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Split-field versus extended-field step-and-shoot IMRT techniques in nasopharyngeal cancer: a report of acute and late toxicities. JOURNAL OF RADIOTHERAPY IN PRACTICE 2021. [DOI: 10.1017/s1460396920000874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractAim:This study aimed to evaluate acute and late toxicities in nasopharyngeal cancer (NPC) patients who were treated between split-field (SF) and extended-field (EF) step-and-shoot intensity-modulated radiotherapy (IMRT) techniques.Materials and methods:Between January 2011 and October 2011, 21 NPC patients with stage I-IVB (7th edition American Joint Committee on Cancer Staging) were randomly assigned to undergo radiotherapy with SF or EF step-and-shoot IMRT technique.Results:At a median follow-up time of 60 months (range 3–77), we reported the comparable acute and late toxicities between the two techniques. One patient (9%) in SF-IMRT arm developed grade 3 acute skin toxicity.Findings:Both SF and EF step-and-shoot IMRT techniques for NPC patients did not produce any statistically significant differences in both acute and late toxicities. Although no difference in toxicity was observed, technical problems due to field matching management were the obstacles in utilisation of SF-IMRT in our routine practice.
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Wilke C, Takiar V, Wang H, Moreno AC, Tung SMS, Quinlan-Davidson SR, Garden AS, Rosenthal DI, Fuller CD, Gunn GB, Reddy JP, Morrison WH, Wang C, Zhao G, Hutcheson KA, Phan J. Defining the dose-volume criteria for laryngeal sparing in locally advanced oropharyngeal cancer utilizing split-field IMRT, whole-field IMRT and VMAT. J Appl Clin Med Phys 2020; 22:37-44. [PMID: 33277960 PMCID: PMC7856483 DOI: 10.1002/acm2.13009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/25/2019] [Accepted: 09/03/2019] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To determine the optimal dose-volume constraint for laryngeal sparing using three commonly employed intensity modulated radiation therapy (IMRT) approaches in patients with oropharyngeal cancer treated to the bilateral neck. MATERIALS AND METHODS Thirty patients with stage II-IVA oropharynx cancers received definitive radiotherapy with split-field IMRT (SF-IMRT) to the bilateral neck between 2008 and 2013. Each case was re-planned using whole-field IMRT (WF-IMRT) and volumetric modulated arc therapy (VMAT) and plan quality metrics and dose to laryngeal structures was evaluated. Two larynx volumes were defined and compared on the current study: the Radiation Therapy Oncology Group (RTOG) larynx as defined per the RTOG 1016 protocol and the MDACC larynx defined as the components of the larynx bounded by the superior and inferior extent of the thyroid cartilage. RESULTS Target coverage, conformity, and heterogeneity indices were similar in all techniques. The RTOG larynx mean dose was lower with WF-IMRT than SF-IMRT (22.1 vs 25.8 Gy; P < 0.01). The MDACC larynx mean dose was 17.5 Gy ± 5.4 Gy with no differences between the 3 techniques. WF-IMRT and VMAT plans were associated with lower mean doses to the supraglottic larynx (42.1 vs 41.2 vs 54.8 Gy; P < 0.01) and esophagus (18.1 vs 18.2 vs 36 Gy; P < 0.01). CONCLUSIONS Modern whole field techniques can provide effective laryngeal sparing in patients receiving radiotherapy to the bilateral neck for advanced oropharyngeal cancers. SUMMARY We evaluated laryngeal dose in patients with locally advanced oropharyngeal cancer treated to the bilateral neck using split-field IMRT (SF-IMRT), whole-field IMRT (WF-IMRT) and volumetric arc therapy (VMAT). All three techniques provided good sparing of laryngeal structures and were able to achieve a mean larynx dose < 33 Gy. There were no significant differences in dose to target structures or non-laryngeal organs at risk among techniques.
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Affiliation(s)
- Christopher Wilke
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vinita Takiar
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - He Wang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amy C Moreno
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shih-Ming Samuel Tung
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sean R Quinlan-Davidson
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Adam S Garden
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Clifton D Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gary B Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jay P Reddy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William H Morrison
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Congjun Wang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - George Zhao
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Katherine A Hutcheson
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jack Phan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Lin CS, Chen YW, Liu SC, Tsao CC, Lin KT, Lee SP, Fan CY, Liu MY, Shen PC, Jen YM. Treatment outcomes with whole-field versus split-field intensity-modulated radiotherapy for patients with nasopharyngeal carcinoma. Head Neck 2018; 41:598-605. [DOI: 10.1002/hed.25328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 01/11/2018] [Accepted: 04/19/2018] [Indexed: 11/11/2022] Open
Affiliation(s)
- Chun-Shu Lin
- Department of Radiation Oncology, Tri-Service General Hospital; National Defense Medical Center; Taipei Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine; Taipei Medical University; Taipei Taiwan
| | - Yuan-Wu Chen
- Department of Oral and Maxillofacial Surgery, Tri-Service General Hospital; National Defense Medical Center; Taipei Taiwan
| | - Shao-Cheng Liu
- Department of Otolaryngology - Head and Neck Surgery, Tri-Service General Hospital; National Defense Medical Center; Taipei Taiwan
| | - Chih-Cheng Tsao
- Department of Radiation Oncology, Tri-Service General Hospital; National Defense Medical Center; Taipei Taiwan
| | - Kuen-Tze Lin
- Department of Radiation Oncology, Tri-Service General Hospital; National Defense Medical Center; Taipei Taiwan
| | - Steve P. Lee
- Department of Radiation Oncology, David Geffen School of Medicine; University of California; Los Angeles California
| | - Chao-Yueh Fan
- Department of Radiation Oncology, Tri-Service General Hospital; National Defense Medical Center; Taipei Taiwan
| | - Ming-Yueh Liu
- Department of Radiation Oncology, Tri-Service General Hospital; National Defense Medical Center; Taipei Taiwan
| | - Po-Chien Shen
- Department of Radiation Oncology, Tri-Service General Hospital; National Defense Medical Center; Taipei Taiwan
| | - Yee-Min Jen
- Department of Radiation Oncology, Tri-Service General Hospital; National Defense Medical Center; Taipei Taiwan
- Department of Radiation Oncology; Yee Zen General Hospital; Taoyuan Taiwan
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BalajiSubramanian S, Balaji K, Thirunavukarasu M, Premkumar S. Sparing dysphagia/aspiration related structures using novel hybrid volumetric modulated arc therapy. Phys Med 2017; 39:80-87. [PMID: 28619290 DOI: 10.1016/j.ejmp.2017.05.073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 05/10/2017] [Accepted: 05/31/2017] [Indexed: 10/19/2022] Open
Abstract
PURPOSE Studies using split field IMRT to spare dysphagia/aspiration related structures (DARS) have raised concern regarding dose uncertainty at matchline. This study explores the utility of hybrid VMAT in sparing the DARS and assesses matchline dose uncertainty in postoperative oral cavity cancer patients and compares it with VMAT. METHODS & MATERIALS Ten postoperative oral cavity cancer patients were planned with h-VMAT and VMAT using the same planning CT dataset. PTV and DARS were contoured using standard delineation guidelines. In h-VMAT 80% of the neck dose was planned using AP/PA technique and then VMAT optimization was done for the total PTV by keeping the corresponding AP/PA plan as the base dose. Planning goal for PTV was V95%≥95% and for DARS, adequate sparing. Plans and dose volume histograms were analyzed using dosimetric indices. Absolute point and portal dose measurements were done for h-VMAT plans to verify dose at the matchline. RESULTS Coverage in both the techniques was comparable. Significant differences were observed in mean doses to DARS (Larynx: 24.36±2.51 versus 16.88±2.41Gy; p<0.0006, Pharyngeal constrictors: 25.16±2.41 versus 21.2±2.1Gy; p<0.005, Esophageal inlet: 18.71±2 versus 12.06±0.79Gy; p<0.0002) favoring h-VMAT. Total MU in both the techniques was comparable. Average percentage variations in point dose measurements in h-VMAT done at +3.5 and -3.5 positions were (1.47±1.48 and 2.28±1.35%) respectively. Average gamma agreement for portal dose measured was 97.07%. CONCLUSION h-VMAT achieves better sparing of DARS with no matchline dose uncertainty. Since these patients have swallowing dysfunction post-operatively, attempts should be made to spare these critical structures as much as possible.
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Affiliation(s)
| | - Karunakaran Balaji
- Department of Radiation Oncology, Gleneagles Global Hospitals, Chennai, India; School of Advanced Sciences, VIT University, Vellore, India
| | | | - Sumana Premkumar
- Department of Radiation Oncology, Gleneagles Global Hospitals, Chennai, India
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Cacicedo J, Fernandez I, Del Hoyo O, Navarro A, Gomez-Iturriaga A, Pijoan JI, Martinez-Indart L, Escudero J, Gomez-Suarez J, de Zarate RO, Perez JF, Bilbao P, Rades D. Prognostic value of maximum standardized uptake value measured by pretreatment 18F-FDG PET/CT in locally advanced head and neck squamous cell carcinoma. Clin Transl Oncol 2017; 19:1337-1349. [PMID: 28540535 DOI: 10.1007/s12094-017-1674-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 05/12/2017] [Indexed: 11/24/2022]
Abstract
PURPOSE/OBJECTIVES To evaluate the prognostic impact of maximum standardized uptake value (SUVmax) in patients with locally advanced head and neck squamous cell carcinoma (HNSCC) undergoing pretreatment [F-18] fluoro-D-glucose-positron emission tomography/computed tomography (FDG PET/CT) imaging. MATERIALS/METHODS Fifty-eight patients undergoing FDG PET/CT before radical treatment with definitive radiotherapy (±concomitant chemotherapy) or surgery + postoperative (chemo)radiation were analyzed. The effects of clinicopathological factors (age, gender, tumor location, stage, Karnofsky Performance Status (KPS), and treatment strategy) including primary tumor SUVmax and nodal SUVmax on overall survival (OS), disease-free survival (DFS), locoregional control (LRC), and distant metastasis-free survival (DMFS) were evaluated. Kaplan-Meier survival curves were generated and compared with the log-rank test. RESULTS Median follow-up for the whole population was 31 months (range 2.3-53.5). Two-year OS, LRC, DFS and DMFS, for the entire cohort were 62.1, 78.3, 55.2 and 67.2%, respectively. Median pretreatment SUVmax for the primary tumor and lymph nodes was 11.85 and 5.4, respectively. According to univariate analysis, patients with KPS < 80% (p < 0.001), AJCC stage IVa or IVb vs III (p = 0.037) and patients undergoing radiotherapy vs surgery (p = 0.042) were significantly associated with worse OS. Patients with KPS < 80% (p = 0.003) or age ≥65 years (p = 0.007) had worse LRC. The KPS < 80% was the only factor associated with decreased DFS (p = 0.001). SUVmax of the primary tumor or the lymph nodes were not associated with OS, DFS or LRC. The KPS < 80% (p = 0.002), tumor location (p = 0.047) and AJCC stage (p = 0.025) were associated with worse cancer-specific survival (CSS). According to Cox regression analysis, on multivariate analysis KPS < 80% was the only independent parameter determining worse OS, DFS, CSS. Regarding LRC only patients with IK < 80% (p = 0.01) and ≥65 years (p = 0.01) remained statistically significant. Nodal SUVmax was the only factor associated with decreased DMFS. Patients with a nodal SUVmax > 5.4 presented an increased risk for distant metastases (HR, 3.3; 95% CI 1.17-9.25; p = 0.023). CONCLUSIONS The pretreatment nodal SUVmax in patients with locally advanced HNSCC is prognostic for DMFS. However, according to our results primary tumor SUVmax and nodal SUVmax were not significantly related to OS, DFS or LRC. Patients presenting KPS < 80% had worse OS, DFS, CSS and LRC.
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Affiliation(s)
- J Cacicedo
- Radiation Oncology Department, Cruces University Hospital (University of the Basque Country)/Biocruces Health Research Institute, c/Plaza de Cruces s/n, 48903, Barakaldo, Bizkaia (Basque Country), Spain.
| | - I Fernandez
- Nuclear Medicine Department, Cruces University Hospital, Barakaldo, Spain
| | - O Del Hoyo
- Radiation Oncology Department, Cruces University Hospital (University of the Basque Country)/Biocruces Health Research Institute, c/Plaza de Cruces s/n, 48903, Barakaldo, Bizkaia (Basque Country), Spain
| | - A Navarro
- Radiation Oncology Department, Hospital Duran i Reynals (ICO) Avda, Gran Via de L´Hospitalet, 199-203, Hospitalet de Llobregat, 08908, Barcelona, Spain
| | - A Gomez-Iturriaga
- Radiation Oncology Department, Cruces University Hospital (University of the Basque Country)/Biocruces Health Research Institute, c/Plaza de Cruces s/n, 48903, Barakaldo, Bizkaia (Basque Country), Spain
| | - J Ignacio Pijoan
- Clinical Epidemiology Unit, Cruces University Hospital/Biocruces Health Research Institute, Barakaldo, Spain.,CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - L Martinez-Indart
- Clinical Epidemiology Unit, Cruces University Hospital/Biocruces Health Research Institute, Barakaldo, Spain
| | - J Escudero
- Clinical Epidemiology Unit, Cruces University Hospital/Biocruces Health Research Institute, Barakaldo, Spain
| | - J Gomez-Suarez
- Otolaryngology Department, Cruces University Hospital, c/Plaza de Cruces s/n, 48903, Barakaldo, Vizcaya (Basque Country), Spain
| | - R Ortiz de Zarate
- Medical Physics and Radioprotection Department, Cruces University Hospital/Biocruces Health Research Institute, Vizcaya, Spain
| | - J Fernando Perez
- Medical Physics and Radioprotection Department, Cruces University Hospital/Biocruces Health Research Institute, Vizcaya, Spain
| | - P Bilbao
- Radiation Oncology Department, Cruces University Hospital (University of the Basque Country)/Biocruces Health Research Institute, c/Plaza de Cruces s/n, 48903, Barakaldo, Bizkaia (Basque Country), Spain
| | - D Rades
- Department of Radiation Oncology, University of Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany
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Guo GZ, Sutherland KR, Myers C, Lambert P, Loewen SK, Quon HC. Prospective swallowing outcomes after IMRT for oropharyngeal cancer: Dosimetric correlations in a population-based cohort. Oral Oncol 2016; 61:135-41. [DOI: 10.1016/j.oraloncology.2016.08.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 07/29/2016] [Accepted: 08/07/2016] [Indexed: 10/21/2022]
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Beyond mean pharyngeal constrictor dose for beam path toxicity in non-target swallowing muscles: Dose-volume correlates of chronic radiation-associated dysphagia (RAD) after oropharyngeal intensity modulated radiotherapy. Radiother Oncol 2016; 118:304-14. [PMID: 26897515 DOI: 10.1016/j.radonc.2016.01.019] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 01/09/2016] [Accepted: 01/11/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE/OBJECTIVE(S) We sought to identify swallowing muscle dose-response thresholds associated with chronic radiation-associated dysphagia (RAD) after IMRT for oropharyngeal cancer. MATERIALS/METHODS T1-4 N0-3 M0 oropharyngeal cancer patients who received definitive IMRT and systemic therapy were examined. Chronic RAD was coded as any of the following ⩾12months post-IMRT: videofluoroscopy/endoscopy detected aspiration or stricture, gastrostomy tube and/or aspiration pneumonia. DICOM-RT plan data were autosegmented using a custom region-of-interest (ROI) library and included inferior, middle and superior constrictors (IPC, MPC, and SPC), medial and lateral pterygoids (MPM, LPM), anterior and posterior digastrics (ADM, PDM), intrinsic tongue muscles (ITM), mylo/geniohyoid complex (MHM), genioglossus (GGM), masseter (MM), buccinator (BM), palatoglossus (PGM), and cricopharyngeus (CPM), with ROI dose-volume histograms (DVHs) calculated. Recursive partitioning analysis (RPA) was used to identify dose-volume effects associated with chronic-RAD, for use in a multivariate (MV) model. RESULTS Of 300 patients, 34 (11%) had chronic-RAD. RPA showed DVH-derived MHM V69 (i.e. the volume receiving⩾69Gy), GGM V35, ADM V60, MPC V49, and SPC V70 were associated with chronic-RAD. A model including age in addition to MHM V69 as continuous variables was optimal among tested MV models (AUC 0.835). CONCLUSION In addition to SPCs, dose to MHM should be monitored and constrained, especially in older patients (>62-years), when feasible.
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Yu Y, Chen J, Leary CI, Shugard E, Yom SS. Split-field vs extended-field intensity-modulated radiation therapy plans for oropharyngeal cancer: Which spares the larynx? Which spares the thyroid? Med Dosim 2016; 41:148-53. [DOI: 10.1016/j.meddos.2015.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 11/24/2015] [Accepted: 11/29/2015] [Indexed: 11/24/2022]
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Merlotti A, Alterio D, Vigna-Taglianti R, Muraglia A, Lastrucci L, Manzo R, Gambaro G, Caspiani O, Miccichè F, Deodato F, Pergolizzi S, Franco P, Corvò R, Russi EG, Sanguineti G. Technical guidelines for head and neck cancer IMRT on behalf of the Italian association of radiation oncology - head and neck working group. Radiat Oncol 2014; 9:264. [PMID: 25544268 PMCID: PMC4316652 DOI: 10.1186/s13014-014-0264-9] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Accepted: 11/17/2014] [Indexed: 12/25/2022] Open
Abstract
Performing intensity-modulated radiotherapy (IMRT) on head and neck cancer patients (HNCPs) requires robust training and experience. Thus, in 2011, the Head and Neck Cancer Working Group (HNCWG) of the Italian Association of Radiation Oncology (AIRO) organized a study group with the aim to run a literature review to outline clinical practice recommendations, to suggest technical solutions and to advise target volumes and doses selection for head and neck cancer IMRT. The main purpose was therefore to standardize the technical approach of radiation oncologists in this context. The following paper describes the results of this working group. Volumes, techniques/strategies and dosage were summarized for each head-and-neck site and subsite according to international guidelines or after reaching a consensus in case of weak literature evidence.
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Affiliation(s)
- Anna Merlotti
- Radioterapia AO Ospedale di Circolo-Busto Arsizio (VA), Piazzale Professor G. Solaro, 3, 21052, Busto Arsizio, VA, Italy.
| | | | | | | | | | - Roberto Manzo
- Radioterapia Azienda Ospedaliera ASL Napoli 1-Napoli, Napoli, Italy.
| | | | - Orietta Caspiani
- Radioterapia Ospedale Fatebenefratelli, Isola Tiberina-Roma, Roma, Italy.
| | | | - Francesco Deodato
- Radioterapia Università Cattolica del S. Cuore -Campobasso, Roma, Italy.
| | - Stefano Pergolizzi
- Dipartimento SBIMOF Sezione di Scienze Radiologiche, Università di Messina, Piazza Pugliatti Salvatore, 1, 98122, Messina, ME, Italy.
| | - Pierfrancesco Franco
- Dipartimento di Oncologia, Radioterapia Oncologica, Università di Torino, Turin, Italy.
| | - Renzo Corvò
- Oncologia Radioterapica, IRCS S. Martino-IST- Istituto Nazionale per la Ricerca sul Cancro, Università Genova, Genova, Italy.
| | - Elvio G Russi
- Radioterapia Az. Ospedaliera S. Croce e Carle-Cuneo, via M. Coppino 26 12100, Cuneo, Italy.
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Romesser PB, Lim R, Spratt DE, Setton J, Riaz N, Lok B, Rao S, Sherman EJ, Schöder H, Lee NY. The relative prognostic utility of standardized uptake value, gross tumor volume, and metabolic tumor volume in oropharyngeal cancer patients treated with platinum based concurrent chemoradiation with a pre-treatment [(18)F] fluorodeoxyglucose positron emission tomography scan. Oral Oncol 2014; 50:802-8. [PMID: 25043882 DOI: 10.1016/j.oraloncology.2014.06.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 06/24/2014] [Accepted: 06/25/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This study compared the relative prognostic utility of the Gross Tumor Volume (GTV), maximum Standardized Uptake Value (SUVmax), and Metabolic Tumor Volume (MTV) in a uniform cohort of oropharyngeal squamous cell carcinoma (OPSCC) patients treated with platinum-based concurrent chemoradiation therapy (CCRT). METHODS AND MATERIALS One-hundred OPSCC with a pretreatment [(18)F] fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET-CT) were treated with CCRT. Kaplan-Meier curves and Cox proportional hazard models were generated. RESULTS When dichotomized by the median, a smaller MTV correlated with improved 5year locoregional control (LRC) (98.0% versus 87.0%, p=0.049), freedom from distant metastasis (FDM) (91.7% versus 65.0%, p=0.005), progression-free survival (PFS) (80.3% versus 56.7%, p=0.015), and overall survival (OS) (84.1% versus 57.8%, p=0.008), whereas a smaller GTV correlated with improved PFS (80.3% versus 57.4%, p=0.040) and OS (82.1% versus 60.1%, p=0.025). SUVmax failed to correlate with any outcome. On multivariate analysis, when adjusted for GTV, T-stage, and N-stage a smaller MTV remained independently correlated with improved FDM, PFS, and OS. GTV failed to reach significance in the multivariate model. CONCLUSIONS A smaller MTV correlates with improved LRC, FDM, PFS, and OS in OPSCC patients undergoing platinum-based CCRT.
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Affiliation(s)
- Paul B Romesser
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Remy Lim
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel E Spratt
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jeremy Setton
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nadeem Riaz
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Benjamin Lok
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Shyam Rao
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Eric J Sherman
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Heiko Schöder
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nancy Y Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Optimal beam design on intensity-modulated radiation therapy with simultaneous integrated boost in nasopharyngeal cancer. Med Dosim 2014; 39:246-50. [PMID: 24857279 DOI: 10.1016/j.meddos.2014.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 03/20/2014] [Indexed: 11/23/2022]
Abstract
This study aims to determine the optimal beam design among various combinations of field numbers and beam trajectories for intensity-modulated radiation therapy (IMRT) with simultaneous integrated boost (SIB) technique for the treatment of nasopharyngeal cancer (NPC). We used 10 fields with gantry angles of 155°, 130°, 75°, 25°, 0° L, 0° R, 335°, 285°, 230°, and 205° denoted as F10. To decrease doses in the spinal cord, the F10 technique was designed by featuring 2 pairs of split-opposed beam fields at 155° to 335° and 205° to 25°, as well as one pair of manually split beam fields at 0°. The F10 technique was compared with 4 other common field arrangements: F7E, 7 fields with 50° equally spaced gantry angles; F7, the basis of F10 with 155°, 130°, 75°, 0°, 285°, 230°, and 205°; F9E, 9 fields with 40° equally spaced gantry angles; and FP, 7 posterior fields with 180°, 150°, 120°, 90°, 270°, 240°, and 210°. For each individual case of 10 patients, the customized constraints derived after optimization with the standard F10 technique were applied to 4 other field arrangements. The 4 new optimized plans of each individual case were normalized to achieve the same coverage of planning target volume (PTV)63Gy as that of the standard F10 technique. The F10 field arrangement exhibited the best coverage in PTV70Gy and the least mean dose in the trachea-esophagus region. Furthermore, the F10 field arrangement demonstrated the highest level of conformity in the low-dose region and the least monitor unit. The F10 field arrangement performed more outstandingly than the other field arrangements in PTV70Gy coverage and spared the central organ. This arrangement also exhibited the highest conformity and delivery efficiency. The F10 technique is recommended as the standard beam geometry for the SIB-IMRT of NPC.
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Early treatment response monitoring using 2-deoxy-2-[ 18F]fluoro-D-glucose positron emission tomography imaging during fractionated radiotherapy of head neck cancer xenografts. BIOMED RESEARCH INTERNATIONAL 2014; 2014:598052. [PMID: 24877119 PMCID: PMC4022256 DOI: 10.1155/2014/598052] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 03/28/2014] [Indexed: 12/15/2022]
Abstract
Background. To determine the optimal timing and analytic method of 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography (PET) imaging during fractionated radiotherapy (RT) to predict tumor control. Methods. Ten head neck squamous cell carcinoma xenografts derived from the UT-14-SCC cell line were irradiated with 50 Gy at 2 Gy per day over 5 weeks. Dynamic PET scans were acquired over 70 minutes at baseline (week 0) and weekly for seven weeks. PET data were analyzed using standard uptake value (SUV), retention index (RI), sensitivity factor (SF), and kinetic index (Ki). Results. Four xenografts had local failure (LF) and 6 had local control. Eighty scans from week 0 to week 7 were analyzed. RI and SF after 10 Gy appeared to be the optimal predictors for LF. In contrast, SUV and Ki during RT were not significant predictors for LF. Conclusion. RI and SF of PET obtained after the first week of fractionated RT were the optimal methods and timing to predict tumor control.
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Abstract
Patients with a history of head and neck cancer resection require extensive prosthodontic rehabilitation following cancer treatment. The oral anatomy drastically changes from ablative therapy, and the oral tissue response becomes altered as a consequence of radiation and chemotherapy. Successful restoration of oral function in this specific patient population was increasingly difficult before the widespread use of dental implants. Implant-borne prosthetics are now often used. However, surgical guidelines remain unclear with regard to oncology-related parameters. In this article, guidelines are introduced for implant therapy in the cancer patients according to radiation dosage and timing. Indications for hyperbaric oxygen treatment are highlighted along with risk assessment associated with implant placement. These guidelines are intended to augment knowledge obtained through oncology consultation; moreover, provide a rationale for implant therapy within the course of cancer treatment.
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Jin X, Yi J, Zhou Y, Yan H, Han C, Xie C. Comparison of whole-field simultaneous integrated boost VMAT and IMRT in the treatment of nasopharyngeal cancer. Med Dosim 2013; 38:418-23. [DOI: 10.1016/j.meddos.2013.05.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Revised: 04/16/2013] [Accepted: 05/16/2013] [Indexed: 11/28/2022]
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Zhang HH, Betzel GT, Yi BY, D'Souza WD. Beam controlled arc therapy--a delivery concept for stationary targets. Phys Med Biol 2013; 58:7117-29. [PMID: 24052088 DOI: 10.1088/0031-9155/58/20/7117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Volumetric modulated arc therapy (VMAT) presupposes that it is beneficial to deliver radiation from all beam angles as the gantry rotates, requiring the multi-leaf collimator to maintain continuity in shape from one angle to another. In turn, radiation from undesirable beam angles could compromise the dose distribution. In this work, we challenge the notion that the radiation beam must be held on as the gantry rotates around the patient. We propose a new approach for delivering intensity-modulated arc therapy, beam-controlled arc therapy (BCAT), during which the radiation beam is controlled on or off and the dose rate is modulated while the gantry rotates around the patient. We employ linear-programming-based dose optimization to each aperture weight, resulting in some zero weight apertures. During delivery, the radiation beam is held off at control points with zero weights as the MLC shape transits to the next non-zero weight shape. This was tested on ten head and neck cases. Plan quality and delivery efficiency were compared with VMAT. Improvements of up to 17% (p-value 0.001) and 57% (p-value 0.018) in organ-at-risk sparing and target dose uniformity, respectively, were achieved. Compared to the fixed number of apertures used in single-arc and double-arc VMAT, the BCAT used 109 and 175 apertures on average, respectively. The difference in total MUs for VMAT and BCAT plans was less than 4%. Plan quality improvement was confirmed after delivery with γ analysis resulting in over 99% agreement, or 4 in 1099 points that failed.
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Affiliation(s)
- H H Zhang
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
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Sanguineti G, Ricchetti F, McNutt T, Wu B, Fiorino C. Dosimetric predictors of dysphonia after intensity-modulated radiotherapy for oropharyngeal carcinoma. Clin Oncol (R Coll Radiol) 2013; 26:32-8. [PMID: 23992739 DOI: 10.1016/j.clon.2013.08.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Revised: 05/13/2013] [Accepted: 06/20/2013] [Indexed: 11/30/2022]
Abstract
AIMS To investigate dosimetric predictors of voice changes after whole-field intensity-modulated radiotherapy (IMRT). MATERIALS AND METHODS Patients treated with whole-field IMRT for oropharyngeal/unknown primary tumours were selected for the present retrospective study having grossly uninvolved larynx at the time of radiotherapy and at least one follow-up visit. Voice changes were prospectively scored at each follow-up examination according to the Common Terminology Criteria for Adverse Events (CTCAE) v3.0 scale and self-reported by two items (HN4 and HN10) of the Functional Assessment of Cancer Therapy-Head and Neck Scale (FACT-HN) questionnaire. Predictors of toxicity were investigated at logistic regression, including various patient and tumour characteristics, as well as individual dosimetric data. RESULTS With a median follow-up of 18 months (range 3-46 months), peak CTCAE dysphonia was graded as 2 in 13 patients (10.5%), whereas 45 patients (36.3%) reported peak grade 0-1 voice changes according to FACT-HN4. Communication (FACT-HN10) was barely affected. At multivariate analysis, the mean laryngeal dose was an independent predictor of both grade 2 CTCAE dysphonia (odds ratio = 1.10, 95% confidence interval 1.01-1.20, P = 0.025) and grade 0-1 FACT-HN4 voice changes (odds ratio = 1.11, 95% confidence interval 1.04-1.18, P = 0.001). Further stratification optimised by a receiver operating characteristic (ROC) analysis showed that, to minimise the risk of grade 0-1 FACT-HN4 voice changes, the mean dose to the larynx has to be kept ≤ 49.4 Gy. CONCLUSION Voice changes after whole-field IMRT are common, but mild, and are strictly correlated to the dose received by the uninvolved larynx; in order to minimise the risk of side-effects, the mean dose to the larynx should be kept ≤ 50 Gy.
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Affiliation(s)
- G Sanguineti
- Radiation Oncology, Johns Hopkins University, Baltimore, MD, USA.
| | - F Ricchetti
- Radiation Oncology, Johns Hopkins University, Baltimore, MD, USA
| | - T McNutt
- Radiation Oncology, Johns Hopkins University, Baltimore, MD, USA
| | - B Wu
- Radiation Oncology, Johns Hopkins University, Baltimore, MD, USA
| | - C Fiorino
- Physics, Ospedale San Raffaele, Milano, Italy
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Zhang HH, Gao S, Chen W, Shi L, D'Souza WD, Meyer RR. A surrogate-based metaheuristic global search method for beam angle selection in radiation treatment planning. Phys Med Biol 2013; 58:1933-46. [PMID: 23459411 DOI: 10.1088/0031-9155/58/6/1933] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
An important element of radiation treatment planning for cancer therapy is the selection of beam angles (out of all possible coplanar and non-coplanar angles in relation to the patient) in order to maximize the delivery of radiation to the tumor site and minimize radiation damage to nearby organs-at-risk. This category of combinatorial optimization problem is particularly difficult because direct evaluation of the quality of treatment corresponding to any proposed selection of beams requires the solution of a large-scale dose optimization problem involving many thousands of variables that represent doses delivered to volume elements (voxels) in the patient. However, if the quality of angle sets can be accurately estimated without expensive computation, a large number of angle sets can be considered, increasing the likelihood of identifying a very high quality set. Using a computationally efficient surrogate beam set evaluation procedure based on single-beam data extracted from plans employing equallyspaced beams (eplans), we have developed a global search metaheuristic process based on the nested partitions framework for this combinatorial optimization problem. The surrogate scoring mechanism allows us to assess thousands of beam set samples within a clinically acceptable time frame. Tests on difficult clinical cases demonstrate that the beam sets obtained via our method are of superior quality.
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Affiliation(s)
- H H Zhang
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA.
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Robert MW, Lok BH, Dutta PR, Riaz N, Setton J, Berry SL, Goenka A, Zhang Z, Rao SS, Wolden SL, Lee NY. Constraining the brachial plexus does not compromise regional control in oropharyngeal carcinoma. Radiat Oncol 2013; 8:173. [PMID: 23835205 PMCID: PMC3729584 DOI: 10.1186/1748-717x-8-173] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 03/17/2013] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Accumulating evidence suggests that brachial plexopathy following head and neck cancer radiotherapy may be underreported and that this toxicity is associated with a dose-response. Our purpose was to determine whether the dose to the brachial plexus (BP) can be constrained, without compromising regional control. METHODS The radiation plans of 324 patients with oropharyngeal carcinoma (OPC) treated with intensity-modulated radiation therapy (IMRT) were reviewed. We identified 42 patients (13%) with gross nodal disease <1 cm from the BP. Normal tissue constraints included a maximum dose of 66 Gy and a D05 of 60 Gy for the BP. These criteria took precedence over planning target volume (PTV) coverage of nodal disease near the BP. RESULTS There was only one regional failure in the vicinity of the BP, salvaged with neck dissection (ND) and regional re-irradiation. There have been no reported episodes of brachial plexopathy to date. CONCLUSIONS In combined-modality therapy, including ND as salvage, regional control did not appear to be compromised by constraining the dose to the BP. This approach may improve the therapeutic ratio by reducing the long-term risk of brachial plexopathy.
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Affiliation(s)
- Mutter W Robert
- Department of Radiation Oncology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA
| | - Benjamin H Lok
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, USA
| | - Pinaki R Dutta
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, USA
| | - Nadeem Riaz
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, USA
| | - Jeremy Setton
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, USA
| | - Sean L Berry
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, USA
| | - Anuj Goenka
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, USA
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, USA
| | - Shyam S Rao
- Department of Radiation Oncology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA
| | - Suzanne L Wolden
- Department of Radiation Oncology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA
| | - Nancy Y Lee
- Department of Radiation Oncology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA
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Feasibility of Tomotherapy-based image-guided radiotherapy to reduce aspiration risk in patients with non-laryngeal and non-pharyngeal head and neck cancer. PLoS One 2013; 8:e56290. [PMID: 23505414 PMCID: PMC3591427 DOI: 10.1371/journal.pone.0056290] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2012] [Accepted: 01/11/2013] [Indexed: 11/19/2022] Open
Abstract
PURPOSE The study aims to assess the feasibility of Tomotherapy-based image-guided radiotherapy (IGRT) to reduce the aspiration risk in patients with non-laryngeal and non-hypopharyngeal cancer. A retrospective review of 48 patients undergoing radiation for non-laryngeal and non-hypopharyngeal head and neck cancers was conducted. All patients had a modified barium swallow (MBS) prior to treatment, which was repeated one month following radiotherapy. Mean middle and inferior pharyngeal dose was recorded and correlated with the MBS results to determine aspiration risk. RESULTS Mean pharyngeal dose was 23.2 Gy for the whole group. Two patients (4.2%) developed trace aspiration following radiotherapy which resolved with swallowing therapy. At a median follow-up of 19 months (1-48 months), all patients were able to resume normal oral feeding without aspiration. CONCLUSION AND CLINICAL RELEVANCE IGRT may reduce the aspiration risk by decreasing the mean pharyngeal dose in the presence of large cervical lymph nodes. Further prospective studies with IGRT should be performed in patients with non-laryngeal and non-hypopharyngeal head and neck cancers to verify this hypothesis.
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20
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Larynx-sparing techniques using intensity-modulated radiation therapy for oropharyngeal cancer. Med Dosim 2012; 37:383-6. [DOI: 10.1016/j.meddos.2012.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2010] [Revised: 11/27/2011] [Accepted: 02/08/2012] [Indexed: 11/20/2022]
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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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Romesser PB, Romanyshyn JC, Schupak KD, Setton J, Riaz N, Wolden SL, Gelblum DY, Sherman EJ, Kraus D, Lee NY. Percutaneous endoscopic gastrostomy in oropharyngeal cancer patients treated with intensity-modulated radiotherapy with concurrent chemotherapy. Cancer 2012; 118:6072-8. [PMID: 22707358 DOI: 10.1002/cncr.27633] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Revised: 04/10/2012] [Accepted: 04/11/2012] [Indexed: 11/10/2022]
Abstract
BACKGROUND The clinical benefit of routine placement of prophylactic percutaneous endoscopic gastrostomy (pPEG) tubes was assessed in patients with oropharyngeal cancer (OPC) who are undergoing intensity-modulated radiotherapy (IMRT) with concurrent chemotherapy. METHODS From 1998 through 2009, 400 consecutive patients with OPC who underwent chemoradiation were included. Of these, 325 had a pPEG and 75 did not (nPEG). Weight and albumin change from baseline to mid-IMRT, end of IMRT, 1 month post-IMRT, and 3 months post-IMRT were evaluated. The treating physicians prospectively recorded acute and late toxicities. RESULTS Significantly lower absolute weight loss at end of IMRT (6.80 kg vs 8.38 kg, P = .007), 1 month post-IMRT (9.06 kg vs 11.33 kg, P = .006), and 3 months post-IMRT (11.10 kg vs 13.09 kg, P = .044) was noted in the pPEG versus nPEG groups. This benefit in reduction of percent weight loss was consistently significant only among patients with BMI < 25. Significant differences were noted in hospital admission rate (15.1% vs 26.7%, P = .026) and volume of nonchemotherapy hydration (8.9 liters vs 17.2 liters, P = .004). There were no differences in percent albumin change, acute dysphagia, acute mucositis, acute xerostomia, chronic dysphagia, radiation treatment duration, and overall survival. Multivariate analysis noted age >55 years (P < .001), female sex (P < .001), and T3/4 category disease (P < .001) were significantly associated with prolonged PEG use. CONCLUSIONS Although pPEG reduced absolute and percent weight loss and need for hospitalizations in our cohort of patients with OPC undergoing chemoradiation, no differences were noted in radiation treatment duration, toxicity, and overall survival. Prolonged PEG use correlated with age >55 years, female sex, and T3/T4 tumors.
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Affiliation(s)
- Paul B Romesser
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York 10065, USA.
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Liu T, Chen J, Gong G, Zhang G, Bai T, Sun T, Lu J, Ma C, Yin Y. Radiation therapy for nasopharyngeal carcinoma using simultaneously integrated boost (SIB) protocol: a comparison planning study between intensity modulated arc radiotherapy vs. intensity modulated radiotherapy. Technol Cancer Res Treat 2012; 11:415-20. [PMID: 22568626 DOI: 10.7785/tcrt.2012.500262] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The aim of this paper is to compare the dosimetric difference between intensity-modulated arc therapy (IMAT) and conventional intensity-modulated radiation therapy (IMRT) for radiotherapy of nasopharyngeal carcinoma (NPC) using simultaneously integrated boost (SIB) protocol. Ten patients with nasopharyngeal carcinoma underwent SIB protocol were retrospectively studied. The plan target volume (PTV) of NPC contained nasopharynx gross target volume and the positive neck lymph nodes, PTV1 contained the high-risk sites of microscopic extension and the whole nasopharynx and PTV2 contained the low-risk sites. The prescription dose of PTV was 66 Gy/30 fractions, and for PTV1 60 Gy/30 fractions and for PTV2 54 Gy/30 fractions. IMAT (two 358° arcs) and IMRT (7 fields) plans were designed for each patients using SIB strategies. The monitor unit (MU), treatment time (T) and dosimetric difference between IMRT and IMAT were compared. IMAT can achieve better conformal index (CI) than IMRT (P < 0.05) for all PTVs, while no significant difference were found in homogeneity index (HI) (P > 0.05). There's no significant difference found in radiation dose of brain stem, lenses and parotids, while the maximum dose of spinal cord of IMAT was higher than IMRT (P < 0.05). The monitor unit of IMRT (1308 ± 213) was more than IMAT (606 ± 96) (P < 0.05), while the treatment time of IMRT (540 ± 160S) was more than IMAT (160 ± 10S). This study shows that IMAT using SIB strategies for NPC radiotherapy can achieve similar target coverage with better conformity with less MU and delivery time comparing to IMRT.
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Affiliation(s)
- Tonghai Liu
- Department of Radiation Oncology, Shandong Cancer Hospital, Shandong Provincial Key Laboratory of Radiation Oncology, Shandong Academy of Medical Sciences, Jinan, PR China
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Xia P, Qi P, Rembert J, Hu AZ, Quivey JM, Yom SS. A treatment planning method to avoid the larynx and eliminate the match-line in the treatment of head and neck cancer with intensity-modulated radiation therapy. ACTA ACUST UNITED AC 2012. [DOI: 10.1007/s13566-012-0015-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Radiothérapie avec modulation d’intensité pour les cancers de la tête et du cou : le standard. Cancer Radiother 2011; 15:473-6. [DOI: 10.1016/j.canrad.2011.05.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Accepted: 05/20/2011] [Indexed: 11/20/2022]
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Wang JJ, Goldsmith TA, Holman AS, Cianchetti M, Chan AW. Pharyngoesophageal stricture after treatment for head and neck cancer. Head Neck 2011; 34:967-73. [PMID: 21953721 DOI: 10.1002/hed.21842] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2011] [Revised: 03/17/2011] [Accepted: 05/12/2011] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The purpose of this study was to report the risk of pharyngoesophageal stricture after treatment for head and neck cancer. METHODS Human studies on radiation therapy with or without chemotherapy for head and neck cancer published in peer-reviewed journals with assessment of pharyngoesophageal stricture with barium swallow or endoscopy were included. RESULTS A total of 4727 patients from 26 studies treated between 1989 and 2008 were eligible for analysis. The reported overall risk of stricture was 7.2%. The risks of pharyngoesophageal stricture in both conventional and intensity-modulated radiation therapy (IMRT) studies were 5.7% and 16.7%, respectively (p < .001). Use of concurrent (p < .001) and taxane (p = .01) chemotherapy was associated with the IMRT technique. Prospective studies reported a 3.3-fold increased risk of stricture compared with that of retrospective studies (odds ratio: 3.3; 95% confidence interval: 2.3-4.8; p < .001). CONCLUSIONS Pharyngoesophageal stricture after IMRT and chemotherapy treatment for head and neck cancer is not uncommon. Videofluoroscopic swallow study should be performed prospectively to evaluate swallowing function.
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Affiliation(s)
- Jing Jing Wang
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Lok BH, Setton J, Caria N, Romanyshyn J, Wolden SL, Zelefsky MJ, Park J, Rowan N, Sherman EJ, Fury MG, Ho A, Pfister DG, Wong RJ, Shah JP, Kraus DH, Zhang Z, Schupak KD, Gelblum DY, Rao SD, Lee NY. Intensity-modulated radiation therapy in oropharyngeal carcinoma: effect of tumor volume on clinical outcomes. Int J Radiat Oncol Biol Phys 2011; 82:1851-7. [PMID: 21640497 DOI: 10.1016/j.ijrobp.2011.03.029] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Revised: 03/23/2011] [Accepted: 03/24/2011] [Indexed: 01/17/2023]
Abstract
PURPOSE To analyze the effect of primary gross tumor volume (pGTV) and nodal gross tumor volume (nGTV) on treatment outcomes in patients treated with definitive intensity-modulated radiation therapy (IMRT) for oropharyngeal cancer (OPC). METHODS AND MATERIALS Between September 1998 and April 2009, a total of 442 patients with squamous cell carcinoma of the oropharynx were treated with IMRT with curative intent at our center. Thirty patients treated postoperatively and 2 additional patients who started treatment more than 6 months after diagnosis were excluded. A total of 340 patients with restorable treatment plans were included in this present study. The majority of the patients underwent concurrent platinum-based chemotherapy. The pGTV and nGTV were calculated using the original clinical treatment plans. Cox proportional hazards models and log-rank tests were used to evaluate the correlation between tumor volumes and overall survival (OS), and competing risks analysis tools were used to evaluate the correlation between local failure (LF), regional failure (RF), distant metastatic failure (DMF) vs. tumor volumes with death as a competing risk. RESULTS Median follow-up among surviving patients was 34 months (range, 5-67). The 2-year cumulative incidence of LF, RF and DF in this cohort of patients was 6.1%, 5.2%, and 12.2%, respectively. The 2-year OS rate was 88.6%. Univariate analysis determined pGTV and T-stage correlated with LF (p < 0.0001 and p = 0.004, respectively), whereas nGTV was not associated with RF. On multivariate analysis, pGTV and N-stage were independent risk factors for overall survival (p = 0.0003 and p = 0.0073, respectively) and distant control (p = 0.0008 and p = 0.002, respectively). CONCLUSIONS In this cohort of patients with OPC treated with IMRT, pGTV was found to be associated with overall survival, local failure, and distant metastatic failure.
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Affiliation(s)
- Benjamin H Lok
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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Setton J, Caria N, Romanyshyn J, Koutcher L, Wolden SL, Zelefsky MJ, Rowan N, Sherman EJ, Fury MG, Pfister DG, Wong RJ, Shah JP, Kraus DH, Shi W, Zhang Z, Schupak KD, Gelblum DY, Rao SD, Lee NY. Intensity-modulated radiotherapy in the treatment of oropharyngeal cancer: an update of the Memorial Sloan-Kettering Cancer Center experience. Int J Radiat Oncol Biol Phys 2010; 82:291-8. [PMID: 21167652 DOI: 10.1016/j.ijrobp.2010.10.041] [Citation(s) in RCA: 141] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Revised: 10/08/2010] [Accepted: 10/12/2010] [Indexed: 01/01/2023]
Abstract
PURPOSE To update the Memorial Sloan-Kettering Cancer Center's experience with intensity-modulated radiotherapy (IMRT) in the treatment of oropharyngeal cancer (OPC). METHODS AND MATERIALS Between September 1998 and April 2009, 442 patients with histologically confirmed OPC underwent IMRT at our center. There were 379 men and 63 women with a median age of 57 years (range, 27-91). The disease was Stage I in 2%, Stage II in 4%, Stage III in 21%, and Stage IV in 73% of patients. The primary tumor subsite was tonsil in 50%, base of tongue in 46%, pharyngeal wall in 3%, and soft palate in 2%. The median prescription dose to the planning target volume of the gross tumor was 70 Gy for definitive (n = 412) cases and 66 Gy for postoperative cases (n = 30). A total 404 patients (91%) received chemotherapy, including 389 (88%) who received concurrent chemotherapy, the majority of which was platinum-based. RESULTS Median follow-up among surviving patients was 36.8 months (range, 3-135). The 3-year cumulative incidence of local failure, regional failure, and distant metastasis was 5.4%, 5.6%, and 12.5%, respectively. The 3-year OS rate was 84.9%. The incidence of late dysphagia and late xerostomia ≥Grade 2 was 11% and 29%, respectively. CONCLUSIONS Our results confirm the feasibility of IMRT in achieving excellent locoregional control and low rates of xerostomia. According to our knowledge, this study is the largest report of patients treated with IMRT for OPC.
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Affiliation(s)
- Jeremy Setton
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
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Turkan S, Iğdem S. Nasopharyngeal cancer around the Mediterranean area: role of newer radiation techniques. Crit Rev Oncol Hematol 2010; 84 Suppl 1:e110-4. [PMID: 20965745 DOI: 10.1016/j.critrevonc.2010.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2010] [Revised: 05/03/2010] [Accepted: 05/27/2010] [Indexed: 11/16/2022] Open
Abstract
Primary radiotherapy has been the mainstay of treatment of patients with nondisseminated nasopharyngeal cancer (NPC). Novel techniques, such as intensity modulated and image guided radiotherapy has the capability to generate steep dose gradients, leading to an improved therapeutic index, especially in NPC. Although it is widely accepted as the treatment of choice in NPC in the modern world, in developing countries the financing of these innovative delivery systems still continues to be a major problem. The purpose of this article is to discuss the difficulties one may experience during the transition from 2D way of thinking to the 3D conformal era and to review the clinical outcome and toxicity profile of these promising new radiation techniques.
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Affiliation(s)
- Sedat Turkan
- Department of Radiation Oncology, İstanbul University, Cerrahpaşa School of Medicine, İstanbul, Turkey
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Chen AM, Hall WH, Li BQ, Guiou M, Wright C, Mathai M, Dublin A, Purdy JA. Intensity-modulated radiotherapy increases dose to the brachial plexus compared with conventional radiotherapy for head and neck cancer. Br J Radiol 2010; 84:58-63. [PMID: 20858665 DOI: 10.1259/bjr/62332495] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE The preferential use of intensity-modulated radiotherapy (IMRT) over conventional radiotherapy (CRT) in the treatment of head and neck cancer has raised concerns regarding dose to non-target tissue. The purpose of this study was to compare dose-volume characteristics with the brachial plexus between treatment plans generated by IMRT and CRT using several common treatment scenarios. METHOD The brachial plexus was delineated on radiation treatment planning CT scans from 10 patients undergoing IMRT for locally advanced head and neck cancer using a Radiation Therapy Oncology Group-endorsed atlas. No brachial plexus constraint was used. For each patient, a conventional three-field shrinking-field plan was generated and the dose-volume histogram (DVH) for the brachial plexus was compared with that of the IMRT plan. RESULTS The mean irradiated volumes of the brachial plexus using the IMRT vs the CRT plan, respectively, were as follows: V50 (18±5 ml) vs (11±6 ml), p = 0.01; V60 (6±4 ml) vs (3±3 ml), p = 0.02; V66 (3±1 ml) vs (1±1 ml), p = 0.04, V70 (0±1 ml) vs (0±1 ml), p = 0.68. The maximum point dose to the brachial plexus was 68.9 Gy (range 62.3-78.7 Gy) and 66.1 Gy (range 60.2-75.6 Gy) for the IMRT and CRT plans, respectively (p = 0.01). CONCLUSION Dose to the brachial plexus is significantly increased among patients undergoing IMRT compared with CRT for head and neck cancer. Preliminary studies on brachial plexus-sparing IMRT are in progress.
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Affiliation(s)
- A M Chen
- Department of Radiation Oncology, University of California Davis Cancer Center, Sacramento, USA.
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Gielda BT, Millunchick CH, Smart JP, Marsh JC, Turian JV, Coleman JL. Helical Tomotherapy and Larynx Sparing in Advanced Oropharyngeal Carcinoma: A Dosimetric Study. Med Dosim 2010; 35:214-9. [DOI: 10.1016/j.meddos.2009.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2009] [Revised: 05/28/2009] [Accepted: 06/08/2009] [Indexed: 11/16/2022]
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Anatomic and Dosimetric Changes During the Treatment Course of Intensity-Modulated Radiotherapy for Locally Advanced Nasopharyngeal Carcinoma. Med Dosim 2010; 35:151-7. [DOI: 10.1016/j.meddos.2009.06.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2009] [Revised: 06/11/2009] [Accepted: 06/16/2009] [Indexed: 11/30/2022]
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Comparison of Methods to Reduce Dose to Swallowing-Related Structures in Head and Neck Cancer. Int J Radiat Oncol Biol Phys 2010; 77:462-7. [DOI: 10.1016/j.ijrobp.2009.05.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2009] [Revised: 05/01/2009] [Accepted: 05/02/2009] [Indexed: 11/22/2022]
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Use of a conventional low neck field (LNF) and intensity-modulated radiotherapy (IMRT): no clinical detriment of IMRT to an anterior LNF during the treatment of head-and neck-cancer. Int J Radiat Oncol Biol Phys 2010; 79:65-70. [PMID: 20385457 DOI: 10.1016/j.ijrobp.2009.10.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2009] [Revised: 10/23/2009] [Accepted: 10/26/2009] [Indexed: 11/23/2022]
Abstract
PURPOSE To determine differences in clinical outcomes using intensity-modulated radiotherapy (IMRT) or a standard low neck field (LNF) to treat low neck. METHODS AND MATERIALS This is a retrospective, single-institution study. Ninety-one patients with squamous cell carcinoma of the head and neck were treated with curative intent. According to physician preference, some patients were treated with LNF (Planning Target Volume 3) field using a single anterior photon field matched to the IMRT field. Field junctions were not feathered. The endpoints were time to failure and use of a percutaneous endoscopic gastrostomy (PEG) tube (as a surrogate of laryngeal edema causing aspiration), and analysis was done with χ(2) and log-rank tests. RESULTS Median follow-up was 21 months (range, 2-89 months). Median age was 60 years. Thirty-seven patients (41%) were treated with LNF, 84% were Stage III or IV. A PEG tube was required in 30%, as opposed to 33% without the use of LNF. Node 2 or 3 neck disease was treated more commonly without LNF (38% vs. 24%, p = 0.009). Failures occurred in 12 patients (13%). Only 1 patient treated with LNF failed regionally, 4.5 cm above the match line. The 3-year disease-free survival rate was 87% and 79% with LNF and without LNF, respectively (p = 0.2), and the 3-year LR failure rate was 4% and 21%, respectively (p = 0.04). CONCLUSIONS Using LNF to treat the low neck did not increase the risk of regional failure "in early T and early N diseases" or decrease PEG tube requirements.
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Tejpal G, JaiPrakash A, Susovan B, Ghosh-Laskar S, Murthy V, Budrukkar A. IMRT and IGRT in head and neck cancer: Have we delivered what we promised? Indian J Surg Oncol 2010; 1:166-85. [PMID: 22930632 PMCID: PMC3421012 DOI: 10.1007/s13193-010-0030-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2009] [Accepted: 02/15/2010] [Indexed: 11/28/2022] Open
Abstract
Intensity-modulated radiation therapy (IMRT) is a revolutionary new paradigm that aims at improving the therapeutic ratio by increasing the dosegradient between target tissues and surrounding normal structures thereby offering probability of better loco-regional control with decreased risk of complications. IMRT is relatively intolerant to set-up uncertainties, warranting periodic image-guidance, making Image-Guided Radiation Therapy (IGRT) a natural corollary to IMRT. There are several challenges associated with the planning, delivery, and quality assurance of the IMRT and IGRT processes that must be addressed to realize the full potential of such exciting and promising technology. Given the complexities involved, it is quite intuitive to understand that IMRT and IGRT are resource-intensive, demanding increased labor, rigour, and expenses too. Other disadvantages associated with high-precision techniques include potentially increased risk of marginal failures, decreased dose homogeneity, and an increase in total body dose with increased risk of secondary carcinogenesis. The aim of this review is to define the role of IMRT and IGRT in contemporary head and neck oncologic practice through a critical appraisal of pertinent literature. Despite relatively short follow-up and limited clinical outcomes data, the weight of evidence suggests that loco-regional control is not inferior (either comparable or even better) and toxicity lesser with IMRT resulting in potentially improved quality-of-life, prompting the widespread adoption of such technology in community practice. Ongoing clinical trials in head and neck IMRT are currently addressing issues to optimize the IMRT process, adopting functional imaging for dose-painting, and incorporating adaptive re-planning strategies to further improve outcomes.
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Affiliation(s)
- Gupta Tejpal
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, 410 210 India
| | - Agarwal JaiPrakash
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, 410 210 India
| | - Bannerjee Susovan
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, 410 210 India
| | | | - Vedang Murthy
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, 410 210 India
| | - Ashwini Budrukkar
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, 410 210 India
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Effectiveness of image-guided radiotherapy for laryngeal sparing in head and neck cancer. Oral Oncol 2010; 46:283-6. [DOI: 10.1016/j.oraloncology.2010.01.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Revised: 01/15/2010] [Accepted: 01/15/2010] [Indexed: 11/22/2022]
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Zhang HH, Meyer RR, Shi L, D'Souza WD. The minimum knowledge base for predicting organ-at-risk dose-volume levels and plan-related complications in IMRT planning. Phys Med Biol 2010; 55:1935-47. [PMID: 20224155 DOI: 10.1088/0031-9155/55/7/010] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
IMRT treatment planning requires consideration of two competing objectives: achieving the required amount of radiation for the planning target volume and minimizing the amount of radiation delivered to all other tissues. It is important for planners to understand the tradeoff between competing factors so that the time-consuming human interaction loop (plan-evaluate-modify) can be eliminated. Treatment-plan-surface models have been proposed as a decision support tool to aid treatment planners and clinicians in choosing between rival treatment plans in a multi-plan environment. In this paper, an empirical approach is introduced to determine the minimum number of treatment plans (minimum knowledge base) required to build accurate representations of the IMRT plan surface in order to predict organ-at-risk (OAR) dose-volume (DV) levels and complications as a function of input DV constraint settings corresponding to all involved OARs in the plan. We have tested our approach on five head and neck patients and five whole pelvis/prostate patients. Our results suggest that approximately 30 plans were sufficient to predict DV levels with less than 3% relative error in both head and neck and whole pelvis/prostate cases. In addition, approximately 30-60 plans were sufficient to predict saliva flow rate with less than 2% relative error and to classify rectal bleeding with an accuracy of 90%.
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Affiliation(s)
- Hao H Zhang
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA.
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Zhang HH, Meyer RR, Wu J, Naqvi SA, Shi L, D'Souza WD. A two-stage sequential linear programming approach to IMRT dose optimization. Phys Med Biol 2010; 55:883-902. [PMID: 20071764 DOI: 10.1088/0031-9155/55/3/022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The conventional IMRT planning process involves two stages in which the first stage consists of fast but approximate idealized pencil beam dose calculations and dose optimization and the second stage consists of discretization of the intensity maps followed by intensity map segmentation and a more accurate final dose calculation corresponding to physical beam apertures. Consequently, there can be differences between the presumed dose distribution corresponding to pencil beam calculations and optimization and a more accurately computed dose distribution corresponding to beam segments that takes into account collimator-specific effects. IMRT optimization is computationally expensive and has therefore led to the use of heuristic (e.g., simulated annealing and genetic algorithms) approaches that do not encompass a global view of the solution space. We modify the traditional two-stage IMRT optimization process by augmenting the second stage via an accurate Monte Carlo-based kernel-superposition dose calculations corresponding to beam apertures combined with an exact mathematical programming-based sequential optimization approach that uses linear programming (SLP). Our approach was tested on three challenging clinical test cases with multileaf collimator constraints corresponding to two vendors. We compared our approach to the conventional IMRT planning approach, a direct-aperture approach and a segment weight optimization approach. Our results in all three cases indicate that the SLP approach outperformed the other approaches, achieving superior critical structure sparing. Convergence of our approach is also demonstrated. Finally, our approach has also been integrated with a commercial treatment planning system and may be utilized clinically.
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Affiliation(s)
- Hao H Zhang
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA.
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Whole-field simultaneous integrated-boost intensity-modulated radiotherapy for patients with nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys 2010; 76:138-45. [PMID: 19646824 DOI: 10.1016/j.ijrobp.2009.01.084] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2008] [Revised: 01/15/2009] [Accepted: 01/20/2009] [Indexed: 02/07/2023]
Abstract
PURPOSE To retrospectively review the outcomes of our patients with newly diagnosed nondisseminated nasopharyngeal carcinoma treated with intensity-modulated radiotherapy using a whole-field simultaneous integrated-boost technique. METHODS AND MATERIALS A total of 175 patients treated with WF-SIB between mid-2004 and 2005 were eligible for study inclusion. The distribution of disease by stage was Stage IA in 10.9%, Stage IIA in 2.3%, Stage IIB in 21.7%, Stage III in 41.1%, Stage IVA in 14.9%, and Stage IVB in 9.1%. Of the 175 patients, 2 (1.2%), 10 (5.7%), and 163 (93.1%) had World Health Organization type I, II, and III histologic features, respectively. We prescribed 70 Gy, 60 Gy, and 54 Gy delivered in 33 fractions within 6.5 weeks at the periphery of three planning target volumes (PTV; PTV70, PTV60, and PTV54, respectively). Of the 175 patients, 46 with early T-stage disease received a brachytherapy boost, and 127 with advanced local or regional disease received chemotherapy. RESULTS The median follow-up period was 34 months. The overall 3-year local failure-free survival, regional failure-free survival, distant failure-free survival, and overall survival rate was 93.6%, 93.3%, 86.6%, and 87.2%, respectively. Cox regression analysis showed Stage N2-N3 disease (p = .029) and PTV (p = .024) to be independent factors predicting a greater risk of distant failure and poor overall survival, respectively. Grade 3 acute mucositis/pharyngitis occurred in 23.4% of patients, and Stage T4 disease was the only significant predictor of mucositis/pharyngitis (p = .021). CONCLUSION Whole-field simultaneous integrated-boost intensity-modulated radiotherapy with a dose >70 Gy achieved excellent locoregional control, without an excess incidence of severe, acute mucositis/pharyngitis, in the present study. Strategies for using such highly conformal treatment for patients with a large tumor and late N-stage disease are potential areas of investigation for future studies.
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Caudell JJ, Schaner PE, Desmond RA, Meredith RF, Spencer SA, Bonner JA. Dosimetric factors associated with long-term dysphagia after definitive radiotherapy for squamous cell carcinoma of the head and neck. Int J Radiat Oncol Biol Phys 2009; 76:403-9. [PMID: 19467801 DOI: 10.1016/j.ijrobp.2009.02.017] [Citation(s) in RCA: 164] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2008] [Revised: 01/27/2009] [Accepted: 02/09/2009] [Indexed: 12/12/2022]
Abstract
PURPOSE Intensification of radiotherapy and chemotherapy for head-and-neck cancer may lead to increased rates of dysphagia. Dosimetric predictors of objective findings of long-term dysphagia were sought. METHODS AND MATERIALS From an institutional database, 83 patients were identified who underwent definitive intensity-modulated radiotherapy for squamous cell carcinoma of the head and neck, after exclusion of those who were treated for a second or recurrent head-and-neck primary lesion, had locoregional recurrence at any time, had less than 12 months of follow-up, or had postoperative radiotherapy. Dosimetric parameters were analyzed relative to three objective endpoints as a surrogate for severe long-term dysphagia: percutaneous endoscopic gastrostomy (PEG) tube dependence at 12 months, aspiration on modified barium swallow, or pharyngoesophageal stricture requiring dilation. RESULTS Mean dose greater than 41 Gy and volume receiving 60 Gy (V(60)) greater than 24% to the larynx were significantly associated with PEG tube dependence and aspiration. V(60) greater than 12% to the inferior pharyngeal constrictor was also significantly associated with increased PEG tube dependence and aspiration. V(65) greater than 33% to the superior pharyngeal constrictor or greater than 75% to the middle pharyngeal constrictor was associated with pharyngoesophageal stricture requiring dilation. CONCLUSIONS Doses to the larynx and pharyngeal constrictors predicted long-term swallowing complications, even when controlled for other clinical factors. The addition of these structures to intensity-modulated radiotherapy optimization may reduce the incidence of dysphagia, although cautious clinical validation is necessary.
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Affiliation(s)
- Jimmy J Caudell
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL 35249, USA
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Eisbruch A, Gregoire V. Balancing risk and reward in target delineation for highly conformal radiotherapy in head and neck cancer. Semin Radiat Oncol 2009; 19:43-52. [PMID: 19028345 PMCID: PMC3734795 DOI: 10.1016/j.semradonc.2008.09.008] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The therapeutic index of highly conformal radiotherapy (RT) depends on adequate selection and delineation of the gross tumor volumes, the clinical target volumes, and the tissues and organs whose sparing is likely to gain clinical benefit. Decisions about target and tissue selection and delineation affect the balance of reward and the risk of highly conformal RT. Some of these issues relating to head and neck cancer, including target delineation after tumor shrinkage by induction chemotherapy or at midradiotherapy, are discussed in this article.
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Affiliation(s)
- Avraham Eisbruch
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA.
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Webster GJ, Rowbottom CG, Ho KF, Slevin NJ, Mackay RI. Evaluation of Larynx-Sparing Techniques With IMRT When Treating the Head and Neck. Int J Radiat Oncol Biol Phys 2008; 72:617-22. [DOI: 10.1016/j.ijrobp.2008.06.1495] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2008] [Revised: 06/04/2008] [Accepted: 06/12/2008] [Indexed: 11/28/2022]
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Caglar HB, Tishler RB, Othus M, Burke E, Li Y, Goguen L, Wirth LJ, Haddad RI, Norris CM, Court LE, Aninno DJ, Posner MR, Allen AM. Dose to larynx predicts for swallowing complications after intensity-modulated radiotherapy. Int J Radiat Oncol Biol Phys 2008; 72:1110-8. [PMID: 18468812 DOI: 10.1016/j.ijrobp.2008.02.048] [Citation(s) in RCA: 174] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2008] [Revised: 02/21/2008] [Accepted: 02/21/2008] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate early swallowing after intensity-modulated radiotherapy for head and neck squamous cell carcinoma and determine factors correlating with aspiration and/or stricture. METHODS AND MATERIALS Consecutive patients treated with intensity-modulated radiotherapy with or without chemotherapy between September 2004 and August 2006 at the Dana Farber Cancer Institute/Brigham and Women's Hospital were evaluated with institutional review board approval. Patients underwent swallowing evaluation after completion of therapy; including video swallow studies. The clinical- and treatment-related variables were examined for correlation with aspiration or strictures, as well as doses to the larynx, pharyngeal constrictor muscles, and cervical esophagus. The correlation was assessed with logistic regression analysis. RESULTS A total of 96 patients were evaluated. Their median age was 55 years, and 79 (82%) were men. The primary site of cancer was the oropharynx in 43, hypopharynx/larynx in 17, oral cavity in 13, nasopharynx in 11, maxillary sinus in 2, and unknown primary in 10. Of the 96 patients, 85% underwent definitive RT and 15% postoperative RT. Also, 28 patients underwent induction chemotherapy followed by concurrent chemotherapy, 59 received concurrent chemotherapy, and 9 patients underwent RT alone. The median follow-up was 10 months. Of the 96 patients, 31 (32%) had clinically significant aspiration and 36 (37%) developed a stricture. The radiation dose-volume metrics, including the volume of the larynx receiving >or=50 Gy (p = 0.04 and p = 0.03, respectively) and volume of the inferior constrictor receiving >or=50 Gy (p = 0.05 and p = 0.02, respectively) were significantly associated with both aspiration and stricture. The mean larynx dose correlated with aspiration (p = 0.003). Smoking history was the only clinical factor to correlate with stricture (p = 0.05) but not aspiration. CONCLUSION Aspiration and stricture are common side effects after intensity-modulated radiotherapy for head-and-neck squamous cell carcinoma. The dose given to the larynx and inferior constrictors correlated with these side effects.
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Affiliation(s)
- Hale B Caglar
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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