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Zhu R, Zhu H. Survival Benefit from Cancer-Directed Surgery for Metastatic Head and Neck Cancer. Laryngoscope 2024; 134:1288-1298. [PMID: 37658720 DOI: 10.1002/lary.31019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/15/2023] [Accepted: 08/17/2023] [Indexed: 09/03/2023]
Abstract
OBJECTIVES This study aimed to gather evidence for the survival benefit of cancer-directed surgery (CDS) in metastatic head and neck cancer (M1 HNC) and identify which patients will benefit most from CDS. METHODS Patients with M1 HNC were identified within the SEER database. According to whether received CDS, patients were divided into the CDS and non-CDS groups. The bias between the two groups was minimized using Propensity Score Matching (PSM), and the prognostic role of CDS was investigated using Kaplan-Meier analysis, log-rank test, and Cox proportional hazard models. The primary endpoint was overall survival (OS), and the secondary endpoint was cancer-specific survival (CSS). RESULTS A total of 3215 patients with M1 HNC were extracted, including 566 patients who received CDS that were 1:1 propensity score-matched with patients who did not receive CDS. In the matched dataset, the median OS and CSS in CDS groups were significantly higher than in non-CDS groups (OS: 19.0 vs. 9.0 months, p < 0.001; CSS: 21.0 vs. 9.0 months, p < 0.001). Meanwhile, multivariable Cox regression analysis also revealed that CDS was a favorable prognostic factor for both OS and CSS. Furthermore, subgroups of patients with M1 HNC (younger age, being married, grade I-II, oropharynx site, earlier T/N stage, radiotherapy) were inclined to benefit from CDS, while those patients who received chemotherapy failed to benefit from CDS. CONCLUSIONS This study indicated that CDS was associated with improved survival in M1 HNC, especially for those subpopulations that benefit more from CDS treatment. LEVEL OF EVIDENCE 3 Laryngoscope, 134:1288-1298, 2024.
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Affiliation(s)
- Runqiu Zhu
- Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- School of Stomatology, College of Medicine, Zhejiang University, Hangzhou, China
| | - Huiyong Zhu
- Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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2
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Liu J, Zhang B, Su Y, Qin G, Kong X, Mo Y, Zhang R, Jiang W. Hypofractionated radiotherapy compared with conventionally fractionated radiotherapy to treat initial distant metastases in nasopharyngeal carcinoma: A multicenter, prospective, randomized, phase II trial. Radiother Oncol 2023; 187:109815. [PMID: 37480994 DOI: 10.1016/j.radonc.2023.109815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 06/05/2023] [Accepted: 07/14/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND AND PURPOSE To investigate the safety and efficacy of hypofractionated plus chemotherapy in patients with initially distant metastatic nasopharyngeal carcinoma (mNPC). MATERIALS AND METHODS Between May 2014 and June 2020, 35 patients initially diagnosed with mNPC were enrolled on prospective trial. The enrolled patients were assigned randomly to receive either hypofractionated plus chemotherapy (HFRT) or conventionally fractionated radiotherapy plus chemotherapy (CFRT). 60 Gy over 25 fractions was administered to the HFRT group (n = 17) and 69.96 Gy over 33 fractions was administered to the CFRT group (n = 18), both groups five times each week.Progression free survival (PFS) comprised the primary endpoint. Overall survival (OS), locoregional relapse-free survival (LRRFS), distant metastasis-free survival (DMFS), and acute and late toxicity comprised the secondary endpoints. RESULTS Twenty-eight patients (seven were excluded) were enrolled. The 2-year PFS was 33.3% (HFRT group) versus 30.0% (CFRT group) (stratified hazard ratio (HR):1.09; 95% confidence interval (CI): 0.45-2.65, P = 0.843). The 2-year OS was 66.7% (HFRT group) versus with 62.5% (CFRT group) (stratified HR, 0.88; 95% CI; 0.31-2.51, P = 0.806). All patients experienced acute grade 1 or 2, skin toxicity, oral mucositis, difficulty swallowing, xerostomia, but no acute grade 3 or 4 toxicities. All patients had grade 1 late xerostomia. Two patients experienced hearing loss in the HFRT group (one grade 1 and one grade 3), and three patients experienced grade 1 hearing loss in the CFRT group. One patient developed mucosal necrosis in the HFRT group. CONCLUSION Improving the balance between severe late toxicities and local control by appropriately reducing the total dose but increasing the fractionated dose has marked clinical significance for those patients.
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Affiliation(s)
- Jian Liu
- Department of Radiation Oncology, Affiliated Hospital of Guilin Medical University, 15 Lequn Road, Guilin 541001, People's Republic of China; Key Laboratory of Oncology (Guilin Medical University), Education Department of Guangxi Zhuang Autonomous Region, 1 Zhiyuan Road, Guilin 541199, China
| | - Bin Zhang
- Department of Radiation Oncology, Wuzhou Red Cross Hospital, Wuzhou 543002, China
| | - Yixin Su
- Department of Radiation Oncology, Lingshan People's Hospital, Zhongxiu Road, Lingshan 535400, China
| | - Guanjie Qin
- Department of Radiation Oncology, Affiliated Hospital of Guilin Medical University, 15 Lequn Road, Guilin 541001, People's Republic of China; Key Laboratory of Oncology (Guilin Medical University), Education Department of Guangxi Zhuang Autonomous Region, 1 Zhiyuan Road, Guilin 541199, China
| | - Xiangyun Kong
- Department of Radiation Oncology, Affiliated Hospital of Guilin Medical University, 15 Lequn Road, Guilin 541001, People's Republic of China; Key Laboratory of Oncology (Guilin Medical University), Education Department of Guangxi Zhuang Autonomous Region, 1 Zhiyuan Road, Guilin 541199, China
| | - Yunyan Mo
- Department of Radiation Oncology, Affiliated Hospital of Guilin Medical University, 15 Lequn Road, Guilin 541001, People's Republic of China; Key Laboratory of Oncology (Guilin Medical University), Education Department of Guangxi Zhuang Autonomous Region, 1 Zhiyuan Road, Guilin 541199, China
| | - Rongjun Zhang
- Department of Radiation Oncology, Affiliated Hospital of Guilin Medical University, 15 Lequn Road, Guilin 541001, People's Republic of China; Key Laboratory of Oncology (Guilin Medical University), Education Department of Guangxi Zhuang Autonomous Region, 1 Zhiyuan Road, Guilin 541199, China
| | - Wei Jiang
- Department of Radiation Oncology, Affiliated Hospital of Guilin Medical University, 15 Lequn Road, Guilin 541001, People's Republic of China; Key Laboratory of Oncology (Guilin Medical University), Education Department of Guangxi Zhuang Autonomous Region, 1 Zhiyuan Road, Guilin 541199, China.
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3
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Embring A, Onjukka E, Mercke C, Lax I, Berglund A, Friesland S. Dose Escalation of Oropharyngeal Cancer: Long-Time Follow-Up and Side Effects. Cancers (Basel) 2023; 15:cancers15092580. [PMID: 37174046 PMCID: PMC10177133 DOI: 10.3390/cancers15092580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 04/13/2023] [Accepted: 04/29/2023] [Indexed: 05/15/2023] Open
Abstract
Previous studies on dose-escalated radiotherapy in head and neck cancer have shown mixed results, and it is not established which patients would benefit from dose escalation. Further, while dose escalation does not appear to increase late toxicity, this needs to be confirmed with longer follow-up. In this study, we analysed treatment outcome and toxicity in 215 patients with oropharyngeal cancer treated with dose-escalated radiotherapy (>72 Gy, EQD2, α/β = 10 Gy, boost by brachytherapy or simultaneous integrated boost) and a matched cohort of 215 patients treated with standard dose external-beam radiotherapy (68 Gy) between 2011 and 2018 at our institution. The 5-year overall survival (OS) was 77.8% (72.4-83.6) and 73.7% (67.8-80.1) in the dose-escalated and standard dose group, respectively (p = 0.24). Median follow-up was 78.1 (49.2-98.4) and 60.2 (38.9-89.4) months in the dose-escalated and standard dose groups, respectively. Grade ≥3 osteoradionecrosis (ORN) and late dysphagia were more common in the dose-escalated group compared to the standard dose group, with 19 (8.8%) vs. 4 (1.9%) patients developing grade ≥3 ORN (p = 0.001), and 39 (18.1%) vs. 21 (9.8%) patients developing grade ≥3 dysphagia (p = 0.01). No predictive factors to help select patients for dose-escalated radiotherapy were found. However, the remarkably good OS in the dose-escalated cohort, despite a predominance of advanced tumour stages, encourages further attempts to identify such factors.
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Affiliation(s)
- Anna Embring
- Department of Oncology, Karolinska University Hospital, 17176 Stockholm, Sweden
- Karolinska Institute, Department of Oncology-Pathology, 17176 Stockholm, Sweden
| | - Eva Onjukka
- Karolinska Institute, Department of Oncology-Pathology, 17176 Stockholm, Sweden
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Claes Mercke
- Department of Oncology, Karolinska University Hospital, 17176 Stockholm, Sweden
- Karolinska Institute, Department of Oncology-Pathology, 17176 Stockholm, Sweden
| | - Ingmar Lax
- Karolinska Institute, Department of Oncology-Pathology, 17176 Stockholm, Sweden
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Anders Berglund
- Epistat Epidemiology and Statistics Consulting, 75655 Uppsala, Sweden
| | - Signe Friesland
- Department of Oncology, Karolinska University Hospital, 17176 Stockholm, Sweden
- Karolinska Institute, Department of Oncology-Pathology, 17176 Stockholm, Sweden
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Mireștean CC, Iancu RI, Iancu DPT. Simultaneous Integrated Boost (SIB) vs. Sequential Boost in Head and Neck Cancer (HNC) Radiotherapy: A Radiomics-Based Decision Proof of Concept. J Clin Med 2023; 12:jcm12062413. [PMID: 36983413 PMCID: PMC10057404 DOI: 10.3390/jcm12062413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/07/2023] [Accepted: 03/14/2023] [Indexed: 03/30/2023] Open
Abstract
Artificial intelligence (AI) and in particular radiomics has opened new horizons by extracting data from medical imaging that could be used not only to improve diagnostic accuracy, but also to be included in predictive models contributing to treatment stratification of cancer. Head and neck cancers (HNC) are associated with higher recurrence rates, especially in advanced stages of disease. It is considered that approximately 50% of cases will evolve with loco-regional recurrence, even if they will benefit from a current standard treatment consisting of definitive chemo-radiotherapy. Radiotherapy, the cornerstone treatment in locally advanced HNC, could be delivered either by the simultaneous integrated boost (SIB) technique or by the sequential boost technique, the decision often being a subjective one. The principles of radiobiology could be the basis of an optimal decision between the two methods of radiation dose delivery, but the heterogeneity of HNC radio-sensitivity makes this approach difficult. Radiomics has demonstrated the ability to non-invasively predict radio-sensitivity and the risk of relapse in HNC. Tumor heterogeneity evaluated with radiomics, the inclusion of coarseness, entropy and other first order features extracted from gross tumor volume (GTV) in multivariate models could identify pre-treatment cases that will benefit from one of the approaches (SIB or sequential boost radio-chemotherapy) considered the current standard of care for locally advanced HNC. Computer tomography (CT) simulation and daily cone beam CT (CBCT) could be chosen as imaging source for radiomic analysis.
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Affiliation(s)
- Camil Ciprian Mireștean
- Department of Oncology and Radiotherapy, University of Medicine and Pharmacy Craiova, 200349 Craiova, Romania
- Department of Surgery, Railways Clinical Hospital Iasi, 700506 Iași, Romania
| | - Roxana Irina Iancu
- Oral Pathology Department, Faculty of Dental Medicine, "Gr. T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- Department of Clinical Laboratory, "St. Spiridon" Emergency Universitary Hospital, 700111 Iași, Romania
| | - Dragoș Petru Teodor Iancu
- Oncology and Radiotherapy Department, Faculty of Medicine, "Gr. T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
- Department of Radiation Oncology, Regional Institute of Oncology, 700483 Iași, Romania
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5
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Mierzwa ML, Aryal M, Lee C, Schipper M, VanTil M, Rivera KM, Swiecicki PL, Casper KA, Malloy KM, Spector ME, Shuman AG, Chinn SB, Prince ME, Stucken CL, Rosko AJ, Lawrence TS, Brenner JC, Rosen B, Schonewolf CA, Shah J, Eisbruch A, Worden FP, Cao Y. Randomized Phase II Study of Physiologic MRI-Directed Adaptive Radiation Boost in Poor Prognosis Head and Neck Cancer. Clin Cancer Res 2022; 28:5049-5057. [PMID: 36107219 PMCID: PMC9773159 DOI: 10.1158/1078-0432.ccr-22-1522] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/06/2022] [Accepted: 09/13/2022] [Indexed: 01/24/2023]
Abstract
PURPOSE We conducted a randomized phase II multicenter clinical trial to test the hypothesis that physiologic MRI-based radiotherapy (RT) dose escalation would improve the outcome of patients with poor prognosis head and neck cancer. PATIENTS AND METHODS MRI was acquired at baseline and at RT fraction 10 to create low blood volume/apparent diffusion coefficient maps for RT boost subvolume definition in gross tumor volume. Patients were randomized to receive 70 Gy (standard RT) or 80 Gy to the boost subvolume (RT boost) with concurrent weekly platinum. The primary endpoint was disease-free survival (DFS) with significance defined at a one-sided 0.1 level, and secondary endpoints included locoregional failure (LRF), overall survival (OS), comparison of adverse events and patient reported outcomes (PRO). RESULTS Among 81 randomized patients, neither the primary endpoint of DFS (HR = 0.849, P = 0.31) nor OS (HR = 1.19, P = 0.66) was significantly improved in the RT boost arm. However, the incidence of LRF was significantly improved with the addition of the RT boost (HR = 0.43, P = 0.047). Two-year estimates [90% confidence interval (CI)] of the cumulative incidence of LRF were 40% (27%-53%) in the standard RT arm and 18% (10%-31%) in the RT boost arm. Two-year estimates (90% CI) for DFS were 48% (34%-60%) in the standard RT arm and 57% (43%-69%) in the RT boost arm. There were no significant differences in toxicity or longitudinal differences seen in EORTC QLQ30/HN35 subscales between treatment arms in linear mixed-effects models. CONCLUSIONS Physiologic MRI-based RT boost decreased LRF without a significant increase in grade 3+ toxicity or longitudinal PRO differences, but did not significantly improve DFS or OS. Additional improvements in systemic therapy are likely necessary to realize improvements in DFS and OS.
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Affiliation(s)
- Michelle L Mierzwa
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Madhava Aryal
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Choonik Lee
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Matthew Schipper
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Monica VanTil
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | | | - Paul L. Swiecicki
- Department of Internal Medicine, Medical Oncology, University of Michigan, Ann Arbor, Michigan
| | - Keith A. Casper
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan
| | - Kelly M. Malloy
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan
| | - Matthew E. Spector
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan
| | - Andrew G. Shuman
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan
| | - Steven B. Chinn
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan
| | - Mark E.P. Prince
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan
| | - Chaz L. Stucken
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan
| | - Andrew J. Rosko
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan
| | | | - J Chad Brenner
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan
| | - Benjamin Rosen
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | | | - Jennifer Shah
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Avraham Eisbruch
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Francis P. Worden
- Department of Internal Medicine, Medical Oncology, University of Michigan, Ann Arbor, Michigan
| | - Yue Cao
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
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6
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Dolezel M, Slavik M, Blazek T, Kazda T, Koranda P, Veverkova L, Burkon P, Cvek J. FMISO-Based Adaptive Radiotherapy in Head and Neck Cancer. J Pers Med 2022; 12:jpm12081245. [PMID: 36013194 PMCID: PMC9410424 DOI: 10.3390/jpm12081245] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/12/2022] [Accepted: 07/27/2022] [Indexed: 11/16/2022] Open
Abstract
Concurrent chemoradiotherapy represents one of the most used strategies in the curative treatment of patients with head and neck (HNC) cancer. Locoregional failure is the predominant recurrence pattern. Tumor hypoxia belongs to the main cause of treatment failure. Positron emission tomography (PET) using hypoxia radiotracers has been studied extensively and has proven its feasibility and reproducibility to detect tumor hypoxia. A number of studies confirmed that the uptake of FMISO in the recurrent region is significantly higher than that in the non-recurrent region. The escalation of dose to hypoxic tumors may improve outcomes. The technical feasibility of optimizing radiotherapeutic plans has been well documented. To define the hypoxic tumour volume, there are two main approaches: dose painting by contour (DPBC) or by number (DPBN) based on PET images. Despite amazing technological advances, precision in target coverage, and surrounding tissue sparring, radiation oncology is still not considered a targeted treatment if the “one dose fits all” approach is used. Using FMISO and other hypoxia tracers may be an important step for individualizing radiation treatment and together with future radiomic principles and a possible genome-based adjusting dose, will move radiation oncology into the precise and personalized era.
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Affiliation(s)
- Martin Dolezel
- Department of Oncology, Palacky University Medical School & Teaching Hospital, 77900 Olomouc, Czech Republic;
| | - Marek Slavik
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, 65652 Brno, Czech Republic; (T.K.); (P.B.)
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic
- Correspondence:
| | - Tomas Blazek
- Department of Oncology, Faculty of Medicine, University Hospital Ostrava, 70852 Ostrava, Czech Republic; (T.B.); (J.C.)
| | - Tomas Kazda
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, 65652 Brno, Czech Republic; (T.K.); (P.B.)
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic
| | - Pavel Koranda
- Department of Nuclear Medicine, Palacky University Medical School & Teaching Hospital, 77900 Olomouc, Czech Republic;
| | - Lucia Veverkova
- Department of Radiology, Palacky University Medical School & Teaching Hospital, 77900 Olomouc, Czech Republic;
| | - Petr Burkon
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, 65652 Brno, Czech Republic; (T.K.); (P.B.)
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic
| | - Jakub Cvek
- Department of Oncology, Faculty of Medicine, University Hospital Ostrava, 70852 Ostrava, Czech Republic; (T.B.); (J.C.)
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7
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Muzumder S, Srikantia N, Udayashankar AH, Kainthaje PB, Sebastian MGJ, Raj JM. Late toxicities in locally advanced head and neck squamous cell carcinoma treated with intensity modulated radiation therapy. Radiat Oncol J 2021; 39:184-192. [PMID: 34610657 PMCID: PMC8497871 DOI: 10.3857/roj.2020.00913] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 05/03/2021] [Indexed: 12/04/2022] Open
Abstract
Purpose The study aims to report late toxicities in locally advanced head-and-neck squamous cell carcinoma (LAHNSCC) treated with intensity-modulated radiation therapy (IMRT). Materials and Methods A retrospective study was conducted on 103 patients of LAHNSCC treated with IMRT. We analyzed the cumulative incidence of late xerostomia, dysphagia, and aspiration at an interval of 6-month, 1-year, 2-year, and 3-year from the start of IMRT. Results At a median follow up of 4.2 years (interquartile range, 3.5 to 6 years), the cumulative incidence of grade ≥2 late xerostomia was 5.5%, dysphagia was 6.9%, and aspiration was 11.1%. Logistic regression showed that Dmean of ≥26 Gy to parotids had higher risk of xerostomia (hazard ratio [HR] = 5.19; 95% confidence interval [CI], 1.90–14.22; p = 0.001). Late dysphagia was associated with Dmean of ≥45 Gy to pharyngeal constrictors (PC) (HR = 7; 95% CI, 1.84–26.61; p =0.004), ≥55 Gy to larynx (HR = 3.25; 95% CI, 1.15–9.11; p = 0.025), and adjuvant RT (HR = 5.26; 95% CI, 1.85–14.87; p = 0.002). Aspiration was associated with Dmean of ≥45 Gy to larynx (HR = 6.5; 95% CI, 1.93–21.88; p = 0.003), Dmean of ≥55 Gy to PC (HR = 3.54; 95% CI, 1.25–9.98; p = 0.017), and patients having late dysphagia (HR = 4.37; 95% CI, 1.55–12.31; p = 0.005). conclusions IMRT is a feasible radiation delivery technique in LAHNSCC with a decreased late toxicity profile.
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Affiliation(s)
- Sandeep Muzumder
- Department of Radiation Oncology, St. John's Medical College and Hospital, Bengaluru, Karnataka, India
| | - Nirmala Srikantia
- Department of Radiation Oncology, St. John's Medical College and Hospital, Bengaluru, Karnataka, India
| | - Avinash H Udayashankar
- Department of Radiation Oncology, St. John's Medical College and Hospital, Bengaluru, Karnataka, India
| | - Prashanth Bhat Kainthaje
- Department of Radiation Oncology, St. John's Medical College and Hospital, Bengaluru, Karnataka, India
| | - M G John Sebastian
- Department of Radiation Oncology, St. John's Medical College and Hospital, Bengaluru, Karnataka, India
| | - John Michael Raj
- Department of Biostatistics, St John's Medical College, Bengaluru, Karnataka, India
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Lis M, Newhauser W, Donetti M, Wolf M, Steinsberger T, Paz A, Graeff C. Dosimetric Validation of a System to Treat Moving Tumors Using Scanned Ion Beams That Are Synchronized With Anatomical Motion. Front Oncol 2021; 11:712126. [PMID: 34568041 PMCID: PMC8456027 DOI: 10.3389/fonc.2021.712126] [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: 05/19/2021] [Accepted: 08/16/2021] [Indexed: 12/25/2022] Open
Abstract
Purpose The purpose of this study was to validate the dosimetric performance of scanned ion beam deliveries with motion-synchronization to heterogenous targets. Methods A 4D library of treatment plans, comprised of up to 10 3D sub-plans, was created with robust and conventional 4D optimization methods. Each sub-plan corresponded to one phase of periodic target motion. The plan libraries were delivered to a test phantom, comprising plastic slabs, dosimeters, and heterogenous phantoms. This phantom emulated range changes that occur when treating moving tumors. Similar treatment plans, but without motion synchronization, were also delivered to a test phantom with a stationary target and to a moving target; these were used to assess how the target motion degrades the quality of dose distributions and the extent to which motion synchronization can improve dosimetric quality. The accuracy of calculated dose distributions was verified by comparison with corresponding measurements. Comparisons utilized the gamma index analysis method. Plan quality was assessed based on conformity, dose coverage, overdose, and homogeneity values, each extracted from calculated dose distributions. Results High pass rates for the gamma index analysis confirmed that the methods used to calculate and reconstruct dose distributions were sufficiently accurate for the purposes of this study. Calculated and reconstructed dose distributions revealed that the motion-synchronized and static deliveries exhibited similar quality in terms of dose coverage, overdose, and homogeneity for all deliveries considered. Motion-synchronization substantially improved conformity in deliveries with moving targets. Importantly, measurements at multiple locations within the target also confirmed that the motion-synchronized delivery system satisfactorily compensated for changes in beam range caused by the phantom motion. Specifically, the overall planning and delivery approach achieved the desired dose distribution by avoiding range undershoots and overshoots caused by tumor motion. Conclusions We validated a dose delivery system that synchronizes the movement of the ion beam to that of a moving target in a test phantom. Measured and calculated dose distributions revealed that this system satisfactorily compensated for target motion in the presence of beam range changes due to target motion. The implication of this finding is that the prototype system is suitable for additional preclinical research studies, such as irregular anatomic motion.
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Affiliation(s)
- Michelle Lis
- Biophysics, GSI Helmholtzzentrum für Schwerionenforschung GmbH, Darmstadt, Germany.,Department of Physics and Astronomy, Louisiana State University, Baton Rouge, LA, United States
| | - Wayne Newhauser
- Department of Physics and Astronomy, Louisiana State University, Baton Rouge, LA, United States.,Department of Radiation Physics, Mary Bird Perkins Cancer Center, Baton Rouge, LA, United States
| | - Marco Donetti
- Research and Development Department, CNAO National Center for Oncological Hadrontherapy, Pavia, Italy
| | - Moritz Wolf
- Biophysics, GSI Helmholtzzentrum für Schwerionenforschung GmbH, Darmstadt, Germany
| | - Timo Steinsberger
- Biophysics, GSI Helmholtzzentrum für Schwerionenforschung GmbH, Darmstadt, Germany.,Institute of Condensed Matter Physics, Technical University of Darmstadt, Darmstadt, Germany
| | - Athena Paz
- Biophysics, GSI Helmholtzzentrum für Schwerionenforschung GmbH, Darmstadt, Germany
| | - Christian Graeff
- Biophysics, GSI Helmholtzzentrum für Schwerionenforschung GmbH, Darmstadt, Germany
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9
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Mierzwa M, Beadle BM, Chua MLK, Ma DJ, Thomson DJ, Margalit DN. Something for Everyone From Low-Risk to High-Risk: 5 Recent Studies to Improve Treatment and Surveillance for All Patients With Squamous Cell Carcinoma of the Head and Neck. Int J Radiat Oncol Biol Phys 2021; 111:1-8. [PMID: 34348102 DOI: 10.1016/j.ijrobp.2021.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/04/2021] [Indexed: 11/18/2022]
Affiliation(s)
| | | | - Melvin L K Chua
- Divisions of Radiation Oncology and Medical Sciences, National Cancer Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | | | - David J Thomson
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; Division of Cancer Sciences, The University of Manchester, Manchester, United Kingdom
| | - Danielle N Margalit
- Brigham & Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.
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10
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Wang H, Wang R, Liu J, Zhang J, Yao K, Yue H, Zhang Y, You J, Wu H. Tree-based exploration of the optimization objectives for automatic cervical cancer IMRT treatment planning. Br J Radiol 2021; 94:20210214. [PMID: 34111955 DOI: 10.1259/bjr.20210214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE To develop and evaluate a practical automatic treatment planning method for intensity-modulated radiation therapy (IMRT) in cervical cancer cases. METHODS A novel algorithm named as Optimization Objectives Tree Search Algorithm (OOTSA) was proposed to emulate the planning optimization process and achieve a progressively improving IMRT plan, based on the Eclipse Scripting Application Programming Interface (ESAPI). 30 previously treated cervical cancer cases were selected from the clinical database and comparison was made between the OOTSA-generated plans and clinical treated plans and RapidPlan-based (RP) plans. RESULTS In clinical evaluation, compared with plan scores of the clinical plans and the RP plans, 22 and 26 of the OOTSA plans were considered as clinically improved in terms of plan quality, respectively. The average conformity index (CI) for the PTV in the OOTSA plans was 0.86 ± 0.01 (mean ± 1 standard deviation), better than those in the RP plans (0.83 ± 0.02) and the clinical plans (0.71 ± 0.11). Compared with the clinical plans, the mean doses of femoral head, rectum, spinal cord and right kidney in the OOTSA plans were reduced by 2.34 ± 2.87 Gy, 1.67 ± 2.10 Gy, 4.12 ± 6.44 Gy and 1.15 ± 2.67 Gy. Compared with the RP plans, the mean doses of femoral head, spinal cord, right kidney and small intestine in the OOTSA plans were reduced by 3.31 ± 1.55 Gy, 4.25 ± 3.69 Gy, 1.54 ± 2.23 Gy and 3.33 ± 1.91 Gy, respectively. In the OOTSA plans, the mean dose of bladder was slightly increased, with 2.33 ± 2.55 Gy (versus clinical plans) and 1.37 ± 1.74 Gy (vs RP plans). The average elapsed time of OOTSA and clinical planning were 59.2 ± 3.47 min and 76.53 ± 5.19 min. CONCLUSION The plans created by OOTSA have been shown marginally better than the manual plans, especially in preserving OARs. In addition, the time of automatic treatment planning has shown a reduction compared to a manual planning process, and the variation of plan quality was greatly reduced. Although improvement on the algorithm is warranted, this proof-of-concept study has demonstrated that the proposed approach can be a practical solution for automatic planning. ADVANCES IN KNOWLEDGE The proposed method is novel in the emulation strategy of the physicists' iterative operation during the planning process. Based on the existing optimizers, this method can be a simple yet effective solution for automated IMRT treatment planning.
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Affiliation(s)
- Hanlin Wang
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital &Institute, Beijing, China
| | - Ruoxi Wang
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital &Institute, Beijing, China
| | - Jiacheng Liu
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital &Institute, Beijing, China
| | - Jian Zhang
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital &Institute, Beijing, China
| | - Kaining Yao
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital &Institute, Beijing, China
| | - Haizhen Yue
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital &Institute, Beijing, China
| | - Yibao Zhang
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital &Institute, Beijing, China.,Institute of Medical Technology, Peking University Health Science Center, Beijing, China
| | - Jing You
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital &Institute, Beijing, China
| | - Hao Wu
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital &Institute, Beijing, China.,Institute of Medical Technology, Peking University Health Science Center, Beijing, China
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11
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Bogowicz M, Pavic M, Riesterer O, Finazzi T, Garcia Schüler H, Holz-Sapra E, Rudofsky L, Basler L, Spaniol M, Ambrusch A, Hüllner M, Guckenberger M, Tanadini-Lang S. Targeting Treatment Resistance in Head and Neck Squamous Cell Carcinoma - Proof of Concept for CT Radiomics-Based Identification of Resistant Sub-Volumes. Front Oncol 2021; 11:664304. [PMID: 34123824 PMCID: PMC8191457 DOI: 10.3389/fonc.2021.664304] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 04/06/2021] [Indexed: 12/18/2022] Open
Abstract
Purpose Radiomics has already been proposed as a prognostic biomarker in head and neck cancer (HNSCC). However, its predictive power in radiotherapy has not yet been studied. Here, we investigated a local radiomics approach to distinguish between tumor sub-volumes with different levels of radiosensitivity as a possible target for radiation dose intensification. Materials and Methods Of 40 patients (n=28 training and n=12 validation) with biopsy confirmed locally recurrent HNSCC, pretreatment contrast-enhanced CT images were registered with follow-up PET/CT imaging allowing identification of controlled (GTVcontrol) vs non-controlled (GTVrec) tumor sub-volumes on pretreatment imaging. A bi-regional model was built using radiomic features extracted from pretreatment CT in the GTVrec and GTVcontrol to differentiate between those regions. Additionally, concept of local radiomics was implemented to perform detection task. The original tumor volume was divided into sub-volumes with no prior information on the location of recurrence. Radiomic features from those sub-volumes were then used to detect recurrent sub-volumes using multivariable logistic regression. Results Radiomic features extracted from non-controlled regions differed significantly from those in controlled regions (training AUC = 0.79 CI 95% 0.66 - 0.91 and validation AUC = 0.88 CI 95% 0.72 – 1.00). Local radiomics analysis allowed efficient detection of non-controlled sub-volumes both in the training AUC = 0.66 (CI 95% 0.56 – 0.75) and validation cohort 0.70 (CI 95% 0.53 – 0.86), however performance of this model was inferior to bi-regional model. Both models indicated that sub-volumes characterized by higher heterogeneity were linked to tumor recurrence. Conclusion Local radiomics is able to detect sub-volumes with decreased radiosensitivity, associated with location of tumor recurrence in HNSCC in the pre-treatment CT imaging. This proof of concept study, indicates that local CT radiomics can be used as predictive biomarker in radiotherapy and potential target for dose intensification.
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Affiliation(s)
- Marta Bogowicz
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Matea Pavic
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Oliver Riesterer
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Centre for Radiation Oncology KSA-KSB, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Tobias Finazzi
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Helena Garcia Schüler
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Edna Holz-Sapra
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Leonie Rudofsky
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Lucas Basler
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Manon Spaniol
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Andreas Ambrusch
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Martin Hüllner
- Department of Nuclear Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Stephanie Tanadini-Lang
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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12
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Kashihara T, Nakamura S, Murakami N, Ito K, Matsumoto Y, Kobayashi K, Omura G, Mori T, Honma Y, Kubo Y, Okamoto H, Takahashi K, Inaba K, Okuma K, Igaki H, Nakayama Y, Kato K, Matsumoto F, Yoshimoto S, Itami J. Initial Experience of Intentional Internal High-Dose Policy Volumetric Modulated Arc Therapy of Neck Lymph Node Metastases ≥ 2 cm in Patients With Head and Neck Squamous Cell Carcinoma. Front Oncol 2021; 11:651409. [PMID: 33987086 PMCID: PMC8112241 DOI: 10.3389/fonc.2021.651409] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 03/30/2021] [Indexed: 12/24/2022] Open
Abstract
Background and Purpose Most locoregional recurrences after definitive radiotherapy for head and neck squamous cell carcinoma (HNSCC) develop "in-field." Dose escalation while sparing organs at risk can be a good solution for improving local control without increasing adverse effects. This study investigated the safety and effectiveness of volumetric modulated arc therapy (VMAT) using intentionally internal high-dose policy (IIHDP) to treat neck lymph node metastases (NLNM) ≥ 2 cm in HNSCC patients. Materials and Methods We analyzed 71 NLNM from 51 HNSCC patients who had received definitive radiotherapy to treat NLNM ≥ 2 cm using the VMAT technique in our institution between February 2017 and August 2019. Thirty-seven NLNM from 25 patients were treated using IIHDP VMAT (group A), and 34 NLNM from 27 patients were treated with homogeneous-dose distribution policy (HDDP) VMAT (group B). One patient with three NLNM had one lymph node assigned to group A and the other two to group B. Adverse events and local recurrence-free survival (LRFS) was compared between the two groups. Results In the median follow-up period of 527 days, there were no significant differences between the groups in terms of dermatitis or mucositis ≥ grade 2/3, but LRFS was significantly longer in group A (p = 0.007). In the Cox regression analysis after adjustment for the propensity score, group A also showed an apparently superior LFRS. Conclusion Our initial experience of IIHDP VMAT suggested that IIHDP VMAT to treat HNSCC neck lymph node metastases measuring ≥ 2 cm was feasible and possibly led to better local control than HDDP VMAT.
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Affiliation(s)
- Tairo Kashihara
- Department of Radiation Therapy in National Cancer Center Hospital, Tokyo, Japan
| | - Satoshi Nakamura
- Department of Radiation Therapy in National Cancer Center Hospital, Tokyo, Japan
| | - Naoya Murakami
- Department of Radiation Therapy in National Cancer Center Hospital, Tokyo, Japan
| | - Kimiteru Ito
- Department of Radiology in National Cancer Center Hospital, Tokyo, Japan
| | - Yoshifumi Matsumoto
- Department of Head and Neck Oncology in National Cancer Center Hospital, Tokyo, Japan
| | - Kenya Kobayashi
- Department of Head and Neck Oncology in National Cancer Center Hospital, Tokyo, Japan
| | - Go Omura
- Department of Head and Neck Oncology in National Cancer Center Hospital, Tokyo, Japan
| | - Taisuke Mori
- Department of Pathology and Clinical Laboratories in National Cancer Center Hospital, Tokyo, Japan
| | - Yoshitaka Honma
- Department of Head and Neck Medical Oncology in National Cancer Center Hospital, Tokyo, Japan
| | - Yuko Kubo
- Department of Radiology in National Cancer Center Hospital, Tokyo, Japan
| | - Hiroyuki Okamoto
- Department of Radiation Therapy in National Cancer Center Hospital, Tokyo, Japan
| | - Kana Takahashi
- Department of Radiation Therapy in National Cancer Center Hospital, Tokyo, Japan
| | - Koji Inaba
- Department of Radiation Therapy in National Cancer Center Hospital, Tokyo, Japan
| | - Kae Okuma
- Department of Radiation Therapy in National Cancer Center Hospital, Tokyo, Japan
| | - Hiroshi Igaki
- Department of Radiation Therapy in National Cancer Center Hospital, Tokyo, Japan
| | - Yuko Nakayama
- Department of Radiation Therapy in National Cancer Center Hospital, Tokyo, Japan
| | - Ken Kato
- Department of Head and Neck Medical Oncology in National Cancer Center Hospital, Tokyo, Japan
| | - Fumihiko Matsumoto
- Department of Head and Neck Oncology in National Cancer Center Hospital, Tokyo, Japan
| | - Seiichi Yoshimoto
- Department of Head and Neck Oncology in National Cancer Center Hospital, Tokyo, Japan
| | - Jun Itami
- Department of Radiation Therapy in National Cancer Center Hospital, Tokyo, Japan
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13
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Pigorsch SU, Kampfer S, Oechsner M, Mayinger MC, Mozes P, Devecka M, Kessel KK, Combs SE, Wilkens JJ. Report on planning comparison of VMAT, IMRT and helical tomotherapy for the ESCALOX-trial pre-study. Radiat Oncol 2020; 15:253. [PMID: 33138837 PMCID: PMC7607845 DOI: 10.1186/s13014-020-01693-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/21/2020] [Indexed: 12/12/2022] Open
Abstract
Background The ESCALOX trial was designed as a multicenter, randomized prospective dose escalation study for head and neck cancer. Therefore, feasibility of treatment planning via different treatment planning systems (TPS) and radiotherapy (RT) techniques is essential. We hypothesized the comparability of dose distributions for simultaneous integrated boost (SIB) volumes respecting the constraints by different TPS and RT techniques. Methods CT data sets of the first six patients (all male, mean age: 61.3 years) of the pre-study (up to 77 Gy) were used for comparison of IMRT, VMAT, and helical tomotherapy (HT). Oropharynx was the primary tumor location. Normalization of the three step SIB (77 Gy, 70 Gy, 56 Gy) was D95% = 77 Gy. Coverage (CVF), healthy tissue conformity index (HTCI), conformation number (CN), and dose homogeneity (HI) were compared for PTVs and conformation index (COIN) for parotids. Results All RT techniques achieved good coverage. For SIB77Gy, CVF was best for IMRT and VMAT, HT achieved highest CN followed by VMAT and IMRT. HT reached good HTCI value, and HI compared to both other techniques. For SIB70Gy, CVF was best by IMRT. HTCI favored HT, consequently CN as well. HI was slightly better for HT. For SIB56Gy, CVF resulted comparably. Conformity favors VMAT as seen by HTCI and CN. Dmean of ipsilateral and contralateral parotids favor HT. Conclusion Different TPS for dose escalation reliably achieved high plan quality. Despite the very good results of HT planning for coverage, conformity, and homogeneity, the TPS also achieved acceptable results for IMRT and VMAT. Trial registration ClinicalTrials.gov Identifier: NCT 01212354, EudraCT-No.: 2010-021139-15. ARO: ARO 14-01
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Affiliation(s)
- Steffi U Pigorsch
- Department of Radiation Oncology, Technical University of Munich (TUM), School of Medicine, Klinikum Rechts Der Isar, Ismaninger Straße 22, 81675, Munich, Germany.
| | - Severin Kampfer
- Department of Radiation Oncology, Technical University of Munich (TUM), School of Medicine, Klinikum Rechts Der Isar, Ismaninger Straße 22, 81675, Munich, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Technical University of Munich (TUM), School of Medicine, Klinikum Rechts Der Isar, Ismaninger Straße 22, 81675, Munich, Germany
| | - Michael C Mayinger
- Department of Radiation Oncology, University Hospital Zurich, Rämistrasse 100, Zurich, Switzerland
| | - Petra Mozes
- Department of Radiation Oncology, Technical University of Munich (TUM), School of Medicine, Klinikum Rechts Der Isar, Ismaninger Straße 22, 81675, Munich, Germany
| | - Michal Devecka
- Department of Radiation Oncology, Technical University of Munich (TUM), School of Medicine, Klinikum Rechts Der Isar, Ismaninger Straße 22, 81675, Munich, Germany
| | - Kerstin K Kessel
- Department of Radiation Oncology, Technical University of Munich (TUM), School of Medicine, Klinikum Rechts Der Isar, Ismaninger Straße 22, 81675, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich (TUM), School of Medicine, Klinikum Rechts Der Isar, Ismaninger Straße 22, 81675, Munich, Germany.,Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Ingolstädter Landstraße 1, Neuherberg, Germany
| | - Jan J Wilkens
- Department of Radiation Oncology, Technical University of Munich (TUM), School of Medicine, Klinikum Rechts Der Isar, Ismaninger Straße 22, 81675, Munich, Germany
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14
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Thaper D, Kamal R, Singh G, Oinam AS, Yadav HP, Kumar V. Derivative-based gamma index: a novel methodology for stringent patient-specific quality assurance in the stereotactic treatment planning of liver cancer. Biomed Phys Eng Express 2020; 6. [PMID: 35125347 DOI: 10.1088/2057-1976/ababf3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 08/03/2020] [Indexed: 11/12/2022]
Abstract
Objective:The development of a stringent derivative-based gamma (DBG) index for patient-specific QA in stereotactic radiotherapy treatment planning (SRTP) to account for the spatial change in dose.Methods:Twenty-five patients of liver SBRT were selected retrospectively for this study. Deliberately, two different kinds of treatment planning approaches were used for each patient. Firstly, the treatment plans were generated using a conventional treatment planning (CTP) approach in which the target was covered with a homogeneous dose along with the nominal dose fall-off around the treatment field. Subsequently, the other treatment plans were generated using an SRTP approach with the intent of heterogeneous dose within the target region along with a steeper dose gradient outside the treatment field as much as possible. For both kinds of treatment plans, two dimensional (2D) conventional gamma (CG) and DBG analysis were performed using the 2D ion chamber array and radiochromic film.Results:Difference in the DBG index was statistically significant whereas, for CG analysis, the difference in CG index was insignificant for both types of treatment plans (CTP and SRTP). A significant positive correlation was observed between the difference in the DBG index and the difference in HI for high gamma criteria.Conclusion:The DBG evaluation is found to be more rigorous, and sensitive to the only SRTP. The proposed method could be opted-in the routine clinical practice in addition to CG.Advances in knowledge:DBG is more sensitive to detect the spatial change of dose, especially in high dose gradient regions.
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Affiliation(s)
- Deepak Thaper
- Centre for Medical Physics, Panjab University, Chandigarh, India.,Department of Radiation Oncology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rose Kamal
- Centre for Medical Physics, Panjab University, Chandigarh, India.,Department of Radiation Oncology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Gaganpreet Singh
- Centre for Medical Physics, Panjab University, Chandigarh, India.,Department of Radiotherapy, PGIMER, Regional Cancer Centre, Chandigarh, India
| | - Arun S Oinam
- Department of Radiotherapy, PGIMER, Regional Cancer Centre, Chandigarh, India
| | - Hanuman P Yadav
- Department of Radiation Oncology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vivek Kumar
- Centre for Medical Physics, Panjab University, Chandigarh, India
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15
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De Felice F, Bonomo P, Sanguineti G, Orlandi E. Moderately accelerated intensity-modulated radiation therapy using simultaneous integrated boost: Practical reasons or evidence-based choice? A critical appraisal of literature. Head Neck 2020; 42:3405-3414. [PMID: 32767530 DOI: 10.1002/hed.26400] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 06/29/2020] [Accepted: 07/14/2020] [Indexed: 01/03/2023] Open
Abstract
Concurrent chemo-radiotherapy is the non-surgical mainstay of treatment for locally advanced head and neck squamous cell carcinoma (HNSCC). The following aspects have emerged as fundamental components of the combined approach: first, intensity modulated radiotherapy (IMRT) is the minimum standard technical requirement, with level 1 evidence in support of its reduction of late treatment-induced morbidity in comparison with 3D conformal radiotherapy. Second, cisplatin-based chemotherapy is the preferred systemic agent to be associated with radiation, with 100 mg/m2 every 3 weeks deemed as the reference schedule. Because of significant progress in irradiation techniques achieved in last 15 years, the optimal fractionation schedule in modern radiation era remains controversial, especially for locally advanced disease. The purpose of this work was to perform a critical review on the value of moderately accelerated IMRT using simultaneous-integrated boost (SIB) in HNSCC, aiming to provide insights on current clinical practice and directions for future research.
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Affiliation(s)
- Francesca De Felice
- Department of Radiotherapy, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - Pierluigi Bonomo
- Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, University of Florence, Florence, Italy
| | | | - Ester Orlandi
- Radiotherapy 2 Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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16
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Dosimetric comparison of dynamic conformal arc integrated with segment shape optimization and variable dose rate versus volumetric modulated arc therapy for liver SBRT. Rep Pract Oncol Radiother 2020; 25:667-677. [PMID: 32565744 DOI: 10.1016/j.rpor.2020.04.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 04/01/2020] [Accepted: 04/23/2020] [Indexed: 12/17/2022] Open
Abstract
Purpose The aim is a dosimetric comparison of dynamic conformal arc integrated with the segment shape optimization and variable dose rate (DCA_SSO_VDR) versus VMAT for liver SBRT and interaction of various treatment plan quality indices with PTV and degree of modulation (DoM) for both techniques. Material Twenty-five patients of liver SBRT treated using the VMAT technique were selected. DCA_SSO_VDR treatment plans were also generated for all patients in Monaco TPS using the same objective constraint template and treatment planning parameters as used for the VMAT technique. For comparison purpose, organs at risk (OARs) doses and treatment plans quality indices, such as maximum dose of PTV (Dmax%), mean dose of PTV (Dmean%), maximum dose at 2 cm in any direction from the PTV (D2cm%), total monitor units (MU's), gradient index R50%, degree of modulation (DoM), conformity index (CI), homogeneity index (HI), and healthy tissue mean dose (HTMD), were compared. Results Significant dosimetric differences were observed in several OARs doses and lowered in VMAT plans. The D2cm%, R50%, CI, HI and HTMD are dosimetrically inferior in DCA_SSO_VDR plans. The higher DoM results in poor dose gradient and better dose gradient for DCA_SSO_VDR and VMAT treatment plans, respectively. Conclusions For liver SBRT, DCA_SSO_VDR treatment plans are neither dosimetrically superior nor better alternative to the VMAT delivery technique. A reduction of 69.75% MU was observed in DCA_SSO_VDR treatment plans. For the large size of PTV and high DoM, DCA_SSO_VDR treatment plans result in poorer quality.
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17
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Patel G, Mandal A, Choudhary S, Mishra R, Shende R. Plan evaluation indices: A journey of evolution. Rep Pract Oncol Radiother 2020; 25:336-344. [PMID: 32210739 PMCID: PMC7082629 DOI: 10.1016/j.rpor.2020.03.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/07/2020] [Accepted: 03/02/2020] [Indexed: 12/27/2022] Open
Abstract
AIM A systemic review and analysis of evolution journey of indices, such as conformity index (CI), homogeneity index (HI) and gradient index (GI), described in the literature. BACKGROUND Modern radiotherapy techniques like VMAT, SRS and SBRT produce highly conformal plans and provide better critical structure and normal tissue sparing. These treatment techniques can generate a number of competitive plans for the same patients with different dose distributions. Therefore, indices like CI, HI and GI serve as complementary tools in addition to visual slice by slice isodose verification while plan evaluation. Reliability and accuracy of these indices have been tested in the past and found shortcomings and benefits when compared to one another. MATERIAL AND METHODS Potentially relevant studies published after 1993 were identified through a pubmed and web of science search using words "conformity index", "Homogeneity index", "Gradient index"," Stereotactic radiosurgery"," stereotactic Body radiotherapy" "complexity metrics" and "plan evaluation index". Combinations of words "plan evaluation index conformity index" were also searched as were bibliographies of downloaded papers. RESULTS AND CONCLUSIONS Mathematical definitions of plan evaluation indices modified with time. CI definitions presented by various authors tested at their own and could not be generalized. Those mathematical definitions of CI which take into account OAR sparing grant more confidence in plan evaluation. Gradient index emerged as a significant plan evaluation index in addition to CI whereas homogeneity index losing its credibility. Biological index base plan evaluation is becoming popular and may replace or alter the role of dosimetrical indices.
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Affiliation(s)
- Ganeshkumar Patel
- Department of Radiotherapy and Radiation Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Abhijit Mandal
- Department of Radiotherapy and Radiation Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Sunil Choudhary
- Department of Radiotherapy and Radiation Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Ritusha Mishra
- Department of Radiotherapy and Radiation Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Ravindra Shende
- Department of Radiotherapy, Balco Medical Center, New Raipur, Sector 36, Raipur, Chattisgarh 493661, India
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18
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Atwell D, Elks J, Cahill K, Hearn N, Vignarajah D, Lagopoulos J, Min M. A Review of Modern Radiation Therapy Dose Escalation in Locally Advanced Head and Neck Cancer. Clin Oncol (R Coll Radiol) 2020; 32:330-341. [PMID: 31911016 DOI: 10.1016/j.clon.2019.12.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 10/27/2019] [Accepted: 11/07/2019] [Indexed: 12/30/2022]
Abstract
The management of head and neck cancer is complex and often involves multimodality treatment. Certain groups of patients, such as those with inoperable or advanced disease, are at higher risk of treatment failure and may therefore benefit from radiation therapy dose escalation. This can be difficult to achieve without increasing toxicity. However, the combination of modern treatment techniques and increased research into the use of functional imaging modalities that assist with target delineation allows researchers to push this boundary further. This review aims to summarise modern dose escalation trials to identify the impact on disease outcomes and explore the growing role of functional imaging modalities. Studies experimenting with dose escalation above standard fractionated regimens as outlined in National Comprehensive Cancer Network guidelines using photon therapy were chosen for review. Seventeen papers were considered suitable for inclusion in the review. Eight studies investigated nasopharyngeal cancer, with the remainder treating a range of subsites. Six studies utilised functional imaging modalities for target delineation. Doses as high as 85.9 Gy in 2.6 Gy fractions (EQD2 90.2 Gy10) were reportedly delivered with the aid of functional imaging modalities. Dose escalation in nasopharyngeal cancer resulted in 3-year locoregional control rates of 86.6-100% and overall survival of 82-95.2%. For other mucosal primary tumour sites, 3-year locoregional control reached 68.2-85.9% and 48.4-54% for overall survival. There were no clear trends in acute or late toxicity across studies, regardless of dose or addition of chemotherapy. However, small cohort sizes and short follow-up times may have resulted in under-reporting. This review highlights the future possibilities of radiation therapy dose escalation in head and neck cancer and the potential for improved target delineation with careful patient selection and the assistance of functional imaging modalities.
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Affiliation(s)
- D Atwell
- Cancer Services, Sunshine Coast University Hospital, Birtinya, Queensland, Australia; Icon Cancer Centre, Maroochydore, Queensland, Australia; Sunshine Coast Mind and Neuroscience - Thompson Institute, University of the Sunshine Coast, Sippy Downs, Queensland, Australia.
| | - J Elks
- Sunshine Coast Mind and Neuroscience - Thompson Institute, University of the Sunshine Coast, Sippy Downs, Queensland, Australia
| | - K Cahill
- Cancer Services, Sunshine Coast University Hospital, Birtinya, Queensland, Australia; Sunshine Coast Mind and Neuroscience - Thompson Institute, University of the Sunshine Coast, Sippy Downs, Queensland, Australia
| | - N Hearn
- Cancer Services, Sunshine Coast University Hospital, Birtinya, Queensland, Australia; Icon Cancer Centre, Maroochydore, Queensland, Australia; Sunshine Coast Mind and Neuroscience - Thompson Institute, University of the Sunshine Coast, Sippy Downs, Queensland, Australia
| | - D Vignarajah
- Cancer Services, Sunshine Coast University Hospital, Birtinya, Queensland, Australia; Icon Cancer Centre, Maroochydore, Queensland, Australia
| | - J Lagopoulos
- Sunshine Coast Mind and Neuroscience - Thompson Institute, University of the Sunshine Coast, Sippy Downs, Queensland, Australia
| | - M Min
- Cancer Services, Sunshine Coast University Hospital, Birtinya, Queensland, Australia; Icon Cancer Centre, Maroochydore, Queensland, Australia; Sunshine Coast Mind and Neuroscience - Thompson Institute, University of the Sunshine Coast, Sippy Downs, Queensland, Australia
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19
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Beaumont J, Acosta O, Devillers A, Palard-Novello X, Chajon E, de Crevoisier R, Castelli J. Voxel-based identification of local recurrence sub-regions from pre-treatment PET/CT for locally advanced head and neck cancers. EJNMMI Res 2019; 9:90. [PMID: 31535233 PMCID: PMC6751236 DOI: 10.1186/s13550-019-0556-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 08/22/2019] [Indexed: 12/13/2022] Open
Abstract
Background Overall, 40% of patients with a locally advanced head and neck cancer (LAHNC) treated by chemoradiotherapy (CRT) present local recurrence within 2 years after the treatment. The aims of this study were to characterize voxel-wise the sub-regions where tumor recurrence appear and to predict their location from pre-treatment 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) images. Materials and methods Twenty-six patients with local failure after treatment were included in this study. Local recurrence volume was identified by co-registering pre-treatment and recurrent PET/CT images using a customized rigid registration algorithm. A large set of voxel-wise features were extracted from pre-treatment PET to train a random forest model allowing to predict local recurrence at the voxel level. Results Out of 26 expert-assessed registrations, 15 provided enough accuracy to identify recurrence volumes and were included for further analysis. Recurrence volume represented on average 23% of the initial tumor volume. The MTV with a threshold of 50% of SUVmax plus a 3D margin of 10 mm covered on average 89.8% of the recurrence and 96.9% of the initial tumor. SUV and MTV alone were not sufficient to identify the area of recurrence. Using a random forest model, 15 parameters, combining radiomics and spatial location, were identified, allowing to predict the recurrence sub-regions with a median area under the receiver operating curve of 0.71 (range 0.14–0.91). Conclusion As opposed to regional comparisons which do not bring enough evidence for accurate prediction of recurrence volume, a voxel-wise analysis of FDG-uptake features suggested a potential to predict recurrence with enough accuracy to consider tailoring CRT by dose escalation within likely radioresistant regions.
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Affiliation(s)
- J Beaumont
- Univ Rennes, CLCC Eugène Marquis, INSERM, LTSI - UMR 1099, 35000, Rennes, France
| | - O Acosta
- Univ Rennes, CLCC Eugène Marquis, INSERM, LTSI - UMR 1099, 35000, Rennes, France
| | - A Devillers
- Univ Rennes, CLCC Eugène Marquis, INSERM, LTSI - UMR 1099, 35000, Rennes, France.,Department of Radiotherapy, Centre Eugene Marquis, avenue de la Bataille Flandre Dunkerque, 35000, Rennes, France
| | - X Palard-Novello
- Univ Rennes, CLCC Eugène Marquis, INSERM, LTSI - UMR 1099, 35000, Rennes, France.,Department of Radiotherapy, Centre Eugene Marquis, avenue de la Bataille Flandre Dunkerque, 35000, Rennes, France
| | - E Chajon
- Department of Radiotherapy, Centre Eugene Marquis, avenue de la Bataille Flandre Dunkerque, 35000, Rennes, France
| | - R de Crevoisier
- Univ Rennes, CLCC Eugène Marquis, INSERM, LTSI - UMR 1099, 35000, Rennes, France.,Department of Radiotherapy, Centre Eugene Marquis, avenue de la Bataille Flandre Dunkerque, 35000, Rennes, France
| | - J Castelli
- Univ Rennes, CLCC Eugène Marquis, INSERM, LTSI - UMR 1099, 35000, Rennes, France. .,Department of Radiotherapy, Centre Eugene Marquis, avenue de la Bataille Flandre Dunkerque, 35000, Rennes, France.
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20
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Palazzi M, Orlandi E, Pignoli E, Lualdi M, Zonca G, Sangalli C, Stucchi C, Olmi P. Target Coverage in Head and Neck Cancer Treated with Intensity-Modulated Radiotherapy: A Comparison between Conventional and Conformal Techniques. TUMORI JOURNAL 2019; 92:503-10. [PMID: 17260491 DOI: 10.1177/030089160609200607] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims and background We designed a comparative planning study aimed at quantifying the advantages of intensity-modu-lated radiotherapy (IMRT) over the conventional 3-field technique (3FT) and a 5-field conformal technique (5FCT) for head and neck (HN) cancer. Methods We selected 9 patients treated at our institution with curative radiotherapy for a HN cancer. For all cases 4 plans were generated: 2 plans using the “standard” techniques (3FT and 5FCT), a third plan using IMRT, and a fourth “mixed” plan using IMRT followed by a conventional boost. Results Our study confirmed literature data on the ability of IMRT to significantly decrease the dose received by organs at risk, compared with previous techniques. Target coverage was systematically better with 5FCT and IMRT than with 3FT. However, the increase in coverage of both PTV2 and PTV1 was only about 3-5% and this was achieved at the price of a similar increase in maximum dose (D1%). Volumetric parameters (V100%, V95%) were much more sensitive in detecting the improvement with IMRT. Conclusions The improvement of target coverage attained by IMRT, as compared with conventional and conformal techniques, might be overestimated by data currently available in the medical literature. If treatment with conventional techniques is planned using all tools provided by currently available fully 3-D planning systems, excellent target coverage can be obtained.
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Affiliation(s)
- Mauro Palazzi
- Unit of Radiotherapy, Istituto Nazionale Tumori, Milan, Italy.
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21
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Vošmik M, Odrážka K, Doležel M, Vaculíková M, Kordač P, Zouhar M, Petera J, Jansa J, Zoul Z, Paluska P, Vokurka J. IMRT with the Use of Simultaneous Integrated Boost in Treatment of Head and Neck Cancer: Acute Toxicity Evaluation. ACTA MEDICA (HRADEC KRÁLOVÉ) 2018. [PMID: 17117605 DOI: 10.14712/18059694.2017.127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Acute toxicity has been evaluated in head and neck cancer patients treated with intensity-modulated radiotherapy using simultaneous integrated boost (SIB-IMRT). The basis of the treatment protocol is an irradiation in 30 fractions with a total dose: 66 Gy to the region of macroscopic tumor, 60 Gy to the region of high-risk subclinical disease and 54 Gy to the region of low-risk subclinical disease. Between December 2003 and September 2005, 38 patients with carcinoma of different locations in the head and neck region were irradiated. Five patients underwent concurrent chemotherapy (weekly cisplatin). Acute toxicity was evaluated according to Radiation Therapy Oncology Group toxicity scale for skin, mucous membrane, salivary glands, pharynx and esophagus and larynx. All 38 patients completed the therapy without urgency of interruption due to acute toxicity of radiotherapy. No patient experienced grade 4 toxicity. More severe toxicity was observed in patients with concurrent chemotherapy. The results confirm that the irradiation according to our SIB-IMRT protocol is a therapy with acceptable toxicity and there is a space for radiobiological enhancement of this regimen by concurrent chemotherapy, e.g. weekly cisplatin.
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22
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Lee AW, Ng WT, Pan JJ, Poh SS, Ahn YC, AlHussain H, Corry J, Grau C, Grégoire V, Harrington KJ, Hu CS, Kwong DL, Langendijk JA, Le QT, Lee NY, Lin JC, Lu TX, Mendenhall WM, O'Sullivan B, Ozyar E, Peters LJ, Rosenthal DI, Soong YL, Tao Y, Yom SS, Wee JT. International guideline for the delineation of the clinical target volumes (CTV) for nasopharyngeal carcinoma. Radiother Oncol 2018; 126:25-36. [DOI: 10.1016/j.radonc.2017.10.032] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 10/25/2017] [Accepted: 10/25/2017] [Indexed: 12/09/2022]
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23
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Belosi MF, van der Meer R, Garcia de Acilu Laa P, Bolsi A, Weber DC, Lomax AJ. Treatment log files as a tool to identify treatment plan sensitivity to inaccuracies in scanned proton beam delivery. Radiother Oncol 2017; 125:514-519. [PMID: 29054379 DOI: 10.1016/j.radonc.2017.09.037] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 09/26/2017] [Accepted: 09/27/2017] [Indexed: 10/18/2022]
Abstract
Dose distributions delivered at Gantry 2 at the Paul Scherrer Institut (PSI) can be reconstructed on the patient anatomy based on machine log files. With the present work, the dependency of the log file calculation on the planning optimization technique and on other planning parameters, such as field direction and tumour size, has been investigated. Interestingly, and despite the typically higher modulation of Intensity Modulated Proton Therapy (IMPT) plans, the results for both Single Field Uniform Distribution and IMPT approaches have been found to be similar. In addition, complex fields with steep in-field dose gradients, such as Simultaneous Integrated Boost, and with couch movements in between the delivery, also resulted in good agreement between planned and reconstructed doses. Nevertheless, highly modulated plans can have regions of larger local dose deviations and attention should therefore be paid during the planning stage to the location of isolated, highly weighted pencil beams. We propose also, that further effort should be invested in order to predict field robustness to delivery fluctuations before the clinical delivery of the plan as part of the plan specific Quality Assurance.
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Affiliation(s)
| | | | | | - Alessandra Bolsi
- Centre for Proton Therapy, Paul Scherrer Institut, Villigen, Switzerland
| | - Damien C Weber
- Centre for Proton Therapy, Paul Scherrer Institut, Villigen, Switzerland; Department of Radiation Oncology, University Hospital of Bern, Switzerland; Department of Radiation Oncology, University Hospital of Zürich, Switzerland
| | - Antony J Lomax
- Centre for Proton Therapy, Paul Scherrer Institut, Villigen, Switzerland; Department of Physics, Swiss Institute of Technology (ETH), Zürich, Switzerland
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24
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Pigorsch SU, Wilkens JJ, Kampfer S, Kehl V, Hapfelmeier A, Schläger C, Bier H, Schwaiger M, Combs SE. Do selective radiation dose escalation and tumour hypoxia status impact the loco-regional tumour control after radio-chemotherapy of head & neck tumours? The ESCALOX protocol. Radiat Oncol 2017; 12:45. [PMID: 28249612 PMCID: PMC5333380 DOI: 10.1186/s13014-017-0776-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 02/06/2017] [Indexed: 11/16/2022] Open
Abstract
Background Standard of care primary treatment of carcinoma of locally advanced squamous cell head and neck cancer (LAHNSCC) consists of platinum-based concomitant chemo-irradiation. Despite progress in the treatment of LAHNSCC using modern radiotherapy techniques the outcome remains still poor. Using IMRT with SIB the escalation of total dose to the GTV is possible with the aim to improve clinical outcome. This study tests the hypothesis if radiation dose escalation to the GTV improves 2-year-LRC and -OS after concomitant chemo-irradiation. Methods The ESCALOX trial is a prospective randomized phase III study using cisplatin chemo-irradiation and the SIB-IMRT concept in patients with LAHNSCC of the oral cavity, oropharynx or hypopharynx to escalate the total dose to the GTV up to 80.5 Gy. Chemotherapy is planned either in the 1st and 5th week (cisplatin 20 mg/m2/d d 1–5 and d 29–33) or weekly (cisplatin 40 mg/m2/d) during RT. RT is delivered as SIB with total doses of 80.5 Gy/70.0 Gy/56.0 Gy with 2.3 Gy/2.0 Gy and 1.6 Gy in the experimental arm and in the control arm with 70.0 Gy/56.0 Gy with 2.0 Gy and 1.6 Gy. A pre-study with dose escalation up to 77.0 Gy/70.0 Gy/56.0 Gy with 2.2 Gy/2.0 Gy and 1.6 Gy is demanded by the German federal office of radiation protection (BfS). In the translational part of the trial 100 of the randomised patients will be investigated by 18-F-FMiso-PET-CT for the presence and behaviour of tumor hypoxia twice in the week before treatment start. Discussion The primary endpoint of the pre-study is acute radiation induced toxicity. Primary endpoint of the main trial is 2-year-LRC. By using the dose escalation up to 80.5 Gy to the GTV of the primary tumor and lymph nodes > 2 cm a LRC benefit of 15% at 2 years should be expected. The ESCALOX trial is supported by Deutsche Forschungsgemeinschaft (DFG); Grant No.: MO-363/4-1. Trial registration ClinicalTrials.gov Identifier: NCT 01212354, EudraCT-No.: 2010-021139-15
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Affiliation(s)
- Steffi U Pigorsch
- Department of Radiaton Oncology, Technical University of Munich, Klinikum rechts der Isar, Ismaninger Strasse 22, D-81675, Munich, Germany. .,Department of Radiation Sciences (DRS), Institut für Innovative Radiotherapie (iRT), Helmholtz Zentrum München, Ingolstaedter Landstrasse 1, D-85764, Oberschleissheim, Germany.
| | - Jan J Wilkens
- Department of Radiaton Oncology, Technical University of Munich, Klinikum rechts der Isar, Ismaninger Strasse 22, D-81675, Munich, Germany.,Department of Radiation Sciences (DRS), Institut für Innovative Radiotherapie (iRT), Helmholtz Zentrum München, Ingolstaedter Landstrasse 1, D-85764, Oberschleissheim, Germany
| | - Severin Kampfer
- Department of Radiaton Oncology, Technical University of Munich, Klinikum rechts der Isar, Ismaninger Strasse 22, D-81675, Munich, Germany.,Department of Radiation Sciences (DRS), Institut für Innovative Radiotherapie (iRT), Helmholtz Zentrum München, Ingolstaedter Landstrasse 1, D-85764, Oberschleissheim, Germany
| | - Victoria Kehl
- Institute of Medical Statistics and Epidemiology (IMSE), Technical University of Munich, Klinikum rechts der Isar, Ismaninger Strasse 22, D-81675, Munich, Germany
| | - Alexander Hapfelmeier
- Institute of Medical Statistics and Epidemiology (IMSE), Technical University of Munich, Klinikum rechts der Isar, Ismaninger Strasse 22, D-81675, Munich, Germany
| | - Christian Schläger
- Münchner Studienzentrum (MSZ Coordination Centre for Clinical Trials), Technical University of Munich, Ismaninger Strasse 22, D-81675, Munich, Germany
| | - Henning Bier
- Department of Ear, Neck and Throat (ENT), Technical University of Munich, Klinikum rechts der Isar, Ismaninger Strasse 22, D-81675, Munich, Germany
| | - Markus Schwaiger
- Department of Nuclear Medicine, Technical University of Munich, Klinikum rechts der Isar, Ismaninger Strasse 22, D-81675, Munich, Germany
| | - Stephanie E Combs
- Department of Radiaton Oncology, Technical University of Munich, Klinikum rechts der Isar, Ismaninger Strasse 22, D-81675, Munich, Germany.,Department of Radiation Sciences (DRS), Institut für Innovative Radiotherapie (iRT), Helmholtz Zentrum München, Ingolstaedter Landstrasse 1, D-85764, Oberschleissheim, Germany
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Costa Ferreira B, Sá-Couto P, Khouri L, Lopes MDC. Biological dose-escalated definitive radiation therapy in head and neck cancer. Br J Radiol 2017; 90:20160477. [PMID: 28186838 DOI: 10.1259/bjr.20160477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To compare treatment outcome of patients with head and neck (HN) tumours treated with definitive radiation therapy that, mainly owing to differences in the fractionation scheme used with simultaneous integrated boost techniques, resulted in a different biological dose. METHODS 181 patients with HN cancer, prescribed to about 70.2 Gy in the primary tumour, were included in this study. Population cohort was divided into Group <70 and Group ≥70 when the mean dose converted to a 2 Gy fractionation in the primary tumour was less or higher than 70.2 Gy, respectively. The probability of local control (LC), locoregional control (LRC), disease-free survival (DFS) and overall survival (OS) was determined for both groups. The incidence of acute and late complications was compared between the two groups. RESULTS At 24 months for Groups <70 and ≥70, LC was 83.2% and 87.5%, LRC was 79.5% and 81.6%, DFS was 56.3% and 66.8% and OS was 63.9% and 71.5% p = ns, respectively. The incidence of acute dysphagia, odynophagia and pain, and late mucositis was significantly higher in Group ≥70 than in Group <70. The rate of xerostomia, dysphonia, radiodermatitis, alopecia, dental complications, hypoacusia and weight loss was comparable between the two groups. CONCLUSION The biological dose escalation was safe, but an increase in the incidence of the acute side effects: dysphagia, odynophagia and pain and late mucositis, was obtained. Advances in knowledge: Despite the significant biological dose escalation, within the range of doses delivered to this cohort, no clear dose-response effect was observed.
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Affiliation(s)
- Brigida Costa Ferreira
- 1 Department of Physics, Aveiro University, Aveiro, Portugal.,2 School of Allied Health Technologies, Polytechnic of Porto, Porto, Portugal
| | - Pedro Sá-Couto
- 3 Department of Mathematics, Center for Research and Development in Mathematics and Applications, Aveiro University, Aveiro, Portugal
| | - Leila Khouri
- 4 Department of Radiation Therapy, Portuguese Oncology Institute of Coimbra Francisco Gentil (IPOCFG), Coimbra, Portugal
| | - Maria do Carmo Lopes
- 5 Department of Medical Physics, Portuguese Oncology Institute of Coimbra Francisco Gentil, Coimbra, Portugal
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Rastogi M, Sapru S, Gupta P, Gandhi AK, Mishra SP, Srivastava AK, Khurana R, Hadi R, Sahni K, S F. Prospective evaluation of Intensity Modulated Radiation Therapy with Simultaneous Integrated Boost (IMRT-SIB) in head and neck squamous cell carcinoma in patients not suitable for chemo-radiotherapy. Oral Oncol 2017; 67:10-16. [PMID: 28351562 DOI: 10.1016/j.oraloncology.2017.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 12/29/2016] [Accepted: 01/07/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND With conformal radiotherapy techniques, acute and late toxicities can be reduced because of better dose conformity and reduced doses to normal tissue. With Intensity Modulated Radiation Therapy (IMRT) further dose escalation is possible and one of the methods is IMRT with simultaneous integrated boost (IMRT-SIB). AIM To evaluate feasibility, toxicity patterns and loco-regional control rates of IMRT-SIB technique in head and neck cancer patients who are not suitable candidates for concurrent chemoradiation. STUDY DESIGN Prospective study of 30 patients treated with IMRT-SIB technique and evaluation of clinical results. METHOD AND MATERIALS 30 patients received definitive treatment using IMRT-SIB without concurrent chemotherapy. Patients were monitored during and after treatment for toxicity using the Radiation Therapy Oncology group (RTOG) criteria. Analysis of acute and late toxicity and early efficacy is presented. RESULTS The median treatment duration was 42days (range 41-43days). Overall, maximum acute Grade 3 toxicity of mucositis, skin, pharynx/esophageal toxicity and laryngeal were 56.66%, 30%, 26.67%, and 6.67% respectively at treatment completion. None of the patients had Grade 4 acute toxicity. No haematological toxicity was seen. Overall, grade 2 late toxicities were 7% (subcutaneous toxicity) and 13.3% (Xerostomia). Loco regional control rate at a median follow up of 13months was 86%. CONCLUSION IMRT-SIB is a safe and acceptable treatment option for patients of head and neck squamous cell carcinoma unsuitable for definitive chemo-radiotherapy.
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Affiliation(s)
| | | | - Pooja Gupta
- Dept. of Radiation Oncology, Medanta Super Specialty Hospital, New Delhi, India
| | | | | | | | | | - Rahat Hadi
- Dept. of Radiation Oncology, RMLIMS, Lucknow, India
| | - Kamal Sahni
- Dept. of Radiation Oncology, RMLIMS, Lucknow, India
| | - Farzana S
- Dept. of Radiation Oncology, RMLIMS, Lucknow, India
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27
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Cheng JY, Huang EY, Hsu SN, Wang CJ. Simultaneous integrated boost (SIB) of the parametrium and cervix in radiotherapy for uterine cervical carcinoma: a dosimetric study using a new alternative approach. Br J Radiol 2016; 89:20160526. [PMID: 27706947 DOI: 10.1259/bjr.20160526] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To compare the dose distributions of intensity-modulated radiotherapy (IMRT) and volumetric-modulated arc therapy (VMAT) using the simultaneous integrated boost (SIB) technique with that of the traditional midline block (MB) technique for boosting the parametrium in patients with cervical cancer. METHODS Treatment plans using VMAT or IMRT with the SIB technique (VMAT-SIB and IMRT-SIB) and IMRT followed by the MB technique (IMRT-MB) were generated for each of the 10 patients with cervical cancer. For the SIB plans, 45-Gy and 50-Gy dose levels in 25 equal fractions were set for the pelvis planning target volume 45 (PTV45) and the parametrial boost volume (PTV50), respectively. For the IMRT-MB plans, the parametrium was sequentially boosted with the MB technique (5.4 Gy in three fractions) after pelvic IMRT (PTV45). RESULTS Volume receiving 100% of the prescribed dose or more coverage of the PTV50 was significantly better for VMAT-SIB and IMRT-SIB than that for IMRT-MB (99.08 and 99.31% compared with 91.79%, respectively; p < 0.05). VMAT-SIB and IMRT-SIB both generated significantly greater doses to the organs at risk (OARs) except for the volume receiving 50 Gy or more doses, which were significantly lower for the bladder and bowel. Comparable results were achieved with VMAT-SIB and IMRT-SIB. CONCLUSION The VMAT-SIB and IMRT-SIB techniques are promising in terms of dose distributions and tumour coverage, although these approaches might result in slightly higher doses of radiation to the OARs. Advances in knowledge: This is the first study to examine the feasibility of the SIB technique using IMRT or VMAT to boost the parametrium. The techniques dosimetrically produced better target coverage but resulted in slightly higher doses to the OARs.
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Affiliation(s)
- Jen-Yu Cheng
- 1 Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Eng-Yen Huang
- 1 Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.,2 School of Traditional Chinese Medicine, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shun-Neng Hsu
- 1 Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chong-Jong Wang
- 1 Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.,3 Department of Medical Imaging and Radiological Sciences, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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An enhanced random walk algorithm for delineation of head and neck cancers in PET studies. Med Biol Eng Comput 2016; 55:897-908. [PMID: 27638108 DOI: 10.1007/s11517-016-1571-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 09/07/2016] [Indexed: 01/09/2023]
Abstract
An algorithm for delineating complex head and neck cancers in positron emission tomography (PET) images is presented in this article. An enhanced random walk (RW) algorithm with automatic seed detection is proposed and used to make the segmentation process feasible in the event of inhomogeneous lesions with bifurcations. In addition, an adaptive probability threshold and a k-means based clustering technique have been integrated in the proposed enhanced RW algorithm. The new threshold is capable of following the intensity changes between adjacent slices along the whole cancer volume, leading to an operator-independent algorithm. Validation experiments were first conducted on phantom studies: High Dice similarity coefficients, high true positive volume fractions, and low Hausdorff distance confirm the accuracy of the proposed method. Subsequently, forty head and neck lesions were segmented in order to evaluate the clinical feasibility of the proposed approach against the most common segmentation algorithms. Experimental results show that the proposed algorithm is more accurate and robust than the most common algorithms in the literature. Finally, the proposed method also shows real-time performance, addressing the physician's requirements in a radiotherapy environment.
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Beitler JJ, Quon H, Jones CU, Salama JK, Busse PM, Cooper JS, Koyfman SA, Ridge JA, Saba NF, Siddiqui F, Smith RV, Worden F, Yao M, Yom SS. ACR Appropriateness Criteria®Locoregional therapy for resectable oropharyngeal squamous cell carcinomas. Head Neck 2016; 38:1299-309. [DOI: 10.1002/hed.24447] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2016] [Indexed: 11/11/2022] Open
Affiliation(s)
| | - Harry Quon
- Johns Hopkins University; Baltimore Maryland
| | | | | | - Paul M. Busse
- Massachusetts General Hospital; Boston Massachusetts
| | | | | | - John A. Ridge
- Fox Chase Cancer Center; Philadelphia Pennsylvania, American College of Surgeons
| | - Nabil F. Saba
- Emory University; Atlanta Georgia, American Society of Clinical Oncology
| | | | - Richard V. Smith
- Montefiore Medical Center; Bronx New York, American College of Surgeons
| | - Francis Worden
- University of Michigan; Ann Arbor Michigan, American Society of Clinical Oncology
| | - Min Yao
- University Hospital Case Medical Center; Cleveland Ohio
| | - Sue S. Yom
- University of California San Francisco; San Francisco California
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Stromberger C, Ghadjar P, Marnitz S, Thieme AH, Jahn U, Raguse JD, Karaj-Rossbacher E, Böttcher A, Jamil B, Budach V. Comparative treatment planning study on sequential vs. simultaneous integrated boost in head and neck cancer patients: Differences in dose distributions and potential implications for clinical practice. Strahlenther Onkol 2016; 192:17-24. [PMID: 26462675 DOI: 10.1007/s00066-015-0913-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 09/25/2015] [Indexed: 11/25/2022]
Abstract
AIM The purpose of this work was to compare sequential (SeqB) versus simultaneous integrated boost (SIB) radiotherapy plans delivered with volumetric modulated arc therapy (VMAT) for patients with locally advanced squamous cell cancer of the head and neck (HNSCC). PATIENTS AND METHODS SeqB and SIB plans using VMAT for 10 HNSCC patients given definitive chemoradiation were generated and analysed for differences in dose distribution, coverage, conformity and homogeneity to the planning target volumes (PTV) 1-3 and sparing of organs at risk (OAR). RESULTS The mean delineated volumes ± standard deviations were 137.7 ± 44.8, 351.3 ± 83.9 and 895.6 ± 120.5 cm3 for PTV1-3. The mean volumes encompassed by the corresponding 95 % isodoses were 281 (+ 110 %) ± 73.4, 712.2 (+ 115 %) ± 146.4 and 1381.1 (+ 54 %) ± 217.3 cm3 with SeqB and 138.2 (+ 7 %) ± 40.1, 380.4 (+ 11 %) ± 91.9 and 1057.3 (+ 21 %) ± 161.4 cm3 with SIB for PTV1-3, respectively. Both strategies achieved excellent PTV coverage. SeqB provided significantly better coverage of PTV1 and 3, worse conformity for PTV1-3 and a higher mean dose than prescribed (111-115 %) to PTV2 and 3 (p ≤ 0.007). Both strategies provided satisfactory OAR sparing. CONCLUSION This study showed significant dosimetric differences with potential clinical relevance between two VMAT boost strategies regarding coverage, conformity and dose to the PTVs. SIB might cause less toxicity. A clinical phase III/IV trial endorsed by the German Head and Neck Clinical Trials Group (IAG-KHT) will evaluate differences in acute/late toxicity as well as in locoregional recurrences between the two boost techniques.
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Choi HS, Jeong BK, Jeong H, Song JH, Kim JP, Park JJ, Woo SH, Kang KM. Carotid sparing intensity modulated radiotherapy on early glottic cancer: preliminary study. Radiat Oncol J 2016; 34:26-33. [PMID: 27104164 PMCID: PMC4831966 DOI: 10.3857/roj.2016.34.1.26] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 02/05/2016] [Accepted: 03/03/2016] [Indexed: 12/11/2022] Open
Abstract
Purpose To compare the dose distribution between carotid sparing intensity modulated radiotherapy (IMRT) and opposed lateral field technique (LAFT), and to determine the effects of carotid sparing IMRT in early glottic cancer patients who have risk factors for atherosclerosis. Materials and Methods Ten early glottic cancer patients were treated with carotid sparing IMRT. For each patient, the conventional LAFT plan was developed for comparison. IMRT and LAFT plans were compared in terms of planning target volume (PTV) coverage, conformity index, homogeneity index, and the doses to planning organ at risk volume (PRV) for carotid arteries, spinal cord and pharyngeal constrictor muscle. Results Recurrence was not observed in any patients during the follow-up period. V95% for PTV showed no significant difference between IMRT and LAFT plans, while V100% was significantly higher in the IMRT plan (95.5% vs. 94.6%, p = 0.005). The homogeneity index (11.6%) and conformity index (1.4) in the IMRT plan were significantly better than those in the LAFT plans (8.5% and 5.1, respectively) (p = 0.005). The median V5Gy (90.0%), V25Gy (13.5%), and V50Gy (0%) for carotid artery PRV in the IMRT plan were significantly lower than those in the LAFT plan (99.1%, 89.0%, and 77.3%, respectively) (p = 0.005). Conclusion Our study suggests that carotid sparing IMRT can significantly decrease the dose to carotid arteries compared to LAFT, and it would be considered for early glottic cancer patient with high risk of atherosclerosis.
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Affiliation(s)
- Hoon Sik Choi
- Department of Radiation Oncology, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Bae Kwon Jeong
- Department of Radiation Oncology, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea.; Institute of Health Science, Gyeongsang National University, Jinju, Korea
| | - Hojin Jeong
- Department of Radiation Oncology, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea.; Institute of Health Science, Gyeongsang National University, Jinju, Korea
| | - Jin Ho Song
- Department of Radiation Oncology, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea.; Institute of Health Science, Gyeongsang National University, Jinju, Korea
| | - Jin Pyeong Kim
- Institute of Health Science, Gyeongsang National University, Jinju, Korea.; Department of Otorhinolaryngology, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Jung Je Park
- Institute of Health Science, Gyeongsang National University, Jinju, Korea.; Department of Otorhinolaryngology, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Seung Hoon Woo
- Institute of Health Science, Gyeongsang National University, Jinju, Korea.; Department of Otorhinolaryngology, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Ki Mun Kang
- Department of Radiation Oncology, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea.; Department of Otorhinolaryngology, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
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Unilateral and bilateral neck SIB for head and neck cancer patients : Intensity-modulated proton therapy, tomotherapy, and RapidArc. Strahlenther Onkol 2016; 192:232-9. [PMID: 26852243 DOI: 10.1007/s00066-016-0945-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 01/14/2016] [Indexed: 12/22/2022]
Abstract
AIM To compare simultaneous integrated boost plans for intensity-modulated proton therapy (IMPT), helical tomotherapy (HT), and RapidArc therapy (RA) for patients with head and neck cancer. PATIENTS AND METHODS A total of 20 patients with squamous cell carcinoma of the head and neck received definitive chemoradiation with bilateral (n = 14) or unilateral (n = 6) neck irradiation and were planned using IMPT, HT, and RA with 54.4, 60.8, and 70.4 GyE/Gy in 32 fractions. Dose distributions, coverage, conformity, homogeneity to planning target volumes (PTV)s and sparing of organs at risk and normal tissue were compared. RESULTS All unilateral and bilateral plans showed excellent PTV coverage and acceptable dose conformity. For unilateral treatment, IMPT delivered substantially lower mean doses to contralateral salivary glands (< 0.001-1.1 Gy) than both rotational techniques did (parotid gland: 6-10 Gy; submandibular gland: 15-20 Gy). Regarding the sparing of classical organs at risk for bilateral treatment, IMPT and HT were similarly excellent and RA was satisfactory. CONCLUSION For unilateral neck irradiation, IMPT may minimize the dry mouth risk in this subgroup but showed no advantage over HT for bilateral neck treatment regarding classical organ-at-risk sparing. All methods satisfied modern standards regarding toxicity and excellent target coverage for unilateral and bilateral treatment of head and neck cancer at the planning level.
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Cilla S, Deodato F, Macchia G, Digesù C, Ianiro A, Piermattei A, Valentini V, Morganti AG. Volumetric modulated arc therapy (VMAT) and simultaneous integrated boost in head-and-neck cancer: is there a place for critical swallowing structures dose sparing? Br J Radiol 2016; 89:20150764. [PMID: 26728543 DOI: 10.1259/bjr.20150764] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To explore the potential of volumetric-modulated arc therapy (VMAT) to reduce the risk of swallowing problems after curative chemoradiotherapy. METHODS 20 patients with head and neck cancer who previously underwent radiotherapy were selected. Radiotherapy was prescribed according to simultaneous integrated boost technique with all targets irradiated simultaneously over 30 daily fractions. Doses of 70.5 (67.5), 60.0 and 55.5 Gy were prescribed to primary tumour, high-risk nodal regions and low-risk nodal regions, respectively. Pharyngeal constrictor muscles (PCM) and glottic and supraglottic larynx (SGL) were considered organs at risk related to swallowing dysfunction (SW-OARs). Upper pharyngeal constrictor muscles (uPCM), middle pharyngeal constrictor muscles (mPCM) and lower pharyngeal constrictor muscles (lPCM) part of PCM were also outlined separately. Clinical standard plans (standard-VMAT) and plans aiming to spare SW-OARs (swallowing dysfunction-VMAT) were also created. Normal tissue complication probabilities (NTCP) for physician-rated swallowing dysfunction were calculated using a recently predictive model developed by Christianen et al. RESULTS Planning with two strategies demonstrated comparable planning target volume coverage and no differences in sparing of parotid glands and other non-swallowing organs at risk. SW-VMAT plans provided mean dose reduction for uPCM and SGL by 3.9 and 4.5 Gy, respectively. NTCP values for Radiation Therapy Oncology Group grade 2-4 swallowing dysfunction was decreased by 9.2%. Dose reductions with SW-VMAT depended on tumour location and overlap with SW-OARs. CONCLUSION VMAT plans aiming at sparing swallowing structures are feasible, providing a significant reduction in NTCP swallowing dysfunction with respect to conventional VMAT. ADVANCES IN KNOWLEDGE Dysphagia is today considered one of the dose-limiting toxicities of chemoradiotherapy. The dose sparing of swallowing structures represents a major challenge in radiotherapy. VMAT is a complex new technology having the potential to significantly reduce the risk of dysphagia after curative chemoradiotherapy.
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Affiliation(s)
- Savino Cilla
- 1 Medical Physics Unit, Fondazione di Ricerca e Cura "Giovanni Paolo II", Universit à Cattolica del Sacro Cuore, Campobasso, Italy
| | - Francesco Deodato
- 2 Radiotherapy Unit, Fondazione di Ricerca e Cura "Giovanni Paolo II", Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Gabriella Macchia
- 2 Radiotherapy Unit, Fondazione di Ricerca e Cura "Giovanni Paolo II", Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Cinzia Digesù
- 2 Radiotherapy Unit, Fondazione di Ricerca e Cura "Giovanni Paolo II", Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Anna Ianiro
- 1 Medical Physics Unit, Fondazione di Ricerca e Cura "Giovanni Paolo II", Universit à Cattolica del Sacro Cuore, Campobasso, Italy
| | - Angelo Piermattei
- 3 Medical Physics Unit, Policlinico Agostino Gemelli, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Vincenzo Valentini
- 2 Radiotherapy Unit, Fondazione di Ricerca e Cura "Giovanni Paolo II", Università Cattolica del Sacro Cuore, Campobasso, Italy.,4 Radiotherapy Department, Policlinico Agostino Gemelli, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Alessio G Morganti
- 5 DIMES Università di Bologna-S.Orsola-Malpighi Hospital, Radiation Oncology Center, Bologna, Italy
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Avanzo M, Chiovati P, Boz G, Sartor G, Dozza F, Capra E. Image-guided volumetric arc radiotherapy of pancreatic cancer with simultaneous integrated boost: Optimization strategies and dosimetric results. Phys Med 2015; 32:169-75. [PMID: 26626610 DOI: 10.1016/j.ejmp.2015.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 08/28/2015] [Accepted: 11/07/2015] [Indexed: 12/25/2022] Open
Abstract
PURPOSE To introduce volumetric modulated arc therapy treatments (VMAT) with simultaneous integrated boost (SIB) for pancreatic cancer and describe dosimetric results on a large patient series. METHODS AND MATERIALS 45 patients with pancreatic malignancies were treated with 18 MV single-arc VMAT. Image guidance was performed with daily online kilo-volt cone-beam computed tomography (CBCT). The conformity index (CI) and homogeneity index (HI) to the target volumes, PTV45Gy and PTV54Gy, and dose-volume indices to OARs from the QUANTEC task group were reported. The risk of clinical nephritis was evaluated using normal tissue complication probability (NTCP). Treatments were verified in-phantom with the Delta4 system. RESULTS Average CI was 1.06 with 95% confidence intervals (95% CI) of 0.97-1.22 for PTV45Gy and 1.17 (0.66-1.61) for PTV54Gy. HI of PTV54Gy was 1.06 (1.04-1.10). OAR constraints were achieved in all patients, except for kidneys V12Gy of 48 (35.4-72.3)%. NTCP of the kidneys was 0.98 (0.6-1.7)%. Kidneys V12Gy and V20Gy were inversely related to PTV54Gy CI and maximum dose. All in-phantom tests had gamma pass rates exceeding 95% with global 3% dose difference and 3 mm distance to agreement. Patient shifts measured with CBCT had 95% CI of -0.8, +0.8 in the RL, -0.7, +0.8 in the SI, and -0.8, +0.7 cm in the AP directions. CONCLUSIONS Dosimetric results of VMAT were excellent on PTVs and organs at risk. The kidneys represent the dose-limiting organ at risk for this technique. NTCP indicates that this technique is safe from radiation-induced side effects to the kidneys.
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Affiliation(s)
- Michele Avanzo
- Medical Physics Unit, Centro di Riferimento Oncologico, 33081 Aviano, Italy.
| | - Paola Chiovati
- Medical Physics Unit, Centro di Riferimento Oncologico, 33081 Aviano, Italy
| | - Giovanni Boz
- Radiation Oncology Department, Centro di Riferimento Oncologico, 33081 Aviano, Italy
| | - Giovanna Sartor
- Medical Physics Unit, Centro di Riferimento Oncologico, 33081 Aviano, Italy
| | - Francesca Dozza
- Radiation Oncology Department, Centro di Riferimento Oncologico, 33081 Aviano, Italy
| | - Elvira Capra
- Medical Physics Unit, Centro di Riferimento Oncologico, 33081 Aviano, Italy
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Jakobi A, Lühr A, Stützer K, Bandurska-Luque A, Löck S, Krause M, Baumann M, Perrin R, Richter C. Increase in Tumor Control and Normal Tissue Complication Probabilities in Advanced Head-and-Neck Cancer for Dose-Escalated Intensity-Modulated Photon and Proton Therapy. Front Oncol 2015; 5:256. [PMID: 26636038 PMCID: PMC4653282 DOI: 10.3389/fonc.2015.00256] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 11/06/2015] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Presently used radiochemotherapy regimens result in moderate local control rates for patients with advanced head-and-neck squamous cell carcinoma (HNSCC). Dose escalation (DE) may be an option to improve patient outcome, but may also increase the risk of toxicities in healthy tissue. The presented treatment planning study evaluated the feasibility of two DE levels for advanced HNSCC patients, planned with either intensity-modulated photon therapy (IMXT) or proton therapy (IMPT). MATERIALS AND METHODS For 45 HNSCC patients, IMXT and IMPT treatment plans were created including DE via a simultaneous integrated boost (SIB) in the high-risk volume, while maintaining standard fractionation with 2 Gy per fraction in the remaining target volume. Two DE levels for the SIB were compared: 2.3 and 2.6 Gy. Treatment plan evaluation included assessment of tumor control probabilities (TCP) and normal tissue complication probabilities (NTCP). RESULTS An increase of approximately 10% in TCP was estimated between the DE levels. A pronounced high-dose rim surrounding the SIB volume was identified in IMXT treatment. Compared to IMPT, this extra dose slightly increased the TCP values and to a larger extent the NTCP values. For both modalities, the higher DE level led only to a small increase in NTCP values (mean differences <2%) in all models, except for the risk of aspiration, which increased on average by 8 and 6% with IMXT and IMPT, respectively, but showed a considerable patient dependence. CONCLUSION Both DE levels appear applicable to patients with IMXT and IMPT since all calculated NTCP values, except for one, increased only little for the higher DE level. The estimated TCP increase is of relevant magnitude. The higher DE schedule needs to be investigated carefully in the setting of a prospective clinical trial, especially regarding toxicities caused by high local doses that lack a sound dose-response description, e.g., ulcers.
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Affiliation(s)
- Annika Jakobi
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf , Dresden , Germany
| | - Armin Lühr
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf , Dresden , Germany ; German Cancer Consortium (DKTK), Partner Site Dresden , Dresden , Germany ; German Cancer Research Center (DKFZ) , Heidelberg , Germany
| | - Kristin Stützer
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf , Dresden , Germany
| | - Anna Bandurska-Luque
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf , Dresden , Germany ; Department of Radiation Oncology, Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden , Dresden , Germany
| | - Steffen Löck
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf , Dresden , Germany
| | - Mechthild Krause
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf , Dresden , Germany ; German Cancer Consortium (DKTK), Partner Site Dresden , Dresden , Germany ; German Cancer Research Center (DKFZ) , Heidelberg , Germany ; Department of Radiation Oncology, Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden , Dresden , Germany ; Institute of Radiooncology, Helmholtz-Zentrum Dresden - Rossendorf , Dresden , Germany
| | - Michael Baumann
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf , Dresden , Germany ; German Cancer Consortium (DKTK), Partner Site Dresden , Dresden , Germany ; German Cancer Research Center (DKFZ) , Heidelberg , Germany ; Department of Radiation Oncology, Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden , Dresden , Germany ; Institute of Radiooncology, Helmholtz-Zentrum Dresden - Rossendorf , Dresden , Germany
| | - Rosalind Perrin
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf , Dresden , Germany
| | - Christian Richter
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf , Dresden , Germany ; German Cancer Consortium (DKTK), Partner Site Dresden , Dresden , Germany ; German Cancer Research Center (DKFZ) , Heidelberg , Germany ; Department of Radiation Oncology, Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden , Dresden , Germany ; Institute of Radiooncology, Helmholtz-Zentrum Dresden - Rossendorf , Dresden , Germany
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Jakobi A, Bandurska-Luque A, Stützer K, Haase R, Löck S, Wack LJ, Mönnich D, Thorwarth D, Perez D, Lühr A, Zips D, Krause M, Baumann M, Perrin R, Richter C. Identification of Patient Benefit From Proton Therapy for Advanced Head and Neck Cancer Patients Based on Individual and Subgroup Normal Tissue Complication Probability Analysis. Int J Radiat Oncol Biol Phys 2015; 92:1165-1174. [PMID: 26194685 DOI: 10.1016/j.ijrobp.2015.04.031] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 04/13/2015] [Accepted: 04/17/2015] [Indexed: 12/25/2022]
Abstract
PURPOSE The purpose of this study was to determine, by treatment plan comparison along with normal tissue complication probability (NTCP) modeling, whether a subpopulation of patients with head and neck squamous cell carcinoma (HNSCC) could be identified that would gain substantial benefit from proton therapy in terms of NTCP. METHODS AND MATERIALS For 45 HNSCC patients, intensity modulated radiation therapy (IMRT) was compared to intensity modulated proton therapy (IMPT). Physical dose distributions were evaluated as well as the resulting NTCP values, using modern models for acute mucositis, xerostomia, aspiration, dysphagia, laryngeal edema, and trismus. Patient subgroups were defined based on primary tumor location. RESULTS Generally, IMPT reduced the NTCP values while keeping similar target coverage for all patients. Subgroup analyses revealed a higher individual reduction of swallowing-related side effects by IMPT for patients with tumors in the upper head and neck area, whereas the risk reduction of acute mucositis was more pronounced in patients with tumors in the larynx region. More patients with tumors in the upper head and neck area had a reduction in NTCP of more than 10%. CONCLUSIONS Subgrouping can help to identify patients who may benefit more than others from the use of IMPT and, thus, can be a useful tool for a preselection of patients in the clinic where there are limited PT resources. Because the individual benefit differs within a subgroup, the relative merits should additionally be evaluated by individual treatment plan comparisons.
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Affiliation(s)
- Annika Jakobi
- OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.
| | - Anna Bandurska-Luque
- OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Kristin Stützer
- OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
| | - Robert Haase
- OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
| | - Steffen Löck
- OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
| | - Linda-Jacqueline Wack
- Section for Biomedical Physics, University Hospital for Radiation Oncology, Eberhard Karls Universät Tübingen, Germany
| | - David Mönnich
- Section for Biomedical Physics, University Hospital for Radiation Oncology, Eberhard Karls Universät Tübingen, Germany; German Cancer Research Center, Heidelberg, Germany; German Cancer Consortium, Tübingen, Germany
| | - Daniela Thorwarth
- Section for Biomedical Physics, University Hospital for Radiation Oncology, Eberhard Karls Universät Tübingen, Germany
| | - Damien Perez
- OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; German Cancer Research Center, Heidelberg, Germany; German Cancer Consortium, Dresden, Germany
| | - Armin Lühr
- OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; German Cancer Research Center, Heidelberg, Germany; German Cancer Consortium, Dresden, Germany
| | - Daniel Zips
- Department of Radiation Oncology, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Mechthild Krause
- OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; German Cancer Research Center, Heidelberg, Germany; German Cancer Consortium, Dresden, Germany; Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology, Dresden, Germany
| | - Michael Baumann
- OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; German Cancer Research Center, Heidelberg, Germany; German Cancer Consortium, Dresden, Germany; Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology, Dresden, Germany
| | - Rosalind Perrin
- OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Paul Scherrer Institute, Villigen, Switzerland
| | - Christian Richter
- OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; German Cancer Research Center, Heidelberg, Germany; German Cancer Consortium, Dresden, Germany; Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology, Dresden, Germany
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Lal P, Nautiyal V, Chaudhuri T, Verma M, Das KJ, Kumar S. Is aspiration as detected on pretreatment video fluorography, a harbinger of poor quality of life and early mortality in cancers of the upper aerodigestive tract treated with radiotherapy? South Asian J Cancer 2014; 3:209-12. [PMID: 25422806 PMCID: PMC4236698 DOI: 10.4103/2278-330x.142968] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: Patients with cancers of the upper aerodigestive tract (head and neck cancer (HNC)) tend to aspirate, either due to disease or treatment. The association of aspiration (documented on video fluorography (VFG)) with quality of life (QOL) and unexpected mortality was studied prospectively in patients treated with simultaneous integrated boost technique of intensity-modulated radiotherapy (SIB-IMRT). Materials and Methods: Moderately advanced (stage III/IV) HNC were treated by SIB-IMRT delivering 66 Gy/30 fr, 60 Gy/30 fr, and 54 Gy/30 fr to high, intermediate, and low risk volumes, respectively. They underwent serial VFG and QOL assessments (Quality of Life Questionnaire-Core 30 (QLQ-C30) and head and neck-35 (HN35) European Organisation for Research and Treatment of Cancer (EORTC) tools) at 0, 3, and 6 months. Pharyngeal musculature (PM) was additionally delineated on planning computed tomography (CT) scans as potential organs at risk (OARs). Results: Between November 2009 and May 2011, 20 HNC were treated as per protocol. All patients were fit (Karnofsky performance status (KPS) ≥ 80). Based on VFG findings, seven patients (4/9 oropharynx and 3/11 laryngopharynx) were grouped as aspirators (A) and remaining 13 as non-aspirators (NA). The QOL study showed that pretreatment coughing and swallowing difficulties were greater in group A versus NA and remained persistently higher. In group A, deaths attributable to aspiration were seen in 3/7 patients, while none occurred in the NA group (Fisher's exact P = 0.03). The mean PM dose was 60 Gy in both the groups and mean V60 was similar at 69 and 67% in A and NA groups, respectively. Conclusions: VFG helps identify patients who aspirate and are at risk of premature death due to its complications, alerting caregivers to direct attention appropriately.
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Affiliation(s)
- Punita Lal
- Department of Radiotherapy, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Vipul Nautiyal
- Department of Radiotherapy, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Tamojit Chaudhuri
- Department of Radiotherapy, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Mranalini Verma
- Department of Radiotherapy, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Koilpillai Joseph Das
- Department of Radiotherapy, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Shaleen Kumar
- Department of Radiotherapy, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Breast conserving treatment for breast cancer: dosimetric comparison of sequential versus simultaneous integrated photon boost. BIOMED RESEARCH INTERNATIONAL 2014; 2014:827475. [PMID: 25162031 PMCID: PMC4137720 DOI: 10.1155/2014/827475] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 06/27/2014] [Accepted: 07/06/2014] [Indexed: 01/13/2023]
Abstract
BACKGROUND Breast conserving surgery followed by whole breast irradiation is widely accepted as standard of care for early breast cancer. Addition of a boost dose to the initial tumor area further reduces local recurrences. We investigated the dosimetric benefits of a simultaneously integrated boost (SIB) compared to a sequential boost to hypofractionate the boost volume, while maintaining normofractionation on the breast. METHODS For 10 patients 4 treatment plans were deployed, 1 with a sequential photon boost, and 3 with different SIB techniques: on a conventional linear accelerator, helical TomoTherapy, and static TomoDirect. Dosimetric comparison was performed. RESULTS PTV-coverage was good in all techniques. Conformity was better with all SIB techniques compared to sequential boost (P = 0.0001). There was less dose spilling to the ipsilateral breast outside the PTVboost (P = 0.04). The dose to the organs at risk (OAR) was not influenced by SIB compared to sequential boost. Helical TomoTherapy showed a higher mean dose to the contralateral breast, but less than 5 Gy for each patient. CONCLUSIONS SIB showed less dose spilling within the breast and equal dose to OAR compared to sequential boost. Both helical TomoTherapy and the conventional technique delivered acceptable dosimetry. SIB seems a safe alternative and can be implemented in clinical routine.
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Comparison of 3D confromal radiotherapy and intensity modulated radiotherapy with or without simultaneous integrated boost during concurrent chemoradiation for locally advanced head and neck cancers. PLoS One 2014; 9:e94456. [PMID: 24714187 PMCID: PMC3979891 DOI: 10.1371/journal.pone.0094456] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 03/17/2014] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Radiotherapy techniques have evolved from 3D conformal radiotherapy (3D-CRT) to intensity modulated radiotherapy (IMRT) where boost fields are delivered either sequentially (IMRTseq) or with a simultaneous integrated boost (IMRT+SIB). Our goal was to compare the outcomes of patients treated with IMRT+SIB to traditional standards. METHODS We analyzed the efficacy and toxicity of patients treated with concurrent chemoradiation using 3D-CRT, IMRTseq or IMRT+SIB. Between 1993 and 2012, 379 patients with non-metastatic Stage III-IV head and neck squamous cell cancer were treated with concurrent chemoradiation using 3D-CRT (n = 125), IMRTseq (n = 120) and IMRT+SIB (n = 134). RESULTS Patients treated with any technique had similar rates of 2y local control, 2y regional control, 2y progression free survival and 2y overall survival. Patients treated with IMRT+SIB had lower rates acute toxicity according to Grade 3 or greater mucositis (3D-CRT: 44.0% vs. IMRTseq: 36.7% vs. IMRT+SIB: 22.4%; P<.0001), dermatitis (3D-CRT: 44.0% vs. IMRTseq: 20.0% vs. IMRT+SIB: 7.5%; P<.0001) and feeding tube placement during radiotherapy (3D-CRT: 80.0% vs. IMRTseq: 50.8% vs. IMRT+SIB: 44.0%; P<.0001) as well as late toxicity as measured by feeding tube use (P<.0001) and tracheostomy use (P<.0001). On multivariate analysis, IMRT+SIB predicted for less mucositis, dermatitis and feeding tube use compared to 3D-CRT and for less dermatitis compared to IMRTseq. CONCLUSIONS Compared to 3D-CRT and IMRTseq, IMRT+SIB provided similar outcomes and potentially less toxicity indicating it is a feasible technique for chemoradiation in locally advanced head and neck cancer.
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Macchia G, Cilla S, Morganti AG, Deodato F, Legge F, Piermattei A, Chiantera V, Scambia G, Valentini V, Ferrandina G. Adjuvant volumetric-modulated arc therapy with simultaneous integrated boost in endometrial cancer. Planning and toxicity comparison. Acta Oncol 2014; 53:251-8. [PMID: 24050516 DOI: 10.3109/0284186x.2013.819997] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To report dosimetric and acute toxicity data in prospectively enrolled high-intermediate risk endometrial cancer (HIR-EC) patients postoperatively irradiated by simultaneous integrated boost volumetric modulated arc therapy (SIB-VMAT). METHODS Thirty prospectively enrolled HIR-EC patients were postoperatively treated by SIB-VMAT. Target coverage, dose homogeneity, and sparing of organs at risk (OARs) were compared with corresponding data retrieved from an historical control (30 consecutive selected matched patients) treated by concomitant boost three-dimensional conformal radiotherapy (3D CRT CB) from a previously published study (ADA-I trial). All patients received 45 Gy on pelvic lymph nodes plus 10 Gy boost on the vaginal vault. RESULTS The SIB-VMAT technique produced more inhomogeneous plans than 3D CRT CB, but showed significantly better conformity index (CIs) for both PTVs. SIB-VMAT was associated with significant reduction in the irradiated small bowel (SB) volume compared with 3D CRT CB for all dose range > 10 Gy (e.g. V15: 163.5 cm(3) vs. 341.3 cm(3), p = 0.001 and V40: 43.8 cm(3) vs. 85.2 cm(3), p = 0.008). With regard to bladder and rectum, SIB-VMAT showed a significant sparing advantage at all dose levels with respect to 3D CRT CB retrieved plans. Moreover, overall OARs Dmean were significantly reduced by the SIB-VMAT (p = 0.001). According to CTCAE v.4.0, acute (within three months) GI toxicities were more frequent in 3D CRT CB versus SIB-VMAT (90.0% vs. 66.7%; p-value 0.028). CONCLUSIONS Compared to data from a historical database of patients administered 3D CRT CB, SIB-VMAT significantly improves the dose conformity and sparing of OARs in HIR-EC patients undergoing postoperative radiotherapy. The improvement in terms of acute toxicity justifies further prospective clinical evaluation.
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Affiliation(s)
- Gabriella Macchia
- Radiotherapy Unit, Department of Oncology, Fondazione di Ricerca e Cura "Giovanni Paolo II", Università Cattolica del S. Cuore , Campobasso , Italy
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Boylan C, Rowbottom C. A bias-free, automated planning tool for technique comparison in radiotherapy - application to nasopharyngeal carcinoma treatments. J Appl Clin Med Phys 2014; 15:4530. [PMID: 24423853 PMCID: PMC5711248 DOI: 10.1120/jacmp.v15i1.4530] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 07/25/2013] [Accepted: 07/17/2013] [Indexed: 12/01/2022] Open
Abstract
In this study a novel, user‐independent automated planning technique was developed to objectively compare volumetric‐modulated arc therapy (VMAT) and intensity‐modulated radiotherapy (IMRT) for nasopharyngeal carcinoma planning, and to determine which technique offers a greater benefit for parotid‐sparing and dose escalation strategies. Ten patients were investigated, with a standard prescription of three dose levels to the target volumes (70, 63, and 56 Gy), using a simultaneous integrated boost in 33 fractions. The automated tool was used to investigate three planning strategies with both IMRT and VMAT: clinically acceptable plan creation, parotid dose sparing, and dose escalation. Clinically acceptable plans were achieved for all patients using both techniques. For parotid‐sparing, automated planning reduced the mean dose to a greater extent using VMAT rather than IMRT (17.0 Gy and 19.6 Gy, respectively, p<0.01). For dose escalation to the mean of the main clinical target volume, neither VMAT nor IMRT offered a significant benefit over the other. The OAR‐limiting prescriptions for VMAT ranged from 84‐98 Gy, compared to 76‐110 Gy for IMRT. Employing a user‐independent planning technique, it was possible to objectively compare VMAT and IMRT for nasopharyngeal carcinoma treatment strategies. VMAT offers a parotid‐sparing improvement, but no significant benefit was observed for dose escalation to the primary target. PACS numbers: 87.55.D‐, 87.55.kd
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Affiliation(s)
- Christopher Boylan
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust.
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Cilla S, Deodato F, Digesù C, Macchia G, Picardi V, Ferro M, Sallustio G, De Spirito M, Piermattei A, Morganti AG. Assessing the feasibility of volumetric-modulated arc therapy using simultaneous integrated boost (SIB-VMAT): An analysis for complex head-neck, high-risk prostate and rectal cancer cases. Med Dosim 2013; 39:108-16. [PMID: 24342167 DOI: 10.1016/j.meddos.2013.11.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2013] [Revised: 10/02/2013] [Accepted: 11/11/2013] [Indexed: 10/25/2022]
Abstract
Intensity-modulated radiotherapy (IMRT) allowed the simultaneous delivery of different doses to different target volumes within a single fraction, an approach called simultaneous integrated boost (SIB). As consequence, the fraction dose to the boost volume can be increased while keeping low doses to the elective volumes, and the number of fractions and overall treatment time will be reduced, translating into better radiobiological effectiveness. In recent years, volumetric-modulated arc therapy (VMAT) has been shown to provide similar plan quality with respect to fixed-field IMRT but with large reduction in treatment time and monitor units (MUs) number. However, the feasibility of VMAT when used with SIB strategy has few investigations to date. We explored the potential of VMAT in a SIB strategy for complex cancer sites. A total of 15 patients were selected, including 5 head-and-neck, 5 high-risk prostate, and 5 rectal cancer cases. Both a double-arc VMAT and a 7-field IMRT plan were generated for each case using Oncentra MasterPlan treatment planning system for an Elekta Precise linac. Dosimetric indexes for targets and organs at risk (OARs) were compared based on dose-volume histograms. Conformity index, homogeneity index, and dose-contrast index were used for target analyses. The equivalent uniform doses and the normal tissue complication probabilities were calculated for main OARs. MUs number and treatment time were analyzed to score treatment efficiency. Pretreatment dosimetry was performed using 2-dimensional (2D)-array dosimeter. SIB-VMAT plans showed a high level of fluence modulation needed for SIB treatments, high conformal dose distribution, similar target coverage, and a tendency to improve OARs sparing compared with the benchmark SIB-IMRT plans. The median treatment times reduced from 13 to 20 minutes to approximately 5 minutes for all cases with SIB-VMAT, with a MUs reduction up to 22.5%. The 2D-array ion-chambers' measurements reported an agreement of more than 95% for a criterion of 3% to 3mm. SIB-VMAT was able to combine the advantages of conventional SIB-IMRT with its highly conformal dose distribution and OARs sparing and the advantages of 3D-conformal radiotherapy with its fast delivery.
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Affiliation(s)
- Savino Cilla
- Medical Physics Unit, Fondazione di ricerca e cura "Giovanni Paolo II," Università Cattolica del Sacro Cuore, Campobasso, Italy.
| | - Francesco Deodato
- Radiation Oncology Unit, Fondazione di ricerca e cura "Giovanni Paolo II," Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Cinzia Digesù
- Radiation Oncology Unit, Fondazione di ricerca e cura "Giovanni Paolo II," Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Gabriella Macchia
- Radiation Oncology Unit, Fondazione di ricerca e cura "Giovanni Paolo II," Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Vincenzo Picardi
- Radiation Oncology Unit, Fondazione di ricerca e cura "Giovanni Paolo II," Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Marica Ferro
- Radiation Oncology Unit, Fondazione di ricerca e cura "Giovanni Paolo II," Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Giuseppina Sallustio
- Radiology Unit, Fondazione di ricerca e cura "Giovanni Paolo II," Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Marco De Spirito
- Physics Institute, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Angelo Piermattei
- Physics Institute, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessio G Morganti
- Radiation Oncology Unit, Fondazione di ricerca e cura "Giovanni Paolo II," Università Cattolica del Sacro Cuore, Campobasso, Italy
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Kam MKM, Wong FCS, Kwong DLW, Sze HCK, Lee AWM. Current controversies in radiotherapy for nasopharyngeal carcinoma (NPC). Oral Oncol 2013; 50:907-12. [PMID: 24126221 DOI: 10.1016/j.oraloncology.2013.09.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Accepted: 09/22/2013] [Indexed: 11/26/2022]
Abstract
Radiotherapy has a good track record in the treatment of NPC, yet the late toxicity profile and local failure rate for locally advanced disease remain a concern. Modern RT techniques incorporating IMRT and IGRT have widened our potential in treating NPC more effectively, and shall be regarded as the standard of care. Out of the various dose fractionation regimens in IMRT, 70 Gy in 35 fractions or the mini-SIB proves to be safe in combination with chemotherapy, but any further attempt of dose escalation must be tried out with extreme caution to avoid severe toxicities. CT-MRI image fusion improves the accuracy of GTV delineation, whereas the role of PET-CT has yet to be verified. RTOG definition of the CTV provides a reasonable template for the inclusion of sites at risk of microscopic involvement, and fine tuning has to be made in the future based on careful analysis of the pattern of local failure with long term follow-up. Toxicity reduction via radiation volume or dose reduction is tempting, but once again it has to be tested under scrutiny. Retrospective data have emerged that suggest a benefit of using adaptive IMRT replanning in NPC, however the optimal timing or frequency of replanning is still unclear. Future prospective studies are thus required to evaluate the cost-effectiveness of adaptive RT and streamline the workflow logistics before it can be widely accepted in routine practice.
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Affiliation(s)
- Michael K M Kam
- Department of Clinical Oncology, Prince of Wales Hospital, Hong Kong, China.
| | - Frank C S Wong
- Department of Clinical Oncology, Tuen Mun Hospital, Hong Kong, China
| | - Dora L W Kwong
- Department of Clinical Oncology, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - Henry C K Sze
- Department of Clinical Oncology, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - Anne W M Lee
- Center of Clinical Oncology, University of Hong Kong-Shenzhen Hospital, China
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Giraud P, Servagi-Vernat S. [IMRT and head and neck tumors: does differential fractionation have a role?]. Cancer Radiother 2013; 17:502-7. [PMID: 23969241 DOI: 10.1016/j.canrad.2013.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 05/25/2013] [Indexed: 11/19/2022]
Abstract
For head and neck cancer, intensity-modulated radiation therapy (IMRT) provides benefits in terms of coverage of the target tumour volume and reduction of the dose to organs at risk. Altered fractionation called SMART (simultaneous modulated accelerated radiation therapy) or SIB (simultaneous integrated boost), equivalent to the "concomitant boost" of conventional techniques, provides additional theoretical gain in the therapeutic index and simplifies the practical implementation of the treatment. The impact on tumour control and acute and late toxicities is encouraging but needs to be confirmed by prospective clinical studies with sufficient follow-up. A lot of different protocols have been tested without really bringing out a "gold standard". However, the current results tend to suggest a SIB/SMART-IMRT moderately accelerated without combined chemotherapy for limited stages (I and II), and SIB-IMRT slightly accelerated with induction and/or concomitant chemotherapy for more advanced stages (III and IV).
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Affiliation(s)
- P Giraud
- Service d'oncologie-radiothérapie, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France; Université Paris Descartes, Sorbonne Paris-Cité , 75015 Paris, France.
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Franceschini D, Paiar F, Meattini I, Agresti B, Pasquetti EM, Greto D, Bonomo P, Marrazzo L, Casati M, Livi L, Biti G. Simultaneous integrated boost-intensity-modulated radiotherapy in head and neck cancer. Laryngoscope 2013; 123:E97-103. [PMID: 23775348 DOI: 10.1002/lary.24257] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 04/30/2013] [Accepted: 05/29/2013] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS To review toxicity and outcomes in patients with head and neck cancer treated with simultaneous integrated boost-intensity-modulated radiotherapy (SIB-IMRT). STUDY DESIGN Review of experience with the SIB-IMRT technique. METHODS Fifty patients were treated with the SIB-IMRT technique. Two possible schedules of radiation therapy (RT) were used: SIB 70 (70/60/54 in 33 fractions) and SIB 66 (66/60/54 in 33 fractions). Forty-one patients also received chemotherapy. RESULTS All but two patients completed treatment as prescribed. No G4 acute toxicity has been reported in our series. We did not observe any G3 to G4 chronic toxicity, apart from one case of cutaneous necrosis. After a median follow-up of 23.3 months (range, 1-60 months), 41 patients (82%) were alive and negative for disease, and one patient (2%) was alive with distant metastases. Eight patients (16%) died, seven because of progressive disease and one for other causes. CONCLUSIONS SIB-IMRT is a highly effective and safe technique of RT in the treatment of head and neck cancer.
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Affiliation(s)
- Davide Franceschini
- Department of Radiation Oncology, IFCA, University of Florence, Florence, Italy
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Piotrowski T, Kaźmierska J, Sokołowski A, Skórska M, Jodda A, Ryczkowski A, Cholewiński W, Bąk B. Impact of the spinal cord position uncertainty on the dose received during head and neck helical tomotherapy. J Med Imaging Radiat Oncol 2013; 57:503-11. [DOI: 10.1111/1754-9485.12056] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Accepted: 01/22/2013] [Indexed: 12/25/2022]
Affiliation(s)
| | | | - Adam Sokołowski
- Department of Medical Physics; Greater Poland Cancer Centre; Poznan; Poland
| | - Małgorzata Skórska
- Department of Medical Physics; Greater Poland Cancer Centre; Poznan; Poland
| | - Agata Jodda
- Department of Medical Physics; Greater Poland Cancer Centre; Poznan; Poland
| | - Adam Ryczkowski
- Department of Medical Physics; Greater Poland Cancer Centre; Poznan; Poland
| | | | - Bartosz Bąk
- Second Radiotherapy Department; Greater Poland Cancer Centre; Poznan; Poland
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Leclerc M, Maingon P, Hamoir M, Dalban C, Calais G, Nuyts S, Serre A, Grégoire V. A dose escalation study with intensity modulated radiation therapy (IMRT) in T2N0, T2N1, T3N0 squamous cell carcinomas (SCC) of the oropharynx, larynx and hypopharynx using a simultaneous integrated boost (SIB) approach. Radiother Oncol 2013; 106:333-40. [PMID: 23541643 DOI: 10.1016/j.radonc.2013.03.002] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 03/02/2013] [Accepted: 03/03/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND The simultaneous integrated boost (SIB) technique with dose per fraction slightly higher than 2Gy offers the advantages of shortening the treatment time and increasing the biologically equivalent dose to the tumor. This study was designed to evaluate the feasibility of a dose-escalating radiotherapy treatment by using a SIB-IMRT approach in patients with early and moderately advanced head and neck cancers. MATERIALS AND METHODS Fifty-seven consecutive patients with pharyngo-laryngeal T2N0 or T2N1, or laryngeal T3N0 SCC were included. The therapeutic PTVs were treated according to three consecutive dose levels i.e., 69 Gy in 30 fractions of 2.3 Gy (dose level I), 72 Gy in 30 fractions of 2.4 Gy (dose level II) or 75 Gy in 30 fractions of 2.5 Gy (dose level III). The prophylactic PTVs received a dose of 55.5 Gy delivered in 30 fractions of 1.85 Gy. The primary endpoint of the study was acute toxicity assessed during treatment and during the first 3 months following the completion of radiotherapy. The secondary endpoints included loco-regional control, disease-free survival, overall survival and late toxicity at 2 years of follow-up. The study design allowed patients to be enrolled in the second dose level group if no more than 10% of grade 4 acute toxicity was observed on the first dose level group within 3 months after the completion of IMRT, and so on for the third level group. RESULTS Forty-four men and 13 women were included in the trial. The majority of them presented with oropharyngeal cancer (53%) and laryngeal cancer (33%). Only 3 patients developed grade 4 acute mucositis during treatment, one in each dose level. Thirty-two patients (56%) experienced grade 3 toxicity, mostly dermatitis and mucositis, without any significant difference between the groups. Late grade 1 and 2 xerostomia was seen in 53% and 33% of patients, respectively. Transient grade 4 late toxicity was observed in 16% of all patients and was equally distributed among the groups. The 2-year loco-regional control was 82% for all 3 groups (79% dose level I, 88% dose level II, 79% dose level III). The 2-year overall survival was 89% for dose level I and II, and 95% for dose level III. CONCLUSIONS This dose escalation SIB-IMRT protocol was safe and effective as the sole treatment of early and moderately advanced SCC of head and neck. No toxicity difference was observed between the groups.
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Affiliation(s)
- Mathieu Leclerc
- Cancer Center and Department of Radiation Oncology, Université catholique de Louvain, Cliniques Universitaires St-Luc, Brussels, Belgium
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Fan TY, Xing J, Lu J, Liu TH, Xu M, Zhang YJ, Shao Q, Li JB, Yu JM. Phase I/II study of induction chemotherapy plus concurrent chemotherapy and SMART-IMRT-based radiotherapy in locoregionally-advanced nasopharyngeal cancer. Oncol Lett 2013; 5:889-895. [PMID: 23426016 PMCID: PMC3576218 DOI: 10.3892/ol.2013.1137] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 01/07/2013] [Indexed: 01/09/2023] Open
Abstract
This study aimed to evaluate the efficacy, toxicity and tolerability of simultaneous modulated accelerated radiation therapy (SMART)-intensity modulated radiotherapy (IMRT) plus cisplatin and 5-fluorouracil (5-FU) chemotherapy for patients with advanced nasopharyngeal cancer (NPC). Forty-five patients with stage II–IV NPC, determined by the American Joint Committee on Cancer system, were treated with prescribed doses of 72 Gy total to the gross tumor volume, 60 Gy to the clinical target volume and metastatic nodal station, and 54 Gy to the clinically-negative neck region. Before radiotherapy, two cycles of cisplatin (30 mg/m2/day on days 1–3) plus 5-FU (400 mg/m2/day on days 1–5) were delivered every three weeks for two cycles. Patients received two cycles of cisplatin (30 mg/m2 day on days 1–3) every three weeks during radiotherapy. In addition, two cycles of cisplatin and 5-FU were given after radiation. All patients completed the prescribed radiotherapy and all scheduled cycles of chemotherapy. Thirty of the 45 patients (66.6%) had a complete response at the end of treatment. Grade 3 mucositis occurred in 4/45 patients (8.8%) and grade 3 dermatitis occurred in 5/45 (11.1%) during radiotherapy. Grade 3 neutropenia occurred in 6/45 (13.3%) during concurrent chemotherapy. There was no treatment-related mortality. After a median follow-up time of 51 months, only three patients’ treatments had failed. Local and distant failure rates were 1.5 and 3.0%, respectively. SMART-IMRT plus cisplatin and 5-FU chemotherapy showed promising activity with manageable toxicity. It is a feasible regimen and improves locoregional disease control.
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Affiliation(s)
- Ting-Yong Fan
- School of Medicine, Shandong University, Jinan, Shandong 250012; ; Shandong Cancer Hospital and Institute, Jinan, Shandong 240117, P.R. China
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Kim JW, Cho JH, Keum KC, Kim JH, Kim GE, Lee JY, Kim SK, Lee CG. IMRT with Simultaneous Integrated Boost and Concurrent Chemotherapy for Nasopharyngeal Cancer: Plan Evaluation and Treatment Outcome. Jpn J Clin Oncol 2012; 42:1152-60. [DOI: 10.1093/jjco/hys169] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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Vila Capel A, Vilar Palop J, Pedro Olivé A, Sanchez-Reyes Fernandez A, Vayreda Ribera J, Julià Sanahuja JC, Pérez de Olaguer Agustín J, Artola Codina N, Moya Cascant LM, Rubio Calatayud E, Carrera Domenech G. IMRT: preliminary results in a series of advanced head-and-neck cancer patients. Clin Transl Oncol 2012; 15:233-42. [PMID: 22855193 DOI: 10.1007/s12094-012-0911-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Accepted: 06/21/2012] [Indexed: 11/25/2022]
Abstract
PURPOSE To determine retrospectively 2-3 year local and regional control (LRC), free-of-disease survival (FDS) and overall survival (OS), as well as summarized toxicities in a group of 31 advanced head-and-neck cancer patients, treated at our institution between 2004 and 2011 with definitive IMRT low-dose concomitant boost, the majority of them with concurrent chemotherapy based on cisplatin. The results are also shown in the sub-group of nasopharyngeal cancer patients (NPC: 15 cases). PATIENTS AND METHODS Radiological basal and contrasted CT series, MR-CT or PET/CT fused images in the setup position with immobilization mask were registered in simulation therapy patients. Planed doses were: 70 Gy in primary tumor and positive nodes >1 cm; 63 Gy in high-risk areas of microscopic diseases +10 mm safety margin; and 56 Gy in low risk of diseases regional lymph nodes. Treatment was delivered using a Varian 2100 Clinac with sliding windows IMRT. Spinal cord doses were limited to a strict maximum of 45 Gy, and optimization aimed for mean doses in parotid glands below 26 Gy, especially in the contralateral parotid gland. Online DRR-portal X-ray comparison images were taken every day with a deviation module tolerance ≤3 mm. RESULTS The mean follow-up since IMRT was 34 months (interval: 8-89; median 31 months). Median follow-up in living patients was 22 months. The 2-year rate for global LRC was 64 %, for FDS 61 % and OS 77 %. For the NPC group after 2 years, LRC was 73 %, FDS 73 % and OS 93 %. The 3-year rates were similar. Seven patients died as a consequence of local and/or regional progression (mean time 10 months). Relapses were observed in eight patients (26 %), but only seven could be confirmed by biopsy (22.6 %; mean time to relapse: 8.6 months). Global acute mucositis was 61 % and chronic mucositis was shown in six cases which developed xerostomia (19 %) in the first control after IMRT, but 1 year later it was reduced to only four patients, two Grade 2 and two Grade 1. CONCLUSIONS No excessive, unwarranted toxicities were observed using concomitant low doses boost in IMRT. High rates of compliance to concurrent chemotherapy were achieved. Late xerostomia associated with this regime decreased 1 year after conclusion of treatment. The implementation of IMRT requires advances in imaging for better tumor delineation; otherwise the physician loses the advantage of dose modulation or faces a risk of geographical miss.
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Affiliation(s)
- Antonio Vila Capel
- Unitat de Radioteràpia i Oncologia, Hospital Plató, C/Plató21, 08006, Barcelona, Spain
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