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Casey DL, Vogelius IR, Brodin NP, Roberts KB, Avanzo M, Moni J, Owens C, Ronckers CM, Constine LS, Bentzen SM, Olch A. Risk of Subsequent Neoplasms in Childhood Cancer Survivors After Radiation Therapy: A PENTEC Comprehensive Review. Int J Radiat Oncol Biol Phys 2024; 119:640-654. [PMID: 37777927 DOI: 10.1016/j.ijrobp.2023.07.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 07/11/2023] [Accepted: 07/18/2023] [Indexed: 10/02/2023]
Abstract
PURPOSE A Pediatric Normal Tissue Effects in the Clinic (PENTEC) analysis of published investigations of central nervous system (CNS) subsequent neoplasms (SNs), subsequent sarcomas, and subsequent lung cancers in childhood cancer survivors who received radiation therapy (RT) was performed to estimate the effect of RT dose on the risk of SNs and the modification of this risk by host and treatment factors. METHODS AND MATERIALS A systematic literature review was performed to identify data published from 1975 to 2022 on SNs after prior RT in childhood cancer survivors. After abstract review, usable quantitative and qualitative data were extracted from 83 studies for CNS SNs, 118 for subsequent sarcomas, and 10 for lung SNs with 4 additional studies (3 for CNS SNs and 1 for lung SNs) later added. The incidences of SNs, RT dose, age, sex, primary cancer diagnosis, chemotherapy exposure, and latent time from primary diagnosis to SNs were extracted to assess the factors influencing risk for SNs. The excess relative ratio (ERR) for developing SNs as a function of dose was analyzed using inverse-variance weighted linear regression, and the ERR/Gy was estimated. Excess absolute risks were also calculated. RESULTS The ERR/Gy for subsequent meningiomas was estimated at 0.44 (95% CI, 0.19-0.68); for malignant CNS neoplasms, 0.15 (95% CI, 0.11-0.18); for sarcomas, 0.045 (95% CI, 0.023-0.067); and for lung cancer, 0.068 (95% CI, 0.03-0.11). Younger age at time of primary diagnosis was associated with higher risk of subsequent meningioma and sarcoma, whereas no significant effect was observed for age at exposure for risk of malignant CNS neoplasm, and insufficient data were available regarding age for lung cancer. Females had a higher risk of subsequent meningioma (odds ratio, 1.46; 95% CI, 1.22-1.76; P < .0001) relative to males, whereas no statistically significant sex difference was seen in risk of malignant CNS neoplasms, sarcoma SNs, or lung SNs. There was an association between chemotherapy receipt (specifically alkylating agents and anthracyclines) and subsequent sarcoma risk, whereas there was no clear association between specific chemotherapeutic agents and risk of CNS SNs and lung SNs. CONCLUSIONS This PENTEC systematic review shows a significant radiation dose-response relationship for CNS SNs, sarcomas, and lung SNs. Given the linear dose response, improved conformality around the target volume that limits the high dose volume might be a promising strategy for reducing the risk of SNs after RT. Other host- and treatment-related factors such as age and chemotherapy play a significant contributory role in the development of SNs and should be considered when estimating the risk of SNs after RT among childhood cancer survivors.
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Affiliation(s)
- Dana L Casey
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
| | - Ivan R Vogelius
- Department of Oncology, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - N Patrik Brodin
- Department of Radiation Oncology, Albert Einstein College of Medicine, Bronx, New York
| | - Kenneth B Roberts
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Michele Avanzo
- Division of Medical Physics, Centro di Riferimento Oncologico Aviano IRCCS, Aviano, Italy
| | - Janaki Moni
- Department of Radiation Oncology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Constance Owens
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Cécile M Ronckers
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Louis S Constine
- Departments of Radiation Oncology and Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Soren M Bentzen
- Division of Biostatistics and Bioinformatics, University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, Maryland; Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Arthur Olch
- Radiation Oncology Department, University of Southern California, Los Angeles, California; Children's Hospital Los Angeles, Los Angeles, California
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Gains JE, Patel A, Chang YC, Mandeville HC, Smyth G, Stacey C, Talbot J, Wheatley K, Gaze MN. A Randomised Phase II Trial to Evaluate the Feasibility of Radiotherapy Dose Escalation, Facilitated by Intensity-Modulated Arc Radiotherapy Techniques, in High-Risk Neuroblastoma. Clin Oncol (R Coll Radiol) 2024; 36:e154-e162. [PMID: 38553363 DOI: 10.1016/j.clon.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/17/2024] [Accepted: 03/08/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND AND PURPOSE For high-risk neuroblastoma, planning target volume coverage is often compromised to respect adjacent kidney tolerance. This trial investigated whether intensity-modulated arc radiotherapy techniques (IMAT) could facilitate dose escalation better than conventional techniques. MATERIALS AND METHODS Children with high-risk abdominal neuroblastoma referred for radiotherapy to the primary tumour site and involved regional lymph nodes were randomised to receive either standard dose (21 Gy in 14 fractions) or escalated dose (36 Gy in 24 fractions) radiotherapy. Dual planning with both a conventional anterior-posterior parallel opposed pair radiotherapy technique and an IMAT technique was performed. The quality of target volume and organ-at-risk delineation, and dosimetric plans, were externally reviewed. Dosimetric parameters were used to judge the superior technique for treatment. This feasibility trial was not powered to detect improvement in outcome with dose escalation. RESULTS Between 2017 and 2020, 50 patients were randomised and dual-planned. The IMAT technique was judged more favourable in 48 patients. In all patients randomised to receive 36 Gy, IMAT would have permitted delivery of the full dose (median D50% 36.0 Gy, inter-quartile range 36.0-36.1 Gy) to the target volume, whereas dose compromise would have been required with conventional planning (median D50% 35.6 Gy, inter-quartile range 28.7-35.9 Gy). CONCLUSION IMAT facilitates safe dose escalation to 36 Gy in patients receiving radiotherapy for neuroblastoma. The value of dose escalation is now being evaluated in a current prospective phase III randomised trial.
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Affiliation(s)
- J E Gains
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - A Patel
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Yen-Ch'ing Chang
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - H C Mandeville
- Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - G Smyth
- National Radiotherapy Trials Quality Assurance Group, The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - C Stacey
- Radiotherapy Physics Group, University College London Hospitals NHS Foundation Trust, London, UK
| | - J Talbot
- Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - K Wheatley
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - M N Gaze
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK. https://twitter.com/@MarkGaze
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Wase V, Wuyckens S, Lee JA, Saint-Guillain M. The proton arc therapy treatment planning problem is NP-Hard. Comput Biol Med 2024; 171:108139. [PMID: 38394800 DOI: 10.1016/j.compbiomed.2024.108139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/12/2024] [Accepted: 02/12/2024] [Indexed: 02/25/2024]
Abstract
Proton arc therapy (PAT) is an advanced radiotherapy technique using charged particles in which the radiation device rotates continuously around the patient while irradiating the tumor. Compared to conventional, fixed-angle beam delivery mode, proton arc therapy has the potential to further improve the quality of cancer treatment by delivering accurate radiation dose to tumors while minimizing damage to surrounding healthy tissues. However, the computational complexity of treatment planning in PAT raises challenges as to its effective implementation. In this paper, we demonstrate that designing a PAT plan through algorithmic methods is a NP-hard problem (in fact, NP-complete), where the problem size is determined by the number of discrete irradiation angles from which the radiation can be delivered. This finding highlights the inherent complexity of PAT treatment planning and emphasizes the need for efficient algorithms and heuristics to address the challenges associated with optimizing the delivery of radiation doses in this context.
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Affiliation(s)
- Viktor Wase
- RaySearch Laboratories AB, Stockholm, Sweden.
| | - Sophie Wuyckens
- UCLouvain, Molecular Imaging, Radiotherapy and Oncology (MIRO), Brussels, Belgium
| | - John A Lee
- UCLouvain, Molecular Imaging, Radiotherapy and Oncology (MIRO), Brussels, Belgium
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Patel TA, Jain B, Cho HL, Corti C, Vapiwala N, Chino F, Leeman JE, Dee EC. Second Malignancy Probabilities in Patients With Breast Cancer Treated With Conventional Versus Hypofractionated External Beam Radiation Therapy in the Adjuvant Setting. Clin Oncol (R Coll Radiol) 2024; 36:183-192. [PMID: 38184401 DOI: 10.1016/j.clon.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 10/12/2023] [Accepted: 12/05/2023] [Indexed: 01/08/2024]
Abstract
AIMS For women with breast cancer, seminal studies have shown that adjuvant hypofractionated external beam radiation therapy (hEBRT) maintains similar outcomes and may reduce overall costs compared with conventionally fractionated external beam radiation therapy (cEBRT). However, it is unclear whether hEBRT may be associated with differential risk of development of radiation-induced second malignancies compared with cEBRT. Because the occurrence of second malignancies is small, large databases may improve our understanding of the relative risk of second malignancies between hEBRT and cEBRT. MATERIALS AND METHODS Using the National Cancer Database, we carried out a retrospective cohort analysis of women diagnosed with non-metastatic, stage 0-III breast cancer from 2004 to 2017. All patients had a lumpectomy or mastectomy and a follow-up time of at least 60 months after diagnosis. The probability of second malignancies in women receiving adjuvant cEBRT or hEBRT was compared using multivariable logistic regression adjusting for sociodemographic, geographical, clinical and treatment factors, allowing for relative (but not absolute) comparison of second malignancy risk. Temporal sensitivity analyses stratified by year of diagnosis and length of follow-up time were also conducted. RESULTS Of the 125 228 women in our study, 115 576 (92.3%) received cEBRT and 9652 (7.71%) received hEBRT. The median age of the cohort was 60 (interquartile range 51-68) years at diagnosis and the median follow-up time was 99.61 (interquartile range 77.5-128.49) months. Upon adjusting for sociodemographic and clinical factors, patients who received hEBRT had no difference in relative risk than patients who received cEBRT (odds ratio 0.937, 95% confidence interval 0.869-1.010, P = 0.091). In analyses stratified by year of diagnosis, and stratified by length of follow-up, there was no difference in second malignancy probability between patients who completed hEBRT and patients who completed cEBRT. CONCLUSIONS In this analysis of over 120 000 women with non-metastatic breast cancer, hEBRT was not associated with different odds of developing second malignancies compared with cEBRT. Our findings may inform patient counselling in the choice of radiation regimens for breast cancer and further support the safety of hypofractionated regimens for breast cancer.
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Affiliation(s)
- T A Patel
- University of Pennsylvania, Philadelphia, PA, USA
| | - B Jain
- Stanford School of Medicine, Stanford, CA, USA
| | - H L Cho
- Department of Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - C Corti
- Breast Oncology Program, Dana-Farber Cancer Centre, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy; Department of Oncology and Hematology-Oncology (DIPO), University of Milan, Milan, Italy
| | - N Vapiwala
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - F Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - J E Leeman
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - E C Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Colori A, Ackwerh R, Chang YC, Cody K, Dunlea C, Gains JE, Gaunt T, Gillies CMS, Hardy C, Lalli N, Lim PS, Soto C, Gaze MN. Paediatric radiotherapy in the United Kingdom: an evolving subspecialty and a paradigm for integrated teamworking in oncology. Br J Radiol 2024; 97:21-30. [PMID: 38263828 PMCID: PMC11027255 DOI: 10.1093/bjr/tqad028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/03/2023] [Accepted: 10/18/2023] [Indexed: 01/25/2024] Open
Abstract
Many different malignancies occur in children, but overall, cancer in childhood is rare. Survival rates have improved appreciably and are higher compared with most adult tumour types. Treatment schedules evolve as a result of clinical trials and are typically complex and multi-modality, with radiotherapy an integral component of many. Risk stratification in paediatric oncology is increasingly refined, resulting in a more personalized use of radiation. Every available modality of radiation delivery: simple and advanced photon techniques, proton beam therapy, molecular radiotherapy, and brachytherapy, have their place in the treatment of children's cancers. Radiotherapy is rarely the sole treatment. As local therapy, it is often given before or after surgery, so the involvement of the surgeon is critically important, particularly when brachytherapy is used. Systemic treatment is the standard of care for most paediatric tumour types, concomitant administration of chemotherapy is typical, and immunotherapy has an increasing role. Delivery of radiotherapy is not done by clinical or radiation oncologists alone; play specialists and anaesthetists are required, together with mould room staff, to ensure compliance and immobilization. The support of clinical radiologists is needed to ensure the correct interpretation of imaging for target volume delineation. Physicists and dosimetrists ensure the optimal dose distribution, minimizing exposure of organs at risk. Paediatric oncology doctors, nurses, and a range of allied health professionals are needed for the holistic wrap-around care of the child and family. Radiographers are essential at every step of the way. With increasing complexity comes a need for greater centralization of services.
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Affiliation(s)
- Amy Colori
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, NW1 2PG, United Kingdom
| | - Raymond Ackwerh
- Department of Anaesthetics, University College London Hospitals NHS Foundation Trust, London, NW1 2BU, United Kingdom
| | - Yen-Ch’ing Chang
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, NW1 2PG, United Kingdom
| | - Kristy Cody
- Department of Radiotherapy, University College London Hospitals NHS Foundation Trust, London, NW1 2BU, United Kingdom
| | - Cathy Dunlea
- Department of Radiotherapy, University College London Hospitals NHS Foundation Trust, London, NW1 2BU, United Kingdom
| | - Jennifer E Gains
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, NW1 2PG, United Kingdom
| | - Trevor Gaunt
- Department of Radiology, University College London Hospitals NHS Foundation Trust, London, NW1 2BU, United Kingdom
| | - Callum M S Gillies
- Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, NW1 2PG, United Kingdom
| | - Claire Hardy
- Department of Radiotherapy, University College London Hospitals NHS Foundation Trust, London, NW1 2BU, United Kingdom
| | - Narinder Lalli
- Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, NW1 2PG, United Kingdom
| | - Pei S Lim
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, NW1 2PG, United Kingdom
| | - Carmen Soto
- Department of Paediatric Oncology, University College London Hospitals NHS Foundation Trust, London, NW1 2BU, United Kingdom
| | - Mark N Gaze
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, NW1 2PG, United Kingdom
- Department of Oncology, UCL Cancer Institute, University College London, London, WC1E 6DD, United Kingdom
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Toussaint L, Indelicato DJ, Muren LP, Stokkevåg CH. Risk of second primary cancer from proton arc therapy of pediatric brain tumors. Phys Imaging Radiat Oncol 2023; 27:100480. [PMID: 37655121 PMCID: PMC10465935 DOI: 10.1016/j.phro.2023.100480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 07/31/2023] [Accepted: 08/02/2023] [Indexed: 09/02/2023] Open
Abstract
Proton arc therapy (PAT) is currently explored for clinical implementation, despite its associated low-dose bath. This study therefore aimed at evaluating the risk of radiation-induced second primary cancer (SPC) for PAT in pediatric brain tumor patients. Two brain-specific models for SPC induction were applied in five cases to compare volumetric modulated arc therapy (VMAT), intensity modulated proton therapy (IMPT) and PAT surrogate plans. The PAT integral dose was reduced by a median of 29% compared to VMAT, and 17% compared to IMPT. For both models, the estimated SPC risks were consistently the lowest for PAT.
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Affiliation(s)
- Laura Toussaint
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Ludvig P Muren
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Camilla H Stokkevåg
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
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Kim N, Lim DH. Recent Updates on Radiation Therapy for Pediatric Optic Pathway Glioma. Brain Tumor Res Treat 2022; 10:94-100. [PMID: 35545828 PMCID: PMC9098980 DOI: 10.14791/btrt.2022.0003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 04/13/2022] [Accepted: 04/19/2022] [Indexed: 11/25/2022] Open
Abstract
Optic pathway glioma (OPG) is a rare tumor located in optic nerve, optic tract, or optic chiasm. Treatment options for OPG include surgery, radiation therapy (RT), and chemotherapy. Although RT may provide favorable long-term outcomes in manner of either adjuvant or salvage aim, chemotherapy-first approach is increasingly performed due to possible late effects of RT. Proton beam RT may allow normal tissue sparing of radiation exposure compared to conventional X-ray treatment. Therefore, proton beam RT is expected to reduce complications from RT. This review discusses the recent updates on oncologic outcomes of OPG, late toxicities following RT, and compares the outcomes between X-ray treatment and proton beam RT.
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Affiliation(s)
- Nalee Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Do Hoon Lim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Chang JS, Chang JH, Kim N, Kim YB, Shin KH, Kim K. Intensity Modulated Radiotherapy and Volumetric Modulated Arc Therapy in the Treatment of Breast Cancer: An Updated Review. J Breast Cancer 2022; 25:349-365. [DOI: 10.4048/jbc.2022.25.e37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 07/16/2022] [Accepted: 07/24/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jee Suk Chang
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hyun Chang
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Nalee Kim
- Department of Radiation Oncology, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Hwan Shin
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Ewha Womans University College of Medicine, Seoul, Korea
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