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Dallavalle S, Campagnoli G, Pastena P, Martinino A, Schiliró D, Giovinazzo F. New Frontiers in Pancreatic Cancer Management: Current Treatment Options and the Emerging Role of Neoadjuvant Therapy. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1070. [PMID: 39064499 PMCID: PMC11278520 DOI: 10.3390/medicina60071070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 06/24/2024] [Accepted: 06/24/2024] [Indexed: 07/28/2024]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) ranks among the 15 most prevalent cancers globally, characterized by aggressive growth and late-stage diagnosis. Advances in imaging and surgical techniques have redefined the classification of pancreatic PDAC into resectable, borderline resectable, and locally advanced pancreatic cancer. While surgery remains the most effective treatment, only 20% of patients are eligible at diagnosis, necessitating innovative strategies to improve outcomes. Therefore, traditional treatment paradigms, primarily surgical resection for eligible patients, are increasingly supplemented by neoadjuvant therapies (NAT), which include chemotherapy, radiotherapy, or a combination of both. By administering systemic therapy prior to surgery, NAT aims to reduce tumor size and increase the feasibility of complete surgical resection, thus enhancing overall survival rates and potentially allowing more patients to undergo curative surgeries. Recent advances in treatment protocols, such as FOLFIRINOX and gemcitabine-nab-paclitaxel, now integral to NAT strategies, have shown promising results in increasing the proportion of patients eligible for surgery by effectively reducing tumor size and addressing micrometastatic disease. Additionally, they offer improved response rates and survival benefits compared to traditional regimes. Despite these advancements, the role of NAT continues to evolve, necessitating ongoing research to optimize treatment regimens, minimize adverse effects, and identify patient populations that would benefit most from these approaches. Through a detailed analysis of current literature and recent clinical trials, this review highlights the transformative potential of NAT in managing PDAC, especially in patients with borderline resectable or locally advanced stages, promising a shift towards more personalized and effective management strategies for PDAC.
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Affiliation(s)
- Sofia Dallavalle
- Faculty of Medicine and Surgery, University of Milan, 20122 Milan, Italy; (S.D.); (G.C.)
| | - Gabriele Campagnoli
- Faculty of Medicine and Surgery, University of Milan, 20122 Milan, Italy; (S.D.); (G.C.)
| | - Paola Pastena
- Department of Medicine, Stony Brook Medicine, Stony Brook, NY 11794, USA;
| | | | - Davide Schiliró
- Department of Surgery, Duke University, Durham, NC 27710, USA
| | - Francesco Giovinazzo
- Department of Surgery, Saint Camillus Hospital, 31100 Treviso, Italy
- Department of Surgery, UniCamillus-Saint Camillus International University of Health Sciences, 00131 Rome, Italy
- Department of Surgery, Agostino Gemelli University Hospital, 00168 Rome, Italy
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Piao Y, Chen H, Yuan F, Fan J, Wu S, Li X, Yang D. Active Breathing Coordinator reduces radiation dose to the stomach in patients with left breast cancer. Acta Oncol 2023; 62:1873-1879. [PMID: 37909907 DOI: 10.1080/0284186x.2023.2275288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/22/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND/PURPOSE Gastric dose parameters comparison for deep inspiration breath-hold (DIBH) or free breathing (FB) mode during radiotherapy (RT) for left-sided breast cancer patients (LSBCPs) has not been investigated before. This study aimed to analyze the impact of Active Breath Coordinator (ABC)-DIBH technique on the dose received by the stomach during RT for LSBCPs and to provide organ-specific dosimetric parameters. MATERIALS AND METHODS The study included 73 LSBCPs. The dosimetric parameters of the stomach were compared between FB and DIBH mode. The correlation between the stomach volume and dosimetric parameters was analyzed. RESULTS Compared to FB mode, statistically significant reductions were observed in gastric dose parameters in ABC-DIBH mode, including Dmax (46.60 vs 17.25, p < 0.001), D1cc (38.42 vs 9.60, p < 0.001), Dmean (4.10 vs 0.80, p < 0.001), V40Gy (0.50 vs 0.00, p < 0.001), V30Gy (6.30 vs 0.00, p < 0.001), V20Gy (20.80 vs 0.00, p < 0.001), V10Gy (51.10 vs 0.77, p < 0.001), and V5Gy (93.20 vs 9.60, p < 0.001). ABC-DIBH increased the distance between the stomach and the breast PTV when compared to FB, from 1.3 cm to 2.8 cm (p < 0.001). Physiologic decrease in stomach volume was not found from FB to ABC-DIBH (415.54 cm3 vs 411.61 cm3, p = 0.260). The stomach volume showed a positive correlation with V40Gy (r2 = 0.289; p < 0.05), V30Gy (r2 = 0.287; p < 0.05), V20Gy (r2 = 0.343; p < 0.05), V10Gy (r2 = 0.039; p < 0.001), V5Gy (r2 = 0.439; p < 0.001), Dmax (r2 = 0.269; p < 0.05) and D1cc (r2 = 0.278; p < 0.05) in FB mode. While in ABC-DIBH mode, most stomach dosimetric parameters were not correlated with gastric volume. CONCLUSIONS The implementation of ABC-DIBH in LSBCPs radiotherapy resulted in lower irradiation of the stomach. Larger stomach volume was associated with statistically significantly higher dose irradiation in FB mode. To reduce radiotherapy related side effects in FB mode, patients should be fast for at least 2 hours before the CT simulation and treatment.
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Affiliation(s)
- Ying Piao
- Department of Radiation Oncology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, People's Republic of China
| | - Hongtao Chen
- Department of Radiation Oncology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, People's Republic of China
| | - Fengshun Yuan
- Sichuan Provincial Center for Disease Control and Prevention, Center for AIDS/STD Control and Prevention, Chengdu, Sichuan, People's Republic of China
| | - Juan Fan
- Department of Radiation Oncology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, People's Republic of China
| | - Shihai Wu
- Department of Radiation Oncology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, People's Republic of China
| | - Xianming Li
- Department of Radiation Oncology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, People's Republic of China
| | - Dong Yang
- Department of Radiation Oncology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, People's Republic of China
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Chen G, Yu Z, Zhang Y, Liu S, Chen C, Zhang S. Radiation-induced gastric injury during radiotherapy: molecular mechanisms and clinical treatment. JOURNAL OF RADIATION RESEARCH 2023; 64:870-879. [PMID: 37788485 PMCID: PMC10665304 DOI: 10.1093/jrr/rrad071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/08/2023] [Indexed: 10/05/2023]
Abstract
Radiotherapy (RT) has been the standard of care for treating a multitude of cancer types. Radiation-induced gastric injury (RIGI) is a common complication of RT for thoracic and abdominal tumors. It manifests acutely as radiation gastritis or gastric ulcers, and chronically as chronic atrophic gastritis or intestinal metaplasia. In recent years, studies have shown that intracellular signals such as oxidative stress response, p38/MAPK pathway and transforming growth factor-β signaling pathway are involved in the progression of RIGI. This review also summarized the risk factors, diagnosis and treatment of this disease. However, the root of therapeutic challenges lies in the incomplete understanding of the mechanisms. Here, we also highlight the potential mechanistic, diagnostic and therapeutic directions of RIGI.
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Affiliation(s)
- Guangxia Chen
- Department of Gastroenterology, The First People’s Hospital of Xuzhou, Xuzhou Municipal Hospital Affiliated to Xuzhou Medical University, Xuzhou 221200, China
| | - Zuxiang Yu
- Laboratory of Radiation Medicine, West China School of Basic Medical Sciences and Forensic Medicine, Sichuan University, Chengdu 610041, China
| | - Yuehua Zhang
- Laboratory of Radiation Medicine, West China School of Basic Medical Sciences and Forensic Medicine, Sichuan University, Chengdu 610041, China
| | - Shiyu Liu
- Department of Gastroenterology, The First People’s Hospital of Xuzhou, Xuzhou Municipal Hospital Affiliated to Xuzhou Medical University, Xuzhou 221200, China
| | - Chong Chen
- Department of Gastroenterology, The First People’s Hospital of Xuzhou, Xuzhou Municipal Hospital Affiliated to Xuzhou Medical University, Xuzhou 221200, China
| | - Shuyu Zhang
- Laboratory of Radiation Medicine, West China School of Basic Medical Sciences and Forensic Medicine, Sichuan University, Chengdu 610041, China
- Department of Nuclear Medicine, The Second Affiliated Hospital of Chengdu Medical College, China National Nuclear Corporation 416 Hospital , Chengdu 610051, China
- NHC Key Laboratory of Nuclear Technology Medical Transformation (Mianyang Central Hospital), Mianyang 621099, China
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Ogata T, Aibe N, Kimoto T, Takenaka T, Suzuki G, Yamada K, Yamazaki H. Comparative dosimetric study of spot-scanning proton therapy versus volumetric-modulated radiation therapy for extrahepatic bile duct cancer. Med Dosim 2023; 49:46-49. [PMID: 37925300 DOI: 10.1016/j.meddos.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/05/2023] [Accepted: 10/05/2023] [Indexed: 11/06/2023]
Abstract
This study aimed to compare the dose distributions and clarify the dosimetric characteristics of spot-scanning proton therapy (SSPT) and photon volumetric modulated arc therapy (VMAT) for extrahepatic bile duct cancer (EBDC). This retrospective study included 10 patients with EBDC treated with real-time image-gated SSPT. Using the simultaneous integrated boost technique, the 2 prescription dose levels for planning target volumes were 72.6 and 44 Gy, delivered in 22 fractions. Plan quality comparisons were conducted by analyzing various parameters, including homogeneity, conformity, dose to organs at risk, and normal tissue complication probability (NTCP) for radiation-induced liver damage (RILD). The target dose distributions using SSPT were almost equivalent to those achieved using photon VMAT. There was a significant reduction in all liver dose parameters, the NTCP value for RILD, and kidney dose (mean, V12 Gy, and V18 Gy) in SSPT than in photon VMAT. No significant differences were observed in the intestinal doses in the high-dose area. Thus, compared with photon VMAT, SSPT for EBDC significantly reduced radiation doses to the liver and kidneys and has shown potential clinical benefits of reduced radiation-induced toxicity.
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Affiliation(s)
- Toshiyuki Ogata
- Department of Radiology, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566 Japan.
| | - Norihiro Aibe
- Department of Radiology, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566 Japan
| | - Takuya Kimoto
- Department of Radiology, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566 Japan
| | - Tadashi Takenaka
- Department of Radiology, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566 Japan
| | - Gen Suzuki
- Department of Radiology, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566 Japan
| | - Kei Yamada
- Department of Radiology, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566 Japan
| | - Hideya Yamazaki
- Department of Radiology, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566 Japan
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Das R, Abbott MR, Hadley SW, Sahai V, Bednar F, Evans JR, Schipper MJ, Lawrence TS, Cuneo KC. Predictors of Acute and Late Toxicity in Patients Receiving Chemoradiation for Unresectable Pancreatic Cancer. Adv Radiat Oncol 2023; 8:101266. [PMID: 38047228 PMCID: PMC10692286 DOI: 10.1016/j.adro.2023.101266] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 04/28/2023] [Indexed: 12/05/2023] Open
Abstract
Purpose Patients with pancreatic cancer undergoing chemoradiation therapy may experience acute and chronic side effects. We conducted an exploratory analysis of patients with locally advanced pancreatic cancer (LAPC) undergoing definitive chemoradiation to identify factors influencing the occurrence of gastrointestinal (GI) bleeding, short-term radiation side effects, patterns of failure, and survival. Methods and Materials Under an institutional review board-approved protocol, we retrospectively studied patients with LAPC treated with chemoradiation. Statistical models were used to test associations between clinical characteristics and outcomes, including upper GI bleeding, radiation treatment breaks, and weight loss during therapy. Results Between 1999 and 2012, 211 patients were treated with radiation for pancreatic cancer. All patients received concurrent chemotherapy with either gemcitabine (174) or 5-fluorouracil (27), and 67 received intensity modulated radiation therapy (IMRT). Overall, 18 patients experienced an upper GI bleed related to treatment, with 70% of bleeds occurring in the stomach or duodenum, and among those patients, 11 (61%) patients had a pancreatic head tumor and 17 (94%) patients had a metallic biliary stent. IMRT was associated with decreased risk of postradiation nausea (odds ratio, 0.27 [0.11, 0.67], P = .006) compared with 3-dimensional conformal radiation. Regarding long-term toxicities, patients with a metallic biliary stent at the time of radiation therapy were at a significantly higher risk of developing upper GI bleeding (unadjusted hazard ratio [HR], 15.41 [2.02, 117.42], P = .008), even after controlling for radiation treatment modality and prescribed radiation dose (adjusted HR, 17.38 [2.26, 133.58], P = .006). Furthermore, biliary stent placement was associated with a higher risk of death (HR, 1.99 [1.41, 2.83], P < .001) after adjusting for demographic, treatment-related, and patient-related variables. Conclusions Metallic biliary stents may be associated with an increased risk of upper GI bleeding and mortality. Furthermore, IMRT was associated with less nausea and short-term toxicity compared with 3-dimensional conformal therapy.
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Affiliation(s)
- Rishi Das
- Department of Internal Medicine, University of Southern California, Los Angeles, California
| | - Madeline R. Abbott
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Scott W. Hadley
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Vaibhav Sahai
- Department of Internal Medicine, Hematology and Oncology, University of Michigan, Ann Arbor, Michigan
| | - Filip Bednar
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Joseph R. Evans
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Matthew J. Schipper
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | | | - Kyle C. Cuneo
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
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Ogawa A, Yoshimura M, Nakamura M, Adachi T, Iwai T, Ashida R, Mizowaki T. Impact of planning organ at risk volume margins and matching method on late gastrointestinal toxicity in moderately hypofractionated IMRT for locally advanced pancreatic ductal adenocarcinoma. Radiat Oncol 2023; 18:103. [PMID: 37337247 PMCID: PMC10280835 DOI: 10.1186/s13014-023-02288-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 05/24/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND This study examined the differences in late gastrointestinal (GI) toxicities in moderately hypofractionated intensity-modulated radiation therapy (IMRT) for locally advanced pancreatic ductal adenocarcinoma (LA-PDAC) by changing the planning organs at risk volume (PRV) margin and the target matching method and assessed the causes of adverse events. METHODS We examined 37 patients with LA-PDAC who underwent moderately hypofractionated IMRT between 2016 and 2020 at our institution; 23 patients were treated with wide PRV margins and soft tissue matching (Protocol A) and 14 with narrow PRV margins and fiducial marker matching (Protocol B). The GI toxicities, local control (LC) rate, and overall survival (OS) were assessed for each protocol. The initially planned and daily doses to the gross tumor volume (GTV), stomach, and duodenum, reproduced from cone-beam computed tomography, were evaluated. RESULTS The late GI toxicity rate of grades 3-4 was higher in Protocol B (42.9%) than in Protocol A (4.3%). Although the 2-year LC rates were significantly higher in Protocol B (90.0%) than in Protocol A (33.3%), no significant difference was observed in OS rates. In the initial plan, no deviations were found for the stomach and duodenum from the dose constraints in either protocol. In contrast, daily dose evaluation for the stomach to duodenal bulb revealed that the frequency of deviation of V3 Gy per session was 44.8% in Protocol B, which was significantly higher than the 24.3% in Protocol A. CONCLUSIONS Reducing PRV margins with fiducial marker matching increased GI toxicities in exchange for improved LC. Daily dose analysis indicated the trade-off between the GTV dose coverage and the irradiated doses to the GI. This study showed that even with strict matching methods, the PRV margin could not be reduced safely because of GI inter-fractional error, which is expected to be resolved with online adaptive radiotherapy.
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Affiliation(s)
- Ayaka Ogawa
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Michio Yoshimura
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Mitsuhiro Nakamura
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
- Department of Advanced Medical Physics, Graduate School of Medicine, Kyoto University, 53 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Takanori Adachi
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Takahiro Iwai
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Ryo Ashida
- Department of Radiation Oncology, Kobe City Medical Center General Hospital, 2-1-1, Minatojima Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
| | - Takashi Mizowaki
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
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Broggi S, Passoni P, Tiberio P, Cicchetti A, Cattaneo GM, Longobardi B, Mori M, Reni M, Slim N, Del Vecchio A, Di Muzio NG, Fiorino C. Stomach and duodenum dose-volume constraints for locally advanced pancreatic cancer patients treated in 15 fractions in combination with chemotherapy. Front Oncol 2023; 12:983984. [PMID: 36761419 PMCID: PMC9902495 DOI: 10.3389/fonc.2022.983984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 12/19/2022] [Indexed: 01/25/2023] Open
Abstract
Purpose To assess dosimetry predictors of gastric and duodenal toxicities for locally advanced pancreatic cancer (LAPC) patients treated with chemo-radiotherapy in 15 fractions. Methods Data from 204 LAPC patients treated with induction+concurrent chemotherapy and radiotherapy (44.25 Gy in 15 fractions) were available. Forty-three patients received a simultaneous integrated boost of 48-58 Gy. Gastric/duodenal Common Terminology Criteria for Adverse Events v. 5 (CTCAEv5) Grade ≥2 toxicities were analyzed. Absolute/% duodenal and stomach dose-volume histograms (DVHs) of patients with/without toxicities were compared: the most predictive DVH points were identified, and their association with toxicity was tested in univariate and multivariate logistic regressions together with near-maximum dose (D0.03) and selected clinical variables. Results Toxicity occurred in 18 patients: 3 duodenal (ulcer and duodenitis) and 10 gastric (ulcer and stomatitis); 5/18 experienced both. At univariate analysis, V44cc (duodenum: p = 0.02, OR = 1.07; stomach: p = 0.01, OR = 1.12) and D0.03 (p = 0.07, OR = 1.19; p = 0.008, OR = 1.12) were found to be the most predictive parameters. Stomach/duodenum V44Gy and stomach D0.03 were confirmed at multivariate analysis and found to be sufficiently robust at internal, bootstrap-based validation; the results regarding duodenum D0.03 were less robust. No clinical variables or %DVH was significantly associated with toxicity. The best duodenum cutoff values were V44Gy < 9.1 cc (and D0.03 < 47.6 Gy); concerning the stomach, they were V44Gy < 2 cc and D0.03 < 45 Gy. The identified predictors showed a high negative predictive value (>94%). Conclusion In a large cohort treated with hypofractionated radiotherapy for LAPC, the risk of duodenal/gastric toxicities was associated with duodenum/stomach DVH. Constraining duodenum V44Gy < 9.1 cc, stomach V44Gy < 2 cc, and stomach D0.03 < 45 Gy should keep the toxicity rate at approximately or below 5%. The association with duodenum D0.03 was not sufficiently robust due to the limited number of events, although results suggest that a limit of 45-46 Gy should be safe.
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Affiliation(s)
- Sara Broggi
- Medical Physics, San Raffaele Scientific Institute, Milano, Italy
| | - Paolo Passoni
- Radiotherapy, San Raffaele Scientific Institute, Milano, Italy
| | - Paolo Tiberio
- Medical Physics, San Raffaele Scientific Institute, Milano, Italy
| | - Alessandro Cicchetti
- Medical Physics, San Raffaele Scientific Institute, Milano, Italy
- Unit of Data Science, Department of Epidemiology and Data Science, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | | | - Martina Mori
- Medical Physics, San Raffaele Scientific Institute, Milano, Italy
| | - Michele Reni
- Oncology, San Raffaele Scientific Institute, Milano, Italy
- Vita-Salute San Raffaele University, Milano, Italy
| | - Najla Slim
- Radiotherapy, San Raffaele Scientific Institute, Milano, Italy
| | | | - Nadia G. Di Muzio
- Radiotherapy, San Raffaele Scientific Institute, Milano, Italy
- Vita-Salute San Raffaele University, Milano, Italy
| | - Claudio Fiorino
- Medical Physics, San Raffaele Scientific Institute, Milano, Italy
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Umezawa R, Nakagawa K, Mizuma M, Katsuta Y, Tanaka S, Kadoya N, Suzuki Y, Takeda K, Takahashi N, Yamamoto T, Unno M, Jingu K. Comparison of acute gastrointestinal toxicities between 3-dimensional conformal radiotherapy and intensity-modulated radiotherapy including prophylactic regions in chemoradiotherapy with S-1 for pancreatic cancer-importance of dose volume histogram parameters in the stomach as the predictive factors. JOURNAL OF RADIATION RESEARCH 2022; 63:856-865. [PMID: 35993332 PMCID: PMC9726699 DOI: 10.1093/jrr/rrac049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/28/2022] [Indexed: 06/15/2023]
Abstract
The purpose of this study was to compare acute gastrointestinal (GI) toxicities in patients who underwent 3-dimensional conformal radiotherapy (3DCRT) and intensity-modulated radiotherapy (IMRT) in chemoradiotherapy (CRT) with S-1 including prophylactic regions for pancreatic cancer. We also investigated the predictive factor of acute GI toxicities in dose volume histogram (DVH) parameters. Patients who received CRT with S-1 for pancreatic cancer between January 2014 and March 2021 were included. Radiotherapy (RT) with a total dose of 50-54 Gy was delivered. We examined the differences in the frequencies of acute GI toxicity of grade 2 or higher and DVH parameters of the stomach (ST) and duodenum (DU) between the 3DCRT group and the IMRT group. The RT-related predictive factors of acute GI toxicities were investigated by univariate and multivariate analyses. There were 25 patients in the 3DCRT group and 31 patients in the IMRT group. The frequencies of acute GI toxicity of G2 or higher were 36% in the 3DCRT group and 9.7% in the IMRT group (p = 0.035). ST V50 was the most predictive factor (p = 0.001), and the incidences of acute GI toxicity of G2 or higher in ST V50 ≥ 4.1 cc and < 4.1cc were 43.7% and 7.7%, respectively. ST V40 was also a significant predictive factor of acute GI toxicity (p = 0.002). IMRT could reduce acute GI toxicities in CRT with S-1 including prophylactic regions for pancreatic cancer. Acute GI toxicities may be affected by moderate to high doses to the ST.
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Affiliation(s)
- Rei Umezawa
- Corresponding author. Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1, Seiryou-machi, Aobaku, Sendai 980-8574, Japan. Tel: +81-22-717-7312; Fax: +81-22-717-7316; E-mail:
| | - Kei Nakagawa
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masamichi Mizuma
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshiyuki Katsuta
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shohei Tanaka
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Noriyuki Kadoya
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yu Suzuki
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kazuya Takeda
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Noriyoshi Takahashi
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takaya Yamamoto
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Keiichi Jingu
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
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Ogawa A, Nakamura M, Iramina H, Yoshimura M, Mizowaki T. Potential utility of cone-beam CT-guided adaptive radiotherapy under end-exhalation breath-hold conditions for pancreatic cancer. J Appl Clin Med Phys 2022; 24:e13827. [PMID: 36316795 PMCID: PMC9924116 DOI: 10.1002/acm2.13827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/15/2022] [Accepted: 10/07/2022] [Indexed: 02/14/2023] Open
Abstract
PURPOSE The purpose of this study was to demonstrate the potential utility of cone-beam computed tomography (CBCT)-guided online adaptive radiotherapy (ART) under end-exhalation breath-hold (EE-BH) conditions for pancreatic cancer (PC). METHODS Eleven PC patients who underwent 15-fraction volumetric-modulated arc therapy under EE-BH conditions were included. Planning CT images and daily 165 CBCT images were imported into a dedicated treatment planning system. The prescription dose was set to 48 Gy in 15 fractions. The reference plan was automatically generated along with predefined clinical goals. After segmentation was completed on CBCT images, two different plans were generated: One was an adapted (ADP) plan in which re-optimization was performed on the anatomy of the day, and the other was a scheduled (SCH) plan, which was the same as the reference plan. The dose distributions calculated using the synthetic CT created from both planning CT and CBCT were compared between the two plans. Independent calculation-based quality assurance was also performed for the ADP plans, with a gamma passing rate of 3%/3 mm. RESULTS All clinical goals were successfully achieved during the reference plan generation. Of the 165 sessions, gross tumor volume D98% and clinical target volume D98% were higher in 100 (60.1%) and 122 (74.0%) ADP fractions. In each fraction, the V3 Gy < 1 cm3 of the stomach and duodenum was violated in 47 (28.5%) and 48 (29.1%), respectively, of the SCH fractions, whereas no violations were observed in the ADP fractions. There were statistically significant differences in the dose-volume indices between the SCH and ADP fractions (p < 0.05). The gamma passing rates were above 95% in all ADP fractions. CONCLUSIONS The CBCT-guided online ART under EE-BH conditions successfully reduced the dose to the stomach and duodenum while maintaining target coverage.
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Affiliation(s)
- Ayaka Ogawa
- Department of Radiation Oncology and Image‐Applied TherapyGraduate School of MedicineKyoto UniversityKyotoJapan
| | - Mitsuhiro Nakamura
- Department of Radiation Oncology and Image‐Applied TherapyGraduate School of MedicineKyoto UniversityKyotoJapan,Division of Medical PhysicsDepartment of Information Technology and Medical EngineeringHuman Health SciencesGraduate School of MedicineKyoto UniversityKyotoJapan
| | - Hiraku Iramina
- Department of Radiation Oncology and Image‐Applied TherapyGraduate School of MedicineKyoto UniversityKyotoJapan
| | - Michio Yoshimura
- Department of Radiation Oncology and Image‐Applied TherapyGraduate School of MedicineKyoto UniversityKyotoJapan
| | - Takashi Mizowaki
- Department of Radiation Oncology and Image‐Applied TherapyGraduate School of MedicineKyoto UniversityKyotoJapan
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10
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Daly M, McWilliam A, Radhakrishna G, Choudhury A, Eccles CL. Radiotherapy respiratory motion management in hepatobiliary and pancreatic malignancies: a systematic review of patient factors influencing effectiveness of motion reduction with abdominal compression. Acta Oncol 2022; 61:833-841. [PMID: 35611555 DOI: 10.1080/0284186x.2022.2073186] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 04/28/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND The effectiveness of abdominal compression for motion management in hepatobiliary-pancreatic (HPB) radiotherapy has not been systematically evaluated. METHODS & MATERIALS A systematic review was carried out using PubMed/Medline, Cochrane Library, Web of Science, and CINAHL databases up to 1 July 2021. No date restrictions were applied. Additional searches were carried out using the University of Manchester digital library, Google Scholar and of retrieved papers' reference lists. Studies conducted evaluating respiratory motion utilising imaging with and without abdominal compression in the same patients available in English were included. Studies conducted in healthy volunteers or majority non-HPB sites, not providing descriptive motion statistics or patient characteristics before and after compression in the same patients or published without peer-review were excluded. A narrative synthesis was employed by tabulating retrieved studies and organising chronologically by abdominal compression device type to help identify patterns in the evidence. RESULTS The inclusion criteria were met by 6 studies with a total of 152 patients. Designs were a mix of retrospective and prospective quantitative designs with chronological, non-randomised recruitment. Abdominal compression reduced craniocaudal respiratory motion in the majority of patients, although in four studies there were increases seen in at least one direction. The influence of patient comorbidities on effectiveness of compression, and/or comfort with compression was not evaluated in any study. CONCLUSION Abdominal compression may not be appropriate for all patients, and benefit should be weighed with potential increase in motion or discomfort in patients with small initial motion (<5 mm). Patient factors including male sex, and high body mass index (BMI) were found to impact the effectiveness of compression, however with limited evidence. High-quality studies are warranted to fully assess the clinical impact of abdominal compression on treatment outcomes and toxicity prospective in comparison to other motion management strategies.
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Affiliation(s)
- Mairead Daly
- Division of Clinical Cancer Sciences, Faculty of Biology, Medicine and Health, School of Medical Sciences, The University of Manchester, Manchester, United Kingdom
| | - Alan McWilliam
- Division of Clinical Cancer Sciences, Faculty of Biology, Medicine and Health, School of Medical Sciences, The University of Manchester, Manchester, United Kingdom
- The Christie NHSFT, Manchester, United Kingdom
| | | | - Ananya Choudhury
- Division of Clinical Cancer Sciences, Faculty of Biology, Medicine and Health, School of Medical Sciences, The University of Manchester, Manchester, United Kingdom
- The Christie NHSFT, Manchester, United Kingdom
| | - Cynthia L Eccles
- Division of Clinical Cancer Sciences, Faculty of Biology, Medicine and Health, School of Medical Sciences, The University of Manchester, Manchester, United Kingdom
- The Christie NHSFT, Manchester, United Kingdom
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11
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Liu P, Gao XS, Wang Z, Li X, Xi C, Jia C, Xie M, Lyu F, Ding X. Investigate the Dosimetric and Potential Clinical Benefits Utilizing Stereotactic Body Radiation Therapy With Simultaneous Integrated Boost Technique for Locally Advanced Pancreatic Cancer: A Comparison Between Photon and Proton Beam Therapy. Front Oncol 2021; 11:747532. [PMID: 34631584 PMCID: PMC8493097 DOI: 10.3389/fonc.2021.747532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/30/2021] [Indexed: 12/24/2022] Open
Abstract
Purpose To investigate the potential clinical benefits of using stereotactic body radiation therapy (SBRT) with simultaneous integrated boost (SIB) technique for locally advanced pancreatic cancer (LAPC) among different treatment modalities and planning strategies, including photon and proton. Method A total of 19 patients were retrospectively selected in this study: 13 cases with the tumor located in the head of the pancreas and 6 cases with the tumor in the body of the pancreas. SBRT-SIB plans were generated using volumetric modulated arc therapy (VMAT), two-field Intensity Modulated Proton Therapy (IMPT), and three-field IMPT. The IMPT used the robust optimization parameters of ± 3.5% range and 5-mm setup uncertainties. Root-mean-square deviation dose (RMSD) volume histograms were used to evaluate the target coverage robustness quantitatively. Dosimetric metrics based on the dose-volume histogram (DVH), homogeneity index (HI), and normal tissue complication probability (NTCP) were analyzed to evaluate the potential clinical benefits among different planning groups. Results With a similar CTV and SIB coverage, two-field IMPT provided a lower maximum dose for the stomach (median: 18.6GyE, p<0.05) and duodenum (median: 32.62GyE, p<0.05) when the target was located in the head of the pancreas compared to VMAT and three-field IMPT. The risks of gastric bleed (3.42%) and grade ≥ 3 GI toxicity (4.55%) were also decreased. However, for the target in the body of the pancreas, VMAT showed a lower maximum dose for the stomach (median 30.93GyE, p<0.05) and toxicity of gastric bleed (median: 8.67%, p<0.05) compared to two-field IMPT and three-field IMPT, while other maximum doses and NTCPs were similar. The RMSD volume histogram (RVH) analysis shows that three-field IMPT provided better robustness for targets but not for OARs. Instead, three-field IMPT increased the Dmean of organs such as the stomach, duodenum, and intestine. Conclusion The results indicated that the tumor locations could play a critical role in determining clinical benefits among different treatment modalities. Two-field IMPT could be a better option for LAPC patients whose tumors are located in the head of the pancreas. It provides lower severe toxicity for the stomach and duodenum. Nevertheless, VMAT is preferred for the body with better protection for the possibility of gastric bleed.
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Affiliation(s)
- Peilin Liu
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Xian-Shu Gao
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Zishen Wang
- Department of Radiation Oncology, Hebei Yizhou Tumor Hospital, Zhuozhou, China
| | - Xiaomei Li
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Cao Xi
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Chenghao Jia
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Mu Xie
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Feng Lyu
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Xuanfeng Ding
- Department of Radiation Oncology, Beaumont Health, Proton Beam Therapy Center, Royal Oak, MI, United States
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12
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Umezawa R, Wakita A, Katsuta Y, Ito Y, Nakamura S, Okamoto H, Kadoya N, Takahashi K, Inaba K, Murakami N, Igaki H, Jingu K, Itami J. A Pilot Study of Synchronization of Respiration-Induced Motions in the Duodenum and Stomach for the Primary Tumor in Radiation Therapy for Pancreatic Cancer Using 4-Dimensional Computed Tomography. Adv Radiat Oncol 2021; 6:100730. [PMID: 34409214 PMCID: PMC8360956 DOI: 10.1016/j.adro.2021.100730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/07/2021] [Accepted: 05/18/2021] [Indexed: 11/26/2022] Open
Abstract
Purpose We investigated the synchronization of respiration-induced motions at the primary tumor and organs at risk at radiation planning for pancreatic cancer. Methods and Materials Four-dimensional computed tomography images were acquired under the condition of shallow free breathing in patients with pancreatic cancer. The gross tumor volume (GTV), duodenum (DU), and stomach (ST) were contoured. The center of mass was computed for each 4-dimensional volume of interest. The respiration dependence of coordinates for the center of each volume of interest was computed relative to its location at the 50% (maximum exhalation) phase. Based on the shift of the GTV, we investigated the synchronization of respiration-induced motions between each contouring target. We examined the differences in the volume averaged dose to the ST and DU in each respiratory phase. Results Nine patients with pancreatic cancer were analyzed in this study. The mean maximum 3-dimensional excursions at the GTV, DU, and ST were 9.6, 9.8, and 11.4 mm, respectively. At phase 0% and 90% (inhale phases), mean distance changes in the positional relationship with the GTV were 0.3 and 0.7 mm respectively for the DU and -2.5 and -2.4 mm respectively for the ST. There was no significant respiration associated change (RAC) between each respiratory phase in the DU (P = .568), and there was a significant RAC in the ST (P < .001). There was a significant RAC of the volume averaged dose to the ST (P = .023). Conclusions Our results indicate that the DU but not the ST might move synchronously with GTV due to respiration.
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Affiliation(s)
- Rei Umezawa
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan.,Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Akihisa Wakita
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yoshiyuki Katsuta
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshinori Ito
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan.,Department of Radiation Oncology, Showa University School of Medicine, Tokyo, Japan
| | - Satoshi Nakamura
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroyuki Okamoto
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Noriyuki Kadoya
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kana Takahashi
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Koji Inaba
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Naoya Murakami
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroshi Igaki
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Keiichi Jingu
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Jun Itami
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
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13
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Camprodon G, Huguet F. Unrecognized digestive toxicities of radiation therapy. Cancer Radiother 2021; 25:723-728. [PMID: 34391649 DOI: 10.1016/j.canrad.2021.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 07/19/2021] [Accepted: 07/24/2021] [Indexed: 12/16/2022]
Abstract
The aim of this article is to review unrecognized toxicities resulting from radiation therapy of digestive neoplasms. Due to their precocious occurrence, acute toxicities are well-known by radiation oncologist, and their treatment well-established. Thus, acute toxicities will not be described in this review. We will focus on incidence, diagnosis, and management of late and uncommon toxicities occurring in the digestive tract and digestive organs. Prevention, by respecting healthy tissues constraints, is the main tool to reduce incidence of those rare complications. Nonetheless, once installed, late toxicities remain a major burden in terms of quality of life and can even be life threatening. Hence, information and education about their diagnosis and management is important.
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Affiliation(s)
- G Camprodon
- Service d'Oncologie Médicale, Institut Gustave Roussy, 114, rue Edouard Vaillant, 94805 Villejuif, France.
| | - F Huguet
- Service d'Oncologie Radiothérapie, Hôpital Tenon, Sorbonne Université, AP-HP, Paris, France
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14
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Ruan JL, Browning RJ, Yildiz YO, Bau L, Kamila S, Gray MD, Folkes L, Hampson A, McHale AP, Callan JF, Vojnovic B, Kiltie AE, Stride E. Evaluation of Loading Strategies to Improve Tumor Uptake of Gemcitabine in a Murine Orthotopic Bladder Cancer Model Using Ultrasound and Microbubbles. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:1596-1615. [PMID: 33707089 DOI: 10.1016/j.ultrasmedbio.2021.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 02/01/2021] [Accepted: 02/02/2021] [Indexed: 06/12/2023]
Abstract
In this study we compared three different microbubble-based approaches to the delivery of a widely used chemotherapy drug, gemcitabine: (i) co-administration of gemcitabine and microbubbles (Gem+MB); (ii) conjugates of microbubbles and gemcitabine-loaded liposomes (GemlipoMB); and (iii) microbubbles with gemcitabine directly bound to their surfaces (GembioMB). Both in vitro and in vivo investigations were carried out, respectively, in the RT112 bladder cancer cell line and in a murine orthotopic muscle-invasive bladder cancer model. The in vitro (in vivo) ultrasound exposure conditions were a 1 (1.1) MHz centre frequency, 0.07 (1.0) MPa peak negative pressure, 3000 (20,000) cycles and 100 (0.5) Hz pulse repetition frequency. Ultrasound exposure produced no significant increase in drug uptake either in vitro or in vivo compared with the drug-only control for co-administered gemcitabine and microbubbles. In vivo, GemlipoMB prolonged the plasma circulation time of gemcitabine, but only GembioMB produced a statistically significant increase in cleaved caspase 3 expression in the tumor, indicative of gemcitabine-induced apoptosis.
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Affiliation(s)
- Jia-Ling Ruan
- MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, United Kingdom
| | - Richard J Browning
- Institute of Biomedical Engineering, University of Oxford, Oxford, United Kingdom
| | - Yesna O Yildiz
- MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, United Kingdom
| | - Luca Bau
- Institute of Biomedical Engineering, University of Oxford, Oxford, United Kingdom
| | - Sukanta Kamila
- Biomedical Sciences Research Institute, University of Ulster, Coleraine, Northern Ireland, United Kingdom
| | - Michael D Gray
- Institute of Biomedical Engineering, University of Oxford, Oxford, United Kingdom
| | - Lisa Folkes
- MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, United Kingdom
| | - Alix Hampson
- MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, United Kingdom
| | - Anthony P McHale
- Biomedical Sciences Research Institute, University of Ulster, Coleraine, Northern Ireland, United Kingdom
| | - John F Callan
- Biomedical Sciences Research Institute, University of Ulster, Coleraine, Northern Ireland, United Kingdom
| | - Borivoj Vojnovic
- MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, United Kingdom
| | - Anne E Kiltie
- MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, United Kingdom
| | - Eleanor Stride
- Institute of Biomedical Engineering, University of Oxford, Oxford, United Kingdom.
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15
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Dosimetric and radiobiological comparison of treatment plan between CyberKnife and EDGE in stereotactic body radiotherapy for pancreatic cancer. Sci Rep 2021; 11:4065. [PMID: 33603030 PMCID: PMC7893157 DOI: 10.1038/s41598-021-83648-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 02/03/2021] [Indexed: 11/09/2022] Open
Abstract
To perform a comparison of the different stereotactic body radiotherapy (SBRT) plans between the Varian EDGE and CyberKnife (CK) systems for locally advanced unresectable pancreatic cancer. Fifteen patients with pancreatic cancer were selected in this study. The median planning target volume (PTV) was 28.688 cm3 (5.736–49.246 cm3). The SBRT plans for the EDGE and CK were generated in the Eclipse and Multiplan systems respectively with the same contouring and dose constrains for PTV and organs at risk (OARs). Dose distributions in PTV were evaluated in terms of coverage, conformity index (CI), new conformity index (nCI), homogeneity index (HI), and gradient index (GI). OARs, including spinal cord, bowel, stomach, duodenum and kidneys were statistically evaluated by different dose-volume metrics and equivalent uniform dose (EUD). The volume covered by the different isodose lines (ISDL) ranging from 10 to 100% for normal tissue were also analyzed. All SBRT plans for EDGE and CK met the dose constraints for PTV and OARs. For the PTV, the dosimetric metrics in EDGE plans were lower than that in CK, except that D99 and GI were slightly higher. The EDGE plans with lower CI, nCI and HI were superior to generate more conformal and homogeneous dose distribution for PTV. For the normal tissue, the CK plans were better at OARs sparing. The radiobiological indices EUD of spinal cord, duodenum, stomach, and kidneys were lower for CK plans, except that liver were higher. The volumes of normal tissue covered by medium ISDLs (with range of 20–70%) were lower for CK plans while that covered by high and low ISDLs were lower for EDGE plans. This study indicated that both EDGE and CK generated equivalent plan quality, and both systems can be considered as beneficial techniques for SBRT of pancreatic cancer. EDGE plans offered more conformal and homogeneous dose distribution for PTV, while the CK plans could minimize the exposure of OARs.
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16
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Montovano M, Zhang M, Oh P, Thor M, Crane C, Yorke E, Wu AJ, Jackson A. Incidence and Dosimetric Predictors of Radiation-Induced Gastric Bleeding After Chemoradiation for Esophageal and Gastroesophageal Junction Cancer. Adv Radiat Oncol 2021; 6:100648. [PMID: 34195487 PMCID: PMC8233466 DOI: 10.1016/j.adro.2021.100648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 11/19/2020] [Accepted: 01/05/2021] [Indexed: 02/07/2023] Open
Abstract
Purpose To determine the incidence and predictors of gastric bleeding after chemoradiation for esophageal or gastroesophageal junction cancer. Methods and Materials We reviewed patients receiving chemoradiation to at least 41.4 Gy for localized esophageal cancer whose fields included the stomach and who did not undergo surgical resection. The primary endpoint was grade ≥3 gastric hemorrhage (GB3+). Comprehensive stomach dose-volume parameters were collected, and stomach dose-volume histograms were generated for analysis. Results A total of 145 patients met our inclusion criteria. Median prescribed dose was 50.4 Gy (range, 41.4-56 Gy). Median stomach Dmax was 53.0 Gy (1.0-62.7 Gy), and median stomach V40, V45, and V50 Gy were 112 cm3 (0-667 cm3), 84 cm3 (0-632 cm3), and 50 cm3 (0-565 cm3), respectively. Two patients (1.4%) developed radiation-induced GB3+. The only dosimetric factor that was significantly different for these patients was a higher stomach Dmax (58.1 and 58.3 Gy) than the cohort median (53 Gy). One of these patients also had cirrhosis, and the other had a history of nonsteroidal anti-inflammatory drug use. Five other patients had GB3+ events associated with documented tumor progression. A Cox proportional hazards model based on stomach Dmax with respect to the development of GB3+ was found to be statistically significant. Time-to-event curves and dose-volume atlases were generated, demonstrating an increased risk of GB3+ only when stomach Dmax was >58 Gy (P < .05). Conclusions We observed a low rate of GB3+ events in patients who received chemoradiation to a median dose of 50.4 Gy to volumes that included a significant portion of the stomach. These results suggest that when prescribing 50.4 Gy for esophageal cancer, there is no need to minimize the irradiated gastric volume or dose for the sake of preventing bleeding complications. Limiting stomach maximum doses to <58 Gy may also avoid bleeding, and particular caution should be taken in patients with other risk factors for bleeding, such as cirrhosis.
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Affiliation(s)
- Margaret Montovano
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.,Rutgers New Jersey Medical School, Newark, New Jersey
| | - Minsi Zhang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Patrick Oh
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Maria Thor
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christopher Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ellen Yorke
- Rutgers New Jersey Medical School, Newark, New Jersey
| | - Abraham J Wu
- Rutgers New Jersey Medical School, Newark, New Jersey
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Nakamura M, Nakao M, Mukumoto N, Ashida R, Hirashima H, Yoshimura M, Mizowaki T. Statistical shape model-based planning organ-at-risk volume: application to pancreatic cancer patients. Phys Med Biol 2021; 66:014001. [PMID: 33227722 DOI: 10.1088/1361-6560/abcd1b] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
PURPOSE To introduce the concept of statistical shape model (SSM)-based planning organ-at-risk volume (sPRV) for pancreatic cancer patients. METHODS A total of 120 pancreatic cancer patients were enrolled in this study. After correcting inter-patient variations in the centroid position of the planning target volume (PTV), four different SSMs were constructed by registering a deformable template model to an individual model for the stomach and duodenum. The sPRV, which focused on the following different components of the inter-patient variations, was then created: Scenario A: shape, rotational angle, volume, and centroid position; Scenario B: shape, rotational angle, and volume; Scenario C: shape and rotational angle; and Scenario D: shape. The conventional PRV (cPRV) was created by adding an isotropic margin R (3-15 mm) to the mean shape model. The corresponding sPRV was created from the SSM until the volume difference between the cPRV and sPRV was less than 1%. Thereafter, we computed the overlapping volume between the PTV and cPRV (OLc) or sPRV (OLs) in each patient. OLs being larger than OLc implies that the local shape variations in the corresponding OAR close to the PTV were large. Therefore, OLs/OLc was calculated in each patient for each R-value, and the median value of OLs/OLc was regarded as a surrogate for plan quality for each R-value. RESULTS For R = 3 and 5 mm, OLs/OLc exceeded 1 for the stomach and duodenum in all scenarios, with a maximum OLs/OLc of 1.21. This indicates that smaller isotropic margins did not sufficiently account for the local shape changes close to the PTV. CONCLUSIONS Our results indicated that, in contrast to conventional PRV, SSM-based PRVs, which account for local shape changes, would result in better dose sparing for the stomach and duodenum in pancreatic cancer patients.
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Affiliation(s)
- Mitsuhiro Nakamura
- Division of Medical Physics, Department of Information Technology and Medical Engineering, Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan. Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
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Loi M, Magallon-Baro A, Suker M, Van Eijck C, Hoogeman M, Nuyttens JJ. Daily dose to organs at risk predicts acute toxicity in pancreatic stereotactic radiotherapy. Acta Oncol 2020; 59:944-948. [PMID: 32207351 DOI: 10.1080/0284186x.2020.1742931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Mauro Loi
- Department of Radiotherapy, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Alba Magallon-Baro
- Department of Radiotherapy, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Mustafa Suker
- Department of Surgery, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Casper Van Eijck
- Department of Surgery, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Mischa Hoogeman
- Department of Radiotherapy, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Joost J. Nuyttens
- Department of Radiotherapy, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
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19
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Prediction of mucositis risk secondary to cancer therapy: a systematic review of current evidence and call to action. Support Care Cancer 2020; 28:5059-5073. [PMID: 32592033 DOI: 10.1007/s00520-020-05579-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 06/12/2020] [Indexed: 01/25/2023]
Abstract
PURPOSE Despite advances in personalizing the efficacy of cancer therapy, our ability to identify patients at risk of severe treatment side effects and provide individualized supportive care is limited. This is particularly the case for mucositis (oral and gastrointestinal), with no comprehensive risk evaluation strategies to identify high-risk patients. We, the Multinational Association for Supportive Care in Cancer/International Society for Oral Oncology (MASCC/ISOO) Mucositis Study Group, therefore aimed to systematically review current evidence on that factors that influence mucositis risk to provide a foundation upon which future risk prediction studies can be based. METHODS We identified 11,018 papers from PubMed and Web of Science, with 197 records extracted for full review and 113 meeting final eligibility criteria. Data were then synthesized into tables to highlight the level of evidence for each risk predictor. RESULTS The strongest level of evidence supported dosimetric parameters as key predictors of mucositis risk. Genetic variants in drug-metabolizing pathways, immune signaling, and cell injury/repair mechanisms were also identified to impact mucositis risk. Factors relating to the individual were variably linked to mucositis outcomes, although female sex and smoking status showed some association with mucositis risk. CONCLUSION Mucositis risk reflects the complex interplay between the host, tumor microenvironment, and treatment specifications, yet the large majority of studies rely on hypothesis-driven, single-candidate approaches. For significant advances in the provision of personalized supportive care, coordinated research efforts with robust multiplexed approaches are strongly advised.
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Raturi VP, Hojo H, Hotta K, Baba H, Takahashi R, Rachi T, Nakamura N, Zenda S, Motegi A, Tachibana H, Ariji T, Motegi K, Nakamura M, Okumura M, Hirano Y, Akimoto T. Radiobiological model-based approach to determine the potential of dose-escalated robust intensity-modulated proton radiotherapy in reducing gastrointestinal toxicity in the treatment of locally advanced unresectable pancreatic cancer of the head. Radiat Oncol 2020; 15:157. [PMID: 32571379 PMCID: PMC7310413 DOI: 10.1186/s13014-020-01592-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 06/03/2020] [Indexed: 12/31/2022] Open
Abstract
Background The purpose of this study was to determine the potential of escalated dose radiation (EDR) robust intensity-modulated proton radiotherapy (ro-IMPT) in reducing GI toxicity risk in locally advanced unresectable pancreatic cancer (LAUPC) of the head in term of normal tissue complication probability (NTCP) predictive model. Methods For 9 patients, intensity-modulated radiotherapy (IMRT) was compared with ro-IMPT. For all plans, the prescription dose was 59.4GyE (Gray equivalent) in 33 fractions with an equivalent organ at risk (OAR) constraints. Physical dose distribution was evaluated. GI toxicity risk for different endpoints was estimated using published NTCP Lyman Kutcher Burman (LKB) models for stomach, duodenum, small bowel, and combine stomach and duodenum (Stoduo). A Wilcoxon signed-rank test was used for dosimetry parameters and NTCP values comparison. Result The dosimetric results have shown that, with similar target coverage, ro-IMPT achieves a significant dose-volume reduction in the stomach, small bowel, and stoduo in low to high dose range in comparison to IMRT. NTCP evaluation for the endpoint gastric bleeding of stomach (10.55% vs. 13.97%, P = 0.007), duodenum (1.87% vs. 5.02%, P = 0.004), and stoduo (5.67% vs. 7.81%, P = 0.008) suggest reduced toxicity by ro-IMPT compared to IMRT. ∆NTCP IMRT – ro-IMPT (using parameter from Pan et al. for gastric bleed) of ≥5 to < 10% was seen in 3 patients (33%) for stomach and 2 patients (22%) for stoduo. An overall GI toxicity relative risk (NTCPro-IMPT/NTCPIMRT) reduction was noted (0.16–0.81) for all GI-OARs except for duodenum (> 1) with endpoint grade ≥ 3 GI toxicity (using parameters from Holyoake et al.). Conclusion With similar target coverage and better conformity, ro-IMPT has the potential to substantially reduce the risk of GI toxicity compared to IMRT in EDR of LAUPC of the head. This result needs to be further evaluated in future clinical studies.
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Affiliation(s)
- Vijay P Raturi
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan.,Course of Advanced Clinical Research of Cancer, Graduate school of Medicine, Juntendo University, Tokyo, Japan
| | - Hidehiro Hojo
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan
| | - Kenji Hotta
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan
| | - Hiromi Baba
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan
| | - Ryo Takahashi
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan
| | - Toshiya Rachi
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan
| | - Naoki Nakamura
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan
| | - Sadamoto Zenda
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan
| | - Atsushi Motegi
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan
| | - Hidenobu Tachibana
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan
| | - Takaki Ariji
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan
| | - Kana Motegi
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan
| | - Masaki Nakamura
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan
| | - Masayuki Okumura
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan
| | - Yasuhiro Hirano
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan
| | - Tetsuo Akimoto
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan. .,Course of Advanced Clinical Research of Cancer, Graduate school of Medicine, Juntendo University, Tokyo, Japan.
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21
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George G, Lewis S, Chopra S, Phurailatpam R, Engineer R. A Retrospective Study of the Dosimetric Parameters and Duodenal Toxicity in Patients With Upper Gastrointestinal and Gynaecological Cancers Treated With Radiation Therapy. Clin Oncol (R Coll Radiol) 2020; 32:e53-e59. [DOI: 10.1016/j.clon.2019.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 06/16/2019] [Accepted: 07/15/2019] [Indexed: 12/23/2022]
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22
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Raturi VP, Tochinai T, Hojo H, Rachi T, Hotta K, Nakamura N, Zenda S, Motegi A, Ariji T, Hirano Y, Baba H, Ohyoshi H, Nakamura M, Okumura M, Bei Y, Akimoto T. Dose-Volume and Radiobiological Model-Based Comparative Evaluation of the Gastrointestinal Toxicity Risk of Photon and Proton Irradiation Plans in Localized Pancreatic Cancer Without Distant Metastasis. Front Oncol 2020; 10:517061. [PMID: 33194580 PMCID: PMC7645056 DOI: 10.3389/fonc.2020.517061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 09/01/2020] [Indexed: 12/25/2022] Open
Abstract
Background: Radiobiological model-based studies of photon-modulated radiotherapy for pancreatic cancer have reported reduced gastrointestinal (GI) toxicity, although the risk is still high. The purpose of this study was to investigate the potential of 3D-passive scattering proton beam therapy (3D-PSPBT) in limiting GI organ at risk (OAR) toxicity in localized pancreatic cancer based on dosimetric data and the normal tissue complication probability (NTCP) model. Methods: The data of 24 pancreatic cancer patients were retrospectively analyzed, and these patients were planned with intensity-modulated radiotherapy (IMRT), volume-modulated arc therapy (VMAT), and 3D-PSPBT. The tumor was targeted without elective nodal coverage. All generated plans consisted of a 50.4-GyE (Gray equivalent) dose in 28 fractions with equivalent OAR constraints, and they were normalized to cover 50% of the planning treatment volume (PTV) with 100% of the prescription dose. Physical dose distributions were evaluated. GI-OAR toxicity risk for different endpoints was estimated by using published NTCP Lyman-Kutcher-Burman (LKB) models. Analysis of variance (ANOVA) was performed to compare the dosimetric data, and ΔNTCPIMRT-PSPBT and ΔNTCPVMAT-PSPBT were also computed. Results: Similar homogeneity and conformity for the clinical target volume (CTV) and PTV were exhibited by all three planning techniques (P > 0.05). 3D-PSPBT resulted in a significant dose reduction for GI-OARs in both the low-intermediate dose range (below 30 GyE) and the highest dose region (D max and V 50 GyE) in comparison with IMRT and VMAT (P < 0.05). Based on the NTCP evaluation, the NTCP reduction for GI-OARs by 3D-PSPBT was minimal in comparison with IMRT and VMAT. Conclusion: 3D-PSPBT results in minimal NTCP reduction and has less potential to substantially reduce the toxicity risk of upper GI bleeding, ulceration, obstruction, and perforation endpoints compared to IMRT and VMAT. 3D-PSPBT may have the potential to reduce acute dose-limiting toxicity in the form of nausea, vomiting, and diarrhea by reducing the GI-OAR treated volume in the low-to-intermediate dose range. However, this result needs to be further evaluated in future clinical studies.
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Affiliation(s)
- Vijay P. Raturi
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
- Course of Advanced Clinical Research of Cancer, Graduate School of Medicine, Juntendo University, Tokyo, Japan
- *Correspondence: Vijay P. Raturi
| | - Taku Tochinai
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
| | - Hidehiro Hojo
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
| | - Toshiya Rachi
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
| | - Kenji Hotta
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
| | - Naoki Nakamura
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
| | - Sadamoto Zenda
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
| | - Atsushi Motegi
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
| | - Takaki Ariji
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
| | - Yasuhiro Hirano
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
| | - Hiromi Baba
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
| | - Hajime Ohyoshi
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
| | - Masaki Nakamura
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
| | - Masayuki Okumura
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
| | - Yanping Bei
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
| | - Tetsuo Akimoto
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
- Course of Advanced Clinical Research of Cancer, Graduate School of Medicine, Juntendo University, Tokyo, Japan
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23
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Monma S, Kato K, Shouji H, Okita N, Takashima A, Honma Y, Iwasa S, Hamaguchi T, Yamada Y, Shimada Y, Boku N, Nagashima K, Ito Y, Itami J. Gastric mucosal injury and hemorrhage after definitive chemoradiotherapy for locally advanced esophageal cancer. Esophagus 2019; 16:402-407. [PMID: 31222680 DOI: 10.1007/s10388-019-00680-1] [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] [Received: 05/26/2018] [Accepted: 06/16/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Definitive chemoradiotherapy is one of the treatment options for locally advanced esophageal cancer with curative intent. Esophagitis and pharyngitis are well-known adverse events that occur during chemoradiotherapy, but gastric mucosal injury has been less frequently reported compared to mucositis. Importantly, gastric mucosal injury is not well known, hard to manage, and sometimes fatal. Hence, we examined the clinical characteristics and the incidence of gastric mucosal injury after CRT for esophageal cancer. METHODS The medical records of patients who received definitive chemoradiotherapy combined with 5-fluorouracil and cisplatin for stage II/III (nonT4) esophageal squamous cell carcinoma from January 2001 to December 2010 at our institute were reviewed retrospectively. RESULTS We investigated 256 patients in whom, data for endoscopic abdomen examinations were both before and after CRT were available. Gastric mucosal damage was observed in 90 patients (35%) (grade 1/2/3 = 69/18/3). One of the possible risk factors identified in this study was the irradiation dose to abdomen. Compared to patients with cervical esophagus-upper thoracic esophagus tumor location, patients with middle thoracic esophagus-abdominal esophagus tumor location were more likely to develop gastric mucosal damage, although there was no statistically significant difference. CONCLUSIONS It is important to consider gastric mucosal injury in patients who receive CRT, particularly when the irradiation field includes stomach.
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Affiliation(s)
- Satoko Monma
- Gastrointestinal Medical Oncology Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Ken Kato
- Gastrointestinal Medical Oncology Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan.
| | - Hirokazu Shouji
- Gastrointestinal Medical Oncology Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Natsuko Okita
- Gastrointestinal Medical Oncology Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Atsuo Takashima
- Gastrointestinal Medical Oncology Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Yoshitaka Honma
- Gastrointestinal Medical Oncology Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Satoru Iwasa
- Gastrointestinal Medical Oncology Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Tetsuya Hamaguchi
- Gastrointestinal Medical Oncology Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Yasuhide Yamada
- Gastrointestinal Medical Oncology Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Yasuhiro Shimada
- Gastrointestinal Medical Oncology Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Narikazu Boku
- Gastrointestinal Medical Oncology Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Kengo Nagashima
- Research Center for Medical and Health Data Science, The Institute of Statistical Mathematics, Tokyo, Japan
| | - Yoshinori Ito
- Radiation Oncology Division, National Cancer Center Hospital, Tokyo, Japan
| | - Jun Itami
- Radiation Oncology Division, National Cancer Center Hospital, Tokyo, Japan
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24
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Koom WS, Mori S, Furuich W, Yamada S. Beam direction arrangement using a superconducting rotating gantry in carbon ion treatment for pancreatic cancer. Br J Radiol 2019; 92:20190101. [PMID: 30943057 DOI: 10.1259/bjr.20190101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES Carbon ion radiotherapy provides a concentrated dose distribution to the target and has several advantages over photon radiotherapy. This study aimed to evaluate the optimal beam direction in carbon ion pencil beam scanning and compare dose distributions between the rotating gantry system (RGS) and fixed-beam port system (FBPS). METHODS Patients with locally advanced pancreatic cancer were randomly selected. First, dose-volume parameters of 7-beam directions in the prone position were evaluated. Second, a composite plan developed using 4-beam directions in RGS was compared with that developed using FBPS, with a total prescribed dose of 55.2 Gy (relative biological effectiveness, RBE) in 12 fractions. RESULTS Target coverages in the composite plan did not widely differ. For the first and second segments of the duodenum, the mean dose of D2cc was not significantly changed (23.80 ± 11.90 Gy [RBE] and 25.63 ± 10.41 Gy [RBE] for RGS and FBPS, respectively). However, the dose-volume histogram curve in RGS showed a prominent dose reduction in the low-dose region. No significant differences were observed in the stomach, third and fourth segments of the duodenum, and spinal cord. The mean dose of the total kidney was similar between RGS and FBPS. CONCLUSIONS Compared with that of FBPS, the 4-beam arrangement in the prone position using RGS provides comparable or superior dose distribution in the surrounding normal organ while achieving the same target coverage. In addition, RGS allows for single-patient positioning. ADVANCES IN KNOWLEDGE RGS is beneficial in delivering radiotherapy doses to the duodenum and allows for single-patient positioning and a simple planning process.
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Affiliation(s)
- Woong Sub Koom
- 1 Department of Radiation Oncology, Yonsei University College of Medicine , Seoul , South Korea.,2 Research Center for Charged Particle Therapy, National Institute of Radiological Sciences , Chiba , Japan
| | - Shinichiro Mori
- 2 Research Center for Charged Particle Therapy, National Institute of Radiological Sciences , Chiba , Japan
| | | | - Shigeru Yamada
- 2 Research Center for Charged Particle Therapy, National Institute of Radiological Sciences , Chiba , Japan
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25
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Nakamura A, Hiraoka M, Itasaka S, Nakamura M, Akimoto M, Ishihara Y, Mukumoto N, Goto Y, Kishi T, Yoshimura M, Matsuo Y, Yano S, Mizowaki T. Evaluation of Dynamic Tumor-tracking Intensity-modulated Radiotherapy for Locally Advanced Pancreatic Cancer. Sci Rep 2018; 8:17096. [PMID: 30459454 PMCID: PMC6244273 DOI: 10.1038/s41598-018-35402-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 11/05/2018] [Indexed: 12/25/2022] Open
Abstract
Intensity-modulated radiotherapy (IMRT) is now regarded as an important treatment option for patients with locally advanced pancreatic cancer (LAPC). To reduce the underlying tumor motions and dosimetric errors during IMRT as well as the burden of respiratory management for patients, we started to apply a new treatment platform of the dynamic tumor dynamic tumor-tracking intensity-modulated radiotherapy (DTT-IMRT) using the gimbaled linac, which can swing IMRT toward the real-time tumor position under patients' voluntary breathing. Between June 2013 and March 2015, ten patients were treated, and the tumor-tracking accuracy and the practical benefits were evaluated. The mean PTV size in DTT-IMRT was 18% smaller than a conventional ITV-based PTV. The root-mean-squared errors between the predicted and the detected tumor positions were 1.3, 1.2, and 1.5 mm in left-right, anterior-posterior, and cranio-caudal directions, respectively. The mean in-room time was 24.5 min. This high-accuracy of tumor-tracking with reasonable treatment time are promising and beneficial to patients with LAPC.
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Affiliation(s)
- Akira Nakamura
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masahiro Hiraoka
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Satoshi Itasaka
- Department of Radiation Oncology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Mitsuhiro Nakamura
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Mami Akimoto
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoshitomo Ishihara
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Nobutaka Mukumoto
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoko Goto
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takahiro Kishi
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Michio Yoshimura
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yukinori Matsuo
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinsuke Yano
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takashi Mizowaki
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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26
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Holyoake DLP, Warren DR, Hurt C, Aznar M, Partridge M, Mukherjee S, Hawkins MA. Stomach Dose-Volume Predicts Acute Gastrointestinal Toxicity in Chemoradiotherapy for Locally Advanced Pancreatic Cancer. Clin Oncol (R Coll Radiol) 2018; 30:418-426. [PMID: 29602584 DOI: 10.1016/j.clon.2018.02.067] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 01/05/2018] [Accepted: 02/27/2018] [Indexed: 01/06/2023]
Abstract
AIMS Gastrointestinal toxicity impedes dose escalation in chemoradiotherapy for hepatobiliary malignancies. Toxicity risk depends on clinical and radiotherapy metrics. We aimed to identify predictive factors using data from two prospective phase II clinical trials of locally advanced pancreatic cancer (LAPC). MATERIALS AND METHODS Ninety-one patients with available data from the ARCII (59.4 Gy in 33 fractions with gemcitabine, cisplatin and nelfinavir, n = 23) and SCALOP (50.4 Gy in 28 fractions with capecitabine or gemcitabine, n = 74) trials were studied. The independent variables analysed comprised age, sex, performance status, baseline symptoms, tumour size, weight loss, chemotherapy regimen and dose-volume histogram of stomach and duodenum in 5 Gy bins. The outcome measures used were Common Terminology Criteria of Adverse Events (CTCAE) grade and risk of CTCAE grade ≥2 acute upper gastrointestinal toxicity (anorexia, pain, nausea and/or vomiting). The risk of CTCAE grade ≥2 events was modelled using multivariable logistic regression and prediction of severity grade using ordinal regression. RESULTS CTCAE grade ≥2 symptoms occurred in 38 patients (42%). On univariate analysis, stomach V35-45Gy was predictive of risk (odds ratio 1.035, 95% confidence interval 1.007-1.063) and grade (1.023, 1.003-1.044) of toxicity. The area under the curve was 0.632 (0.516-0.747) with toxicity risk 33/66 (50%) above and 5/25 (20%) below the optimal discriminatory threshold (7.1 cm3). Using a threshold of 30 cm3, risk was 13/20 (65%) versus 25/71 (35%). The optimal multivariable logistic regression model incorporated patient sex, chemotherapy regimen and stomach V35-45Gy. Receiving gemcitabine rather than capecitabine (odds ratio 3.965, 95% confidence interval 1.274-12.342) and weight loss during induction chemotherapy (1.216, 1.043-1.419) were significant predictors for the SCALOP cohort, whereas age predicted toxicity risk in ARCII only (1.344, 1.015-1.780). Duodenum dose-volume did not predict toxicity risk or severity in any cohort. CONCLUSIONS In chemoradiotherapy for LAPC the volume of stomach irradiated to a moderately high dose (35-45 Gy) predicts the incidence and severity of acute toxicity. Other predictive factors can include age, sex, recent weight loss and concomitant chemotherapy agents.
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Affiliation(s)
- D L P Holyoake
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - D R Warren
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, UK
| | - C Hurt
- Centre for Trials Research, Cardiff University, Cardiff, Wales, UK
| | - M Aznar
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - M Partridge
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, UK
| | - S Mukherjee
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - M A Hawkins
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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27
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Clinical evaluation of intensity-modulated radiotherapy for locally advanced pancreatic cancer. Radiat Oncol 2018; 13:118. [PMID: 29940984 PMCID: PMC6019294 DOI: 10.1186/s13014-018-1063-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 06/14/2018] [Indexed: 01/05/2023] Open
Abstract
Background The purpose was to retrospectively evaluate the effect of intensity-modulated radiotherapy (IMRT) on gastrointestinal (GI) toxicities and outcomes compared to three-dimensional conformal radiotherapy (3DCRT) for locally advanced pancreatic cancer (LAPC). Methods We included 107 consecutive patients who underwent CRT for LAPC from September 2001 to March 2015; 80 patients underwent 3DCRT and 27 patients underwent IMRT. They were compared for GI toxicities, locoregional progression free survival (LRPFS), distant metastasis free survival (DMS), and overall survival (OS). Results Median radiation dose and fractions for 3DCRT and IMRT were 54 Gy/30 fr. and 48 Gy/15 fr. The regimens of CRT consisted of weekly gemcitabine 250 mg/m2 (for 3DCRT) or 1000 mg/m2 (for IMRT). Acute GI toxicity ≥grade 2 occurred in 32 patients (40%) treated with 3DCRT compared with five patients (19%) treated with IMRT. Late GI toxicity of grade 3 occurred in 10 patients (12%) treated with 3DCRT and one patient (4%) treated with IMRT. Patients who underwent IMRT had superior 1-year LRPFS (73.1% vs. 63.2%, p = 0.035) and 1-year OS (92.3% vs. 68.2%, p = 0.037) as compared with those treated with 3DCRT. Multivariate analysis showed that in IMRT patients, higher dose (≥45 Gy) was an independent factor for better LRPFS and OS. Conclusions LAPC patients treated with hypofractionated full-dose gemcitabine IMRT had improved OS and LRPFS without increased GI toxicities when compared to those of patients treated with conventionally fractionated low dose gemcitabine 3DCRT. In IMRT patients, higher dose was an independent favorable prognostic factor for better LRPFS and OS, which suggests that dose escalation with IMRT for LAPC is a promising strategy.
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28
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Stereotactic Body Radiation Therapy (SBRT) Combined With Chemotherapy for Unresected Pancreatic Adenocarcinoma. Am J Clin Oncol 2017; 40:152-157. [PMID: 25171298 PMCID: PMC4418949 DOI: 10.1097/coc.0000000000000118] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objectives: The role of radiation therapy in the management of unresectable pancreatic cancer is controversial. One concern about concurrent chemoradiation relates to the timing of chemotherapy. In contrast to conventional radiation therapy, stereotactic body radiation therapy (SBRT) delivers high doses in a shorter duration resulting in minimal disruption in chemotherapy. Here, we report our results of patients treated with SBRT and chemotherapy for inoperable pancreatic cancer. Materials and Methods: Thirty-eight patients treated with SBRT and chemotherapy for locally advanced, borderline resectable, and medically inoperable pancreatic cancer at our institution from January 2008 to December 2012 were included in this retrospective analysis. Treatment was delivered in 5 fractions of 5 or 6 Gy per fraction over 5 days. Toxicities were scored using the Common Terminology Criteria for Adverse Events version 3. Survival was calculated using the Kaplan-Meier method. Results: The median age was 70 years (range, 45 to 90 y). Eastern Cooperative Oncology Group performance status ranged from 0 to 3. Thirty-four patients received concurrent chemotherapy. Four patients received sequential chemotherapy. Median overall survival was 14.3 months and median progression-free survival was 9.2 months from diagnosis. From radiation, overall survival and progression-free survival were 12.3 and 6.8 months, respectively. The overall local control rate was 79%. Acute toxicity was minimal. Severe late SBRT-related toxicities included 1 grade 3 gastric outlet obstruction, 1 grade 4 biliary stricture, and 1 grade 5 gastric hemorrhage. Conclusions: SBRT combined with chemotherapy for unresectable pancreatic cancer is convenient, feasible, and generally well tolerated. Outcomes of SBRT combined with chemotherapy compare favorably to results obtained with chemotherapy and conventional radiation therapy.
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Mukumoto N, Nakamura M, Akimoto M, Miyabe Y, Yokota K, Matsuo Y, Mizowaki T, Hiraoka M. Impact of sampling interval in training data acquisition on intrafractional predictive accuracy of indirect dynamic tumor‐tracking radiotherapy. Med Phys 2017; 44:3899-3908. [DOI: 10.1002/mp.12351] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 05/05/2017] [Accepted: 05/10/2017] [Indexed: 12/25/2022] Open
Affiliation(s)
- Nobutaka Mukumoto
- Department of Radiation Oncology and Image‐applied Therapy Graduate School of Medicine Kyoto University Kyoto Japan
| | - Mitsuhiro Nakamura
- Department of Radiation Oncology and Image‐applied Therapy Graduate School of Medicine Kyoto University Kyoto Japan
| | - Mami Akimoto
- Department of Radiation Oncology and Image‐applied Therapy Graduate School of Medicine Kyoto University Kyoto Japan
| | - Yuki Miyabe
- Department of Radiation Oncology and Image‐applied Therapy Graduate School of Medicine Kyoto University Kyoto Japan
| | - Kenji Yokota
- Department of Radiation Oncology and Image‐applied Therapy Graduate School of Medicine Kyoto University Kyoto Japan
| | - Yukinori Matsuo
- Department of Radiation Oncology and Image‐applied Therapy Graduate School of Medicine Kyoto University Kyoto Japan
| | - Takashi Mizowaki
- Department of Radiation Oncology and Image‐applied Therapy Graduate School of Medicine Kyoto University Kyoto Japan
| | - Masahiro Hiraoka
- Department of Radiation Oncology and Image‐applied Therapy Graduate School of Medicine Kyoto University Kyoto Japan
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Modelling duodenum radiotherapy toxicity using cohort dose-volume-histogram data. Radiother Oncol 2017; 123:431-437. [PMID: 28600084 PMCID: PMC5486774 DOI: 10.1016/j.radonc.2017.04.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 04/20/2017] [Accepted: 04/24/2017] [Indexed: 12/25/2022]
Abstract
Background and purpose Gastro-intestinal toxicity is dose-limiting in abdominal radiotherapy and correlated with duodenum dose-volume parameters. We aimed to derive updated NTCP model parameters using published data and prospective radiotherapy quality-assured cohort data. Material and methods A systematic search identified publications providing duodenum dose-volume histogram (DVH) statistics for clinical studies of conventionally-fractionated radiotherapy. Values for the Lyman-Kutcher-Burman (LKB) NTCP model were derived through sum-squared-error minimisation and using leave-one-out cross-validation. Data were corrected for fraction size and weighted according to patient numbers, and the model refined using individual patient DVH data for two further cohorts from prospective clinical trials. Results Six studies with published DVH data were utilised, and with individual patient data included outcomes for 531 patients in total (median follow-up 16 months). Observed gastro-intestinal toxicity rates ranged from 0% to 14% (median 8%). LKB parameter values for unconstrained fit to published data were: n = 0.070, m = 0.46, TD50(1) [Gy] = 183.8, while the values for the model incorporating the individual patient data were n = 0.193, m = 0.51, TD50(1) [Gy] = 299.1. Conclusions LKB parameters derived using published data are shown to be consistent to those previously obtained using individual patient data, supporting a small volume-effect and dependence on exposure to high threshold dose.
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Mukumoto N, Nakamura M, Yamada M, Takahashi K, Akimoto M, Miyabe Y, Yokota K, Kaneko S, Nakamura A, Itasaka S, Matsuo Y, Mizowaki T, Kokubo M, Hiraoka M. Development of a four-axis moving phantom for patient-specific QA of surrogate signal-based tracking IMRT. Med Phys 2017; 43:6364. [PMID: 27908156 PMCID: PMC5648581 DOI: 10.1118/1.4966130] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Purpose: The purposes of this study were two-fold: first, to develop a four-axis moving phantom for patient-specific quality assurance (QA) in surrogate signal-based dynamic tumor-tracking intensity-modulated radiotherapy (DTT-IMRT), and second, to evaluate the accuracy of the moving phantom and perform patient-specific dosimetric QA of the surrogate signal-based DTT-IMRT. Methods: The four-axis moving phantom comprised three orthogonal linear actuators for target motion and a fourth one for surrogate motion. The positional accuracy was verified using four laser displacement gauges under static conditions (±40 mm displacements along each axis) and moving conditions [eight regular sinusoidal and fourth-power-of-sinusoidal patterns with peak-to-peak motion ranges (H) of 10–80 mm and a breathing period (T) of 4 s, and three irregular respiratory patterns with H of 1.4–2.5 mm in the left–right, 7.7–11.6 mm in the superior-inferior, and 3.1–4.2 mm in the anterior–posterior directions for the target motion, and 4.8–14.5 mm in the anterior–posterior direction for the surrogate motion, and T of 3.9–4.9 s]. Furthermore, perpendicularity, defined as the vector angle between any two axes, was measured using an optical measurement system. The reproducibility of the uncertainties in DTT-IMRT was then evaluated. Respiratory motions from 20 patients acquired in advance were reproduced and compared three-dimensionally with the originals. Furthermore, patient-specific dosimetric QAs of DTT-IMRT were performed for ten pancreatic cancer patients. The doses delivered to Gafchromic films under tracking and moving conditions were compared with those delivered under static conditions without dose normalization. Results: Positional errors of the moving phantom under static and moving conditions were within 0.05 mm. The perpendicularity of the moving phantom was within 0.2° of 90°. The differences in prediction errors between the original and reproduced respiratory motions were −0.1 ± 0.1 mm for the lateral direction, −0.1 ± 0.2 mm for the superior-inferior direction, and −0.1 ± 0.1 mm for the anterior–posterior direction. The dosimetric accuracy showed significant improvements, of 92.9% ± 4.0% with tracking versus 69.8% ± 7.4% without tracking, in the passing rates of γ with the criterion of 3%/1 mm (p < 0.001). Although the dosimetric accuracy of IMRT without tracking showed a significant negative correlation with the 3D motion range of the target (r = − 0.59, p < 0.05), there was no significant correlation for DTT-IMRT (r = 0.03, p = 0.464). Conclusions: The developed four-axis moving phantom had sufficient accuracy to reproduce patient respiratory motions, allowing patient-specific QA of the surrogate signal-based DTT-IMRT under realistic conditions. Although IMRT without tracking decreased the dosimetric accuracy as the target motion increased, the DTT-IMRT achieved high dosimetric accuracy.
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Affiliation(s)
- Nobutaka Mukumoto
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Mitsuhiro Nakamura
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Masahiro Yamada
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Kunio Takahashi
- Mitsubishi Heavy Industries, Ltd., Hiroshima 733-8553, Japan
| | - Mami Akimoto
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Yuki Miyabe
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Kenji Yokota
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Shuji Kaneko
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Akira Nakamura
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Satoshi Itasaka
- Department of Radiology, Kurashiki Central Hospital, Kurashiki 710-8602, Japan
| | - Yukinori Matsuo
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Takashi Mizowaki
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Masaki Kokubo
- Department of Radiation Oncology, Kobe City Medical Center General Hospital, Kobe 650-0047, Japan and Division of Radiation Oncology, Institute of Biomedical Research and Innovation, Kobe 650-0047, Japan
| | - Masahiro Hiraoka
- Department of Radiation Oncology and Image-applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
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Houweling AC, Crama K, Visser J, Fukata K, Rasch CRN, Ohno T, Bel A, van der Horst A. Comparing the dosimetric impact of interfractional anatomical changes in photon, proton and carbon ion radiotherapy for pancreatic cancer patients. Phys Med Biol 2017; 62:3051-3064. [PMID: 28252445 DOI: 10.1088/1361-6560/aa6419] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Radiotherapy using charged particles is characterized by a low dose to the surrounding healthy organs, while delivering a high dose to the tumor. However, interfractional anatomical changes can greatly affect the robustness of particle therapy. Therefore, we compared the dosimetric impact of interfractional anatomical changes (i.e. body contour differences and gastrointestinal gas volume changes) in photon, proton and carbon ion therapy for pancreatic cancer patients. In this retrospective planning study, photon, proton and carbon ion treatment plans were created for 9 patients. Fraction dose calculations were performed using daily cone-beam CT (CBCT) images. To this end, the planning CT was deformably registered to each CBCT; gastrointestinal gas volumes were delineated on the CBCTs and copied to the deformed CT. Fraction doses were accumulated rigidly. To compare planned and accumulated dose, dose-volume histogram (DVH) parameters of the planned and accumulated dose of the different radiotherapy modalities were determined for the internal gross tumor volume, internal clinical target volume (iCTV) and organs-at-risk (OARs; duodenum, stomach, kidneys, liver and spinal cord). Photon plans were highly robust against interfractional anatomical changes. The difference between the planned and accumulated DVH parameters for the photon plans was less than 0.5% for the target and OARs. In both proton and carbon ion therapy, however, coverage of the iCTV was considerably reduced for the accumulated dose compared with the planned dose. The near-minimum dose ([Formula: see text]) of the iCTV reduced with 8% for proton therapy and with 10% for carbon ion therapy. The DVH parameters of the OARs differed less than 3% for both particle modalities. Fractionated radiotherapy using photons is highly robust against interfractional anatomical changes. In proton and carbon ion therapy, such changes can severely reduce the dose coverage of the target.
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Affiliation(s)
- Antonetta C Houweling
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Lens E, Kotte ANTJ, Patel A, Heerkens HD, Bal M, van Tienhoven G, Bel A, van der Horst A, Meijer GJ. Probabilistic treatment planning for pancreatic cancer treatment: prospective incorporation of respiratory motion shows only limited dosimetric benefit. Acta Oncol 2017; 56:398-404. [PMID: 27885864 DOI: 10.1080/0284186x.2016.1257863] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND We introduced a probabilistic treatment planning approach that prospectively incorporates respiratory-induced motion in the treatment plan optimization. The aim of this study was to determine the potential dosimetric benefit by comparing this approach to the use of an internal target volume (ITV). MATERIAL AND METHOD We retrospectively compared the probabilistic respiratory motion-incorporated (RMI) approach to the ITV approach for 18 pancreatic cancer patients, for seven simulated respiratory amplitudes from 5 to 50 mm in the superior-inferior (SI) direction. For each plan, we assessed the target coverage (required: D98%≥95% of 50 Gy prescribed dose). For the RMI plans, we investigated whether target coverage was robust against daily variations in respiratory amplitude. We determined the distance between the clinical target volume and the 30 Gy isodose line (i.e. dose gradient steepness) in the SI direction. To investigate the clinical benefit of the RMI approach, we created for each patient an ITV and RMI treatment plan for the three-dimensional (3D) respiratory amplitudes observed on their pretreatment 4D computed tomography (4DCT). We determined Dmean, V30Gy, V40Gy and V50Gy for the duodenum. RESULTS All treatment plans yielded good target coverage. The RMI plans were robust against respiratory amplitude variations up to 10 mm, as D98% remained ≥95%. We observed steeper dose gradients compared to the ITV approach, with a mean decrease from 25.9 to 19.2 mm for a motion amplitude of 50 mm. For the 4DCT motion amplitudes, the RMI approach resulted in a mean decrease of 0.43 Gy, 1.1 cm3, 1.4 cm3 and 0.9 cm3 for the Dmean, V30Gy, V40Gy and V50Gy of the duodenum, respectively. CONCLUSION The probabilistic treatment planning approach yielded significantly steeper dose gradients and therefore significantly lower dose to surrounding healthy tissues than the ITV approach. However, the observed dosimetric gain for clinically observed respiratory motion amplitudes for this patient group was limited.
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Affiliation(s)
- Eelco Lens
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Alexis N. T. J. Kotte
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ajay Patel
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hanne D. Heerkens
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Geertjan van Tienhoven
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Arjan Bel
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Astrid van der Horst
- Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Gert J. Meijer
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
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Lee KJ, Yoon HI, Chung MJ, Park JY, Bang S, Park SW, Seong JS, Song SY. A Comparison of Gastrointestinal Toxicities between Intensity-Modulated Radiotherapy and Three-Dimensional Conformal Radiotherapy for Pancreatic Cancer. Gut Liver 2016; 10:303-9. [PMID: 26470767 PMCID: PMC4780462 DOI: 10.5009/gnl15186] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background/Aims Concurrent chemoradiotherapy (CCRT) is considered the treatment option for locally advanced pancreatic cancer, but accompanying gastrointestinal toxicities are the most common complication. With the introduction of three-dimensional conformal radiotherapy (3-D CRT) and intensity-modulated radiotherapy (IMRT), CCRT-related adverse events are expected to diminish. Here, we evaluated the benefits of radiation modalities by comparing gastrointestinal toxicities between 3-D CRT and IMRT. Methods Patients who received CCRT between July 2010 and June 2012 in Severance Hospital, Yonsei University College of Medicine, were enrolled prospectively. The patients underwent upper endoscopy before and 1 month after CCRT. Results A total of 84 patients were enrolled during the study period. The radiotherapy modalities delivered included 3D-CRT (n=40) and IMRT (n=44). The median follow-up period from the start of CCRT was 10.6 months (range, 3.8 to 29.9 months). The symptoms of dyspepsia, nausea/vomiting, and diarrhea did not differ between the groups. Upper endoscopy revealed significantly more gastroduodenal ulcers in the 3-D CRT group (p=0.003). The modality of radiotherapy (3D-CRT; odds ratio [OR], 11.67; p=0.011) and tumor location (body of pancreas; OR, 11.06; p=0.009) were risk factors for gastrointestinal toxicities. Conclusions IMRT is associated with significantly fewer gastroduodenal injuries among patients treated with CCRT for pancreatic cancer.
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Affiliation(s)
- Kyong Joo Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hong In Yoon
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea.,Brain Korea 21 Plus Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Moon Jae Chung
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong Youp Park
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seungmin Bang
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seung-Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Sil Seong
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Si Young Song
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Witztum A, George B, Warren S, Partridge M, Hawkins MA. Unwrapping 3D complex hollow organs for spatial dose surface analysis. Med Phys 2016; 43:6009. [PMID: 27806596 DOI: 10.1118/1.4964790] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 08/16/2016] [Accepted: 09/27/2016] [Indexed: 02/11/2024] Open
Abstract
PURPOSE Toxicity dose-response models describe the correlation between dose delivered to an organ and a given toxic endpoint. Duodenal toxicity is a dose limiting factor in the treatment of pancreatic cancer with radiation but the relationship between dose and toxicity in the duodenum is not well understood. While there have been limited studies into duodenal toxicity through investigations of the volume of the organ receiving dose over a specific threshold, both dose-volume and dose-surface histograms lack spatial information about the dose distribution, which may be important in determining normal tissue response. Due to the complex geometry of the duodenum, previous methods for unwrapping tubular organs for spatial modeling of toxicity are insufficient. A geometrically robust method for producing 2D dose surface maps (DSMs), specifically for the duodenum, has been developed and tested in order to characterize the spatial dose distribution. METHODS The organ contour is defined using Delaunay triangulation. The user selects a start and end coordinate in the structure and a path is found by regulating both length and curvature. This path is discretized and rays are cast from each point on the plane normal to the vector between the previous and the next point on the path and the dose at the closest perimeter point recorded. These angular perimeter slices are "unwrapped" from the edge distal to the pancreas to ensure the high dose region (proximal to the tumor) falls in the centre of the dose map. Gamma analysis is used to quantify the robustness of this method and the effect of overlapping planes. RESULTS This method was used to extract DSMs for 15 duodena, with one esophagus case to illustrate the application to simpler geometries. Visual comparison indicates that a 30 × 30 map provides sufficient resolution to view gross spatial features of interest. A lookup table is created to store the area (cm2) represented by each pixel in the DSMs in order to allow spatial descriptors in absolute size. The method described in this paper is robust, requires minimal human interaction, has been shown to be generalizable to simpler geometries, and uses readily available commercial software. The difference seen in DSMs due to overlapping planes is large and justifies the need for a solution that removes such planes. CONCLUSIONS This is the first time 2D dose surface maps have been produced for the duodenum and provide spatial dose distribution information which can be explored to create models that may improve toxicity prediction in treatments for locally advanced pancreatic cancer.
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Affiliation(s)
- A Witztum
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford OX3 7DQ, United Kingdom
| | - B George
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford OX3 7DQ, United Kingdom
| | - S Warren
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford OX3 7DQ, United Kingdom
| | - M Partridge
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford OX3 7DQ, United Kingdom
| | - M A Hawkins
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford OX3 7DQ, United Kingdom
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Liu Q, Cai XW, Fu XL, Chen JC, Xiang JQ. Tolerance and dose-volume relationship of intrathoracic stomach irradiation after esophagectomy for patients with thoracic esophageal squamous cell carcinoma. Oncotarget 2016; 6:32220-7. [PMID: 26314958 PMCID: PMC4741672 DOI: 10.18632/oncotarget.4730] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 07/24/2015] [Indexed: 12/25/2022] Open
Abstract
Purpose To identify the tolerance of radiation with a high prescribed dose and predictors for the development of intrathoracic stomach toxicity in patients with thoracic esophageal squamous cell carcinoma (SCC) after esophagectomy followed by gastric conduit reconstruction. Methods and Materials From 2011 to 2013, 105 patients after esophagectomy were treated with postoperative radiotherapy. The intrathoracic stomach was outlined with the calculation of a dose-volume histogram (DVH) for the initial intended treatment of 6020 cGy or 6300 cGy. The volume of the intrathoracic stomach receiving each dose was recorded at 10-Gy intervals between 10 and 40 Gy and at 5-Gy intervals between 40 and 60 Gy. The grade of toxicities was defined by the National Cancer Institute Common Toxicity Criteria version 4.0. Results The mean and maximum doses of the intrathoracic stomach were 2449 ± 986 cGy and 6519 ± 406 cGy, respectively. Sixteen (15.2%) and three (2.9%) experienced Common Toxicity Criteria Grade 2 and Grade 3 acute gastric toxicity. There were no Grade 4 toxicities. Fourteen patients (13.3%) exhibited late gastric complications possibly related to radiation. The volume percent of the intrathoracic stomach receiving at least 50 Gy (V50) was strongly associated with the degree of toxicity (p = 0.024, respectively). Multivariate analysis of patient and treatment-related factors revealed no other significant predictors of severe toxicities. Conclusions The intrathoracic stomach is well tolerated with a high-dose irradiation for patients with esophageal SCC receiving radiotherapy after esophagectomy. A strong dose-volume relationship exists for the development of Grade 2 acute intrathoracic stomach toxicity in our study.
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Affiliation(s)
- Qi Liu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xu-Wei Cai
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Radiation Oncology, Shanghai Jiaotong University Chest Hospital, Shanghai, China
| | - Xiao-Long Fu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Radiation Oncology, Shanghai Jiaotong University Chest Hospital, Shanghai, China
| | - Jun-Chao Chen
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jia-Qing Xiang
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
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Shinoto M, Shioyama Y, Matsunobu A, Okamoto K, Suefuji H, Toyama S, Honda H, Kudo S. Dosimetric analysis of upper gastrointestinal ulcer after carbon-ion radiotherapy for pancreatic cancer. Radiother Oncol 2016; 120:140-4. [DOI: 10.1016/j.radonc.2016.04.040] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 04/12/2016] [Accepted: 04/28/2016] [Indexed: 10/21/2022]
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Liu X, Ren G, Li L, Xia T. Predictive dosimetric parameters for gastrointestinal toxicity with hypofractioned radiotherapy in pancreatic adenocarcinoma. Onco Targets Ther 2016; 9:2489-94. [PMID: 27217772 PMCID: PMC4853153 DOI: 10.2147/ott.s102035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
To better guide the development and optimization of radiotherapy planning, to reduce the incidence of radiation reactions, and to improve the quality of life of the patients with pancreatic cancer using radiotherapy, we conducted this study to explore the dosimetric parameters that predict the risk of gastrointestinal (GI) toxicity with hypofractioned radiotherapy for pancreatic cancer. Between January 2014 and January 2015, the medical records of 68 patients with pancreatic cancer who underwent helical tomotherapy at the Air Force General Hospital were analyzed. The doses delivered to the planning target volume, clinical target volume, and gross tumor volume-internal gross tumor volume of the primary pancreatic lesions were 50, 60, and 70-80 Gy in 15-20 fractions, respectively. GI toxicity was scored according to version 4.0 of the National Cancer Institute Common Terminology Criteria for Adverse Events. The stomach and duodenum were contoured separately to determine the dose-volume histogram parameters. Univariate and multivariate analyses were adopted to identify clinical and physical risk factors associated with GI toxicity. The median follow-up was 9 months (range: 4-16 months). Eighteen patients had grade II acute GI toxicity, one patient had grade III acute GI toxicity, 17 patients had grade II late GI toxicity, and one patient had grade III late GI toxicity. On univariate analysis, the volume, the average dose D mean, the maximum dose to 1, 3, 5, and 10 cm(3) of the stomach and duodenum (D1, D3, D5, and D10), and the relative volumes receiving 5-40 Gy (V5-V40), and the absolute volumes receiving 5-45 Gy (aV5-aV45) of the duodenum were significantly associated with grade II or higher GI toxicity (P<0.05). On multivariate analysis, aV45 of the duodenum was an independent predictor for grade II or higher GI toxicity (P=0.031). The receiver operating characteristic analysis also showed that an aV45 of 0.5 cm(3) was the optimal threshold to predict GI toxicity for the entire cohort. Our findings indicate that many dosimetric parameters of the duodenum correlate with grade II or higher GI toxicity. To reduce GI toxicity, the absolute volume of the irradiated duodenum should be reduced.
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Affiliation(s)
- Xian Liu
- Department of Radiation Oncology, Air Force General Hospital, Beijing, People's Republic of China
| | - Gang Ren
- Department of Radiation Oncology, Air Force General Hospital, Beijing, People's Republic of China
| | - Liqin Li
- Department of Radiation Oncology, Air Force General Hospital, Beijing, People's Republic of China
| | - Tingyi Xia
- Department of Radiation Oncology, Air Force General Hospital, Beijing, People's Republic of China
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Houweling AC, Fukata K, Kubota Y, Shimada H, Rasch CR, Ohno T, Bel A, van der Horst A. The impact of interfractional anatomical changes on the accumulated dose in carbon ion therapy of pancreatic cancer patients. Radiother Oncol 2016; 119:319-25. [DOI: 10.1016/j.radonc.2016.03.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 02/23/2016] [Accepted: 03/04/2016] [Indexed: 01/17/2023]
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Shiomi M, Mori S, Shinoto M, Nakayama Y, Kamada T, Yamada S. Comparison of carbon-ion passive and scanning irradiation for pancreatic cancer. Radiother Oncol 2016; 119:326-30. [DOI: 10.1016/j.radonc.2016.04.026] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Revised: 04/17/2016] [Accepted: 04/19/2016] [Indexed: 11/28/2022]
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Kennoki N, Nakayama H, Nagakawa Y, Hosokawa Y, Itonaga T, Tajima YU, Shiraishi S, Mikami R, Tsuchida A, Tokuuye K. Feasibility of intensity-modulated radiotherapy combined with gemcitabine and S-1 for patients with pancreatic cancer. Mol Clin Oncol 2015; 4:43-46. [PMID: 26870355 DOI: 10.3892/mco.2015.664] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 10/22/2015] [Indexed: 12/22/2022] Open
Abstract
The aim of the present study was to establish whether intensity-modulated radiotherapy (IMRT) with concurrent gemcitabine and S-1 is a feasible treatment option for patients with locally advanced pancreatic ductal adenocarcinoma. Patients with pancreatic ductal adenocarcinoma were prospectively enrolled. An IMRT dose of 50.4 Gy in 28 fractions with concurrent gemcitabine at a dose of 600 mg/m2 and S-1 at a dose of 60 mg were administrated. Adverse events and associated dosimetric factors were assessed. Between February 2012 and January 2014, 17 patients with borderline resectable and 4 with unresectable pancreatic cancer were enrolled. None of the patients experienced grade 3 or worse nausea and vomiting. The planning target volume (≥200 vs. <200 ml) was a statistically significant predictive factor for neutrocytopenia (≥500 vs. 500/µl, P=0.02). Concurrent IMRT with gemcitabine and S-1 for patients with locally advanced pancreatic cancer is feasible, with tolerable hematological toxicities and low gastrointestinal toxicities.
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Affiliation(s)
- Norifumi Kennoki
- Department of Radiology, Tokyo Medical University, Shinjyuku, Tokyo 160-0023, Japan
| | - Hidetsugu Nakayama
- Department of Radiology, Tokyo Medical University, Shinjyuku, Tokyo 160-0023, Japan
| | - Yuichi Nagakawa
- Third Department of Surgery, Tokyo Medical University, Shinjyuku, Tokyo 160-0023, Japan
| | - Yuichi Hosokawa
- Third Department of Surgery, Tokyo Medical University, Shinjyuku, Tokyo 160-0023, Japan
| | - Tomohiro Itonaga
- Department of Radiology, Tokyo Medical University, Shinjyuku, Tokyo 160-0023, Japan
| | - Y U Tajima
- Department of Radiology, Tokyo Medical University, Shinjyuku, Tokyo 160-0023, Japan
| | - Sachica Shiraishi
- Department of Radiology, Tokyo Medical University, Shinjyuku, Tokyo 160-0023, Japan
| | - Ryuji Mikami
- Department of Radiology, Tokyo Medical University, Shinjyuku, Tokyo 160-0023, Japan
| | - Akihiko Tsuchida
- Third Department of Surgery, Tokyo Medical University, Shinjyuku, Tokyo 160-0023, Japan
| | - Koichi Tokuuye
- Department of Radiology, Tokyo Medical University, Shinjyuku, Tokyo 160-0023, Japan
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Thompson RF, Mayekar SU, Zhai H, Both S, Apisarnthanarax S, Metz JM, Plastaras JP, Ben-Josef E. A dosimetric comparison of proton and photon therapy in unresectable cancers of the head of pancreas. Med Phys 2015; 41:081711. [PMID: 25086521 DOI: 10.1118/1.4887797] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Uncontrolled local growth is the cause of death in ∼ 30% of patients with unresectable pancreatic cancers. The addition of standard-dose radiotherapy to gemcitabine has been shown to confer a modest survival benefit in this population. Radiation dose escalation with three-dimensional planning is not feasible, but high-dose intensity-modulated radiation therapy (IMRT) has been shown to improve local control. Still, dose-escalation remains limited by gastrointestinal toxicity. In this study, the authors investigate the potential use of double scattering (DS) and pencil beam scanning (PBS) proton therapy in limiting dose to critical organs at risk. METHODS The authors compared DS, PBS, and IMRT plans in 13 patients with unresectable cancer of the pancreatic head, paying particular attention to duodenum, small intestine, stomach, liver, kidney, and cord constraints in addition to target volume coverage. All plans were calculated to 5500 cGy in 25 fractions with equivalent constraints and normalized to prescription dose. All statistics were by two-tailed paired t-test. RESULTS Both DS and PBS decreased stomach, duodenum, and small bowel dose in low-dose regions compared to IMRT (p < 0.01). However, protons yielded increased doses in the mid to high dose regions (e.g., 23.6-53.8 and 34.9-52.4 Gy for duodenum using DS and PBS, respectively; p < 0.05). Protons also increased generalized equivalent uniform dose to duodenum and stomach, however these differences were small (<5% and 10%, respectively; p < 0.01). Doses to other organs-at-risk were within institutional constraints and placed no obvious limitations on treatment planning. CONCLUSIONS Proton therapy does not appear to reduce OAR volumes receiving high dose. Protons are able to reduce the treated volume receiving low-intermediate doses, however the clinical significance of this remains to be determined in future investigations.
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Affiliation(s)
- Reid F Thompson
- University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | - Sonal U Mayekar
- Thomas Jefferson University, Philadelphia, Pennsylvania 19107
| | - Huifang Zhai
- University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | - Stefan Both
- University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | | | - James M Metz
- University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | | | - Edgar Ben-Josef
- University of Pennsylvania, Philadelphia, Pennsylvania 19104
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Zhang HJ, Zhu XF. Clinical implementation of stereotactic body radiation therapy in pancreatic cancer and hepatocellular carcinoma. Shijie Huaren Xiaohua Zazhi 2015; 23:3989-3996. [DOI: 10.11569/wcjd.v23.i25.3989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
With the development of radiation technology, more emphasis has been placed on the application of stereotactic body radiation therapy (SBRT) for the treatment of pancreatic cancer and hepatocellular carcinoma. The use of SBRT contributes to the advantage of dose distributions, resulting in maximum doses in target volumes and minimum doses in surrounding normal tissues. Due to a variety of treatment modalities, different clinical results have been presented in different plans. This article gives a summary of SBRT in the treatment of pancreatic cancer and hepatocellular carcinoma.
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Definitive Chemoradiation With Full-dose Gemcitabine for Unresectable Pancreatic Cancer: Efficacy of Involved-Field Radiotherapy. Am J Clin Oncol 2015; 40:517-522. [PMID: 26165418 DOI: 10.1097/coc.0000000000000200] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES Definitive chemoradiotherapy for unresectable pancreatic cancer has traditionally involved 5-fluorouracil-based chemotherapy. Our institution has a long history of combining gemcitabine and radiotherapy (RT), and performed a retrospective review of all patients treated in this manner. MATERIALS AND METHODS We reviewed the records of 180 patients treated from 1999 to 2012. Mean RT dose was 40.9 Gy in 2.2-Gy fractions, and targeted only radiographically apparent disease. Ninety-six percent of patients received full-dose gemcitabine-based chemotherapy with RT. Kaplan-Meier was used to analyze time-to-event endpoints, and Cox regression models were used to assess significant prognostic variables. RESULTS Eighty-nine percent of patients completed RT without a toxicity-related treatment break. Median follow-up was 10.2 months. Twenty-nine percent of patients had a radiographic decrease in primary tumor size following treatment. Median overall survival was 11.8 months, time to distant metastasis (TDM) was 6.7 months, and time to local recurrence (TLR) was 8.3 months. On multivariate analysis, male sex, lower performance status, and higher posttreatment CA 19-9 level predicted for worse overall survival. Posttreatment, CA 19-9 was also associated with TDM and TLR, and radiographic tumor response was associated with better TLR. CONCLUSION Definitive chemoradiation using full-dose gemcitabine is well tolerated and achieves survival outcomes comparable to reported trials in the literature.
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Lens E, van der Horst A, Versteijne E, van Tienhoven G, Bel A. Dosimetric Advantages of Midventilation Compared With Internal Target Volume for Radiation Therapy of Pancreatic Cancer. Int J Radiat Oncol Biol Phys 2015; 92:675-82. [DOI: 10.1016/j.ijrobp.2015.02.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 02/05/2015] [Accepted: 02/09/2015] [Indexed: 01/18/2023]
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Weltman E, Marta GN, Baraldi HS, Pimentel L, Castilho M, Maia MAC, Lundgren MSFS, Chen MJ, Novaes PERS, Gadia R, Ferrigno R, Motta R, Hanna SA, Almeida W. Treatment of abdominal tumors using radiotherapy. Rev Assoc Med Bras (1992) 2015; 61:108-13. [DOI: 10.1590/1806-9282.61.02.108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
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Nakamura M, Akimoto M, Ono T, Nakamura A, Yano S, Nakata M, Itasaka S, Mizowaki T, Shibuya K, Hiraoka M. Interfraction positional variation in pancreatic tumors using daily breath-hold cone-beam computed tomography with visual feedback. J Appl Clin Med Phys 2015; 16:5123. [PMID: 26103180 PMCID: PMC5690071 DOI: 10.1120/jacmp.v16i2.5123] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 12/10/2014] [Accepted: 12/08/2014] [Indexed: 12/11/2022] Open
Abstract
We assessed interfraction positional variation in pancreatic tumors using daily breath‐hold cone‐beam computed tomography at end‐exhalation (EE) with visual feedback (BH‐CBCT). Eleven consecutive patients with pancreatic cancer who underwent BH intensity‐modulated radiation therapy with visual feedback were enrolled. All participating patients stopped oral intake, with the exception of drugs and water, for >3 hr before treatment planning and daily treatment. Each patient was fixed in the supine position on an individualized vacuum pillow. An isotropic margin of 5 mm was added to the clinical target volume to create the planning target volume (PTV). The prescription dose was 42 to 51 Gy in 15 fractions. After correcting initial setup errors based on bony anatomy, the first BH‐CBCT scans were performed before beam delivery in every fraction. BH‐CBCT acquisition was obtained in three or four times breath holds by interrupting the acquisition two or three times, depending on the patient's BH ability. The image acquisition time for a 360° gantry rotation was approximately 90 s, including the interruption time due to BH. The initial setup errors were corrected based on bony structure, and the residual errors in the target position were then recorded. The magnitude of the interruptions variation in target position was assessed for 165 fractions. The systematic and random errors were 1.2 and 1.8 mm, 1.1 and 1.8 mm, and 1.7 and 2.9 mm in the left–right (LR), anterior–posterior (AP), and superior–inferior (SI) directions, respectively. Absolute interfraction variations of >5 mm were observed in 18 fractions (11.0%) from seven patients because of EE‐BH failure. In conclusion, target matching is required to correct interfraction variation even with visual feedback, especially to ensure safe delivery of escalated doses to patients with pancreatic cancer. PACS number: 87.57.Q‐, 87.57.‐s, 87.55.Qr
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Akimoto M, Nakamura M, Mukumoto N, Yamada M, Tanabe H, Ueki N, Kaneko S, Matsuo Y, Mizowaki T, Kokubo M, Hiraoka M. Baseline correction of a correlation model for improving the prediction accuracy of infrared marker-based dynamic tumor tracking. J Appl Clin Med Phys 2015; 16:4896. [PMID: 26103167 PMCID: PMC5690072 DOI: 10.1120/jacmp.v16i2.4896] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Revised: 12/08/2014] [Accepted: 12/03/2014] [Indexed: 12/25/2022] Open
Abstract
We previously found that the baseline drift of external and internal respiratory motion reduced the prediction accuracy of infrared (IR) marker‐based dynamic tumor tracking irradiation (IR Tracking) using the Vero4DRT system. Here, we proposed a baseline correction method, applied immediately before beam delivery, to improve the prediction accuracy of IR Tracking. To perform IR Tracking, a four‐dimensional (4D) model was constructed at the beginning of treatment to correlate the internal and external respiratory signals, and the model was expressed using a quadratic function involving the IR marker position (x) and its velocity (v), namely function F(x,v). First, the first 4D model, F1st(x,v), was adjusted by the baseline drift of IR markers (BDIR) along the x‐axis, as function F′(x,v). Next, BDdetect, that defined as the difference between the target positions indicated by the implanted fiducial markers (Pdetect) and the predicted target positions with F′(x,v) (Ppredict) was determined using orthogonal kV X‐ray images at the peaks of the Pdetect of the end‐inhale and end‐exhale phases for 10 s just before irradiation. F′(x,v) was corrected with BDdetect to compensate for the residual error. The final corrected 4D model was expressed as Fcor(x,v)=F1st{(x−BDIR),v}−BDdetect. We retrospectively applied this function to 53 paired log files of the 4D model for 12 lung cancer patients who underwent IR Tracking. The 95th percentile of the absolute differences between Pdetect and Ppredict (|Ep|) was compared between F1st(x,v) and Fcor(x,v). The median 95th percentile of |Ep| (units: mm) was 1.0, 1.7, and 3.5 for F1st(x,v), and 0.6, 1.1, and 2.1 for Fcor(x,v) in the left–right, anterior–posterior, and superior–inferior directions, respectively. Over all treatment sessions, the 95th percentile of |Ep| peaked at 3.2 mm using Fcor(x,v) compared with 8.4 mm using F1st(x,v). Our proposed method improved the prediction accuracy of IR Tracking by correcting the baseline drift immediately before irradiation. PACS number: 87.19.rs, 87.19.Wx, 87.56.‐v, 87.59.‐e, 88.10.gc
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Comparing outcomes of stereotactic body radiotherapy with intensity-modulated radiotherapy for patients with locally advanced unresectable pancreatic cancer. Eur J Gastroenterol Hepatol 2015; 27:259-64. [PMID: 25629569 DOI: 10.1097/meg.0000000000000283] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Survival in patients with locally advanced unresectable pancreatic cancer (LAUPC) is poor, and local recurrence continues to be a major problem in the management of this disease. Radiotherapy (RT) using different RT techniques, including intensity-modulated radiotherapy (IMRT) and stereotactic body radiation therapy (SBRT), may lead to different clinical outcomes for patients with LAUPC. Here, we compared SBRT with IMRT for patients with LAUPC with respect to survival rate, local control (LC) rate, and toxicity-related dose distribution. MATERIALS AND METHODS This retrospective study from March 2007 to March 2011 included 41 patients with LAUPC who were divided into two groups, with 20 patients receiving SBRT and 21 patients receiving IMRT. The median follow-up time was 16 months. RESULTS For the IMRT and SBRT groups, the median survival times were 13 and 20 months, and 1-year overall survival (OS) rates were 70.7 and 80.0%, respectively. There was no difference in OS between the two RT techniques. RT with SBRT showed significantly better local disease-free survival than IMRT for patients with LAUPC. Tobacco use had a borderline effect on LC. Thus, further statistical analysis showed that patients who used tobacco had better LC after receiving SBRT than IMRT. CONCLUSION SBRT improved LC for LAUPC patients and had similar radiation toxicity compared with IMRT. Further study is required to define the effects of administered radiation dose and fractionation, as well as to further expand the sample size, to use a prospective study, and to observe the long-term efficacy of these techniques.
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50
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Nakamura M, Akimoto M, Mukumoto N, Yamada M, Tanabe H, Ueki N, Matsuo Y, Mizowaki T, Kokubo M, Hiraoka M. Influence of the correlation modeling period on the prediction accuracy of infrared marker-based dynamic tumor tracking using a gimbaled X-ray head. Phys Med 2015; 31:204-9. [PMID: 25639590 DOI: 10.1016/j.ejmp.2015.01.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 01/10/2015] [Accepted: 01/12/2015] [Indexed: 12/25/2022] Open
Abstract
PURPOSE To assess the utility of 10 s and 20 s modeling periods, rather than the 40 s currently used, in the clinical construction of practical correlation models (CMs) in dynamic tumor tracking irradiation using the Vero4DRT. METHODS The CMs with five independent parameters (CM parameters) were analyzed retrospectively for 10 consecutive lung cancer patients. CM remodeling was performed two or three times per treatment session. Three different CMs trained over modeling periods of 10, 20, and 40 s were built from a single, original CM log file. The predicted target positions were calculated from the CM parameters and the vertical displacement of infrared markers on the abdomen (PIR) during the modeling. We assessed how the CM parameters obtained over modeling periods of T s (T = 10, 20, and 40 s) were robust to changes in respiratory patterns after several minutes. The mimic-predicted target positions after several minutes were computed based on the previous CM parameters and PIR during the next modeling. The 95th percentiles of the differences between mimic-predicted and detected target positions over 40 s (E95robust,T: T = 10, 20, and 40 s) were then calculated. RESULTS Strong correlations greater than 0.92 were observed between the E95robust,20 and E95robust,40 values. Meanwhile, irregular respiratory patterns with inconsistent amplitudes of motion created differences between the E95robust,10 and E95robust,40 values of ≥10 mm. CONCLUSIONS The accuracies of CMs derived using 20 s were almost identical to those obtained over 40 s, and superior to those obtained over 10 s.
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Affiliation(s)
- Mitsuhiro Nakamura
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Japan.
| | - Mami Akimoto
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Japan
| | - Nobutaka Mukumoto
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Japan
| | - Masahiro Yamada
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Japan
| | - Hiroaki Tanabe
- Division of Radiation Oncology, Institute of Biomedical Research and Innovation, Japan
| | - Nami Ueki
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Japan
| | - Yukinori Matsuo
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Japan
| | - Takashi Mizowaki
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Japan
| | - Masaki Kokubo
- Department of Radiation Oncology, Kobe City Medical Center General Hospital, Japan
| | - Masahiro Hiraoka
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Japan
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