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Chomchai T, Klunklin P, Tongprasert S, Kanthawang T, Toapichattrakul P, Chitapanarux I. Is there any radiation-induced brachial plexopathy after hypofractionated postmastectomy radiotherapy with helical tomotherapy? Front Oncol 2024; 14:1392313. [PMID: 38741780 PMCID: PMC11089205 DOI: 10.3389/fonc.2024.1392313] [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: 02/27/2024] [Accepted: 04/15/2024] [Indexed: 05/16/2024] Open
Abstract
Introduction Radiation-induced brachial plexopathy (RIBP) is one of the most concerning late radiation effects after hypofractionated postmastectomy radiotherapy (HF-PMRT) to the chest wall and regional lymph nodes. The purpose of this study was to investigate the RIBP events occurring in breast cancer patients after HF-PMRT using intensity-modulated radiation therapy (IMRT) by helical tomotherapy. Furthermore, the dosimetric parameters of the ipsilateral brachial plexus were reported. Materials and methods Breast cancer patients who underwent HF-PMRT using the IMRT via HT at our institute were included. In the first cohort, subjective RIBP symptoms were measured using a QuickDASH questionnaire, whereas objective RIBP events were assessed using a comprehensive physical evaluation in the second cohort. The ipsilateral brachial plexus from all eligible patients' treatment plans was contoured, and the dosimetric parameters were explored. Results From March 2014 to December 2022, 229 patients were enrolled; 107 and 72 individuals were in the first and second cohorts, respectively. The first cohort's median follow-up period was 27 months, and the second cohort was 31 months. In the first cohort, 80 patients (74.77%) had a normal function, 21 (19.63%) had a mild grade, and 6 (5.61%) had a moderate grade; no severe or very severe RIBP was observed. However, the comprehensive physical evaluation of the second cohort indicated no RIBP events. Dosimetric analysis revealed that the median maximum dose was 44.52, 44.52, and 44.60 Gy; the median mean dose was 33.00, 32.23, and 32.33 Gy; and the median dose at 0.03 cc was 44.33, 44.36, and 44.39 Gy for all patients, patients in the first and second cohort, respectively. Each dosimetric parameter was evaluated, and no statistically significant differences were detected. Conclusion The absence of RIBP events supports the safety of employing HF-PMRT by HT for the chest wall and all regional lymph nodes. We propose that applying the ICRU Report 83 criteria for IMRT planning, which limit the maximum dose (107% of the prescribed dose) to less than 2% of the planning target volume and exclude the brachial plexus region from the maximal dose area, is a practical way to minimize the risk of RIBP from HF-PMRT.
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Affiliation(s)
- Thinnakorn Chomchai
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Pitchayaponne Klunklin
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Siam Tongprasert
- Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Thanat Kanthawang
- Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Piyapasara Toapichattrakul
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Imjai Chitapanarux
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Shekouhi R, Gerhold C, Chim H. The role of surgery in the management of radiation-induced brachial plexopathy: a systematic review. J Hand Surg Eur Vol 2024; 49:490-498. [PMID: 37684017 DOI: 10.1177/17531934231197794] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
This systematic literature review of the clinical characteristics of radiation-induced brachial plexopathy and outcomes after intervention includes 30 trials with 611 patients. The mean radiation dose to the brachial plexus was 56 Gy, and the mean duration of radiation was 4 weeks. The mean time from radiation to the onset of symptoms was 35 months. The most commonly reported symptom was sensory loss (n = 323, 62%), followed by motor deficits (n = 294, 56%) and neuropathic pain (n = 284, 54%). In total, 65 (56%) patients had panplexus involvement and 51 (44%) patients had partial plexus involvement. The most common surgical procedure was neurolysis with flap coverage (n = 108, 6%), followed by neurolysis alone (n = 71, 30%). Of the 237 patients who underwent surgery, 125 (53%) reported an improvement in pain. Motor and sensory deficits were improved in 46 (19%) and 39 (16%) patients, respectively, suggesting that surgery is beneficial in relieving pain, but not as beneficial in restoring motor and sensory function.
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Affiliation(s)
- Ramin Shekouhi
- Division of Plastic & Reconstructive Surgery, Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Cameron Gerhold
- College of Medicine, Florida State University College of Medicine, Tallahassee, FL, USA
| | - Harvey Chim
- Division of Plastic & Reconstructive Surgery, Department of Surgery, University of Florida, Gainesville, FL, USA
- Lilian S. Wells Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
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Milano MT, Doucette C, Mavroidis P, Yorke E, Ryckman J, Mahadevan A, Kapitanova I, Kong FMS, Grimm J, Marks LB. Hypofractionated Stereotactic Radiation Therapy Dosimetric Tolerances for the Inferior Aspect of the Brachial Plexus: A Systematic Review. Int J Radiat Oncol Biol Phys 2024; 118:931-943. [PMID: 36682981 PMCID: PMC11325459 DOI: 10.1016/j.ijrobp.2022.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 10/17/2022] [Accepted: 11/06/2022] [Indexed: 01/22/2023]
Abstract
We sought to systematically review and summarize dosimetric factors associated with radiation-induced brachial plexopathy (RIBP) after stereotactic body radiation therapy (SBRT) or hypofractionated image guided radiation therapy (HIGRT). From published studies identified from searches of PubMed and Embase databases, data quantifying risks of RIBP after 1- to 10-fraction SBRT/HIGRT were extracted and summarized. Published studies have reported <10% risks of RIBP with maximum doses (Dmax) to the inferior aspect of the brachial plexus of 32 Gy in 5 fractions and 25 Gy in 3 fractions. For 10-fraction HIGRT, risks of RIBP appear to be low with Dmax < 40 to 50 Gy. For a given dose value, greater risks are anticipated with point volume-based metrics (ie, D0.03-0.035cc: minimum dose to hottest 0.03-0.035 cc) versus Dmax. With SBRT/HIGRT, there were insufficient published data to predict risks of RIBP relative to brachial plexus dose-volume exposure. Minimizing maximum doses and possibly volume exposure of the brachial plexus can reduce risks of RIBP after SBRT/HIGRT. Further study is needed to better understand the effect of volume exposure on the brachial plexus and whether there are location-specific susceptibilities along or within the brachial plexus structure.
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Affiliation(s)
- Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, New York.
| | | | - Panayiotis Mavroidis
- Department of Radiation Oncology and Lineberger Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Jeff Ryckman
- Department of Radiation Oncology, West Virginia University, Parkersburg, West Virginia
| | - Anand Mahadevan
- Department of Radiation Oncology, Geisinger Cancer Institute, Danville, Pennsylvania
| | - Irina Kapitanova
- Department of Radiation Oncology, Geisinger Cancer Institute, Danville, Pennsylvania
| | - Feng-Ming Spring Kong
- Department of Clinical Oncology, University of Hong Kong-Shenzhen Hospital/Li Ka Shing School of Medicine, Shenzhen/Hong Kong, China
| | - Jimm Grimm
- Department of Radiation Oncology, Geisinger Cancer Institute, Danville, Pennsylvania
| | - Lawrence B Marks
- Department of Radiation Oncology and Lineberger Cancer Center, University of North Carolina, Chapel Hill, North Carolina
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4
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Choi JI, McCormick B, Park P, Millar M, Walker K, Tung CC, Huang S, Florio P, Chen CC, Lozano A, Hanlon AL, Fox J, Xu AJ, Zinovoy M, Mueller B, Bakst R, LaPlant Q, Braunstein LZ, Khan AJ, Powell SN, Cahlon O. Comparative Evaluation of Proton Therapy and Volumetric Modulated Arc Therapy for Brachial Plexus Sparing in the Comprehensive Reirradiation of High-Risk Recurrent Breast Cancer. Adv Radiat Oncol 2024; 9:101355. [PMID: 38405315 PMCID: PMC10885571 DOI: 10.1016/j.adro.2023.101355] [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: 04/27/2023] [Accepted: 08/07/2023] [Indexed: 02/27/2024] Open
Abstract
Purpose Recurrent or new primary breast cancer requiring comprehensive regional nodal irradiation after prior radiation therapy (RT) to the supraclavicular area and upper axilla is challenging due to cumulative brachial plexus (BP) dose tolerance. We assessed BP dose sparing achieved with pencil beam scanning proton therapy (PBS-PT) and photon volumetric modulated arc therapy (VMAT). Methods and Materials In an institutional review board-approved planning study, all patients with ipsilateral recurrent breast cancer treated with PBS-PT re-RT (PBT1) with at least partial BP overlap from prior photon RT were identified. Comparative VMAT plans (XRT1) using matched BP dose constraints were developed. A second pair of proton (PBT2) and VMAT (XRT2) plans using standardized target volumes were created, applying uniform prescription dose of 50.4 per 1.8 Gy and a maximum BP constraint <25 Gy. Incidence of brachial plexopathy was also assessed. Results Ten consecutive patients were identified. Median time between RT courses was 48 months (15-276). Median first, second, and cumulative RT doses were 50.4 Gy (range, 42.6-60.0), 50.4 Gy relative biologic effectiveness (RBE) (45.0-64.4), and 102.4 Gy (RBE) (95.0-120.0), respectively. Median follow-up was 15 months (5-33) and 18 months for living patients (11-33) Mean BP max was 37.5 Gy (RBE) for PBT1 and 36.9 Gy for XRT1. Target volume coverage of V85% (volume receiving 85% of prescription dose), V90%, and V95% were numerically lower for XRT1 versus PBT1. Similarly, axilla I-III and supraclavicular area coverage were significantly higher for PBT2 than XRT2 at dose levels of V55%, V65%, V75%, V85%, and V95%. Only axilla I V55% did not reach significance (P = .06) favoring PBS-PT. Two patients with high cumulative BPmax (95.2 Gy [RBE], 101.6 Gy [RBE]) developed brachial plexopathy symptoms with ulnar nerve distribution neuropathy without pain or weakness (1 of 2 had symptom resolution after 6 months without intervention). Conclusions PBS-PT improved BP sparing and target volume coverage versus VMAT. For patients requiring comprehensive re-RT for high-risk, nonmetastatic breast cancer recurrence with BP overlap and reasonable expectation for prolonged life expectancy, PBT may be the preferred treatment modality.
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Affiliation(s)
- J. Isabelle Choi
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
- New York Proton Center, New York, New York
| | - Beryl McCormick
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Peter Park
- New York Proton Center, New York, New York
| | | | - Katherine Walker
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | - Peter Florio
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Alicia Lozano
- Center for Biostatistics and Health Data Science, Department of Statistics, Virginia Tech, Roanoke, Virginia
| | - Alexandra L. Hanlon
- Center for Biostatistics and Health Data Science, Department of Statistics, Virginia Tech, Roanoke, Virginia
| | - Jana Fox
- New York Proton Center, New York, New York
- Department of Radiation Oncology, Montefiore Medical Center
| | - Amy J. Xu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Melissa Zinovoy
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Boris Mueller
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Richard Bakst
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Radiation Oncology, Mt. Sinai Health System, New York, New York
| | - Quincey LaPlant
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lior Z. Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Atif J. Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Simon N. Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Radiation Oncology, New York University Langone, New York, New York
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Masumoto A, Yokoyama K, Namba M, Sasamura K, Yoshimura RI. A Case of Radiation-Induced Brachial Plexopathy Below the Tolerance Dose. Cureus 2024; 16:e52283. [PMID: 38357089 PMCID: PMC10865071 DOI: 10.7759/cureus.52283] [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] [Accepted: 01/15/2024] [Indexed: 02/16/2024] Open
Abstract
This case report details a rare instance of radiation-induced brachial plexopathy (RIBP) occurring below the typical tolerance dose in a 55-year-old woman following chemoradiotherapy for apical non-small cell lung carcinoma. Despite receiving a radiation dose considered safe (47-48 Gray in 25 fractions), she developed sensory abnormalities and motor weakness in the right upper limb. The diagnostic distinction between RIBP and tumor recurrence was achieved using MRI, which showed characteristic features of radiation-induced damage. The patient's medical history included smoking and rheumatoid arthritis, highlighting the role of patient-specific factors in the development of RIBP. The case underscores the importance of recognizing RIBP as a potential diagnosis in patients with new-onset brachial plexopathy post-radiation therapy, even when radiation exposure is within conventional safety limits. This report contributes to the literature by demonstrating that RIBP can occur at lower-than-expected radiation doses, especially in the presence of contributing factors like neurotoxic chemotherapy and individual patient risks. It emphasizes the need for careful assessment and management in such cases to distinguish between RIBP and cancer recurrence.
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Affiliation(s)
- Akane Masumoto
- Radiation Therapeutics and Oncology, Tokyo Medical and Dental University, Tokyo, JPN
| | - Kota Yokoyama
- Radiology, Tokyo Medical and Dental University, Tokyo, JPN
| | - Meika Namba
- Radiology, Japanese Red Cross Musashino Hospital, Tokyo, JPN
| | - Kazuma Sasamura
- Radiology, Japanese Red Cross Musashino Hospital, Tokyo, JPN
| | - Ryo-Ichi Yoshimura
- Radiation Therapeutics and Oncology, Tokyo Medical and Dental University, Tokyo, JPN
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Quashie EE, Li XA, Prior P, Awan M, Schultz C, Tai A. Obtaining organ-specific radiobiological parameters from clinical data for radiation therapy planning of head and neck cancers. Phys Med Biol 2023; 68:245015. [PMID: 37903437 DOI: 10.1088/1361-6560/ad07f5] [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: 06/20/2023] [Accepted: 10/30/2023] [Indexed: 11/01/2023]
Abstract
Objective.Different radiation therapy (RT) strategies, e.g. conventional fractionation RT (CFRT), hypofractionation RT (HFRT), stereotactic body RT (SBRT), adaptive RT, and re-irradiation are often used to treat head and neck (HN) cancers. Combining and/or comparing these strategies requires calculating biological effective dose (BED). The purpose of this study is to develop a practical process to estimate organ-specific radiobiologic model parameters that may be used for BED calculations in individualized RT planning for HN cancers.Approach.Clinical dose constraint data for CFRT, HFRT and SBRT for 5 organs at risk (OARs) namely spinal cord, brainstem, brachial plexus, optic pathway, and esophagus obtained from literature were analyzed. These clinical data correspond to a particular endpoint. The linear-quadratic (LQ) and linear-quadratic-linear (LQ-L) models were used to fit these clinical data and extract relevant model parameters (alpha/beta ratio, gamma/alpha,dTand BED) from the iso-effective curve. The dose constraints in terms of equivalent physical dose in 2 Gy-fraction (EQD2) were calculated using the obtained parameters.Main results.The LQ-L and LQ models fitted clinical data well from the CFRT to SBRT with the LQ-L representing a better fit for most of the OARs. The alpha/beta values for LQ-L (LQ) were found to be 2.72 (2.11) Gy, 0.55 (0.30) Gy, 2.82 (2.90) Gy, 6.57 (3.86) Gy, 5.38 (4.71) Gy, and the dose constraint EQD2 were 55.91 (54.90) Gy, 57.35 (56.79) Gy, 57.54 (56.35) Gy, 60.13 (59.72) Gy and 65.66 (64.50) Gy for spinal cord, optic pathway, brainstem, brachial plexus, and esophagus, respectively. Additional two LQ-L parametersdTwere 5.24 Gy, 5.09 Gy, 7.00 Gy, 5.23 Gy, and 6.16 Gy, and gamma/alpha were 7.91, 34.02, 8.67, 5.62 and 4.95.Significance.A practical process was developed to extract organ-specific radiobiological model parameters from clinical data. The obtained parameters can be used for biologically based radiation planning such as calculating dose constraints of different fractionation regimens.
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Affiliation(s)
- Edwin E Quashie
- Department of Radiation Oncology, Medical College of Wisconsin, WI 53226, United States of America
- Department of Radiation Oncology, Brown University School of Medicine, Providence, RI 02903, United States of America
- Department of Radiation Oncology, Rhode Island Hospital, Providence, RI 02903, United States of America
| | - X Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, WI 53226, United States of America
| | - Phillip Prior
- Department of Radiation Oncology, Medical College of Wisconsin, WI 53226, United States of America
| | - Musaddiq Awan
- Department of Radiation Oncology, Medical College of Wisconsin, WI 53226, United States of America
| | - Christopher Schultz
- Department of Radiation Oncology, Medical College of Wisconsin, WI 53226, United States of America
| | - An Tai
- Department of Radiation Oncology, Medical College of Wisconsin, WI 53226, United States of America
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7
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Milano MT, Mavroidis P, Ryckman J, Yorke E, Doucette C, Mahadevan A, Kapitanova I, Spring Kong FM, Marks LB, Grimm J. Radiation-induced inferior brachial plexopathy after stereotactic body radiotherapy: Pooled analyses of risks. Radiother Oncol 2023; 182:109583. [PMID: 36842665 PMCID: PMC10501316 DOI: 10.1016/j.radonc.2023.109583] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/31/2023] [Accepted: 02/20/2023] [Indexed: 02/28/2023]
Abstract
INTRODUCTION Radiation-induced brachial plexopathy (RIBP), resulting in symptomatic motor or sensory deficits of the upper extremity, is a risk after exposure of the brachial plexus to therapeutic doses of radiation. We sought to model dosimetric factors associated with risks of RIBP after stereotactic body radiotherapy (SBRT). METHODS From a prior systematic review, 4 studies were identified that included individual patient data amenable to normal tissue complication probability (NTCP) modelling after SBRT for apical lung tumors. Two probit NTCP models were derived: one from 4 studies (including 221 patients with 229 targets and 18 events); and another from 3 studies (including 185 patients with 192 targets and 11 events) that similarly contoured the brachial plexus. RESULTS NTCP models suggest ≈10% risks associated with brachial plexus maximum dose (Dmax) of ∼32-34 Gy in 3 fractions and ∼40-43 Gy in 5 fractions. RIBP risks increase with increasing brachial plexus Dmax. Compared to previously published data from conventionally-fractionated or moderately-hypofractionated radiotherapy for breast, lung and head and neck cancers (which tend to utilize radiation fields that circumferentially irradiate the brachial plexus), SBRT (characterized by steep dose gradients outside of the target volume) exhibits a much less steep dose-response with brachial plexus Dmax > 90-100 Gy in 2-Gy equivalents. CONCLUSIONS A dose-response for risk of RIBP after SBRT is observed relative to brachial plexus Dmax. Comparisons to data from less conformal radiotherapy suggests potential dose-volume dependences of RIBP risks, though published data were not amenable to NTCP modelling of dose-volume measures associated with RIBP after SBRT.
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Affiliation(s)
- Michael T Milano
- Department of Radiation Oncology, University of Rochester, 601 Elmwood Ave. Box 647, Rochester, NY, United States.
| | - Panayiotis Mavroidis
- Department of Radiation Oncology and Lineberger Cancer Center, University of North Carolina, Chapel Hill, NC, United States
| | - Jeff Ryckman
- Department of Radiation Oncology, West Virginia University, Parkersburg, WV, United States
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Christopher Doucette
- Department of Radiation Oncology, University of Rochester, 601 Elmwood Ave. Box 647, Rochester, NY, United States
| | - Anand Mahadevan
- Laura and Isaac Perlmutter Cancer Center at NYU Langone Health, NY, United States
| | - Irina Kapitanova
- Department of Radiation Oncology, Geisinger Cancer Institute, Danville, PA, United States
| | - Feng-Ming Spring Kong
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital/Li Ka Shing School of Medicine, Shenzhen, Hong Kong, China
| | - Lawrence B Marks
- Department of Radiation Oncology and Lineberger Cancer Center, University of North Carolina, Chapel Hill, NC, United States
| | - Jimm Grimm
- Department of Radiation Oncology, ThedaCare Regional Medical Center, Appleton, WI, USA
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Iovoli AJ, Prasad S, Malhotra HK, Malik NK, Fung-Kee-Fung S, Singh AK, Farrugia MK. Brachial Plexopathy After Single-Fraction Stereotactic Body Radiation Therapy in Apical Lung Tumors. Pract Radiat Oncol 2022; 13:e246-e253. [PMID: 36581198 DOI: 10.1016/j.prro.2022.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE The objective of this study was to evaluate the incidence of brachial plexus injury (BPI) after single-fraction stereotactic body radiation therapy (SBRT) to apical lung tumors. METHODS AND MATERIALS A retrospective cohort analysis was performed of all patients treated with single-fraction lung SBRT at our institution from 2007 to 2022. Apical tumors were identified as those with an epicenter located above the arch of the aorta. Dosimetric analysis of dose to the brachial plexus (BP) was done using both the subclavian vessel (SCV) surrogate structure and anatomic BP. BPI was assessed per Common Terminology Criteria for Adverse Events, version 4.0, as regional paresthesia, marked discomfort and muscle weakness, and limited movement of the arm or hand. RESULTS A total of 45 patients met inclusion criteria with median follow-up of 21 months. There were 9 patients who exceeded the BP dose constraint using the SCV or anatomic BP volume. Only 1 patient (2.2%) developed grade 2 BPI, occurring 7 months after SBRT. Dose to the anatomic BP for the affected patient was 26.39 Gy. For the entire cohort, the median SCV and anatomic maximum BP doses were 8.44 and 7.14 Gy, respectively. CONCLUSIONS There is considerable variability in dose delivered to the BP after SBRT to apical lung tumors. BPI after single-fraction SBRT to apical tumors is rare and rates are comparable with those reported with multifraction regimens.
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Affiliation(s)
- Austin J Iovoli
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Sharan Prasad
- College of Human Ecology, Cornell University, Ithaca, New York
| | - Harish K Malhotra
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Nadia K Malik
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Simon Fung-Kee-Fung
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Anurag K Singh
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Mark K Farrugia
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York.
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Kang TM, Hardcastle N, Singh AK, Slotman BJ, Videtic GMM, Stephans KL, Couñago F, Louie AV, Guckenberger M, Harden SV, Plumridge NM, Siva S. Practical considerations of single-fraction stereotactic ablative radiotherapy to the lung. Lung Cancer 2022; 170:185-193. [PMID: 35843149 DOI: 10.1016/j.lungcan.2022.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/21/2022] [Accepted: 06/24/2022] [Indexed: 10/17/2022]
Abstract
Stereotactic ablative radiotherapy (SABR) is a well-established treatment for patients with medically inoperable early-stage non-small cell lung cancer (NSCLC) and pulmonary oligometastases. The use of single-fraction SABR in this setting is supported by excellent local control and safety profiles which appear equivalent to multi-fraction SABR based on the available data. The resource efficiency and reduction in hospital outpatient visits associated with single-fraction SABR have been particularly advantageous during the COVID-19 pandemic. Despite the increased interest, single-fraction SABR in subgroups of patients remains controversial, including those with centrally located tumours, synchronous targets, proximity to dose-limiting organs at risk, and concomitant severe respiratory illness. This review provides an overview of the published randomised evidence evaluating single-fraction SABR in primary lung cancer and pulmonary oligometastases, the common clinical challenges faced, immunogenic effect of SABR, as well as technical and cost-utility considerations.
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Affiliation(s)
- Therese Mj Kang
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Nicholas Hardcastle
- Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum, Department of Oncology, University of Melbourne, Australia; Centre for Medical Radiation Physics, University of Wollongong, New South Wales, Australia
| | - Anurag K Singh
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Ben J Slotman
- Department of Radiation Oncology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Gregory M M Videtic
- Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio, USA
| | - Kevin L Stephans
- Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio, USA
| | - Felipe Couñago
- Department of Radiation Oncology, Hospital Universitario Quirónsalud, Madrid, Spain
| | - Alexander V Louie
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Susan V Harden
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Nikki M Plumridge
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Shankar Siva
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum, Department of Oncology, University of Melbourne, Australia.
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10
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Glare P, Aubrey K, Gulati A, Lee YC, Moryl N, Overton S. Pharmacologic Management of Persistent Pain in Cancer Survivors. Drugs 2022; 82:275-291. [PMID: 35175587 PMCID: PMC8888381 DOI: 10.1007/s40265-022-01675-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2022] [Indexed: 12/14/2022]
Abstract
Improvements in screening, diagnosis and treatment of cancer has seen cancer mortality substantially diminish in the past three decades. It is estimated there are almost 20 million cancer survivors in the USA alone, but some 40% live with chronic pain after completing treatment. While a broad definition of survivorship that includes all people living with, through and beyond a cancer diagnosis—including those with active cancer—is often used, this narrative review primarily focuses on the management of pain in people who are disease-free after completing primary cancer treatment as adults. Chronic pain in this population needs a different approach to that used for people with a limited prognosis. After describing the common chronic pain syndromes caused by cancer treatment, and the pathophysiologic mechanisms involved, the pharmacologic management of entities such as post-surgical pain, chemotherapy-induced neuropathy, aromatase inhibitor musculoskeletal syndrome and checkpoint inhibitor-related pain are described. The challenges associated with opioid prescribing in this population are given special attention. Expert guidelines on pain management in cancer survivors now recommend a combination of pharmacologic and non-pharmacologic modalities, and these are also briefly covered.
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Affiliation(s)
- Paul Glare
- Pain Management Research Institute, Kolling Institute, University of Sydney and Northern Sydney Local Health District, Sydney, NSW, Australia.
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.
| | - Karin Aubrey
- Pain Management Research Institute, Kolling Institute, University of Sydney and Northern Sydney Local Health District, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Amitabh Gulati
- Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Yi Ching Lee
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Chris O'Brien Lifehouse, Sydney, NSW, Australia
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Natalie Moryl
- Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Sarah Overton
- Pain Management Research Centre, Royal North Shore Hospital, Sydney, NSW, Australia
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11
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Morse RT, Doke K, Ganju RG, Sood S, Mavroidis P, Chen AM. Stereotactic body radiotherapy for apical lung tumors: Dosimetric analysis of the brachial plexus and preliminary clinical outcomes. Pract Radiat Oncol 2021; 12:e183-e192. [PMID: 34929402 DOI: 10.1016/j.prro.2021.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/19/2021] [Accepted: 12/03/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Dosimetric constraints of the brachial plexus have not yet been well-established for patients undergoing stereotactic body radiotherapy (SBRT). This study evaluated long-term experience with the treatment of early stage apical lung tumors with SBRT and reports on dosimetric correlates of outcome. METHODS Between 2009 and 2018, a total of 78 consecutive patients with 81 apical lung tumors underwent SBRT for T1-3N0 non-small cell lung cancer. Apical tumors were those with tumor epicenter superior to the aortic arch. The brachial plexus (BP) was anatomically contoured according to the Radiation Therapy Oncology Group (RTOG) atlas. Patient medical records were retrospectively reviewed to determine incidence of brachial plexus injury (BPI) and a normal tissue complication probability model (NTCP) was applied to the dosimetric data. RESULTS Five patients (6.4%) reported neuropathic symptoms consistent with BPI and occurred a median 11.9 months after treatment (range, 5.2 to 28.1 months). Most common dose and fractionation in those developing BPI were 50 Gy in 5 fractions (4 patients). Symptoms consisted of pain in 2 patients (40.0%), numbness in the hand or axilla in 4 patients (80.0%), and ipsilateral hand weakness in 1 patient (20.0%). In the overall cohort the median BP Dmax (EQD23 Gy) was 5.13 Gy (range, 0.18 to 217.2 Gy) and in patients with BPI the median BP Dmax (EQD23 Gy) was 32.14 Gy (range, 13.4 to 99.9 Gy). The NTCP model gave good fit with an area under the curve (AUC) of 0.75 (OR 7.3, 95% CI: 0.8-68.3) for BP Dmax (EQD23 Gy) threshold of 20 Gy. CONCLUSION Significant variation exists in the dose delivered to the brachial plexus for patients treated by SBRT for apical lung tumors. The incidence of neuropathic symptoms in the post-SBRT setting was appreciable and prospective clinical correlation with dosimetric information should be utilized in order to develop evidence-based dose constraints.
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Affiliation(s)
- Ryan T Morse
- Department of Radiation Oncology, University of Kansas Medical Center
| | - Kaleigh Doke
- Department of Radiation Oncology, University of Colorado
| | - Rohit G Ganju
- Department of Radiation Oncology, University of Kansas Medical Center
| | - Sumit Sood
- Department of Radiation Oncology, University of Minnesota
| | | | - Allen M Chen
- Department of Radiation Oncology, University of California Irvine.
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12
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Attard KA, Vella JC, Chircop C. Late-onset radiation-induced brachial plexopathy. BMJ Case Rep 2021; 14:e243354. [PMID: 34518178 PMCID: PMC8438927 DOI: 10.1136/bcr-2021-243354] [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] [Accepted: 08/05/2021] [Indexed: 11/03/2022] Open
Abstract
The late-onset variant of radiation-induced brachial plexopathy is most often seen after treatment for breast or lung cancers. It has an insidious onset, with symptoms noted years after receiving radiotherapy, and the condition gradually continues to deteriorate with time. We present the case of an elderly man who we saw in view of worsening paraesthesias and weakness of his left arm with associated prominent muscle wasting along the left shoulder girdle. Fifteen years prior to this, he had received radiotherapy for the treatment of nasopharyngeal carcinoma.
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Affiliation(s)
| | - James Carlos Vella
- Department of Neurology, Mater Dei Hospital, Msida, Malta
- Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Charmaine Chircop
- Department of Neurology, Mater Dei Hospital, Msida, Malta
- Faculty of Medicine and Surgery, University of Malta, Msida, Malta
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13
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Ricard D, Durand T, Bompaire F, Tauziède-Espariat A, Psimaras D. Complicanze neurologiche della radioterapia. Neurologia 2020. [DOI: 10.1016/s1634-7072(20)43683-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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14
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Yan M, Kong W, Kerr A, Brundage M. The radiation dose tolerance of the brachial plexus: A systematic review and meta-analysis. Clin Transl Radiat Oncol 2019; 18:23-31. [PMID: 31309161 PMCID: PMC6606964 DOI: 10.1016/j.ctro.2019.06.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 06/12/2019] [Indexed: 12/25/2022] Open
Abstract
PURPOSE We performed a systematic review and meta-analysis of studies reporting the incidence of radiation induced brachial plexopathy (RIBP) and the associated radiotherapy doses to this structure. METHODS Databases were queried without language restriction for cohort studies reporting RIBP incidence and associated brachial plexus dose maximum dose (bpDmax). Studies specifying RIBP relative risk (RR) effect size were selected for meta-analysis. RRs for RIBP from each study were converted to a regression coefficient (β) and standard error corresponding to a continuous representation of bpDmax. The adjusted β from individual studies were combined using a random effects model and weighted by inverse variance (1/SE2). The trim and fill approach was used to assess publication bias. RESULTS We identified 25 studies that included 37 unique patient cohorts eligible for analysis. Seventeen cohorts experienced an RIBP incidence ≤5%, of which 6 cohorts exceeded conventional plexus constraints of 60 Gy for bpDmax. Five of the 6 cohorts were simulated with 3D-CT techniques. Meta-analysis of eligible studies demonstrated a significant increase in RIBP risk for each Gy increase in bpDmax (RR, 1.11; 95% CI 1.07-1.15). Results remained significant after adjustment for publication bias and when sensitivity analysis was performed. CONCLUSIONS Our results suggest that current brachial plexus constraints of 60-66 Gy are safe. Meta-analysis provides a log-linear model to quantify the association of brachial plexus dose and RIBP risk, and thus inform the therapeutic ratio for dose escalation. Further prospective studies reporting dosimetric data can better refine this model and inform brachial plexus constraint guidelines.
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Affiliation(s)
- Michael Yan
- Department of Radiation Oncology, Cancer Centre of Southeastern Ontario, Kingston, ON, Canada
| | - Weidong Kong
- Division of Cancer Care and Epidemiology, Queen’s University Cancer Research Institute, Kingston, ON, Canada
| | - Andrew Kerr
- Department of Medical Physics, Cancer Centre of Southeastern Ontario, Kingston, ON, Canada
| | - Michael Brundage
- Department of Radiation Oncology, Cancer Centre of Southeastern Ontario, Kingston, ON, Canada
- Division of Cancer Care and Epidemiology, Queen’s University Cancer Research Institute, Kingston, ON, Canada
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15
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Lindberg K, Grozman V, Lindberg S, Onjukka E, Lax I, Lewensohn R, Wersäll P. Radiation-induced brachial plexus toxicity after SBRT of apically located lung lesions. Acta Oncol 2019; 58:1178-1186. [PMID: 31066326 DOI: 10.1080/0284186x.2019.1601255] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Purpose: To evaluate the rate and dose response of brachial plexus toxicity post stereotactic body radiation therapy (SBRT) of apically situated lung lesions. Material/methods: We retrospectively identified all patients with apically located tumors, defined by the epicenter of the tumor being located superiorly to the aortic arch, and treated with SBRT between 2008 and 2013. Patients with a shorter follow-up than 6 months were excluded. Primary aim was to evaluate radiation-induced brachial plexopathy (RIBP). Dose to the plexus was assessed by a retrospective delineation of the brachial plexus on the CT used for treatment planning. Then, Dmax, D0.1cc, D1cc and D3.0cc of the brachial plexus were collected from the dose-volume histograms (DVH) and recalculated to the biologically effective dose (BED) using α/β = 3 Gy. A normal tissue complication probability (NTCP) model, based on four different dose-volume parameters (BED3,max, BED3,0.1cc, BED3,1.0cc, BED3,3.0cc) was fitted to the data. Results: Fifty-two patients with 56 apically located tumors were identified. Median prescription dose per fraction was 15 Gy (range 6-17) and median number of fractions was 3 (3-10). With a median follow-up of 30 months (6.1-72) seven patients experienced maximum grade 2 (scored 3 times) or 3 (scored 4 times) RIBP after a median of 8.7 months (range 4.0-31). Three patients had combined symptoms with pain, sensory and motor affection and four patients had isolated pain. Median BED3,max for the patients experiencing RIBP was 381 Gy (range 30-524) versus BED3,max of 34 Gy (range 0.10-483) for the patients without RIBP. The NTCP models showed a very high predictive ability (area under the receiver operating characteristic curve (AUC) 0.80-0.88). Conclusion: SBRT of apically located lung lesions may cause severe neurological symptoms; for a three-fraction treatment, we suggest that the maximum dose to the plexus should be kept ≤30 Gy (130 Gy BED3).
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Affiliation(s)
- Karin Lindberg
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
- Section of Head, Neck, Lung and Skin tumors, Department of Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Vitali Grozman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Section of Thoracic Radiology, Department of Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Sara Lindberg
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
- Department of Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Eva Onjukka
- Section of Radiotherapy Physics and Engineering, Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Ingmar Lax
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
- Section of Radiotherapy Physics and Engineering, Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Rolf Lewensohn
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
- Section of Head, Neck, Lung and Skin tumors, Department of Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Peter Wersäll
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
- Section of Radiotherapy, Department of Cancer, Karolinska University Hospital, Stockholm, Sweden
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16
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Chang EI, Rose MI, Rossi K, Elkwood AI. Microneurosurgical treatment options in peripheral nerve compression syndromes after chemotherapy and radiation treatment. J Surg Oncol 2018; 118:793-799. [PMID: 30261113 DOI: 10.1002/jso.25254] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 09/05/2018] [Indexed: 12/25/2022]
Abstract
Chemotherapy-induced peripheral neuropathy and radiation-induced brachial plexopathy are extremely debilitating conditions which can occur after treatment of malignancy. Unfortunately, the diagnosis can be elusive, and this dilemma is further compounded by the lack of efficacious therapeutics to prevent the onset of neurotoxicity before initiating chemotherapy or radiation or to treat these sequelae after treatment. However, microsurgical nerve decompression can provide these patients with a viable option to treat this complication.
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Affiliation(s)
- Eric I Chang
- The Institute for Advanced Reconstruction at The Plastic Surgery Center, Shrewsbury, New Jersey.,Center for Treatment of Paralysis and Reconstructive Nerve Surgery, Jersey Shore University Medical Center, Neptune, New Jersey
| | - Michael I Rose
- The Institute for Advanced Reconstruction at The Plastic Surgery Center, Shrewsbury, New Jersey.,Center for Treatment of Paralysis and Reconstructive Nerve Surgery, Jersey Shore University Medical Center, Neptune, New Jersey
| | - Kristie Rossi
- The Institute for Advanced Reconstruction at The Plastic Surgery Center, Shrewsbury, New Jersey.,Center for Treatment of Paralysis and Reconstructive Nerve Surgery, Jersey Shore University Medical Center, Neptune, New Jersey
| | - Andrew I Elkwood
- The Institute for Advanced Reconstruction at The Plastic Surgery Center, Shrewsbury, New Jersey.,Center for Treatment of Paralysis and Reconstructive Nerve Surgery, Jersey Shore University Medical Center, Neptune, New Jersey
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17
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Sood SS, McClinton C, Badkul R, Aguilera N, Wang F, Chen AM. Brachial plexopathy after stereotactic body radiation therapy for apical lung cancer: Dosimetric analysis and preliminary clinical outcomes. Adv Radiat Oncol 2018; 3:81-86. [PMID: 29556585 PMCID: PMC5856987 DOI: 10.1016/j.adro.2017.10.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 08/17/2017] [Accepted: 10/03/2017] [Indexed: 12/25/2022] Open
Abstract
Purpose The treatment of apical lung tumors with stereotactic body radiation therapy (SBRT) is challenging due to the proximity of the brachial plexus and the concern for nerve damage. Methods and materials Between June 2009 and February 2017, a total of 75 consecutive patients underwent SBRT for T1-T3N0 non-small cell lung cancer involving the upper lobe of the lung. All patients were treated with 4-dimensional computed tomography (CT)-based image guided SBRT to a dose of 40 to 60 Gy in 3 to 5 fractions. For dosimetric analysis, only apical tumors as defined by the location of the tumor epicenter superior to the aortic arch were included. The anatomical brachial plexus was delineated using the Radiation Therapy Oncology Group atlas. Results Thirty-one patients with 31 apical lung tumors satisfied the anatomical criteria for inclusion. The median age was 73 years (range, 58-89). The median planning target volume was 26.5 cc (range, 8.2-81.4 cc). The median brachial plexus, brachial plexus maximum dose (Dmax), Dmax per fraction, V22 (cc, 3-4 fractions), V30 (cc, 5 fractions), and biologically effective dose 3 Gy were 15.8 Gy (range, 1.7-66.5 Gy), 3.4 Gy (range, 0.6-14.7 Gy), 0.0 cc (range, 0-0.9 cc), 0.06 cc (range, 0-2.5 cc), and 31.5 Gy (range, 3.3-133.1 Gy), respectively. At a median follow-up of 17 months, the observed incidence of brachial plexopathy was 0%. Conclusions There is significant variation in dose to the brachial plexus for patients treated with SBRT for apical lung tumors. Although the incidence of neuropathic symptoms in this series was zero, further attention should be focused on the clinical implications of these findings.
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Affiliation(s)
- Sumit S Sood
- Department of Radiation Oncology, The University of Kansas School of Medicine, Kansas City, Kansas
| | - Christopher McClinton
- Department of Radiation Oncology, The University of Kansas School of Medicine, Kansas City, Kansas
| | - Rajeev Badkul
- Department of Radiation Oncology, The University of Kansas School of Medicine, Kansas City, Kansas
| | - Nathan Aguilera
- Department of Radiation Oncology, The University of Kansas School of Medicine, Kansas City, Kansas
| | - Fen Wang
- Department of Radiation Oncology, The University of Kansas School of Medicine, Kansas City, Kansas
| | - Allen M Chen
- Department of Radiation Oncology, The University of Kansas School of Medicine, Kansas City, Kansas
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18
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De Ruysscher D, Lambrecht M, van Baardwijk A, Peeters S, Reymen B, Verhoeven K, Wanders R, Öllers M, van Elmpt W, van Loon J. Standard of care in high-dose radiotherapy for localized non-small cell lung cancer. Acta Oncol 2017; 56:1610-1613. [PMID: 28840754 DOI: 10.1080/0284186x.2017.1349337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Dirk De Ruysscher
- Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
- Radiation Oncology, KU Leuven, Leuven, Belgium
| | - Maarten Lambrecht
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Angela van Baardwijk
- Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Stéphanie Peeters
- Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Bart Reymen
- Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Karolien Verhoeven
- Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rinus Wanders
- Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Michel Öllers
- Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Wouter van Elmpt
- Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Judith van Loon
- Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
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19
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De Ruysscher D, Faivre-Finn C, Moeller D, Nestle U, Hurkmans CW, Le Péchoux C, Belderbos J, Guckenberger M, Senan S. European Organization for Research and Treatment of Cancer (EORTC) recommendations for planning and delivery of high-dose, high precision radiotherapy for lung cancer. Radiother Oncol 2017; 124:1-10. [PMID: 28666551 DOI: 10.1016/j.radonc.2017.06.003] [Citation(s) in RCA: 135] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 04/25/2017] [Accepted: 06/05/2017] [Indexed: 12/23/2022]
Abstract
PURPOSE To update literature-based recommendations for techniques used in high-precision thoracic radiotherapy for lung cancer, in both routine practice and clinical trials. METHODS A literature search was performed to identify published articles that were considered clinically relevant and practical to use. Recommendations were categorised under the following headings: patient positioning and immobilisation, Tumour and nodal changes, CT and FDG-PET imaging, target volumes definition, radiotherapy treatment planning and treatment delivery. An adapted grading of evidence from the Infectious Disease Society of America, and for models the TRIPOD criteria, were used. RESULTS Recommendations were identified for each of the above categories. CONCLUSION Recommendations for the clinical implementation of high-precision conformal radiotherapy and stereotactic body radiotherapy for lung tumours were identified from the literature. Techniques that were considered investigational at present are highlighted.
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Affiliation(s)
- Dirk De Ruysscher
- Maastricht University Medical Center+, Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, The Netherlands; KU Leuven, Radiation Oncology, Belgium.
| | - Corinne Faivre-Finn
- Division of Cancer Sciences University of Manchester, Christie NHS Foundation Trust, UK
| | - Ditte Moeller
- Aarhus University Hospital, Department of Oncology, Denmark
| | - Ursula Nestle
- Freiburg University Medical Center (DKTK partner site), Department of Radiation Oncology, Germany; Department of Radiation Oncology, Kliniken Maria Hilf, Moenchengladbach, Germany
| | - Coen W Hurkmans
- Catharina Hospital, Department of Radiation Oncology, Eindhoven, The Netherlands
| | | | - José Belderbos
- Netherlands Cancer Institute, Department of Radiation Oncology, Amsterdam, The Netherlands
| | | | - Suresh Senan
- VU University Medical Center, Department of Radiation Oncology, Amsterdam, The Netherlands
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20
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Chen AM, Yoshizaki T, Velez MA, Mikaeilian AG, Hsu S, Cao M. Tolerance of the Brachial Plexus to High-Dose Reirradiation. Int J Radiat Oncol Biol Phys 2017; 98:83-90. [PMID: 28587056 DOI: 10.1016/j.ijrobp.2017.01.244] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 01/13/2017] [Accepted: 01/31/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE To study the tolerance of the brachial plexus to high doses of radiation exceeding historically accepted limits by analyzing human subjects treated with reirradiation for recurrent tumors of the head and neck. METHODS AND MATERIALS Data from 43 patients who were confirmed to have received overlapping dose to the brachial plexus after review of radiation treatment plans from the initial and reirradiation courses were used to model the tolerance of this normal tissue structure. A standardized instrument for symptoms of neuropathy believed to be related to brachial plexus injury was utilized to screen for toxicity. Cumulative dose was calculated by fusing the initial dose distributions onto the reirradiation plan, thereby creating a composite plan via deformable image registration. The median elapsed time from the initial course of radiation therapy to reirradiation was 24 months (range, 3-144 months). RESULTS The dominant complaints among patients with symptoms were ipsilateral pain (54%), numbness/tingling (31%), and motor weakness and/or difficulty with manual dexterity (15%). The cumulative maximum dose (Dmax) received by the brachial plexus ranged from 60.5 Gy to 150.1 Gy (median, 95.0 Gy). The cumulative mean (Dmean) dose ranged from 20.2 Gy to 111.5 Gy (median, 63.8 Gy). The 1-year freedom from brachial plexus-related neuropathy was 67% and 86% for subjects with a cumulative Dmax greater than and less than 95.0 Gy, respectively (P=.05). The 1-year complication-free rate was 66% and 87%, for those reirradiated within and after 2 years from the initial course, respectively (P=.06). CONCLUSION The development of brachial plexus-related symptoms was less than expected owing to repair kinetics and to the relatively short survival of the subject population. Time-dose factors were demonstrated to be predictive of complications.
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Affiliation(s)
- Allen M Chen
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.
| | - Taeko Yoshizaki
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Maria A Velez
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Argin G Mikaeilian
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Sophia Hsu
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Minsong Cao
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
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21
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Dosimetric Factors and Toxicity in Highly Conformal Thoracic Reirradiation. Int J Radiat Oncol Biol Phys 2016; 94:808-15. [DOI: 10.1016/j.ijrobp.2015.12.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 10/03/2015] [Accepted: 12/08/2015] [Indexed: 12/21/2022]
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Abstract
Cancer and its treatment exert a heavy psychological and physical toll. Of the myriad symptoms which result, pain is common, encountered in between 30% and 60% of cancer survivors. Pain in cancer survivors is a major and growing problem, impeding the recovery and rehabilitation of patients who have beaten cancer and negatively impacting on cancer patients' quality of life, work prospects and mental health. Persistent pain in cancer survivors remains challenging to treat successfully. Pain can arise both due to the underlying disease and the various treatments the patient has been subjected to. Chemotherapy causes painful chemotherapy-induced peripheral neuropathy (CIPN), radiotherapy can produce late effect radiation toxicity and surgery may lead to the development of persistent post-surgical pain syndromes. This review explores a selection of the common causes of persistent pain in cancer survivors, detailing our current understanding of the pathophysiology and outlining both the clinical manifestations of individual pain states and the treatment options available.
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Affiliation(s)
- Matthew Rd Brown
- Pain Management Department, The Royal Marsden Hospital, London, UK ; Institute of Cancer Research, London, UK
| | - Juan D Ramirez
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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23
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Lundstedt D, Gustafsson M, Steineck G, Sundberg A, Wilderäng U, Holmberg E, Johansson KA, Karlsson P. Radiation Therapy to the Plexus Brachialis in Breast Cancer Patients: Analysis of Paresthesia in Relation to Dose and Volume. Int J Radiat Oncol Biol Phys 2015; 92:277-83. [PMID: 25765147 DOI: 10.1016/j.ijrobp.2015.01.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 12/03/2014] [Accepted: 01/13/2015] [Indexed: 12/25/2022]
Abstract
PURPOSE To identify volume and dose predictors of paresthesia after irradiation of the brachial plexus among women treated for breast cancer. METHODS AND MATERIALS The women had breast surgery with axillary dissection, followed by radiation therapy with (n=192) or without irradiation (n=509) of the supraclavicular lymph nodes (SCLNs). The breast area was treated to 50 Gy in 2.0-Gy fractions, and 192 of the women also had 46 to 50 Gy to the SCLNs. We delineated the brachial plexus on 3-dimensional dose-planning computerized tomography. Three to eight years after radiation therapy the women answered a questionnaire. Irradiated volumes and doses were calculated and related to the occurrence of paresthesia in the hand. RESULTS After treatment with axillary dissection with radiation therapy to the SCLNs 20% of the women reported paresthesia, compared with 13% after axillary dissection without radiation therapy, resulting in a relative risk (RR) of 1.47 (95% confidence interval [CI] 1.02-2.11). Paresthesia was reported by 25% after radiation therapy to the SCLNs with a V40 Gy ≥ 13.5 cm(3), compared with 13% without radiation therapy, RR 1.83 (95% CI 1.13-2.95). Women having a maximum dose to the brachial plexus of ≥55.0 Gy had a 25% occurrence of paresthesia, with RR 1.86 (95% CI 0.68-5.07, not significant). CONCLUSION Our results indicate that there is a correlation between larger irradiated volumes of the brachial plexus and an increased risk of reported paresthesia among women treated for breast cancer.
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Affiliation(s)
- Dan Lundstedt
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden; Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden.
| | - Magnus Gustafsson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden; Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden; Department of Therapeutic Radiation Physics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Gunnar Steineck
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden; Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden; Division of Clinical Cancer Epidemiology, Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - Agnetha Sundberg
- Department of Therapeutic Radiation Physics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ulrica Wilderäng
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden; Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Erik Holmberg
- Regional Cancer Center, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Karl-Axel Johansson
- Department of Therapeutic Radiation Physics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Per Karlsson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden
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Barsoum M, Mostafa M, El Hossieny H, Nasr A, Mahmoud M, Fouda S. Dosimetric prospective study comparing 2D and 3D planning for irradiation of supraclavicular and infraclavicular regions in breast cancer patients. J Egypt Natl Canc Inst 2015; 27:25-34. [PMID: 25631950 DOI: 10.1016/j.jnci.2014.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 11/23/2014] [Accepted: 11/23/2014] [Indexed: 12/25/2022] Open
Abstract
PURPOSE The purpose of this study is to compare 2D plan and 3D plan regarding coverage of the target (supraclavicular and infraclavicular regions) and dose reaching the risk organs (using mean DVH). Depending on the results of this study, modifications can be made to the 2D conventional planning of supraclavicular and infraclavicular regions in order to achieve better coverage of the target tissues. MATERIALS AND METHODS This is a dosimetric study carried out at the radiation oncology department in NCI-Cairo University in the period from January 2012 to October 2012, on 15 patients with breast cancer who are eligible for supraclavicular and infraclavicular irradiation. For All patients, a 2D and a 3D plan were done. RESULTS We found that the coverage of the supraclavicular and infraclavicular regions and the chest wall or breast together with levels I and II axilla (PTV) were significantly better with the 3D technique with less over dose than the 2D technique. That difference was highly significant and was most evident in MRM cases. Also we found that organs at risk received a dose in the 3D technique that was more than that received in the 2D technique, again that difference was highly significant and was also most evident in MRM cases but all doses were still within tolerance. CONCLUSIONS From the present study we concluded that the coverage of the supraclavicular and infraclavicular PTV is significantly worse with the 2D technique using a single oblique field at a fixed depth of 3 cm for all patients despite their different builts.
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Affiliation(s)
- Mohsen Barsoum
- Radiation Oncology Department, National Cancer Institute, Cairo University, Egypt
| | - Magda Mostafa
- Clinical Oncology Department, Faculty of Medicine, Cairo University, Egypt
| | - Hisham El Hossieny
- Radiation Oncology Department, National Cancer Institute, Cairo University, Egypt
| | - Azza Nasr
- Radiation Oncology Department, National Cancer Institute, Cairo University, Egypt
| | - Mohamed Mahmoud
- Radiation Oncology Department, National Cancer Institute, Cairo University, Egypt.
| | - Sally Fouda
- Radiation Oncology Department, National Cancer Institute, Cairo University, Egypt
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Warren M, Webster G, Ryder D, Rowbottom C, Faivre-Finn C. An isotoxic planning comparison study for stage II-III non-small cell lung cancer: is intensity-modulated radiotherapy the answer? Clin Oncol (R Coll Radiol) 2014; 26:461-7. [PMID: 24793504 DOI: 10.1016/j.clon.2014.03.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 03/06/2014] [Accepted: 03/10/2014] [Indexed: 12/25/2022]
Abstract
AIMS Recent clinical series suggest that treating patients with isotoxic twice-daily radiotherapy may be beneficial. This dosimetric planning study compared the use of intensity-modulated radiotherapy (IMRT) and three-dimensional conformal radiotherapy (3DRT) to deliver isotoxic treatment for non-small cell lung cancer (NSCLC) patients. MATERIALS AND METHODS Twenty patients with stage II/III NSCLC were selected. A dose-escalated plan was produced retrospectively for each using three different methods: (i) three to five beams 3DRT; (ii) seven beams inverse-planned conformal radiotherapy; (iii) seven beams IMRT. The starting point for dose escalation was 55.8 Gy in 1.8 Gy per fraction twice-daily. The number of fractions was then increased until one or more organ at risk tolerance dose was exceeded or a maximum dose of 79.2 Gy was reached. RESULTS The median escalated doses were 70.2, 66.6 and 64.8 Gy for IMRT, 3DRT and inverse-planned conformal radiotherapy, respectively. IMRT allowed a significant dose increase in comparison with the other two methods (P < 0.05), whereas no significant difference was found between 3DRT and inverse-planned conformal radiotherapy. IMRT was more successful at escalating dose in patients where the brachial plexus and spinal canal were close to the planning target volume. IMRT did not allow the escalation of dose beyond 70.2 Gy (82.8 Gy BED10, 69 Gy EQD2) due to the proximity of disease to the great vessels and the proximal bronchial tree. CONCLUSIONS IMRT allows increased dose escalation compared with conformal radiotherapy. However, there is limited opportunity to escalate the prescription dose beyond 70.2 Gy twice-daily in disease close to the central mediastinal structures.
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Affiliation(s)
- M Warren
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK.
| | - G Webster
- Medical Physics, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - D Ryder
- MAHSC-CTU Trials Coordination Unit, The Christie NHS Foundation Trust, Manchester, UK
| | - C Rowbottom
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - C Faivre-Finn
- Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, UK
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Chen AM, Wang PC, Daly ME, Cui J, Hall WH, Vijayakumar S, Phillips TL, Farwell DG, Purdy JA. Dose–Volume Modeling of Brachial Plexus-Associated Neuropathy After Radiation Therapy for Head-and-Neck Cancer: Findings From a Prospective Screening Protocol. Int J Radiat Oncol Biol Phys 2014; 88:771-7. [DOI: 10.1016/j.ijrobp.2013.11.244] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 11/16/2013] [Accepted: 11/25/2013] [Indexed: 12/25/2022]
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Automatic contouring of brachial plexus using a multi-atlas approach for lung cancer radiation therapy. Pract Radiat Oncol 2013; 3:e139-47. [PMID: 24674411 DOI: 10.1016/j.prro.2013.01.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 01/05/2013] [Accepted: 01/07/2013] [Indexed: 02/03/2023]
Abstract
PURPOSE To demonstrate a multi-atlas segmentation approach to facilitating accurate and consistent delineation of low-contrast brachial plexuses on computed tomographic images for lung cancer radiation therapy. METHODS AND MATERIALS We retrospectively identified 90 lung cancer patients with treatment volumes near the brachial plexus. Ten representative patients were selected to form an atlas group, and their brachial plexuses were delineated manually. We used deformable image registration to map each atlas brachial plexus to the remaining 80 patients. In each patient, a composite contour was created from 10 individual segmentations using the simultaneous truth and performance level estimation algorithm. This auto-delineated contour was reviewed and modified appropriately for each patient. We also performed 10 leave-one-out tests using the 10 atlases to validate the segmentation accuracy and demonstrate the contouring consistency using multi-atlas segmentation. RESULTS The multi-atlas segmentation took less than 2 minutes to complete. Contour modification took 5 minutes compared with 20 minutes for manual contouring from scratch. The multi-atlas segmentation from the 10 leave-one-out tests had a mean 3-dimensional (3D) volume overlap of 59.2% ± 8.2% and a mean 3D surface distance of 2.4 mm ± 0.5 mm. The distances between the individual and average contours in the 10 leave-one-out tests demonstrated much better contouring consistency for modified contours than for manual contours. The auto-segmented contours did not require substantial modification, demonstrated by the good agreement between the modified and auto-segmented contours in the 80 patients. Dose volume histograms of auto-segmented and modified contours were also in good agreement, showing that editing auto-segmented contours is clinically acceptable in view of the dosimetric impact. CONCLUSIONS Multi-atlas segmentation greatly reduced contouring time and improved contouring consistency. Editing auto-segmented contours to delineate the brachial plexus proved to be a better clinical practice than manually contouring from scratch.
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Clinical observation of peripheral nerve injury in 2 patients with cancer after radiotherapy. Contemp Oncol (Pozn) 2013; 17:196-9. [PMID: 23788990 PMCID: PMC3685374 DOI: 10.5114/wo.2013.34625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2012] [Revised: 09/22/2012] [Accepted: 10/03/2012] [Indexed: 12/25/2022] Open
Abstract
Aim of the study This study aims to analyze the clinical manifestations and sequelae of peripheral nerve radiation damage of two cases of cancer patients after radiotherapy at the corresponding sites in clinical practice and to summarize experiences and lesions in order to provide a reference for future tumor radiotherapy. Material and methods Some data of two cases of patients, such as doses of radiotherapy, clinical manifestations and damage occurrence time, were collected and examinations were conducted to define diagnosis. Afterwards, therapies and follow-up were conducted. Results Case 1 (rectal cancer) was diagnosed as mild left lower extremity nerve damage. After the symptomatic treatment, the disease condition was improved, and there was no tumor recurrence sign. Case 2 (breast cancer) was diagnosed as left brachial plexus damage, and left upper extremity movement function was lost completely. While the analgesic treatment was conducted, anti-tumor relevant treatments were being carried out. Conclusions Radiotherapy can cause different extents of radioactive nerve damage. In practice, it is necessary to constantly improve the radiotherapy technology level and actively prevent the occurrence of complications. Once symptoms appear, the diagnosis and treatment should be conducted as early as possible in order to avoid aggravating damage to cause dysfunction and cause lifetime pain to patients.
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