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Giannini N, Gadducci G, Fuentes T, Gonnelli A, Di Martino F, Puccini P, Naso M, Pasqualetti F, Capaccioli S, Paiar F. Electron FLASH radiotherapy in vivo studies. A systematic review. Front Oncol 2024; 14:1373453. [PMID: 38655137 PMCID: PMC11035725 DOI: 10.3389/fonc.2024.1373453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 03/15/2024] [Indexed: 04/26/2024] Open
Abstract
FLASH-radiotherapy delivers a radiation beam a thousand times faster compared to conventional radiotherapy, reducing radiation damage in healthy tissues with an equivalent tumor response. Although not completely understood, this radiobiological phenomenon has been proved in several animal models with a spectrum of all kinds of particles currently used in contemporary radiotherapy, especially electrons. However, all the research teams have performed FLASH preclinical studies using industrial linear accelerator or LINAC commonly employed in conventional radiotherapy and modified for the delivery of ultra-high-dose-rate (UHDRs). Unfortunately, the delivering and measuring of UHDR beams have been proved not to be completely reliable with such devices. Concerns arise regarding the accuracy of beam monitoring and dosimetry systems. Additionally, this LINAC totally lacks an integrated and dedicated Treatment Planning System (TPS) able to evaluate the internal dose distribution in the case of in vivo experiments. Finally, these devices cannot modify dose-time parameters of the beam relevant to the flash effect, such as average dose rate; dose per pulse; and instantaneous dose rate. This aspect also precludes the exploration of the quantitative relationship with biological phenomena. The dependence on these parameters need to be further investigated. A promising advancement is represented by a new generation of electron LINAC that has successfully overcome some of these technological challenges. In this review, we aim to provide a comprehensive summary of the existing literature on in vivo experiments using electron FLASH radiotherapy and explore the promising clinical perspectives associated with this technology.
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Affiliation(s)
- Noemi Giannini
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Tuscany, Italy
- Centro Pisano Multidisciplinare Sulla Ricerca e Implementazione Clinica Della Flash Radiotherapy (CPFR), University of Pisa, Pisa, Italy
| | - Giovanni Gadducci
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Tuscany, Italy
- Centro Pisano Multidisciplinare Sulla Ricerca e Implementazione Clinica Della Flash Radiotherapy (CPFR), University of Pisa, Pisa, Italy
| | - Taiusha Fuentes
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Tuscany, Italy
- Centro Pisano Multidisciplinare Sulla Ricerca e Implementazione Clinica Della Flash Radiotherapy (CPFR), University of Pisa, Pisa, Italy
| | - Alessandra Gonnelli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Tuscany, Italy
- Centro Pisano Multidisciplinare Sulla Ricerca e Implementazione Clinica Della Flash Radiotherapy (CPFR), University of Pisa, Pisa, Italy
| | - Fabio Di Martino
- Centro Pisano Multidisciplinare Sulla Ricerca e Implementazione Clinica Della Flash Radiotherapy (CPFR), University of Pisa, Pisa, Italy
- Unit of Medical Physics, Azienda Ospedaliero-Universitaria Pisana, Pisa, Tuscany, Italy
- National Institute of Nuclear Physics (INFN)-section of Pisa, Pisa, Tuscany, Italy
| | - Paola Puccini
- Department of Radiation Oncology, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Tuscany, Italy
| | - Monica Naso
- Department of Radiation Oncology, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Tuscany, Italy
| | - Francesco Pasqualetti
- Department of Radiation Oncology, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Tuscany, Italy
| | - Simone Capaccioli
- Centro Pisano Multidisciplinare Sulla Ricerca e Implementazione Clinica Della Flash Radiotherapy (CPFR), University of Pisa, Pisa, Italy
- Department of Physics, University of Pisa, Pisa, Tuscany, Italy
| | - Fabiola Paiar
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Tuscany, Italy
- Centro Pisano Multidisciplinare Sulla Ricerca e Implementazione Clinica Della Flash Radiotherapy (CPFR), University of Pisa, Pisa, Italy
- Department of Radiation Oncology, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Tuscany, Italy
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Köksal M, Baumert J, Jazmati D, Schoroth F, Garbe S, Koch D, Scafa D, Sarria GR, Leitzen C, Massoth G, Delis A, Heine A, Holderried T, Brossart P, Müdder T, Schmeel LC. Whole body irradiation with intensity-modulated helical tomotherapy prior to haematopoietic stem cell transplantation: analysis of organs at risk by dose and its effect on blood kinetics. J Cancer Res Clin Oncol 2023; 149:7007-7015. [PMID: 36856852 PMCID: PMC10374741 DOI: 10.1007/s00432-023-04657-7] [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: 01/25/2023] [Accepted: 02/15/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND Intensity-modulated helical tomotherapy (HT) is a promising technique in preparation for bone marrow transplantation. Nevertheless, radiation-sensitive organs can be substantially compromised due to suboptimal delivery techniques of total body irradiation (TBI). To reduce the potential burden of radiation toxicity to organs at risk (OAR), high-quality coverage and homogeneity are essential. We investigated dosimetric data from kidney, lung and thorax, liver, and spleen in relation to peripheral blood kinetics. To further advance intensity-modulated total body irradiation (TBI), the potential for dose reduction to lung and kidney was considered in the analysis. PATIENTS AND METHODS 46 patients undergoing TBI were included in this analysis, partially divided into dose groups (2, 4, 8, and 12 Gy). HT was performed using a rotating gantry to ensuring optimal reduction of radiation to the lungs and kidneys and to provide optimal coverage of other OAR. Common dosimetric parameters, such as D05, D95, and D50, were calculated and analysed. Leukocytes, neutrophils, platelets, creatinine, GFR, haemoglobin, overall survival, and graft-versus-host disease were related to the dosimetric evaluation using statistical tests. RESULTS The mean D95 of the lung is 48.23%, less than half the prescribed and unreduced dose. The D95 of the chest is almost twice as high at 84.95%. Overall liver coverage values ranged from 96.79% for D95 to 107% for D05. The average dose sparing of all patients analysed resulted in an average D95 of 68.64% in the right kidney and 69.31% in the left kidney. Average D95 in the spleen was 94.28% and D05 was 107.05%. Homogeneity indexes ranged from 1.12 for liver to 2.28 for lung. The additional significance analyses conducted on these blood kinetics showed a significant difference between the 2 Gray group and the other three groups for leukocyte counts. Further statistical comparisons of the dose groups showed no significant differences. However, there were significant changes in the dose of OAR prescribed with dose sparing (e.g., lung vs. rib and kidney). CONCLUSION Using intensity-modulated helical tomotherapy to deliver TBI is a feasible method in preparation for haematopoietic stem cell transplantation. Significant dose sparing in radiosensitive organs such as the lungs and kidneys is achievable with good overall quality of coverage. Peripheral blood kinetics support the positive impact of HT and its advantages strongly encourage its implementation within clinical routine.
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Affiliation(s)
- Mümtaz Köksal
- Radiation Oncology, University Hospital Bonn, Bonn, Germany.
| | | | - Danny Jazmati
- Radiation Oncology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Felix Schoroth
- Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | - Stephan Garbe
- Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | - David Koch
- Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | - Davide Scafa
- Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | | | | | - Gregor Massoth
- Anaesthesiology, Perioperative and Pain Medicine, University Hospital Bonn, Bonn, Germany
| | - Achilles Delis
- Anaesthesiology, Perioperative and Pain Medicine, University Hospital Bonn, Bonn, Germany
| | - Annkristin Heine
- Internal Medicine-Oncology, Haematology and Rheumatology, University Hospital Bonn, Bonn, Germany
| | - Tobias Holderried
- Internal Medicine-Oncology, Haematology and Rheumatology, University Hospital Bonn, Bonn, Germany
| | - Peter Brossart
- Internal Medicine-Oncology, Haematology and Rheumatology, University Hospital Bonn, Bonn, Germany
| | - Thomas Müdder
- Radiation Oncology, University Hospital Bonn, Bonn, Germany
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Reilly M, Dandapani SV, Kumar KA, Constine L, Fogh SE, Roberts KB, Small W, Schechter NR. ACR-ARS Practice Parameter for the Performance of Total Body Irradiation. Am J Clin Oncol 2023; 46:185-192. [PMID: 36907934 DOI: 10.1097/coc.0000000000000997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
OBJECTIVES This practice parameter was revised collaboratively by the American College of Radiology (ACR) and the American Radium Society (ARS). This practice parameter provides updated reference literature regarding both clinical-based conventional total body irradiation and evolving volumetric modulated total body irradiation. METHODS This practice parameter was developed according to the process described under the heading The Process for Developing ACR Practice Parameters and Technical Standards on the ACR website ( https://www.acr.org/Clinical-Resources/Practice-Parameters-and-Technical-Standards ) by the Committee on Practice Parameters-Radiation Oncology of the ACR Commission on Radiation Oncology in collaboration with the ARS. RESULTS This practice parameter provides a comprehensive update to the reference literature regarding conventional total body irradiation and modulated total body irradiation. Dependence on dose rate remains an active area of ongoing investigation in both the conventional setting (where instantaneous dose rate can be varied) and in more modern rotational techniques, in which average dose rate is the relevant variable. The role of imaging during patient setup and the role of inhomogeneity corrections due to computer-based treatment planning systems are included as evolving areas of clinical interest notably surrounding the overall dose inhomogeneity. There is increasing emphasis on the importance of evaluating mean lung dose as it relates to toxicity during high-dose total body irradiation regimens. CONCLUSIONS This practice parameter can be used as an effective tool in designing and evaluating a total body irradiation program that successfully incorporates the close interaction and coordination among the radiation oncologists, medical physicists, dosimetrists, nurses, and radiation therapists.
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Affiliation(s)
| | | | - Kiran A Kumar
- UT Southwestern Medical Center 5323 Harry Hines Blvd, Dallas, TX
| | - Louis Constine
- University of Rochester Medical Center 601 Elmwood Ave, Rochester, NY
| | - Shannon E Fogh
- Department of Radiation Oncology, University of California San Francisco, CA
| | | | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago Loyola University Medical Center Department of Radiation Oncology Maguire Center - Room 2944 2160 S. 1st Ave. Maywood, IL
| | - Naomi R Schechter
- South Florida Proton Therapy Institute and Rakuten-Medical, Inc., Delray Beach, FL
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Köksal M, Baumert J, Schoroth F, Müdder T, Scafa D, Koch D, Leitzen C, Sarria GR, Schmeel LC, Giordano FA. Helical versus static approaches to delivering tomotherapy to the junctional target for patients taller than 135 cm undergoing total body irradiation. Eur J Med Res 2022; 27:265. [PMID: 36434707 PMCID: PMC9694876 DOI: 10.1186/s40001-022-00886-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 11/05/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Helical TomoTherapy® is widely used for total body irradiation as a component of conditioning regimens before allogeneic bone-marrow transplantation. However, this technique limits the maximum length of a planning target volume to 135 cm. Therefore, patients taller than 135 cm require two planning computed tomography scans and treatment plans. The junctional target between these two treatment plans is thus a critical region for treatment planning and delivery. Here, we compare radiation coverage of the junctional target between helical and static approaches to treatment planning and delivery to determine which approach allows high quality irradiation planning and provides more robustness against patient movement. METHODS We retrospectively analyzed 10 patients who underwent total body irradiation using a static four-field box planning approach and nine patients who underwent total body irradiation using a helical planning approach. All patients were taller than 135 cm. The junctional target volume was divided into 10 slices of 1 cm thickness (JT1-JT10) for analysis. Dosimetric parameters and dose-volume histograms were compared to assess the quality of coverage of the junctional target between the helical and static planning approaches. RESULTS The D50 for the total junctional target was slightly higher than the prescribed dose for both helical and static approaches, with a mean of 108.12% for the helical group and 107.81% for the static group. The mean D95 was 98.44% ± 4.19% for the helical group and 96.20% ± 4.59% for the static group. The mean homogeneity index covering the entire junctional target volume was 1.20 ± 0.04 for the helical group and 1.21 ± 0.05 for the static group. The mean homogeneity index ranged from 1.08 ± 0.01 in JT1 to 1.22 ± 0.06 in JT6 for the helical group and from 1.06 ± 0.02 in JT1 to 1.19 ± 0.05 in JT6 for the static group. There were no significant differences in parameters between helical and static groups. However, the static approach provided robustness against up to 30 mm of lateral movement of the patient. CONCLUSIONS As long as TBI using helical TomoTherapy® is limited to a maximum length of 135 cm, the junctional target must be addressed during treatment planning. Our analysis shows that the static four-field box approach is viable and offers higher robustness against lateral movement of the patient than the helical approach.
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Affiliation(s)
- Mümtaz Köksal
- Department of Radiation Oncology, University Medical Center Bonn, Bonn, Germany
| | - Jonathan Baumert
- Department of Radiation Oncology, University Medical Center Bonn, Bonn, Germany
| | - Felix Schoroth
- Department of Radiation Oncology, University Medical Center Bonn, Bonn, Germany
| | - Thomas Müdder
- Department of Radiation Oncology, University Medical Center Bonn, Bonn, Germany
| | - Davide Scafa
- Department of Radiation Oncology, University Medical Center Bonn, Bonn, Germany
| | - David Koch
- Department of Radiation Oncology, University Medical Center Bonn, Bonn, Germany
| | - Christina Leitzen
- Department of Radiation Oncology, University Medical Center Bonn, Bonn, Germany
| | - Gustavo R. Sarria
- Department of Radiation Oncology, University Medical Center Bonn, Bonn, Germany
| | - Leonard C. Schmeel
- Department of Radiation Oncology, University Medical Center Bonn, Bonn, Germany
| | - Frank A. Giordano
- Department of Radiation Oncology, University Medical Center Bonn, Bonn, Germany ,grid.411778.c0000 0001 2162 1728Department of Radiation Oncology, University Medical Center Mannheim, Mannheim, Germany
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Oertel M, Eich HT. Strahlentherapeutische Behandlung von Leukämien. BEST PRACTICE ONKOLOGIE 2022. [PMCID: PMC9472722 DOI: 10.1007/s11654-022-00431-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Hintergrund Ziel der Arbeit Material und Methoden Ergebnisse Schlussfolgerung
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Affiliation(s)
- Michael Oertel
- Klinik für Strahlentherapie – Radioonkologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149 Münster, Deutschland
| | - Hans Theodor Eich
- Klinik für Strahlentherapie – Radioonkologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149 Münster, Deutschland
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6
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Abstract
Hintergrund Lymphoide Zellen weisen eine hohe Strahlensensitivität auf, sodass die Strahlentherapie eine sinnvolle Ergänzung der Systemtherapie bei Leukämien darstellt. Vor allem als konditionierende Behandlung vor allogener Stammzelltransplantation ist die Radiotherapie in Form einer Ganzkörperbestrahlung etabliert. Ziel der Arbeit Die vorliegende Arbeit ermöglicht einen Überblick über Durchführung und Nebenwirkungen der strahlentherapeutischen Behandlung bei Leukämien. Hierbei werden insbesondere die (Langzeit‑)Nebenwirkungen nach Ganzkörperbestrahlung dargestellt. Material und Methoden Es erfolgte eine selektive Literaturrecherche über die Datenbank PubMed zur Radiotherapie von Leukämien und zu Ganzkörperbestrahlungen mit Fokus auf Nebenwirkungen sowie technische und konzeptionelle Neuerungen. Ergebnisse Die Ganzkörperbestrahlung ist eine effektive Therapie zur Konditionierung vor allogener Stammzelltransplantation und weist ein diverses, aber beherrschbares, Toxizitätsspektrum mit endokrinen, kardiopulmonalen, okulären, nephrologischen und neurologischen Langzeitnebenwirkungen sowie Sekundärneoplasien auf. Zusätzlich kann eine Radiotherapie in Niedrigdosis effektiv zur Behandlung myeloider Sarkome (Chlorome) angewendet werden. Schlussfolgerung Die Vielfalt der Nebenwirkungen nach Ganzkörperbestrahlung erfordert eine interdisziplinäre und langfristige Nachsorgebetreuung durch internistische Onkolog*innen/Transplantationsmediziner*innen und Radioonkolog*innen. Technische Entwicklungen der Strahlentherapie können in Zukunft eine selektive Adressierung des Knochenmarks sowie der lymphatischen Organe realisieren. Aktuell sind diese noch nicht in der klinischen Routine etabliert und werden im Rahmen klinischer Studien evaluiert.
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Arora A, Bhuria V, Singh S, Pathak U, Mathur S, Hazari PP, Roy BG, Sandhir R, Soni R, Dwarakanath BS, Bhatt AN. Amifostine analog, DRDE-30, alleviates radiation induced lung damage by attenuating inflammation and fibrosis. Life Sci 2022; 298:120518. [PMID: 35367468 DOI: 10.1016/j.lfs.2022.120518] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 03/18/2022] [Accepted: 03/26/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Radiotherapy of thoracic neoplasms and accidental radiation exposure often results in pneumonitis and fibrosis of lungs. Here, we investigated the potential of amifostine analogs: DRDE-07, DRDE-30, and DRDE-35, in alleviating radiation-induced lung damage. METHODS C57BL/6 mice were exposed to 13.5 Gy thoracic irradiation, 30 min after intraperitoneal administration of the analogs, and assessed for modulation of the pathological response at 12 and 24 weeks. KEY FINDINGS DRDE-07, DRDE-30 and DRDE-35 increased the survival of irradiated mice from 20% to 30%, 80% and 70% respectively. Reduced parenchymal opacity (X-ray CT) in the lungs of DRDE-30 pre-treated mice corroborated well with the significant decrease in Ashcroft score (p < 0.01). Two-fold increase in SOD and catalase activities (p < 0.05), coupled with a 50% increase in GSH content and a 60% decrease in MDA content (p < 0.05) suggested restoration of the antioxidant defence system. A 20% to 40% decrease in radiation-induced apoptotic and mitotic death in the lung tissue (micronuclei: p < 0.01), resulted in attenuated lung and vascular permeability (FITC-Dextran leakage) by 50% (p < 0.01), and a commensurate reduction (~50%) in leukocyte infiltration in the injured tissue (p < 0.05). DRDE-30 abrogated the activation of pro-inflammatory NF-κB and p38/MAPK signaling cascades, suppressing the release of pro-inflammatory cytokines (IL-1β: p < 0.05; TNF-α: p < 0.05; IL-6: p < 0.05) and up-regulation of CAMs on the endothelial cell surface. Reduction in hydroxyproline content (p < 0.01) and collagen suggested inhibition of lung fibrosis which was associated with attenuation of TGF-β/Smad pathway-mediated-EMT. CONCLUSION DRDE-30 could be a potential prophylactic agent against radiation-induced lung injury.
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Affiliation(s)
- Aastha Arora
- Institute of Nuclear Medicine & Allied Sciences, Delhi, India; Department of Biochemistry, Panjab University, Chandigarh, India
| | - Vikas Bhuria
- Institute of Nuclear Medicine & Allied Sciences, Delhi, India
| | - Saurabh Singh
- Institute of Nuclear Medicine & Allied Sciences, Delhi, India
| | - Uma Pathak
- Defence Research and Development Establishment, Gwalior, India
| | - Sweta Mathur
- Defence Research and Development Establishment, Gwalior, India
| | - Puja P Hazari
- Institute of Nuclear Medicine & Allied Sciences, Delhi, India
| | - Bal G Roy
- Institute of Nuclear Medicine & Allied Sciences, Delhi, India
| | - Rajat Sandhir
- Department of Biochemistry, Panjab University, Chandigarh, India
| | - Ravi Soni
- Institute of Nuclear Medicine & Allied Sciences, Delhi, India
| | - Bilikere S Dwarakanath
- Institute of Nuclear Medicine & Allied Sciences, Delhi, India; Central Research Facility, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
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8
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Sieker K, Fleischmann M, Trommel M, Ramm U, Licher J, Bug G, Martin H, Serve H, Rödel C, Balermpas P. Twenty years of experience of a tertiary cancer center in total body irradiation with focus on oncological outcome and secondary malignancies. Strahlenther Onkol 2022; 198:547-557. [PMID: 35318487 PMCID: PMC9165288 DOI: 10.1007/s00066-022-01914-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 02/20/2022] [Indexed: 12/17/2022]
Abstract
Purpose Total body irradiation (TBI) is a common part of the myelo- and immuno-ablative conditioning regimen prior to an allogeneic hematopoietic stem cell transplantation (allo-HSCT). Due to concerns regarding acute and long-term complications, there is currently a decline in otherwise successfully established TBI-based conditioning regimens. Here we present an analysis of patient and treatment data with focus on survival and long-term toxicity. Methods Patients with hematologic diseases who received TBI as part of their conditioning regimen prior to allo-HSCT at Frankfurt University Hospital between 1997 and 2015 were identified and retrospectively analyzed. Results In all, 285 patients with a median age of 45 years were identified. Median radiotherapy dose applied was 10.5 Gy. Overall survival at 1, 2, 5, and 10 years was 72.6, 64.6, 54.4, and 51.6%, respectively. Median follow-up of patients alive was 102 months. The cumulative incidence of secondary malignancies was 12.3% (n = 35), with hematologic malignancies and skin cancer predominating. A TBI dose ≥ 8 Gy resulted in significantly improved event-free (p = 0.030) and overall survival (p = 0.025), whereas a total dose ≤ 8 Gy and acute myeloid leukemia (AML) diagnosis were associated with significantly increased rates of secondary malignancies (p = 0.003, p = 0.048) in univariate analysis. No significant correlation was observed between impaired renal or pulmonary function and TBI dose. Conclusion TBI remains an effective and well-established treatment, associated with distinct late-toxicity. However, in the present study we cannot confirm a dose–response relationship in intermediate dose ranges. Survival, occurrence of secondary malignancies, and late toxicities appear to be subject to substantial confounding in this context. Supplementary Information The online version of this article (10.1007/s00066-022-01914-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Katharina Sieker
- Department of Radiation Oncology, University Hospital-Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Maximilian Fleischmann
- Department of Radiation Oncology, University Hospital-Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
| | - Martin Trommel
- Department of Radiation Oncology, University Hospital-Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Ulla Ramm
- Department of Radiation Oncology, University Hospital-Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Jörg Licher
- Department of Radiation Oncology, University Hospital-Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Gesine Bug
- Department of Medicine 2, Hematology/Oncology, Goethe University, Frankfurt, Germany
| | - Hans Martin
- Department of Medicine 2, Hematology/Oncology, Goethe University, Frankfurt, Germany
| | - Hubert Serve
- Department of Medicine 2, Hematology/Oncology, Goethe University, Frankfurt, Germany.,Frankfurt Cancer Institute, Goethe University, Frankfurt/Main, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK) partner site: Frankfurt am Main, Frankfurt am Main, Germany
| | - Claus Rödel
- Department of Radiation Oncology, University Hospital-Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.,Frankfurt Cancer Institute, Goethe University, Frankfurt/Main, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK) partner site: Frankfurt am Main, Frankfurt am Main, Germany
| | - Panagiotis Balermpas
- Department of Radiation Oncology, University Hospital-Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.,Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
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9
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Oertel M, Martel J, Mikesch JH, Scobioala S, Reicherts C, Kröger K, Lenz G, Stelljes M, Eich HT. The Burden of Survivorship on Hematological Patients-Long-Term Analysis of Toxicities after Total Body Irradiation and Allogeneic Stem Cell Transplantation. Cancers (Basel) 2021; 13:cancers13225640. [PMID: 34830802 PMCID: PMC8616356 DOI: 10.3390/cancers13225640] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/04/2021] [Accepted: 11/09/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary Total body irradiation is an essential large-field technique enabling myeloablation before allogeneic stem cell transplantation. With its field encompassing all organs, a diverse spectrum of toxicities may arise. This work analyzes long-term pulmonary, cardiac, ocular, neurological and renal toxicities in a monocentric patient cohort and identifies possible risk factors. Both the number of patients and the duration of the follow-up period exceed those of many comparable studies in the literature. Abstract Total body irradiation is an effective conditioning modality before autologous or allogeneic stem cell transplantation. With the whole body being the radiation target volume, a diverse spectrum of toxicities has been reported. This fact prompted us to investigate the long-term sequelae of this treatment concept in a large patient cohort. Overall, 322 patients with acute leukemia or myelodysplastic syndrome with a minimum follow-up of one year were included (the median follow-up in this study was 68 months). Pulmonary, cardiac, ocular, neurological and renal toxicities were observed in 23.9%, 14.0%, 23.6%, 23.9% and 20.2% of all patients, respectively. The majority of these side effects were grades 1 and 2 (64.9–89.2% of all toxicities in the respective categories). The use of 12 Gray total body irradiation resulted in a significant increase in ocular toxicities (p = 0.013) and severe mucositis (p < 0.001). Renal toxicities were influenced by the age at transplantation (relative risk: 1.06, p < 0.001) and disease entity. In summary, total body irradiation triggers a multifaceted, but manageable, toxicity profile. Except for ocular toxicities and mucositis, a 12 Gray regimen did not lead to an increase in long-term side effects.
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Affiliation(s)
- Michael Oertel
- Department of Radiation Oncology, University Hospital Muenster, 48149 Munster, Germany; (J.M.); (S.S.); (K.K.); (H.T.E.)
- Correspondence: ; Tel.: +49-251-83-47384; Fax: +49-251-83-47355
| | - Jonas Martel
- Department of Radiation Oncology, University Hospital Muenster, 48149 Munster, Germany; (J.M.); (S.S.); (K.K.); (H.T.E.)
| | - Jan-Henrik Mikesch
- Department of Medicine A—Hematology, Hemostaseology, Oncology, Pulmonology, University Hospital Muenster, 48149 Munster, Germany; (J.-H.M.); (C.R.); (G.L.); (M.S.)
| | - Sergiu Scobioala
- Department of Radiation Oncology, University Hospital Muenster, 48149 Munster, Germany; (J.M.); (S.S.); (K.K.); (H.T.E.)
| | - Christian Reicherts
- Department of Medicine A—Hematology, Hemostaseology, Oncology, Pulmonology, University Hospital Muenster, 48149 Munster, Germany; (J.-H.M.); (C.R.); (G.L.); (M.S.)
| | - Kai Kröger
- Department of Radiation Oncology, University Hospital Muenster, 48149 Munster, Germany; (J.M.); (S.S.); (K.K.); (H.T.E.)
| | - Georg Lenz
- Department of Medicine A—Hematology, Hemostaseology, Oncology, Pulmonology, University Hospital Muenster, 48149 Munster, Germany; (J.-H.M.); (C.R.); (G.L.); (M.S.)
| | - Matthias Stelljes
- Department of Medicine A—Hematology, Hemostaseology, Oncology, Pulmonology, University Hospital Muenster, 48149 Munster, Germany; (J.-H.M.); (C.R.); (G.L.); (M.S.)
| | - Hans Theodor Eich
- Department of Radiation Oncology, University Hospital Muenster, 48149 Munster, Germany; (J.M.); (S.S.); (K.K.); (H.T.E.)
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10
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Pearlman R, Hanna R, Burmeister J, Abrams J, Dominello M. Adverse Effects of Total Body Irradiation: A Two-Decade, Single Institution Analysis. Adv Radiat Oncol 2021; 6:100723. [PMID: 34195500 PMCID: PMC8237301 DOI: 10.1016/j.adro.2021.100723] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 04/26/2021] [Accepted: 05/07/2021] [Indexed: 12/18/2022] Open
Abstract
Purpose Several adverse effects have been reported in the literature associated with total body irradiation (TBI). Reports of the adverse effects of TBI have been primarily drawn from single-institution retrospective analyses. We report, to our knowledge, one of the largest cohorts of patients treated with TBI using multiple preparative chemotherapy and radiation regimens. Methods and Materials A retrospective chart review was performed for all 705 patients treated with TBI at our institution from 1995 to 2017. Based on availability of TBI records, 622 patients (88%) had sufficient evaluable documentation for analysis. Patients received 1 of 4 conditioning regimens: busulfan-fludarabine, 2 Gy (BUFLU); fludarabine-melphalan, 2 Gy (FLUMEL); cyclophosphamide, 12 Gy fractionated (CY); or etoposide, 12 Gy fractionated (VP16). Individual patients were evaluated for 13 specific recognized adverse effects based on the Common Terminology Criteria for Adverse Events, version 5.0. Results Mucositis (grade 3) was the most common serious adverse effect and occurred most frequently in the group receiving the VP16 12 Gy regimen (40% vs less than 14% in each of the other groups). Serious febrile neutropenia (grade 3-5) was less frequent (24%) among patients receiving CY than among those receiving the other conditioning regimens (more than 38% in each of the other groups). The incidence of serious lung infection was less common (5%) in patients receiving CY than in those receiving VP16 (18%). There was a higher frequency of grade 3-5 diarrhea among those receiving FLUMEL (5%) and VP16 (4%) than in the other groups (<3%) (P = .034). Otherwise, there were no detectable differences in serious toxicity by regimen for the 13 adverse effects reviewed. Only 2 secondary malignancies were reported, and both were in the BUFLU group. Cataract formation occurred in approximately 16% of patients overall, and the rates were similar across regimens. Median time to cataract formation was 1 to 4 years across regimens, with cataracts occurring earlier in the 2-Gy regimens. The overall rate of grade ≥3 pneumonitis was approximately 2% across the entire cohort. Conclusions Our nearly 20-year TBI experience showed relatively low rates of radiation-related toxicities. However, cataracts were common with a relatively short onset time.
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Affiliation(s)
- Richard Pearlman
- Detroit Medical Center, Detroit, Michigan
- Corresponding author: Richard Pearlman, MD
| | - Renee Hanna
- Michigan State University College of Human Medicine, Lansing, Michigan
| | - Jay Burmeister
- Wayne State University, Detroit, Michigan
- Karmanos Cancer Institute, Detroit, Michigan
- Corresponding author: Richard Pearlman, MD
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11
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Cardiotoxicity of mediastinal radiotherapy. Rep Pract Oncol Radiother 2019; 24:629-643. [PMID: 31719801 DOI: 10.1016/j.rpor.2019.09.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 09/21/2019] [Indexed: 12/16/2022] Open
Abstract
Aim To explore available recent literature related to cardiotoxicity following mediastinal radiation. Background Radiotherapy-related heart injury is well documented, with no apparent safety threshold dose. The number of long-term cancer survivors exposed to mediastinal radiotherapy at some point of their treatment is increasing. Heart dosimetric parameters are of great importance in developing a treatment plan, but few data are available regarding radiosensitivity and dose-volume constraints for specific heart structures. Materials and Methods In October 2018, we identified articles published after 1990 through a PubMed/MEDLINE database search. The authors examined rough search results and manuscripts not relevant for the topic were excluded. We extracted clinical outcomes following mediastinal radiotherapy of childhood cancers, lymphoma, medulloblastoma, thymic cancers and hematopoietic cell transplantation survivors and evaluated treatment planning data, whenever available. Results A total of 1311 manuscripts were identified in our first-round search. Of these manuscripts, only 115 articles, matching our selection criteria, were included. Conclusions Studies uniformly show a linear radiation dose-response relationship between mean absorbed dose to the heart (heart-Dmean) and the risk of dying as a result of cardiac disease, particularly when heart-Dmean exceeds 5 Gy. Limited data are available regarding dose-volume predictors for heart substructures and the risk of subsequent cardiac toxicity. An individual patient's cardiotoxicity risk can be modified with advanced treatment planning techniques, including deep inspiration breath hold. Proton therapy is currently showing advantages in improving treatment planning parameters when compared to advanced photon techniques in lymphoma, thymic malignancies, malignant mesothelioma and craniospinal irradiation.
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Key Words
- 2D-RT, two-dimensional radiotherapy
- 3D-CRT, three-dimensional conformal radiation therapy
- CI, confidence interval
- CSI, craniospinal irradiation
- CVD, Cardiovascular disease
- Cardiotoxicity
- Dmax, maximum absorbed dose in a specified volume
- Dmean, mean absorbed radiation dose in a specified volume
- Dose-volume predictors
- EQD2, equivalent dose in 2 Gy fractions
- G, grade
- Gy, Gray
- HR, hazard ratio
- HT, Helical tomotherapy
- IFRT, involved field radiotherapy
- IMRT, intensity modulated radiation therapy
- INRT, involved node radiotherapy
- ISRT, involved site radiotherapy
- LAD, left anterior descending artery
- Mediastinal radiotherapy
- Mediastinal tumours
- Mv, megavoltage
- NTCP, normal tissue complication probability
- Normal tissue complication probability
- OAR, organs at risk
- OR, odds ratio
- PTV, planning target volume
- RR, relative risks
- TBI, total body irradiation
- VMAT, volumetric modulated arc therapy
- Vx, receiving at last x Gy
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12
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Potdar RR, Gupta S, Giebel S, Savani BN, Varadi G, Nagler A, Blamek S. Current Status and Perspectives of Irradiation-Based Conditioning Regimens for Patients with Acute Leukemia Undergoing Hematopoietic Stem Cell Transplantation. Clin Hematol Int 2019; 1:19-27. [PMID: 34595407 PMCID: PMC8432382 DOI: 10.2991/chi.d.190218.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 02/18/2019] [Indexed: 11/01/2022] Open
Abstract
Acute myeloid leukemia and acute lymphoblastic leukemia are the most common indications for allogeneic hematopoietic stem cell transplantation. Total body irradiation (TBI) is an important part of conditioning regimens. TBI-based regimens offer advantages in sanctuary sites but are associated with significant risks of early and late side effects, including pulmonary toxicity, growth retardation, and second malignancy. TBI is also associated with technical problems, such as dose heterogeneity. With evolving techniques in radiation oncology, it is possible to focus the dose to the entire skeleton while sparing the rest of the body. This technique is called total marrow irradiation (TMI). TMI is able to deliver the same or higher doses to bone marrow while reducing toxicity. With the success of TMI, we are moving toward ultra-personalized conditioning. We review the clinical role of the irradiation-based regimens currently in clinical use, emphasizing on their strengths and limitations. Novel technologies with targeted irradiation accompanied by the modern imaging techniques and increased knowledge of the disease process can help us achieve our goal of maximum response with minimum toxicity.
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Affiliation(s)
- Rashmika R Potdar
- Division of Hematology and Oncology, Department of Internal Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Sorab Gupta
- Division of Hematology and Oncology, Department of Internal Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Sebastian Giebel
- Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie Institute-Oncology Center, Gliwice Branch, Gliwice, Poland
| | - Bipin N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center & Veterans Affairs Medical Center, Nashville, TN, USA
| | - Gabor Varadi
- Division of Hematology and Oncology, Department of Internal Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Arnon Nagler
- Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel
| | - Slawomir Blamek
- Department of Radiotherapy, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Gliwice, Poland
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13
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Usui K, Isobe A, Hara N, Shikama N, Sasai K, Ogawa K. Appropriate treatment planning method for field joint dose in total body irradiation using helical tomotherapy. Med Dosim 2018; 44:344-353. [PMID: 30598391 DOI: 10.1016/j.meddos.2018.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 10/21/2018] [Accepted: 12/13/2018] [Indexed: 10/27/2022]
Abstract
Total body irradiation (TBI) using helical tomotherapy (HT) has advantages over the standard linear accelerator-based approach to the conditioning regimen for hematopoietic cell transplantation. However, the radiation field has to be divided into two independent irradiation plans to deliver a homogeneous dose to the whole body. A clinical target volume near the skin increases the skin surface dose; therefore, high- or low-dose regions arise depending on the set-up position accuracy because the two radiation fields are somewhat overlapped or separated. We aimed to determine an adequate treatment planning method robust to the set-up accuracy for the field joint dose distribution using HT-TBI. We calculated treatment plans reducing target volumes at the interface between the upper and lower body irradiations and evaluated these joint dose distributions via simulation and experimental studies. Target volumes used for the optimization calculation were reduced by 0, 0.5, 1.0, 2.0, 2.5, and 3.0 cm from the boundary surface on the upper and lower sides. Combined dose distributions with set-up error simulated by modifying coordinate positions were investigated to find the optimal planning method. In the ideal set-up position, the target volume without a gap area caused field junctional doses of up to approximately 200%; therefore, target volumes reduced by 2.0-3.0 cm could suppress the maximum dose to within 150%. However, with set-up error, high-dose areas exceeding 150% and low-dose areas below 100% were found with 2.0 and 3.0 cm target volume reduction. Using the dynamic jaw (DJ) system, dose deviations caused by set-up error reached approximately 20%, which is not suitable for HT-TBI. Moreover, these dose distributions can be easily adjusted when combined with the intensity modulation technique for field boundary regions. The results of a simulation and experimental study using a film dosimetry were almost identical, which indicated that reducing the target volume at the field boundary surface by 2.5 cm produces the most appropriate target definition.
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Affiliation(s)
- Keisuke Usui
- Department of Radiation Oncology, Juntendo University, Bunkyo-ku, Tokyo, Japan.
| | - Akira Isobe
- Department of Radiology, Juntendo University Hospital, Bunkyo-ku, Tokyo, Japan
| | - Naoya Hara
- Department of Radiology, Juntendo University Hospital, Bunkyo-ku, Tokyo, Japan
| | - Naoto Shikama
- Department of Radiation Oncology, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Keisuke Sasai
- Department of Radiation Oncology, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Koichi Ogawa
- Faculty of Science and Engineering, Hosei University, Koganei, Tokyo, Japan
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14
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Single-Dose Daily Fractionation Is Not Inferior to Twice-a-Day Fractionated Total-Body Irradiation Before Allogeneic Stem Cell Transplantation for Acute Leukemia: A Useful Practice Simplification Resulting From the SARASIN Study. Int J Radiat Oncol Biol Phys 2018; 102:515-526. [PMID: 29928948 DOI: 10.1016/j.ijrobp.2018.06.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 06/01/2018] [Accepted: 06/09/2018] [Indexed: 01/28/2023]
Abstract
PURPOSE Total-body irradiation (TBI) is a major constituent of myeloablative conditioning regimens. The standard technique consists of 12 Gy in 6 fractions over a period of 3 days. The Standard-fractionation compAred to one-daily fRaction total body irrAdiation prior to tranSplant In LEUkemia patieNts (SARASIN) study aimed to compare standard fractionation with once-daily fractionation before transplant in leukemia. METHODS AND MATERIALS We retrospectively compared TBI regimens delivered in 2993 patients from the European Society for Blood and Marrow Transplantation database, who underwent transplantation between 2000 and 2014 for acute lymphoblastic leukemia (ALL, n = 1729) or acute myeloid leukemia (AML, n = 1264). TBI was delivered as either 12 Gy in 6 fractions (group 1, considered the reference group; 1362 ALL and 857 AML patients), 9 to 12 Gy in 2 fractions (group 2, 173 ALL and 256 AML patients), or 12 Gy in 3 to 4 fractions (group 3, 194 ALL and 151 AML patients). RESULTS The median follow-up was 60 and 84 months in ALL and AML patients, respectively. At 5 years, the leukemia-free survival rate, overall survival rate, relapse incidence, and nonrelapse mortality rate were 46.6%, 50.4%, 28.8%, and 24.6%, respectively, in ALL patients and 46.6%, 48.9%, 29.7%, and 23.6%, respectively, in AML patients. In multivariate analyses, the outcomes of groups 2 and 3 were not statistically different from those in group 1. The cumulative incidence of secondary malignancies (SMs) was significantly higher in group 2 (7.2%; P < 10-6 for group 2 vs group 1). However, group 2 was not associated with an increase in SMs when we considered non-T-cell-depleted transplant patients. CONCLUSIONS We showed that the 12-Gy fractionated TBI dose delivered either in 2 fractions or in 1 fraction per day over a period of 3 to 4 days resulted in nonsignificant differences in disease control and survival. However, 1-day fractionation may be associated with a higher risk of mucositis and hemorrhagic cystitis. The absence of a significant difference in the SM incidence in the non-T-cell-depleted group should be interpreted with caution in the context of a retrospective study design. Our findings are important to consider for radiation therapy department organization. In-depth analyses of other nonlethal toxicities and late effects are required.
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15
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Paix A, Antoni D, Waissi W, Ledoux MP, Bilger K, Fornecker L, Noel G. Total body irradiation in allogeneic bone marrow transplantation conditioning regimens: A review. Crit Rev Oncol Hematol 2018; 123:138-148. [PMID: 29482775 DOI: 10.1016/j.critrevonc.2018.01.011] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 09/28/2017] [Accepted: 01/24/2018] [Indexed: 12/30/2022] Open
Abstract
Hematologic malignancies may require, at one point during their treatment, allogeneic bone marrow transplantation. Total body irradiation combined with chemotherapy or radiomimetic used in allogeneic bone marrow transplantation is known to be very toxic. Total body irradiation (TBI) induces immunosuppression to prevent the rejection of donor marrow. TBI is also used to eradicate malignant cells and is in sanctuary organs that are not reached by chemotherapy drugs. TBI has evolved since its introduction in the late fifties, but acute and late toxicities remain. Helical tomotherapy, which is widely used for some solid tumors, is a path for the improvement of outcomes and toxicities in TBI because of its sparing capacities. In this article, we first review the practical aspects of TBI with patient positioning, radiobiological considerations and total dose and fractionation prescriptions. Second, we review the use of intensity modulated radiation therapy in bone marrow transplantation with a focus on helical tomotherapy TBI, helical tomotherapy total marrow irradiation (TMI) and total marrow and lymphoid irradiation (TMLI) and their dosimetric and clinical outcomes. Finally, we review the perspective of dose escalation and the extension to older patients and patients with comorbidity who do not benefit from a standard bone marrow transplantation conditioning regimen.
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Affiliation(s)
- Adrien Paix
- Radiation Oncology Department, Centre Paul Strauss 3 rue de la Porte de l'hôpital, 67065, Strasbourg Cedex, France
| | - Delphine Antoni
- Radiation Oncology Department, Centre Paul Strauss 3 rue de la Porte de l'hôpital, 67065, Strasbourg Cedex, France; Radiobiology Laboratory, EA3430, Strasbourg University, 3 rue de la Porte de l'hôpital, 67000, Strasbourg, France
| | - Waisse Waissi
- Radiation Oncology Department, Centre Paul Strauss 3 rue de la Porte de l'hôpital, 67065, Strasbourg Cedex, France; Radiobiology Laboratory, EA3430, Strasbourg University, 3 rue de la Porte de l'hôpital, 67000, Strasbourg, France
| | - Marie-Pierre Ledoux
- Hematology Department, CHU Hautepierre, 1, rue Molière, 67000, Strasbourg, France
| | - Karin Bilger
- Hematology Department, CHU Hautepierre, 1, rue Molière, 67000, Strasbourg, France
| | - Luc Fornecker
- Hematology Department, CHU Hautepierre, 1, rue Molière, 67000, Strasbourg, France
| | - Georges Noel
- Radiation Oncology Department, Centre Paul Strauss 3 rue de la Porte de l'hôpital, 67065, Strasbourg Cedex, France; Radiobiology Laboratory, EA3430, Strasbourg University, 3 rue de la Porte de l'hôpital, 67000, Strasbourg, France.
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16
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Total Body Irradiation without Chemotherapy as Conditioning for an Allogeneic Hematopoietic Cell Transplantation for Adult Acute Myeloid Leukemia. Case Rep Hematol 2016; 2016:1257679. [PMID: 27957357 PMCID: PMC5124456 DOI: 10.1155/2016/1257679] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 10/16/2016] [Indexed: 11/17/2022] Open
Abstract
Current therapies for acute myeloid leukemia (AML), failing induction, are rarely effective. We report our experience in 4 patients with AML who received 16 Gy TBI prior to allogeneic hematopoietic cell transplantation (alloHCT), between June 2010 and May 2011. Patients were 20 to 55 years of age, 2 with relapsed disease and 2 with AML failing induction. An HLA-matched graft from related or unrelated donor was infused on day 0. All but one, who received a CD34+-selected graft, received methotrexate and tacrolimus +/- antithymocyte globulin, as GVHD prophylaxis. The other patient received tacrolimus alone. Neutrophil and platelet engraftment occurred at a median of 18 and 14 days, respectively. Patients were discharged at a median of 28 days. There were no unexpected toxicities in the first 30 days. One patient had cytomegalovirus (CMV) viremia and anorexia, at two months. One patient had grade 2 acute GVHD of the skin. One patient developed chronic GVHD of the eyes, mouth, skin, joints, and lung at 4 months. Two patients died from relapse of their leukemia at days 65 and 125. Two patients remain in remission beyond day 1500. 16 Gy TBI followed by an alloHCT for AML, failing induction, is feasible and tolerable.
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17
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Härtl PM, Treutwein M, Hautmann MG, März M, Pohl F, Kölbl O, Dobler B. Total body irradiation-an attachment free sweeping beam technique. Radiat Oncol 2016; 11:81. [PMID: 27287010 PMCID: PMC4902948 DOI: 10.1186/s13014-016-0658-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 06/07/2016] [Indexed: 01/01/2023] Open
Abstract
Introduction A sweeping beam technique for total body irradiation in standard treatment rooms and for standard linear accelerators (linacs) is introduced, which does not require any accessory attached to the linac. Lung shielding is facilitated to reduce the risk of pulmonary toxicity. Additionally, the applicability of a commercial radiotherapy planning system (RTPS) is examined. Material and Methods The patient is positioned on a low couch on the floor, the longitudinal axis of the body in the rotational plane of the linac. Eight arc fields and five additional fixed beams are applied to the patient in supine and prone position respectively. The dose distributions were measured in a solid water phantom and in an Alderson phantom. Diode detectors were calibrated for in-vivo dosimetry. The RTPS Oncentra was employed for calculations of the dose distribution. Results For the cranial 120 cm the longitudinal dose profile in a slab phantom measured with ionization chamber varies between 94 and 107 % of the prescription dose. These values were confirmed by film measurements and RTPS calculations. The transmittance of the lung shields has been determined as a function of the thickness of the absorber material. Measurements in an Alderson phantom and in-vivo dosimetry of the first patients match the calculated dose. Discussion and conclusion A treatment technique with clinically good dose distributions has been introduced, which can be applied with each standard linac and in standard treatment rooms. Dose calculations were performed with a commercial RTPS and should enable individual dose optimization.
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Affiliation(s)
- Petra M Härtl
- Department of Radiotherapy, Regensburg University Medical Center, Regensburg, Germany
| | - Marius Treutwein
- Department of Radiotherapy, Regensburg University Medical Center, Regensburg, Germany.
| | - Matthias G Hautmann
- Department of Radiotherapy, Regensburg University Medical Center, Regensburg, Germany
| | - Manuel März
- Department of Radiotherapy, Regensburg University Medical Center, Regensburg, Germany
| | - Fabian Pohl
- Department of Radiotherapy, Regensburg University Medical Center, Regensburg, Germany
| | - Oliver Kölbl
- Department of Radiotherapy, Regensburg University Medical Center, Regensburg, Germany
| | - Barbara Dobler
- Department of Radiotherapy, Regensburg University Medical Center, Regensburg, Germany
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18
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Springer A, Hammer J, Winkler E, Track C, Huppert R, Böhm A, Kasparu H, Weltermann A, Aschauer G, Petzer AL, Putz E, Altenburger A, Gruber R, Moser K, Wiesauer K, Geinitz H. Total body irradiation with volumetric modulated arc therapy: Dosimetric data and first clinical experience. Radiat Oncol 2016; 11:46. [PMID: 27000180 PMCID: PMC4802832 DOI: 10.1186/s13014-016-0625-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 03/18/2016] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND To implement total body irradiation (TBI) using volumetric modulated arc therapy (VMAT). We applied the Varian RapidArc™ software to calculate and optimize the dose distribution. Emphasis was placed on applying a homogenous dose to the PTV and on reducing the dose to the lungs. METHODS From July 2013 to July 2014 seven patients with leukaemia were planned and treated with a VMAT-based TBI-technique with photon energy of 6 MV. The overall planning target volume (PTV), comprising the whole body, had to be split into 8 segments with a subsequent multi-isocentric planning. In a first step a dose optimization of each single segment was performed. In a second step all these elements were calculated in one overall dose-plan, considering particular constraints and weighting factors, to achieve the final total body dose distribution. The quality assurance comprised the verification of the irradiation plans via ArcCheck™ (Sun Nuclear), followed by in vivo dosimetry via dosimeters (MOSFETs) on the patient. RESULTS The time requirements for treatment planning were high: contouring took 5-6 h, optimization and dose calculation 25-30 h and quality assurance 6-8 h. The couch-time per fraction was 2 h on day one, decreasing to around 1.5 h for the following fractions, including patient information, time for arc positioning, patient positioning verification, mounting of the MOSFETs and irradiation. The mean lung dose was decreased to at least 80 % of the planned total body dose and in the central parts to 50 %. In two cases we additionally pursued a dose reduction of 30 to 50 % in a pre-irradiated brain and in renal insufficiency. All high dose areas were outside the lungs and other OARs. The planned dose was in line with the measured dose via MOSFETs: in the axilla the mean difference between calculated and measured dose was 3.6 % (range 1.1-6.8 %), and for the wrist/hip-inguinal region it was 4.3 % (range 1.1-8.1 %). CONCLUSION TBI with VMAT provides the benefit of satisfactory dose distribution within the PTV, while selectively reducing the dose to the lungs and, if necessary, in other organs. Planning time, however, is extensive.
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Affiliation(s)
- Andreas Springer
- />Department of Radiation Oncology, Krankenhaus der Barmherzigen Schwestern Linz, Seilerstätte 4, 4010 Linz, Austria
| | - Josef Hammer
- />Department of Radiation Oncology, Krankenhaus der Barmherzigen Schwestern Linz, Seilerstätte 4, 4010 Linz, Austria
| | - Erwin Winkler
- />Department of Radiation Oncology, Krankenhaus der Barmherzigen Schwestern Linz, Seilerstätte 4, 4010 Linz, Austria
| | - Christine Track
- />Department of Radiation Oncology, Krankenhaus der Barmherzigen Schwestern Linz, Seilerstätte 4, 4010 Linz, Austria
| | - Roswitha Huppert
- />Department of Radiation Oncology, Krankenhaus der Barmherzigen Schwestern Linz, Seilerstätte 4, 4010 Linz, Austria
| | - Alexandra Böhm
- />Internal Department I - Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Krankenhaus der Elisabethinen Linz, Linz, Austria
- />Division of Medical Oncology, University of Washington, Fred Hutchinson Cancer Research Center, Seattle, WA USA
| | - Hedwig Kasparu
- />Internal Department I - Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Krankenhaus der Elisabethinen Linz, Linz, Austria
| | - Ansgar Weltermann
- />Internal Department I - Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Krankenhaus der Elisabethinen Linz, Linz, Austria
- />Medical Faculty, Johannes Kepler University, Linz, Austria
| | - Gregor Aschauer
- />Internal Medicine I - Medical Oncology, Hematology and Gastroenterology, Krankenhaus der Barmherzigen Schwestern Linz, Linz, Austria
| | - Andreas L. Petzer
- />Internal Medicine I - Medical Oncology, Hematology and Gastroenterology, Krankenhaus der Barmherzigen Schwestern Linz, Linz, Austria
- />Medical Faculty, Johannes Kepler University, Linz, Austria
| | - Ernst Putz
- />Department of Radiation Oncology, Krankenhaus der Barmherzigen Schwestern Linz, Seilerstätte 4, 4010 Linz, Austria
| | - Alexander Altenburger
- />Department of Radiation Oncology, Krankenhaus der Barmherzigen Schwestern Linz, Seilerstätte 4, 4010 Linz, Austria
| | - Rainer Gruber
- />Department of Radiation Oncology, Krankenhaus der Barmherzigen Schwestern Linz, Seilerstätte 4, 4010 Linz, Austria
| | - Karin Moser
- />Department of Radiation Oncology, Krankenhaus der Barmherzigen Schwestern Linz, Seilerstätte 4, 4010 Linz, Austria
| | - Karin Wiesauer
- />Department of Radiation Oncology, Krankenhaus der Barmherzigen Schwestern Linz, Seilerstätte 4, 4010 Linz, Austria
| | - Hans Geinitz
- />Department of Radiation Oncology, Krankenhaus der Barmherzigen Schwestern Linz, Seilerstätte 4, 4010 Linz, Austria
- />Medical Faculty, Johannes Kepler University, Linz, Austria
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19
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Bronova I, Smith B, Aydogan B, Weichselbaum RR, Vemuri K, Erdelyi K, Makriyannis A, Pacher P, Berdyshev EV. Protection from Radiation-Induced Pulmonary Fibrosis by Peripheral Targeting of Cannabinoid Receptor-1. Am J Respir Cell Mol Biol 2015; 53:555-62. [PMID: 26426981 DOI: 10.1165/rcmb.2014-0331oc] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Radiation-induced pulmonary fibrosis (RIF) is a severe complication of thoracic radiotherapy that limits its dose, intensity, and duration. The contribution of the endocannabinoid signaling system in pulmonary fibrogenesis is not known. Using a well-established mouse model of RIF, we assessed the involvement of cannabinoid receptor-1 (CB1) in the onset and progression of pulmonary fibrosis. Female C57BL/6 mice and CB1 knockout mice generated on C57BL/6 background received 20 Gy (2 Gy/min) single-dose thoracic irradiation that resulted in pulmonary fibrosis and animal death within 15 to 18 weeks. Some C57BL/6 animals received the CB1 peripherally restricted antagonist AM6545 at 1 mg/kg intraperitoneally three times per week. Animal survival and parameters of pulmonary inflammation and fibrosis were evaluated. Thoracic irradiation (20 Gy) was associated with marked pulmonary inflammation and fibrosis in mice and high mortality within 15 to 18 weeks after exposure. Genetic deletion or pharmacological inhibition of CB1 receptors with a peripheral CB1 antagonist AM6545 markedly attenuated or delayed the lung inflammation and fibrosis and increased animal survival. Our results show that CB1 signaling plays a key pathological role in the development of radiation-induced pulmonary inflammation and fibrosis, and peripherally restricted CB1 antagonists may represent a novel therapeutic approach against this devastating complication of radiotherapy/irradiation.
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Affiliation(s)
- Irina Bronova
- 1 Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, and
| | | | | | | | | | - Katalin Erdelyi
- 5 Laboratory of Physiological Studies, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland; and
| | - Alex Makriyannis
- 6 Center for Drug Discovery, Departments of Pharmaceutical Sciences and Chemistry & Chemical Biology, Northeastern University, Boston, Massachusetts
| | | | - Evgeny V Berdyshev
- 1 Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, and
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Pixberg C, Koch R, Eich HT, Martinsson U, Kristensen I, Matuschek C, Kortmann RD, Pohl F, Elsayad K, Christiansen H, Willich N, Lindh J, Steinmann D. Acute Toxicity Grade 3 and 4 After Irradiation in Children and Adolescents: Results From the IPPARCA Collaboration. Int J Radiat Oncol Biol Phys 2015; 94:792-9. [PMID: 26972652 DOI: 10.1016/j.ijrobp.2015.12.353] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 12/03/2015] [Accepted: 12/14/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE In the context of oncologic therapy for children, radiation therapy is frequently indicated. This study identified the frequency of and reasons for the development of high-grade acute toxicity and possible sequelae. MATERIALS AND METHODS Irradiated children have been prospectively documented since 2001 in the Registry for the Evaluation of Side Effects After Radiation in Childhood and Adolescence (RiSK) database in Germany and since 2008 in the registry for radiation therapy toxicity (RADTOX) in Sweden. Data were collected using standardized, published forms. Toxicity classification was based on Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer criteria. RESULTS As of June 2013, 1500 children have been recruited into the RiSK database and 485 into the RADTOX registry leading to an analysis population of 1359 patients (age range 0-18). A total of 18.9% (n=257) of all investigated patients developed high-grade acute toxicity (grades 3/4). High-grade toxicity of the bone marrow was documented for 63.8% (n=201) of those patients, oral mucositis for 7.6% (n=24), and dermatitis for 7.6% (n=24). Patients with high-grade acute toxicity received concomitant chemotherapy more frequently (56%) than patients with no or lower acute toxicity (31.5%). In multivariate analyses, concomitant chemotherapy, diagnosis of Ewing sarcoma, and total radiation dose showed a statistically noticeable effect (P≤.05) on acute toxicity, whereas age, concomitant chemotherapy, Hodgkin lymphoma, Ewing sarcoma, total radiation dose, and acute toxicity influenced the time until maximal late toxicity. CONCLUSIONS Generally, high-grade acute toxicity after irradiation in children and adolescence occurs in a moderate proportion of patients (18.9%). As anticipated, the probability of acute toxicity appeared to depend on the prescribed dose as well as concomitant chemotherapy. The occurrence of chronic toxicity correlates with the prior acute toxicity grade. Age seems to influence the time until maximal late toxicity but not the development of acute toxicity.
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Affiliation(s)
- Caroline Pixberg
- Department of Radiation Oncology, University Hospital of Muenster, Muenster, Germany
| | - Raphael Koch
- Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
| | - Hans Theodor Eich
- Department of Radiation Oncology, University Hospital of Muenster, Muenster, Germany; Department of Radiation Oncology, University of Koeln, Koeln, Germany.
| | - Ulla Martinsson
- Department of Oncology, University Hospital, Uppsala, Sweden
| | - Ingrid Kristensen
- Department of Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Christiane Matuschek
- Department of Radiation Oncology, University Hospital of Duesseldorf, Duesseldorf, Germany
| | - Rolf-Dieter Kortmann
- Department of Radiation Oncology, University Hospital of Leipzig, Leipzig, Germany
| | - Fabian Pohl
- Department of Radiation Oncology, University of Regensburg, Regensburg, Germany
| | - Khaled Elsayad
- Department of Radiation Oncology, University Hospital of Muenster, Muenster, Germany
| | - Hans Christiansen
- Department of Radiation Oncology, Medical School Hannover, Hannover, Germany
| | - Normann Willich
- Department of Radiation Oncology, University Hospital of Muenster, Muenster, Germany
| | - Jack Lindh
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Diana Steinmann
- Department of Radiation Oncology, University Hospital of Muenster, Muenster, Germany; Department of Radiation Oncology, Medical School Hannover, Hannover, Germany
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Ottanelli S. Prevention and treatment of bone fragility in cancer patient. CLINICAL CASES IN MINERAL AND BONE METABOLISM : THE OFFICIAL JOURNAL OF THE ITALIAN SOCIETY OF OSTEOPOROSIS, MINERAL METABOLISM, AND SKELETAL DISEASES 2015; 12:116-29. [PMID: 26604936 PMCID: PMC4625767 DOI: 10.11138/ccmbm/2015.12.2.116] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
It is well known that fractures increase the risk of morbidity and mortality. The various mechanisms responsible for bone loss in cancer patients may have a different impact depending on the characteristics of the clinical case and correlates with the therapies used, or caused by the therapies used against cancer. Some hormonal treatments cause hypogonadism, event which contributes to the progressive loss of bone mass. This is detectable in patients with breast cancer receiving determines that estrogen-deprivation and in men with prostate cancer with therapies that determine androgen deprivation. Chemotherapy treatments used in cancer patients have reduced bone mass. In addition, low bone mass is detectable in patients with lymphoma treated with corticosteroids or radiation or alkylating agents. In premenopausal patients suffering from breast cancer, treatment with cytotoxic therapy or ablation of ovarian function, can lead to an 8% reduction in bone mineral density at the spine and 4% in the femur. With a chemotherapy regimen in CMF, the reduction of BMD is 6.5%; this bone loss is not recovered after discontinuation of therapy. Tamoxifen given for five years reduces bone remodeling and cause a 32% increase in the risk of osteoporotic fractures when used in premenopausal. After menopause, tamoxifen has a protective effect on bone mass, with a reduced risk of new fractures. Aromatase inhibitors in post-menopausal women, depending on the formulation can cause different effects on the reduction of BMD and fracture risk. We have in fact steroids, exemestane and nonsteroidal, letrozole and anastrozole. Patients at increased risk of fragility fractures should undergo preventive therapies as soon as possible after tests performed for the study of bone health. They can be used DEXA and the FRAX algorithm, which can define a secondary osteoporosis. Prevention and treatment of the increased risk of osteoporotic fracture is to maintain adequate levels of calcium and vitamin D. Bisphosphonates and denosumab are used for the management of bone remodeling and bone loss induced by cancer treatments. Bisphosphonates also have anti-tumor effects per se, which are expressed in potentially prevent the development of bone metastases. In men with metastatic prostate cancer and which is induced androgen deprivation, it is usefully used denosumab 120 mg monthly or zoledronic acid 4 mg monthly.
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Affiliation(s)
- Silva Ottanelli
- Bone Metabolic Diseases Unit, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
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