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Yadav BS, Dey T. Radiotherapy dose de-escalation in patients with high grade non-Hodgkin lymphoma in a real-world clinical practice. Radiat Oncol J 2023; 41:237-247. [PMID: 38185928 PMCID: PMC10772589 DOI: 10.3857/roj.2023.00339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 08/08/2023] [Indexed: 01/09/2024] Open
Abstract
PURPOSE The standard treatment of non-Hodgkin lymphoma (NHL) comprises combined modality treatment, radiotherapy (RT), and chemotherapy with rituximab which has significantly improved both disease-free survival (DFS) and overall survival (OS). However, there is no uniformity in radiation dose usage in these patients. In this retrospective study, we compared lower radiation dose with higher in patients with aggressive NHL. MATERIALS AND METHODS From 2007 to 2017, treatment records of all high-grade NHL or diffuse large B-cell lymphoma and non-central nervous system NHL were included. We compared response rates, OS and DFS of patients who received ≤30 Gy RT to those with >30 Gy. Univariate and multivariate analyses were done to determine factors affecting prognosis, i.e., age, sex, stage, International Prognostic Index (IPI), adding rituximab, and radiation dose. RESULTS A total of 184 NHL patients treated with combined modality or radiation alone having complete follow-up details were analyzed. At median follow-up of 66.8 months, 5-year OS was 72.8% in high-dose group versus 69.9% in low-dose group (p = 0.772) and 5-year DFS 64.7% versus 64.1% (p = 0.871). Patients having early-stage disease receiving low dose and those with advanced disease treated with >30 Gy had better OS and DFS though not statistically significant. Adding rituximab was associated with significantly better OS and DFS irrespective of radiation dose delivered. High IPI score and omitting rituximab were the only factors that significantly worsened both OS and DFS. Acute radiation toxicities were comparable in both groups (p = 0.82). Among late toxicities, no patient developed a second malignancy and 5% died due to cardiovascular complications (p = 0.595) though only two patients (1.1%) had received thoracic radiation. CONCLUSION The two groups had comparable response rates, acute toxicities, DFS and OS. This study suggests that RT dose reduction may be possible in high-grade NHL without compromising the DFS and OS.
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Affiliation(s)
- Budhi Singh Yadav
- Department of Radiotherapy and Oncology, Regional Cancer Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Treshita Dey
- Department of Radiotherapy and Oncology, Regional Cancer Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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2
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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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3
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Ritter A, Quartermaine C, Pierre-Charles J, Balasubramanian S, Raeisi-Giglou P, Addison D, Miller E. Cardiotoxicity of Anti-Cancer Radiation Therapy: a Focus on Heart Failure. Curr Heart Fail Rep 2023; 20:44-55. [PMID: 36692820 DOI: 10.1007/s11897-023-00587-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE OF REVIEW As the percentage of patients achieving long-term survival following treatment of their cancer grows, it is increasingly important to understand the long-term toxicities of cancer-directed treatment. In this review, we highlight the recent findings regarding radiation-induced cardiotoxicity across multiple disease sites, with a particular focus on heart failure. RECENT FINDINGS Despite its relative lack of study historically, radiation-induced heart failure has now recently been implicated in several studies of breast cancer, lung cancer, esophageal cancer, and lymphoma as a non-trivial potential consequence of thoracic radiotherapy. Data regarding specific cardiac dosimetric endpoints relevant to cardiotoxicity continue to accumulate. Radiation-induced heart failure is a rare but significant toxicity of thoracic radiotherapy, that is likely underreported. Important areas for future focus include understanding the interplay between thoracic radiotherapy and concurrent cardiotoxic systemic therapy as well as development of potential mitigation strategies and novel therapeutics.
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Affiliation(s)
- Alex Ritter
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, OH, Columbus, USA
| | - Cooper Quartermaine
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, OH, USA
| | - Jovan Pierre-Charles
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, OH, USA
| | - Suryakumar Balasubramanian
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, OH, USA
- Velammal Medical College Hospital & Research Institute, Madurai, India
| | - Pejman Raeisi-Giglou
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, OH, USA
| | - Daniel Addison
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, OH, USA
- Division of Cancer Control, James Cancer Hospital and Solove Research Institute at The Ohio State University, Columbus, OH, USA
| | - Eric Miller
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, OH, Columbus, USA.
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4
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Petersen PM, Mikhaeel NG, Ricardi U, Brady JL. Harnessing benefit of highly conformal RT techniques for lymphoma patients. Br J Radiol 2021; 94:20210469. [PMID: 34379521 DOI: 10.1259/bjr.20210469] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
This status article describes current state-of-the-art radiotherapy for lymphomas and new emerging techniques. Current state-of-the-art radiotherapy is sophisticated, individualised, CT-based, intensity-modulated treatment, using PET/CT to define the target. The concept of involved site radiotherapy should be used, delineating the target using the exact same principles as for solid tumours. The optimal treatment delivery includes motion management and online treatment verification systems, which reduce intra- and interfractional anatomical variation. Emerging radiotherapy techniques in lymphomas include adaptive radiotherapy in MR- and CT-based treatment systems and proton therapy. The next generation linear accelerators have the capability to deliver adaptive treatment and allow relatively quick online adaptation to the daily variations of the anatomy. The computer systems use machine leaning to facilitate rapid automatic contouring of the target and organs-at-risk. Moreover, emerging MR-based planning and treatment facilities allow target definition directly from MR scans and allow intra-fractional tracking of structures recognisable on MR. Proton facilities are now being widely implemented. The benefits of proton therapy are due to the physical properties of protons, which in many cases allow sparing of normal tissue. The variety of techniques in modern radiotherapy means that the radiation oncologist must be able to choose the right technique for each patient. The choice is mainly based on experience and standard protocols, but new systems calculating risks for the patients with a specific treatment plan and also systems integrating clinical factors and risk factors into the planning process itself are emerging.
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Affiliation(s)
- Peter Meidahl Petersen
- Department of Oncology, The Finsen Centre, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - N George Mikhaeel
- Guy's Cancer Centre, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | | | - Jessica L Brady
- Guy's Cancer Centre, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
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5
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Wei T, Cheng Y. The cardiac toxicity of radiotherapy - a review of characteristics, mechanisms, diagnosis, and prevention. Int J Radiat Biol 2021; 97:1333-1340. [PMID: 34264176 DOI: 10.1080/09553002.2021.1956007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE Radiation-induced heart disease (RIHD) is one of the most serious complications of radiotherapy. The purpose of this paper is to review recent researches about cardiac toxicity of radiotherapy in clinical characteristics, mechanisms, diagnosis, and prevention. CONCLUSIONS Powered by the rapid development of medicine, the overall survival (OS) of cancer has been improved significantly. Surgery, chemotherapy, and radiotherapy (RT) are three critical ways in the comprehensive treatments of cancer. There is a consensus that early diagnosis and interventions for the prevention of RIHD are crucial. This review concludes recent clinical and experimental studies on RIHD. RIHD, a heterogeneous and serious disease, is a spectrum of heart disease including myocardial disease, pericarditis, coronary artery disease, valvular heart disease, and conduction system dysfunction. Mean heart dose, biomarkers, and detecting techniques are important components in detecting heart injury. Improvements in radiotherapy regimens remain the primary goal of prevention. Further investigation is needed beyond the observation period of most of these studies.
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Affiliation(s)
- Tianhui Wei
- Department of Radiation Oncology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Yufeng Cheng
- Department of Radiation Oncology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Jinan, Shandong, China
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6
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Bakkach J, Pellegrino B, Elghazawy H, Novosad O, Agrawal S, Bennani Mechita M. Current overview and special considerations for second breast cancer in Hodgkin lymphoma survivors. Crit Rev Oncol Hematol 2020; 157:103175. [PMID: 33321295 DOI: 10.1016/j.critrevonc.2020.103175] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 06/28/2020] [Accepted: 11/05/2020] [Indexed: 12/15/2022] Open
Abstract
Second breast cancer (SBC) is the most common solid cancer among Hodgkin Lymphoma (HL) female survivors. We reviewed the related modifying risk factors, radiation-induced carcinogenesis, tumors characteristics, management specificities, prevention and surveillance modalities based on current evidence. The risk of developing SBC may be influenced essentially by the age at HL treatment, follow-up latency, dose of irradiation received and the extent of irradiated field. SBCs generally develop at younger age, they are often bilateral, and exhibit more aggressive biological features and worse prognosis. No firm answer about the benefits of breast surveillance is provided by literature, but compelling evidence tends toward a clinical benefit in early detection. Increasing awareness among health providers' care and current survivors as well as the implementation of screening measures is crucial. Great efforts are ongoing in individualizing treatment strategies for future HL patients and response-adapted approaches are holding promise in prevention of these second malignancies.
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Affiliation(s)
- Joaira Bakkach
- Biomedical Genomics and Oncogenetics Research Laboratory, Faculty of Sciences and Techniques of Tangier, Abdelmalek Essaâdi University, Morocco.
| | | | - Hagar Elghazawy
- Clinical Oncology Department, Faculty of Medicine, Ain Shams University, Egypt.
| | - Olga Novosad
- Onco-Hematology Department, National Cancer Institute of the MPH Ukraine, Kiev, Ukraine.
| | - Sanjit Agrawal
- Department of Breast Oncosurgery, Tata Medical Center, Kolkata, West Bengal, India.
| | - Mohcine Bennani Mechita
- Biomedical Genomics and Oncogenetics Research Laboratory, Faculty of Sciences and Techniques of Tangier, Abdelmalek Essaâdi University, Morocco.
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7
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Jouglar E, Escande A, Martin V, Demoor-Goldschmidt C, Carrie C, Claude L, Bernier-Chastagner V. [Influence of age on indications and modalities of radiation therapy: What to keep in mind for adolescents and young adults?]. Bull Cancer 2020; 108:203-209. [PMID: 33051053 DOI: 10.1016/j.bulcan.2020.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/25/2020] [Accepted: 09/06/2020] [Indexed: 10/23/2022]
Abstract
When using radiation therapy for adolescents and young adults (AYA), paediatricians, adults' oncologists and radiation oncologists need to keep in mind several particularities through the whole therapeutic process. They embrace the indication, target volumes, prescribed dose, treatment techniques and follow-up. Indeed, the young age and the cancer features that characterised this population influence the modalities of irradiation. This article highlights the key points of AYA care with radiation therapy.
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Affiliation(s)
- Emmanuel Jouglar
- Institut de cancérologie de l'ouest, service de radiothérapie, boulevard Jacques-Monod, 44800 Saint-Herblain, France.
| | - Alexandre Escande
- Centre Oscar-Lambret, département universitaire de radiothérapie, 59800 Lille, France; Université de Lille 3, faculté Henri-Warembourg, Laboratoire cristal UMR 9189, 59800 Lille, France
| | - Valentine Martin
- Gustave-Roussy, département universitaire de radiothérapie, 94800 Villejuif, France
| | - Charlotte Demoor-Goldschmidt
- Université Paris-Saclay, Université Paris-Sud, UVSQ, cancer et radiothérapie, Inserm U1018, 94800 Villejuif, France
| | - Christian Carrie
- Centre Léon-Berard, département de radiothérapie, 69008 Lyon, France
| | - Line Claude
- Centre Léon-Berard, département de radiothérapie, 69008 Lyon, France
| | - Valérie Bernier-Chastagner
- Institut de cancérologie de Lorraine, département de radiothérapie, 3, avenue de Bourgogne, 54500 Vandoeuvre-lès-Nancy, France
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8
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Wang S, Jia M, Han J, Zhang R, Huang K, Li P, Li Q, Qiao Y, Song Q, Fu Z. Radiotherapy for patients with stage IV classical Hodgkin lymphoma: a propensity-matched analysis of the surveillance, epidemiology, and end results database. Cancer Biol Ther 2020; 21:832-840. [PMID: 32835569 DOI: 10.1080/15384047.2020.1796194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Background The survival advantage of radiotherapy for patients with stage IV classic Hodgkin lymphoma (HL) has not been adequately evaluated. Methods We analyzed patients with stage IV HL enrolled from the Surveillance, Epidemiology, and End Results (SEER) registry from January 2000 to December 2012. Propensity score (PS) analysis with 1:2 matching was performed to ensure well-balanced characteristics of the comparison groups. Kaplan-Meier and Cox proportional hazardous model were used to evaluate the overall survival (OS), cancer-specific survival (CSS), the hazards ratio (HR) and corresponding 95% confidence intervals (95% CI). Results Overall, for all patients with stage IV HL, receiving radiotherapy was associated with both significantly improved OS and CSS. Radiotherapy to any lesions could independently improve the OS and CSS by 30% to 36% in the multivariate analyses before and after PS matching (PSM), with the best improvement of 33% to 40% observed for patients with nodular sclerosis (P < 0.05) among all HL pathological types. In particular, radiotherapy, most likely to the residual site, was more pronouncedly associated with the improvement in survival for patients with stage IV HL who were young (age<45, P < .05) or without B symptoms (PInteraction for OS = 0.099, PInteraction for CSS = 0.255). For those patients without B symptoms, after PSM, the OS was improved by 65% (P = .021). Conclusions The large SEER results support that radiotherapy is associated with better survival of patients with stage IV HL.
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Affiliation(s)
- Shijie Wang
- Cancer Center, Renmin Hospital of Wuhan University , Wuhan, China
| | - Mingfang Jia
- Department of Health Management, Renmin Hospital of Wuhan University , Wuhan, China
| | - Jianglong Han
- Cancer Center, Renmin Hospital of Wuhan University , Wuhan, China
| | - Rui Zhang
- Cancer Center, Renmin Hospital of Wuhan University , Wuhan, China
| | - Kejie Huang
- Cancer Center, Renmin Hospital of Wuhan University , Wuhan, China
| | - Ping Li
- Cancer Center, Renmin Hospital of Wuhan University , Wuhan, China
| | - Qin Li
- Cancer Center, Renmin Hospital of Wuhan University , Wuhan, China
| | - Yunfeng Qiao
- Cancer Center, Renmin Hospital of Wuhan University , Wuhan, China
| | - Qibin Song
- Cancer Center, Renmin Hospital of Wuhan University , Wuhan, China
| | - Zhenming Fu
- Cancer Center, Renmin Hospital of Wuhan University , Wuhan, China
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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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Xiang M, Chang DT, Pollom EL. Second cancer risk after primary cancer treatment with three-dimensional conformal, intensity-modulated, or proton beam radiation therapy. Cancer 2020; 126:3560-3568. [PMID: 32426866 DOI: 10.1002/cncr.32938] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 01/08/2020] [Accepted: 01/25/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND The comparative risks of a second cancer diagnosis are uncertain after primary cancer treatment with 3-dimensional conformal radiotherapy (3DCRT), intensity-modulated radiotherapy (IMRT), or proton beam radiotherapy (PBRT). METHODS Pediatric and adult patients with a first cancer diagnosis between 2004 and 2015 who received 3DCRT, IMRT, or PBRT were identified in the National Cancer Database from 9 tumor types: head and neck, gastrointestinal, gynecologic, lymphoma, lung, prostate, breast, bone/soft tissue, and brain/central nervous system. The diagnosis of second cancer was modeled using multivariable logistic regression adjusting for age, follow-up duration, radiotherapy (RT) dose, chemotherapy, sociodemographic variables, and other factors. Propensity score matching also was used to balance baseline characteristics. RESULTS In total, 450,373 patients were identified (33.5% received 3DCRT, 65.2% received IMRT, and 1.3% received PBRT) with median follow-up of 5.1 years after RT completion and a cumulative follow-up period of 2.54 million person-years. Overall, the incidence of second cancer diagnosis was 1.55 per 100 patient-years. In a comparison between IMRT versus 3DCRT, there was no overall difference in the risk of second cancer (adjusted odds ratio [OR], 1.00; 95% CI, 0.97-1.02; P = .75). By comparison, PBRT had an overall lower risk of second cancer versus IMRT (adjusted OR, 0.31; 95% CI, 0.26-0.36; P < .0001). Results within each tumor type generally were consistent in the pooled analyses and also were maintained in propensity score-matched analyses. CONCLUSIONS The risk of a second cancer diagnosis was similar after IMRT versus 3DCRT, whereas PBRT was associated with a lower risk of second cancer risk. Future work is warranted to determine the cost-effectiveness of PBRT and to identify the population best suited for this treatment.
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Affiliation(s)
- Michael Xiang
- Department of Radiation Oncology, Stanford University, Stanford, California, USA.,Palo Alto Veterans Affairs Hospital, Palo Alto, California, USA
| | - Daniel T Chang
- Department of Radiation Oncology, Stanford University, Stanford, California, USA
| | - Erqi L Pollom
- Department of Radiation Oncology, Stanford University, Stanford, California, USA.,Palo Alto Veterans Affairs Hospital, Palo Alto, California, USA
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11
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Hoppe BS, Bates JE, Mendenhall NP, Morris CG, Louis D, Ho MW, Hoppe RT, Shaikh M, Li Z, Flampouri S. The Meaningless Meaning of Mean Heart Dose in Mediastinal Lymphoma in the Modern Radiation Therapy Era. Pract Radiat Oncol 2020; 10:e147-e154. [DOI: 10.1016/j.prro.2019.09.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 09/10/2019] [Accepted: 09/15/2019] [Indexed: 10/25/2022]
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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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Sardaro A, Carbonara R, Petruzzelli MF, Turi B, Moschetta M, Scardapane A, Stabile Ianora AA. Proton therapy in the most common pediatric non-central nervous system malignancies: an overview of clinical and dosimetric outcomes. Ital J Pediatr 2019; 45:170. [PMID: 31881905 PMCID: PMC6935184 DOI: 10.1186/s13052-019-0763-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 12/17/2019] [Indexed: 11/20/2022] Open
Abstract
Radiation therapy represents an important approach in the therapeutic management of children and adolescents with malignant tumors and its application with modern techniques – including Proton Beam Therapy (PBT) – is of great interest. In particular, potential radiation-induced injuries and secondary malignancies – also associated to the prolonged life expectancy of patients – are still questions of concern that increase the debate on the usefulness of PBT in pediatric treatments. This paper presents a literary review of current applications of PBT in non-Central Nervous System pediatric tumors (such as retinoblastoma, Hodgkin Lymphoma, Wilms tumor, bone and soft tissues sarcomas). We specifically reported clinical results achieved with PBT and dosimetric comparisons between PBT and the most common photon-therapy techniques. The analysis emphasizes that PBT minimizes radiation doses to healthy growing organs, suggesting for reduced risks of late side-effects and radiation-induced secondary malignancies. Extended follow up and confirms by prospective clinical trials should support the effectiveness and long-term tolerance of PBT in the considered setting.
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Affiliation(s)
- Angela Sardaro
- Interdisciplinary Department of Medicine, Section of Radiology and Radiation Oncology, University of Bari, p.zza Giulio Cesare nr.11, 70124, Bari, Italy
| | - Roberta Carbonara
- Interdisciplinary Department of Medicine, Section of Radiology and Radiation Oncology, University of Bari, p.zza Giulio Cesare nr.11, 70124, Bari, Italy.
| | - Maria Fonte Petruzzelli
- Interdisciplinary Department of Medicine, Section of Radiology and Radiation Oncology, University of Bari, p.zza Giulio Cesare nr.11, 70124, Bari, Italy
| | - Barbara Turi
- Interdisciplinary Department of Medicine, Section of Radiology and Radiation Oncology, University of Bari, p.zza Giulio Cesare nr.11, 70124, Bari, Italy
| | - Marco Moschetta
- Interdisciplinary Department of Medicine, Section of Radiology and Radiation Oncology, University of Bari, p.zza Giulio Cesare nr.11, 70124, Bari, Italy
| | - Arnaldo Scardapane
- Interdisciplinary Department of Medicine, Section of Radiology and Radiation Oncology, University of Bari, p.zza Giulio Cesare nr.11, 70124, Bari, Italy
| | - Amato Antonio Stabile Ianora
- Interdisciplinary Department of Medicine, Section of Radiology and Radiation Oncology, University of Bari, p.zza Giulio Cesare nr.11, 70124, Bari, Italy
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14
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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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15
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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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16
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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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17
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Lautenschlaeger S, Iancu G, Flatten V, Baumann K, Thiemer M, Dumke C, Zink K, Hauswald H, Vordermark D, Mauz-Körholz C, Engenhart-Cabillic R, Eberle F. Advantage of proton-radiotherapy for pediatric patients and adolescents with Hodgkin's disease. Radiat Oncol 2019; 14:157. [PMID: 31477141 PMCID: PMC6721251 DOI: 10.1186/s13014-019-1360-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 08/16/2019] [Indexed: 01/26/2023] Open
Abstract
Abstract Radiotherapy is frequently used in the therapy of lymphoma. Since lymphoma, for example Hodgkin’s disease, frequently affect rather young patients, the induction of secondary cancer or other long-term adverse effects after irradiation are important issues to deal with. Especially for mediastinal manifestations numerous organs and substructures at risk play a role. The heart, its coronary vessels and cardiac valves, the lungs, the thyroid and, for female patients, the breast tissue are only the most important organs at risk. In this study we investigated if proton-radiotherapy might reduce the dose delivered to the organs at risk and thus minimize the therapy-associated toxicity. Methods In this work we compared the dose delivered to the heart, its coronary vessels and valves, the lungs, the thyroid gland and the breast tissue by different volumetric photon plans and a proton plan, all calculated for a dose of 28.8 Gy (EURO-NET-PHL-C2). Target Volumes have been defined by F18-FDG PET-positive areas, following a modified involved node approach. Data from ten young female patients with mediastinal lymphoma have been evaluated. Three different modern volumetric IMRT (VMAT) photon plans have been benchmarked against each other and against proton-irradiation concepts. For plan-evaluation conformity- and homogeneity-indices have been calculated as suggested in ICRU 83. The target volume coverage as well as the dose to important organs at risk as the heart with its substructures, the lungs, the breast tissue, the thyroid and the spinal cord were calculated and compared. For statistical evaluation mean doses to organs at risk were evaluated by non- parametric Kruskal-Wallis calculations with pairwise comparisons. Results Proton-plans and three different volumetric photon-plans have been calculated. Proton irradiation results in significant lower doses delivered to organ at risk. The median doses and the mean doses could be decreased while PTV coverage is comparable. As well conformity as homogeneity are slightly better for proton plans. For several organs a risk reduction for secondary malignancies has been calculated using literature data as reference. According to the used data derived from literature especially the secondary breast cancer risk, the secondary lung cancer risk and the risk for ischemic cardiac insults can be reduced significantly by using protons for radiotherapy of mediastinal lymphomas. Conclusion Irradiation with protons for mediastinal Hodgkin-lymphoma results in significant lower doses for almost all organs at risk and is suitable to reduce long term side effects for pediatric and adolescent patients. Electronic supplementary material The online version of this article (10.1186/s13014-019-1360-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- S Lautenschlaeger
- Klinik für Strahlentherapie und Radioonkologie, Klinikum der Philipps Universität Marburg, Baldingerstr, 35043, Marburg, Germany.
| | - G Iancu
- Klinik für Strahlentherapie und Radioonkologie, Klinikum der Philipps Universität Marburg, Baldingerstr, 35043, Marburg, Germany
| | - V Flatten
- Klinik für Strahlentherapie und Radioonkologie, Klinikum der Philipps Universität Marburg, Baldingerstr, 35043, Marburg, Germany.,Technische Hochschule Mittelhessen, Institut für Medizinische Physik und Strahlenschutz, Gießen, Germany
| | - K Baumann
- Klinik für Strahlentherapie und Radioonkologie, Klinikum der Philipps Universität Marburg, Baldingerstr, 35043, Marburg, Germany.,Technische Hochschule Mittelhessen, Institut für Medizinische Physik und Strahlenschutz, Gießen, Germany
| | - M Thiemer
- Klinik für Strahlentherapie und Radioonkologie, Klinikum der Philipps Universität Marburg, Baldingerstr, 35043, Marburg, Germany
| | - C Dumke
- Klinik für Strahlentherapie und Radioonkologie, Klinikum der Philipps Universität Marburg, Baldingerstr, 35043, Marburg, Germany
| | - K Zink
- Klinik für Strahlentherapie und Radioonkologie, Klinikum der Philipps Universität Marburg, Baldingerstr, 35043, Marburg, Germany.,Technische Hochschule Mittelhessen, Institut für Medizinische Physik und Strahlenschutz, Gießen, Germany
| | - H Hauswald
- Klinik für Strahlentherapie und Radioonkologie, Klinikum der Philipps Universität Marburg, Baldingerstr, 35043, Marburg, Germany.,Klinik für Radio-Onkologie, Universitätsklinikum Heidelberg, Heidelberg, Germany.,Marburg Ion-Beam Therapy Center (MIT), Marburg, Germany
| | - D Vordermark
- Klinik und Poliklinik für Strahlentherapie, Universitätsklinikum der Martin-Luther-Universität Halle-Wittenberg, Halle, Germany
| | - C Mauz-Körholz
- Abteilung für Pädiatrische Hämatologie und Onkologie, Universitätsklinikum Gießen, Gießen, Germany.,Department für operative und konservative Kinder- und Jugendmedizin, Universitätsklinikum der Martin-Luther-Universität Halle-Wittenberg, Halle, Germany
| | - R Engenhart-Cabillic
- Klinik für Strahlentherapie und Radioonkologie, Klinikum der Philipps Universität Marburg, Baldingerstr, 35043, Marburg, Germany.,Marburg Ion-Beam Therapy Center (MIT), Marburg, Germany
| | - F Eberle
- Klinik für Strahlentherapie und Radioonkologie, Klinikum der Philipps Universität Marburg, Baldingerstr, 35043, Marburg, Germany.,Marburg Ion-Beam Therapy Center (MIT), Marburg, Germany
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18
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Holtzman AL, Stahl JM, Zhu S, Morris CG, Hoppe BS, Kirwan JE, Mendenhall NP. Does the Incidence of Treatment-Related Toxicity Plateau After Radiation Therapy: The Long-Term Impact of Integral Dose in Hodgkin's Lymphoma Survivors. Adv Radiat Oncol 2019; 4:699-705. [PMID: 31673663 PMCID: PMC6817558 DOI: 10.1016/j.adro.2019.07.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 06/21/2019] [Accepted: 07/15/2019] [Indexed: 12/04/2022] Open
Abstract
Background Conventional radiation therapy (RT) has produced unprecedented cure rates in patients with Hodgkin's lymphoma (HL) but exposed large volumes of nontargeted tissue to radiation (integral dose). Objective Our goal was to report the effects of integral radiation dose on health outcomes in patients with at least 20 years of potential follow-up time. Methods and Materials We reviewed the medical records of 365 patients who were treated with RT for HL between 1965 and 1995. All patients were confirmed to have received primary RT with curative intent at our institution for de novo HL. Serious adverse events were classified as HL progression or death, grade ≥3 treatment- or staging-related acute or late effects, second malignancies, or cardiovascular events. Results The minimum potential follow-up time was 20 years, and the actual median follow-up time 22 years (range, <1-49 years) for all patients and 27 years (range, 5-49 years) for surviving patients. The overall survival rates at 5, 10, 20, 30, and 40 years were 86%, 76%, 64%, 44%, and 27%, respectively. The observed-to-expected ratio for second malignancy was 3.6 (95% confidence interval, 2.9-4.4). Grade ≥3 cardiovascular events occurred in 31% of all patients (n = 112). At the time of the most recent follow up, serious adverse events occurred in 70% of the entire cohort (n = 256) and 58% (n = 103), 77% (n = 103), and 93% (n = 50) among those with a potential 20, 30, and 40 years of follow up, respectively. Conclusions With increased survivorship, the long-term impact of the integral radiation dose may result in clinically significant adverse events, which suggests the importance of surveillance and affirms advances in both chemotherapy and RT that minimize the integral dose in future patients with HL.
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Affiliation(s)
- Adam L Holtzman
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - John M Stahl
- Department of Radiation Oncology, University of Alabama-Birmingham School of Medicine, Birmingham, Alabama
| | - Simeng Zhu
- Department of Radiation Oncology, Wayne State University School of Medicine, Detroit, Michigan
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Bradford S Hoppe
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Jessica E Kirwan
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Nancy P Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida
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19
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Donnellan E, Jellis CL, Griffin BP. Radiation-Associated Cardiac Disease: From Molecular Mechanisms to Clinical Management. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:22. [PMID: 31020465 DOI: 10.1007/s11936-019-0726-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Radiation-associated cardiac disease (RACD) is an increasingly recognized latent manifestation of chest and mediastinal radiation therapy. The delayed presentation reflects increased survival rates from malignancies successfully treated decades previously. However, individuals are now presenting with multiple coexistent manifestations of RACD and pulmonary disease as a consequence of high-dose radiation administered prior to the routine institution of modern dose-modulating regimens. Increased awareness of RACD is critical for implementation of appropriate screening algorithms and for specific management strategies involving the timing and strategies of intervention in these patients. RECENT FINDINGS Recent advances in multimodality cardiac imaging have demonstrated pathognomonic findings of RACD, which can predict outcomes including mortality. Accurate diagnosis of these typically concurrent manifestations is critical and should prompt referral to a center experienced in managing RACD as surgical risk is significantly increased for this patient cohort, particularly for those undergoing redo operation. The latent effect of RACD and its unique combination of manifestations means that these patients will increasingly present with challenging management issues, resulting in increased rates of morbidity and mortality. Timing of treatment intervention must be carefully considered, although percutaneous options may provide alternative future strategies for this higher risk cohort.
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Affiliation(s)
- Eoin Donnellan
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Christine L Jellis
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Brian P Griffin
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA. .,Department of Cardiovascular Medicine, Desk J1-5, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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20
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König L, Bougatf N, Hörner-Rieber J, Chaudhri N, Mielke T, Klüter S, Haefner MF, Rieken S, Haberer T, Debus J, Herfarth K. Consolidative mediastinal irradiation of malignant lymphoma using active scanning proton beams: clinical outcome and dosimetric comparison. Strahlenther Onkol 2019; 195:677-687. [PMID: 30972453 DOI: 10.1007/s00066-019-01460-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 03/25/2019] [Indexed: 12/25/2022]
Abstract
PURPOSE Current research approaches in lymphoma focus on reduction of therapy-associated long-term side effects. Especially in mediastinal lymphoma, proton beam radiotherapy (PT) may be a promising approach for reducing the dose to organs at risk (OAR). PATIENTS In total, 20 patients were irradiated with active scanning PT at Heidelberg Ion Beam Therapy Center (HIT) between September 2014 and February 2017. For comparative analysis, additional photon irradiation plans with helical intensity-modulated radiotherapy (IMRT) were calculated and quantitative and qualitative dose evaluations were made for both treatment modalities. Toxicity and survival outcomes were evaluated. RESULTS Clinical target volume coverage was comparable in both treatment modalities and did not significantly differ between IMRT and PT. Nevertheless, PT showed superiority regarding the homogeneity index (HIPT = 1.041 vs. HIIMRT = 1.075, p < 0.001). For all OAR, PT showed significantly higher dose reductions compared with IMRT. In particular, the dose to the heart was reduced in PT (absolute dose reduction of Dmean of 3.3 Gy [all patients] and 4.2 Gy [patients with pericardial involvement]). Likewise, the subgroup analysis of female patients, who were expected to receive higher doses to the breast, showed a higher dose reduction in Dmean of 1.2 Gy (right side) and 2.2 Gy (left side). After a median follow-up of 32 months (range 21-48 months), local and distant progression free survival (LPFS and DPFS) were 95.5% and 95.0%, respectively. Radiotherapy was tolerated well with only mild (grade 1-2) radiation-induced acute and chronic side effects. CONCLUSION A significant reduction in the dose to the surrounding OAR was achieved with PT compared with photon irradiation, without compromising target volume coverage. Dosimetric advantages may have the potential to translate into a reduction of long-term radiation-induced toxicity in young patients with malignant lymphoma of the mediastinum.
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Affiliation(s)
- Laila König
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany. .,Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany. .,Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120, Heidelberg, Germany.
| | - Nina Bougatf
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120, Heidelberg, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120, Heidelberg, Germany
| | - Naved Chaudhri
- Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120, Heidelberg, Germany
| | - Thomas Mielke
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120, Heidelberg, Germany
| | - Sebastian Klüter
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Matthias Felix Haefner
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120, Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120, Heidelberg, Germany
| | - Thomas Haberer
- Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120, Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120, Heidelberg, Germany
| | - Klaus Herfarth
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120, Heidelberg, Germany
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21
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O'steen L, Bellardini J, Cury J, Jones L, Seeram VK, Mendenhall NP, Hoppe BS. Pulmonary Function after Proton Therapy for Hodgkin Lymphoma. Int J Part Ther 2019; 5:1-4. [PMID: 31788502 PMCID: PMC6874186 DOI: 10.14338/ijpt-18-00040.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 12/03/2018] [Indexed: 11/21/2022] Open
Abstract
Purpose: Acute and late toxicity from chemotherapy, targeted therapy, and radiation therapy can cause significant morbidity among survivors of Hodgkin lymphoma (HL), including pulmonary dysfunction. Improved dosimetry may influence pulmonary function tests (PFTs), an objective and clinically significant measure of pulmonary toxicity. The present study investigates the impact of proton therapy on PFTs among HL survivors. Patients and Methods: We monitored 15 patients with mediastinal HL who were enrolled in an institutional HL trial. All patients were treated with combination chemotherapy plus involved-node proton therapy. All patients were to undergo PFTs before starting treatment and at approximately 6 and 12 months after completing proton therapy. Results: Twelve patients were included in the analysis and 3 excluded. The mean forced vital capacity (FVC) was 96.2% ± 16.5% (mean ± SD) predicted at baseline and 98.2% ± 19.4% predicted at 12 months. The mean forced expiratory volume in 1 second (FEV1) was 96.7% ± 17.2% predicted at baseline and 97% ± 15.1% predicted at 12 months. The mean FEV1/FVC ratio was 99.5 ± 8.29 at baseline and 97.8 ± 8.02 at 12 months. The mean diffusing capacity of the lung for carbon monoxide was 81.4% ± 18.4% predicted at baseline and 95.7% ± 23.5% predicted at 12 months. Conclusion: No unexpected changes were observed to the lungs as illustrated through follow-up PFTs. Long-term follow-up and validation in a larger cohort are needed.
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Affiliation(s)
- Lillie O'steen
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Jason Bellardini
- Department of Medicine, University of Florida College of Medicine, Jacksonville, FL, USA
| | - James Cury
- Department of Medicine, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Lisa Jones
- Department of Medicine, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Vandana K Seeram
- Department of Medicine, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Nancy P Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Bradford S Hoppe
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
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22
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Cardiovascular Damage Induced by Radiotherapy. CARDIOVASCULAR COMPLICATIONS IN CANCER THERAPY 2019. [DOI: 10.1007/978-3-319-93402-0_4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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23
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24
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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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Chow EJ, Antal Z, Constine LS, Gardner R, Wallace WH, Weil BR, Yeh JM, Fox E. New Agents, Emerging Late Effects, and the Development of Precision Survivorship. J Clin Oncol 2018; 36:2231-2240. [PMID: 29874142 PMCID: PMC6053298 DOI: 10.1200/jco.2017.76.4647] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Incremental improvements in the treatment of children and adolescents with cancer have led to 5-year survival rates reaching nearly 85%. In the past decade, impressive progress has been made in understanding the biology of many pediatric cancers. With that understanding, multiple new agents have become available that offer the promise of more-effective and less-toxic treatment. These include agents that target various cell surface antigens and engage the adaptive immune system, as well as those that interfere with key signaling pathways involved in tumor development and growth. For local control, surgery and radiation techniques also have evolved, becoming less invasive or featuring new techniques and particles that more precisely target the tumor and limit the dose to normal tissue. Nevertheless, targeted agents, like conventional chemotherapy, radiotherapy, and surgery, may have off-target effects and deserve long-term follow-up of their safety and efficacy. These include injury to the endocrine, cardiovascular, and immunologic systems. New radiation and surgical techniques that theoretically reduce morbidity and improve long-term quality of life must also be validated with actual patient outcomes. Finally, with advances in genomics, information on host susceptibility to late effects is beginning to emerge. Such knowledge, coupled with improved metrics that better describe the spectrum of potential late effects across the entire lifespan, can lead to the development of decision models that project the potential long-term health outcomes associated with various treatment and follow-up strategies. These developments will help extend the current focus on precision medicine to precision survivorship, where clinicians, patients, and families will have a better grasp of the potential risks, benefits, and tradeoffs associated with the growing number of cancer treatment options.
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Affiliation(s)
- Eric J Chow
- Eric J. Chow and Rebecca Gardner, Fred Hutchinson Cancer Research Center, Seattle Children's Hospital, and University of Washington, Seattle, WA; Zoltan Antal, Weill Cornell Medical College, New York Presbyterian Hospital, and Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; W. Hamish Wallace, Royal Hospital for Sick Children, University of Edinburgh, Edinburgh, United Kingdom; Brent R. Weil and Jennifer M. Yeh, Boston Children's Hospital, Harvard Medical School, Boston, MA; and Elizabeth Fox, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Zoltan Antal
- Eric J. Chow and Rebecca Gardner, Fred Hutchinson Cancer Research Center, Seattle Children's Hospital, and University of Washington, Seattle, WA; Zoltan Antal, Weill Cornell Medical College, New York Presbyterian Hospital, and Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; W. Hamish Wallace, Royal Hospital for Sick Children, University of Edinburgh, Edinburgh, United Kingdom; Brent R. Weil and Jennifer M. Yeh, Boston Children's Hospital, Harvard Medical School, Boston, MA; and Elizabeth Fox, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Louis S Constine
- Eric J. Chow and Rebecca Gardner, Fred Hutchinson Cancer Research Center, Seattle Children's Hospital, and University of Washington, Seattle, WA; Zoltan Antal, Weill Cornell Medical College, New York Presbyterian Hospital, and Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; W. Hamish Wallace, Royal Hospital for Sick Children, University of Edinburgh, Edinburgh, United Kingdom; Brent R. Weil and Jennifer M. Yeh, Boston Children's Hospital, Harvard Medical School, Boston, MA; and Elizabeth Fox, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Rebecca Gardner
- Eric J. Chow and Rebecca Gardner, Fred Hutchinson Cancer Research Center, Seattle Children's Hospital, and University of Washington, Seattle, WA; Zoltan Antal, Weill Cornell Medical College, New York Presbyterian Hospital, and Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; W. Hamish Wallace, Royal Hospital for Sick Children, University of Edinburgh, Edinburgh, United Kingdom; Brent R. Weil and Jennifer M. Yeh, Boston Children's Hospital, Harvard Medical School, Boston, MA; and Elizabeth Fox, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - W Hamish Wallace
- Eric J. Chow and Rebecca Gardner, Fred Hutchinson Cancer Research Center, Seattle Children's Hospital, and University of Washington, Seattle, WA; Zoltan Antal, Weill Cornell Medical College, New York Presbyterian Hospital, and Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; W. Hamish Wallace, Royal Hospital for Sick Children, University of Edinburgh, Edinburgh, United Kingdom; Brent R. Weil and Jennifer M. Yeh, Boston Children's Hospital, Harvard Medical School, Boston, MA; and Elizabeth Fox, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Brent R Weil
- Eric J. Chow and Rebecca Gardner, Fred Hutchinson Cancer Research Center, Seattle Children's Hospital, and University of Washington, Seattle, WA; Zoltan Antal, Weill Cornell Medical College, New York Presbyterian Hospital, and Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; W. Hamish Wallace, Royal Hospital for Sick Children, University of Edinburgh, Edinburgh, United Kingdom; Brent R. Weil and Jennifer M. Yeh, Boston Children's Hospital, Harvard Medical School, Boston, MA; and Elizabeth Fox, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Jennifer M Yeh
- Eric J. Chow and Rebecca Gardner, Fred Hutchinson Cancer Research Center, Seattle Children's Hospital, and University of Washington, Seattle, WA; Zoltan Antal, Weill Cornell Medical College, New York Presbyterian Hospital, and Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; W. Hamish Wallace, Royal Hospital for Sick Children, University of Edinburgh, Edinburgh, United Kingdom; Brent R. Weil and Jennifer M. Yeh, Boston Children's Hospital, Harvard Medical School, Boston, MA; and Elizabeth Fox, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Elizabeth Fox
- Eric J. Chow and Rebecca Gardner, Fred Hutchinson Cancer Research Center, Seattle Children's Hospital, and University of Washington, Seattle, WA; Zoltan Antal, Weill Cornell Medical College, New York Presbyterian Hospital, and Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; W. Hamish Wallace, Royal Hospital for Sick Children, University of Edinburgh, Edinburgh, United Kingdom; Brent R. Weil and Jennifer M. Yeh, Boston Children's Hospital, Harvard Medical School, Boston, MA; and Elizabeth Fox, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
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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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Hoppe BS, Hill-Kayser CE, Tseng YD, Flampouri S, Elmongy HM, Cahlon O, Mendenhall NP, Maity A, McGee LA, Plastaras JP. Consolidative proton therapy after chemotherapy for patients with Hodgkin lymphoma. Ann Oncol 2018; 28:2179-2184. [PMID: 28911093 PMCID: PMC5834068 DOI: 10.1093/annonc/mdx287] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background We investigated early outcomes for patients receiving chemotherapy followed by consolidative proton therapy (PT) for the treatment of Hodgkin lymphoma (HL). Patients and methods From June 2008 through August 2015, 138 patients with HL enrolled on either IRB-approved outcomes tracking protocols or registry studies received consolidative PT. Patients were excluded due to relapsed or refractory disease. Involved-site radiotherapy field designs were used for all patients. Pediatric patients received a median dose of 21 Gy(RBE) [range 15–36 Gy(RBE)]; adult patients received a median dose of 30.6 Gy(RBE) [range, 20–45 Gy(RBE)]. Patients receiving PT were young (median age, 20 years; range 6–57). Overall, 42% were pediatric (≤18 years) and 93% were under the age of 40 years. Thirty-eight percent of patients were male and 62% female. Stage distribution included 73% with I/II and 27% with III/IV disease. Patients predominantly had mediastinal involvement (96%) and bulky disease (57%), whereas 37% had B symptoms. The median follow-up was 32 months (range, 5–92 months). Results The 3-year relapse-free survival rate was 92% for all patients; it was 96% for adults and 87% for pediatric patients (P = 0.18). When evaluated by positron emission tomography/computed tomography scan response at the end of chemotherapy, patients with a partial response had worse 3-year progression-free survival compared with other patients (78% versus 94%; P = 0.0034). No grade 3 radiation-related toxicities have occurred to date. Conclusion Consolidative PT following standard chemotherapy in HL is primarily used in young patients with mediastinal and bulky disease. Early relapse-free survival rates are similar to those reported with photon radiation treatment, and no early grade 3 toxicities have been observed. Continued follow-up to assess late effects is critical.
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Affiliation(s)
- B S Hoppe
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville.,University of Florida Health Proton Therapy Institute, Jacksonville
| | - C E Hill-Kayser
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia
| | - Y D Tseng
- Department of Radiation Oncology, University of Washington, Seattle.,Proton Collaborative Group Registry Membership Site, Warrenville.,Seattle Cancer Care Alliance Proton Therapy Center, Seattle
| | - S Flampouri
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville
| | - H M Elmongy
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia
| | - O Cahlon
- Proton Collaborative Group Registry Membership Site, Warrenville.,Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York.,Procure Proton Therapy Center, Somerset
| | - N P Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville.,University of Florida Health Proton Therapy Institute, Jacksonville
| | - A Maity
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia
| | - L A McGee
- Proton Collaborative Group Registry Membership Site, Warrenville.,Mayo Clinic, Scottsdale, USA
| | - J P Plastaras
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia
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28
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Nanda R, Flampouri S, Mendenhall NP, Indelicato DJ, Jones LM, Seeram VK, Hoppe BS. Pulmonary Toxicity Following Proton Therapy for Thoracic Lymphoma. Int J Radiat Oncol Biol Phys 2017; 99:494-497. [DOI: 10.1016/j.ijrobp.2017.04.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Indexed: 01/17/2023]
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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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Figura N, Flampouri S, Mendenhall NP, Morris CG, McCook B, Ozdemir S, Slayton W, Sandler E, Hoppe BS. Importance of baseline PET/CT imaging on radiation field design and relapse rates in patients with Hodgkin lymphoma. Adv Radiat Oncol 2017; 2:197-203. [PMID: 28740932 PMCID: PMC5514251 DOI: 10.1016/j.adro.2017.01.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 01/10/2017] [Accepted: 01/11/2017] [Indexed: 12/24/2022] Open
Abstract
PURPOSE This study analyzed the impact of pretreatment positron emission tomography/computed tomography (PET/CT) scans on involved site radiation therapy (ISRT) field design and pattern of relapse among patients with Hodgkin lymphoma (HL). METHODS AND MATERIALS Thirty-seven patients with stage I or II HL who received first-line chemotherapy followed by consolidative ISRT to all initial sites of disease were enrolled in an institutional review board-approved outcomes-tracking protocol between January 2009 and December 2014. Patients underwent standard-of-care follow-up. Relapse-free survival (RFS) was evaluated using a Kaplan-Meier analysis and cohort comparisons using a χ2 test. RESULTS Thirty-one patients underwent (PET/CT) scans before chemotherapy and 6 did not because of a lack of insurance (n = 2), inpatient chemotherapy administration (n = 2), scheduling conflicts (n = 1), and unknown reasons (n = 1). The median follow-up was 46 months, and the 4-year RFS rate was 92%. Patients without pretreatment PET imaging were more likely to experience disease relapse (4-year RFS, 97% vs. 67%; P = .001). Among the 6 patients who did not receive a baseline PET/CT scan, all 3 recurrences occurred in lymph node regions outside of, but immediately adjacent to, the radiation field. CONCLUSIONS Patients with stage I/II HL who receive ISRT without pretreatment PET/CT scans appear to have an increased risk for relapse in adjacent nodal stations just outside the radiation field. A larger cohort with a longer follow-up is needed to confirm these findings.
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Affiliation(s)
- Nick Figura
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Stella Flampouri
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Nancy P. Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Christopher G. Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Barry McCook
- Department of Radiology, University of Florida College of Medicine, Jacksonville, Florida
| | - Savas Ozdemir
- Department of Radiology, University of Florida College of Medicine, Jacksonville, Florida
| | - William Slayton
- Division of Hematology & Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Eric Sandler
- Nemours Children’s Specialty Care, Jacksonville, Florida
| | - Bradford S. Hoppe
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida
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Hahn E, Jiang H, Ng A, Bashir S, Ahmed S, Tsang R, Sun A, Gospodarowicz M, Hodgson D. Late Cardiac Toxicity After Mediastinal Radiation Therapy for Hodgkin Lymphoma: Contributions of Coronary Artery and Whole Heart Dose-Volume Variables to Risk Prediction. Int J Radiat Oncol Biol Phys 2017; 98:1116-1123. [PMID: 28721895 DOI: 10.1016/j.ijrobp.2017.03.026] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 02/24/2017] [Accepted: 03/18/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Mediastinal radiation therapy (RT) for Hodgkin lymphoma (HL) is associated with late cardiotoxicity, but there are limited data to indicate which dosimetric parameters are most valuable for predicting this risk. This study investigated which whole heart dosimetric measurements provide the most information regarding late cardiotoxicity, and whether coronary artery dosimetry was more predictive of this outcome than whole heart dosimetry. METHODS AND MATERIALS A random sample of 125 HL patients treated with mediastinal RT was selected, and 3-dimensional cardiac dose-volume data were generated from historical plans using validated methods. Cardiac events were determined by linking patients to population-based datasets of inpatient and same-day hospitalizations and same-day procedures. Variables collected for the whole heart and 3 coronary arteries included the following: Dmean, Dmax, Dmin, dose homogeneity, V5, V10, V20, and V30. Multivariable competing risk regression models were generated for the whole heart and coronary arteries. RESULTS There were 44 cardiac events documented, of which 70% were ischemic. The best multivariable model included the following covariates: whole heart Dmean (hazard ratio [HR] 1.09, P=.0083), dose homogeneity (HR 0.94, P=.0034), male sex (HR 2.31, P=.014), and age (HR 1.03, P=.0049). When any adverse cardiac event was the outcome, models using coronary artery variables did not perform better than models using whole heart variables. However, in a subanalysis of ischemic cardiac events only, the model using coronary artery variables was superior to the whole heart model and included the following covariates: age (HR 1.05, P<.001), volume of left anterior descending artery receiving 5 Gy (HR 0.98, P=.003), and volume of left circumflex artery receiving 20 Gy (HR 1.03, P<.001). CONCLUSION In addition to higher mean heart dose, increasing inhomogeneity in cardiac dose was associated with a greater risk of late cardiac effects. When all types of cardiotoxicity were evaluated, the whole heart variable model outperformed the coronary artery models. However, when events were limited to ischemic cardiotoxicity, the coronary artery-based model was superior.
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Affiliation(s)
- Ezra Hahn
- Radiation Medicine Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Haiyan Jiang
- Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Angela Ng
- Radiation Therapy, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Shaheena Bashir
- Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sameera Ahmed
- Radiation Medicine Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Richard Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Alexander Sun
- Radiation Medicine Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Mary Gospodarowicz
- Radiation Medicine Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - David Hodgson
- Radiation Medicine Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada; Pediatric Oncology Group of Ontario, Toronto, Ontario, Canada.
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Armenian SH, Lacchetti C, Barac A, Carver J, Constine LS, Denduluri N, Dent S, Douglas PS, Durand JB, Ewer M, Fabian C, Hudson M, Jessup M, Jones LW, Ky B, Mayer EL, Moslehi J, Oeffinger K, Ray K, Ruddy K, Lenihan D. Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol 2017; 35:893-911. [DOI: 10.1200/jco.2016.70.5400] [Citation(s) in RCA: 652] [Impact Index Per Article: 93.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Purpose Cardiac dysfunction is a serious adverse effect of certain cancer-directed therapies that can interfere with the efficacy of treatment, decrease quality of life, or impact the actual survival of the patient with cancer. The purpose of this effort was to develop recommendations for prevention and monitoring of cardiac dysfunction in survivors of adult-onset cancers. Methods Recommendations were developed by an expert panel with multidisciplinary representation using a systematic review (1996 to 2016) of meta-analyses, randomized clinical trials, observational studies, and clinical experience. Study quality was assessed using established methods, per study design. The guideline recommendations were crafted in part using the Guidelines Into Decision Support methodology. Results A total of 104 studies met eligibility criteria and compose the evidentiary basis for the recommendations. The strength of the recommendations in these guidelines is based on the quality, amount, and consistency of the evidence and the balance between benefits and harms. Recommendations It is important for health care providers to initiate the discussion regarding the potential for cardiac dysfunction in individuals in whom the risk is sufficiently high before beginning therapy. Certain higher risk populations of survivors of cancer may benefit from prevention and screening strategies implemented during cancer-directed therapies. Clinical suspicion for cardiac disease should be high and threshold for cardiac evaluation should be low in any survivor who has received potentially cardiotoxic therapy. For certain higher risk survivors of cancer, routine surveillance with cardiac imaging may be warranted after completion of cancer-directed therapy, so that appropriate interventions can be initiated to halt or even reverse the progression of cardiac dysfunction.
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Affiliation(s)
- Saro H. Armenian
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Christina Lacchetti
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Ana Barac
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Joseph Carver
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Louis S. Constine
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Neelima Denduluri
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Susan Dent
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Pamela S. Douglas
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Jean-Bernard Durand
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Michael Ewer
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Carol Fabian
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Melissa Hudson
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Mariell Jessup
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Lee W. Jones
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Bonnie Ky
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Erica L. Mayer
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Javid Moslehi
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Kevin Oeffinger
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Katharine Ray
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Kathryn Ruddy
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
| | - Daniel Lenihan
- Saro H. Armenian, City of Hope, Duarte, CA; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Neelima Denduluri, Virginia Cancer Specialists, Arlington, VA; Ana Barac, Medstar Heart Institute, Medstar Washington Hospital Center, Washington, DC; Joseph Carver and Mariell Jessup, University of Pennsylvania; Bonnie Ky, Hospital of the University of Pennsylvania, Philadelphia, PA; Louis S. Constine, University of Rochester Medical Center, Rochester; Lee W. Jones and Kevin Oeffinger,
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Chargari C, Goodman KA, Diallo I, Guy JB, Rancoule C, Cosset JM, Deutsch E, Magne N. Risk of second cancers in the era of modern radiation therapy: does the risk/benefit analysis overcome theoretical models? Cancer Metastasis Rev 2017; 35:277-88. [PMID: 26970966 DOI: 10.1007/s10555-016-9616-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
In the era of modern radiation therapy, the compromise between the reductions in deterministic radiation-induced toxicities through highly conformal devices may be impacting the stochastic risk of second malignancies. We reviewed the clinical literature and evolving theoretical models evaluating the impact of intensity-modulated radiation therapy (IMRT) on the risk of second cancers, as a consequence of the increase in volumes of normal tissues receiving low doses. The risk increase (if any) is not as high as theoretical models have predicted in adults. Moreover, the increase in out-of-field radiation doses with IMRT could be counterbalanced by the decrease in volumes receiving high doses. Clinical studies with short follow-up have not corroborated the hypothesis that IMRT would drastically increase the incidence of second cancers. In children, the risk of radiation-induced carcinogenesis increases from low doses and consequently the relative risk of second cancers after IMRT could be higher than in adults, justifying current developments of proton therapy with priority given to this population. Although only longer follow-up will allow a true assessment of the real impact of these modern techniques on radiation-induced carcinogenesis, a comprehensive risk-adapted strategy will help minimize the probability of second cancers.
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Affiliation(s)
- Cyrus Chargari
- Radiotherapy Department, Hôpital d'Instruction des Armées du Val-de-Grâce, Paris, France.,INSERM 1030, Molecular Radiotherapy, Gustave Roussy campus Cancer, Grand Paris, France
| | - Karyn A Goodman
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ibrahima Diallo
- U1018 Institut National de la Santé et de la Recherche Médicale, Villejuif, France
| | - Jean-Baptiste Guy
- Cellular and Molecular Radiotherapy Laboratory, EMR3738, 69921, Oullins, France.,Department of Radiotherapy, Lucien Neuwirth Cancer Institute, Saint Priest en Jarez, France
| | - Chloe Rancoule
- Department of Radiotherapy, Lucien Neuwirth Cancer Institute, Saint Priest en Jarez, France
| | - Jean-Marc Cosset
- Oncology/Radiotherapy Department, Institut Curie, 75005, Paris, France.,Charlebourg-La Défense Radiotherapy Center, Amethyst Group, La Garenne-Colombes, 92250, Paris, France
| | - Eric Deutsch
- INSERM 1030, Molecular Radiotherapy, Gustave Roussy campus Cancer, Grand Paris, France
| | - Nicolas Magne
- Cellular and Molecular Radiotherapy Laboratory, EMR3738, 69921, Oullins, France. .,Department of Radiotherapy, Lucien Neuwirth Cancer Institute, Saint Priest en Jarez, France. .,Chef du Département de Radiothérapie, Directeur de la Recherche et de l'Innovation, Institut de Cancérologie Lucien Neuwirth, 108 bis, avenue Albert Raimond, BP 60008, 42270, Saint-Priest en Jarez cedex, France.
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Hoppe BS, Tsai H, Larson G, Laramore GE, Vargas C, Tseng YD, Dunn M, McGee L, Cahlon O, Hartsell W. Proton therapy patterns-of-care and early outcomes for Hodgkin lymphoma: results from the Proton Collaborative Group Registry. Acta Oncol 2016; 55:1378-1380. [PMID: 27579554 DOI: 10.1080/0284186x.2016.1197422] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Bradford S. Hoppe
- University of Florida Health Proton Therapy Institute, Jacksonville, Florida, USA
| | - Henry Tsai
- Procure Proton Therapy Center, Somerset, New Jersey, USA
| | - Gary Larson
- Procure Proton Therapy Center, Oklahoma City, Oklahoma, USA
| | - George E. Laramore
- Seattle Cancer Care Alliance Proton Therapy Center, Seattle, Washington, USA
| | | | - Yolanda D. Tseng
- Seattle Cancer Care Alliance Proton Therapy Center, Seattle, Washington, USA
| | - Megan Dunn
- Chicago Proton Center, Warrenville, Illinois, USA
| | - Lisa McGee
- Chicago Proton Center, Warrenville, Illinois, USA
| | - Oren Cahlon
- Memorial Sloan-Kettering Cancer Center, New York City, New York, USA
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36
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Gastaud L, Rossignol B, Peyrade F, Ré D, Thariat J, Thyss A, Doyen J. Place de la radiothérapie dans la prise en charge des lymphomes malins non hodgkiniens. Cancer Radiother 2016; 20:236-47. [DOI: 10.1016/j.canrad.2016.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 12/27/2015] [Accepted: 01/29/2016] [Indexed: 12/11/2022]
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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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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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Doyen J, Falk AT, Floquet V, Hérault J, Hannoun-Lévi JM. Proton beams in cancer treatments: Clinical outcomes and dosimetric comparisons with photon therapy. Cancer Treat Rev 2016; 43:104-12. [PMID: 26827698 DOI: 10.1016/j.ctrv.2015.12.007] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 12/24/2015] [Accepted: 12/29/2015] [Indexed: 12/25/2022]
Abstract
PURPOSE To review current evidence of the role of proton therapy (PT) in other tumors than skull base, sinusal/parasinusal, spinal and pediatric tumors; to determine medico-economic aspects raised by PT. MATERIAL AND METHODS A systematic review on Medline was performed with the following keywords: proton therapy, proton beam, protontherapy, cancer; publications with comparison between PT and photon-therapy were also selected. RESULTS In silico studies have shown superiority (better dose delivery to the target and/or to organs at risk) of PT toward photon-therapy in most of thoracic and abdominal malignant tumors. Potential benefits of PT could be: reduction of toxicities (including radiation-induced cancer), increase of tumor control through a dose-escalation approach, hypofractionation. Cost of treatment is always cited as an issue which actually can be managed by a precise patient selection making PT a cost-effective procedure. Comparison plan with photon therapy may be useful to determine the dosimetric and clinical advantages of PT (Normal Tissue Complications Probability). CONCLUSION PT may be associated with a great advantage compared to the best photon-therapies in various types of cancers. Accumulation of clinical data is on-going and will challenge the in silico data analysis. Some indications are associated with strong superiority of PT and may be discussed as a new standard within prospective observational studies.
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Affiliation(s)
- Jérôme Doyen
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Nice-Sophia, Nice, France
| | - Alexander Tuan Falk
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Nice-Sophia, Nice, France
| | - Vincent Floquet
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Nice-Sophia, Nice, France
| | - Joël Hérault
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Nice-Sophia, Nice, France
| | - Jean-Michel Hannoun-Lévi
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Nice-Sophia, Nice, France.
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Abstract
Hodgkin lymphoma and non-Hodgkin lymphoma are common hematologic malignancies with such a favorable prognosis that many survivors live decades after combined chemotherapy and radiotherapy. These survivors, however, are at risk of developing late treatment adverse effects from collateral damage, including secondary malignancies, cardiac toxicities, and ischemic heart diseases. Recent efforts have successfully reduced the radiation dose and treatment field without compromising cure rates. Proton therapy has the potential of further lowering the treatment-related toxicity owing to its ability to deposit a high dose only at the target. Although this finding has been supported by several current dosimetric studies, its utilization in the management of lymphoma has been limited during the past 5 years because of the paucity of facilities and the difficulty of obtaining insurance coverage. With diligent follow-up, the clinical impact of proton therapy will be established to improve the therapeutic ratio and to reduce late treatment-related morbidity.
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The concept and evolution of involved site radiation therapy for lymphoma. Int J Clin Oncol 2015; 20:849-54. [DOI: 10.1007/s10147-015-0863-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 06/14/2015] [Indexed: 01/22/2023]
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Abstract
Hodgkin lymphoma has gone from an incurable disease to one for which the majority of patients will be cured. Combined chemotherapy and radiotherapy achieves the best disease control rates and results in many long-term survivors. As a result, a majority of long-term Hodgkin lymphoma survivors live to experience severe late treatment-related complications, especially cardiovascular disease and second malignancies. The focus of research and treatment for Hodgkin lymphoma is to maintain the current high rates of disease control while reducing treatment-related morbidity and mortality. Efforts to reduce late treatment complications focus on improvements in both systemic therapies and radiotherapy. Herein we review the basis for the benefits of proton therapy over conventional X-ray therapy. We review outcomes of Hodgkin lymphoma treated with proton therapy, and discuss the ability of protons to reduce radiation dose to organs at risk and the impact on the most significant late complications related to the treatment.
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Sachsman S, Flampouri S, Li Z, Lynch J, Mendenhall NP, Hoppe BS. Proton therapy in the management of non-Hodgkin lymphoma. Leuk Lymphoma 2015; 56:2608-12. [PMID: 25669925 PMCID: PMC4732409 DOI: 10.3109/10428194.2015.1014364] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Proton therapy (PT) is a highly conformal type of radiation therapy that can target the tumor while sparing dose to surrounding normal tissues. This study reviews a single institution's experience managing patients with non-Hodgkin lymphoma (NHL) treated with PT. Eleven patients with NHL were treated with PT from January 2008 to January 2014 on an institutional review board-approved outcomes tracking protocol, and included patients with indolent orbital lymphoma (n = 4), primary mediastinal B-cell lymphoma (n = 3), plasmablastic lymphoma (n = 2) and natural killer (NK) T-cell lymphoma (n = 2). The median follow-up was 38 months. The 2-year rate of local control was 91%, with one patient with NK T-cell lymphoma having recurrence in-field. Toxicities were limited to grade 2 at highest, during follow-up. PT is a feasible and effective treatment for NHL. Early outcomes are favorable. Longer follow-up and more patients are needed to confirm our findings.
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Affiliation(s)
- Suzanne Sachsman
- a University of Florida Proton Therapy Institute , Jacksonville , FL , USA
| | - Stella Flampouri
- a University of Florida Proton Therapy Institute , Jacksonville , FL , USA
| | - Zuofeng Li
- a University of Florida Proton Therapy Institute , Jacksonville , FL , USA
| | - James Lynch
- b Department of Hematology and Oncology , University of Florida, College of Medicine , Gainesville , FL , USA
| | - Nancy P Mendenhall
- a University of Florida Proton Therapy Institute , Jacksonville , FL , USA
| | - Bradford S Hoppe
- a University of Florida Proton Therapy Institute , Jacksonville , FL , USA
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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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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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Ladra MM, Edgington SK, Mahajan A, Grosshans D, Szymonifka J, Khan F, Moteabbed M, Friedmann AM, MacDonald SM, Tarbell NJ, Yock TI. A dosimetric comparison of proton and intensity modulated radiation therapy in pediatric rhabdomyosarcoma patients enrolled on a prospective phase II proton study. Radiother Oncol 2014; 113:77-83. [PMID: 25443861 DOI: 10.1016/j.radonc.2014.08.033] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 08/10/2014] [Accepted: 08/12/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Pediatric rhabdomyosarcoma (RMS) is highly curable, however, cure may come with significant radiation related toxicity in developing tissues. Proton therapy (PT) can spare excess dose to normal structures, potentially reducing the incidence of adverse effects. METHODS Between 2005 and 2012, 54 patients were enrolled on a prospective multi-institutional phase II trial using PT in pediatric RMS. As part of the protocol, intensity modulated radiation therapy (IMRT) plans were generated for comparison with clinical PT plans. RESULTS Target coverage was comparable between PT and IMRT plans with a mean CTV V95 of 100% for both modalities (p=0.82). However, mean integral dose was 1.8 times higher for IMRT (range 1.0-4.9). By site, mean integral dose for IMRT was 1.8 times higher for H&N (p<0.01) and GU (p=0.02), 2.0 times higher for trunk/extremity (p<0.01), and 3.5 times higher for orbit (p<0.01) compared to PT. Significant sparing was seen with PT in 26 of 30 critical structures assessed for orbital, head and neck, pelvic, and trunk/extremity patients. CONCLUSIONS Proton radiation lowers integral dose and improves normal tissue sparing when compared to IMRT for pediatric RMS. Correlation with clinical outcomes is necessary once mature long-term toxicity data are available.
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Affiliation(s)
- Matthew M Ladra
- Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | | | - Anita Mahajan
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - David Grosshans
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | | | - Fazal Khan
- Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Maryam Moteabbed
- Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | | | | | - Nancy J Tarbell
- Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Torunn I Yock
- Massachusetts General Hospital, Harvard Medical School, Boston, USA.
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Rombi B, Vennarini S, Vinante L, Ravanelli D, Amichetti M. Proton radiotherapy for pediatric tumors: review of first clinical results. Ital J Pediatr 2014; 40:74. [PMID: 25260976 PMCID: PMC4421929 DOI: 10.1186/s13052-014-0074-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 08/04/2014] [Indexed: 12/03/2022] Open
Abstract
Radiation therapy is a part of multidisciplinary management of several childhood cancers. Proton therapy is a new method of irradiation, which uses protons instead of photons. Proton radiation has been used safely and effectively for medulloblastoma, primitive neuro-ectodermal tumors, craniopharyngioma, ependymoma, germ cell intracranial tumors, low-grade glioma, retinoblastoma, rhabdomyosarcoma and other soft tissue sarcomas, Ewing’s sarcoma and other bone sarcomas. Moreover, other possible applications are emerging, in particular for lymphoma and neuroblastoma. Although both photon and proton techniques allow similar target volume coverage, the main advantage of proton radiation therapy is to sparing of intermediate-to-low-dose to healthy tissues. This characteristic could translate into clinical reduction of side effects, including a lower risk for secondary cancers. The following review presents the state of the art of proton therapy in the treatment of pediatric malignancies.
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Affiliation(s)
- Barbara Rombi
- Unità Operativa di Protonterapia, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy.
| | - Sabina Vennarini
- Unità Operativa di Protonterapia, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy.
| | - Lorenzo Vinante
- Unità Operativa di Protonterapia, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy. .,Dipartimento di Medicina, Università di Padova, Padova, Italy.
| | - Daniele Ravanelli
- Unità Operativa di Protonterapia, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy.
| | - Maurizio Amichetti
- Unità Operativa di Protonterapia, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy.
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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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