alone (n = 11) or surgery and post-operative RT (n = 11)). RESULTS Patients who had non-selective pre-operative radiotherapy appeared to have a higher LRFS, 88.0% compared to 66.5% in the selective RT group (p = 0.096, Kaplan Meier; p = 0.028, Chi-squared). Administration of non-selective, pre-operative RT to all patients with pelvic ES elevates the LFRS to that of the good responder group (≥90% tumour necrosis and margins, p = 0.880). There was no difference in metastasis-free survival, 60.0% and 54.5% (p = 0.728) and overall survival (OS), 57.7% and 63.6% (p = 0.893). The majority of pre-operative RT patients had both good necrosis (≥90%) (p = 0.003) and widely excised tumours, 81.5% vs 59.1% (p = 0.080). Tumour volume ≥250 ml was associated with worse LRFS (p = 0.045) and post-operative complications (p = 0.017). There may be improved LRFS (p = 0.057) with pre-operative proton-beam RT compared to surgery and selective post-operative RT. CONCLUSION Pre-operative photon or proton-beam RT to all pelvic ES may improve LRFS compared to the selective delivery of post-operative RT. Radiotherapy delivered to all patients results in a greater percentage of highly necrotic tumours at surgical excision, enabling a greater proportion of patients with wide resection margins.
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Affiliation(s)
- Johnathan R Lex
- Oncology Department, The Royal Orthopaedic Hospital, Birmingham, UK; Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada.
| | - Vineet Kurisunkal
- Oncology Department, The Royal Orthopaedic Hospital, Birmingham, UK.
| | - Yoichi Kaneuchi
- Oncology Department, The Royal Orthopaedic Hospital, Birmingham, UK.
| | - Tomohiro Fujiwara
- Oncology Department, The Royal Orthopaedic Hospital, Birmingham, UK.
| | - Jenny Sherriff
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| | - Catrin Wigley
- Oncology Department, The Royal Orthopaedic Hospital, Birmingham, UK.
| | - Jonathan D Stevenson
- Oncology Department, The Royal Orthopaedic Hospital, Birmingham, UK; Aston University Medical School, Aston University, Birmingham, UK.
| | - Michael C Parry
- Oncology Department, The Royal Orthopaedic Hospital, Birmingham, UK; Aston University Medical School, Aston University, Birmingham, UK.
| | - Lee M Jeys
- Oncology Department, The Royal Orthopaedic Hospital, Birmingham, UK; Faculty of Health Sciences, Aston University, Birmingham, UK.
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6
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Tseng YD, Hoppe BS, Dedeckova K, Patel CG, Hill-Kayser CE, Miller DM, Maity A, Mendenhall NP, Mailhot Vega RB, Yock TI, Baliga S, Hess CB, Winkfield KM, Mohindra P, Rosen LR, Tsai H, Chang J, Hartsell WF, Plastaras JP. Risk of Pneumonitis and Outcomes After Mediastinal Proton Therapy for Relapsed/Refractory Lymphoma: A PTCOG and PCG Collaboration. Int J Radiat Oncol Biol Phys 2020; 109:220-230. [PMID: 32866566 DOI: 10.1016/j.ijrobp.2020.08.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 08/09/2020] [Accepted: 08/25/2020] [Indexed: 01/07/2023]
Abstract
PURPOSE Despite high response rates, there has been reluctance to use radiation therapy for patients with relapsed/refractory (r/r) Hodgkin (HL) or aggressive non-Hodgkin lymphoma (NHL) given concerns for subacute and late toxicities. Symptomatic pneumonitis, a subacute toxicity, has an incidence of 17% to 24% (≥grade 2) even with intensity modulated radiation therapy. Proton therapy (PT), which has no exit radiation dose, is associated with a lower dose to lung compared with other radiation techniques. As risk of radiation pneumonitis is associated with lung dose, we evaluated whether pneumonitis rates are lower with PT. METHODS AND MATERIALS Within an international, multi-institutional cohort, we retrospectively evaluated the incidence and grade of radiation pneumonitis (National Cancer Institute Common Terminology Criteria for Adverse Events v4) among patients with r/r HL or NHL treated with PT. RESULTS A total of 85 patients with r/r lymphoma (66% HL, 34% NHL; 46% primary chemorefractory) received thoracic PT from 2009 to 2017 in the consolidation (45%) or salvage (54%) setting. Median dose was 36 Gy(RBE). Before PT, patients underwent a median of 1 salvage systemic therapy (range, 0-4); 40% received PT within 4 months of transplant. With a median follow-up of 26.3 months among living patients, 11 patients developed symptomatic (grade 2) pneumonitis (12.8%). No grade 3 or higher pneumonitis was observed. Dose to lung, including mean lung dose, lung V5, and V20, significantly predicted risk of symptomatic pneumonitis, but not receipt of brentuximab, history of bleomycin toxicity, sex, or peritransplant radiation. CONCLUSIONS PT for relapsed/refractory lymphoma was associated with favorable rates of pneumonitis compared with historical controls. We confirm that among patients treated with PT, pneumonitis risk is associated with mean lung and lung V20 dose. These findings highlight how advancements in radiation delivery may improve the therapeutic ratio for patients with relapsed/refractory lymphoma. PT may be considered as a treatment modality for patients with relapsed/refractory lymphoma in the consolidation or salvage setting.
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Affiliation(s)
- Yolanda D Tseng
- Department of Radiation Oncology, University of Washington, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Proton Collaborative Group Registry Membership Site, Warrenville, Illinois.
| | - Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic Florida, Jacksonville, Florida
| | | | - Chirayu G Patel
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | - Christine E Hill-Kayser
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David M Miller
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amit Maity
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nancy P Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Torunn I Yock
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | - Sujith Baliga
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Clayton B Hess
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Karen M Winkfield
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Pranshu Mohindra
- Proton Collaborative Group Registry Membership Site, Warrenville, Illinois; Department of Radiation Oncology, University of Maryland School of Medicine and Maryland Proton Treatment Center, Baltimore, Maryland
| | - Lane R Rosen
- Department of Radiation Oncology, Willis-Knighton Cancer Center, Shreveport, Lousiana
| | - Henry Tsai
- Proton Collaborative Group Registry Membership Site, Warrenville, Illinois; Procure Proton Therapy Center, Somerset, New Jersey
| | - John Chang
- Proton Collaborative Group Registry Membership Site, Warrenville, Illinois; Oklahoma Proton Center, Oklahoma City, Oklahoma
| | - William F Hartsell
- Proton Collaborative Group Registry Membership Site, Warrenville, Illinois; Northwestern Medicine Proton Center, Warrenville, Illinois
| | - John P Plastaras
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
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7
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Hoppe BS, Mailhot Vega RB, Mendenhall NP, Sandler ES, Slayton WB, Katzenstein H, Joyce MJ, Li Z, Flampouri S. Irradiating Residual Disease to 30 Gy with Proton Therapy in Pediatric Mediastinal Hodgkin Lymphoma. Int J Part Ther 2020; 6:11-16. [PMID: 32582815 PMCID: PMC7302731 DOI: 10.14338/ijpt-19-00077.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 03/05/2020] [Indexed: 11/24/2022] Open
Abstract
Background: Local relapse is a predominant form of recurrence among pediatric patients with Hodgkin lymphoma (PHL). Although PHL radiotherapy doses have been approximately 20 Gy, adults with Hodgkin lymphoma receiving 30 to 36 Gy experience fewer in-field relapses. We investigated the dosimetric effect of such a dose escalation to the organs at risk (OARs). Materials and Methods: Ten patients with PHL treated with proton therapy to 21 Gy involved-site radiation therapy (ISRT21Gy) were replanned to deliver 30 Gy by treating the ISRT to 30 Gy (ISRT30Gy), delivering 21 Gy to the ISRT plus a 9-Gy boost to postchemotherapy residual volume (rISRTboost), and delivering 30 Gy to the residual ISRT target only (rISRT30Gy). Radiation doses to the OARs were compared. Results: The ISRT30Gy escalated the dose to the target by 42% but also to the OARs. The rISRTboost escalated the residual target dose by 42%, and the OAR dose by only 17% to 26%. The rISRT30Gy escalated the residual target dose by 42% but reduced the OAR dose by 25% to 46%. Conclusion: Boosting the postchemotherapy residual target dose to 30Gy can allow for dose escalation with a slight OAR dose increase. Treating the residual disease for the full 30Gy, however, would reduce the OAR dose significantly compared with ISRT21Gy. Studies should evaluate these strategies to improve outcomes and minimize the late effects.
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Affiliation(s)
- Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | | | - Nancy P Mendenhall
- Department of Radiation Oncology, University of Florida, Jacksonville, FL, USA
| | - Eric S Sandler
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Nemours Children's Specialty Care, Jacksonville, FL, USA
| | - William B Slayton
- Department of Pediatric Hematology/Oncology, University of Florida, Gainesville, FL, USA
| | - Howard Katzenstein
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Nemours Children's Specialty Care, Jacksonville, FL, USA
| | - Michael J Joyce
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Nemours Children's Specialty Care, Jacksonville, FL, USA
| | - Zuofeng Li
- Department of Radiation Oncology, University of Florida, Jacksonville, FL, USA
| | - Stella Flampouri
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
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8
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Jhawar SR, Rivera-Núñez Z, Drachtman R, Cole PD, Hoppe BS, Parikh RR. Association of Combined Modality Therapy vs Chemotherapy Alone With Overall Survival in Early-Stage Pediatric Hodgkin Lymphoma. JAMA Oncol 2020; 5:689-695. [PMID: 30605220 DOI: 10.1001/jamaoncol.2018.5911] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance To date, there is no well-defined standard of care for early-stage pediatric Hodgkin lymphoma (HL), which may include chemotherapy alone or combined modality therapy (CMT) with chemotherapy followed by radiotherapy. Although the use of radiotherapy in pediatric HL is decreasing, this strategy remains controversial. Objective To examine the use of CMT in pediatric HL and its association with improved overall survival using data from a large cancer registry. Design, Setting, and Participants This observational cohort study used data from the National Cancer Database to evaluate clinical features and survival outcomes among 5657 pediatric patients (age, 0.1-21 years) who received a diagnosis of stage I or II HL in the United States from January 1, 2004, to December 31, 2015. Statistical analysis was conducted from May 1 to November 1, 2018. Exposures Patients received definitive treatment with chemotherapy or CMT, defined as chemotherapy followed by radiotherapy. Main Outcomes and Measures Kaplan-Meier survival curves were used to examine overall survival. The association between CMT use, covariables, and overall survival was assessed in multivariable Cox proportional hazards regression models. Use of radiotherapy was assessed over time. Results Among the 11 546 pediatric patients with HL in the National Cancer Database, 5657 patients (3004 females, 2596 males, and 57 missing information on sex; mean [SD] age, 17.1 [3.6] years) with stage I or II classic HL were analyzed. Of these patients, 2845 (50.3%) received CMT; use of CMT vs chemotherapy alone was associated with younger age (<16 years, 1102 of 2845 [38.7%] vs 856 of 2812 [30.4%]; P < .001), male sex (1369 of 2845 [48.1%] vs 1227 of 2812 [43.6%]; P < .001), stage II disease (2467 of 2845 [86.7%] vs 2376 of 2812 [84.5%]; P = .02), and private health insurance (2065 of 2845 [72.6%] vs 1949 of 2812 [69.3%]; P = .002). The 5-year overall survival was 94.5% (confidence limits, 93.8%, 95.8%) for patients who received chemotherapy alone and 97.3% (confidence limits, 96.4%, 97.9%) for those who received CMT, which remained significant in the intention-to-treat analysis and multivariate analysis (adjusted hazard ratio for CMT, 0.57; 95% CI, 0.42-0.78; P < .001). In the sensitivity analysis, the low-risk cohort (stage I-IIA) and adolescent and young adult patients had the greatest benefit from CMT (adjusted hazard ratio, 0.47; 95% CI, 0.40-0.56; P < .001). The use of CMT decreased by 24.8% from 2004 to 2015 (from 59.7% [271 of 454] to 34.9% [153 of 438]). Conclusions and Relevance In this study, pediatric patients with early-stage HL receiving CMT experienced improved overall survival 5 years after treatment. There is a nationwide decrease in the use of CMT, perhaps reflecting the bias of ongoing clinical trials designed to avoid consolidation radiotherapy. This study represents the largest data set to date examining the role of CMT in pediatric HL.
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Affiliation(s)
- Sachin R Jhawar
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick
| | - Zorimar Rivera-Núñez
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick.,Biometrics Division, Rutgers Cancer Institute of New Jersey, New Brunswick.,Department of Biostatistics, Rutgers School of Public Health, New Brunswick, New Jersey
| | - Richard Drachtman
- Section of Pediatric Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick
| | - Peter D Cole
- Section of Pediatric Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick
| | - Bradford S Hoppe
- Department of Radiation Oncology, University of Florida, Gainesville.,University of Florida Health Proton Therapy Institute, Jacksonville
| | - Rahul R Parikh
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick
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9
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Daw S, Hasenclever D, Mascarin M, Fernández-Teijeiro A, Balwierz W, Beishuizen A, Burnelli R, Cepelova M, Claviez A, Dieckmann K, Landman-Parker J, Kluge R, Körholz D, Mauz-Körholz C, Wallace WH, Leblanc T. Risk and Response Adapted Treatment Guidelines for Managing First Relapsed and Refractory Classical Hodgkin Lymphoma in Children and Young People. Recommendations from the EuroNet Pediatric Hodgkin Lymphoma Group. Hemasphere 2020; 4:e329. [PMID: 32072145 PMCID: PMC7000476 DOI: 10.1097/hs9.0000000000000329] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 11/14/2019] [Accepted: 11/22/2019] [Indexed: 01/21/2023] Open
Abstract
The objective of this guideline is to aid clinicians in making individual salvage treatment plans for pediatric and adolescent patients with first relapse or refractory (R/R) classical Hodgkin lymphoma (cHL). While salvage with standard dose chemotherapy followed by high dose chemotherapy and autologous stem cell transplant is often considered the standard of care in adult practice, pediatric practice adopts a more individualized risk stratified and response adapted approach to salvage treatment with greater use of non-transplant salvage. Here, we present on behalf of the EuroNet Pediatric Hodgkin Lymphoma group, evidence and consensus-based guidelines for standardized diagnostic, prognostic and response procedures to allocate children and adolescents with R/R cHL to stratified salvage treatments.
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Affiliation(s)
- Stephen Daw
- Children and Young People's Cancer Services, University College Hospital London, London, UK
| | - Dirk Hasenclever
- Institute of Medical Informatics, Statistics and Epidemiology, University of Leipzig, Leipzig, Germany
| | - Maurizio Mascarin
- AYA and Pediatric Radiotherapy Unit, Centro di Riferimento Oncologico, Aviano, Italy
| | - Ana Fernández-Teijeiro
- Unit of Pediatric Onco-Hematology, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Walentyna Balwierz
- Department of Pediatric Oncology and Hematology, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
| | - Auke Beishuizen
- Prinses Máxima Centrum voor Kinderoncologie, Utrecht, The Netherlands
| | - Roberta Burnelli
- Section of Pediatrics, Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italy
| | - Michaela Cepelova
- Department of Pediatric Hematology and Oncology, University Hospital Motol, Czech Republic
| | - Alexander Claviez
- University Hospital Schleswig Holstein, Department of Pediatric and Adolescent Medicine, Pediatric Hematology, Oncology and Stem Cell Transplantation, Kiel, Germany
| | - Karin Dieckmann
- Department of Radiation Oncology, Medical University of Vienna, Vienna
| | | | - Regine Kluge
- Department of Nuclear Medicine, University of Leipzig, Leipzig, Germany
| | - Dieter Körholz
- Pädiatrische Hämatologie und Onkologie, Zentrum für Kinderheilkunde der Justus-Liebig-Universität Gießen, Gießen, Germany
| | - Christine Mauz-Körholz
- Pädiatrische Hämatologie und Onkologie, Zentrum für Kinderheilkunde der Justus-Liebig-Universität Gießen, Gießen, Germany
| | | | - Thierry Leblanc
- University of Edinburgh and Department of Pediatrics, Royal Hospital for Sick Children, Edinburgh, Scotland, UK
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10
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Abstract
PURPOSE OF REVIEW The purpose of this review is to describe current advances in pediatric precision therapy through innovations in technology and engineering. A multimodal approach of chemotherapy, surgery and/or radiation therapy has improved survival outcomes for pediatric cancer but with significant early and late toxicities. The pediatric population is particularly vulnerable given their age during treatment. Advances in precision interventions discussed include image guidance, ablation techniques, radiation therapy and novel drug delivery mechanisms that offer the potential for more targeted approach approaches with improved efficacy while limiting acute and late toxicities. RECENT FINDINGS Image-guidance provides improved treatment planning, real time monitoring and targeting when combined with ablative techniques and radiation therapy. Advances in drug delivery including radioisotopes, nanoparticles and antibody drug conjugates have shown benefit in adult malignancies with increasing use in pediatrics. These therapies alone and combined may lead to augmented local antitumor effect while sparing systemic exposure and potentially limiting early and late toxicities. SUMMARY Pediatric cancer medicine often requires a multimodal approach, each with early and late toxicities. Precision interventions and therapies offer promise for more targeted approaches in treating pediatric malignancies and require further investigation to determine long-term benefit.
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11
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Sardaro A, Carbonara R, Petruzzelli MF, Turi B, Moschetta M, Scardapane A, Stabile Ianora AA. Proton therapy in the most common pediatric non-central nervous system malignancies: an overview of clinical and dosimetric outcomes. Ital J Pediatr 2019; 45:170. [PMID: 31881905 PMCID: PMC6935184 DOI: 10.1186/s13052-019-0763-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 12/17/2019] [Indexed: 11/20/2022] Open
Abstract
Radiation therapy represents an important approach in the therapeutic management of children and adolescents with malignant tumors and its application with modern techniques – including Proton Beam Therapy (PBT) – is of great interest. In particular, potential radiation-induced injuries and secondary malignancies – also associated to the prolonged life expectancy of patients – are still questions of concern that increase the debate on the usefulness of PBT in pediatric treatments. This paper presents a literary review of current applications of PBT in non-Central Nervous System pediatric tumors (such as retinoblastoma, Hodgkin Lymphoma, Wilms tumor, bone and soft tissues sarcomas). We specifically reported clinical results achieved with PBT and dosimetric comparisons between PBT and the most common photon-therapy techniques. The analysis emphasizes that PBT minimizes radiation doses to healthy growing organs, suggesting for reduced risks of late side-effects and radiation-induced secondary malignancies. Extended follow up and confirms by prospective clinical trials should support the effectiveness and long-term tolerance of PBT in the considered setting.
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Affiliation(s)
- Angela Sardaro
- Interdisciplinary Department of Medicine, Section of Radiology and Radiation Oncology, University of Bari, p.zza Giulio Cesare nr.11, 70124, Bari, Italy
| | - Roberta Carbonara
- Interdisciplinary Department of Medicine, Section of Radiology and Radiation Oncology, University of Bari, p.zza Giulio Cesare nr.11, 70124, Bari, Italy.
| | - Maria Fonte Petruzzelli
- Interdisciplinary Department of Medicine, Section of Radiology and Radiation Oncology, University of Bari, p.zza Giulio Cesare nr.11, 70124, Bari, Italy
| | - Barbara Turi
- Interdisciplinary Department of Medicine, Section of Radiology and Radiation Oncology, University of Bari, p.zza Giulio Cesare nr.11, 70124, Bari, Italy
| | - Marco Moschetta
- Interdisciplinary Department of Medicine, Section of Radiology and Radiation Oncology, University of Bari, p.zza Giulio Cesare nr.11, 70124, Bari, Italy
| | - Arnaldo Scardapane
- Interdisciplinary Department of Medicine, Section of Radiology and Radiation Oncology, University of Bari, p.zza Giulio Cesare nr.11, 70124, Bari, Italy
| | - Amato Antonio Stabile Ianora
- Interdisciplinary Department of Medicine, Section of Radiology and Radiation Oncology, University of Bari, p.zza Giulio Cesare nr.11, 70124, Bari, Italy
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12
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Ricardi U, Maraldo MV, Levis M, Parikh RR. Proton Therapy For Lymphomas: Current State Of The Art. Onco Targets Ther 2019; 12:8033-8046. [PMID: 31632057 PMCID: PMC6781741 DOI: 10.2147/ott.s220730] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 09/13/2019] [Indexed: 12/19/2022] Open
Abstract
The combination of brief chemo-radiotherapy provides high cure rates and represents the first line of treatment for many lymphoma patients. As a result, a high proportion of long-term survivors may experience treatment-related toxic events many years later. Excess and unintended radiation dose to organs at risk (particularly heart, lungs and breasts) may translate in an increased risk of cardiovascular events and second cancers after a few decades. Minimizing dose to organs at risk is thus pivotal to restrain the risk of long-term complications. Proton therapy, with its peculiar physic properties, may help to better spare organs at risk and consequently to reduce toxicities especially in patients receiving mediastinal radiotherapy. Herein, we review the physical basis of proton therapy and the rationale for its implementation in lymphoma patients, with a detailed description of the clinical data. We also discuss the potential disadvantages and uncertainties of protons that may limit their application and critically review the dosimetric studies comparing the risk of late complications between proton and photon radiotherapy.
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Affiliation(s)
| | - Maja V Maraldo
- Department of Clinical Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Mario Levis
- Department of Oncology, University of Torino, Torino, Italy
| | - Rahul R Parikh
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
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13
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Lautenschlaeger S, Iancu G, Flatten V, Baumann K, Thiemer M, Dumke C, Zink K, Hauswald H, Vordermark D, Mauz-Körholz C, Engenhart-Cabillic R, Eberle F. Advantage of proton-radiotherapy for pediatric patients and adolescents with Hodgkin's disease. Radiat Oncol 2019; 14:157. [PMID: 31477141 PMCID: PMC6721251 DOI: 10.1186/s13014-019-1360-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 08/16/2019] [Indexed: 01/26/2023] Open
Abstract
Abstract Radiotherapy is frequently used in the therapy of lymphoma. Since lymphoma, for example Hodgkin’s disease, frequently affect rather young patients, the induction of secondary cancer or other long-term adverse effects after irradiation are important issues to deal with. Especially for mediastinal manifestations numerous organs and substructures at risk play a role. The heart, its coronary vessels and cardiac valves, the lungs, the thyroid and, for female patients, the breast tissue are only the most important organs at risk. In this study we investigated if proton-radiotherapy might reduce the dose delivered to the organs at risk and thus minimize the therapy-associated toxicity. Methods In this work we compared the dose delivered to the heart, its coronary vessels and valves, the lungs, the thyroid gland and the breast tissue by different volumetric photon plans and a proton plan, all calculated for a dose of 28.8 Gy (EURO-NET-PHL-C2). Target Volumes have been defined by F18-FDG PET-positive areas, following a modified involved node approach. Data from ten young female patients with mediastinal lymphoma have been evaluated. Three different modern volumetric IMRT (VMAT) photon plans have been benchmarked against each other and against proton-irradiation concepts. For plan-evaluation conformity- and homogeneity-indices have been calculated as suggested in ICRU 83. The target volume coverage as well as the dose to important organs at risk as the heart with its substructures, the lungs, the breast tissue, the thyroid and the spinal cord were calculated and compared. For statistical evaluation mean doses to organs at risk were evaluated by non- parametric Kruskal-Wallis calculations with pairwise comparisons. Results Proton-plans and three different volumetric photon-plans have been calculated. Proton irradiation results in significant lower doses delivered to organ at risk. The median doses and the mean doses could be decreased while PTV coverage is comparable. As well conformity as homogeneity are slightly better for proton plans. For several organs a risk reduction for secondary malignancies has been calculated using literature data as reference. According to the used data derived from literature especially the secondary breast cancer risk, the secondary lung cancer risk and the risk for ischemic cardiac insults can be reduced significantly by using protons for radiotherapy of mediastinal lymphomas. Conclusion Irradiation with protons for mediastinal Hodgkin-lymphoma results in significant lower doses for almost all organs at risk and is suitable to reduce long term side effects for pediatric and adolescent patients. Electronic supplementary material The online version of this article (10.1186/s13014-019-1360-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- S Lautenschlaeger
- Klinik für Strahlentherapie und Radioonkologie, Klinikum der Philipps Universität Marburg, Baldingerstr, 35043, Marburg, Germany.
| | - G Iancu
- Klinik für Strahlentherapie und Radioonkologie, Klinikum der Philipps Universität Marburg, Baldingerstr, 35043, Marburg, Germany
| | - V Flatten
- Klinik für Strahlentherapie und Radioonkologie, Klinikum der Philipps Universität Marburg, Baldingerstr, 35043, Marburg, Germany.,Technische Hochschule Mittelhessen, Institut für Medizinische Physik und Strahlenschutz, Gießen, Germany
| | - K Baumann
- Klinik für Strahlentherapie und Radioonkologie, Klinikum der Philipps Universität Marburg, Baldingerstr, 35043, Marburg, Germany.,Technische Hochschule Mittelhessen, Institut für Medizinische Physik und Strahlenschutz, Gießen, Germany
| | - M Thiemer
- Klinik für Strahlentherapie und Radioonkologie, Klinikum der Philipps Universität Marburg, Baldingerstr, 35043, Marburg, Germany
| | - C Dumke
- Klinik für Strahlentherapie und Radioonkologie, Klinikum der Philipps Universität Marburg, Baldingerstr, 35043, Marburg, Germany
| | - K Zink
- Klinik für Strahlentherapie und Radioonkologie, Klinikum der Philipps Universität Marburg, Baldingerstr, 35043, Marburg, Germany.,Technische Hochschule Mittelhessen, Institut für Medizinische Physik und Strahlenschutz, Gießen, Germany
| | - H Hauswald
- Klinik für Strahlentherapie und Radioonkologie, Klinikum der Philipps Universität Marburg, Baldingerstr, 35043, Marburg, Germany.,Klinik für Radio-Onkologie, Universitätsklinikum Heidelberg, Heidelberg, Germany.,Marburg Ion-Beam Therapy Center (MIT), Marburg, Germany
| | - D Vordermark
- Klinik und Poliklinik für Strahlentherapie, Universitätsklinikum der Martin-Luther-Universität Halle-Wittenberg, Halle, Germany
| | - C Mauz-Körholz
- Abteilung für Pädiatrische Hämatologie und Onkologie, Universitätsklinikum Gießen, Gießen, Germany.,Department für operative und konservative Kinder- und Jugendmedizin, Universitätsklinikum der Martin-Luther-Universität Halle-Wittenberg, Halle, Germany
| | - R Engenhart-Cabillic
- Klinik für Strahlentherapie und Radioonkologie, Klinikum der Philipps Universität Marburg, Baldingerstr, 35043, Marburg, Germany.,Marburg Ion-Beam Therapy Center (MIT), Marburg, Germany
| | - F Eberle
- Klinik für Strahlentherapie und Radioonkologie, Klinikum der Philipps Universität Marburg, Baldingerstr, 35043, Marburg, Germany.,Marburg Ion-Beam Therapy Center (MIT), Marburg, Germany
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14
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Abstract
PURPOSE OF REVIEW The advent of proton beam therapy (PBT) has initiated a paradigm shift in the field of pediatric radiation oncology, with increasing promise to alleviate both short-term and long-term toxicities. Given the dramatic rise in proton therapy centers in the United States, a discussion of the quality of evidence supporting its use in pediatric cancers is warranted. RECENT FINDINGS Proton radiotherapy appears to decrease the incidence and severity of late effects with the strongest evidence in pediatric brain tumor cohorts that shows benefits in neurocognitive, hearing, and endocrine outcomes. However, emerging data has shown that more conservative brainstem dose limits with protons compared with photons are required to limit brainstem toxicity; these modified recommendations have been incorporated into national cooperative group studies. Decreased toxicity in tumors outside of the CNS for PBT have also been reported in sarcomas, Hodgkin disease and neuroblastoma. Similarly, QoL outcomes are improved in brain tumor and other cohorts of patients treated with PBT. SUMMARY The collective findings demonstrate improved understanding and refinement of PBT in pediatric cancers. Data on QOL, toxicity and disease outcomes with PBT should continue to be collected and reported in order to understand the full extent of the risks and benefits associated with PBT.
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15
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Proton therapy for pediatric malignancies: Fact, figures and costs. A joint consensus statement from the pediatric subcommittee of PTCOG, PROS and EPTN. Radiother Oncol 2018; 128:44-55. [PMID: 29937209 DOI: 10.1016/j.radonc.2018.05.020] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 05/11/2018] [Accepted: 05/15/2018] [Indexed: 12/18/2022]
Abstract
Radiotherapy plays an important role in the management of childhood cancer, with the primary aim of achieving the highest likelihood of cure with the lowest risk of radiation-induced morbidity. Proton therapy (PT) provides an undisputable advantage by reducing the radiation 'bath' dose delivered to non-target structures/volume while optimally covering the tumor with tumoricidal dose. This treatment modality comes, however, with an additional costs compared to conventional radiotherapy that could put substantial financial pressure to the health care systems with societal implications. In this review we assess the data available to the oncology community of PT delivered to children with cancer, discuss on the urgency to develop high-quality data. Additionally, we look at the advantage of combining systemic agents with protons and look at the cost-effectiveness data published so far.
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16
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Tseng YD, Cutter DJ, Plastaras JP, Parikh RR, Cahlon O, Chuong MD, Dedeckova K, Khan MK, Lin SY, McGee LA, Shen EYL, Terezakis SA, Badiyan SN, Kirova YM, Hoppe RT, Mendenhall NP, Pankuch M, Flampouri S, Ricardi U, Hoppe BS. Evidence-based Review on the Use of Proton Therapy in Lymphoma From the Particle Therapy Cooperative Group (PTCOG) Lymphoma Subcommittee. Int J Radiat Oncol Biol Phys 2017; 99:825-842. [PMID: 28943076 DOI: 10.1016/j.ijrobp.2017.05.004] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 04/24/2017] [Accepted: 05/02/2017] [Indexed: 12/25/2022]
Affiliation(s)
- Yolanda D Tseng
- Department of Radiation Oncology, University of Washington, Seattle Cancer Care Alliance Proton Therapy Center, Seattle, Washington
| | - David J Cutter
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - John P Plastaras
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rahul R Parikh
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael D Chuong
- Miami Cancer Institute at Baptist Health South Florida, Miami, Florida
| | - Katerina Dedeckova
- Proton Therapy Department, Proton Therapy Center, Prague, Czech Republic
| | - Mohammad K Khan
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Shinn-Yn Lin
- Department of Radiation Oncology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan City, Taiwan
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Eric Yi-Liang Shen
- Department of Radiation Oncology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan City, Taiwan
| | - Stephanie A Terezakis
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shahed N Badiyan
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Youlia M Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Richard T Hoppe
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Nancy P Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida; University of Florida Health Proton Therapy Institute, Jacksonville, Florida
| | - Mark Pankuch
- Northwestern Medicine Chicago Proton Center, Warrenville, Illinois
| | - Stella Flampouri
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida; University of Florida Health Proton Therapy Institute, Jacksonville, Florida
| | | | - Bradford S Hoppe
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida; University of Florida Health Proton Therapy Institute, Jacksonville, Florida.
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17
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Filippi AR, Levis M, Parikh R, Hoppe B. Optimal Therapy for Early-Stage Hodgkin's Lymphoma: Risk Adapting, Response Adapting, and Role of Radiotherapy. Curr Oncol Rep 2017; 19:34. [PMID: 28365830 DOI: 10.1007/s11912-017-0592-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE OF REVIEW The aim of this article is to discuss the current role of radiotherapy (RT) for early-stage Hodgkin's lymphoma (HL) in the context of risk-adapted and response-adapted treatment strategy, and describe changes in RT technical approach. RECENT FINDINGS In low-risk patients, RT could be omitted but, at the price of a lower progression-free survival, and its role is still debated. Ongoing trials are combining new agents with chemotherapy alone or response-adapted combined modality therapy, and results are awaited. Modern RT incorporates lower doses and smaller fields, together with the implementation of sophisticated delivery techniques aimed to reducing the dose to critical structures such as the heart. The role of RT for early-stage HL is still under debate, and new combinations are emerging; an individualized approach should be recommended, considering all RT technical opportunities to minimize toxicity while maintaining efficacy.
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Affiliation(s)
- Andrea Riccardo Filippi
- Department of Oncology, San Luigi Gonzaga University Hospital, University of Torino, Regione Gonzole 10, 10043, Orbassano, Turin, Italy.
| | - Mario Levis
- Department of Oncology, San Luigi Gonzaga University Hospital, University of Torino, Regione Gonzole 10, 10043, Orbassano, Turin, Italy
| | - Rahul Parikh
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, USA
| | - Bradford Hoppe
- Department of Radiation Oncology, University of Florida, Gainesville, USA.,University of Florida Health Proton Therapy Institute, Jacksonville, USA
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18
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Lee KA, O'Sullivan C, Daly P, Pears J, Owens C, Timmermann B, Ares C, Combs SE, Indelicato D, Capra M. Proton therapy in paediatric oncology: an Irish perspective. Ir J Med Sci 2016; 186:577-582. [PMID: 27744643 DOI: 10.1007/s11845-016-1520-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 10/11/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Proton therapy (PT) is a radiotherapy treatment modality that uses protons, rather than conventional photons. PT is often used in paediatric oncology due to its reported capability to reduce acute and late adverse treatment effects. As PT is unavailable in Ireland, patients are referred abroad for treatment. AIMS To: (1) produce a descriptive study of Irish children referred abroad for PT, and (2) discuss the case for PT in general. METHODS A retrospective review of all children referred for PT before October 2015 was performed. Information was gathered regarding demographics, diagnosis, referral timeline, adverse effects attributable to PT, current status and cost. A review of the relevant literature was performed. RESULTS Seventeen children treated in Ireland have been referred abroad for PT. The largest number was in the 0-4 year old group. At initial diagnosis the median age was 4.8 years. The average cost per child was €37,312. Two patients suffered disease relapse. Four have encountered PT-related adverse effects. CONCLUSION Despite the fact that >100,000 patients worldwide have been treated with PT, the level of published evidence to support superiority over conventional treatment remains low. It is debated that randomised control trials in this area would be inconsistent with the principle of clinical equipoise. In contrast, there is a call for level 1 evidence to justify drastic changes in patient care, particularly in light of recent reports of unexpected toxicities. In time, careful evaluation, follow-up and clinical trials will likely support the preferential use of PT in children.
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Affiliation(s)
- K A Lee
- St. Luke's Radiation Oncology Network, Radiation Oncology, Dublin, Ireland. .,Our Lady's Children's Hospital Crumlin, Paediatic Oncology, Dublin, Ireland.
| | - C O'Sullivan
- St. Luke's Radiation Oncology Network, Radiation Oncology, Dublin, Ireland.,Our Lady's Children's Hospital Crumlin, Paediatic Oncology, Dublin, Ireland
| | - P Daly
- St. Luke's Radiation Oncology Network, Radiation Oncology, Dublin, Ireland.,Our Lady's Children's Hospital Crumlin, Paediatic Oncology, Dublin, Ireland
| | - J Pears
- Our Lady's Children's Hospital Crumlin, Paediatic Oncology, Dublin, Ireland
| | - C Owens
- Our Lady's Children's Hospital Crumlin, Paediatic Oncology, Dublin, Ireland
| | - B Timmermann
- Department of Radiation Sciences (DRS), Institute of Innovative Radiotherapy (iRT), HelmholtzZentrum Munchen (HMGU) Ingolstädter Landstraße 1, 85764, Neuherberg, Germany.,Particle Therapy Department, West German Proton Therapy Centre Essen, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - C Ares
- Paul Scherrer Institute, Center for Proton Therapy, 5232, Villigen Psi, Switzerland.,Hopitaux Universitaires de Geneve, Service de Radio-oncologie, Geneve, GE, Switzerland
| | - S E Combs
- Universitätsklinikum Heidelberg, Klinik für Radioonkologie und Strahlentherapie Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Department of Radiation Oncology, Technical University of Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany
| | - D Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, 32610-0385, USA
| | - M Capra
- Our Lady's Children's Hospital Crumlin, Paediatic Oncology, Dublin, Ireland
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