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Brincker M, Jensen I, Rechner LA, Schut DA, Johansen TS, Nielsen M, Thomsen JB. Multi-center comparison between proton and photon plans for mediastinal lymphomas. Acta Oncol 2023; 62:1251-1255. [PMID: 37624751 DOI: 10.1080/0284186x.2023.2251089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023]
Affiliation(s)
- Mads Brincker
- Department of Medical Physics, Oncology, Aalborg University Hospital, Aalborg, Denmark
| | - Ingelise Jensen
- Department of Medical Physics, Oncology, Aalborg University Hospital, Aalborg, Denmark
| | - Laura Ann Rechner
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Oncology, Radiotherapy Research Unit, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Deborah Anne Schut
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Morten Nielsen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
| | - Jakob Borup Thomsen
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
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2
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Wang X, Bai H, Li R, Wang L, Zhang W, Liang J, Yuan Z. High versus standard radiation dose of definitive concurrent chemoradiotherapy for esophageal cancer: A systematic review and meta-analysis of randomized clinical trials. Radiother Oncol 2023; 180:109463. [PMID: 36642387 DOI: 10.1016/j.radonc.2023.109463] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 12/12/2022] [Accepted: 12/30/2022] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Compare the efficacy and safety of high vs standard radiation dose of definitive concurrent chemoradiotherapy (dCCRT) for esophageal cancer (EC). METHODS AND MATERIALS This meta-analysis is registered in PROSPERO, and it was followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. Eligible randomized clinical trials (RCTs) comparing high dose (HD;≥59.4 Gy/1.8 Gy) and standard doses (SD; 50 Gy/2Gy or 50.4 Gy/1.8 Gy) were identified on electronic databases. STATA16.0 was used for statistical analysis. A meta-analysis was performed to compare treatment effect and toxicity. RESULTS Four articles with a total of 1014 patients were finally included. The results showed that the two groups had similar 1-, 2-, and 3-year OS rates (RR = 1.08, 95 % CI = 0.90-1.30, P = 0.395; RR = 1.07, 95 % CI = 0.95-1.20, P = 0.272; RR = 1.06, 95 % CI = 0.97-1.17, P = 0.184; respectively) and 2-, and 3-year locoregional progression-free survival (LRPFS) (RR = 0.95, 95 % CI = 0.81-1.10, P = 0.478; RR = 0.97, 95 % CI = 0.85-1.11, P = 0.674; respectively). The HD-RT group had higher grade ≥ 3 treatment-related toxicities (OR = 1.35, 95 % CI = 1.03-1.77, P = 0.029) and treatment-related deaths rates (OR = 1.85, 95 % CI = 1.04-3.28, P = 0.036) compared with the SD-RT group. Results of subgroup analysis also indicated that HD could not bring benefit compared to SD, even with modern radiotherapy techniques. CONCLUSION SD-RT had similar treatment effect but lower Grade ≥ 3 treatment-related toxicities rates compared with the HD-RT. Therefore, SD (50 Gy/2Gy or 50.4 Gy/1.8 Gy) should be considered as the recommended dose in dCCRT for EC. Further RCTs are needed to verify our conclusions.
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Affiliation(s)
- Xiaofeng Wang
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Hui Bai
- Department of Radiation Oncology, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou 510095, China
| | - Rui Li
- Department of Thoracic Surgery, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo 315016, China
| | - Lide Wang
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Wencheng Zhang
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China.
| | - Jun Liang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China; Department of Radiation Oncology, National Cancer Center/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen 518116, China.
| | - Zhiyong Yuan
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China.
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3
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Patel CG, Peterson J, Aznar M, Tseng YD, Lester S, Pafundi D, Flampouri S, Mohindra P, Parikh RR, Mailhot Vega R, Konig L, Plastaras JP, Bates JE, Loap P, Kirova YM, Orlandi E, Lütgendorf-Caucig C, Ntentas G, Hoppe B. Systematic review for deep inspiration breath hold in proton therapy for mediastinal lymphoma: A PTCOG Lymphoma Subcommittee report and recommendations. Radiother Oncol 2022; 177:21-32. [PMID: 36252635 DOI: 10.1016/j.radonc.2022.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 09/14/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE To systematically review all dosimetric studies investigating the impact of deep inspiration breath hold (DIBH) compared with free breathing (FB) in mediastinal lymphoma patients treated with proton therapy as compared to IMRT (intensity-modulated radiation therapy)-DIBH. MATERIALS AND METHODS We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline using the PubMed database to identify studies of mediastinal lymphoma patients with dosimetric comparisons of proton-FB and/or proton-DIBH with IMRT-DIBH. Parameters included mean heart (MHD), lung (MLD), and breast (MBD) doses, among other parameters. Case reports were excluded. Absolute differences in mean doses > 1 Gy between comparators were considered to be clinically meaningful. RESULTS As of April 2021, eight studies fit these criteria (n = 8), with the following comparisons: proton-FB vs IMRT-DIBH (n = 5), proton-DIBH vs proton-FB (n = 5), and proton-DIBH vs IMRT-DIBH (n = 8). When comparing proton-FB with IMRT-DIBH in 5 studies, MHD was reduced with proton-FB in 2 studies, was similar (<1 Gy difference) in 2 studies, and increased in 1 study. On the other hand, MLD and MBD were reduced with proton-FB in 3 and 4 studies, respectively. When comparing proton-DIBH with proton-FB, MHD and MLD were reduced with proton DIBH in 4 and 3 studies, respectively, while MBD remained similar. Compared with IMRT-DIBH in 8 studies, proton-DIBH reduced the MHD in 7 studies and was similar in 1 study. Furthermore, MLD and MBD were reduced with proton-DIBH in 8 and 6 studies respectively. Integral dose was similar between proton-FB and proton-DIBH, and both were substantially lower than IMRT-DIBH. CONCLUSION Accounting for heart, lung, breast, and integral dose, proton therapy (FB or DIBH) was superior to IMRT-DIBH. Proton-DIBH can lower dose to the lungs and heart even further compared with proton-FB, depending on disease location in the mediastinum, and organ-sparing and target coverage priorities.
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Affiliation(s)
- Chirayu G Patel
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, USA.
| | | | - Marianne Aznar
- University of Manchester, Division of Cancer Sciences, Manchester, United Kingdom
| | - Yolanda D Tseng
- Department of Radiation Oncology, University of Washington, Seattle, USA
| | | | | | - Stella Flampouri
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, USA
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Rahul R Parikh
- Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, New Brunswick, NJ, USA
| | - Raymond Mailhot Vega
- Department of Radiation Oncology, University of Florida, Gainsville, Florida, USA
| | - Laila Konig
- Department of Radiation Oncology, Heidelberg University Hospital; Heidelberg Ion Beam Therapy Centre (HIT); National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - John P Plastaras
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - James E Bates
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, USA
| | - Pierre Loap
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Youlia M Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Ester Orlandi
- National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | | | - Georgios Ntentas
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; Guy's and St Thomas' NHS Foundation Trust, Department of Medical Physics, London, United Kingdom
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4
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Yang R, Tan C, Najafi M. Cardiac inflammation and fibrosis following chemo/radiation therapy: mechanisms and therapeutic agents. Inflammopharmacology 2021; 30:73-89. [PMID: 34813027 DOI: 10.1007/s10787-021-00894-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/08/2021] [Indexed: 12/14/2022]
Abstract
The incidence of cardiovascular disorders is one of the most concerns among people who underwent cancer therapy. The heart side effects of cancer therapy may occur during treatment to some years after the end of treatment. Some epidemiological studies confirm that heart diseases are one of the most common reasons for mortality among patients that were received treatment for cancer. Experimental studies and also clinical investigations indicate that inflammatory changes such as pericarditis, myocarditis, and also fibrosis are key mechanisms of cardiac diseases following chemotherapy/radiotherapy. It seems that chronic oxidative stress, massive cell death, and chronic overproduction of pro-inflammatory and pro-fibrosis cytokines are the key mechanisms of cardiovascular diseases following cancer therapy. Furthermore, infiltration of inflammatory cells and upregulation of some enzymes such as NADPH Oxidases are a hallmark of heart diseases after cancer therapy. In the current review, we aim to explain how radiation or chemotherapy can induce inflammatory and fibrosis-related diseases in the heart. We will explain the cellular and molecular mechanisms of cardiac inflammation and fibrosis following chemo/radiation therapy, and then review some adjuvants to reduce the risk of inflammation and fibrosis in the heart.
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Affiliation(s)
- Run Yang
- Department of Cardiovascular Surgery, The Second Xiangya Hospital of Central South University, No. 139 Renmin Road, Changsha, Hunan, People's Republic of China
| | - Changming Tan
- Department of Cardiovascular Surgery, The Second Xiangya Hospital of Central South University, No. 139 Renmin Road, Changsha, Hunan, People's Republic of China.
| | - Masoud Najafi
- Medical Technology Research Center, Institute of Health Technology, Kermanshah University of Medical Sciences, Kermanshah, Iran.
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5
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Buglione M, Guerini AE, Filippi AR, Spiazzi L, Pasinetti N, Magli A, Toraci C, Borghetti P, Triggiani L, Alghisi A, Costantino G, Bertagna F, Giaj Levra N, Pegurri L, Magrini SM. A Systematic Review on Intensity Modulated Radiation Therapy for Mediastinal Hodgkin's Lymphoma. Crit Rev Oncol Hematol 2021; 167:103437. [PMID: 34358649 DOI: 10.1016/j.critrevonc.2021.103437] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 05/20/2021] [Accepted: 07/28/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Secondary malignant neoplasms (SMNs) and cardiovascular diseases induced by chemotherapy and radiotherapy represent the main cause of excess mortality for early-stage Hodgkin lymphoma patients, especially when the mediastinum is involved. Conformal radiotherapy techniques such as Intensity-Modulated Radiation Therapy (IMRT) could allow a reduction of the dose to the organs-at-risk (OARs) and therefore limit long-term toxicity. METHODS We performed a systematic review of the current literature regarding comparisons between IMRT and conventional photon beam radiotherapy, or between different IMRT techniques, for the treatment of mediastinal lymphoma. RESULTS AND CONCLUSIONS IMRT allows a substantial reduction of the volumes of OARs exposed to high doses, reducing the risk of long-term toxicity. This benefit is conterbalanced by the increase of volumes receiving low doses, that could potentially increase the risk of SMNs. Treatment planning should be personalized on patient and disease characteristics. Dedicated techniques such as "butterfly" VMAT often provide the best trade-off.
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Affiliation(s)
- Michela Buglione
- Università degli Studi di Brescia, Department of Radiation Oncology, Brescia University, P.le Spedali Civili 1, 25123 Brescia, Italy.
| | - Andrea Emanuele Guerini
- Università degli Studi di Brescia, Department of Radiation Oncology, Brescia University, P.le Spedali Civili 1, 25123 Brescia, Italy.
| | - Andrea Riccardo Filippi
- Radiation Oncology, Fondazione IRCCS Policlinico San Matteo and University of Pavia, Pavia, Italy.
| | - Luigi Spiazzi
- Department of Radiation Oncology, ASST Spedali Civili di Brescia, P.le Spedali Civili 1, 25123 Brescia, Italy.
| | - Nadia Pasinetti
- Università degli Studi di Brescia, Department of Radiation Oncology, Brescia University, P.le Spedali Civili 1, 25123 Brescia, Italy; Radiation Oncology Service, ASST Valcamonica Esine, Italy.
| | - Alessandro Magli
- Department of Radiation Oncology, Udine General Hospital, Udine, Italy.
| | - Cristian Toraci
- Department of Radiation Oncology, ASST Spedali Civili di Brescia, P.le Spedali Civili 1, 25123 Brescia, Italy.
| | - Paolo Borghetti
- Department of Radiation Oncology, ASST Spedali Civili di Brescia, P.le Spedali Civili 1, 25123 Brescia, Italy.
| | - Luca Triggiani
- Università degli Studi di Brescia, Department of Radiation Oncology, Brescia University, P.le Spedali Civili 1, 25123 Brescia, Italy.
| | - Alessandro Alghisi
- Department of Radiation Oncology, Alessandro Manzoni Hospital, Lecco, Italy.
| | | | - Francesco Bertagna
- Nuclear Medicine Department, University of Brescia and Spedali Civili of Brescia, Brescia, Italy.
| | - Niccolò Giaj Levra
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Italy.
| | - Ludovica Pegurri
- Department of Radiation Oncology, ASST Spedali Civili di Brescia, P.le Spedali Civili 1, 25123 Brescia, Italy.
| | - Stefano Maria Magrini
- Università degli Studi di Brescia, Department of Radiation Oncology, Brescia University, P.le Spedali Civili 1, 25123 Brescia, Italy.
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Zhang Y, Li Z, Chen Y, Tan L, Zeng Z, Ding J, Du S. Induction Strategy for Locally Advanced Thymoma. Front Oncol 2021; 11:704220. [PMID: 34367988 PMCID: PMC8339962 DOI: 10.3389/fonc.2021.704220] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 07/12/2021] [Indexed: 12/11/2022] Open
Abstract
Surgery remains cornerstone for the management of thymoma. Complete surgical resection (R0), is recognized as the constant and significant factor for prognosis. However, in locally advanced (Masaoka-Koga stages III-IVa) thymomas, achieving R0 resection remains challenging due to local-regional invasion of the disease. Induction treatment, with the aim of reducing bulky tumor mass, offers new strategy to facilitate totally surgical resection. Herein, we reviewed recent progress and provided a comprehensive overview of induction strategy in locally advance thymoma.
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Affiliation(s)
- Yang Zhang
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zongjuan Li
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yixing Chen
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lijie Tan
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhaochong Zeng
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jianyong Ding
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shisuo Du
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
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7
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Mondal D, Jhawar SR, Millevoi R, Haffty BG, Parikh RR. Proton versus Photon Breath-Hold Radiation for Left-Sided Breast Cancer after Breast-Conserving Surgery: A Dosimetric Comparison. Int J Part Ther 2020; 7:24-33. [PMID: 33604413 PMCID: PMC7886268 DOI: 10.14338/ijpt-20-00026.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 10/09/2020] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Radiation to breast, chest wall, and/or regional nodes is an integral component of breast cancer management in many situations. Irradiating left-sided breast and/or regional nodes may be technically challenging because of cardiac tolerance and subsequent risk of long-term cardiac complications. Deep inspiratory breath-hold (DIBH) technique physically separates cardiac structures away from radiation target volume, thus reducing cardiac dose with either photon (Ph) or proton beam therapy (PBT). The utility of combining PBT with DIBH is less well understood. METHODS AND MATERIALS We compared photon-DIBH (Ph-DIBH) versus proton DIBH (Pr-DIBH) for different planning parameters, including target coverage and organ at risk (OAR) sparing. Necessary ethical permission was obtained from the institutional review board. Ten previous patients with irradiated, intact, left-sided breast and Ph-DIBH were replanned with PBT for dosimetric comparison. Clinically relevant normal OARs were contoured, and Ph plans were generated with parallel, opposed tangent beams and direct fields for supraclavicular and/or axillae whenever required. For proton planning, all targets were delineated individually and best possible coverage of planning target volume was achieved. Dose-volume histogram was analyzed to determine the difference in doses received by different OARs. Minimum and maximum dose (Dmin and Dmax ) as well as dose received by a specific volume of OAR were compared. Each patient's initial plan (Ph-DIBH) was used as a control for comparing newly devised PBT plan (Pr-DIBH). Matched, paired t tests were applied to determine any significant differences between the 2 plans. RESULTS Both the plans were adequate in target coverage. Dose to cardiac structure subunits and ipsilateral lung were significantly reduced with the proton breath-hold technique. Significant dose reduction with Pr-DIBH was observed in comparison to Ph-DIBH for mean dose (D mean) to the heart (0.23 Gy versus 1.19 Gy; P < .001); D mean to the left ventricle (0.25 Gy versus 1.7 Gy; P < .001); D mean, D max, and the half-maximal dose to the left anterior descending artery (1.15 Gy versus 5.54 Gy; P < .003; 7.7 Gy versus 22.15 Gy; P < .007; 1.61 Gy versus 4.42 Gy, P < .049); D max of the left circumflex coronary artery (0.13 Gy versus 1.35 Gy; P < .001) and D mean, the volume to the ipsilateral lung receiving 20 Gy and 5 Gy (2.28 Gy versus 8.04 Gy; P < .001; 2.36 Gy versus 15.54 Gy, P < .001; 13.9 Gy versus 30.28 Gy; P = .002). However, skin dose and contralateral breast dose were not significantly improved with proton. CONCLUSION This comparative dosimetric study showed significant benefit of Pr-DIBH technique compared with Ph-DIBH in terms of cardiopulmonary sparing and may be the area of future clinical research.
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Affiliation(s)
- Dodul Mondal
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USAOAR
- Indraprastha Apollo Hospital, Department of Radiation Oncology, New Delhi, India
| | - Sachin R. Jhawar
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USAOAR
- Department of Radiation Oncology, Ohio State University Comprehensive Cancer Center, The James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Rihan Millevoi
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USAOAR
| | - Bruce G. Haffty
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USAOAR
| | - Rahul R. Parikh
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USAOAR
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8
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Moreno AC, Gunther JR, Milgrom S, Fuller CD, Williamson T, Liu A, Wu R, Zhu XR, Dabaja BS, Pinnix CC. Effect of Deep Inspiration Breath Hold on Normal Tissue Sparing With Intensity Modulated Radiation Therapy Versus Proton Therapy for Mediastinal Lymphoma. Adv Radiat Oncol 2020; 5:1255-1266. [PMID: 33305086 PMCID: PMC7718527 DOI: 10.1016/j.adro.2020.08.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 07/27/2020] [Accepted: 08/03/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose Intensity modulated radiation therapy delivered with deep-inspiration breath hold (IMRT-BH) provides favorable normal tissue dosimetric profiles when treating patients with mediastinal lymphoma. However, it is unclear if IMRT-BH plans are comparable to free breathing (FB) proton plans. We performed a retrospective, comparative dosimetric study between IMRT-BH and FB passive scatter proton therapy (P-FB) or intensity modulated proton therapy (IMPT-FB). Hypothesizing that BH would provide superior normal tissue sparing when added to proton therapy, we also compared plans to passive scatter BH (P-BH). Methods and Materials For 15 patients who received involved-site RT with "butterfly" IMRT-BH, 3 additional proton plans (P-FB, IMPT-FB, P-BH) were optimized to deliver 30.6 Gy/Gy relative biological effectiveness. Dosimetric variables (mean dose, V30, V25, V15, and V5) for organs at risk (OARs) were calculated and compared using nonparametric Wilcoxon signed-rank tests. Results Of 57 studied OAR parameters, IMRT-BH plans were comparable in 37 (65%) parameters with P-FB plans, 32 (56%) of IMPT-FB parameters, and 30 (53%) of P-BH parameters. Doses to breasts were generally equivalent among plans while esophageal dosing was worse with IMRT-BH. Mean doses and V5 of the total lung and heart were the highest with IMRT-BH; however, IMRT-BH resulted in comparable coronary and superior lung V30 relative to proton plans. The addition of BH with proton therapy resulted in the greatest lung sparing, with mean lung dose reductions of 11% to 38%. Conclusions The use of BH with IMRT reduces the disparity in OAR doses with equivalence achieved in nearly two-thirds of OAR metrics compared with P-FB and 50% compared with IMPT-BH. Because each modality exhibited unique benefits, personalization of modality selection is recommended. Proton therapy via BH provides additional benefits in heart and lung sparing.
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Affiliation(s)
- Amy C Moreno
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jillian R Gunther
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sarah Milgrom
- Department of Radiation Oncology at the University of Colorado, Denver, Colorado
| | - C David Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Tyler Williamson
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amy Liu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Richard Wu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - X Ronald Zhu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bouthaina S Dabaja
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Chelsea C Pinnix
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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9
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König L, Haering P, Lang C, Splinter M, von Nettelbladt B, Weykamp F, Hoegen P, Lischalk JW, Herfarth K, Debus J, Hörner-Rieber J. Secondary Malignancy Risk Following Proton vs. X-ray Treatment of Mediastinal Malignant Lymphoma: A Comparative Modeling Study of Thoracic Organ-Specific Cancer Risk. Front Oncol 2020; 10:989. [PMID: 32733794 PMCID: PMC7358352 DOI: 10.3389/fonc.2020.00989] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 05/19/2020] [Indexed: 12/13/2022] Open
Abstract
Purpose: Proton radiotherapy (PRT) is potentially associated with a lower risk for secondary malignancies due to a decreased integral dose to the surrounding organs at risk (OARs). Prospective trials confirming this are lacking due to the need for long-term follow-up and the ethical complexities of randomizing patients between modalities. The objective of the current study is to calculate the risk for secondary malignancies following PRT and photon-based intensity-modulated radiotherapy (IMRT). Materials and Methods: Twenty-three patients (16 female and seven male), previously treated with active scanning PRT for malignant mediastinal lymphoma at Heidelberg Ion Beam Therapy Center, were retrospectively re-planned using helical photon IMRT. The risk for radiation-induced secondary malignancies was estimated and evaluated using two distinct prediction models (1–4). Results: According to the Dasu model, the median absolute total risk for tumor induction following IMRT was 4.4% (range, 3.3–5.8%), 9.9% (range, 2.0–27.6%), and 1.0% (range, 0.5–1.5%) for lung, breast, and esophageal cancer, respectively. For PRT, it was significantly lower for the aforementioned organs at 1.6% (range, 0.7–2.1%), 4.5% (range, 0.0–15.5), and 0.8% (range, 0.0–1.6%), respectively (p ≤ 0.01). The mortality risk from secondary malignancies was also significantly reduced for PRT relative to IMRT at 1.1 vs. 3.1% (p ≤ 0.001), 0.9 vs. 1.9% (p ≤ 0.001), and 0.7 vs. 1.0% (p ≤ 0.001) for lung, breast, and esophageal tumors, respectively. Using the Schneider model, a significant risk reduction of 54.4% (range, 32.2–84.0%), 56.4% (range, 16.0–99.4%), and 24.4% (range, 0.0–99.0%) was seen for secondary lung, breast, and esophageal malignancies, favoring PRT vs. X-ray-based IMRT (p ≤ 0.01). Conclusion: Based on the two prediction models, PRT for malignant mediastinal lymphoma is expected to reduce the risk for radiation-induced secondary malignancies compared with the X-ray-based IMRT. The young age and the long natural history of patients diagnosed with mediastinal lymphoma predisposes them to a high risk of secondary malignancies following curative radiotherapy treatment and, as a consequence, potentially reducing this risk by utilizing advanced radiation therapy techniques such as PRT should be considered.
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Affiliation(s)
- Laila König
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Peter Haering
- Department for Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Clemens Lang
- Department for Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Mona Splinter
- Department for Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Bastian von Nettelbladt
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Fabian Weykamp
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Philipp Hoegen
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jonathan W Lischalk
- Department of Radiation Medicine, Georgetown University School of Medicine, Washington, DC, United States
| | - Klaus Herfarth
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department for Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department for Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
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10
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Percussion assisted radiation therapy in Hodgkin lymphoma allows a marked reduction in heart dose. Radiother Oncol 2020; 152:163-168. [PMID: 32448409 DOI: 10.1016/j.radonc.2019.11.009] [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: 05/10/2019] [Revised: 11/07/2019] [Accepted: 11/11/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND PURPOSE Early-stage Hodgkin lymphoma (HL) is a highly curable disease but the treatment can induce late complications many years later. Irradiation of the healthy heart is inevitable during radiation treatment of mediastinal sites. We developed a novel method to induce a prolonged apnea-like state that can help decrease the dose to organs at risk during radiation therapy. We present the results of the first 8 HL patients treated routinely with percussion assisted radiation therapy (PART) in our clinic. MATERIAL AND METHODS We used a newly developed high-frequency non-invasive ventilation system to suppress respiratory motion for prolonged periods and push the heart away from the treated volume. RESULTS All 8 patients were able to rapidly learn the technique and had an advantage to be treated by PART. We lowered the mean heart dose by an average of 3 Gy with similar target coverage compared to a classical free breathing treatment plan. They were all treated for 15 radiotherapy sessions by PART without any notable side effects. CONCLUSIONS Percussion assisted radiation therapy can be used routinely to reduce the dose to the heart in Hodgkin lymphoma.
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11
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Filippi AR, Meregalli S, DI Russo A, Levis M, Ciammella P, Buglione M, Guerini AE, De Marco G, De Sanctis V, Vagge S, Ricardi U, Simontacchi G. Fondazione Italiana Linfomi (FIL) expert consensus on the use of intensity-modulated and image-guided radiotherapy for Hodgkin's lymphoma involving the mediastinum. Radiat Oncol 2020; 15:62. [PMID: 32164700 PMCID: PMC7066773 DOI: 10.1186/s13014-020-01504-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 02/21/2020] [Indexed: 12/14/2022] Open
Abstract
Aim Advances in therapy have resulted in improved cure rates and an increasing number of long-term Hodgkin's lymphoma (HL) survivors. However, radiotherapy (RT)-related late effects are still a significant issue, particularly for younger patients with mediastinal disease (secondary cancers, heart diseases). In many Centers, technological evolution has substantially changed RT planning and delivery. This consensus document aims to analyze the current knowledge of Intensity-Modulated Radiation Therapy (IMRT) and Image-Guided Radiation Therapy (IGRT) for mediastinal HL and formulate practical recommendations based on scientific evidence and expert opinions. Methods A dedicated working group was set up within the Fondazione Italiana Linfomi (FIL) Radiotherapy Committee in May 2018. After a first meeting, the group adopted a dedicated platform to share retrieved articles and other material. Two group coordinators redacted a first document draft, that was further discussed and finalized in two subsequent meetings. Topics of interest were: 1) Published data comparing 3D-conformal radiotherapy (3D-CRT) and IMRT 2) dose objectives for the organs at risk 3) IGRT protocols and motion management. Results Data review showed that IMRT might allow for an essential reduction in the high-dose regions for all different thoracic OAR. As very few studies included specific dose constraints for lungs and breasts, the low-dose component for these OAR resulted slightly higher with IMRT vs. 3D-CRT, depending on the technique used. We propose a set of dose objectives for the heart, breasts, lungs, and thyroid. The use of IGRT is advised for margin reduction without specific indications, such as the use of breath-holding techniques. An individual approach, including comparative planning and considering different risk factors for late morbidity, is recommended for each patient. Conclusions As HL therapy continues to evolve, with an emphasis on treatment reduction, radiation oncologists should use at best all the available tools to minimize the dose to organs at risk and optimize treatment plans. This document provides indications on the use of IMRT/IGRT based on expert consensus, providing a basis for clinical implementation and future development.
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Affiliation(s)
- Andrea Riccardo Filippi
- Radiation Oncology Department, Fondazione IRCCS Policlinico S. Matteo, Viale Golgi 19, 27100, Pavia, Italy.
| | | | - Anna DI Russo
- Fondazione IRCCS Policlinico San Matteo and University of Pavia, Viale Golgi 19, 27100, Pavia, Italy
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12
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Mailhot Vega RB, Hoppe BS. A positive approach: advances in proton therapy for the treatment of mediastinal lymphoma. Expert Rev Hematol 2020; 13:197-200. [PMID: 31976780 DOI: 10.1080/17474086.2020.1713745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Fl, USA
| | - Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
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13
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Everett AS, Hoppe BS, Louis D, McDonald AM, Morris CG, Mendenhall NP, Li Z, Flampouri S. Comparison of Techniques for Involved-Site Radiation Therapy in Patients With Lower Mediastinal Lymphoma. Pract Radiat Oncol 2019; 9:426-434. [DOI: 10.1016/j.prro.2019.05.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 05/08/2019] [Accepted: 05/13/2019] [Indexed: 12/25/2022]
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14
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Cardiotoxicity of mediastinal radiotherapy. Rep Pract Oncol Radiother 2019; 24:629-643. [PMID: 31719801 DOI: 10.1016/j.rpor.2019.09.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 09/21/2019] [Indexed: 12/16/2022] Open
Abstract
Aim To explore available recent literature related to cardiotoxicity following mediastinal radiation. Background Radiotherapy-related heart injury is well documented, with no apparent safety threshold dose. The number of long-term cancer survivors exposed to mediastinal radiotherapy at some point of their treatment is increasing. Heart dosimetric parameters are of great importance in developing a treatment plan, but few data are available regarding radiosensitivity and dose-volume constraints for specific heart structures. Materials and Methods In October 2018, we identified articles published after 1990 through a PubMed/MEDLINE database search. The authors examined rough search results and manuscripts not relevant for the topic were excluded. We extracted clinical outcomes following mediastinal radiotherapy of childhood cancers, lymphoma, medulloblastoma, thymic cancers and hematopoietic cell transplantation survivors and evaluated treatment planning data, whenever available. Results A total of 1311 manuscripts were identified in our first-round search. Of these manuscripts, only 115 articles, matching our selection criteria, were included. Conclusions Studies uniformly show a linear radiation dose-response relationship between mean absorbed dose to the heart (heart-Dmean) and the risk of dying as a result of cardiac disease, particularly when heart-Dmean exceeds 5 Gy. Limited data are available regarding dose-volume predictors for heart substructures and the risk of subsequent cardiac toxicity. An individual patient's cardiotoxicity risk can be modified with advanced treatment planning techniques, including deep inspiration breath hold. Proton therapy is currently showing advantages in improving treatment planning parameters when compared to advanced photon techniques in lymphoma, thymic malignancies, malignant mesothelioma and craniospinal irradiation.
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Key Words
- 2D-RT, two-dimensional radiotherapy
- 3D-CRT, three-dimensional conformal radiation therapy
- CI, confidence interval
- CSI, craniospinal irradiation
- CVD, Cardiovascular disease
- Cardiotoxicity
- Dmax, maximum absorbed dose in a specified volume
- Dmean, mean absorbed radiation dose in a specified volume
- Dose-volume predictors
- EQD2, equivalent dose in 2 Gy fractions
- G, grade
- Gy, Gray
- HR, hazard ratio
- HT, Helical tomotherapy
- IFRT, involved field radiotherapy
- IMRT, intensity modulated radiation therapy
- INRT, involved node radiotherapy
- ISRT, involved site radiotherapy
- LAD, left anterior descending artery
- Mediastinal radiotherapy
- Mediastinal tumours
- Mv, megavoltage
- NTCP, normal tissue complication probability
- Normal tissue complication probability
- OAR, organs at risk
- OR, odds ratio
- PTV, planning target volume
- RR, relative risks
- TBI, total body irradiation
- VMAT, volumetric modulated arc therapy
- Vx, receiving at last x Gy
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15
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Ricardi U, Maraldo MV, Levis M, Parikh RR. Proton Therapy For Lymphomas: Current State Of The Art. Onco Targets Ther 2019; 12:8033-8046. [PMID: 31632057 PMCID: PMC6781741 DOI: 10.2147/ott.s220730] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 09/13/2019] [Indexed: 12/19/2022] Open
Abstract
The combination of brief chemo-radiotherapy provides high cure rates and represents the first line of treatment for many lymphoma patients. As a result, a high proportion of long-term survivors may experience treatment-related toxic events many years later. Excess and unintended radiation dose to organs at risk (particularly heart, lungs and breasts) may translate in an increased risk of cardiovascular events and second cancers after a few decades. Minimizing dose to organs at risk is thus pivotal to restrain the risk of long-term complications. Proton therapy, with its peculiar physic properties, may help to better spare organs at risk and consequently to reduce toxicities especially in patients receiving mediastinal radiotherapy. Herein, we review the physical basis of proton therapy and the rationale for its implementation in lymphoma patients, with a detailed description of the clinical data. We also discuss the potential disadvantages and uncertainties of protons that may limit their application and critically review the dosimetric studies comparing the risk of late complications between proton and photon radiotherapy.
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Affiliation(s)
| | - Maja V Maraldo
- Department of Clinical Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Mario Levis
- Department of Oncology, University of Torino, Torino, Italy
| | - Rahul R Parikh
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
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16
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Abbassi LM, Goudjil F, Arsène-Henry A, Dendale R, Kirova YM. Protontherapy versus best photon for mediastinal Hodgkin lymphoma: Dosimetry comparison and treatment using ILROG guidelines. Cancer Radiother 2019; 23:922-925. [PMID: 31257097 DOI: 10.1016/j.canrad.2019.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 02/19/2019] [Accepted: 02/21/2019] [Indexed: 11/15/2022]
Abstract
The purpose of this work was reducing treatment-related toxicity for Hodgkin lymphomas using practical procedure inspired by the ILROG guidelines. Reporting the first case of localized Hodgkin lymphoma treated with protontherapy in France. A 24-year-old female with mediastinal, bulky, localized, mixed-cellularity, classic Hodgkin lymphoma required an involved-site radiation therapy after complete response following polychemotherapy. Three-dimensional conformal radiation therapy was not acceptable due to high doses to breasts, heart and lungs. We realized a four-dimensional computed tomography (CT) to evaluate target movements and another CT with gating and breath-hold technique. Delineation was performed on both CT using the initial fluorodeoxyglucose positron-emission tomography/CT. One dosimetric plan with rotational intensity-modulated radiation therapy with a helical Tomotherapy© was realized and compared to another one with conformational protontherapy. Ninety-five percent of the planning target volume was covered by 98 and 99% of the prescribed dose with protontherapy and helical Tomotherapy©. Protontherapy provided the best organ at risk protection. Lung and heart protections were better with protontherapy: lung mean dose (3.7Gy vs. 8.4Gy) and median dose (0.002Gy vs. 6.9Gy), heart mean dose (2.6Gy vs. 3.7Gy). Breast sparing was better for both breasts using protontherapy: right breast mean dose (2.4Gy vs. 4.4Gy) and left (1.9Gy vs. 4.6Gy). The biggest difference was seen with low doses, which were better with protontherapy: volume of lung receiving 5Gy was 17.5% vs. 54.2% with Helical Tomotherapy©. In view of these results, we decided to treat our patient with protontherapy using respiratory assessment. We delivered 30Gy (15 fractions) using protontherapy with one direct anterior field using pencil beam scanning and deep inspiration breath-hold technique. We observed only grade 1 skin erythema during treatment and no toxicity during early follow-up.
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Affiliation(s)
- L M Abbassi
- Department of radiation oncology, institut Curie Paris-Orsay, 26, rue d'Ulm, 75005 Paris, France.
| | - F Goudjil
- Department of radiation oncology, institut Curie Paris-Orsay, 26, rue d'Ulm, 75005 Paris, France
| | - A Arsène-Henry
- Department of radiation oncology, institut Curie Paris-Orsay, 26, rue d'Ulm, 75005 Paris, France
| | - R Dendale
- Department of radiation oncology, institut Curie Paris-Orsay, 26, rue d'Ulm, 75005 Paris, France
| | - Y M Kirova
- Department of radiation oncology, institut Curie Paris-Orsay, 26, rue d'Ulm, 75005 Paris, France
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17
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Edvardsson A, Kügele M, Alkner S, Enmark M, Nilsson J, Kristensen I, Kjellén E, Engelholm S, Ceberg S. Comparative treatment planning study for mediastinal Hodgkin's lymphoma: impact on normal tissue dose using deep inspiration breath hold proton and photon therapy. Acta Oncol 2019; 58:95-104. [PMID: 30280626 DOI: 10.1080/0284186x.2018.1512153] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Late effects induced by radiotherapy (RT) are of great concern for mediastinal Hodgkin's lymphoma (HL) patients and it is therefore important to reduce normal tissue dose. The aim of this study was to investigate the impact on the normal tissue dose and target coverage, using various combinations of intensity modulated proton therapy (IMPT), volumetric modulated arc therapy (VMAT) and 3-dimensional conformal RT (3D-CRT), planned in both deep inspiration breath hold (DIBH) and free breathing (FB). MATERIAL AND METHODS Eighteen patients were enrolled in this study and planned with involved site RT. Two computed tomography images were acquired for each patient, one during DIBH and one during FB. Six treatment plans were created for each patient; 3D-CRT in FB, 3D-CRT in DIBH, VMAT in FB, VMAT in DIBH, IMPT in FB and IMPT in DIBH. Dosimetric impact on the heart, left anterior descending (LAD) coronary artery, lungs, female breasts, target coverage, and also conformity index and integral dose (ID), was compared between the different treatment techniques. RESULTS The use of DIBH significantly reduced the lung dose for all three treatment techniques, however, no significant difference in the dose to the female breasts was observed. Regarding the heart and LAD doses, large individual variations were observed. For VMAT, the mean heart and LAD doses were significantly reduced using DIBH, but no significant difference was observed for 3D-CRT and IMPT. Both IMPT and VMAT resulted in improved target coverage and more conform dose distributions compared to 3D-CRT. IMPT generally showed the lowest organs at risk (OAR) doses and significantly reduced the ID compared to both 3D-CRT and VMAT. CONCLUSIONS The majority of patients benefited from treatment in DIBH, however, the impact on the normal tissue dose was highly individual and therefore comparative treatment planning is encouraged. The lowest OAR doses were generally observed for IMPT in combination with DIBH.
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Affiliation(s)
- Anneli Edvardsson
- Department of Medical Radiation Physics, Clinical Sciences, Lund University, Lund, Sweden
| | - Malin Kügele
- Department of Medical Radiation Physics, Clinical Sciences, Lund University, Lund, Sweden
- Department of Hematology, Oncology and Radiation Physics, Skane University Hospital, Lund, Sweden
| | - Sara Alkner
- Department of Hematology, Oncology and Radiation Physics, Skane University Hospital, Lund, Sweden
| | - Marika Enmark
- Department of Hematology, Oncology and Radiation Physics, Skane University Hospital, Lund, Sweden
| | - Joakim Nilsson
- Department of Hematology, Oncology and Radiation Physics, Skane University Hospital, Lund, Sweden
| | - Ingrid Kristensen
- Department of Hematology, Oncology and Radiation Physics, Skane University Hospital, Lund, Sweden
| | - Elisabeth Kjellén
- Department of Hematology, Oncology and Radiation Physics, Skane University Hospital, Lund, Sweden
| | - Silke Engelholm
- Department of Hematology, Oncology and Radiation Physics, Skane University Hospital, Lund, Sweden
| | - Sofie Ceberg
- Department of Medical Radiation Physics, Clinical Sciences, Lund University, Lund, Sweden
- Department of Hematology, Oncology and Radiation Physics, Skane University Hospital, Lund, Sweden
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18
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Dabaja BS, Hoppe BS, Plastaras JP, Newhauser W, Rosolova K, Flampouri S, Mohan R, Mikhaeel NG, Kirova Y, Specht L, Yahalom J. Proton therapy for adults with mediastinal lymphomas: the International Lymphoma Radiation Oncology Group guidelines. Blood 2018; 132:1635-1646. [PMID: 30108066 PMCID: PMC6212652 DOI: 10.1182/blood-2018-03-837633] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 07/19/2018] [Indexed: 12/25/2022] Open
Abstract
Among adult lymphoma survivors, radiation treatment techniques that increase the excess radiation dose to organs at risk (OARs) put patients at risk for increased side effects, especially late toxicities. Minimizing radiation to OARs in adults patients with Hodgkin and non-Hodgkin lymphomas involving the mediastinum is the deciding factor for the choice of treatment modality. Proton therapy may help to reduce the radiation dose to the OARs and reduce toxicities, especially the risks for cardiac morbidity and second cancers. Because proton therapy may have some disadvantages, identifying the patients and the circumstances that may benefit the most from proton therapy is important. We present modern guidelines to identify adult lymphoma patients who may derive the greatest benefit from proton therapy, along with an analysis of the advantages and disadvantages of proton treatment.
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Affiliation(s)
- Bouthaina Shbib Dabaja
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Bradford S Hoppe
- Department of Radiation Oncology, University of Florida, Jacksonville, FL
| | - John P Plastaras
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Wayne Newhauser
- Department of Radiation Physics, University of Louisiana, Baton Rouge, LA
| | - Katerina Rosolova
- Proton Therapy Department, Proton Therapy Center Czech, Prague, Czech Republic
- Department of Oncology, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Stella Flampouri
- Department of Radiation Oncology, University of Florida, Jacksonville, FL
| | - Radhe Mohan
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - N George Mikhaeel
- Department of Radiation Oncology, Guy's and St. Thomas' Hospital, London, United Kingdom
| | - Youlia Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Lena Specht
- Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; and
| | - Joachim Yahalom
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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20
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Boros A, Ribrag V, Deutsch É, Chargari C, Izar F. [Radiation therapy planning for Hodgkin lymphoma: Focus on intensity-modulated radiotherapy, gating, protons. Which techniques to best deliver radiation?]. Cancer Radiother 2018; 22:404-410. [PMID: 30076071 DOI: 10.1016/j.canrad.2018.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 06/21/2018] [Indexed: 11/28/2022]
Abstract
The optimization of radiotherapy in these young and long-lived survivors raises the question about the interest of using modern techniques to allow a better distribution of the dose. The choice of the irradiation technique must take into account the incidence of side effects related to radiation. In this context, the definition of the target volumes as well as the verification and monitoring of the delivered processing are essential. International recommendations for treatment fields are based on the "involved node radiotherapy" concept. The best irradiation technique to use remains to be defined. The use of intensity-modulated radiotherapy improves the coverage and reduces the dose to the organs at risk with a variable gain depending on the topography of the lymph nodes: upper or lower mediastinum, right or left lateralization, the techniques used. The deep inspiration breath-hold technique allows an increase of the pulmonary volume, extension of the mediastinum with an up down of the heart which make possible to move the planning target volume away from the cardiac structures. The volumetric-modulated arctherapy technique with several arches can be particularly interesting to reduce the dose to the breasts, as well as tomotherapy when bulky disease. Proton therapy with the Bragg peak specificity can play a key role in limiting doses to organs at risk, when robust planning that will take into account geometric and physical uncertainties is available. The heterogeneity of Hodgkin lymphomas in terms of volume, shape and initial location are the key elements to take into account when choosing the preferred radiotherapy technique.
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Affiliation(s)
- A Boros
- Département de radiothérapie, Cancer campus Grand-Paris, Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France; Université Paris Sud, université Paris Saclay, 94270 Le Kremlin-Bicêtre, France.
| | - V Ribrag
- Département d'hématologie, Cancer campus Grand-Paris, Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France; Département des innovations thérapeutiques et essais précoces, Cancer campus Grand-Paris, Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - É Deutsch
- Département de radiothérapie, Cancer campus Grand-Paris, Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France; Université Paris Sud, université Paris Saclay, 94270 Le Kremlin-Bicêtre, France; U1030, Inserm, molecular radiotherapy, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - C Chargari
- Département de radiothérapie, Cancer campus Grand-Paris, Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France; Université Paris Sud, université Paris Saclay, 94270 Le Kremlin-Bicêtre, France; D19, institut de recherche biomédicale des armées, 91220 Brétigny-sur-Orge, France; Service de santé des armées, école du Val-de-Grâce, 74, boulevard de Port-Royal, 75005 Paris, France
| | - F Izar
- Département de radiothérapie, Institut universitaire du cancer de Toulouse, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex 9, France
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21
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Baues C, Marnitz S, Engert A, Baus W, Jablonska K, Fogliata A, Vásquez-Torres A, Scorsetti M, Cozzi L. Proton versus photon deep inspiration breath hold technique in patients with hodgkin lymphoma and mediastinal radiation : A PLANNING COMPARISON OF DEEP INSPIRATION BREATH HOLD INTENSITY MODULATION RADIOTHERAPY AND INTENSITY MODULATED PROTON THERAPY. Radiat Oncol 2018; 13:122. [PMID: 29970105 PMCID: PMC6029162 DOI: 10.1186/s13014-018-1066-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 06/15/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The benefits of proton therapy in the treatment of patients with Hodgkin lymphoma (HL) are controversially discussed. Therefore we compared intensitiy modulated proton therapy (IMPT) with intensity modulated radiotherapy (IMRT), in the form of volumetric modulated arc therapy (VMAT) in patients with Hodgkin lymphoma (HL), through a comparative treatment planning study. METHODS Radiation plans for 21 patients with Hodgkin Lymphoma (HL) were computed for IMPT and deep inspiration breath hold (DIBH) VMAT. Plans were optimized and computed assuming deep inspiration breath holding conditions. Dosimetric comparison on standard metrics from dose volume histograms was performed to appraise the relative merits of the two techniques, while proton plan robustness was assessed by re-computing the dose distribution of each plan by varying the Hounsfield Units to stopping power calibration by applying a ± 3 and 4% error. RESULTS DIBH-VMAT and IMPT both provided excellent coverage, conformity and heterogeneity of the clinical target volume (CTV) and planning target volume (PTV). IMPT reduced mean doses to the breasts, lungs, heart and normal tissue by 38-83%. IMPT significantly reduced mean doses to the heart to < 5 Gy despite bulky mediastinal disease and decreased breast doses in female patients to < 1 Gy. Despite the simulated 3 and 4% miscalibration errors, no remarkable or measurable impact was observed on the organs at risk (OARs). CONCLUSIONS This is the first comparison between DIBH-VMAT and IMPT in HL treatment. We could demonstrate statistically significant decreases in all dose/volume metrics of the OARs. Regardless of the planning paradigm used, range uncertainties can substantially under dose the PTV, while perhaps not leading to clinically significant deterioration of CTV coverage. With the geometry applied no impact was observed for OARs, suggesting IMPT as a superior technique for potentially reducing future health risks for HL patients.
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Affiliation(s)
- Christian Baues
- Medical Faculty, Department of Radiation Oncology, CyberKnife Center and Radiation Reference Center of the GHSG, University of Cologne, Kerpener Str. 52, 50937 Köln, Cologne, Germany
| | - Simone Marnitz
- Medical Faculty, Department of Radiation Oncology, CyberKnife Center and Radiation Reference Center of the GHSG, University of Cologne, Kerpener Str. 52, 50937 Köln, Cologne, Germany
| | - Andreas Engert
- Medical Faculty, Department of Hematology and Oncology, University of Cologne, Cologne, Germany
- German Hodgkin Study Group, Cologne, Germany
| | - Wolfgang Baus
- Medical Faculty, Department of Radiation Oncology, CyberKnife Center and Radiation Reference Center of the GHSG, University of Cologne, Kerpener Str. 52, 50937 Köln, Cologne, Germany
| | - Karolina Jablonska
- Medical Faculty, Department of Radiation Oncology, CyberKnife Center and Radiation Reference Center of the GHSG, University of Cologne, Kerpener Str. 52, 50937 Köln, Cologne, Germany
| | - Antonella Fogliata
- Radiotherapy and Radiosurgery, Humanitas Cancer Center and Research Hospital, Milan, Italy
| | - Andrés Vásquez-Torres
- Medical Faculty, Department of Radiation Oncology, CyberKnife Center and Radiation Reference Center of the GHSG, University of Cologne, Kerpener Str. 52, 50937 Köln, Cologne, Germany
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery, Humanitas Cancer Center and Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Luca Cozzi
- Radiotherapy and Radiosurgery, Humanitas Cancer Center and Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
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Tseng YD, Cutter DJ, Plastaras JP, Parikh RR, Cahlon O, Chuong MD, Dedeckova K, Khan MK, Lin SY, McGee LA, Shen EYL, Terezakis SA, Badiyan SN, Kirova YM, Hoppe RT, Mendenhall NP, Pankuch M, Flampouri S, Ricardi U, Hoppe BS. Evidence-based Review on the Use of Proton Therapy in Lymphoma From the Particle Therapy Cooperative Group (PTCOG) Lymphoma Subcommittee. Int J Radiat Oncol Biol Phys 2017; 99:825-842. [PMID: 28943076 DOI: 10.1016/j.ijrobp.2017.05.004] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 04/24/2017] [Accepted: 05/02/2017] [Indexed: 12/25/2022]
Affiliation(s)
- Yolanda D Tseng
- Department of Radiation Oncology, University of Washington, Seattle Cancer Care Alliance Proton Therapy Center, Seattle, Washington
| | - David J Cutter
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - John P Plastaras
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rahul R Parikh
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael D Chuong
- Miami Cancer Institute at Baptist Health South Florida, Miami, Florida
| | - Katerina Dedeckova
- Proton Therapy Department, Proton Therapy Center, Prague, Czech Republic
| | - Mohammad K Khan
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Shinn-Yn Lin
- Department of Radiation Oncology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan City, Taiwan
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Eric Yi-Liang Shen
- Department of Radiation Oncology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan City, Taiwan
| | - Stephanie A Terezakis
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shahed N Badiyan
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Youlia M Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Richard T Hoppe
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Nancy P Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida; University of Florida Health Proton Therapy Institute, Jacksonville, Florida
| | - Mark Pankuch
- Northwestern Medicine Chicago Proton Center, Warrenville, Illinois
| | - Stella Flampouri
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida; University of Florida Health Proton Therapy Institute, Jacksonville, Florida
| | | | - Bradford S Hoppe
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida; University of Florida Health Proton Therapy Institute, Jacksonville, Florida.
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23
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Rechner LA, Maraldo MV, Vogelius IR, Zhu XR, Dabaja BS, Brodin NP, Petersen PM, Specht L, Aznar MC. Life years lost attributable to late effects after radiotherapy for early stage Hodgkin lymphoma: The impact of proton therapy and/or deep inspiration breath hold. Radiother Oncol 2017; 125:41-47. [PMID: 28838605 PMCID: PMC5844950 DOI: 10.1016/j.radonc.2017.07.033] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 07/27/2017] [Accepted: 07/27/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND PURPOSE Due to the long life expectancy after treatment, the risk of late effects after radiotherapy (RT) is of particular importance for patients with Hodgkin lymphoma (HL). Both deep inspiration breath hold (DIBH) and proton therapy have been shown to reduce the dose to normal tissues for mediastinal HL, but the impact of these techniques in combination is unknown. The purpose of this study was to compare the life years lost (LYL) attributable to late effects after RT for mediastinal HL using intensity modulated radiation therapy (IMRT) in free breathing (FB) and DIBH, and proton therapy in FB and DIBH. MATERIALS AND METHODS Plans for each technique were created for 22 patients with HL. Doses were extracted and the risk of late effects and LYL were estimated. RESULTS We found that the use of DIBH, proton therapy, and the combination significantly reduced the LYL compared to IMRT in FB. The lowest LYL was found for proton therapy in DIBH. However, when IMRT in DIBH was compared to proton therapy in FB, no significant difference was found. CONCLUSIONS Patient-specific plan comparisons should be used to select the optimal technique when comparing IMRT in DIBH and proton therapy in FB.
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Affiliation(s)
- Laura Ann Rechner
- Department of Oncology, Rigshospitalet, University of Copenhagen, Denmark; Niels Bohr Insitute, University of Copenhagen, Denmark.
| | | | | | - Xiaorong Ronald Zhu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Bouthaina Shbib Dabaja
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Nils Patrik Brodin
- Institute for Onco-Physics, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, USA
| | | | - Lena Specht
- Department of Oncology, Rigshospitalet, University of Copenhagen, Denmark
| | - Marianne Camille Aznar
- Niels Bohr Insitute, University of Copenhagen, Denmark; Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
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Filippi AR, Levis M, Parikh R, Hoppe B. Optimal Therapy for Early-Stage Hodgkin's Lymphoma: Risk Adapting, Response Adapting, and Role of Radiotherapy. Curr Oncol Rep 2017; 19:34. [PMID: 28365830 DOI: 10.1007/s11912-017-0592-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE OF REVIEW The aim of this article is to discuss the current role of radiotherapy (RT) for early-stage Hodgkin's lymphoma (HL) in the context of risk-adapted and response-adapted treatment strategy, and describe changes in RT technical approach. RECENT FINDINGS In low-risk patients, RT could be omitted but, at the price of a lower progression-free survival, and its role is still debated. Ongoing trials are combining new agents with chemotherapy alone or response-adapted combined modality therapy, and results are awaited. Modern RT incorporates lower doses and smaller fields, together with the implementation of sophisticated delivery techniques aimed to reducing the dose to critical structures such as the heart. The role of RT for early-stage HL is still under debate, and new combinations are emerging; an individualized approach should be recommended, considering all RT technical opportunities to minimize toxicity while maintaining efficacy.
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Affiliation(s)
- Andrea Riccardo Filippi
- Department of Oncology, San Luigi Gonzaga University Hospital, University of Torino, Regione Gonzole 10, 10043, Orbassano, Turin, Italy.
| | - Mario Levis
- Department of Oncology, San Luigi Gonzaga University Hospital, University of Torino, Regione Gonzole 10, 10043, Orbassano, Turin, Italy
| | - Rahul Parikh
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, USA
| | - Bradford Hoppe
- Department of Radiation Oncology, University of Florida, Gainesville, USA.,University of Florida Health Proton Therapy Institute, Jacksonville, USA
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25
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Breast Cancer in Lymphoma Survivors. Breast Cancer 2017. [DOI: 10.1007/978-3-319-48848-6_30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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26
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Kriz J, Baues C, Engenhart-Cabillic R, Haverkamp U, Herfarth K, Lukas P, Schmidberger H, Marnitz-Schulze S, Fuchs M, Engert A, Eich HT. New quality assurance program integrating "modern radiotherapy" within the German Hodgkin Study Group. Strahlenther Onkol 2016; 193:100-108. [PMID: 27678010 DOI: 10.1007/s00066-016-1048-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 08/29/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Field design changed substantially from extended-field RT (EF-RT) to involved-field RT (IF-RT) and now to involved-node RT (IN-RT) and involved-site RT (IS-RT) as well as treatment techniques in radiotherapy (RT) of Hodgkin's lymphoma (HL). The purpose of this article is to demonstrate the establishment of a quality assurance program (QAP) including modern RT techniques and field designs within the German Hodgkin Study Group (GHSG). METHODS In the era of modern conformal RT, this QAP had to be fundamentally adapted and a new evaluation process has been intensively discussed by the radiotherapeutic expert panel of the GHSG. RESULTS The expert panel developed guidelines and criteria to analyse "modern" field designs and treatment techniques. This work is based on a dataset of 11 patients treated within the sixth study generation (HD16-17). CONCLUSION To develop a QAP of "modern RT", the expert panel defined criteria for analysing current RT procedures. The consensus of a modified QAP in ongoing and future trials is presented. With this schedule, the QAP of the GHSG could serve as a model for other study groups.
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Affiliation(s)
- J Kriz
- Department of Radiation Oncology, University of Muenster, Albert-Schweitzer Campus 1, Gebäude 1 A, 48419, Muenster, Germany
| | - C Baues
- Department of Radiation Oncology, University of Cologne, Köln, Deutschland
| | | | - U Haverkamp
- Department of Radiation Oncology, University of Muenster, Albert-Schweitzer Campus 1, Gebäude 1 A, 48419, Muenster, Germany
| | - K Herfarth
- Department of Radiation Oncology, University of Heidelberg, Heidelberg, Deutschland
| | - P Lukas
- Department of Radiation Oncology, University of Innsbruck, Innsbruck, Deutschland
| | - H Schmidberger
- Department of Radiation Oncology, University of Mainz, Mainz, Deutschland
| | - S Marnitz-Schulze
- Department of Radiation Oncology, University of Cologne, Köln, Deutschland
| | - M Fuchs
- Department of Internal Medicine, University of Cologne, Köln, Deutschland
| | - A Engert
- Department of Internal Medicine, University of Cologne, Köln, Deutschland
| | - H T Eich
- Department of Radiation Oncology, University of Muenster, Albert-Schweitzer Campus 1, Gebäude 1 A, 48419, Muenster, Germany.
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27
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Delivery of radiation therapy of large target volumes in Hodgkin's disease using IMRT technique: A dosimetric case study. Radiography (Lond) 2016. [DOI: 10.1016/j.radi.2016.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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28
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Horn S, Fournier-Bidoz N, Pernin V, Peurien D, Vaillant M, Dendale R, Fourquet A, Kirova YM. Comparison of passive-beam proton therapy, helical tomotherapy and 3D conformal radiation therapy in Hodgkin's lymphoma female patients receiving involved-field or involved site radiation therapy. Cancer Radiother 2016; 20:98-103. [PMID: 26992750 DOI: 10.1016/j.canrad.2015.11.002] [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: 07/31/2015] [Revised: 09/23/2015] [Accepted: 11/09/2015] [Indexed: 01/10/2023]
Abstract
PURPOSE Second cancers and cardiovascular toxicities are long term radiation toxicity in locally advanced Hodgkin's lymphomas. In this study, we evaluate the potential reduction of dose to normal tissue with helical tomotherapy and proton therapy for Hodgkin's lymphoma involved-field or involved-site irradiation compared to standard 3D conformal radiation therapy. PATIENTS AND METHODS Fourteen female patients with supradiaphragmatic Hodgkin's lymphoma were treated at our institution with 3D conformal radiation therapy or helical tomotherapy to a dose of 30Gy in 15 fractions. A planning comparison was achieved including proton therapy with anterior/posterior passive scattered beams weighted 20Gy/10Gy. RESULTS Mean doses to breasts, lung tissue and heart with proton therapy were significantly lower compared to helical tomotherapy and to 3D conformal radiation therapy. Helical tomotherapy assured the best protection of lungs from doses above 15Gy with the V20Gy equal to 16.4%, compared to 19.7% for proton therapy (P=0.01) or 22.4% with 3D conformal radiation therapy (P<0.01). Volumes of lung receiving doses below 15Gy were significantly larger for helical tomotherapy than for proton therapy or 3D conformal radiation therapy, with respective lung doses V10Gy=37.2%, 24.6% and 27.4%. Also, in the domain of low doses, the volumes of breast that received more than 10Gy or more than 4Gy with helical tomotherapy were double the corresponding volumes for proton therapy, with V4Gy representing more than a third of one breast volume with helical tomotherapy. CONCLUSIONS Helical tomotherapy achieved a better protection to the lungs for doses above 15Gy than passive proton therapy or 3D conformal radiation therapy. However, dose distributions could generally be improved by using protons even with our current passive-beam technology, especially allowing less low dose spreading and better breast tissue sparing, which is an important factor to consider when treating Hodgkin's lymphomas in female patients. Prospective clinical study is needed to evaluate the tolerance and confirm these findings.
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Affiliation(s)
- S Horn
- Department of Radiation Oncology, institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - N Fournier-Bidoz
- Department of Radiation Oncology, institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - V Pernin
- Department of Radiation Oncology, institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - D Peurien
- Department of Radiation Oncology, institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - M Vaillant
- Department of Radiation Oncology, institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - R Dendale
- Department of Radiation Oncology, institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - A Fourquet
- Department of Radiation Oncology, institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - Y M Kirova
- Department of Radiation Oncology, institut Curie, 26, rue d'Ulm, 75005 Paris, France.
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Homann K, Howell R, Eley J. The need for individualized studies to compare radiogenic second cancer (RSC) risk in proton versus photon Hodgkin Lymphoma patient treatments. ACTA ACUST UNITED AC 2016. [DOI: 10.14319/jpt.11.8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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30
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Maraldo MV, Ng AK. Minimizing Cardiac Risks With Contemporary Radiation Therapy for Hodgkin Lymphoma. J Clin Oncol 2016; 34:208-10. [DOI: 10.1200/jco.2015.64.6588] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Andrea K. Ng
- Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
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31
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Kriz J, Spickermann M, Lehrich P, Schmidberger H, Reinartz G, Eich H, Haverkamp U. Breath-hold technique in conventional APPA or intensity-modulated radiotherapy for Hodgkin's lymphoma: Comparison of ILROG IS-RT and the GHSG IF-RT. Strahlenther Onkol 2015; 191:717-25. [PMID: 25876905 DOI: 10.1007/s00066-015-0839-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 03/25/2015] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The present study addresses the role of intensity-modulated radiotherapy (IMRT) in contrast to standard RT (APPA) for patients with Hodgkin's lymphoma (HL) with a focus on deep inspiration breath-hold (DIBH) technique and a comparison between the International Lymphoma Radiation Oncology Group (ILROG) Involved Site Radiotherapy (IS-RT) versus the German Hodgkin Study Group (GHSG) Involved Field Radiotherapy (IF-RT). METHODS APPA treatment and 2 IMRT plans were compared for 11 patients with HL. Furthermore, treatment with DIBH versus free breathing (FB) and two different treatment volumes, i.e. IF-RT versus IS-RT, were compared. IMRT was planned as a sliding-window technique with 5 and 7 beam angles. For each patient 12 different treatment plans were calculated (132 plans). Following organs at risk (OAR) were analysed: lung, heart, spinal cord, oesophagus, female breast and skin. Comparisons of the different values with regard to dose-volume histograms (DVH), conformity and homogeneity indices were made. RESULTS IS-RT reduces treatment volumes. With respect to the planning target volume (PTV), IMRT achieves better conformity but the same homogeneity. Regarding the D mean for the lung, IMRT shows increased doses, while RT in DIBH reduces doses. The IMRT shows improved values for Dmax concerning the spinal cord, whereas the APPA shows an improved D mean of the lung and the female breast. CONCLUSION IS-RT reduces treatment volumes. Intensity-modulated radiotherapy shows advantages in the conformity. Treatment in DIBH also reduces the dose applied to the lungs and the heart.
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Affiliation(s)
- Jan Kriz
- Department of Radiation Oncology, University of Muenster, Albert-Schweitzer Campus 1, Gebäude 1A, 48419, Muenster, Germany,
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Zeng C, Plastaras JP, Tochner ZA, White BM, Hill-Kayser CE, Hahn SM, Both S. Proton pencil beam scanning for mediastinal lymphoma: the impact of interplay between target motion and beam scanning. Phys Med Biol 2015; 60:3013-29. [DOI: 10.1088/0031-9155/60/7/3013] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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33
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Feng Z, Wu H, Zhang Y, Zhang Y, Cheng J, Su X. Dosimetric comparison between jaw tracking and static jaw techniques in intensity-modulated radiotherapy. Radiat Oncol 2015; 10:28. [PMID: 25623899 PMCID: PMC4326511 DOI: 10.1186/s13014-015-0329-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 01/07/2015] [Indexed: 12/25/2022] Open
Abstract
Purpose To compare the dosimetric differences between jaw tracking technique (JTT) and static jaw technique (SJT) in dynamic intensity-modulated radiotherapy (d-IMRT) and assess the potential advantages of jaw tracking technique. Methods Two techniques, jaw tracking and static jaw, were used respectively to develop the d-IMRT plans for 28 cancer patients with various lesion sites: head and neck, lungs, esophageal, abdominal, prostate, rectal and cervical. The dose volume histograms (DVH) and selected dosimetric indexes for the whole body and for organs at risk (OARs) were compared. A two dimensional ionization chamber Array Seven29 (PTW, Freiburg, Germany) and OCTAVIUS Octagonal phantom (PTW, Freiburg, Germany) were used to verify all the plans. Results For all patients, the treatment plans using both techniques met the clinical requirements. The V5, V10, V20, V30, V40 (volumes receiving 5, 10, 20, 30 and 40 Gy at least, respectively), mean dose (Dmean) for the whole body and V5, V10, V20, Dmean for lungs in the JTT d-IMRT plans were significantly less than the corresponding values of the SJT d-IMRT plans (p < 0.001). The JTT d-IMRT plans deposited lower maximum dose (Dmax) to the lens, eyes, brainstem, spinal cord, and right optic nerve, the doses reductions for these OARs ranged from 2.2% to 28.6%. The JTT d-IMRT plans deposited significantly lower Dmean to various OARs (all p values < 0.05), the mean doses reductions for these OARs ranged from 1.1% to 31.0%, and the value reductions depend on the volume and the location of the OARs. The γ evaluation method showed an excellent agreement between calculation and measurement for all techniques with criteria of 3%/3 mm. Conclusions Both jaw tracking and static jaw d-IMRT plans can achieve comparable target dose coverage. JTT displays superior OARs sparing than SJT plans. These results are of clinical importance, especially for the patients with large and complex targets but close to some highly radio-sensitive organs to spare, and for patients with local recurrent or secondary primary malignant lesion within a previously irradiated area.
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Affiliation(s)
- Zhongsu Feng
- Chinese Center for Medical Response to Radiation Emergency, National Institute for Radiological Protection, Chinese Center for Disease Control and Prevention, 2 Xinkang Street, Deshengmenwai, Beijing, 100088, China.
| | - Hao Wu
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiotherapy, Peking University Cancer Hospital & Institute, 52 Fuchen Road, Haidian, Beijing, 100142, China.
| | - Yibao Zhang
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiotherapy, Peking University Cancer Hospital & Institute, 52 Fuchen Road, Haidian, Beijing, 100142, China.
| | - Yunjun Zhang
- School of Foundational Education, Peking University Health Science Center, 38 Xueyuan Road, Haidian, Beijing, 100191, China.
| | - Jinsheng Cheng
- Chinese Center for Medical Response to Radiation Emergency, National Institute for Radiological Protection, Chinese Center for Disease Control and Prevention, 2 Xinkang Street, Deshengmenwai, Beijing, 100088, China.
| | - Xu Su
- Chinese Center for Medical Response to Radiation Emergency, National Institute for Radiological Protection, Chinese Center for Disease Control and Prevention, 2 Xinkang Street, Deshengmenwai, Beijing, 100088, China.
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Maraldo MV, Specht L. A Decade of Comparative Dose Planning Studies for Early-Stage Hodgkin Lymphoma: What Can We Learn? Int J Radiat Oncol Biol Phys 2014; 90:1126-35. [DOI: 10.1016/j.ijrobp.2014.06.069] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 06/13/2014] [Accepted: 06/26/2014] [Indexed: 01/20/2023]
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35
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Sharma S, Moros EG, Boerma M, Sridharan V, Han EY, Clarkson R, Hauer-Jensen M, Corry PM. A novel technique for image-guided local heart irradiation in the rat. Technol Cancer Res Treat 2014; 13:593-603. [PMID: 24000983 PMCID: PMC3951712 DOI: 10.7785/tcrtexpress.2013.600256] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 01/28/2013] [Accepted: 01/30/2013] [Indexed: 11/06/2022] Open
Abstract
In radiotherapy treatment of thoracic, breast and chest wall tumors, the heart may be included (partially or fully) in the radiation field. As a result, patients may develop radiation-induced heart disease (RIHD) several years after exposure to radiation. There are few methods available to prevent or reverse RIHD and the biological mechanisms remain poorly understood. In order to further study the effects of radiation on the heart, we developed a model of local heart irradiation in rats using an image-guided small animal conformal radiation therapy device (SACRTD) developed at our institution. First, Monte Carlo based simulations were used to design an appropriate collimator. EBT-2 films were used to measure relative dosimetry, and the absolute dose rate at the isocenter was measured using the AAPM protocol TG-61. The hearts of adult male Sprague-Dawley rats were irradiated with a total dose of 21 Gy. For this purpose, rats were anesthetized with isoflurane and placed in a custom-made vertical rat holder. Each heart was irradiated with a 3-beam technique (one AP field and 2 lateral fields), with each beam delivering 7 Gy. For each field, the heart was visualized with a digital flat panel X-ray imager and placed at the isocenter of the 1.8 cm diameter beam. In biological analysis of radiation exposure, immunohistochemistry showed γH2Ax foci and nitrotyrosine throughout the irradiated hearts but not in the lungs. Long-term follow-up of animals revealed histopathological manifestations of RIHD, including myocardial degeneration and fibrosis. The results demonstrate that the rat heart irradiation technique using the SACRTD was successful and that surrounding untargeted tissues were spared, making this approach a powerful tool for in vivo radiobiological studies of RIHD. Functional and structural changes in the rat heart after local irradiation are ongoing.
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Affiliation(s)
- Sunil Sharma
- Department of Radiation Oncology, Radiation Oncology Center, University of Arkansas for Medical _Sciences, Little Rock, AR .
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Plastaras JP, Berman AT, Freedman GM. Special Cases for Proton Beam Radiotherapy: Re-irradiation, Lymphoma, and Breast Cancer. Semin Oncol 2014; 41:807-19. [DOI: 10.1053/j.seminoncol.2014.10.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Lohr F, Georg D, Cozzi L, Eich HT, Weber DC, Koeck J, Knäusl B, Dieckmann K, Abo-Madyan Y, Fiandra C, Mueller RP, Engert A, Ricardi U. Novel radiotherapy techniques for involved-field and involved-node treatment of mediastinal Hodgkin lymphoma: when should they be considered and which questions remain open? Strahlenther Onkol 2014; 190:864-6, 868-71. [PMID: 25209551 DOI: 10.1007/s00066-014-0719-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 07/01/2014] [Indexed: 01/10/2023]
Abstract
PURPOSE Hodgkin lymphoma (HL) is a highly curable disease. Reducing late complications and second malignancies has become increasingly important. Radiotherapy target paradigms are currently changing and radiotherapy techniques are evolving rapidly. DESIGN This overview reports to what extent target volume reduction in involved-node (IN) and advanced radiotherapy techniques, such as intensity-modulated radiotherapy (IMRT) and proton therapy-compared with involved-field (IF) and 3D radiotherapy (3D-RT)- can reduce high doses to organs at risk (OAR) and examines the issues that still remain open. RESULTS Although no comparison of all available techniques on identical patient datasets exists, clear patterns emerge. Advanced dose-calculation algorithms (e.g., convolution-superposition/Monte Carlo) should be used in mediastinal HL. INRT consistently reduces treated volumes when compared with IFRT with the exact amount depending on the INRT definition. The number of patients that might significantly benefit from highly conformal techniques such as IMRT over 3D-RT regarding high-dose exposure to organs at risk (OAR) is smaller with INRT. The impact of larger volumes treated with low doses in advanced techniques is unclear. The type of IMRT used (static/rotational) is of minor importance. All advanced photon techniques result in similar potential benefits and disadvantages, therefore only the degree-of-modulation should be chosen based on individual treatment goals. Treatment in deep inspiration breath hold is being evaluated. Protons theoretically provide both excellent high-dose conformality and reduced integral dose. CONCLUSION Further reduction of treated volumes most effectively reduces OAR dose, most likely without disadvantages if the excellent control rates achieved currently are maintained. For both IFRT and INRT, the benefits of advanced radiotherapy techniques depend on the individual patient/target geometry. Their use should therefore be decided case by case with comparative treatment planning.
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Affiliation(s)
- Frank Lohr
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany,
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Holtzman AL, Hoppe BS, Li Z, Su Z, Slayton WB, Ozdemir S, Joyce M, Sandler E, Mendenhall NP, Flampouri S. Advancing the Therapeutic Index in Stage III/IV Pediatric Hodgkin Lymphoma with Proton Therapy. Int J Part Ther 2014. [DOI: 10.14338/ijpt.14.00001.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Hoppe BS, Flampouri S, Zaiden R, Slayton W, Sandler E, Ozdemir S, Dang NH, Lynch JW, Li Z, Morris CG, Mendenhall NP. Involved-node proton therapy in combined modality therapy for Hodgkin lymphoma: results of a phase 2 study. Int J Radiat Oncol Biol Phys 2014; 89:1053-1059. [PMID: 24928256 DOI: 10.1016/j.ijrobp.2014.04.029] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 04/04/2014] [Accepted: 04/16/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE This study describes the early clinical outcomes of a prospective phase 2 study of consolidative involved-node proton therapy (INPT) as a component of combined-mode therapy in patients with stages I to III Hodgkin lymphoma (HL) with mediastinal involvement. METHODS AND MATERIALS Between September 2009 and June 2013, 15 patients with newly diagnosed HL received INPT after completing chemotherapy in an institutional review board-approved protocol comparing the dosimetric impact of PT with those of three-dimensional conformal radiation therapy (3DCRT) and intensity modulated RT. Based on (18)F-Fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) response, 5 children received 15 to 25.5 cobalt Gy equivalent (CGE) of INPT after receiving 4 cycles of Adriamycin, Bleomycin, Vincristine, Etoposide, Prednisone, Cyclophosphamide or Vincristine, adriamycin, methotrexate, Prednisone chemotherapy, and 10 adults received 30.6 to 39.6 CGE of INPT after 3 to 6 cycles of Adriamycin, Bleomycine, Vinblastine, Dacarbazine. Patients were routinely evaluated for toxicity during and after treatment, using Common Terminology Criteria for Adverse Events, version 3.0, and for relapse by physical examination and routine imaging. Relapse-free survival (RFS) and event-free survival (EFS) rates were calculated using the Kaplan-Meier method from the time of diagnosis. RESULTS The median follow-up was 37 months (range, 26-55). Two events occurred during follow-up: 1 relapse (inside and outside the targeted field) and 1 transformation into a primary mediastinal large B cell lymphoma. The 3-year RFS rate was 93%, and the 3-year EFS rate was 87%. No acute or late grade 3 nonhematologic toxicities were observed. CONCLUSIONS Although decades of follow-up will be needed to realize the likely benefit of PT in reducing the risk of radiation-induced late effects, PT following chemotherapy in patients with HL is well-tolerated, and disease outcomes were similar to those of conventional photon therapy.
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Affiliation(s)
- Bradford S Hoppe
- Radiation Oncology, University of Florida Proton Therapy Institute, Jacksonville, Florida.
| | - Stella Flampouri
- Radiation Oncology, University of Florida Proton Therapy Institute, Jacksonville, Florida
| | - Robert Zaiden
- Department of Medicine, Division of Hematology and Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - William Slayton
- Department of Pediatrics, Division of Hematology and Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Eric Sandler
- Department of Pediatrics, Division of Hematology/Oncology Nemours Children's Clinic, Jacksonville, Florida
| | - Savas Ozdemir
- Department of Radiology, Division of Functional and Molecular Imaging, University of Florida College of Medicine, Jacksonville, Florida
| | - Nam H Dang
- Department of Medicine, Division of Hematology and Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - James W Lynch
- Department of Medicine, Division of Hematology and Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Zuofeng Li
- Radiation Oncology, University of Florida Proton Therapy Institute, Jacksonville, Florida
| | - Christopher G Morris
- Radiation Oncology, University of Florida Proton Therapy Institute, Jacksonville, Florida
| | - Nancy P Mendenhall
- Radiation Oncology, University of Florida Proton Therapy Institute, Jacksonville, Florida
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Hirst AM, Frame FM, Maitland NJ, O'Connell D. Low temperature plasma: a novel focal therapy for localized prostate cancer? BIOMED RESEARCH INTERNATIONAL 2014; 2014:878319. [PMID: 24738076 PMCID: PMC3971493 DOI: 10.1155/2014/878319] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 02/06/2014] [Indexed: 12/16/2022]
Abstract
Despite considerable advances in recent years for the focal treatment of localized prostate cancer, high recurrence rates and detrimental side effects are still a cause for concern. In this review, we compare current focal therapies to a potentially novel approach for the treatment of early onset prostate cancer: low temperature plasma. The rapidly evolving plasma technology has the potential to deliver a wide range of promising medical applications via the delivery of plasma-induced reactive oxygen and nitrogen species. Studies assessing the effect of low temperature plasma on cell lines and xenografts have demonstrated DNA damage leading to apoptosis and reduction in cell viability. However, there have been no studies on prostate cancer, which is an obvious candidate for this novel therapy. We present here the potential of low temperature plasma as a focal therapy for prostate cancer.
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Affiliation(s)
- Adam M Hirst
- Department of Physics, York Plasma Institute, University of York, Heslington, York YO10 5DD, UK
| | - Fiona M Frame
- YCR Cancer Research Unit, Department of Biology, University of York, Heslington, York YO10 5DD, UK
| | - Norman J Maitland
- YCR Cancer Research Unit, Department of Biology, University of York, Heslington, York YO10 5DD, UK
| | - Deborah O'Connell
- Department of Physics, York Plasma Institute, University of York, Heslington, York YO10 5DD, UK
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Maraldo M, Brodin N, Aznar M, Vogelius I, Munck af Rosenschöld P, Petersen P, Specht L. Doses to head and neck normal tissues for early stage Hodgkin lymphoma after involved node radiotherapy. Radiother Oncol 2014; 110:441-7. [DOI: 10.1016/j.radonc.2013.09.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 08/28/2013] [Accepted: 09/01/2013] [Indexed: 10/26/2022]
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Sridharan V, Tripathi P, Sharma S, Moros EG, Zheng J, Hauer-Jensen M, Boerma M. Roles of sensory nerves in the regulation of radiation-induced structural and functional changes in the heart. Int J Radiat Oncol Biol Phys 2014; 88:167-74. [PMID: 24331664 PMCID: PMC3868013 DOI: 10.1016/j.ijrobp.2013.10.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 09/13/2013] [Accepted: 10/07/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE Radiation-induced heart disease (RIHD) is a chronic severe side effect of radiation therapy of intrathoracic and chest wall tumors. The heart contains a dense network of sensory neurons that not only are involved in monitoring of cardiac events such as ischemia and reperfusion but also play a role in cardiac tissue homeostasis, preconditioning, and repair. The purpose of this study was to examine the role of sensory nerves in RIHD. METHODS AND MATERIALS Male Sprague-Dawley rats were administered capsaicin to permanently ablate sensory nerves, 2 weeks before local image-guided heart x-ray irradiation with a single dose of 21 Gy. During the 6 months of follow-up, heart function was assessed with high-resolution echocardiography. At 6 months after irradiation, cardiac structural and molecular changes were examined with histology, immunohistochemistry, and Western blot analysis. RESULTS Capsaicin pretreatment blunted the effects of radiation on myocardial fibrosis and mast cell infiltration and activity. By contrast, capsaicin pretreatment caused a small but significant reduction in cardiac output 6 months after irradiation. Capsaicin did not alter the effects of radiation on cardiac macrophage number or indicators of autophagy and apoptosis. CONCLUSIONS These results suggest that sensory nerves, although they play a predominantly protective role in radiation-induced cardiac function changes, may eventually enhance radiation-induced myocardial fibrosis and mast cell activity.
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MESH Headings
- Animals
- Capsaicin/pharmacology
- Cardiac Output/drug effects
- Cardiac Output/physiology
- Cardiac Output/radiation effects
- Denervation/methods
- Echocardiography/methods
- Fibrosis
- Heart/innervation
- Heart/physiopathology
- Heart/radiation effects
- Macrophages/drug effects
- Macrophages/radiation effects
- Male
- Mast Cells/drug effects
- Mast Cells/physiology
- Mast Cells/radiation effects
- Myocardium/pathology
- Neurons, Afferent/drug effects
- Neurons, Afferent/physiology
- Neurons, Afferent/radiation effects
- Nuclear Receptor Subfamily 4, Group A, Member 1/metabolism
- Nuclear Receptor Subfamily 4, Group A, Member 1/radiation effects
- Nuclear Receptor Subfamily 4, Group A, Member 2/metabolism
- Nuclear Receptor Subfamily 4, Group A, Member 2/radiation effects
- Organ Size/radiation effects
- Radiation Injuries, Experimental/physiopathology
- Rats
- Rats, Sprague-Dawley
- Sensory Receptor Cells/drug effects
- Sensory Receptor Cells/physiology
- Sensory Receptor Cells/radiation effects
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Affiliation(s)
- Vijayalakshmi Sridharan
- Department of Pharmaceutical Sciences, Division of Radiation Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Preeti Tripathi
- Department of Pharmaceutical Sciences, Division of Radiation Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Sunil Sharma
- Department of Radiation Oncology, Division of Radiation Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Eduardo G Moros
- Department of Radiation Oncology, Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Junying Zheng
- Department of Pharmaceutical Sciences, Division of Radiation Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Martin Hauer-Jensen
- Department of Pharmaceutical Sciences, Division of Radiation Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas; Surgical Service, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
| | - Marjan Boerma
- Department of Pharmaceutical Sciences, Division of Radiation Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
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Hay AE, Klimm B, Chen BE, Goergen H, Shepherd LE, Fuchs M, Gospodarowicz MK, Borchmann P, Connors JM, Markova J, Crump M, Lohri A, Winter JN, Dörken B, Pearcey RG, Diehl V, Horning SJ, Eich HT, Engert A, Meyer RM. An individual patient-data comparison of combined modality therapy and ABVD alone for patients with limited-stage Hodgkin lymphoma. Ann Oncol 2013; 24:3065-9. [PMID: 24121121 DOI: 10.1093/annonc/mdt389] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Treatment options for patients with nonbulky stage IA-IIA Hodgkin lymphoma include combined modality therapy (CMT) using doxorubicin, bleomycin, vinblastine and dacarbazine (ABVD) plus involved-field radiation therapy (IFRT), and chemotherapy with ABVD alone. There are no mature randomized data comparing ABVD with CMT using modern radiation techniques. PATIENTS AND METHODS Using German Hodgkin Study Group HD10/HD11 and NCIC Clinical Trials Group HD.6 databases, we identified 588 patients who met mutually inclusive eligibility criteria from the preferred arms of HD10 or 11 (n = 406) and HD.6 (n = 182). We evaluated time to progression (TTP), progression-free (PFS) and overall survival, including in three predefined exploratory subset analyses. RESULTS With median follow-up of 91 (HD10/11) and 134 (HD.6) months, respective 8-year outcomes were for TTP, 93% versus 87% [hazard ratio (HR) 0.44, 95% confidence interval (CI) 0.24-0.78]; for PFS, 89% versus 86% (HR 0.71, 95% CI 0.42-1.18) and for overall survival, 95% versus 95% (HR 1.09, 95% CI 0.49-2.40). In the exploratory subset analysis including HD10 eligible patients who achieved complete response (CR) or unconfirmed complete response (CRu) after two cycles of ABVD, 8-year PFS was 87% (HD10) versus 95% (HD.6) (HR 2.8; 95% CI 0.64-12.5) and overall survival 96% versus 100%. In contrast, among those without CR/CRu after two cycles of ABVD, 8-year PFS was 88% versus 74% (HR 0.35; 95% CI 0.16-0.79) and overall survival 95% versus 91%, respectively (HR 0.42; 95% CI 0.12-1.44). CONCLUSIONS In patients with nonbulky stage IA-IIA Hodgkin lymphoma, CMT provides better disease control than ABVD alone, especially among those not achieving complete response after two cycles of ABVD. Within the follow-up duration evaluated, overall survivals were similar. Longer follow-up is required to understand the implications of radiation and chemotherapy-related late effects. CLINICAL TRIALS The trials included in this analysis were registered at ClinicalTrials.gov: HD10 - NCT00265018, HD11 - NCT00264953, HD.6 - NCT00002561.
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Affiliation(s)
- A E Hay
- NCIC Clinical Trials Group and Queen's University, Kingston, Ontario, Canada
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Zhang R, Howell RM, Homann K, Giebeler A, Taddei PJ, Mahajan A, Newhauser WD. Predicted risks of radiogenic cardiac toxicity in two pediatric patients undergoing photon or proton radiotherapy. Radiat Oncol 2013; 8:184. [PMID: 23880421 PMCID: PMC3751146 DOI: 10.1186/1748-717x-8-184] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 07/21/2013] [Indexed: 01/12/2023] Open
Abstract
Background Hodgkin disease (HD) and medulloblastoma (MB) are common malignancies found in children and young adults, and radiotherapy is part of the standard treatment. It was reported that these patients who received radiation therapy have an increased risk of cardiovascular late effects. We compared the predicted risk of developing radiogenic cardiac toxicity after photon versus proton radiotherapies for a pediatric patient with HD and a pediatric patient with MB. Methods In the treatment plans, each patient’s heart was contoured in fine detail, including substructures of the pericardium and myocardium. Risk calculations took into account both therapeutic and stray radiation doses. We calculated the relative risk (RR) of cardiac toxicity using a linear risk model and the normal tissue complication probability (NTCP) values using relative seriality and Lyman models. Uncertainty analyses were also performed. Results The RR values of cardiac toxicity for the HD patient were 7.27 (proton) and 8.37 (photon), respectively; the RR values for the MB patient were 1.28 (proton) and 8.39 (photon), respectively. The predicted NTCP values for the HD patient were 2.17% (proton) and 2.67% (photon) for the myocardium, and were 2.11% (proton) and 1.92% (photon) for the whole heart. The predicted ratios of NTCP values (proton/photon) for the MB patient were much less than unity. Uncertainty analyses revealed that the predicted ratio of risk between proton and photon therapies was sensitive to uncertainties in the NTCP model parameters and the mean radiation weighting factor for neutrons, but was not sensitive to heart structure contours. The qualitative findings of the study were not sensitive to uncertainties in these factors. Conclusions We conclude that proton and photon radiotherapies confer similar predicted risks of cardiac toxicity for the HD patient in this study, and that proton therapy reduced the predicted risk for the MB patient in this study.
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Affiliation(s)
- Rui Zhang
- The University of Texas Graduate School of Biomedical Sciences at Houston, Houston, TX, USA.
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Sridharan V, Tripathi P, Sharma S, Corry PM, Moros EG, Singh A, Compadre CM, Hauer-Jensen M, Boerma M. Effects of late administration of pentoxifylline and tocotrienols in an image-guided rat model of localized heart irradiation. PLoS One 2013; 8:e68762. [PMID: 23894340 PMCID: PMC3718790 DOI: 10.1371/journal.pone.0068762] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 06/02/2013] [Indexed: 01/15/2023] Open
Abstract
Radiation-induced heart disease (RIHD) is a long-term side effect of radiotherapy of intrathoracic, chest wall and breast tumors when radiation fields encompass all or part of the heart. Previous studies have shown that pentoxifylline (PTX) in combination with α-tocopherol reduced manifestations of RIHD in rat models of local heart irradiation. The relative contribution of PTX and α-tocopherol to these beneficial effects are not known. This study examined the effects of PTX alone or in combination with tocotrienols, forms of vitamin E with potential potent radiation mitigation properties. Rats received localized X-irradiation of the heart with an image-guided irradiation technique. At 3 months after irradiation rats received oral treatment with vehicle, PTX, or PTX in combination with a tocotrienol-enriched formulation. At 6 months after irradiation, PTX-treated rats showed arrhythmia in 5 out of 14 animals. PTX alone or in combination with tocotrienols did not alter cardiac radiation fibrosis, left ventricular protein expression of the endothelial markers von Willebrand factor and neuregulin-1, or phosphorylation of the signal mediators Akt, Erk1/2, or PKCα. On the other hand, tocotrienols reduced cardiac numbers of mast cells and macrophages, but enhanced the expression of tissue factor. While this new rat model of localized heart irradiation does not support the use of PTX alone, the effects of tocotrienols on chronic manifestations of RIHD deserve further investigation.
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Affiliation(s)
- Vijayalakshmi Sridharan
- Division of Radiation Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States of America
| | - Preeti Tripathi
- Division of Radiation Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States of America
| | - Sunil Sharma
- Department of Radiation Oncology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States of America
| | - Peter M. Corry
- Department of Radiation Oncology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States of America
| | - Eduardo G. Moros
- Department of Radiation Oncology, Moffitt Cancer Center and Research Institute, Tampa, Florida, United States of America
| | - Awantika Singh
- Department of Pharmaceutical Sciences, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States of America
| | - Cesar M. Compadre
- Department of Pharmaceutical Sciences, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States of America
| | - Martin Hauer-Jensen
- Division of Radiation Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States of America
- Surgical Service, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas, United States of America
| | - Marjan Boerma
- Division of Radiation Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States of America
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Stewart FA, Seemann I, Hoving S, Russell NS. Understanding radiation-induced cardiovascular damage and strategies for intervention. Clin Oncol (R Coll Radiol) 2013; 25:617-24. [PMID: 23876528 DOI: 10.1016/j.clon.2013.06.012] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Revised: 04/26/2013] [Accepted: 06/30/2013] [Indexed: 12/22/2022]
Abstract
There is a clear association between therapeutic doses of thoracic irradiation and an increased risk of cardiovascular disease (CVD) in cancer survivors, although these effects may take decades to become symptomatic. Long-term survivors of Hodgkin's lymphoma and childhood cancers have two-fold to more than seven-fold increased risks for late cardiac deaths after total tumour doses of 30-40 Gy, given in 2 Gy fractions, where large volumes of heart were included in the field. Increased cardiac mortality is also seen in women irradiated for breast cancer. Breast doses are generally 40-50 Gy in 2 Gy fractions, but only a small part of the heart is included in the treatment fields and mean heart doses rarely exceeded 10-15 Gy, even with older techniques. The relative risks of cardiac mortality (1.1-1.4) are consequently lower than for Hodgkin's lymphoma survivors. Some epidemiological studies show increased risks of cardiac death after accidental or environmental total body exposures to much lower radiation doses. The mechanisms whereby these cardiac effects occur are not fully understood and different mechanisms are probably involved after high therapeutic doses to the heart, or part of the heart, than after low total body exposures. These various mechanisms probably result in different cardiac pathologies, e.g. coronary artery atherosclerosis leading to myocardial infarct, versus microvascular damage and fibrosis leading to congestive heart failure. Experimental studies can help to unravel some of these mechanisms and may identify suitable strategies for managing or inhibiting CVD. In this overview, the main epidemiological and clinical evidence for radiation-induced CVD is summarised. Experimental data shedding light on some of the underlying pathologies and possible targets for intervention are also discussed.
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Affiliation(s)
- F A Stewart
- Division of Biological Stress Response, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
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Gueth P, Dauvergne D, Freud N, Létang JM, Ray C, Testa E, Sarrut D. Machine learning-based patient specific prompt-gamma dose monitoring in proton therapy. Phys Med Biol 2013; 58:4563-77. [DOI: 10.1088/0031-9155/58/13/4563] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Antoni D, Natarajan-Ame S, Meyer P, Niederst C, Bourahla K, Noel G. Contribution of three-dimensional conformal intensity-modulated radiation therapy for women affected by bulky stage II supradiaphragmatic Hodgkin disease. Radiat Oncol 2013; 8:112. [PMID: 23638873 PMCID: PMC3671200 DOI: 10.1186/1748-717x-8-112] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2012] [Accepted: 04/16/2013] [Indexed: 12/25/2022] Open
Abstract
Purpose To analyze the outcome and dose distribution of intensity-modulated radiation therapy (IMRT) by helical tomotherapy in women treated for large supradiaphragmatic Hodgkin’s disease. Material and methods A total of 13 patients received adjuvant radiation at a dose of 30 Gy to the initially involved sites with a boost of 6 Gy to those areas suspected of harboring residual disease on the simulation CT scan. Results With a median follow-up of 23 months, the two-year progression-free survival was 91.6%, and the 2- and 3-year overall survivals were 100%. We did not report any heart or lung acute side effects. The conformity index of PTV (Planning Target Volume) was better for IMRT than for 3D-CRT (p=0.001). For the breasts, lungs, heart, thyroid and esophagus, the volume distributions favored the IMRT plans. For the breasts, the V20Gy, V25Gy and V30Gy were 1.5, 2.5 and 3.5 times lower, respectively, for IMRT than for 3D-CRT. For the lung tissues, the V20Gy and V30Gy were 2 times and 4.5 times lower, respectively, for IMRT than for 3D-CRT. For the heart, the V20Gy and V30Gy were 1.4 and 2 times lower, respectively, for IMRT than for 3D-CRT. For the esophagus, the V35Gy was 1.7 lower for IMRT than for 3D-CRT, and for the thyroid, the V30Gy was 1.2 times lower for IMRT. Conclusion IMRT by helical tomotherapy improved the PTV coverage and dramatically decreased the dose in organs at risk. The treatment was well tolerated, but a longer follow-up is necessary to prove a translation of these dosimetric improvements in the outcome of the patients.
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Improving the therapeutic ratio by using proton therapy in patients with stage I or II seminoma. Am J Clin Oncol 2013; 36:31-7. [PMID: 22134517 DOI: 10.1097/coc.0b013e3182354b9e] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The goal of the present study was to evaluate possible dosimetric advantages of proton therapy (PT) compared with 3-dimensional conformal radiotherapy (3DCRT) or intensity-modulated radiotherapy (IMRT) in the treatment of patients with stage I and II seminoma. METHODS Two representative patients (1 with left-sided and 1 with right-sided seminoma) underwent treatment planning for stage I seminoma (paraaortic lymph nodes alone) with 3DCRT (PA3d), IMRT (PAimrt) double-scatter protons (PAPds), and uniform-scanning protons (PAPus) and for stage II seminoma (paraaortics lymph nodes and iliac nodes) with 3DCRT (PI3d) , IMRT (PIimrt) double-scatter protons (PIPds), and uniform-scanning protons (PIPus). The doses to the organs at risk were compared for photons and protons. RESULTS For stage I seminoma, PT reduced the mean dose to the stomach, ipsilateral kidney, pancreas, bowel space, small bowel, and colon compared with 3DCRT and IMRT. For stage II seminoma, PT reduced the mean dose to the same organs as in stage I seminoma with additional reductions in mean dose to the bladder and rectum compared with 3DCRT and IMRT. Uniform-scanning protons further reduced the dose to the organs at risk compared with double-scatter protons. CONCLUSIONS PT may offer an improvement in the therapeutic ratio in patients with seminoma by reducing the dose to normal tissue. This improvement may translate into lower risks of acute gastrointestinal side effects, infertility, and secondary malignancies, which should be explored in a prospective study.
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Abstract
Abstract
The results of recent clinical trials for the management of limited-stage Hodgkin lymphoma have led to considerable debate, especially regarding the role of radiation therapy. This review highlights those recent trials and provides perspectives regarding their interpretation from a radiation oncologist and a hematologist. The trial protocol is available at http://www.nejm.org/doi/suppl/10.1056/NEJMoa1111961/suppl_file/nejmoa1111961_protocol.pdf.
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