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Azemar N, Fontbonne C, Claude Quintyn J, Lebertz D, Marc Fontbonne J, Thariat J. Assessment of gaze direction during head and neck irradiation and dosimetric impact on the retina, macula and papilla in a cohort of 240 patients with paraoptic tumors. Radiother Oncol 2024; 197:110342. [PMID: 38782302 DOI: 10.1016/j.radonc.2024.110342] [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: 01/13/2024] [Revised: 05/14/2024] [Accepted: 05/15/2024] [Indexed: 05/25/2024]
Abstract
In a prospective cohort of 240 paraoptic tumors patients treated with protons, there was 10° inter-individual gaze angle variability (up to 30°). In a random 21-patient subset with initial CTs versus and adaptive CTs, 6 (28.57 %) patients had at least twice a 10°-difference in their gaze angle, with > 5 Gy difference on the retina/macula or papilla in 2/21 (9.52 %) and 1/21 (4.76 %) based on cumulative dose from rescans, respectively.
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Affiliation(s)
- Nathan Azemar
- Université de Caen Normandie, ENSICAEN, CNRS/IN2P3, LPC Caen UMR6534, Caen F-14000, France.
| | - Cathy Fontbonne
- Université de Caen Normandie, ENSICAEN, CNRS/IN2P3, LPC Caen UMR6534, Caen F-14000, France
| | | | - Dorothee Lebertz
- Université de Caen Normandie, ENSICAEN, CNRS/IN2P3, LPC Caen UMR6534, Caen F-14000, France; Department of Radiation Therapy, Centre François Baclesse, Caen, France
| | - Jean Marc Fontbonne
- Université de Caen Normandie, ENSICAEN, CNRS/IN2P3, LPC Caen UMR6534, Caen F-14000, France
| | - Juliette Thariat
- Université de Caen Normandie, ENSICAEN, CNRS/IN2P3, LPC Caen UMR6534, Caen F-14000, France; Department of Radiation Therapy, Centre François Baclesse, Caen, France.
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Foote RL, Harmsen WS, Amundson AC, Carr AB, Gamez ME, Garces YI, Lester SC, Ma DJ, McGee LA, Moore EJ, Neben Wittich MA, Patel SH, Routman DM, Rwigema JCM, Van Abel KM, Yin LX, Muller OM, Shiraishi S. Mean Oral Cavity Organ-at-Risk Dose Predicts Opioid Use and Hospitalization during Radiotherapy for Patients with Head and Neck Tumors. Cancers (Basel) 2024; 16:349. [PMID: 38254837 PMCID: PMC10814074 DOI: 10.3390/cancers16020349] [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: 12/07/2023] [Revised: 01/04/2024] [Accepted: 01/10/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Approximately 75% of all head and neck cancer patients are treated with radiotherapy (RT). RT to the oral cavity results in acute and late adverse events which can be severe and detrimental to a patient's quality of life and function. The purpose of this study was to explore associations between RT dose to a defined oral cavity organ-at-risk (OAR) avoidance structure, provider- and patient-reported outcomes (PROs), opioid use, and hospitalization. METHODS This was a retrospective analysis of prospectively obtained outcomes using multivariable modeling. The study included 196 patients treated with RT involving the oral cavity for a head and neck tumor. A defined oral cavity OAR avoidance structure was used in all patients for RT treatment planning. Validated PROs were collected prospectively. Opioid use and hospitalization were abstracted electronically from medical records. RESULTS Multivariable modeling revealed the mean dose to the oral cavity OAR was significantly associated with opioid use (p = 0.0082) and hospitalization (p = 0.0356) during and within 30 days of completing RT. CONCLUSIONS The findings of this study may be valuable in RT treatment planning for patients with tumors of the head and neck region to reduce the need for opioid use and hospitalization during treatment.
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Affiliation(s)
- Robert L. Foote
- Department of Radiation Oncology, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA; (A.C.A.); (M.E.G.); (Y.I.G.); (S.C.L.); (D.J.M.); (M.A.N.W.); (D.M.R.)
| | - W. Scott Harmsen
- Department of Quantitative Health Sciences, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA;
| | - Adam C. Amundson
- Department of Radiation Oncology, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA; (A.C.A.); (M.E.G.); (Y.I.G.); (S.C.L.); (D.J.M.); (M.A.N.W.); (D.M.R.)
| | - Alan B. Carr
- Department of Dental Specialties, Division of Esthetic and Prosthetic Dentistry, Department of Advanced Prosthodontics, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA; (A.B.C.); (O.M.M.)
| | - Mauricio E. Gamez
- Department of Radiation Oncology, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA; (A.C.A.); (M.E.G.); (Y.I.G.); (S.C.L.); (D.J.M.); (M.A.N.W.); (D.M.R.)
| | - Yolanda I. Garces
- Department of Radiation Oncology, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA; (A.C.A.); (M.E.G.); (Y.I.G.); (S.C.L.); (D.J.M.); (M.A.N.W.); (D.M.R.)
| | - Scott C. Lester
- Department of Radiation Oncology, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA; (A.C.A.); (M.E.G.); (Y.I.G.); (S.C.L.); (D.J.M.); (M.A.N.W.); (D.M.R.)
| | - Daniel J. Ma
- Department of Radiation Oncology, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA; (A.C.A.); (M.E.G.); (Y.I.G.); (S.C.L.); (D.J.M.); (M.A.N.W.); (D.M.R.)
| | - Lisa A. McGee
- Department of Radiation Oncology, Mayo Clinic Arizona, 5777 E. Mayo Blvd., Phoenix, AZ 85054, USA; (L.A.M.); (S.H.P.); (J.-C.M.R.)
| | - Eric J. Moore
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA; (E.J.M.); (K.M.V.A.); (L.X.Y.)
| | - Michelle A. Neben Wittich
- Department of Radiation Oncology, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA; (A.C.A.); (M.E.G.); (Y.I.G.); (S.C.L.); (D.J.M.); (M.A.N.W.); (D.M.R.)
| | - Samir H. Patel
- Department of Radiation Oncology, Mayo Clinic Arizona, 5777 E. Mayo Blvd., Phoenix, AZ 85054, USA; (L.A.M.); (S.H.P.); (J.-C.M.R.)
| | - David M. Routman
- Department of Radiation Oncology, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA; (A.C.A.); (M.E.G.); (Y.I.G.); (S.C.L.); (D.J.M.); (M.A.N.W.); (D.M.R.)
| | - Jean-Claude M. Rwigema
- Department of Radiation Oncology, Mayo Clinic Arizona, 5777 E. Mayo Blvd., Phoenix, AZ 85054, USA; (L.A.M.); (S.H.P.); (J.-C.M.R.)
| | - Kathryn M. Van Abel
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA; (E.J.M.); (K.M.V.A.); (L.X.Y.)
| | - Linda X. Yin
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA; (E.J.M.); (K.M.V.A.); (L.X.Y.)
| | - Olivia M. Muller
- Department of Dental Specialties, Division of Esthetic and Prosthetic Dentistry, Department of Advanced Prosthodontics, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA; (A.B.C.); (O.M.M.)
| | - Satomi Shiraishi
- Division of Medical Physics, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA;
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Huynh TTM, Dale E, Falk RS, Hellebust TP, Astrup GL, Malinen E, Edin NFJ, Bjordal K, Herlofson BB, Kiserud CE, Helland Å, Amdal CD. Radiation-induced long-term dysphagia in survivors of head and neck cancer and association with dose-volume parameters. Radiother Oncol 2024; 190:110044. [PMID: 38061420 DOI: 10.1016/j.radonc.2023.110044] [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: 05/31/2023] [Revised: 11/19/2023] [Accepted: 11/29/2023] [Indexed: 02/20/2024]
Abstract
BACKGROUND Although dysphagia is a common side effect after radiotherapy (RT) of head and neck cancer (HNC), data on long-term dysphagia is scarce. We aimed to 1) compare radiation dose parameters in HNC survivors with and without dysphagia, 2) investigate factors associated with long-term dysphagia and its possible impact on health-related quality of life (HRQoL), and 3) investigate how our data agree with existing NTCP models. METHODS This cross-sectional study conducted in 2018-2020, included HNC survivors treated in 2007-2013. Participants attended a one-day examination in hospital and filled in patient questionnaires. Dysphagia was measured with the EORTC QLQ-H&N35 swallowing scale. Toxicity was scored with CTCAE v.4. We contoured swallowing organs at risk (SWOAR) on RT plans, calculated dose-volume histograms (DVHs), performed logistic regression analyses and tested our data in established NTCP models. RESULTS Of the 239 participants, 75 (31%) reported dysphagia. Compared to survivors without dysphagia, this group had reduced HRQoL and the DVHs for infrahyoid SWOAR were significantly shifted to the right. Long-term dysphagia was associated with age (OR 1.07, 95% CI 1.03-1.10), female sex (OR 2.75, 95% CI 1.45-5.21), and mean dose to middle pharyngeal constrictor muscle (MD-MPCM) (OR 1.06, 95% CI 1.03-1.09). NTCP models overall underestimated the risk of long-term dysphagia. CONCLUSIONS Long-term dysphagia was associated with higher age, being female, and high MD-MPCM. Doses to distally located SWOAR seemed to be risk factors. Existing NTCP models do not sufficiently predict long-term dysphagia. Further efforts are needed to reduce the prevalence and consequences of this late effect.
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Affiliation(s)
- Thuy-Tien Maria Huynh
- Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Oncology, Oslo University Hospital, Oslo, Norway.
| | - Einar Dale
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | | | - Taran Paulsen Hellebust
- Department of Physics, University of Oslo, Oslo, Norway; Department of Medical Physics, Oslo University Hospital, Oslo, Norway
| | | | - Eirik Malinen
- Department of Physics, University of Oslo, Oslo, Norway; Department of Medical Physics, Oslo University Hospital, Oslo, Norway
| | | | - Kristin Bjordal
- Faculty of Medicine, University of Oslo, Oslo, Norway; Research support services, Oslo University Hospital, Oslo, Norway
| | - Bente Brokstad Herlofson
- Faculty of Dentistry, University of Oslo, Oslo, Norway; Department of Otorhinolaryngology, Head and Neck Surgery, Oslo University Hospital, Oslo, Norway
| | | | - Åslaug Helland
- Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Cecilie Delphin Amdal
- Department of Oncology, Oslo University Hospital, Oslo, Norway; Research support services, Oslo University Hospital, Oslo, Norway
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Li Q, Deng F, Pan X, Bai H, Bai J, Liu X, Chen F, Ge R. Application research on reducing radiation-induced lung injury with a trigger operator based on overlap volume histogram (OVH) in breast cancer postoperative radiotherapy. Sci Rep 2023; 13:22042. [PMID: 38086847 PMCID: PMC10716111 DOI: 10.1038/s41598-023-49282-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 12/06/2023] [Indexed: 12/18/2023] Open
Abstract
This study aims to develop a trigger operator based on the Overlap Volume Histogram (OVH) and examined its effectiveness in enhancing plan quality to minimize radiation-induced lung injury in postoperative radiotherapy for breast cancer. This trigger operator was applied for plan re-optimization to the previous Volumetric Modulated Arc Therapy (VMAT) plans of 16 left breast conserving surgery cases. These cases were categorized into a Contiguous Group (CG) and a Separated Group (SG) based on the relative position between the target and the Left-Lung (L-Lung). We investigated the changes in Vx, mean dose, and Normal Tissue Complication Probability (NTCP) values of organs-at-risk (OARs) before and after using the trigger operator. The Pairwise Sample T test was employed to evaluate the differences in indices between the two groups before and after optimizations. The trigger operator effectively initiated plan re-optimization. The values of V5, V10, V20, V30, and V40 of the L-Lung, as well as the mean dose of the heart, all decreased after re-optimization. The Pairwise Sample T test results showed statistically significant differences in the V20, V30, and V40 of the L-Lung in the CG (P < 0.01), and in the V5, V10, V20, V30, and V40 of the L-Lung in the SG (P < 0.01). Our findings suggest that the proposed trigger operator can improve plan quality, thereby reducing radiation-induced lung injury in postoperative radiotherapy for breast cancer.
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Affiliation(s)
- Qianyan Li
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Yunnan Tumor Hospital, Kunming, Yunnan, China
| | - Feifei Deng
- Department of Oncology, 920Th Hospital of Joint Logistics Support Force, PLA, Kunming, Yunnan, China
| | - Xiang Pan
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Yunnan Tumor Hospital, Kunming, Yunnan, China
| | - Han Bai
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Yunnan Tumor Hospital, Kunming, Yunnan, China.
- Department of Physics and Astronomy, Yunnan University, Kunming, Yunnan, China.
| | - Jie Bai
- Department of Radiation Oncology, Daqin Tumor Hospital, Guiyang, Guizhou, China
| | - Xuhong Liu
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Yunnan Tumor Hospital, Kunming, Yunnan, China
| | - Feihu Chen
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Yunnan Tumor Hospital, Kunming, Yunnan, China
| | - Ren Ge
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hongkong, China
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Hu J, Fatyga M, Liu W, Schild SE, Wong WW, Vora SA, Li J. Radiotherapy toxicity prediction using knowledge-constrained generalized linear model. IISE TRANSACTIONS ON HEALTHCARE SYSTEMS ENGINEERING 2023; 14:130-140. [PMID: 39055377 PMCID: PMC11271844 DOI: 10.1080/24725579.2023.2227199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Radiation therapy (RT) is a frontline approach to treating cancer. While the target of radiation dose delivery is the tumor, there is an inevitable spill of dose to nearby normal organs causing complications. This phenomenon is known as radiotherapy toxicity. To predict the outcome of the toxicity, statistical models can be built based on dosimetric variables received by the normal organ at risk (OAR), known as Normal Tissue Complication Probability (NTCP) models. To tackle the challenge of the high dimensionality of dosimetric variables and limited clinical sample sizes, statistical models with variable selection techniques are viable choices. However, existing variable selection techniques are data-driven and do not integrate medical domain knowledge into the model formulation. We propose a knowledge-constrained generalized linear model (KC-GLM). KC-GLM includes a new mathematical formulation to translate three pieces of domain knowledge into non-negativity, monotonicity, and adjacent similarity constraints on the model coefficients. We further propose an equivalent transformation of the KC-GLM formulation, which makes it possible to solve the model coefficients using existing optimization solvers. Furthermore, we compare KC-GLM and several well-known variable selection techniques via a simulation study and on two real datasets of prostate cancer and lung cancer, respectively. These experiments show that KC-GLM selects variables with better interpretability, avoids producing counter-intuitive and misleading results, and has better prediction accuracy.
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Affiliation(s)
- Jiuyun Hu
- School of Computing & Augmented Intelligence, Arizona State University, Tempe, AZ, USA
| | - Mirek Fatyga
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Steven E. Schild
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - William W. Wong
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Sujay A. Vora
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Jing Li
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA, USA
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Abdollahi H, Dehesh T, Abdalvand N, Rahmim A. Radiomics and dosiomics-based prediction of radiotherapy-induced xerostomia in head and neck cancer patients. Int J Radiat Biol 2023; 99:1669-1683. [PMID: 37171485 DOI: 10.1080/09553002.2023.2214206] [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: 11/17/2022] [Accepted: 05/05/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND AND AIM Dose-response modeling for radiotherapy-induced xerostomia in head and neck cancer (HN) patients is a promising frontier for personalized therapy. Feature extraction from diagnostic and therapeutic images (radiomics and dosiomics features) can be used for data-driven response modeling. The aim of this study is to develop xerostomia predictive models based on radiomics-dosiomics features. METHODS Data from the cancer imaging archive (TCIA) for 31 HN cancer patients were employed. For all patients, parotid CT radiomics features were extracted, utilizing Lasso regression for feature selection and multivariate modeling. The models were developed by selected features from pretreatment (CT1), mid-treatment (CT2), post-treatment (CT3), and delta features (ΔCT2-1, ΔCT3-1, ΔCT3-2). We also considered dosiomics features extracted from the parotid dose distribution images (Dose model). Thus, combination models of radio-dosiomics (CT + dose & ΔCT + dose) were developed. Moreover, clinical, and dose-volume histogram (DVH) models were built. Nested 10-fold cross-validation was used to assess the predictive classification of patients into those with and without xerostomia, and the area under the receiver operative characteristic curve (AUC) was used to compare the predictive power of the models. The sensitivity and accuracy of models also were obtained. RESULTS In total, 59 parotids were assessed, and 13 models were developed. Our results showed three models with AUC of 0.89 as most predictive, namely ΔCT2-1 + Dose (Sensitivity 0.99, Accuracy 0.94 & Specificity 0.86), CT3 model (Sensitivity 0.96, Accuracy 0.94 & Specificity 0.86) and DVH (Sensitivity 0.93, Accuracy 0.89 & Specificity 0.84). These models were followed by Clinical (AUC 0.89, Sensitivity 0.81, Accuracy 0.97 & Specificity 0.89) and CT2 & Dose (AUC 0.86, Sensitivity 0.97, Accuracy 0.87 & Specificity 0.82). The Dose model (developed by dosiomics features only) had AUC, Sensitivity, Specificity, and Accuracy of 0.72, 0.98, 0.33, and 0.79 respectively. CONCLUSION Quantitative features extracted from diagnostic imaging during and after radiotherapy alone or in combination with dosiomics markers obtained from dose distribution images can be used for radiotherapy response modeling, opening up prospects for personalization of therapies toward improved therapeutic outcomes.
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Affiliation(s)
- Hamid Abdollahi
- Department of Integrative Oncology, BC Cancer Research Institute, Vancouver, BC, Canada
| | - Tania Dehesh
- Modelling in Health Research Center, Institute for Future Studies in Health, Kerman University ofMedical Sciences, Kerman, Iran
| | - Neda Abdalvand
- Department of Medical Physics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Arman Rahmim
- Department of Integrative Oncology, BC Cancer Research Institute, Vancouver, BC, Canada
- Departments of Radiology and Physics, University of British Columbia, Vancouver, British Columbia, Canada
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Leeuwenberg AM, Reitsma JB, Van den Bosch LGLJ, Hoogland J, van der Schaaf A, Hoebers FJP, Wijers OB, Langendijk JA, Moons KGM, Schuit E. The relation between prediction model performance measures and patient selection outcomes for proton therapy in head and neck cancer. Radiother Oncol 2023; 179:109449. [PMID: 36566991 DOI: 10.1016/j.radonc.2022.109449] [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: 10/26/2022] [Revised: 12/08/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Normal-tissue complication probability (NTCP) models predict complication risk in patients receiving radiotherapy, considering radiation dose to healthy tissues, and are used to select patients for proton therapy, based on their expected reduction in risk after proton therapy versus photon radiotherapy (ΔNTCP). Recommended model evaluation measures include area under the receiver operating characteristic curve (AUC), overall calibration (CITL), and calibration slope (CS), whose precise relation to patient selection is still unclear. We investigated how each measure relates to patient selection outcomes. METHODS The model validation and consequent patient selection process was simulated within empirical head and neck cancer patient data. By manipulating performance measures independently via model perturbations, the relation between model performance and patient selection was studied. RESULTS Small reductions in AUC (-0.02) yielded mean changes in ΔNTCP between 0.9-3.2 %, and single-model patient selection differences between 2-19 %. Deviations (-0.2 or +0.2) in CITL or CS yielded mean changes in ΔNTCP between 0.3-1.4 %, and single-model patient selection differences between 1-10 %. CONCLUSIONS Each measure independently impacts ΔNTCP and patient selection and should thus be assessed in a representative sufficiently large external sample. Our suggested practical model selection approach is considering the model with the highest AUC, and recalibrating it if needed.
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Affiliation(s)
- Artuur M Leeuwenberg
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - Johannes B Reitsma
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Lisa G L J Van den Bosch
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Jeroen Hoogland
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Arjen van der Schaaf
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Frank J P Hoebers
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Oda B Wijers
- Radiotherapeutic Institute Friesland, Leeuwarden, the Netherlands
| | - Johannes A Langendijk
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Karel G M Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Ewoud Schuit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Vogel M, Gade J, Timm B, Schürmann M, Auerbach H, Nüsken F, Rübe C, Melchior P, Dzierma Y. Comparison of Breast Cancer Radiotherapy Techniques Regarding Secondary Cancer Risk and Normal Tissue Complication Probability - Modelling and Measurements Using a 3D-Printed Phantom. Front Oncol 2022; 12:892923. [PMID: 35965556 PMCID: PMC9365503 DOI: 10.3389/fonc.2022.892923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background Radiotherapy after breast-conserving therapy is a standard postoperative treatment of breast cancer, which can be carried out with a variety of irradiation techniques. The treatment planning must take into consideration detrimental effects on the neighbouring organs at risk-the lung, the heart, and the contralateral breast, which can include both short- and long-term effects represented by the normal tissue complication probability and secondary cancer risk. Patients and Methods In this planning study, we investigate intensity-modulated (IMRT) and three-dimensional conformal (3D-CRT) radiotherapy techniques including sequential or simultaneously integrated boosts as well as interstitial multicatheter brachytherapy boost techniques of 38 patients with breast-conserving surgery retrospectively. We furthermore develop a 3D-printed breast phantom add-on to allow for catheter placement and to measure the out-of-field dose using thermoluminescent dosimeters placed inside an anthropomorphic phantom. Finally, we estimate normal tissue complication probabilities using the Lyman-Kutcher-Burman model and secondary cancer risks using the linear non-threshold model (out-of-field) and the model by Schneider et al. (in-field). Results The results depend on the combination of primary whole-breast irradiation and boost technique. The normal tissue complication probabilities for various endpoints are of the following order: 1%-2% (symptomatic pneumonitis, ipsilateral lung), 2%-3% (symptomatic pneumonitis, whole lung), and 1%-2% (radiation pneumonitis grade ≥ 2, whole lung). The additional relative risk of ischemic heart disease ranges from +25% to +35%. In-field secondary cancer risk of the ipsilateral lung in left-sided treatment is around 50 per 10,000 person-years for 20 years after exposure at age 55. Out-of-field estimation of secondary cancer risk results in approximately 5 per 10,000 person-years each for the contralateral lung and breast. Conclusions In general, 3D-CRT shows the best risk reduction in contrast to IMRT. Regarding the boost concepts, brachytherapy is the most effective method in order to minimise normal tissue complication probability and secondary cancer risk compared to teletherapy boost concepts. Hence, the 3D-CRT technique in combination with an interstitial multicatheter brachytherapy boost is most suitable in terms of risk avoidance for treating breast cancer with techniques including boost concepts.
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Affiliation(s)
- Marc Vogel
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Jonas Gade
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Bernd Timm
- Siemens Healthcare GmbH, Technical Service, Erlangen, Germany
| | - Michaela Schürmann
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Hendrik Auerbach
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Frank Nüsken
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Christian Rübe
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Patrick Melchior
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Yvonne Dzierma
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
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Deligiorgi MV, Trafalis DT. The continuum of care of anticancer treatment-induced hypothyroidism in patients with solid non thyroid tumors: time for an intimate collaboration between oncologists and endocrinologists. Expert Rev Clin Pharmacol 2022; 15:531-549. [PMID: 35757870 DOI: 10.1080/17512433.2022.2093714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Hypothyroidism is a common adverse event of various anticancer treatment modalities, constituting a notable paradigm of the integration of the endocrine perspective into precision oncology. AREAS COVERED The present narrative review provides a comprehensive and updated overview of anticancer treatment-induced hypothyroidism in patients with solid non-thyroid tumors. A study search was conducted on the following electronic databases: PubMed, Google Scholar, Scopus.com, ClinicalTrials.gov, and European Union Clinical Trials Register from 2011 until August 2021. EXPERT OPINION In patients with solid non-thyroid tumors, hypothyroidism is a common adverse event of radiotherapy, high dose interleukin 2 (HD IL-2), interferon alpha (IFN-α), bexarotene, immune checkpoint inhibitors (ICPi), and tyrosine kinase inhibitors (TKIs), while chemotherapy may induce hypothyroidism more often than initially considered. The path forward for the management of anticancer treatment-induced hypothyroidism in patients with solid non-thyroid tumors is an integrated approach grounded on 5 pillars: prevention, vigilance, diagnosis, treatment and monitoring. Current challenges concerning anticancer treatment-induced hypothyroidism await counteraction, namely awareness of the growing list of related anticancer treatments, identification of predictive factors, counteraction of diagnostic pitfalls, tuning of thyroid hormone replacement, and elucidation of its prognostic significance. Close collaboration of oncologists with endocrinologists will provide optimal patient care.
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Affiliation(s)
- Maria V Deligiorgi
- Department of Pharmacology - Clinical Pharmacology Unit, National and Kapodistrian University of Athens, Faculty of Medicine, Athens, Greece
| | - Dimitrios T Trafalis
- Department of Pharmacology - Clinical Pharmacology Unit, National and Kapodistrian University of Athens, Faculty of Medicine, Athens, Greece
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10
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Yahya N, Linge A, Leger K, Maile T, Kemper M, Haim D, Jöhrens K, Troost EGC, Krause M, Löck S. Assessment of gene expressions from squamous cell carcinoma of the head and neck to predict radiochemotherapy-related xerostomia and dysphagia. Acta Oncol 2022; 61:856-863. [PMID: 35657056 DOI: 10.1080/0284186x.2022.2081931] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
PURPOSE We tested the hypothesis that gene expressions from biopsies of locally advanced head and neck squamous cell carcinoma (HNSCC) patients can supplement dose-volume parameters to predict dysphagia and xerostomia following primary radiochemotherapy (RCTx). MATERIAL AND METHODS A panel of 178 genes previously related to radiochemosensitivity of HNSCC was considered for nanoString analysis based on tumour biopsies of 90 patients with locally advanced HNSCC treated by primary RCTx. Dose-volume parameters were extracted from the parotid, submandibular glands, oral cavity, larynx, buccal mucosa, and lips. Normal tissue complication probability (NTCP) models were developed for acute, late, and for the improvement of xerostomia grade ≥2 and dysphagia grade ≥3 using a cross-validation-based least absolute shrinkage and selection operator (LASSO) approach combined with stepwise logistic regression for feature selection. The final signatures were included in a logistic regression model with optimism correction. Performance was assessed by the area under the receiver operating characteristic curve (AUC). RESULTS NTCP models for acute and late xerostomia and the improvement of dysphagia resulted in optimism-corrected AUC values of 0.84, 0.76, and 0.70, respectively. The minimum dose to the contralateral parotid was selected for both acute and late xerostomia and the minimum dose to the larynx was selected for dysphagia improvement. For the xerostomia endpoints, the following gene expressions were selected: RPA2 (cellular response to DNA damage), TCF3 (salivary gland cells development), GBE1 (glycogen storage and regulation), and MAPK3 (regulation of cellular processes). No gene expression features were selected for the prediction of dysphagia. CONCLUSION This hypothesis-generating study showed the potential of improving NTCP models using gene expression data for HNSCC patients. The presented models require independent validation before potential application in clinical practice.
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Affiliation(s)
- Noorazrul Yahya
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden – Rossendorf, Dresden, Germany
- Faculty of Health Sciences, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Annett Linge
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden – Rossendorf, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Karoline Leger
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden – Rossendorf, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Till Maile
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden – Rossendorf, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Max Kemper
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
- Department of Otorhinolaryngology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Dominik Haim
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Korinna Jöhrens
- German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
- Institute of Pathology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Esther G. C. Troost
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden – Rossendorf, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
- Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology – OncoRay, Dresden, Germany
| | - Mechthild Krause
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden – Rossendorf, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
- Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology – OncoRay, Dresden, Germany
| | - Steffen Löck
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden – Rossendorf, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
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Case study of a bolus helmet used to maintain optic chiasm and nerve sparing while improving target coverage using IMPT. Med Dosim 2022; 47:242-246. [PMID: 35513997 DOI: 10.1016/j.meddos.2022.03.003] [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: 12/03/2021] [Revised: 03/21/2022] [Accepted: 03/21/2022] [Indexed: 11/21/2022]
Abstract
The purpose of this study was to examine if the use of a bolus helmet when treating the head with intensity modulated proton therapy (IMPT) will maintain organs at risk (OAR) sparing while improving the clinical target volume (CTV) coverage. A bolus helmet is a device that aims to improve on the traditionally used range shifter in proton therapy by improving dose distribution characteristics. Ten patients were retrospectively selected who had 2 separate treatment planning scans performed, a scan with the bolus helmet and a second scan without. Plans were created using both scans. Dose to organs at risk (OAR) including the left optic nerve, right optic nerve, optic chiasm, and normal brain minus CTV (brain-CTV), as well as CTV coverage were compared between the 2 plans. The use of the bolus helmet displayed lower mean OAR doses as well as higher CTV coverage, suggesting that use of the bolus helmet provides benefit when treating the head with IMPT.
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12
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Schack LMH, Naderi E, Fachal L, Dorling L, Luccarini C, Dunning AM, Ong EHW, Chua MLK, Langendijk JA, Alizadeh BZ, Overgaard J, Eriksen JG, Andreassen CN, Alsner J. A genome-wide association study of radiotherapy induced toxicity in head and neck cancer patients identifies a susceptibility locus associated with mucositis. Br J Cancer 2022; 126:1082-1090. [PMID: 35039627 PMCID: PMC8980077 DOI: 10.1038/s41416-021-01670-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 11/21/2021] [Accepted: 12/06/2021] [Indexed: 01/21/2023] Open
Abstract
PURPOSE A two-stage genome-wide association study was carried out in head and neck cancer (HNC) patients aiming to identify genetic variants associated with either specific radiotherapy-induced (RT) toxicity endpoints or a general proneness to develop toxicity after RT. MATERIALS AND METHODS The analysis included 1780 HNC patients treated with primary RT for laryngeal or oro/hypopharyngeal cancers. In a non-hypothesis-driven explorative discovery study, associations were tested in 1183 patients treated within The Danish Head and Neck Cancer Group. Significant associations were later tested in an independent Dutch cohort of 597 HNC patients and if replicated, summary data obtained from discovery and replication studies were meta-analysed. Further validation of significantly replicated findings was pursued in an Asian cohort of 235 HNC patients with nasopharynx as the primary tumour site. RESULTS We found and replicated a significant association between a locus on chromosome 5 and mucositis with a pooled OR for rs1131769*C in meta-analysis = 1.95 (95% CI 1.48-2.41; ppooled = 4.34 × 10-16). CONCLUSION This first exploratory GWAS in European cohorts of HNC patients identified and replicated a risk locus for mucositis. A larger Meta-GWAS to identify further risk variants for RT-induced toxicity in HNC patients is warranted.
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Affiliation(s)
- Line M H Schack
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark.
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark.
| | - Elnaz Naderi
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, Groningen, The Netherlands
- University of Groningen, University Medical Center Groningen, Department of Epidemiology, Groningen, The Netherlands
| | - Laura Fachal
- Centre for Cancer Genetic Epidemiology, Department of Oncology, University of Cambridge, Cambridge, UK
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, UK
| | - Leila Dorling
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Craig Luccarini
- Centre for Cancer Genetic Epidemiology, Department of Oncology, University of Cambridge, Cambridge, UK
| | - Alison M Dunning
- Centre for Cancer Genetic Epidemiology, Department of Oncology, University of Cambridge, Cambridge, UK
| | - Enya H W Ong
- Division of Medical Sciences, National Cancer Centre Singapore, Singapore, Singapore
| | - Melvin L K Chua
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore, Singapore
- Oncology Academic Clinical Programme, Duke-NUS Medical School, Singapore, Singapore
| | - Johannes A Langendijk
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, Groningen, The Netherlands
| | - Behrooz Z Alizadeh
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, Groningen, The Netherlands
- University of Groningen, University Medical Center Groningen, Department of Epidemiology, Groningen, The Netherlands
| | - Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Jesper Grau Eriksen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Nicolaj Andreassen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Jan Alsner
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
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Abel E, Silander E, Nordström F, Olsson C, Brodin NP, Nyman J, Björk-Eriksson T, Hammerlid E. Fatigue in head and neck cancer patients treated with radiotherapy: a prospective study of patient-reported outcomes and their association with radiation dose to the cerebellum. Adv Radiat Oncol 2022; 7:100960. [PMID: 35847551 PMCID: PMC9280038 DOI: 10.1016/j.adro.2022.100960] [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: 10/30/2021] [Accepted: 03/28/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Although fatigue is a known side effect in patients with head and neck cancer (HNC) receiving radiation therapy, knowledge regarding long-term fatigue and dose-response relationships to organs at risk is scarce. The aim of this prospective study was to analyze patient-reported fatigue in patients with HNC receiving radiation therapy and to explore any possible association with organ-at-risk doses. Methods and Materials Patients with HNC referred for curative radiation therapy were eligible for inclusion in the study. To assess patient-reported fatigue, quality of life questionnaires (European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-FA12) were distributed before treatment and 1, 3, 6, 12, 24, and 60 months after the start of treatment. Mean dose (Dmean) and near maximum dose (D2%) of the cerebellum and brain stem were evaluated in relation to baseline-adjusted fatigue scores at 3 months. Results One hundred twenty-six patients treated with intensity modulated radiation therapy between 2008 and 2010 were available for final analysis. Female sex and age <60 years were associated with higher fatigue at baseline, whereas patients also treated with chemotherapy had reduced physical and emotional fatigue at 6 months. Physical fatigue (QLQ-FA12 scale) increased from baseline up to 3 months (29 vs 59; P < .0001) but showed no difference compared with baseline from 1 to 5 years. Emotional fatigue was significantly lower at 5 years compared with baseline (14 vs 28; P < .0001). Patients with cerebellum Dmean > 3.5 Gy had higher mean physical fatigue scores at 3 months (38 vs 27; P = .036). Conclusions Although there is a significant increase in fatigue scores for patients with HNC up to 1 year after radiation therapy, this study showed a return to baseline levels at 5 years. A possible association was found between physical fatigue and a higher mean dose to the cerebellum.
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Mathematical oncology: A new frontier in cancer biology and clinical decision making: Comment on "Improving cancer treatments via dynamical biophysical models" by M. Kuznetsov, J. Clairambault & V. Volpert. Phys Life Rev 2022; 40:60-62. [PMID: 34857476 PMCID: PMC9870030 DOI: 10.1016/j.plrev.2021.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 11/18/2021] [Indexed: 01/26/2023]
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Lee CT, Galloway TJ. Pathogenesis and Amelioration of Radiation-Induced Oral Mucositis. Curr Treat Options Oncol 2022; 23:311-324. [PMID: 35244887 PMCID: PMC8931694 DOI: 10.1007/s11864-022-00959-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 11/29/2022]
Abstract
OPINION STATEMENT Oral mucositis (OM) causes significant detriment to patient quality of life. Despite advances in RT, chemotherapy, and surgery for HNC which have led to improved local control and survival, management of certain toxicities such as OM have not kept pace. Numerous strategies have emerged with demonstrable benefit in preventing severe OM. However, ones which are not only effective, but practical and affordable to implement are rare. For example, infusion of growth factors or free radical scavengers, and daily treatment of intra-oral sites with lasers are supported by high-quality evidence but have not become widely adopted. It falls to familiarity of the physician with the available preventative measures and ultimately, patient preference in accepting which strategies for OM amelioration are used. In this review, we present a pathophysiological-based review of prevention techniques available for reducing the incidence and duration of severe OM.
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Affiliation(s)
- Charles T. Lee
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Thomas J. Galloway
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
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Mandal A, Patel G, Bharati A, Choudhary S, Mishra R, Mourya A. Development and validation of an indigenous, radiobiological model-based tumor control probability and normal tissue complication probability estimation software for routine plan evaluation in clinics. J Cancer Res Ther 2022; 18:1697-1705. [DOI: 10.4103/jcrt.jcrt_330_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Vreugdenhil M, Fong C, Iqbal G, Roques T, Evans M, Palaniappan N, Yang H, O'Toole L, Sanghera P, Nutting C, Foran B, Sen M, Al Booz H, Fulton-Lieuw T, Dalby M, Dunn J, Hartley A, Mehanna H. Improvement in Dysphagia Outcomes Following Clinical Target Volume Reduction in the De-ESCALaTE Study. Clin Oncol (R Coll Radiol) 2021; 33:795-803. [PMID: 34340917 DOI: 10.1016/j.clon.2021.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/02/2021] [Accepted: 07/14/2021] [Indexed: 11/29/2022]
Abstract
AIMS The De-ESCALaTE study showed an overall survival advantage for the administration of synchronous cisplatin chemotherapy with radiotherapy in low-risk oropharyngeal cancer when compared with synchronous cetuximab. During the trial, a radiotherapy quality assurance protocol amendment permitted centres to swap from the original radiotherapy contouring protocol (incorporating the whole oropharynx into the high-dose clinical target volume (CTV); anatomical protocol) to a protocol that incorporated the gross tumour volume with a 10 mm margin into the CTV (volumetric protocol). The purpose of this study was to examine both toxicity and tumour control related to this protocol amendment. MATERIALS AND METHODS Overall survival and recurrence at 2 years were used to compare tumour control in the two contouring cohorts. For toxicity, the cohorts were compared by both the number of severe (grades 3-5) and all grades acute and late toxicities. In addition, quality of life and swallowing were compared using EORTC-C30 and MD Anderson Dysphagia Inventory, respectively. RESULTS Of 327 patients included in this study, 185 were contoured according to the anatomical protocol and 142 by the volumetric protocol. The two cohorts were well balanced, with the exception of significantly more patients in the anatomical cohort undergoing prophylactic feeding tube insertion (P < 0.001). With a minimum of 2 years of follow-up there was no significant difference in overall survival or recurrence between the two contouring protocols. Similarly, there was no significant difference in the rate of reported severe or all grades acute or late toxicity and no sustained significant difference in quality of life. However, there was a significant difference in favour of volumetric contouring in several domains of the MD Anderson Dysphagia Inventory questionnaire at 1 year, which persisted to 2 years in the dysphagia functional (P = 0.002), dysphagia physical (P = 0.009) and dysphagia overall function (P = 0.008) domains. CONCLUSION In the context of the unplanned post-hoc analysis of a randomised trial, measurable improvement in long-term dysphagia has been shown following a reduction in the CTV. Further reductions in the CTV should be subject to similar scrutiny within the confines of a prospective study.
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Affiliation(s)
- M Vreugdenhil
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, Birmingham, UK
| | - C Fong
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, Birmingham, UK
| | - G Iqbal
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - T Roques
- Norfolk and Norwich University Hospitals, Norwich, UK
| | - M Evans
- Velindre University NHS Trust, Cardiff, UK
| | | | - H Yang
- Addenbrooke's Hospital, Cambridge, UK
| | - L O'Toole
- Castle Hill Hospital, Cottingham, UK
| | - P Sanghera
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, Birmingham, UK
| | | | - B Foran
- Weston Park Hospital, Sheffield, UK
| | - M Sen
- St James' Institute of Oncology, Leeds, UK
| | - H Al Booz
- Bristol Haematology and Oncology Centre, Bristol, UK
| | - T Fulton-Lieuw
- Institute of Head and Neck Studies and Education (InHANSE), University of Birmingham, Birmingham, UK
| | - M Dalby
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - J Dunn
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - A Hartley
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, Birmingham, UK.
| | - H Mehanna
- Institute of Head and Neck Studies and Education (InHANSE), University of Birmingham, Birmingham, UK
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Naderi E, Crijns APG, Steenbakkers RJHM, van den Hoek JGM, Boezen HM, Alizadeh BZ, Langendijk JA. A two-stage genome-wide association study of radiation-induced acute toxicity in head and neck cancer. J Transl Med 2021; 19:481. [PMID: 34838041 PMCID: PMC8626989 DOI: 10.1186/s12967-021-03145-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/15/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Most head and neck cancer (HNC) patients receive radiotherapy (RT) and develop toxicities. This genome-wide association study (GWAS) was designed to identify single nucleotide polymorphisms (SNPs) associated with common acute radiation-induced toxicities (RITs) in an HNC cohort. METHODS A two-stage GWAS was performed in 1279 HNC patients treated with RT and prospectively scored for mucositis, xerostomia, sticky saliva, and dysphagia. The area under the curve (AUC) was used to estimate the average load of toxicity during RT. At the discovery study, multivariate linear regression was used in 957 patients, and the top-ranking SNPs were tested in 322 independent replication cohort. Next, the discovery and the replication studies were meta-analyzed. RESULTS A region on 5q21.3 containing 16 SNPs showed genome-wide (GW) significance association at P-value < 5.0 × 10-8 with patient-rated acute xerostomia in the discovery study. The top signal was rs35542 with an adjusted effect size of 0.17*A (95% CI 0.12 to 0.23; P-value < = 3.78 × 10-9). The genome wide significant SNPs were located within three genes (EFNA5, FBXL17, and FER). In-silico functional analysis showed these genes may be involved in DNA damage response and co-expressed in minor salivary glands. We found 428 suggestive SNPs (P-value < 1.0 × 10-5) for other toxicities, taken to the replication study. Eleven of them showed a nominal association (P-value < 0.05). CONCLUSIONS This GWAS suggested novel SNPs for patient-rated acute xerostomia in HNC patients. If validated, these SNPs and their related functional pathways could lead to a predictive assay to identify sensitive patients to radiation, which may eventually allow a more individualized RT treatment.
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Affiliation(s)
- Elnaz Naderi
- Department of Radiation Oncology, University Medical Center Groningen, Hanzeplein 1, HPC; DA 30, P.O. Box 30 001, 9700 RB, Groningen, The Netherlands.
- Department of Epidemiology, University Medical Center Groningen, Groningen, The Netherlands.
| | - Anne Petra Gerarda Crijns
- Department of Radiation Oncology, University Medical Center Groningen, Hanzeplein 1, HPC; DA 30, P.O. Box 30 001, 9700 RB, Groningen, The Netherlands
| | | | - Johanna Geertruida Maria van den Hoek
- Department of Radiation Oncology, University Medical Center Groningen, Hanzeplein 1, HPC; DA 30, P.O. Box 30 001, 9700 RB, Groningen, The Netherlands
| | - Hendrika Marike Boezen
- Department of Epidemiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Behrooz Ziad Alizadeh
- Department of Epidemiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Johannes Albertus Langendijk
- Department of Radiation Oncology, University Medical Center Groningen, Hanzeplein 1, HPC; DA 30, P.O. Box 30 001, 9700 RB, Groningen, The Netherlands.
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Dell'Oro M, Wilson P, Short M, Hua CH, Merchant TE, Bezak E. Normal tissue complication probability modeling to guide individual treatment planning in pediatric cranial proton and photon radiotherapy. Med Phys 2021; 49:742-755. [PMID: 34796509 DOI: 10.1002/mp.15360] [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: 07/05/2021] [Revised: 11/05/2021] [Accepted: 11/09/2021] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Proton therapy (PT) is broadly accepted as the gold standard of care for pediatric patients with cranial cancer. The superior dose distribution of PT compared to photon radiotherapy reduces normal tissue complication probability (NTCP) for organs at risk. As NTCPs for pediatric organs are not well understood, clinics generally base radiation response on adult data. However, there is evidence that radiation response strongly depends on the age and even sex of a patient. Furthermore, questions surround the influence of individual intrinsic radiosensitivity (α/β ratio) on pediatric NTCP. While the clinical pediatric NTCP data is scarce, radiobiological modeling and sensitivity analyses can be used to investigate the NTCP trends and its dependence on individual modeling parameters. The purpose of this study was to perform sensitivity analyses of NTCP models to ascertain the dependence of radiosensitivity, sex, and age of a child and predict cranial side-effects following intensity-modulated proton therapy (IMPT) and intensity-modulated radiotherapy (IMRT). METHODS Previously, six sex-matched pediatric cranial datasets (5, 9, and 13 years old) were planned in Varian Eclipse treatment planning system (13.7). Up to 108 scanning beam IMPT plans and 108 IMRT plans were retrospectively optimized for a range of simulated target volumes and locations. In this work, dose-volume histograms were extracted and imported into BioSuite Software for radiobiological modeling. Relative-Seriality and Lyman-Kutcher-Burman models were used to calculate NTCP values for toxicity endpoints, where TD50, (based on reported adult clinical data) was varied to simulate sex dependence of NTCP. Plausible parameter ranges, based on published literature for adults, were used in modeling. In addition to sensitivity analyses, a 20% difference in TD50 was used to represent the radiosensitivity between the sexes (with females considered more radiosensitive) for ease of data comparison as a function of parameters such as α/β ratio. RESULTS IMPT plans resulted in lower NTCP compared to IMRT across all models (p < 0.0001). For medulloblastoma treatment, the risk of brainstem necrosis (> 10%) and cochlea tinnitus (> 20%) among females could potentially be underestimated considering a lower TD50 value for females. Sensitivity analyses show that the difference in NTCP between sexes was significant (p < 0.0001). Similarly, both brainstem necrosis and cochlea tinnitus NTCP varied significantly (p < 0.0001) across tested α/β as a function of TD50 values (assumption being that TD50 values are 20% lower in females). If the true α/β of these pediatric tissues is higher than expected (α/β ∼ 3), the risk of tinnitus for IMRT can significantly increase (p < 0.0001). CONCLUSION Due to the scarcity of pediatric NTCP data available, sensitivity analyses were performed using plausible ranges based on published adult data. In the clinical scenario where, if female pediatric patients were 20% more radiosensitive (lower TD50 value), they could be up to twice as likely to experience side-effects of brainstem necrosis and cochlea tinnitus compared to males, highlighting the need for considering the sex in NTCP models. Based on our sensitivity analyses, age and sex of a pediatric patient could significantly affect the resultant NTCP from cranial radiotherapy, especially at higher α/β values.
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Affiliation(s)
- Mikaela Dell'Oro
- Cancer Research Institute, University of South Australia, Adelaide, Australia.,Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, Australia
| | - Puthenparampil Wilson
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, Australia.,UniSA STEM, University of South Australia, Adelaide, Australia
| | - Michala Short
- Cancer Research Institute, University of South Australia, Adelaide, Australia
| | - Chia-Ho Hua
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Thomas E Merchant
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Eva Bezak
- Cancer Research Institute, University of South Australia, Adelaide, Australia.,Department of Physics, University of Adelaide, Adelaide, Australia
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20
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Smyczynska U, Grabia S, Nowicka Z, Papis-Ubych A, Bibik R, Latusek T, Rutkowski T, Fijuth J, Fendler W, Tomasik B. Prediction of Radiation-Induced Hypothyroidism Using Radiomic Data Analysis Does Not Show Superiority over Standard Normal Tissue Complication Models. Cancers (Basel) 2021; 13:cancers13215584. [PMID: 34771747 PMCID: PMC8582656 DOI: 10.3390/cancers13215584] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/02/2021] [Accepted: 11/04/2021] [Indexed: 12/03/2022] Open
Abstract
Simple Summary Radiation-induced hypothyroidism (RIHT) commonly develops in cancer survivors that receive radiation therapy for cancers in the head and neck region. The state-of-art normal tissue complication probability (NTCP) models perform satisfactorily; however, they do not use the whole spectrum of information that can be obtained from imaging techniques. The radiomic approach offers the ability to efficiently mine features, which are imperceptible to the human eye, but may provide crucial data about the patient’s condition. We gathered CT images and clinical data from 98 patients undergoing radiotherapy for head and neck cancers, 27 of whom later developed RIHT. For them, we created machine-learning models to predict RIHT using automatically extracted radiomic features and appropriate clinical and dosimetric parameters. We also validated the well-established external state-of-art NTCP models on our datasets and observed that our radiomic-based models performed very similarly to them. This shows that automated tools may perform as well as the current standard but can be theoretically applied faster and be implemented into existing imaging software used when planning radiotherapy. Abstract State-of-art normal tissue complication probability (NTCP) models do not take into account more complex individual anatomical variations, which can be objectively quantitated and compared in radiomic analysis. The goal of this project was development of radiomic NTCP model for radiation-induced hypothyroidism (RIHT) using imaging biomarkers (radiomics). We gathered CT images and clinical data from 98 patients, who underwent intensity-modulated radiation therapy (IMRT) for head and neck cancers with a planned total dose of 70.0 Gy (33–35 fractions). During the 28-month (median) follow-up 27 patients (28%) developed RIHT. For each patient, we extracted 1316 radiomic features from original and transformed images using manually contoured thyroid masks. Creating models based on clinical, radiomic features or a combination thereof, we considered 3 variants of data preprocessing. Based on their performance metrics (sensitivity, specificity), we picked best models for each variant ((0.8, 0.96), (0.9, 0.93), (0.9, 0.89) variant-wise) and compared them with external NTCP models ((0.82, 0.88), (0.82, 0.88), (0.76, 0.91)). We showed that radiomic-based models did not outperform state-of-art NTCP models (p > 0.05). The potential benefit of radiomic-based approach is that it is dose-independent, and models can be used prior to treatment planning allowing faster selection of susceptible population.
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Affiliation(s)
- Urszula Smyczynska
- Department of Biostatistics and Translational Medicine, Medical University of Lodz, 92-215 Lodz, Poland; (U.S.); (S.G.); (Z.N.); (B.T.)
| | - Szymon Grabia
- Department of Biostatistics and Translational Medicine, Medical University of Lodz, 92-215 Lodz, Poland; (U.S.); (S.G.); (Z.N.); (B.T.)
| | - Zuzanna Nowicka
- Department of Biostatistics and Translational Medicine, Medical University of Lodz, 92-215 Lodz, Poland; (U.S.); (S.G.); (Z.N.); (B.T.)
| | - Anna Papis-Ubych
- Department of Radiotherapy, N. Copernicus Memorial Regional Specialist Hospital, 93-513 Lodz, Poland; (A.P.-U.); (J.F.)
| | - Robert Bibik
- Department of Radiation Oncology, Oncology Center of Radom, 26-600 Radom, Poland;
| | - Tomasz Latusek
- Radiotherapy Department, Maria Sklodowska-Curie National Research Institute of Oncology (MSCNRIO)—Branch in Gliwice, 44-101 Gliwice, Poland;
| | - Tomasz Rutkowski
- I Radiation and Clinical Oncology Department, Maria Sklodowska-Curie National Research Institute of Oncology (MSCNRIO)—Branch in Gliwice, 44-101 Gliwice, Poland;
| | - Jacek Fijuth
- Department of Radiotherapy, N. Copernicus Memorial Regional Specialist Hospital, 93-513 Lodz, Poland; (A.P.-U.); (J.F.)
- Department of Radiotherapy, Chair of Oncology, Medical University of Lodz, 93-509 Lodz, Poland
| | - Wojciech Fendler
- Department of Biostatistics and Translational Medicine, Medical University of Lodz, 92-215 Lodz, Poland; (U.S.); (S.G.); (Z.N.); (B.T.)
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA 02115, USA
- Correspondence:
| | - Bartlomiej Tomasik
- Department of Biostatistics and Translational Medicine, Medical University of Lodz, 92-215 Lodz, Poland; (U.S.); (S.G.); (Z.N.); (B.T.)
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA 02115, USA
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21
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Kanehira T, van Kranen S, Jansen T, Hamming-Vrieze O, Al-Mamgani A, Sonke JJ. Comparisons of normal tissue complication probability models derived from planned and delivered dose for head and neck cancer patients. Radiother Oncol 2021; 164:209-215. [PMID: 34619234 DOI: 10.1016/j.radonc.2021.09.015] [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: 05/07/2021] [Revised: 08/24/2021] [Accepted: 09/18/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND PURPOSE Normal tissue complication probability (NTCP) models are typically derived from the planned dose distribution, which can deviate from the delivered dose due to anatomical day-to-day variations. The aim of this study was to compare NTCP models derived from the planned and the delivered dose for head and neck cancer (HNC) patients. MATERIAL AND METHOD 322 HNC patients who received radiotherapy with daily CBCT guidance were included in this retrospective study. The delivered dose was estimated by deformably accumulating dose from daily CBCT to planning anatomy. We used a Lyman-Kutcher-Burman NTCP model, to relate the equivalent uniform dose (EUD) of organs at risk (OAR) with oral mucositis, xerostomia and dysphagia respectively. We compared the model parameters and performances. RESULTS The median differences between planned and delivered EUD to the OARs were significantly larger for patients with toxicity than without for acute dysphagia (≥G2 and ≥G3) and late dysphagia (≥G3) (p < 0.05). Those differences resulted in small differences in steepness and agreement to the data between delivered- and planned-fitted NTCP curves, and the differences were not significant. The differences in AUC were less than 0.01. CONCLUSION Differences between delivered and planned dose did not lead to significant differences in NTCP curves. The additional clinical relevance of NTCP models using accumulated dose for oral mucositis, xerostomia and dysphagia in HNC radiotherapy is likely to be limited.
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Affiliation(s)
- Takahiro Kanehira
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Simon van Kranen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Tomas Jansen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Olga Hamming-Vrieze
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Abrahim Al-Mamgani
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
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22
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Corbeau A, Kuipers SC, de Boer SM, Horeweg N, Hoogeman MS, Godart J, Nout RA. Correlations between bone marrow radiation dose and hematologic toxicity in locally advanced cervical cancer patients receiving chemoradiation with cisplatin: a systematic review. Radiother Oncol 2021; 164:128-137. [PMID: 34560187 DOI: 10.1016/j.radonc.2021.09.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/10/2021] [Accepted: 09/13/2021] [Indexed: 10/20/2022]
Abstract
Patients with locally advanced cervical cancer (LACC) treated with chemoradiation often experience hematologic toxicity (HT), as chemoradiation can induce bone marrow (BM) suppression. Studies on the relationship between BM dosimetric parameters and clinically significant HT might provide relevant indices for developing BM sparing (BMS) radiotherapy techniques. This systematic review studied the relationship between BM dose and HT in patients with LACC treated with primary cisplatin-based chemoradiation. A systematic search was conducted in Embase, Medline, and Web of Science. Eligibility criteria were treatment of LACC-patients with cisplatin-based chemoradiation and report of HT or complete blood cell count (CBC). The search identified 1346 papers, which were screened on title and abstract before two reviewers independently evaluated the full-text. 17 articles were included and scored according to a selection of the TRIPOD criteria. The mean TRIPOD score was 12.1 out of 29. Fourteen studies defining BM as the whole pelvic bone contour (PB) detected significant associations with V10 (3/14), V20 (6/14), and V40 (4/11). Recommended cut-off values were V10 > 95-75%, V20 > 80-65%, and V40 > 37-28%. The studies using lower density marrow spaces (PBM) or active bone marrow (ABM) as a proxy for BM only found limited associations with HT. Our study was the first literature review providing an overview of articles evaluating the correlation between BM and HT for patients with LACC undergoing cisplatin-based chemoradiation. There is a scarcity of studies independently validating developed prediction models between BM dose and HT. Future studies may use PB contouring to develop normal tissue complication probability models.
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Affiliation(s)
- Anouk Corbeau
- Department of Radiotherapy, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Sander C Kuipers
- Department of Radiotherapy, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Stephanie M de Boer
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Nanda Horeweg
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Mischa S Hoogeman
- Department of Radiotherapy, Erasmus MC Cancer Institute, Rotterdam, The Netherlands; HollandPTC, Delft, The Netherlands
| | - Jérémy Godart
- Department of Radiotherapy, Erasmus MC Cancer Institute, Rotterdam, The Netherlands; HollandPTC, Delft, The Netherlands
| | - Remi A Nout
- Department of Radiotherapy, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
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23
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Yang K, Xie W, Zhang X, Wang Y, Shou A, Wang Q, Tian J, Yang J, Li G. A nomogram for predicting late radiation-induced xerostomia among locoregionally advanced nasopharyngeal carcinoma in intensity modulated radiation therapy era. Aging (Albany NY) 2021; 13:18645-18657. [PMID: 34282056 PMCID: PMC8351700 DOI: 10.18632/aging.203308] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 06/29/2021] [Indexed: 02/05/2023]
Abstract
Background: Dry mouth sensation cannot be improved completely even though parotids are spared correctly. Our purpose is to develop a nomogram to predict the moderate-to-severe late radiation xerostomia for patients with locoregionally advanced nasopharyngeal carcinoma (LA-NPC) in intensity modulated radiation therapy (IMRT) / volumetric modulated arc radiotherapy (VMAT) era. Methods: A dataset of 311 patients was retrospectively collected between January 2010 and February 2013. The binary logistic regression was to estimate each factor’s prognostic value for development of moderate-to-severe patient-reported xerostomia at least 2 years (Xer2y) after completion of radiotherapy. Therefore, we can develop a nomogram according to binary logistic regression coefficients. This novel model was validated by bootstrapping analyses. Results: Contralateral Parotid mean dose (coMD<24.4Gy), VMAT (yes), and platinum-based concurrent chemoradiotherapy (no) were significantly related to patient-reported xerostomia at least 2 years (Xer2y) (all p < 0.001), and were included in the nomogram. Receiver operating characteristic (ROC) analysis revealed AUC (area under the ROC curve) with the value of 0.811 (0.710-0.912) of the nomogram, which was significantly higher than coMD 0.698 (0.560-0.840) from QUANTEC2010 (p<0.001). Calibration plots illustrated that the predicted Xer2y was close to the actual observation, and decision curve analyses (DCA) indicated valid positive net benefits. Conclusion: We developed a feasible nomogram to predict patient-rated Xer2y based on comprehensive individual data in patients with LA-NPC in the real world. The proposed model is able to facilitate the development of treatment plan and quality of life improvement.
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Affiliation(s)
- Kaixuan Yang
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China.,Department of Radiation Oncology, West China Second University Hospital and Key Laboratory of Obstetrics and Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Wenji Xie
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Xiangbin Zhang
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Yu Wang
- West China School of Medicine, Sichuan University, Chengdu 610041, Sichuan, China
| | - Arthur Shou
- School of Basic Medical Sciences and Forensic Medicine, Sichuan University, Chengdu 610041, Sichuan, China
| | - Qiang Wang
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Jiangfang Tian
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Jiangping Yang
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Guangjun Li
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
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24
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Bridhikitti J, Viehman JK, Harmsen WS, Amundson AC, Shiraishi S, Mundy DW, Rwigema JCM, McGee LA, Patel SH, Routman DM, Lester SC, Neben-Wittich MA, Garces YI, Ma DJ, Foote RL. Oncologic Outcomes for Head and Neck Skin Malignancies Treated with Protons. Int J Part Ther 2021; 8:294-303. [PMID: 34285955 PMCID: PMC8270091 DOI: 10.14338/ijpt-20-00045.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 02/12/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose Radiation therapy (RT) is the standard treatment for patients with inoperable skin malignancies of the head and neck region (H&N), and as adjuvant treatment post surgery in patients at high risk for local or regional recurrence. This study reports clinical outcomes of intensity-modulated proton therapy (IMPT) for these malignancies. Materials and Methods We retrospectively reviewed cases involving 47 patients with H&N malignancies of the skin (squamous cell, basal cell, melanoma, Merkel cell, angiosarcoma, other) who underwent IMPT for curative intent between July 2016 and July 2019. Overall survival was estimated via Kaplan-Meier analysis, and oncologic outcomes were reported as cumulative incidence with death as a competing risk. Results The 2-year estimated local recurrence rate, regional recurrence rate, local regional recurrence rate, distant metastasis rate, and overall survival were 11.1% (95% confidence interval [CI], 4.1%-30.3%), 4.4% (95% CI, 1.1%-17.4%), 15.5% (95% CI, 7%-34.3%), 23.4% (95% CI, 5.8%-95.5%), and 87.2% (95% CI, 75.7%-100%), respectively. No patient was reported to have a grade 3 or higher adverse event during the last week of treatment or at the 3-month follow-up visit. Conclusion IMPT is safe and effective in the treatment of skin malignancies of the H&N.
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Affiliation(s)
| | - Jason K Viehman
- Division of Biomedical Statistics & Informatics, Mayo Clinic, Rochester, MN, USA
| | - W Scott Harmsen
- Department of Biostatistics and Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Adam C Amundson
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Satomi Shiraishi
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Daniel W Mundy
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Samir H Patel
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - David M Routman
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Scott C Lester
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Yolanda I Garces
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Daniel J Ma
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
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25
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Guo H, Wang J, Xia X, Zhong Y, Peng J, Zhang Z, Hu W. The dosimetric impact of deep learning-based auto-segmentation of organs at risk on nasopharyngeal and rectal cancer. Radiat Oncol 2021; 16:113. [PMID: 34162410 PMCID: PMC8220801 DOI: 10.1186/s13014-021-01837-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 06/10/2021] [Indexed: 12/25/2022] Open
Abstract
Purpose To investigate the dosimetric impact of deep learning-based auto-segmentation of organs at risk (OARs) on nasopharyngeal and rectal cancer. Methods and materials Twenty patients, including ten nasopharyngeal carcinoma (NPC) patients and ten rectal cancer patients, who received radiotherapy in our department were enrolled in this study. Two deep learning-based auto-segmentation systems, including an in-house developed system (FD) and a commercial product (UIH), were used to generate two auto-segmented OARs sets (OAR_FD and OAR_UIH). Treatment plans based on auto-segmented OARs and following our clinical requirements were generated for each patient on each OARs sets (Plan_FD and Plan_UIH). Geometric metrics (Hausdorff distance (HD), mean distance to agreement (MDA), the Dice similarity coefficient (DICE) and the Jaccard index) were calculated for geometric evaluation. The dosimetric impact was evaluated by comparing Plan_FD and Plan_UIH to original clinically approved plans (Plan_Manual) with dose-volume metrics and 3D gamma analysis. Spearman’s correlation analysis was performed to investigate the correlation between dosimetric difference and geometric metrics. Results FD and UIH could provide similar geometric performance in parotids, temporal lobes, lens, and eyes (DICE, p > 0.05). OAR_FD had better geometric performance in the optic nerves, oral cavity, larynx, and femoral heads (DICE, p < 0.05). OAR_UIH had better geometric performance in the bladder (DICE, p < 0.05). In dosimetric analysis, both Plan_FD and Plan_UIH had nonsignificant dosimetric differences compared to Plan_Manual for most PTV and OARs dose-volume metrics. The only significant dosimetric difference was the max dose of the left temporal lobe for Plan_FD vs. Plan_Manual (p = 0.05). Only one significant correlation was found between the mean dose of the femoral head and its HD index (R = 0.4, p = 0.01), there is no OARs showed strong correlation between its dosimetric difference and all of four geometric metrics. Conclusions Deep learning-based OARs auto-segmentation for NPC and rectal cancer has a nonsignificant impact on most PTV and OARs dose-volume metrics. Correlations between the auto-segmentation geometric metric and dosimetric difference were not observed for most OARs. Supplementary Information The online version contains supplementary material available at 10.1186/s13014-021-01837-y.
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Affiliation(s)
- Hongbo Guo
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China.,Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Jiazhou Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China.,Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Xiang Xia
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China.,Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Yang Zhong
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China.,Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Jiayuan Peng
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China.,Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Zhen Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China. .,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China. .,Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China.
| | - Weigang Hu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China. .,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China.
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26
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Sharabiani M, Clementel E, Andratschke N, Collette L, Fortpied C, Grégoire V, Overgaard J, Willmann J, Hurkmans C. Independent external validation using the EORTC HNCG-ROG 1219 DAHANCA trial data of NTCP models for acute oral mucositis. Radiother Oncol 2021; 161:35-39. [PMID: 33872641 DOI: 10.1016/j.radonc.2021.04.006] [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: 09/02/2020] [Revised: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 11/15/2022]
Abstract
PURPOSE To externally validate previously published Normal Tissue Complication Probability (NTCP) models developed by separate teams for grade 3 oral mucositis (g3OM). MATERIALS AND METHODS Two models were validated: a logistic model, based on 144 head and neck cancer (HNC) patients receiving induction chemotherapy followed by chemo-IMRT; a multivariable logistic model for prediction of g3OM for 253 patients receiving radical treatment for the head and neck squamous cell carcinoma (HNSCC). The EORTC HNCG-ROG 1219 DAHANCA trial dataset, consisting of 169 patients was used as the validation cohort. This cohort was treated with accelerated fractionated chemo-IMRT, with/without the hypoxic radiosensitizer Nimorazole for HNSCC. External validity was assessed using the scaled Brier score. Calibration was assessed in terms of calibration curves as well as measures of mean and weak calibration. Hosmer-Lemeshow was used for goodness-of-fit test. Discrimination was calculated using the area under the receiver operating curve (AUC-ROC). RESULTS The prevalence of g3OM in the validation cohort (35.5%) was similar to that of two development cohorts, i.e. 38.7% and 31.9% for Bhide logistic and Otter multivariable logistic models respectively. The scaled Brier scores showed good overall model performance. Perfect calibration was observed in the prevalence range of 20% to 40%. AUC-ROC was acceptable in external validation (0.67). The Hosmer-Lemeshow test showed good agreement between predicted and observed outcomes for two models. CONCLUSION The NTCP models were validated and lead to valid predictions in a wide range of diverse treatment techniques and patient characteristics, also when Nimorazole is added as hypoxic radiosensitizer.
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Affiliation(s)
| | | | - N Andratschke
- Department of Radiation Oncology, University Hospital Zürich, University of Zurich, Switzerland
| | - L Collette
- Department of Biostatistics, International Drug Development Institute, Louvain-la-Neuve, Belgium
| | | | - V Grégoire
- Radiation Oncology Department, Léon Bérard Cancer Center, Lyon, France
| | - J Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
| | - J Willmann
- Department of Radiation Oncology, University Hospital Zürich, University of Zurich, Switzerland
| | - C Hurkmans
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
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Brodin NP, Kabarriti R, Schechter CB, Pankuch M, Gondi V, Kalnicki S, Garg MK, Tomé WA. Individualized quality of life benefit and cost-effectiveness estimates of proton therapy for patients with oropharyngeal cancer. Radiat Oncol 2021; 16:19. [PMID: 33478544 PMCID: PMC7819210 DOI: 10.1186/s13014-021-01745-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 01/02/2021] [Indexed: 11/16/2022] Open
Abstract
Background Proton therapy is a promising advancement in radiation oncology especially in terms of reducing normal tissue toxicity, although it is currently expensive and of limited availability. Here we estimated the individual quality of life benefit and cost-effectiveness of proton therapy in patients with oropharyngeal cancer treated with definitive radiation therapy (RT), as a decision-making tool for treatment individualization.
Methods and materials Normal tissue complication probability models were used to estimate the risk of dysphagia, esophagitis, hypothyroidism, xerostomia and oral mucositis for 33 patients, comparing delivered photon intensity-modulated RT (IMRT) plans to intensity-modulated proton therapy (IMPT) plans. Quality-adjusted life years (QALYs) lost were calculated for each complication while accounting for patient-specific conditional survival probability and assigning quality-adjustment factors based on complication severity. Cost-effectiveness was modeled based on upfront costs of IMPT and IMRT, and the cost of acute and/or long-term management of treatment complications. Uncertainties in all model parameters and sensitivity analyses were included through Monte Carlo sampling.
Results The incremental cost-effectiveness ratios (ICERs) showed considerable variability in the cost of QALYs spared between patients, with median $361,405/QALY for all patients, varying from $54,477/QALY to $1,508,845/QALY between individual patients. Proton therapy was more likely to be cost-effective for patients with p16-positive tumors ($234,201/QALY), compared to p16-negative tumors ($516,297/QALY). For patients with p16-positive tumors treated with comprehensive nodal irradiation, proton therapy is estimated to be cost-effective in ≥ 50% of sampled cases for 8/9 patients at $500,000/QALY, compared to 6/24 patients who either have p16-negative tumors or receive unilateral neck irradiation. Conclusions Proton therapy cost-effectiveness varies greatly among oropharyngeal cancer patients, and highlights the importance of individualized decision-making. Although the upfront cost, societal willingness to pay and healthcare administration can vary greatly among different countries, identifying patients for whom proton therapy will have the greatest benefit can optimize resource allocation and inform prospective clinical trial design.
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Affiliation(s)
- N Patrik Brodin
- Institute for Onco-Physics, Albert Einstein College of Medicine, Bronx, NY, 10461, USA. .,Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, 10461, USA.
| | - Rafi Kabarriti
- Institute for Onco-Physics, Albert Einstein College of Medicine, Bronx, NY, 10461, USA.,Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, 10461, USA
| | - Clyde B Schechter
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, 10461, USA
| | - Mark Pankuch
- Northwestern Medicine Chicago Proton Center, Warrenville, IL, 60555, USA
| | - Vinai Gondi
- Northwestern Medicine Chicago Proton Center, Warrenville, IL, 60555, USA
| | - Shalom Kalnicki
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, 10461, USA.,Department of Urology, Montefiore Medical Center, Bronx, NY, 10461, USA
| | - Madhur K Garg
- Institute for Onco-Physics, Albert Einstein College of Medicine, Bronx, NY, 10461, USA.,Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, 10461, USA.,Department of Otorhinolaryngology - Head and Neck Surgery, Montefiore Medical Center, Bronx, NY, 10461, USA.,Department of Urology, Montefiore Medical Center, Bronx, NY, 10461, USA
| | - Wolfgang A Tomé
- Institute for Onco-Physics, Albert Einstein College of Medicine, Bronx, NY, 10461, USA. .,Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, 10461, USA. .,Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, 10461, USA.
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Mesbahi A, Alizade-Harakiyan M, Jangjoo A, Jafari-Koshki T, Fatemi A. Radiobiological modeling of acute esophagitis after radiation therapy of head, neck, and thorax tumors: The influence of chemo-radiation. J Cancer Res Ther 2021; 18:1706-1715. [DOI: 10.4103/jcrt.jcrt_271_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Akbaba S, Bostel T, Lang K, Bahadir S, Lipman D, Schmidberger H, Matthias C, Rotter N, Knopf A, Freudlsperger C, Plinkert P, Debus J, Adeberg S. Large German Multicenter Experience on the Treatment Outcome of 207 Patients With Adenoid Cystic Carcinoma of the Major Salivary Glands. Front Oncol 2020; 10:593379. [PMID: 33262950 PMCID: PMC7686540 DOI: 10.3389/fonc.2020.593379] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 10/19/2020] [Indexed: 11/13/2022] Open
Abstract
Introdution We aimed to evaluate treatment outcome of combined radiotherapy (RT) including photon intensity modulated radiotherapy (IMRT) and carbon ion boost for adenoid cystic carcinomas (ACCs) of the major salivary glands, the currently available largest German collective for this cohort. Materials and Methods Overall, 207 patients who were irradiated with combined RT between 2009 and 2019 at Heidelberg University Hospital were analyzed retrospectively for local control (LC), progression-free survival (PFS) and overall survival (OS) using Kaplan-Meier estimates. The majority of patients received postoperative RT (n=176/207, 85%) after previous surgery in large German hospitals mainly Mainz, Freiburg, Mannheim and Heidelberg University Hospitals and 15% received primary RT (n=31/207). Results After a median follow-up time of 50 months, 84% of the patients were still alive (n=174/207). Disease progression occurred in 32% of the patients (n=66/207) while local recurrence was diagnosed in 12% (n=25/207), and distant relapse in 27% (n=56/207). Estimated 5-year LC, PFS and OS rates were 84%, 56% and 83% for OS, respectively. In multivariate analysis, we could identify two prognostic subgroups: one subgroup resulting in decreased LC, PFS and OS rates and another subgroup having an additional survival disadvantage in PFS and OS. Patients with a macroscopic tumor disease (yes vs. no; p<0.001 for LC, p=0.010 for PFS and p=0.040 for OS) treated in a definitive setting (vs. postoperative setting; p=0.001 for LC, p=0.006 for PFS, p=0.049 for OS) and tumors of upper T stage (T1-4; p=0.004 for LC, p<0.001 for PFS, p<0.001 for OS) showed significantly more local relapses and a decreased PFS and OS. Upper Age (p<0.001 for both PFS and OS), lower Karnofsky Performance Score (<80% vs. ≥80%; p<0.001 for both PFS and OS) and solid histology (vs. non-solid; p=0.049 for PFS and p=0.003 for OS) were in addition associated with worse survival outcome. Toxicity was moderate with 18% late grade 2 and 3 toxicity. Conclusions Combined RT results in superior LC rates compared to photon data with moderate toxicity. In multivariate analysis, upper T stage, the existence of a macroscopic tumor before RT and definitive RT setting were identified as major prognostic factors affecting LC negatively.
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Affiliation(s)
- Sati Akbaba
- Department of Radiation Oncology, University Medical Center Mainz, Mainz, Germany.,Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - Tilman Bostel
- Department of Radiation Oncology, University Medical Center Mainz, Mainz, Germany
| | - Kristin Lang
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - Suzan Bahadir
- Department of Radiology, University Hospital Heidelberg, Heidelberg, Germany.,Department of Radiology, Koru Hospitals-Yuksek Ihtisas University, Ankara, Turkey
| | - Djoeri Lipman
- Department of Radiation Oncology, Isala Hospital Zwolle, Zwolle, Netherlands
| | - Heinz Schmidberger
- Department of Radiation Oncology, University Medical Center Mainz, Mainz, Germany
| | - Christoph Matthias
- Department of Laryngology and Head and Neck Surgery, University Medical Center Mainz, Mainz, Germany
| | - Nicole Rotter
- Department of Laryngology and Head and Neck Surgery, University Hospital Mannheim, Mannheim, Germany
| | - Andreas Knopf
- Department of Laryngology and Head and Neck Surgery, University Hospital Freiburg, Freiburg im Breisgau, Germany
| | - Christian Freudlsperger
- Department of Oral and Maxillofacial Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter Plinkert
- Department of Laryngology and Head and Neck Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Juergen Debus
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - Sebastian Adeberg
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
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Radiation-Induced Hypothyroidism in Patients with Oropharyngeal Cancer Treated with IMRT: Independent and External Validation of Five Normal Tissue Complication Probability Models. Cancers (Basel) 2020; 12:cancers12092716. [PMID: 32971838 PMCID: PMC7563778 DOI: 10.3390/cancers12092716] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/12/2020] [Accepted: 09/19/2020] [Indexed: 01/07/2023] Open
Abstract
Simple Summary Hypothyroidism is a common complication of therapeutic irradiation in the neck area. Several dose-response models have been proposed to predict its’ occurrence based on clinical and radiomic features. We aimed to externally validate the results of five such models in a prospectively recruited cohort of 108 patients with oropharyngeal cancer. Two of the evaluated models, published by Rønjom et al. and by Boomsma et al., had satisfactory performance. Both models are based on mean thyroid dose and thyroid volume. Three remaining models, by Cella et al., Bakhshandeh et al. and Vogelius et al., performed significantly worse. Short-term change in the level of thyroid-stimulating hormone (TSH) after radiation therapy was not indicative of hypothyroidism development in long term. We conclude that the models by Rønjom et al. and by Boomsma et al. are feasible for long-term prediction of hypothyroidism in oropharyngeal cancer survivors treated with intensity-modulated radiation therapy. Abstract We aimed to externally validate five normal tissue complication probability (NTCP) models for radiation-induced hypothyroidism (RIHT) in a prospectively recruited cohort of 108 patients with oropharyngeal cancer (OPC). NTCP scores were calculated using original published formulas. Plasma thyrotropin (TSH) level was additionally assessed in the short-term after RT. After a median of 28 months of follow-up, thirty one (28.7%) patients developed RIHT. Thyroid mean dose and thyroid volume were significant predictors of RIHT: odds ratio equal to 1.11 (95% CI 1.03–1.19) for mean thyroid dose and 0.87 (95%CI 0.81–0.93) for thyroid volume in univariate analyses. Two of the evaluated NTCP models, published by Rønjom et al. and by Boomsma et al., had satisfactory performance with accuracies of 0.87 (95%CI 0.79–0.93) and 0.84 (95%CI: 0.76–0.91), respectively. Three remaining models, by Cella et al., Bakhshandeh et al. and Vogelius et al., performed significantly worse, overestimating the risk of RIHT in this patient cohort. A short-term TSH level change relative to baseline was not indicative of RIHT development in the follow-up (OR 0.96, 95%CI: 0.65–1.42, p = 0.825). In conclusion, the models by Rønjom et al. and by Boomsma et al. demonstrated external validity and feasibility for long-term prediction of RIHT in survivors of OPC treated with Intensity-Modulated Radiation Therapy (IMRT).
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Tseng M, Ho F, Leong YH, Wong LC, Tham IW, Cheo T, Lee AW. Emerging radiotherapy technologies and trends in nasopharyngeal cancer. Cancer Commun (Lond) 2020; 40:395-405. [PMID: 32745354 PMCID: PMC7494066 DOI: 10.1002/cac2.12082] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 07/14/2020] [Indexed: 12/19/2022] Open
Abstract
Technology has always driven advances in radiotherapy treatment. In this review, we describe the main technological advances in radiotherapy over the past decades for the treatment of nasopharyngeal cancer (NPC) and highlight some of the pressing issues and challenges that remain. We aim to identify emerging trends in radiation medicine. These include advances in personalized medicine and advanced imaging modalities, standardization of planning and delineation, assessment of treatment response and adaptive re‐planning, impact of particle therapy, and role of artificial intelligence or automation in clinical care. In conclusion, we expect significant improvement in the therapeutic ratio of radiotherapy treatment for NPC over the next decade.
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Affiliation(s)
- Michelle Tseng
- Radiation Oncology Centre, Mt Elizabeth Novena Hospital, Singapore, 329563, Singapore
| | - Francis Ho
- Radiation Oncology Centre, Mt Elizabeth Novena Hospital, Singapore, 329563, Singapore
| | - Yiat Horng Leong
- Radiation Oncology Centre, Mt Elizabeth Novena Hospital, Singapore, 329563, Singapore
| | - Lea Choung Wong
- Radiation Oncology Centre, Mt Elizabeth Novena Hospital, Singapore, 329563, Singapore
| | - Ivan Wk Tham
- Radiation Oncology Centre, Mt Elizabeth Novena Hospital, Singapore, 329563, Singapore
| | - Timothy Cheo
- Radiation Oncology Centre, Mt Elizabeth Novena Hospital, Singapore, 329563, Singapore
| | - Anne Wm Lee
- Department of Clinical Oncology, the University of Hong Kong-Shenzhen Hospital, the University of Hong Kong, Hong Kong, 999077, P. R. China
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Jain V, Niezink AGH, Frick M, Doucette A, Mendes A, Simone CB, Langendijk JA, Wijsman R, Feigenberg SJ, Levin W, Cengel KA, van der Schaaf A, Berman AT. Updating Photon-Based Normal Tissue Complication Probability Models for Pneumonitis in Patients With Lung Cancer Treated With Proton Beam Therapy. Pract Radiat Oncol 2020; 10:e330-e338. [PMID: 32416270 DOI: 10.1016/j.prro.2020.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 04/14/2020] [Accepted: 04/28/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE No validated models for predicting the risk of radiation pneumonitis (RP) with proton beam therapy (PBT) currently exist. Our goal was to externally validate and recalibrate multiple established photon-based normal tissue complication probability models for RP in a cohort with locally advanced nonsmall cell lung cancer treated with contemporary doses of chemoradiation using PBT. METHODS AND MATERIALS The external validation cohort consisted of 99 consecutive patients with locally advanced nonsmall cell lung cancer treated with chemoradiation using PBT. RP was retrospectively scored at 3 and 6 months posttreatment. We evaluated the performance of the photon Quantitative Analyses of Normal Tissue Effects in the Clinic (QUANTEC) pneumonitis model, the QUANTEC model adjusted for clinical risk factors, and the newer Netherlands updated QUANTEC model. A closed testing procedure was performed to test the need for model updating, either by recalibration-in-the-large (re-estimation of intercept), recalibration (re-estimation of intercept/slope), or model revision (re-estimation of all coefficients). RESULTS There were 21 events (21%) of ≥grade 2 RP. The closed testing procedure on the PBT data set did not detect major deviations between the models and the data and recommended adjustment of the intercept only for the photon-based Netherlands updated QUANTEC model (intercept update: -1.2). However, an update of the slope and revision of the model coefficients were not recommended by the closed testing procedure, as the deviations were not significant within the power of the data. CONCLUSIONS The similarity between the dose-response relationship for PBT and photons for normal tissue complications has been an assumption until now. We demonstrate that the preexisting, widely used photon based models fit our PBT data well with minor modifications. These now-validated and updated normal tissue complication probability models can aid in individualizing selection of the most optimal treatment technique for a particular patient.
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Affiliation(s)
- Varsha Jain
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anne G H Niezink
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Melissa Frick
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Abigail Doucette
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amberly Mendes
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Johannes A Langendijk
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robin Wijsman
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Steven J Feigenberg
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - William Levin
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Keith A Cengel
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Arjen van der Schaaf
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Abigail T Berman
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
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Generalizability assessment of head and neck cancer NTCP models based on the TRIPOD criteria. Radiother Oncol 2020; 146:143-150. [DOI: 10.1016/j.radonc.2020.02.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 02/06/2020] [Accepted: 02/17/2020] [Indexed: 12/23/2022]
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Three-Dimensional Printed Silicone Bite Blocks for Radiotherapy of Head and Neck Cancer—A Preliminary Study. APPLIED SCIENCES-BASEL 2020. [DOI: 10.3390/app10051688] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Conventional methods that have been developed to immobilize the mouth and tongue for radiotherapy (RT) in head and neck cancer (HNC) treatment have been unsatisfactory. We, therefore, developed three-dimensional (3D), customizable, silicone bite blocks and examined their clinical feasibility. For HNC patients, before RT, the 3D printed bite blocks were fabricated based on primary computed tomography (CT) simulation images. The placement of the 3D bite blocks was followed by a secondary CT simulation before RT planning was finalized. Dosimetric parameters and positioning verification achieved with the propose bite blocks were compared with conventional universal oral corks. The 3D printed bite blocks were conformal to the occlusal surface, ensuring immobilization of the tongue without eliciting a gag reflex, and an elastic and firm texture that supports opening of the mouth, with a smooth surface with tolerable intraoral tactility. The dosimetry of patients using the proposed bite blocks showed better coverage of the planning target volume and surface of a tumour bed along with reduction in normal tissue doses. Good concordance of positioning by 3D printed bite blocks during the RT course was verified. The 3D printed bite blocks with silicone might be a customizable, safe, and practical advanced technology in RT for HNC.
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Montaseri G, Alfonso JCL, Hatzikirou H, Meyer-Hermann M. A minimal modeling framework of radiation and immune system synergy to assist radiotherapy planning. J Theor Biol 2020; 486:110099. [PMID: 31790681 DOI: 10.1016/j.jtbi.2019.110099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 10/15/2019] [Accepted: 11/28/2019] [Indexed: 02/07/2023]
Abstract
Recent evidence indicates the ability of radiotherapy to induce local and systemic tumor-specific immune responses as a result of immunogenic cell death. However, fractionation regimes routinely used in clinical practice typically ignore the synergy between radiation and the immune system, and instead attempt to completely eradicate tumors by the direct lethal effect of radiation on cancer cells. This paradigm is expected to change in the near future due to the potential benefits of considering radiation-induced antitumor immunity during treatment planning. Towards this goal, we propose a minimal modeling framework based on key aspects of the tumor-immune system interplay to simulate the effects of radiation on tumors and the immunological consequences of radiotherapy. The impacts of tumor-associated vasculature and intratumoral oxygen-mediated heterogeneity on treatment outcomes are ininvestigated. The model provides estimates of the minimum radiation doses required for tumor eradication given a certain number of treatment fractions. Moreover, estimates of treatment duration for disease control given predetermined fractional radiation doses can be also obtained. Although theoretical in nature, this study motivates the development and establishment of immune-based decision-support tools in radiotherapy planning.
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Affiliation(s)
- Ghazal Montaseri
- Department of Systems Immunology and Braunschweig Integrated Centre of Systems Biology, Helmholtz Centre for Infection Research, Braunschweig, Germany; Centre for Individualised Infection Medicine (CIIM), Hannover, Germany
| | - Juan Carlos López Alfonso
- Department of Systems Immunology and Braunschweig Integrated Centre of Systems Biology, Helmholtz Centre for Infection Research, Braunschweig, Germany; Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.
| | - Haralampos Hatzikirou
- Department of Systems Immunology and Braunschweig Integrated Centre of Systems Biology, Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Michael Meyer-Hermann
- Department of Systems Immunology and Braunschweig Integrated Centre of Systems Biology, Helmholtz Centre for Infection Research, Braunschweig, Germany; Centre for Individualised Infection Medicine (CIIM), Hannover, Germany; Institute of Biochemistry, Biotechnology and Bioinformatics, Technische Universität Braunschweig, Germany.
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Treatment Outcome of 227 Patients with Sinonasal Adenoid Cystic Carcinoma (ACC) after Intensity Modulated Radiotherapy and Active Raster-Scanning Carbon Ion Boost: A 10-Year Single-Center Experience. Cancers (Basel) 2019; 11:cancers11111705. [PMID: 31683896 PMCID: PMC6895865 DOI: 10.3390/cancers11111705] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 10/28/2019] [Accepted: 10/29/2019] [Indexed: 01/25/2023] Open
Abstract
We aimed to evaluate the treatment outcome of primary and postoperative bimodal radiotherapy (RT) including intensity modulated photon radiotherapy (IMRT) and carbon ion radiotherapy (CIRT) for sinonasal adenoid cystic carcinoma (ACC) patients. Medical records of 227 consecutive patients who received either a primary (n = 90, 40%) or postoperative (n = 137, 60%; R2, n = 86, 63%) IMRT with doses between 48 and 56 Gy in 1.8 or 2 Gy fractions and active raster-scanning carbon ion boost with 18 to 24 Gy (RBE, relative biological effectiveness) in 3 Gy (RBE) fractions between 2009 and 2019 up to a median total dose of 80 Gy (EQD2, equivalent dose in 2 Gy single dose fractions, range 71–80 Gy) were reviewed. Results: Median follow-up was 50 months. In univariate and multivariate analysis, no significant difference in local control (LC) could be shown between the two treatment groups (p = 0.33). Corresponding 3-year LC rates were 79% for primary bimodal RT and 82% for postoperative bimodal RT, respectively. T4 stage (p = 0.002) and solid histology (p = 0.005) were identified as independent prognostic factors for decreased LC. Significant worse long-term treatment tolerance was observed for postoperatively irradiated patients with 17% vs. 6% late grade 3 toxicity (p < 0.001). Primary radiotherapy including IMRT and carbon ion boost for dose-escalation results in adequate LC with less long-term grade 3 toxicity compared to postoperative bimodal radiotherapy in sinonasal ACC patients. The high rate of macroscopic tumor disease in the postoperative group makes the interpretation of the beneficial results in LC for primary RT difficult.
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Akbaba S, Mock A, Hoerner-Rieber J, Held T, Katayama S, Forster T, Freudlsperger C, Rieken S, Herfarth K, Plinkert P, Debus J, Adeberg S. Treatment Outcome of a Combined Dose-Escalated Treatment Regime With Helical TomoTherapy® and Active Raster-Scanning Carbon Ion Boost for Adenocarcinomas of the Head and Neck. Front Oncol 2019; 9:755. [PMID: 31475108 PMCID: PMC6705231 DOI: 10.3389/fonc.2019.00755] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 07/26/2019] [Indexed: 12/25/2022] Open
Abstract
Introduction: Data regarding treatment and survival outcome of patients with adenocarcinoma of the head and neck are limited to case reports and case series. As a consequence of lacking evidence, treatment guidelines do not exist. We aimed to analyze the effect of a bimodal irradiation regime with intensity modulated radiotherapy (IMRT) and carbon ion boost on local control (LC) and survival in adenocarcinoma patients for a large patient collective. Materials and Methods: Patient records of eighty consecutive patients treated between 2009 and 2018 were analyzed retrospectively and Kaplan-Meier estimates for LC, overall survival (OS) and progression-free survival (PFS) were compared among patients with salivary gland adenocarcinoma (SGAC), salivary duct adenocarcinoma (SDAC), and intestinal-type adenocarcinoma (ITAC) according to the World Health Organization (WHO). Prognostic factors were identified using the log-rank test and cox-regression modeling. Toxicity was assessed according to the Common Terminology Criteria for Adverse Events (CTCAE). Results: Median follow-up was 41 months. The 3-year and estimated 5-year Kaplan-Meier rates for all patients were 83 and 75% for LC, 74 and 50% for OS and 60 and 53% for PFS, respectively. While bimodal RT for ITAC resulted in a significantly decreased 3-year LC rate of 50 vs. 93% for each SGAC and SDAC (p < 0.01), no statistical significant survival differences could be identified across the three groups regarding OS (p = 0.08) and PFS (p = 0.063). 3-year OS was 88% for SGAC, 78% for SDAC and 67% for ITAC and 3-year PFS was 72% for SGAC, 53% for SDAC and 44% for ITAC, respectively. Nevertheless, in subgroup analysis, OS for ITAC was significantly worse compared to SGAC (p = 0.024). In multivariate analysis, bilateral tumor side (vs. unilateral) solely could be identified as independent negative prognostic factor for LC (p < 0.01). Treatment was well-tolerated with 21% acute (n = 17) and 25% (n = 20) late grade ≥3 toxicities. Conclusion: Radiotherapy including active raster-scanning carbon ion boost for relatively radio resistant adenocarcinomas of the head and neck resulted in favorable survival outcome for salivary gland and salivary duct adenocarcinomas with moderate toxicity. However, local control and prognosis for bilateral intestinal-type adenocarcinomas (ITAC) seem to remain low even after dose-escalation.
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Affiliation(s)
- Sati Akbaba
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
- Department of Radiation Oncology, Heidelberg Institute of Radiation Oncology, Heidelberg, Germany
- National Center for Tumor Diseases, Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center, Heidelberg, Germany
| | - Andreas Mock
- Department of Medical Oncology, National Center for Tumor Diseases Heidelberg, Heidelberg, Germany
- Department of Translational Medical Oncology, National Center for Tumor Diseases Heidelberg, German Cancer Research Center, Heidelberg, Germany
| | - Juliane Hoerner-Rieber
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
- Department of Radiation Oncology, Heidelberg Institute of Radiation Oncology, Heidelberg, Germany
- National Center for Tumor Diseases, Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center, Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center, Heidelberg, Germany
| | - Thomas Held
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
- Department of Radiation Oncology, Heidelberg Institute of Radiation Oncology, Heidelberg, Germany
- National Center for Tumor Diseases, Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center, Heidelberg, Germany
| | - Sonja Katayama
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
- Department of Radiation Oncology, Heidelberg Institute of Radiation Oncology, Heidelberg, Germany
- National Center for Tumor Diseases, Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center, Heidelberg, Germany
| | - Tobias Forster
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
- Department of Radiation Oncology, Heidelberg Institute of Radiation Oncology, Heidelberg, Germany
- National Center for Tumor Diseases, Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center, Heidelberg, Germany
| | - Christian Freudlsperger
- Department of Oral and Maxillofacial Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
- Department of Radiation Oncology, Heidelberg Institute of Radiation Oncology, Heidelberg, Germany
- National Center for Tumor Diseases, Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center, Heidelberg, Germany
| | - Klaus Herfarth
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
- Department of Radiation Oncology, Heidelberg Institute of Radiation Oncology, Heidelberg, Germany
- National Center for Tumor Diseases, Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center, Heidelberg, Germany
- Department of Medical Oncology, National Center for Tumor Diseases Heidelberg, Heidelberg, Germany
| | - Peter Plinkert
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Juergen Debus
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
- Department of Radiation Oncology, Heidelberg Institute of Radiation Oncology, Heidelberg, Germany
- National Center for Tumor Diseases, Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center, Heidelberg, Germany
- Department of Medical Oncology, National Center for Tumor Diseases Heidelberg, Heidelberg, Germany
| | - Sebastian Adeberg
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
- Department of Radiation Oncology, Heidelberg Institute of Radiation Oncology, Heidelberg, Germany
- National Center for Tumor Diseases, Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center, Heidelberg, Germany
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Gebauer J, Higham C, Langer T, Denzer C, Brabant G. Long-Term Endocrine and Metabolic Consequences of Cancer Treatment: A Systematic Review. Endocr Rev 2019; 40:711-767. [PMID: 30476004 DOI: 10.1210/er.2018-00092] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 06/21/2018] [Indexed: 02/08/2023]
Abstract
The number of patients surviving ≥5 years after initial cancer diagnosis has significantly increased during the last decades due to considerable improvements in the treatment of many cancer entities. A negative consequence of this is that the emergence of long-term sequelae and endocrine disorders account for a high proportion of these. These late effects can occur decades after cancer treatment and affect up to 50% of childhood cancer survivors. Multiple predisposing factors for endocrine late effects have been identified, including radiation, sex, and age at the time of diagnosis. A systematic literature search has been conducted using the PubMed database to offer a detailed overview of the spectrum of late endocrine disorders following oncological treatment. Most data are based on late effects of treatment in former childhood cancer patients for whom specific guidelines and recommendations already exist, whereas current knowledge concerning late effects in adult-onset cancer survivors is much less clear. Endocrine sequelae of cancer therapy include functional alterations in hypothalamic-pituitary, thyroid, parathyroid, adrenal, and gonadal regulation as well as bone and metabolic complications. Surgery, radiotherapy, chemotherapy, and immunotherapy all contribute to these sequelae. Following irradiation, endocrine organs such as the thyroid are also at risk for subsequent malignancies. Although diagnosis and management of functional and neoplastic long-term consequences of cancer therapy are comparable to other causes of endocrine disorders, cancer survivors need individually structured follow-up care in specialized surveillance centers to improve care for this rapidly growing group of patients.
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Affiliation(s)
- Judith Gebauer
- Experimental and Clinical Endocrinology, University Hospital of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Claire Higham
- Department of Endocrinology, Christie Hospital NHS Foundation Trust, Manchester, United Kingdom.,Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Thorsten Langer
- Division of Pediatric Hematology and Oncology, University Hospital of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Christian Denzer
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Endocrinology and Diabetes, Ulm University Medical Center, Ulm, Germany
| | - Georg Brabant
- Experimental and Clinical Endocrinology, University Hospital of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany.,Department of Endocrinology, Christie Hospital NHS Foundation Trust, Manchester, United Kingdom
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Head and Neck Cancer Adaptive Radiation Therapy (ART): Conceptual Considerations for the Informed Clinician. Semin Radiat Oncol 2019; 29:258-273. [PMID: 31027643 DOI: 10.1016/j.semradonc.2019.02.008] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
For nearly 2 decades, adaptive radiation therapy (ART) has been proposed as a method to account for changes in head and neck tumor and normal tissue to enhance therapeutic ratios. While technical advances in imaging, planning and delivery have allowed greater capacity for ART delivery, and a series of dosimetric explorations have consistently shown capacity for improvement, there remains a paucity of clinical trials demonstrating the utility of ART. Furthermore, while ad hoc implementation of head and neck ART is reported, systematic full-scale head and neck ART remains an as yet unreached reality. To some degree, this lack of scalability may be related to not only the complexity of ART, but also variability in the nomenclature and descriptions of what is encompassed by ART. Consequently, we present an overview of the history, current status, and recommendations for the future of ART, with an eye toward improving the clarity and description of head and neck ART for interested clinicians, noting practical considerations for implementation of an ART program or clinical trial. Process level considerations for ART are noted, reminding the reader that, paraphrasing the writer Elbert Hubbard, "Art is not a thing, it is a way."
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40
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Perspectives on optimizing radiotherapy dose to the dysphagia/aspiration-related structures for patients with head and neck cancer. Curr Opin Otolaryngol Head Neck Surg 2019; 27:157-161. [PMID: 30893132 DOI: 10.1097/moo.0000000000000532] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The purpose of this study is to provide an overview on the methodologies, outcomes and clinical implications of studies that have investigated swallowing outcomes after head and neck cancer (HNC) treatment when reducing radiotherapy dose to specific dysphagia/aspiration-related structures (DARS). RECENT FINDINGS Overall, there is limited recent evidence, with a lack of high-quality studies, which examine the outcomes of DARS-optimized radiotherapy treatment. Large variations exist in the methodology of these studies in regards to which DARS are delineated and how swallowing outcomes are measured. Consequently, there is a wide range of dose limits recommended to a variety of DARS structures. Despite these limitations, there appears to be a general consensus that optimizing dose to the DARS will result in some reduction of dysphagia after radiotherapy without compromising on treatment to the tumour. SUMMARY More rigorous study must be completed to determine the true extent of clinical benefit from this practice. Institutions must take into consideration the limitations of the evidence as well as logistical costs of implementing this technique into practice. However, optimizing dose to the DARS appears to be a well-tolerated practice that may have substantial positive benefits for patients' swallowing function and quality of life after HNC treatment.
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Sunassee ED, Tan D, Ji N, Brady R, Moros EG, Caudell JJ, Yartsev S, Enderling H. Proliferation saturation index in an adaptive Bayesian approach to predict patient-specific radiotherapy responses. Int J Radiat Biol 2019; 95:1421-1426. [PMID: 30831050 DOI: 10.1080/09553002.2019.1589013] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Purpose: Radiotherapy prescription dose and dose fractionation protocols vary little between individual patients having the same tumor grade and stage. To personalize radiotherapy a predictive model is needed to simulate radiation response. Previous modeling attempts with multiple variables and parameters have been shown to yield excellent data fits at the cost of non-identifiability and clinically unrealistic results. Materials and methods: We develop a mathematical model based on a proliferation saturation index (PSI) that is a measurement of pre-treatment tumor volume-to-carrying capacity ratio that modulates intrinsic tumor growth and radiation response rates. In an adaptive Bayesian approach, we utilize an increasing number of data points for individual patients to predict patient-specific responses to subsequent radiation doses. Results: Model analysis shows that using PSI as the only patient-specific parameter, model simulations can fit longitudinal clinical data with high accuracy (R2=0.84). By analyzing tumor response to radiation using daily CT scans early in the treatment, response to the remaining treatment fractions can be predicted after two weeks with high accuracy (c-index = 0.89). Conclusion: The PSI model may be suited to forecast treatment response for individual patients and offers actionable decision points for mid-treatment protocol adaptation. The presented work provides an actionable image-derived biomarker prior to and during therapy to personalize and adapt radiotherapy.
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Affiliation(s)
- Enakshi D Sunassee
- Department of Integrated Mathematical Oncology, H. Lee Moffitt Cancer Center & Research Institute , Tampa , FL , USA
| | - Dean Tan
- Department of Integrated Mathematical Oncology, H. Lee Moffitt Cancer Center & Research Institute , Tampa , FL , USA
| | - Nathan Ji
- Department of Integrated Mathematical Oncology, H. Lee Moffitt Cancer Center & Research Institute , Tampa , FL , USA
| | - Renee Brady
- Department of Integrated Mathematical Oncology, H. Lee Moffitt Cancer Center & Research Institute , Tampa , FL , USA
| | - Eduardo G Moros
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute , Tampa , FL , USA.,Department of Cancer Physiology, H. Lee Moffitt Cancer Center & Research Institute , Tampa , FL , USA
| | - Jimmy J Caudell
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute , Tampa , FL , USA
| | - Slav Yartsev
- London Health Sciences Centre, London Regional Cancer Program , London , ON , Canada
| | - Heiko Enderling
- Department of Integrated Mathematical Oncology, H. Lee Moffitt Cancer Center & Research Institute , Tampa , FL , USA.,Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute , Tampa , FL , USA
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Results of a combination treatment with intensity modulated radiotherapy and active raster-scanning carbon ion boost for adenoid cystic carcinoma of the minor salivary glands of the nasopharynx. Oral Oncol 2019; 91:39-46. [PMID: 30926061 DOI: 10.1016/j.oraloncology.2019.02.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 02/21/2019] [Indexed: 01/24/2023]
Abstract
OBJECTIVES We aimed to present the first clinical results for adenoid cystic carcinoma (ACC) of the nasopharynx after primary radiotherapy (RT) with the focus on local control (LC) and patterns of recurrence. MATERIALS AND METHODS We retrospectively analyzed 59 patients with ACC of the nasopharynx, who were treated with bimodal radiotherapy (RT) consisting of intensity modulated radiotherapy and carbon ion boost at the Heidelberg Ion-Beam Therapy Center between 2009 and 2018. The patients had predominantly inoperable (n = 42, 72%) or incompletely resected (n = 17, 29%) tumors. Kaplan-Meier estimates and the log-rank (Mantel-Cox) test were used for univariate and multivariate analyses. RESULTS The median follow-up was 32 months. At last follow-up, 67% of the patients were still alive (n = 39/58), of whom 74% were free of progression (n = 29/39). The 2-year LC, distant progression-free survival (DPFS) and overall survival (OS) were 83%, 81%, 87% and the estimated 5-year LC, DPFS and OS were 49%, 54%, 69%, respectively. LC was significantly inferior in patients with large tumor volumes (gross tumor volume, GTV > 100 cc, p = 0.020) and T4 tumors (p = 0.021). The majority of the recurrences occurred at the margin, where critical structures were spared (n = 11/19, 58%). Overall, grade 3 toxicity was moderate with 12% acute and 8% late side effects. CONCLUSION Bimodal RT including active raster-scanning carbon ion boost for nasopharyngeal ACC resulted in adequate LC and OS rates with moderate toxicity. T4 stage, large tumor volume and the necessary dose sparing in critical structures, i.e. optic nerves, brain stem and orbit, negatively affected LC.
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Barnhart MK, Cartmill B, Ward EC, Brown E, Sim J, Saade G, Rayner S, Robinson RA, Simms VA, Smee RI. Optimising Radiation Therapy Dose to the Swallowing Organs at Risk: An In Silico Study of feasibility for Patients with Oropharyngeal Tumours. Dysphagia 2019; 34:869-878. [PMID: 30741335 DOI: 10.1007/s00455-019-09983-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Accepted: 01/21/2019] [Indexed: 10/27/2022]
Abstract
Recent evidence suggests that reducing radiotherapy dose delivered to specific anatomical swallowing structures [Swallowing Organs at Risk (SWOARs)] may improve swallowing outcomes post-treatment for patients with head and neck cancer. However, for those patients with tumours of the oropharynx, which typically directly overlap the SWOARs, reducing dose to these structures may be unachievable without compromising on the treatment of the disease. To assess the feasibility of dose reduction in this cohort, standard IMRT plans (ST-IMRT) and plans with reduced dose to the SWOARs (SW-IMRT) were generated for 25 oropharyngeal cancer patients (Brouwer et al. in Radiother Oncol 117(1):83-90, https://doi.org/10.1016/j.radonc.2015.07.041 , 2015; Christianen et al. in Radiother Oncol 101(3):394-402, https://doi.org/10.1016/j.radonc.2011.05.015 , 2011). ST-IMRT and SW-IMRT plans were compared for: mean dose to the SWOARs, volume of pharynx and larynx receiving 50 Gy and 60 Gy (V50 and V60 respectively) and overlap between the tumour volume and the SWOARs. Additionally, two different SWOARs delineation guidelines (Brouwer et al. in Radiother Oncol 117(1):83-90, https://doi.org/10.1016/j.radonc.2015.07.041 , 2015; Christianen et al. in Radiother Oncol 101(3):394-402, https://doi.org/10.1016/j.radonc.2011.05.015 , 2011) were used to highlight differences in calculated volumes between existing contouring guidelines. Agreement in SWOARs volumes between the two guidelines was calculated using a concordance index (CI). Despite a large overlap between the tumour and SWOARs, significant (p < 0.05) reductions in mean dose to 4 of the 5 SWOARs, and V50/V60 for the pharynx and larynx were achieved with SW-IMRT plans. Low CIs per structure (0.15-0.45) were found between the two guidelines highlighting issues comparing data between studies when different guidelines have been used (Hawkins et al. in Semin Radiat Oncol 28(1):46-52, https://doi.org/10.1016/j.semradonc.2017.08.002 , 2018; Brodin et al. in Int J Radiat Oncol Biol Phys 100(2):391-407, https://doi.org/10.1016/j.ijrobp.2017.09.041 , 2018). This study found reducing dose to the SWOARs is a feasible practice for patients with oropharyngeal cancer. However, future prospective research is needed to determine if the extent of dose reduction achieved equates to clinical benefits.
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Affiliation(s)
- Molly K Barnhart
- Speech Pathology Department, Prince of Wales Hospital (POWH), Randwick, Sydney, NSW, 2031, Australia. .,School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, QLD, 4072, Australia.
| | - Bena Cartmill
- Centre for Functioning and Health Research, Metro South Hospital and Health Service, Queensland Health, Buranda, QLD, 4102, Australia.,Speech Pathology, Princess Alexandra Hospital, Metro South Hospital and Health Service, Queensland Health, Woolloongabba, QLD, 4102, Australia
| | - Elizabeth C Ward
- School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, QLD, 4072, Australia.,Centre for Functioning and Health Research, Metro South Hospital and Health Service, Queensland Health, Buranda, QLD, 4102, Australia
| | - Elizabeth Brown
- Radiation Oncology, Princess Alexandra Hospital, Metro South Hospital and Health Service, Queensland Health, Woolloongabba, QLD, 4102, Australia
| | - Jonathon Sim
- Radiation Oncology, Nelune Comprehensive Cancer Centre, POWH, Sydney, NSW, 2031, Australia
| | - George Saade
- Radiation Oncology, Nelune Comprehensive Cancer Centre, POWH, Sydney, NSW, 2031, Australia
| | - Sandra Rayner
- Radiation Oncology, Nelune Comprehensive Cancer Centre, POWH, Sydney, NSW, 2031, Australia
| | - Rachelle A Robinson
- Speech Pathology Department, Prince of Wales Hospital (POWH), Randwick, Sydney, NSW, 2031, Australia
| | - Virginia A Simms
- Speech Pathology Department, Prince of Wales Hospital (POWH), Randwick, Sydney, NSW, 2031, Australia
| | - Robert I Smee
- Radiation Oncology, Nelune Comprehensive Cancer Centre, POWH, Sydney, NSW, 2031, Australia.,The Clinical Teaching School, University New South Wales, Kensington, NSW, Australia
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A Quantitative Clinical Decision-Support Strategy Identifying Which Patients With Oropharyngeal Head and Neck Cancer May Benefit the Most From Proton Radiation Therapy. Int J Radiat Oncol Biol Phys 2018; 104:540-552. [PMID: 30496877 DOI: 10.1016/j.ijrobp.2018.11.039] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 11/02/2018] [Accepted: 11/16/2018] [Indexed: 01/10/2023]
Abstract
PURPOSE Developing a quantitative decision-support strategy estimating the impact of normal tissue complications from definitive radiation therapy (RT) for head and neck cancer (HNC). We developed this strategy to identify patients with oropharyngeal HNC who may benefit most from receiving proton RT. METHODS AND MATERIALS Recent normal tissue complication probability (NTCP) models for dysphagia, esophagitis, hypothyroidism, xerostomia, and oral mucositis were used to estimate NTCP for 33 patients with oropharyngeal HNC previously treated with photon intensity modulated radiation therapy (IMRT). Comparative proton therapy plans were generated using clinical protocols for HNC RT at a collaborating proton center. Organ-at-risk (OAR) doses from photon and proton RT plans were used to calculate NTCPs; Monte Carlo sampling 10,000 times was used for each patient to account for model parameter uncertainty. The latency and duration of each complication were modeled from calculated NTCP, accounting for age-, sex-, smoking- and p16-specific conditional survival probability. Complications were then assigned quality-adjustment factors based on severity to calculate quality-adjusted life years (QALYs) lost from each complication. RESULTS Based on our institutional-delivered photon IMRT doses and the achievable proton therapy doses, the average QALY reduction from all HNC RT complications for photon and proton therapy was 1.52 QALYs versus 1.15 QALYs, with proton therapy sparing 0.37 QALYs on average (composite 95% confidence interval, 0.27-2.53 QALYs). Long-term complications (dysphagia and xerostomia) contributed most to the QALY reduction. The QALYs spared with proton RT varied considerably among patients, ranging from 0.06 to 0.84 QALYs. Younger patients with p16-positive tumors who smoked ≤10 pack-years may benefit most from proton therapy, although this finding should be validated using larger patient series. A sensitivity analysis reducing photon IMRT doses to all OARs by 20% resulted in no overall estimated benefit with proton therapy with -0.02 QALYs spared, although some patients still had an estimated benefit in this scenario, ranging from -0.50 to 0.43 QALYs spared. CONCLUSIONS This quantitative decision-support strategy allowed us to identify patients with oropharyngeal cancer who might benefit the most from proton RT, although the estimated benefit of proton therapy ultimately depends on the OAR doses achievable with modern photon IMRT solutions. These results can help radiation oncologists and proton therapy centers optimize resource allocation and improve quality of life for patients with HNC.
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Brodin NP, Tomé WA. Revisiting the dose constraints for head and neck OARs in the current era of IMRT. Oral Oncol 2018; 86:8-18. [PMID: 30409324 DOI: 10.1016/j.oraloncology.2018.08.018] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 08/20/2018] [Accepted: 08/25/2018] [Indexed: 12/25/2022]
Abstract
Head and neck cancer poses a particular challenge in radiation therapy, whilst being an effective treatment modality it requires very high doses of radiation to provide effective therapy. This is further complicated by the fact that the head and neck region contains a large number of radiosensitive tissues, often resulting in patients experiencing debilitating normal tissue complications. In the era of intensity-modulated radiation therapy (IMRT) treatments can be delivered using non-uniform dose distributions selectively aimed at reducing the dose to critical organs-at-risk while still adequately covering the tumor target. Dose-volume constraints for the different risk organs play a vital role in one's ability to devise the best IMRT treatment plan for a head and neck cancer patient. To this end, it is pivotal to have access to the latest and most relevant dose constraints available and as such the goal of this review is to provide a summary of suggested dose-volume constraints for head and neck cancer RT that have been published after the QUANTEC reports were made available in early 2010.
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Affiliation(s)
- N Patrik Brodin
- Institute for Onco-Physics, Albert Einstein College of Medicine, Bronx, NY 10461, USA; Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY 10461, USA
| | - Wolfgang A Tomé
- Institute for Onco-Physics, Albert Einstein College of Medicine, Bronx, NY 10461, USA; Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY 10461, USA; Department of Neurology, Albert Einstein College of Medicine, Bronx, NY 10461, USA.
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Bresciani S, Poli M, Miranti A, Maggio A, Di Dia A, Bracco C, Gabriele P, Stasi M. Comparison of two different EPID-based solutions performing pretreatment quality assurance: 2D portal dosimetry versus 3D forward projection method. Phys Med 2018; 52:65-71. [PMID: 30139611 DOI: 10.1016/j.ejmp.2018.06.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 05/13/2018] [Accepted: 06/05/2018] [Indexed: 01/08/2023] Open
Abstract
PURPOSE The aim of this paper is to characterize two different EPID-based solutions for pre-treatment VMAT quality assurance, the 2D portal dosimetry and the 3D projection technique. Their ability to catch the main critical delivery errors was studied. METHODS Measurements were performed with a linac accelerator equipped with EPID aSi1000, Portal Dose Image Prediction (PDIP), and PerFRACTION softwares. Their performances were studied simulating perturbations of a reference plan through systematic variations in dose values and micromultileaf collimator position. The performance of PDIP, based on 2D forward method, was evaluated calculating gamma passing rate (%GP) between no-error and error-simulated measurements. The impact of errors with PerFRACTION, based on 3D projection technique, was analyzed by calculating the difference between reference and perturbed DVH (%ΔD). Subsequently pre-treatment verification with PerFRACTION was done for 27 patients of different pathologies. RESULTS The sensitivity of PerFRACTION was slightly higher than sensitivity of PDIP, reaching a maximum of 0.9. Specificity was 1 for PerFRACTION and 0.6 for PDIP. The analysis of patients' DVHs indicated that the mean %ΔD was (1.2 ± 1.9)% for D2%, (0.6 ± 1.7)% for D95% and (-0.0 ± 1.2)% for Dmean of PTV. Regarding OARs, we observed important discrepancies on DVH but that the higher dose variations were in low dose area (<10 Gy). CONCLUSIONS This study supports the introduction of the new 3D forward projection method for pretreatment QA raising the claim that the visualization of the delivered dose distribution on patient anatomy has major advantages over traditional portal dosimetry QA systems.
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Affiliation(s)
- Sara Bresciani
- Medical Physics Division, Candiolo Cancer Institute - FPO, IRCCS, Strada Provinciale 142 km 3.95, 10060 Candiolo (TO), Italy.
| | - Matteo Poli
- Medical Physics Division, Candiolo Cancer Institute - FPO, IRCCS, Strada Provinciale 142 km 3.95, 10060 Candiolo (TO), Italy
| | - Anna Miranti
- Medical Physics Division, Candiolo Cancer Institute - FPO, IRCCS, Strada Provinciale 142 km 3.95, 10060 Candiolo (TO), Italy
| | - Angelo Maggio
- Medical Physics Division, Candiolo Cancer Institute - FPO, IRCCS, Strada Provinciale 142 km 3.95, 10060 Candiolo (TO), Italy
| | - Amalia Di Dia
- Medical Physics Division, Candiolo Cancer Institute - FPO, IRCCS, Strada Provinciale 142 km 3.95, 10060 Candiolo (TO), Italy
| | - Christian Bracco
- Medical Physics Division, Candiolo Cancer Institute - FPO, IRCCS, Strada Provinciale 142 km 3.95, 10060 Candiolo (TO), Italy
| | - Pietro Gabriele
- Radiotherapy Division, Candiolo Cancer Institute - FPO, IRCCS, Strada Provinciale 142 km 3.95, 10060 Candiolo (TO), Italy
| | - Michele Stasi
- Medical Physics Division, Candiolo Cancer Institute - FPO, IRCCS, Strada Provinciale 142 km 3.95, 10060 Candiolo (TO), Italy
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