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Poppe MM, Tai A, Li XA, Miften M, Olch A, Marks LB, Qureshi BM, Spunt SL, Shnorhavorian M, Nelson G, Ronckers C, Kalapurakal J, Marples B, Constine LS, Liu AK. Kidney Disease in Childhood Cancer Survivors Treated With Radiation Therapy: A PENTEC Comprehensive Review. Int J Radiat Oncol Biol Phys 2024; 119:560-574. [PMID: 37452796 DOI: 10.1016/j.ijrobp.2023.02.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 02/11/2023] [Accepted: 02/16/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE Kidney injury is a known late and potentially devastating complication of abdominal radiation therapy (RT) in pediatric patients. A comprehensive Pediatric Normal Tissue Effects in the Clinic review by the Genitourinary (GU) Task Force aimed to describe RT dose-volume relationships for GU dysfunction, including kidney, bladder, and hypertension, for pediatric malignancies. The effect of chemotherapy was also considered. METHODS AND MATERIALS We conducted a comprehensive PubMed search of peer-reviewed manuscripts published from 1990 to 2017 for investigations on RT-associated GU toxicities in children treated for cancer. We retrieved 3271 articles with 100 fulfilling criteria for full review, 24 with RT dose data and 13 adequate for modeling. Endpoints were heterogenous and grouped according to National Kidney Foundation: grade ≥1, grade ≥2, and grade ≥3. We modeled whole kidney exposure from total body irradiation (TBI) for hematopoietic stem cell transplant and whole abdominal irradiation (WAI) for patients with Wilms tumor. Partial kidney tolerance was modeled from a single publication from 2021 after the comprehensive review revealed no usable partial kidney data. Inadequate data existed for analysis of bladder RT-associated toxicities. RESULTS The 13 reports with long-term GU outcomes suitable for modeling included 4 on WAI for Wilms tumor, 8 on TBI, and 1 for partial renal RT exposure. These reports evaluated a total of 1191 pediatric patients, including: WAI 86, TBI 666, and 439 partial kidney. The age range at the time of RT was 1 month to 18 years with medians of 2 to 11 years in the various reports. In our whole kidney analysis we were unable to include chemotherapy because of the heterogeneity of regimens and paucity of data. Age-specific toxicity data were also unavailable. Wilms studies occurred from 1968 to 2011 with mean follow-ups 8 to 15 years. TBI studies occurred from 1969 to 2004 with mean follow-ups of 4 months to 16 years. We modeled risk of dysfunction by RT dose and grade of toxicity. Normal tissue complication rates ≥5%, expressed as equivalent doses, 2 Gy/fx for whole kidney exposures occurred at 8.5, 10.2, and 14.5 Gy for National Kidney Foundation grades ≥1, ≥2, and ≥3, respectively. Conventional Wilms WAI of 10.5 Gy in 6 fx had risks of ≥grade 2 toxicity 4% and ≥grade 3 toxicity 1%. For fractionated 12 Gy TBI, those risks were 8% and <3%, respectively. Data did not support whole kidney modeling with chemotherapy. Partial kidney modeling from 439 survivors who received RT (median age, 7.3 years) demonstrated 5 or 10 Gy to 100% kidney gave a <5% risk of grades 3 to 5 toxicity with 1500 mg/m2 carboplatin or no chemo. With 480 mg/m2 cisplatin, a 3% risk of ≥grade 3 toxicity occurred without RT and a 5% risk when 26% kidney received ≥10 Gy. With 63 g/m2 of ifosfamide, a 5% risk of ≥grade 3 toxicity occurred with no RT, and a 10% toxicity risk occurred when 42% kidney received ≥10 Gy. CONCLUSIONS In patients with Wilms tumor, the risk of toxicity from 10.5 Gy of WAI is low. For 12 Gy fractionated TBI with various mixtures of chemotherapy, the risk of severe toxicity is low, but low-grade toxicity is not uncommon. Partial kidney data are limited and toxicity is associated heavily with the use of nephrotoxic chemotherapeutic agents. Our efforts demonstrate the need for improved data gathering, systematic follow-up, and reporting in future clinical studies. Current radiation dose used for Wilms tumor and TBI appear to be safe; however, efforts in effective kidney-sparing TBI and WAI regimens may reduce the risks of renal injury without compromising cure.
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Affiliation(s)
- Matthew M Poppe
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah.
| | - An Tai
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - X Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Moyed Miften
- Department of Radiation Oncology, University of Colorado School of Medicine, Denver, Colorado
| | - Arthur Olch
- Department of Radiation Oncology, Keck School of Medicine, University of Southern California, and Children's Hospital Los Angeles, Los Angeles, California
| | - Lawrence B Marks
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Bilal Mazhar Qureshi
- Radiation Oncology Section, Department of Oncology, Aga Khan University, Karachi, Pakistan
| | - Sheri L Spunt
- Stanford University School of Medicine, Department of Pediatrics, Stanford, California
| | - Margarett Shnorhavorian
- Department of Urology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Geoff Nelson
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Cecile Ronckers
- Princess Máxima Center for Paediatric Oncology, Utrecht, Netherlands; Division of Organisational Health Care Research, Departement of Health Care Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - John Kalapurakal
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Brian Marples
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Louis S Constine
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Arthur K Liu
- UC Health - Poudre Valley Hospital, Radiation Oncology, Fort Collins, Colorado
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Briere TM, Agrusa JE, Martel MK, Jackson A, Olch AJ, Ronckers CM, Kremer LCM, Constine LS, McAleer MF. Acute and Late Pulmonary Effects After Radiation Therapy in Childhood Cancer Survivors: A PENTEC Comprehensive Review. Int J Radiat Oncol Biol Phys 2024; 119:533-548. [PMID: 35525723 DOI: 10.1016/j.ijrobp.2022.01.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 12/07/2021] [Accepted: 01/29/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The Pediatric Normal Tissue Effects in the Clinic (PENTEC) pulmonary task force reviewed dosimetric and clinical factors associated with radiation therapy (RT)-associated pulmonary toxicity in children. METHODS Comprehensive search of PubMed (1965-2020) was conducted to assess available evidence and predictive models of RT-induced lung injury in pediatric cancer patients (<21 years old). Lung dose for radiation pneumonitis (RP) was obtained from dose-volume histogram (DVH) data. RP grade was obtained from standard criteria. Clinical pulmonary outcomes were evaluated using pulmonary function tests (PFTs), clinical assessment, and questionnaires. RESULTS More than 2,400 abstracts were identified; 460 articles had detailed treatment and toxicity data; and 11 articles with both detailed DVH and toxicity data were formally reviewed. Pooled cohorts treated during 1999 to 2016 included 277 and 507 patients age 0.04 to 22.7 years who were evaluable for acute and late RP analysis, respectively. After partial lung RT, there were 0.4% acute and 2.8% late grade 2, 0.4% acute and 0.8% late grade 3, and no grade 4 to 5 RP. RP risk after partial thoracic RT with mean lung dose (MLD) <14 Gy and total lung V20Gy <30% is low. Clinical and self-reported pulmonary outcomes data included 8,628 patients treated during 1970 to 2013, age 0 to 21.9 years. At a median 2.9- to 21.9-year follow-up, patients were often asymptomatic; abnormal PFTs were common and severity correlated with lung dose. At ≥10-year follow-up, multi-institutional studies suggested associations between total or ipsilateral lung doses >10 Gy and pulmonary complications and deaths. After whole lung irradiation (WLI), pulmonary toxicity is higher; no dose response relationship was identified. Bleomycin and other chemotherapeutics at current dose regimens do not contribute substantially to adverse pulmonary outcomes after partial lung irradiation but increase risk with WLI. CONCLUSIONS After partial lung RT, acute pulmonary toxicity is uncommon; grade 2 to 3 RP incidences are <1%. Late toxicities, including subclinical/asymptomatic impaired pulmonary function, are more common (<4%). Incidence and severity appear to increase over time. Upon review of available literature, there appears to be low risk of pulmonary complications in children with MLD < 14 Gy and V20Gy <30% using standard fractionated RT to partial lung volumes. A lack of robust data limit guidance on lung dose/volume constraints, highlighting the need for additional work to define factors associated with RT-induced lung injury.
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Affiliation(s)
- Tina Marie Briere
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jennifer E Agrusa
- Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Mary K Martel
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Arthur J Olch
- Department of Radiation Oncology University of Southern California Keck School of Medicine and Children's Hospital Los Angeles, Los Angeles, California; Radiation Oncology Program, Children's Hospital Los Angeles, Los Angeles, California
| | - Cécile M Ronckers
- Department of Pediatrics, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Institute of Biostatistics and Registry Research, Medical University Brandenburg Medical School-Theodor Fontane, Neuruppin, Germany
| | - Leontien C M Kremer
- Department of Pediatrics, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Department of Pediatrics, UMC Amsterdam, Location AMC, Amsterdam, the Netherlands
| | - Louis S Constine
- Departments of Radiation Oncology and Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Mary Frances McAleer
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas.
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Gough J, Mowat S, Sellman L, Robinson K, Youings M, Mandeville H. Institutional experience of using active breathing control for paediatric and teenage patients receiving thoraco-abdominal radiotherapy. Clin Transl Radiat Oncol 2023; 39:100575. [PMID: 36686562 PMCID: PMC9850023 DOI: 10.1016/j.ctro.2022.100575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 12/23/2022] [Accepted: 12/29/2022] [Indexed: 01/03/2023] Open
Abstract
Introduction Active Breathing Control (ABC) is a motion management strategy that facilitates reproducible breath-hold for thoracic radiotherapy (RT), which may reduce radiation dose to organs at risk (OARs). Reduction of radiation-induced toxicity is of high importance in younger patients. However, there is little published literature on the feasibility of ABC in this group. The purpose of this study was to report our experience of using ABC for paediatric and teenage patients. Methods Patients ≤18 years referred for thoracic RT using ABC at our centre from 2013-2021 were identified. Electronic records were retrospectively reviewed to obtain information on diagnosis, RT dose and technique, OAR dosimetry, tolerability of ABC, post-treatment imaging and early toxicity rates. Results 12 patients completed RT and were able to comply with ABC during planning and for the duration of RT. Median age was 15.5 years (10-18 years). Diagnoses were: Hodgkin lymphoma (n = 5), mediastinal B-cell lymphoma (n = 1), Ewing sarcoma (n = 5) and rhabdomyosarcoma (n = 1). For mediastinal RT cases (n = 6), median dose delivered was 30.6Gy(19.8-40Gy), median mean heart dose was 11.4Gy(4.8-19.4Gy), median mean lung dose was 9.9Gy(5.7-14.5Gy) and mean lung V20 was 10.9%. For ipsilateral RT cases, (n = 6), median hemithorax and total doses to primary tumour were 18Gy(15-20Gy) and 52.2Gy(36-60Gy) respectively. Median mean heart dose was 19.5Gy(10.6-33.2Gy) and median mean lung dose was 17.7Gy(16.3-30.5Gy). Mean bilateral lung V20 was 39.6%. Median mean contralateral lung dose was 5.2Gy(3.5-11.6Gy) and mean contralateral lung V20 was 1.5%. At a median follow-up of 36 months, only 1 patient had symptomatic radiation pneumonitis having received further thoracic RT following relapse. Conclusions ABC is feasible and well tolerated in younger patients receiving RT. Children as young as 10 years are able to comply. Use of ABC results in OAR dosimetry which is comparable to similar data in adults and can facilitate RT for extensive thoracic sarcoma.
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Affiliation(s)
- Jessica Gough
- The Royal Marsden Hospital, Sutton, UK,The Institute of Cancer Research, London, UK,Corresponding author at: Royal Marsden Hospital, Downs road, Sutton SM2 5PT, UK.
| | | | | | | | | | - Henry Mandeville
- The Royal Marsden Hospital, Sutton, UK,The Institute of Cancer Research, London, UK
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Bian C, Zheng Z, Su J, Wang H, Chang S, Xin Y, Jiang X. Targeting Mitochondrial Metabolism to Reverse Radioresistance: An Alternative to Glucose Metabolism. Antioxidants (Basel) 2022; 11:2202. [PMID: 36358574 PMCID: PMC9686736 DOI: 10.3390/antiox11112202] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/27/2022] [Accepted: 11/02/2022] [Indexed: 07/30/2023] Open
Abstract
Radiotherapy failure and poor tumor prognosis are primarily attributed to radioresistance. Improving the curative effect of radiotherapy and delaying cancer progression have become difficult problems for clinicians. Glucose metabolism has long been regarded as the main metabolic process by which tumor cells meet their bioenergetic and anabolic needs, with the complex interactions between the mitochondria and tumors being ignored. This misconception was not dispelled until the early 2000s; however, the cellular molecules and signaling pathways involved in radioresistance remain incompletely defined. In addition to being a key metabolic site that regulates tumorigenesis, mitochondria can influence the radiation effects of malignancies by controlling redox reactions, participating in oxidative phosphorylation, producing oncometabolites, and triggering apoptosis. Therefore, the mitochondria are promising targets for the development of novel anticancer drugs. In this review, we summarize the internal relationship and related mechanisms between mitochondrial metabolism and cancer radioresistance, thus exploring the possibility of targeting mitochondrial signaling pathways to reverse radiation insensitivity. We suggest that attention should be paid to the potential value of mitochondria in prolonging the survival of cancer patients.
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Affiliation(s)
- Chenbin Bian
- Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun 130021, China
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun 130021, China
- NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University, Changchun 130021, China
| | - Zhuangzhuang Zheng
- Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun 130021, China
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun 130021, China
- NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University, Changchun 130021, China
| | - Jing Su
- Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun 130021, China
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun 130021, China
- NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University, Changchun 130021, China
| | - Huanhuan Wang
- Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun 130021, China
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun 130021, China
- NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University, Changchun 130021, China
| | - Sitong Chang
- Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun 130021, China
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun 130021, China
- NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University, Changchun 130021, China
| | - Ying Xin
- Key Laboratory of Pathobiology, Ministry of Education, Jilin University, Changchun 130021, China
| | - Xin Jiang
- Jilin Provincial Key Laboratory of Radiation Oncology & Therapy, The First Hospital of Jilin University, Changchun 130021, China
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun 130021, China
- NHC Key Laboratory of Radiobiology, School of Public Health, Jilin University, Changchun 130021, China
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Pediatric radiotherapy for thoracic and abdominal targets: organ motion, reported margin sizes, and delineation variations – a systematic review. Radiother Oncol 2022; 173:134-145. [DOI: 10.1016/j.radonc.2022.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 05/09/2022] [Accepted: 05/26/2022] [Indexed: 11/21/2022]
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Abstract
Radiotherapy for Hodgkin lymphomas has evolved a lot over time, but still plays an important role, almost always in addition to chemotherapy, for the management of the early stages. The major objective is to preserve the quality of life of patients who will be cured from this disease in the vast majority of cases. Also, the personalization of the indications for the purpose of de-escalating toxicity is very refined and is essentially based on the pre- and pertherapeutic assessment by FDG-PET. The indications for radiotherapy are more limited for non-Hodgkin lymphomas, but the same principles are found, regardless of the histological type. We present the update of the recommendations of the French society of oncological radiotherapy for radiotherapy of lymphomas, which remains a very evolving field in terms of therapeutic strategy and evaluation.
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Hua CH, Mascia AE, Servalli E, Lomax AJ, Seiersen K, Ulin K. Advances in radiotherapy technology for pediatric cancer patients and roles of medical physicists: COG and SIOP Europe perspectives. Pediatr Blood Cancer 2021; 68 Suppl 2:e28344. [PMID: 33818892 PMCID: PMC8030241 DOI: 10.1002/pbc.28344] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/27/2020] [Accepted: 04/02/2020] [Indexed: 11/11/2022]
Abstract
Over the last two decades, rapid technological advances have dramatically changed radiation delivery to children with cancer, enabling improved normal-tissue sparing. This article describes recent advances in photon and proton therapy technologies, image-guided patient positioning, motion management, and adaptive therapy that are relevant to pediatric cancer patients. For medical physicists who are at the forefront of realizing the promise of technology, challenges remain with respect to ensuring patient safety as new technologies are implemented with increasing treatment complexity. The contributions of medical physicists to meeting these challenges in daily practice, in the conduct of clinical trials, and in pediatric oncology cooperative groups are highlighted. Representing the perspective of the physics committees of the Children's Oncology Group (COG) and the European Society for Paediatric Oncology (SIOP Europe), this paper provides recommendations regarding the safe delivery of pediatric radiotherapy. Emerging innovations are highlighted to encourage pediatric applications with a view to maximizing the therapeutic ratio.
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Affiliation(s)
- Chia-ho Hua
- Department of Radiation Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Anthony E. Mascia
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Enrica Servalli
- Department of Radiotherapy, University Medical Center Utrecht, The Netherlands
| | - Antony J. Lomax
- Center for Proton Therapy, Paul Scherrer Institute, PSI Villigen, Switzerland
| | | | - Kenneth Ulin
- Department of Radiation Oncology, University of Massachusetts, Worcester, Massachusetts, USA
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Lundgaard AY, Josipovic M, Rechner LA, Bidstrup PE, Hansen R, Damkjaer SS, Joergensen M, Safwat A, Specht L, Hjalgrim LL, Maraldo MV. The Feasibility of Implementing Deep Inspiration Breath-Hold for Pediatric Radiation Therapy. Int J Radiat Oncol Biol Phys 2020; 106:977-984. [PMID: 32005489 DOI: 10.1016/j.ijrobp.2019.12.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 12/13/2019] [Accepted: 12/19/2019] [Indexed: 12/23/2022]
Abstract
PURPOSE Radiation therapy delivery during deep inspiration breath-hold (DIBH) reduces the irradiation of the heart and lungs and is therefore recommended for adults with mediastinal lymphoma. However, no studies have addressed the use of DIBH in children. This pilot study investigates the feasibility of and compliance with DIBH in children. METHODS AND MATERIALS Children from the age of 5 years were recruited to a training session to assess their ability to perform DIBH. No children received radiation therapy. The children were placed in a potential radiation therapy position. The DIBH was voluntary and monitored using an optical surface system providing visual feedback. Children who performed 3 stable DIBHs of 20 seconds each and remained motionless were deemed DIBH compliant. Compliance, equipment suitability, and coaching were further assessed in a semistructured interview. RESULTS We included 33 children (18 healthy and 15 hospitalized children with cancer) with a mean age of 8.5 years (range, 5-15). A total of 28 (85%) children were DIBH compliant. Twenty children were deemed immediately DIBH compliant, and 8 were deemed conditionally DIBH compliant, as DIBH compliance was presumed with custom-made immobilization and/or additional DIBH training. Mean age of the DIBH-compliant and the non-DIBH-compliant children was 8.9 years (range, 5-15) and 6 years (range, 5-9), respectively. Only 1 of 15 hospitalized children was not DIBH compliant and only 1 of all 33 children was unable to grasp the DIBH concept. The available DIBH equipment was suitable for children, and 94% reported that they were happy with training and performing DIBH. CONCLUSIONS This pilot study demonstrated that children from the age of 5 years can potentially comply with the DIBH technique and perform stable and reproducible DIBHs suitable for radiation therapy. Custom-made immobilization and adequate training will potentially increase DIBH compliance. A prospective clinical trial (NCT03315546), investigating the dosimetric benefit of radiation therapy delivery in DIBH compared with free breathing with pediatric patients, has been initiated.
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Affiliation(s)
| | - Mirjana Josipovic
- Department of Oncology, Rigshospitalet, University of Copenhagen, Denmark
| | - Laura Ann Rechner
- Department of Oncology, Rigshospitalet, University of Copenhagen, Denmark
| | - Pernille Envold Bidstrup
- Research Group on Psycological Aspects of Cancer, Danish Cancer Society Research Center, Copenhagen & Institute of Psychology, University of Copenhagen, Denmark
| | - Rune Hansen
- Department of Oncology, Aarhus University Hospital, Denmark
| | | | - Morten Joergensen
- Department of Oncology, Rigshospitalet, University of Copenhagen, Denmark
| | - Akmal Safwat
- Department of Oncology, Aarhus University Hospital, Denmark
| | - Lena Specht
- Department of Oncology, Rigshospitalet, University of Copenhagen, Denmark
| | - Lisa Lyngsie Hjalgrim
- Department of Pediatric Hematology and Oncology, Rigshospitalet, University of Copenhagen, Denmark
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Huijskens SC, van Dijk IWEM, Visser J, Balgobind BV, Rasch CRN, Alderliesten T, Bel A. Predictive value of pediatric respiratory-induced diaphragm motion quantified using pre-treatment 4DCT and CBCTs. Radiat Oncol 2018; 13:198. [PMID: 30305118 PMCID: PMC6180457 DOI: 10.1186/s13014-018-1143-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 09/30/2018] [Indexed: 12/25/2022] Open
Abstract
Background In adults, a single pre-treatment four-dimensional CT (4D-CT) acquisition is often used to account for respiratory-induced target motion during radiotherapy. However, studies have indicated that a 4D-CT is not always representative for respiratory motion. Our aim was to investigate whether respiratory-induced diaphragm motion in children on a single pre-treatment 4DCT can accurately predict respiratory-induced diaphragm motion as observed on cone beam CTs (CBCTs). Methods Twelve patients (mean age 14.5 yrs.; range 8.6–17.9 yrs) were retrospectively included based on visibility of the diaphragm on abdominal or thoracic imaging data acquired during free breathing. A 4DCT for planning purposes and daily/weekly CBCTs (total 125; range 4–29 per patient) acquired prior to dose delivery were available. The amplitude, corresponding to the difference in position of the diaphragm in cranial-caudal direction in end-inspiration and end-expiration phases, was extracted from the 4DCT (A4DCT). The amplitude in CBCTs (ACBCT) was defined as displacement between averaged in- and expiration diaphragm positions on corresponding projection images, and the distribution of ACBCT was compared to A4DCT (one-sample t-test, significance level p < 0.05). Results Over all patients, the mean A4DCT was 10.4 mm and the mean ACBCT 11.6 mm. For 9/12 patients, A4DCT differed significantly (p < 0.05) from ACBCT. Differences > 3 mm were found in 69/125 CBCTs (55%), with A4DCT mostly underestimating ACBCT. For 7/12 patients, diaphragm positions differed significantly from the baseline position. Conclusion Respiratory-induced diaphragm motion determined on 4DCT does not accurately predict the daily respiratory-induced diaphragm motion observed on CBCTs, as the amplitude and baseline position differed statistically significantly in the majority of patients. Regular monitoring of respiratory motion during the treatment course using CBCTs could yield a higher accuracy when a daily adaptation to the actual breathing amplitude takes place. Electronic supplementary material The online version of this article (10.1186/s13014-018-1143-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sophie C Huijskens
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Office Z1-217, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| | - Irma W E M van Dijk
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Office Z1-217, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Jorrit Visser
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Office Z1-217, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Brian V Balgobind
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Office Z1-217, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Coen R N Rasch
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Office Z1-217, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Tanja Alderliesten
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Office Z1-217, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Arjan Bel
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Office Z1-217, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
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Huijskens SC, van Dijk IWEM, Visser J, Balgobind BV, Te Lindert D, Rasch CRN, Alderliesten T, Bel A. Abdominal organ position variation in children during image-guided radiotherapy. Radiat Oncol 2018; 13:173. [PMID: 30208936 PMCID: PMC6136223 DOI: 10.1186/s13014-018-1108-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 08/20/2018] [Indexed: 12/03/2022] Open
Abstract
Background Interfractional organ position variation might differ for abdominal organs and this could have consequences for defining safety margins. Therefore, the purpose of this study is to quantify interfractional position variations of abdominal organs in children in order to investigate possible correlations between abdominal organs and determine whether position variation is location-dependent. Methods For 20 children (2.2–17.8 years), we retrospectively analyzed 113 CBCTs acquired during the treatment course, which were registered to the reference CT to assess interfractional position variation of the liver, spleen, kidneys, and both diaphragm domes. Organ position variation was assessed in three orthogonal directions and relative to the bony anatomy. Diaphragm dome position variation was assessed in the cranial-caudal (CC) direction only. We investigated possible correlations between position variations of the organs (Spearman’s correlation test, ρ), and tested if organ position variations in the CC direction are related to the diaphragm dome position variations (linear regression analysis, R2) (both tests: significance level p < 0.05). Differences of variations of systematic (∑) and random errors (σ) between organs were tested (Bonferroni significance level p < 0.004). Results In all directions, correlations between liver and spleen position variations, and between right and left kidney position variations were weak (ρ ≤ 0.43). In the CC direction, the position variations of the right and left diaphragm domes were significantly, and stronger, correlated with position variations of the liver (R2 = 0.55) and spleen (R2 = 0.63), respectively, compared to the right (R2 = 0.00) and left kidney (R2 = 0.25). Differences in ∑ and σ between all organs were small and insignificant. Conclusions No (strong) correlations between interfractional position variations of abdominal organs in children were observed. From present results, we concluded that diaphragm dome position variations could be more representative for superiorly located abdominal (liver, spleen) organ position variations than for inferiorly located (kidneys) organ position variations. Differences of systematic and random errors between abdominal organs were small, suggesting that for margin definitions, there was insufficient evidence of a dependence of organ position variation on anatomical location. Electronic supplementary material The online version of this article (10.1186/s13014-018-1108-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sophie C Huijskens
- Amsterdam UMC, University of Amsterdam, Department of Radiation Oncology, Cancer Center Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
| | - Irma W E M van Dijk
- Amsterdam UMC, University of Amsterdam, Department of Radiation Oncology, Cancer Center Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Jorrit Visser
- Amsterdam UMC, University of Amsterdam, Department of Radiation Oncology, Cancer Center Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Brian V Balgobind
- Amsterdam UMC, University of Amsterdam, Department of Radiation Oncology, Cancer Center Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - D Te Lindert
- Amsterdam UMC, University of Amsterdam, Department of Radiation Oncology, Cancer Center Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Coen R N Rasch
- Amsterdam UMC, University of Amsterdam, Department of Radiation Oncology, Cancer Center Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Tanja Alderliesten
- Amsterdam UMC, University of Amsterdam, Department of Radiation Oncology, Cancer Center Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Arjan Bel
- Amsterdam UMC, University of Amsterdam, Department of Radiation Oncology, Cancer Center Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
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Lundgaard AY, Hjalgrim LL, Rechner LA, Josipovic M, Joergensen M, Aznar MC, Berthelsen AK, Borgwardt L, Johansen C, Loft A, Safwat A, Vaalavirta L, Specht L, Maraldo MV. TEDDI: radiotherapy delivery in deep inspiration for pediatric patients - a NOPHO feasibility study. Radiat Oncol 2018; 13:56. [PMID: 29587881 PMCID: PMC5872576 DOI: 10.1186/s13014-018-1003-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 03/16/2018] [Indexed: 01/30/2023] Open
Abstract
Background Radiotherapy (RT) delivered in deep inspiration breath-hold (DIBH) is a simple technique, in which changes in patient anatomy can significantly reduce the irradiation of the organs at risk (OARs) surrounding the treatment target. DIBH is routinely used in the treatment of some adult patients to diminish the risk of late effects; however, no formalized studies have addressed the potential benefit of DIBH in children. Methods/Design TEDDI is a multicenter, non-randomized, feasibility study. The study investigates the dosimetric benefit of RT delivered in DIBH compared to free breathing (FB) in pediatric patients. Also, the study aims to establish the compliance to DIBH and to determine the accuracy and reproducibility in a pediatric setting. Pediatric patients (aged 5–17 years) with a tumor in the mediastinum or upper abdomen with the possible need of RT will be included in the study. Written informed consent is obligatory. Prior to any treatment, patients will undergo a DIBH training session followed by a diagnostic PET/CT- or CT-staging scan in both DIBH and FB. If the patient proceeds to RT, a RT planning CT scan will be performed in both DIBH and FB and two separate treatment plans will be calculated. The superior treatment plan, i.e. equal target coverage and lowest overall dose to the OARs, will be chosen for treatment. Patient comfort will be assessed daily by questionnaires and by adherence to the respiratory management procedure. Discussion RT in DIBH is expected to diminish irradiation of the OARs surrounding the treatment target and thereby reduce the risk of late effects in childhood cancer survivors. Trial registration The Danish Ethical Committee (H-16035870, approved November 24th 2016, prospectively registered). The Danish Data Protection Agency (2012–58-0004, approved January 1st 2017, prospectively registered). Registered at clinicaltrials.gov (NCT03315546, October 20th 2017, retrospectively registered).
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Affiliation(s)
- Anni Young Lundgaard
- Department of Clinical Oncology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Lisa Lyngsie Hjalgrim
- Department of Pediatric Haematology and Oncology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Laura Ann Rechner
- Department of Clinical Oncology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark.,Niels Bohr Institute, University of Copenhagen, Blegdamsvej 17, 2100, Copenhagen, Denmark
| | - Mirjana Josipovic
- Department of Clinical Oncology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark.,Niels Bohr Institute, University of Copenhagen, Blegdamsvej 17, 2100, Copenhagen, Denmark
| | - Morten Joergensen
- Department of Clinical Oncology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Marianne Camille Aznar
- Manchester Cancer Research Centre, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester c/o Christie Hospital, Department 58, Floor 2A, Wilmslow Road, Manchester, M20 4BX, UK
| | - Anne Kill Berthelsen
- Department of Clinical Oncology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark.,Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Lise Borgwardt
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Christoffer Johansen
- Department of Clinical Oncology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark.,Danish Cancer Society Research Center, Strandboulevarden 49, 2100, Copenhagen, Denmark
| | - Annika Loft
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Akmal Safwat
- Department of Clinical Oncology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Leila Vaalavirta
- Department of Radiation Oncology, Comprehensive Cancer Center, Helsinki University Hospital, Haartmaninkatu 4, 00290, Helsinki, Finland
| | - Lena Specht
- Department of Clinical Oncology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Maja Vestmoe Maraldo
- Department of Clinical Oncology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
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