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Bates JE, Rancati T, Keshavarz H, Gagliardi G, Aznar MC, Howell RM, Shrestha S, Moiseenko V, Yorke E, Armenian S, Kremer L, Chen MH, van der Pal HJ, Cutter DJ, Constine LS, Hodgson D. Cardiac Disease in Childhood Cancer Survivors Treated With Radiation Therapy: A PENTEC Comprehensive Review. Int J Radiat Oncol Biol Phys 2024; 119:522-532. [PMID: 37061912 DOI: 10.1016/j.ijrobp.2023.03.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 02/10/2023] [Accepted: 03/10/2023] [Indexed: 04/17/2023]
Abstract
PURPOSE Radiation therapy (RT) is an essential component in the treatment of many pediatric malignancies. Thoracic RT may expose the heart to radiation dose and thereby increase the risk of late cardiac disease. This comprehensive review from the Pediatric Normal Tissue Effects in the Clinic (PENTEC) initiative focused on late cardiac disease in survivors of childhood cancer treated with RT. METHODS AND MATERIALS This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. We identified 1496 articles; 4 were included for dose-response modeling between mean cardiac radiation dose and risk of late coronary artery disease, heart failure (HF), valvular disease, and any cardiac disease. RESULTS For each 10-Gy increase in corrected mean cardiac radiation dose in 1.8- to 2.0-Gy fractions, we estimated a hazard ratio of 2.01 (95% confidence interval [CI], 1.79-2.25) for coronary artery disease, of 1.87 (95% CI, 1.70-2.06) for HF, of 1.87 (95% CI, 1.78-1.96) for valvular disease, and of 1.88 (95% CI, 1.75-2.03) for any cardiac disease. From the same model, for each 100-mg/m2 increase in cumulative anthracycline dose, the hazard ratio for the development of HF was 1.93 (95% CI, 1.58-2.36), equivalent to an increase in mean heart dose of approximately 10.5 Gy. Other nontreatment factors were inconsistently reported in the analyzed articles. CONCLUSIONS Radiation dose to the heart increases the risk of late cardiac disease, but survivors of childhood cancer who receive a mean dose <10 Gy at standard fractionation are at low absolute risk (<∼2% approximately 30 years after exposure) of late cardiac disease in the absence of anthracycline exposure. Minimizing cardiac radiation dose is especially relevant in children receiving anthracyclines. When cardiac sparing is not possible, we recommend prioritizing target coverage. It is likely that individual cardiac substructure doses will be a better predictor of specific cardiac diseases than mean dose, and we urge the pediatric oncology community to further study these relationships.
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Affiliation(s)
- James E Bates
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia.
| | - Tiziana Rancati
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Giovanna Gagliardi
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Marianne C Aznar
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Rebecca M Howell
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas; Graduate School of Biomedical Sciences, MD Anderson UT Health, Houston, Texas
| | - Suman Shrestha
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas; Graduate School of Biomedical Sciences, MD Anderson UT Health, Houston, Texas
| | - Vitali Moiseenko
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Saro Armenian
- Department of Pediatrics, City of Hope, Duarte, California
| | - Leontien Kremer
- Princess Maxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Ming Hui Chen
- Departments of Cardiology and Pediatrics, Boston Children's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | | | - David J Cutter
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Louis S Constine
- Departments of Radiation Oncology and Pediatrics, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - David Hodgson
- Department of Radiation Oncology, Princess Margaret Hospital, Toronto, Ontario, Canada
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2
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Briere TM, Agrusa JE, Martel MK, Jackson A, Olch AJ, Ronckers CM, Kremer LCM, Constine LS, McAleer MF. Acute and Late Pulmonary Effects After Radiation Therapy in Childhood Cancer Survivors: A PENTEC Comprehensive Review. Int J Radiat Oncol Biol Phys 2024; 119:533-548. [PMID: 35525723 DOI: 10.1016/j.ijrobp.2022.01.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 12/07/2021] [Accepted: 01/29/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The Pediatric Normal Tissue Effects in the Clinic (PENTEC) pulmonary task force reviewed dosimetric and clinical factors associated with radiation therapy (RT)-associated pulmonary toxicity in children. METHODS Comprehensive search of PubMed (1965-2020) was conducted to assess available evidence and predictive models of RT-induced lung injury in pediatric cancer patients (<21 years old). Lung dose for radiation pneumonitis (RP) was obtained from dose-volume histogram (DVH) data. RP grade was obtained from standard criteria. Clinical pulmonary outcomes were evaluated using pulmonary function tests (PFTs), clinical assessment, and questionnaires. RESULTS More than 2,400 abstracts were identified; 460 articles had detailed treatment and toxicity data; and 11 articles with both detailed DVH and toxicity data were formally reviewed. Pooled cohorts treated during 1999 to 2016 included 277 and 507 patients age 0.04 to 22.7 years who were evaluable for acute and late RP analysis, respectively. After partial lung RT, there were 0.4% acute and 2.8% late grade 2, 0.4% acute and 0.8% late grade 3, and no grade 4 to 5 RP. RP risk after partial thoracic RT with mean lung dose (MLD) <14 Gy and total lung V20Gy <30% is low. Clinical and self-reported pulmonary outcomes data included 8,628 patients treated during 1970 to 2013, age 0 to 21.9 years. At a median 2.9- to 21.9-year follow-up, patients were often asymptomatic; abnormal PFTs were common and severity correlated with lung dose. At ≥10-year follow-up, multi-institutional studies suggested associations between total or ipsilateral lung doses >10 Gy and pulmonary complications and deaths. After whole lung irradiation (WLI), pulmonary toxicity is higher; no dose response relationship was identified. Bleomycin and other chemotherapeutics at current dose regimens do not contribute substantially to adverse pulmonary outcomes after partial lung irradiation but increase risk with WLI. CONCLUSIONS After partial lung RT, acute pulmonary toxicity is uncommon; grade 2 to 3 RP incidences are <1%. Late toxicities, including subclinical/asymptomatic impaired pulmonary function, are more common (<4%). Incidence and severity appear to increase over time. Upon review of available literature, there appears to be low risk of pulmonary complications in children with MLD < 14 Gy and V20Gy <30% using standard fractionated RT to partial lung volumes. A lack of robust data limit guidance on lung dose/volume constraints, highlighting the need for additional work to define factors associated with RT-induced lung injury.
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Affiliation(s)
- Tina Marie Briere
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jennifer E Agrusa
- Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Mary K Martel
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Arthur J Olch
- Department of Radiation Oncology University of Southern California Keck School of Medicine and Children's Hospital Los Angeles, Los Angeles, California; Radiation Oncology Program, Children's Hospital Los Angeles, Los Angeles, California
| | - Cécile M Ronckers
- Department of Pediatrics, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Institute of Biostatistics and Registry Research, Medical University Brandenburg Medical School-Theodor Fontane, Neuruppin, Germany
| | - Leontien C M Kremer
- Department of Pediatrics, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Department of Pediatrics, UMC Amsterdam, Location AMC, Amsterdam, the Netherlands
| | - Louis S Constine
- Departments of Radiation Oncology and Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Mary Frances McAleer
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas.
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3
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Conte B, Shen C, Thompson P, Davis I, Casey DL. Long-Term Outcomes After Abdominal Radiation for Wilms Tumor: A 20-Year Experience. Am J Clin Oncol 2024; 47:128-131. [PMID: 38088232 DOI: 10.1097/coc.0000000000001074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
BACKGROUND As radiation therapy (RT) for Wilms tumor (WT) evolves with more conformal techniques, it is necessary to evaluate patterns of failure and toxicity. We sought to determine the rate of local failure (LF) after abdominal RT in WT, specifically focusing on those with contained rupture treated with whole abdominal and pelvic RT (WAPRT) vs flank RT. Secondary objectives were to determine overall survival (OS), distant failure (DF), and late toxicities. METHODS A single institution retrospective study of 54 pediatric patients with WT treated with abdominal RT between May 2000 and October 2022. LF and DF were calculated through cumulative incidence function and OS by Kaplan-Meier method. RESULTS The median age was 4.5 years and the median follow-up was 6 years. Most patients (91%) had favorable histology. Only 1 patient experienced LF, 15 months from completion of RT (cumulative incidence 2% at 5 y). All patients who received unilateral flank radiation for contained rupture/spillage (n=13) experienced long-lasting intra-abdominal tumor control. A total of 5 patients experienced a DF at a median of 7 months, all in the lung. No patient relapsed in the lungs after upfront whole lung irradiation (n=16). OS was 96% at 5 years. Among 28 patients who followed through puberty, 4 female patients with prior WAPRT experienced hormonal irregularities/infertility. CONCLUSIONS Unilateral flank radiation may be a viable alternative to WAPRT for contained rupture/spillage and should be further explored prospectively. Our results may also be utilized in the future for outcome and toxicity comparison as conformal radiation techniques evolve.
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Affiliation(s)
- Brianna Conte
- University of Miami Miller School of Medicine, Miami, FL
| | | | - Patrick Thompson
- Department of Pediatric Oncology, University of North Carolina, Chapel Hill, NC
| | - Ian Davis
- Department of Pediatric Oncology, University of North Carolina, Chapel Hill, NC
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Yamauchi R, Akiyama S, Mizuno N, Kobayashi T, Itazawa T, Masuda T, Hirano M, Tomita F, Hosoya Y, Kawamori J. Dosimetric Comparison of 3D Conformal Radiotherapy (3D-CRT), Intensity-Modulated Radiotherapy (IMRT), and Volumetric-Modulated Arc Therapy (VMAT) in Cardiac-Sparing Whole Lung Irradiation. Cureus 2023; 15:e51047. [PMID: 38264368 PMCID: PMC10805560 DOI: 10.7759/cureus.51047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2023] [Indexed: 01/25/2024] Open
Abstract
Introduction Whole lung irradiation (WLI) is used for the treatment of lung metastasis in Wilms tumor and Ewing sarcoma; however, cardiac complications are one of the concerns. We report the dosimetric advantages of WLI using volumetric-modulated arc therapy (VMAT) and present a dosimetric comparison of VMAT with anteroposterior-posteroanterior (AP-PA) and static-field intensity-modulated radiation therapy (IMRT). Additionally, we evaluated the dosimetric impact of respiratory motion and intra-fractional motion during VMAT treatment. Methods Seven patients were recruited in this study. AP-PA, IMRT, one-isocenter (1-IC) VMAT, and 2-IC VMAT were planned on the maximum inspiration and expiration CT, respectively. The prescribed dose was 15 Gy in 10 fractions. To determine the effects of respiratory motion, the CT series was replaced and the dose was evaluated while maintaining the beam information. To determine the effect of patient motion, perturbed dose calculations were performed using a two-IC VMAT. The perturbation doses were calculated by shifting only the IC of the one side beam by 3 mm or 5 mm in the right-to-left (RL) direction. Results The mean heart dose was 1467.0 cGy, 790.0 cGy, 764.2 cGy, and 738.4 cGy for AP-PA, IMRT, 1-IC VMAT, and 2-IC VMAT, respectively. When the expiration CT plan was recalculated with inspiration CT, Dmax increased approximately by 8%. In the 2-IC VMAT plan, the D50%, D98%, and D2% dose differences were within ±2%, even with a 5 mm IC shift. Conclusion We confirmed a significant dosimetric advantage of VMAT over other techniques. 2-IC VMAT should be considered an effective treatment option during irradiation for large target volumes.
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Affiliation(s)
- Ryohei Yamauchi
- Department of Radiation Oncology, St. Luke's International Hospital, Tokyo, JPN
| | - Shinobu Akiyama
- Department of Radiation Oncology, St. Luke's International Hospital, Tokyo, JPN
| | - Norifumi Mizuno
- Department of Radiation Oncology, St. Luke's International Hospital, Tokyo, JPN
| | - Takako Kobayashi
- Department of Radiation Oncology, St. Luke's International Hospital, Tokyo, JPN
| | - Tomoko Itazawa
- Department of Radiation Oncology, St. Luke's International Hospital, Tokyo, JPN
| | - Tomoyuki Masuda
- Department of Radiation Oncology, St. Luke's International Hospital, Tokyo, JPN
| | - Miki Hirano
- Department of Radiation Oncology, St. Luke's International Hospital, Tokyo, JPN
| | - Fumihiro Tomita
- Department of Radiation Oncology, St. Luke's International Hospital, Tokyo, JPN
| | - Yosuke Hosoya
- Department of Pediatrics, St. Luke's International Hospital, Tokyo, JPN
| | - Jiro Kawamori
- Department of Radiation Oncology, St. Luke's International Hospital, Tokyo, JPN
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Gupta A, Riedel RF, Shah C, Borinstein SC, Isakoff MS, Chugh R, Rosenblum JM, Murphy ES, Campbell SR, Albert CM, Zahler S, Thomas SM, Trucco M. Consensus recommendations in the management of Ewing sarcoma from the National Ewing Sarcoma Tumor Board. Cancer 2023; 129:3363-3371. [PMID: 37403815 DOI: 10.1002/cncr.34942] [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: 02/17/2023] [Revised: 05/01/2023] [Accepted: 05/17/2023] [Indexed: 07/06/2023]
Abstract
Ewing sarcoma (ES) is a malignant tumor of bone and soft tissue that most often occurs in adolescents and young adults. Despite an international coordinated approach, several nuances, discrepancies, and debates remain in defining the standard of care for treating ES. In this review, the authors leverage the expertise assembled by formation of the National Ewing Sarcoma Tumor Board, a multi-institution, multidisciplinary virtual tumor board that meets monthly to discuss complicated and challenging cases of ES. This report is focused on select topics that apply to the management of patients with newly diagnosed ES. The specific topics covered include indications for bone marrow aspirate and biopsy for initial evaluation compared with fluorodeoxyglucose-positron emission tomography, the role of interval compressed chemotherapy in patients aged 18 years and older, the role of adding ifosfamide/etoposide to vincristine/doxorubicin/cyclophosphamide for patients with metastatic disease, the data on and role of high-dose chemotherapy with autologous stem cell transplantation, maintenance therapy, and whole-lung irradiation. The data referenced are often limited to subgroup analyses and/or compiled from multiple sources. Although not intended to replace the clinical judgement of treating physicians, the guidelines are intended to provide clarity and recommendations for the upfront management of patients with ES. PLAIN LANGUAGE SUMMARY: Ewing sarcoma is a malignant tumor of bone and soft tissue that most often occurs in adolescents and young adults. For this review, the authors used the experience of the National Ewing Sarcoma Tumor Board, a multi-institution, multidisciplinary virtual tumor board that meets monthly to discuss complicated and challenging cases of Ewing sarcoma. Although not intended to replace the clinical judgement of treating physicians, the guidelines will focus on the development of consensus statements for the upfront management of patients with Ewing sarcoma.
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Affiliation(s)
- Ajay Gupta
- Division of Pediatric Oncology, Department of Pediatrics, Roswell Park Comprehensive Cancer Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Richard F Riedel
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Scott C Borinstein
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael S Isakoff
- Center for Cancer and Blood Disorders, Connecticut Children's Medical Center, Hartford, Connecticut, USA
| | - Rashmi Chugh
- Department of Medicine, Division of Hematology and Oncology, Rogel Cancer Center, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Jeremy M Rosenblum
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Department of Pediatrics, New York Medical College, Valhalla, New York, USA
| | - Erin S Murphy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shauna R Campbell
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Catherine M Albert
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington, USA
| | - Stacey Zahler
- Department of Hematology/Oncology/Bone Marrow Transplantation, Cleveland Clinic Children's, Cleveland, Ohio, USA
| | - Stefanie M Thomas
- Department of Hematology/Oncology/Bone Marrow Transplantation, Cleveland Clinic Children's, Cleveland, Ohio, USA
| | - Matteo Trucco
- Department of Hematology/Oncology/Bone Marrow Transplantation, Cleveland Clinic Children's, Cleveland, Ohio, USA
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Kalapurakal JA, Wolden SL, Haas-Kogan D, Laack NN, Hua CH, Paulino AC, Hill-Kayser CE, Hoppe BS, Fitzgerald TJ. Children's Oncology Group's 2023 blueprint for research: Radiation oncology. Pediatr Blood Cancer 2023; 70 Suppl 6:e30593. [PMID: 37486145 PMCID: PMC10588230 DOI: 10.1002/pbc.30593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 07/10/2023] [Indexed: 07/25/2023]
Abstract
Radiation oncology is an integral part of the multidisciplinary team caring for children with cancer. The primary goal of our committee is to enable the delivery of the safest dose of radiation therapy (RT) with the maximal potential for cure, and to minimize toxicity in children by delivering lower doses to normal tissues using advanced technologies like intensity-modulated RT (IMRT) and proton therapy. We provide mentorship for y ators and are actively involved in educating the global radiation oncology community. We are leaders in the effort to discover novel radiosensitizers, radioprotectors, and advanced RT technologies that could help improve outcomes of children with cancer.
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Affiliation(s)
| | | | | | | | - Chia-ho Hua
- St. Jude Children’s Research Hospital, Memphis, Tennessee
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7
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Digklia A, Dolcan A, Kucharczyk MA, Jones RL, Napolitano A. Optimal Delivery of Follow-Up Care Following Treatment for Adults Treated for Ewing Sarcoma. Cancer Manag Res 2023; 15:537-545. [PMID: 37351338 PMCID: PMC10284160 DOI: 10.2147/cmar.s362693] [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: 12/05/2022] [Accepted: 05/23/2023] [Indexed: 06/24/2023] Open
Abstract
Ewing sarcoma (ES) is a rare, highly malignant sarcoma. It usually presents in the second decade of life; however, patients can be diagnosed as early as newborns and as late as in their seventies. ES is most frequently found in the long bones of the extremities and the pelvis. In older patients, ES can also arise in the soft tissues. Currently, there is no standard schedule for surveillance of adult patients with ES after their initial treatment for localised disease, not only for the early detection of recurrence but also for long-term side effects. Follow-up is based on group recommendations using extrapolated data obtained primarily from studies with paediatric patients. The main objective of this review is to summarise the data available on treatment-associated complications in long-term survivors. Furthermore, we provide a set of recommendations for optimising the follow-up of adults ES survivors, as well as for managing the sequelae that result from intensive multimodal treatment.
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Affiliation(s)
- Antonia Digklia
- Department of Oncology, Lausanne University Hospital, University of Lausanne, Lausanne, 1011, Switzerland
| | - Ana Dolcan
- Department of Oncology, Lausanne University Hospital, University of Lausanne, Lausanne, 1011, Switzerland
| | | | - Robin L Jones
- Sarcoma Unit, The Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, UK
| | - Andrea Napolitano
- Sarcoma Unit, The Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, UK
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8
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de Baat EC, Feijen EA, Reulen RC, Allodji RS, Bagnasco F, Bardi E, Belle FN, Byrne J, van Dalen EC, Debiche G, Diallo I, Grabow D, Hjorth L, Jankovic M, Kuehni CE, Levitt G, Llanas D, Loonen J, Zaletel LZ, Maule MM, Miligi L, van der Pal HJ, Ronckers CM, Sacerdote C, Skinner R, Jakab Z, Veres C, Haddy N, Winter DL, de Vathaire F, Hawkins MM, Kremer LC. Risk Factors for Heart Failure Among Pan-European Childhood Cancer Survivors: A PanCareSurFup and ProCardio Cohort and Nested Case-Control Study. J Clin Oncol 2023; 41:96-106. [PMID: 36075007 PMCID: PMC9788976 DOI: 10.1200/jco.21.02944] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
PURPOSE Heart failure (HF) is a potentially life-threatening complication of treatment for childhood cancer. We evaluated the risk and risk factors for HF in a large European study of long-term survivors. Little is known of the effects of low doses of treatment, which is needed to improve current treatment protocols and surveillance guidelines. METHODS This study includes the PanCareSurFup and ProCardio cohort of ≥ 5-year childhood cancer survivors diagnosed between 1940 and 2009 in seven European countries (N = 42,361). We calculated the cumulative incidence of HF and conducted a nested case-control study to evaluate detailed treatment-related risk factors. RESULTS The cumulative incidence of HF was 2% (95% CI, 1.7 to 2.2) by age 50 years. The case-control study (n = 1,000) showed that survivors who received a mean heart radiation therapy (RT) dose of 5 to < 15 Gy have an increased risk of HF (odds ratio, 5.5; 95% CI, 2.5 to 12.3), when compared with no heart RT. The risk associated with doses 5 to < 15 Gy increased with exposure of a larger heart volume. In addition, the HF risk increased in a linear fashion with higher mean heart RT doses. Regarding total cumulative anthracycline dose, survivors who received ≥ 100 mg/m2 had a substantially increased risk of HF and survivors treated with a lower dose showed no significantly increased risk of HF. The dose-response relationship appeared quadratic with higher anthracycline doses. CONCLUSION Survivors who received a mean heart RT dose of ≥ 5 Gy have an increased risk of HF. The risk associated with RT increases with larger volumes exposed. Survivors treated with < 100 mg/m2 total cumulative anthracycline dose have no significantly increased risk of HF. These new findings might have consequences for new treatment protocols for children with cancer and for cardiomyopathy surveillance guidelines.
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Affiliation(s)
- Esmée C. de Baat
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands,Esmée C. de Baat, MD, Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, the Netherlands; e-mail:
| | | | - Raoul C. Reulen
- Centre for Childhood Cancer Survivor Studies, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Rodrigue S. Allodji
- Radiation Epidemiology Group, Inserm, UMR1018, Villejuif, France,Gustave Roussy, Department of Clinical Research, Villejuif, France,University of Paris-Saclay, Villejuif, France
| | - Francesca Bagnasco
- Epidemiology and Biostatistics Unit and DOPO Clinic, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Edit Bardi
- St Anna Children's Hospital, Vienna, Austria,Department of Paediatrics and Adolescent Medicine, Johannes Kepler University Linz, Kepler University Hospital, Linz, Austria
| | - Fabiën N. Belle
- Childhood Cancer Research Group, ISPM Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland,PMU Unisanté, University of Lausanne, Lausanne, Switzerland
| | | | | | - Ghazi Debiche
- Radiation Epidemiology Group, Inserm, UMR1018, Villejuif, France,Gustave Roussy, Department of Clinical Research, Villejuif, France,University of Paris-Saclay, Villejuif, France
| | - Ibrahima Diallo
- Radiation Epidemiology Group, Inserm, UMR1018, Villejuif, France,Gustave Roussy, Department of Clinical Research, Villejuif, France,University of Paris-Saclay, Villejuif, France
| | - Desiree Grabow
- German Childhood Cancer Registry (GCCR), Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center, Mainz, Germany
| | - Lars Hjorth
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Paediatrics, Lund, Sweden
| | - Momcilo Jankovic
- Pediatric Clinic University of Milano-Bicocca, Foundation MBBM, Monza, Italy
| | - Claudia E. Kuehni
- Childhood Cancer Research Group, ISPM Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland,Pediatric Hematology/Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Gill Levitt
- Department of Paediatric and Oncology, Great Ormond St Hospital for Children NHS Foundation Trust London, United Kingdom
| | - Damien Llanas
- Radiation Epidemiology Group, Inserm, UMR1018, Villejuif, France,Gustave Roussy, Department of Clinical Research, Villejuif, France,University of Paris-Saclay, Villejuif, France
| | - Jacqueline Loonen
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Milena M. Maule
- Cancer Epidemiology Unit, Department of Medical Sciences, University of Turin and AOU Città della Salute e della Scienza, CPO-Piemonte, Turin, Italy
| | - Lucia Miligi
- Institute for Cancer Research, Prevention and Clinical Network (ISPRO), Firenze, Italy
| | | | | | - Carlotta Sacerdote
- Cancer Epidemiology Unit, Department of Medical Sciences, University of Turin and AOU Città della Salute e della Scienza, CPO-Piemonte, Turin, Italy
| | - Roderick Skinner
- Translational and Clinical Research Institute, Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, United Kingdom,Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Zsuzsanna Jakab
- Hungarian Childhood Cancer Registry, Semmelweis University, Budapest Hungary
| | - Cristina Veres
- Radiation Epidemiology Group, Inserm, UMR1018, Villejuif, France,Gustave Roussy, Department of Clinical Research, Villejuif, France,University of Paris-Saclay, Villejuif, France
| | - Nadia Haddy
- Radiation Epidemiology Group, Inserm, UMR1018, Villejuif, France,Gustave Roussy, Department of Clinical Research, Villejuif, France,University of Paris-Saclay, Villejuif, France
| | - David L. Winter
- Centre for Childhood Cancer Survivor Studies, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Florent de Vathaire
- Radiation Epidemiology Group, Inserm, UMR1018, Villejuif, France,Gustave Roussy, Department of Clinical Research, Villejuif, France,University of Paris-Saclay, Villejuif, France
| | - Michael M. Hawkins
- Centre for Childhood Cancer Survivor Studies, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Leontien C.M. Kremer
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands,Emma Children's Hospital, Amsterdam UMC, the Netherlands
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9
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McAleer MF, Melchior P, Parkes J, Pater L, Rübe C, Saunders D, Paulino AC, Janssens GO, Kalapurakal J. Harmonica consensus, controversies, and future directions in radiotherapy for pediatric Wilms tumors. Pediatr Blood Cancer 2022; 70 Suppl 2:e30090. [PMID: 36482883 DOI: 10.1002/pbc.30090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 10/16/2022] [Accepted: 10/18/2022] [Indexed: 12/13/2022]
Abstract
Radiotherapy (RT) is essential for multimodality treatment of pediatric renal tumors, particularly in higher-risk and metastatic disease. Despite decades of use, particularly for Wilms tumor, there remain controversies regarding RT indications, timing, dose, and targets. To align global management, we address these issues in this international HARMONIsation and CollAboration (HARMONICA) project. There are multiple knowledge gaps and opportunities for future research including: (1) utilization of advanced RT technologies, including intensity-modulated RT, proton beam therapy, combined with image-guided RT to reduce target volumes; (2) impact of molecular biomarkers including loss of heterozygosity at 1p, 16q, and 1q gain on RT indications; (3) mitigation of reproductive toxicity following RT; (4) promotion of RT late effects research; and (5) support to overcome challenges in RT utilization in low- and middle-income countries where 90% of the world's children reside. Here, we outline current status and future directions for RT in pediatric renal tumors.
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Affiliation(s)
- Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Patrick Melchior
- Department of Radiation Oncology, Saarland University Hospital, Homburg, Germany
| | - Jeannette Parkes
- Department of Radiation Oncology, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa.,Low- and Middle-Income Countries Committee Co-Chair, Paediatric Radiation Oncology Society, Cape Town, South Africa
| | - Luke Pater
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Christian Rübe
- Department of Radiation Oncology, Saarland University Hospital, Homburg, Germany
| | | | - Arnold C Paulino
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Geert O Janssens
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - John Kalapurakal
- Department of Radiation Oncology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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10
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Radiation-Induced Cardiovascular Toxicities. Curr Treat Options Oncol 2022; 23:1388-1404. [DOI: 10.1007/s11864-022-01012-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2022] [Indexed: 11/03/2022]
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11
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Ding L, Bradford C, Kuo IL, Fan Y, Ulin K, Khalifeh A, Yu S, Liu F, Saleeby J, Bushe H, Smith K, Bianciu C, LaRosa S, Prior F, Saltz J, Sharma A, Smyczynski M, Bishop-Jodoin M, Laurie F, Iandoli M, Moni J, Cicchetti MG, FitzGerald TJ. Radiation Oncology: Future Vision for Quality Assurance and Data Management in Clinical Trials and Translational Science. Front Oncol 2022; 12:931294. [PMID: 36033446 PMCID: PMC9399423 DOI: 10.3389/fonc.2022.931294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 06/21/2022] [Indexed: 11/13/2022] Open
Abstract
The future of radiation oncology is exceptionally strong as we are increasingly involved in nearly all oncology disease sites due to extraordinary advances in radiation oncology treatment management platforms and improvements in treatment execution. Due to our technology and consistent accuracy, compressed radiation oncology treatment strategies are becoming more commonplace secondary to our ability to successfully treat tumor targets with increased normal tissue avoidance. In many disease sites including the central nervous system, pulmonary parenchyma, liver, and other areas, our service is redefining the standards of care. Targeting of disease has improved due to advances in tumor imaging and application of integrated imaging datasets into sophisticated planning systems which can optimize volume driven plans created by talented personnel. Treatment times have significantly decreased due to volume driven arc therapy and positioning is secured by real time imaging and optical tracking. Normal tissue exclusion has permitted compressed treatment schedules making treatment more convenient for the patient. These changes require additional study to further optimize care. Because data exchange worldwide have evolved through digital platforms and prisms, images and radiation datasets worldwide can be shared/reviewed on a same day basis using established de-identification and anonymization methods. Data storage post-trial completion can co-exist with digital pathomic and radiomic information in a single database coupled with patient specific outcome information and serve to move our translational science forward with nimble query elements and artificial intelligence to ask better questions of the data we collect and collate. This will be important moving forward to validate our process improvements at an enterprise level and support our science. We have to be thorough and complete in our data acquisition processes, however if we remain disciplined in our data management plan, our field can grow further and become more successful generating new standards of care from validated datasets.
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Affiliation(s)
- Linda Ding
- Department of Radiation Oncology, UMass Chan Medical School, Worcester, MA, United States
| | - Carla Bradford
- Department of Radiation Oncology, UMass Chan Medical School, Worcester, MA, United States
| | - I-Lin Kuo
- Department of Radiation Oncology, UMass Chan Medical School, Worcester, MA, United States
| | - Yankhua Fan
- Department of Radiation Oncology, UMass Chan Medical School, Worcester, MA, United States
| | - Kenneth Ulin
- Department of Radiation Oncology, UMass Chan Medical School, Worcester, MA, United States
| | - Abdulnasser Khalifeh
- Department of Radiation Oncology, UMass Chan Medical School, Worcester, MA, United States
| | - Suhong Yu
- Department of Radiation Oncology, UMass Chan Medical School, Worcester, MA, United States
| | - Fenghong Liu
- Department of Radiation Oncology, UMass Chan Medical School, Worcester, MA, United States
| | - Jonathan Saleeby
- Department of Radiation Oncology, UMass Chan Medical School, Worcester, MA, United States
| | - Harry Bushe
- Department of Radiation Oncology, UMass Chan Medical School, Worcester, MA, United States
| | - Koren Smith
- Department of Radiation Oncology, UMass Chan Medical School, Worcester, MA, United States
| | - Camelia Bianciu
- Department of Radiation Oncology, UMass Chan Medical School, Worcester, MA, United States
| | - Salvatore LaRosa
- Department of Radiation Oncology, UMass Chan Medical School, Worcester, MA, United States
| | - Fred Prior
- Department of Biomedical Informatics, University of Arkansas, Little Rock, AR, United States
| | - Joel Saltz
- Department of Biomedical Informatics, Stony Brook University, Stony Brook, NY, United States
| | - Ashish Sharma
- Department of Biomedical Informatics, Emory University, Atlanta, GA, United States
| | - Mark Smyczynski
- Department of Radiation Oncology, UMass Chan Medical School, Worcester, MA, United States
| | - Maryann Bishop-Jodoin
- Department of Radiation Oncology, UMass Chan Medical School, Worcester, MA, United States
| | - Fran Laurie
- Department of Radiation Oncology, UMass Chan Medical School, Worcester, MA, United States
| | - Matthew Iandoli
- Department of Radiation Oncology, UMass Chan Medical School, Worcester, MA, United States
| | - Janaki Moni
- Department of Radiation Oncology, UMass Chan Medical School, Worcester, MA, United States
| | - M. Giulia Cicchetti
- Department of Radiation Oncology, UMass Chan Medical School, Worcester, MA, United States
| | - Thomas J. FitzGerald
- Department of Radiation Oncology, UMass Chan Medical School, Worcester, MA, United States
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12
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Brickler M, Raskin A, Ryan TD. Current State of Pediatric Cardio-Oncology: A Review. CHILDREN 2022; 9:children9020127. [PMID: 35204848 PMCID: PMC8870613 DOI: 10.3390/children9020127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/23/2021] [Accepted: 11/30/2021] [Indexed: 01/03/2023]
Abstract
The landscape of pediatric oncology has dramatically changed over the course of the past several decades with five-year survival rates surpassing 80%. Anthracycline therapy has been the cornerstone of many chemotherapy regimens for pediatric patients since its introduction in the 1960s, and recent improved survival has been in large part due to advancements in chemotherapy, refinement of supportive care treatments, and development of novel therapeutics such as small molecule inhibitors, chimeric antigen receptor T-cell therapy, and immune checkpoint inhibitors. Unfortunately, many cancer-targeted therapies can lead to acute and chronic cardiovascular pathologies. The range of cardiotoxicity can vary but includes symptomatic or asymptotic heart failure, arrhythmias, coronary artery disease, valvar disease, pericardial disease, hypertension, and peripheral vascular disease. There is lack of data guiding primary prevention and treatment strategies in the pediatric population, which leads to substantial practice variability. Several important future research directions have been identified, including as they relate to cardiac disease, prevention strategies, management of cardiovascular risk factors, risk prediction, early detection, and the role of genetic susceptibility in development of cardiotoxicity. Continued collaborative research will be key in advancing the field. The ideal model for pediatric cardio-oncology is a proactive partnership between pediatric cardiologists and oncologists in order to better understand, treat, and ideally prevent cardiac disease in pediatric oncology patients.
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Affiliation(s)
| | | | - Thomas D. Ryan
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA;
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13
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Laprie A, Bernier V, Padovani L, Martin V, Chargari C, Supiot S, Claude L. Guide for paediatric radiotherapy procedures. Cancer Radiother 2021; 26:356-367. [PMID: 34969622 DOI: 10.1016/j.canrad.2021.11.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
A third of children with cancer receive radiotherapy as part of their initial treatment, which represents 800 paediatric irradiations per year in France carried out in 15 specialized centres approved on the recommendations of the French national cancer institute in decreasing order of frequency, the types of cancer that require irradiation are: brain tumours, neuroblastomas, Ewing's sarcomas, Hodgkin's lymphomas, soft tissue sarcomas including rhabdomyosarcomas, and nephroblastomas. The treatment guidelines follow the recommendations of the French society for childhood cancers (SFCE) or the French and European prospective protocols. The therapeutic indications, the technical and/and ballistic choices of complex cases are frequently discussed during bimonthly paediatric radiotherapy technical web-conferences. All cancers combined, overall survival being 80%, long-term toxicity logically becomes an important concern, making the preparation of treatments complex. The irradiation methods include all the techniques currently available: 3D conformational irradiation, intensity modulation radiation therapy, irradiation under normal or hypofractionated stereotaxic conditions, brachytherapy and proton therapy. We present the update of the recommendations of the French society for radiation oncology on the indications, the technical methods of realization and the organisation and the specificities of paediatric radiation oncology.
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Affiliation(s)
- A Laprie
- Département d'oncologie radiothérapie, Institut universitaire du cancer de Toulouse-Oncopole (IUCT-oncopole), université Paul-Sabatier Toulouse III, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex 9, France.
| | - V Bernier
- Département d'oncologie radiothérapie, Institut de cancérologie de Lorraine centre Alexis-Vautrin, 6, avenue de Bourgogne, CS 30519, 54519 Vandœuvre-lès-Nancy cedex, France
| | - L Padovani
- Département de cancérologie radiothérapie, CHU, 13000 Marseille, France; Université Aix-Marseille, 13000 Marseille, France
| | - V Martin
- Département de cancérologie radiothérapie, institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif cedex, France
| | - C Chargari
- Département d'oncologie radiothérapie, institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif cedex, France; Service de santé des armées, 75000 Paris, France
| | - S Supiot
- Département de radiothérapie, Institut de cancérologie de l'Ouest (ICO) centre René-Gauducheau, 44800 Saint-Herblain, France; Université de Nantes, 44000 Nantes, France
| | - L Claude
- Département d'oncologie radiothérapie, centre Léon-Bérard, 28, rue Laennec, 69373 Lyon cedex 08, France
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14
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Parekh AD, Indelicato DJ, Hoppe BS, Vega RBM, Rotondo RL, Bradley JA. Pulmonary dose tolerance in hemithorax radiotherapy for Ewing sarcoma of the chest wall: Are we overestimating the risk of radiation pneumonitis? Pediatr Blood Cancer 2021; 68:e29287. [PMID: 34398486 DOI: 10.1002/pbc.29287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 07/28/2021] [Accepted: 08/02/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Children with chest wall Ewing sarcoma with malignant pulmonary effusion or pleural stranding require hemithorax radiation, often with plans that exceed lung constraints. We investigated disease control and pneumonitis in children requiring hemithorax radiation. PROCEDURE Eleven children (median age 13 years) received hemithorax radiotherapy. Symptomatic radiation pneumonitis was considered National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) grade 1+ with respiratory symptoms. Mean lung dose (MLD), volume of lung exposed to a dose ≥5 Gy (V5), ≥20 Gy (V20), and ≥35 Gy (V35) were recorded. Adult and pediatric lung constraints were obtained from Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC) guidelines and Children's Oncology Group (COG) protocols, respectively. RESULTS Median hemithorax dose was 15 Gy (1.5 Gy/fraction). Median total dose was 51 Gy (1.8 Gy/fraction). Most plans delivered both protons and photons. The ipsilateral MLD, V5, and V20 were 27.2 Gy, 100%, and 48.3%; the bilateral MLD, V20, and V35 were 14.1 Gy, 22.8%, and 14.3%, respectively. One hundred percent, 36%, and 91% of treatments exceeded recommended adult ipsilateral lung constraints of V5 <65%, V20 <52%, and MLD of 22 Gy; 64%, 45%, and 82% exceeded COG bilateral lung constraints of V20 <20%, MLD <15 Gy, and MLD <12 Gy, respectively; 82% of treatments exceeded the COG ipsilateral lung constraint of V20 <30%. At a median 36 months (range 12-129), the symptomatic radiation pneumonitis incidence was 0%. Two patients progressed with nonpulmonary metastatic disease and died at a median 12 months following radiotherapy. CONCLUSIONS Existing guidelines may overestimate pneumonitis risk, even among young children receiving multiagent chemotherapy. For children with chest wall Ewing sarcoma and other thoracic malignancies, more data are needed to refine pediatric dose-effect models for pulmonary toxicity.
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Affiliation(s)
- Akash D Parekh
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Ronny L Rotondo
- Department of Radiation Oncology, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
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15
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Balis F, Green DM, Anderson C, Cook S, Dhillon J, Gow K, Hiniker S, Jasty-Rao R, Lin C, Lovvorn H, MacEwan I, Martinez-Agosto J, Mullen E, Murphy ES, Ranalli M, Rhee D, Rokitka D, Tracy EL, Vern-Gross T, Walsh MF, Walz A, Wickiser J, Zapala M, Berardi RA, Hughes M. Wilms Tumor (Nephroblastoma), Version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2021; 19:945-977. [PMID: 34416707 DOI: 10.6004/jnccn.2021.0037] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The NCCN Guidelines for Wilms Tumor focus on the screening, diagnosis, staging, treatment, and management of Wilms tumor (WT, also known as nephroblastoma). WT is the most common primary renal tumor in children. Five-year survival is more than 90% for children with all stages of favorable histology WT who receive appropriate treatment. All patients with WT should be managed by a multidisciplinary team with experience in managing renal tumors; consulting a pediatric oncologist is strongly encouraged. Treatment of WT includes surgery, neoadjuvant or adjuvant chemotherapy, and radiation therapy (RT) if needed. Careful use of available therapies is necessary to maximize cure and minimize long-term toxicities. This article discusses the NCCN Guidelines recommendations for favorable histology WT.
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Affiliation(s)
- Frank Balis
- Abramson Cancer Center at the University of Pennsylvania
| | - Daniel M Green
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | - Shelly Cook
- University of Wisconsin Carbone Cancer Center
| | | | - Kenneth Gow
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | | | | | - Chi Lin
- Fred & Pamela Buffett Cancer Center
| | | | | | | | | | - Erin S Murphy
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | - Mark Ranalli
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Daniel Rhee
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | | | | | | | | | - Amy Walz
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | - Matthew Zapala
- UCSF Helen Diller Family Comprehensive Cancer Center; and
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16
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Pater L, Melchior P, Rübe C, Cooper BT, McAleer MF, Kalapurakal JA, Paulino AC. Wilms tumor. Pediatr Blood Cancer 2021; 68 Suppl 2:e28257. [PMID: 32893998 DOI: 10.1002/pbc.28257] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 02/24/2020] [Accepted: 02/25/2020] [Indexed: 01/03/2023]
Abstract
The objectives for the treatment of Wilms tumor in both the Children's Oncology Group (COG) and the International Society of Paediatric Oncology (SIOP) have focused on improving cure rates and minimizing toxicity by limiting the use of radiation and doxorubicin. Although the timing of surgery is different in COG (upfront surgery) and SIOP (upfront chemotherapy with delayed surgery), both are effective strategies and have the same survival. Fewer patients are treated with radiotherapy in the SIOP trials but with higher doses. The prognostic significance of biological markers such as 1q gain and clinical outcomes with novel radiation techniques such as intensity modulated radiation therapy will be determined in upcoming clinical trials. A closer collaboration between COG and SIOP could help promote research and improve the clinical outcomes of children with Wilms tumor.
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Affiliation(s)
- Luke Pater
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, Ohio
| | - Patrick Melchior
- Department of Radiation Oncology, Saarland University Hospital, Homburg, Germany
| | - Christian Rübe
- Department of Radiation Oncology, Saarland University Hospital, Homburg, Germany
| | - Benjamin T Cooper
- Department of Radiation Oncology, Perlmutter Cancer Center, New York University School of Medicine, New York, New York
| | - Mary Fran McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - John A Kalapurakal
- Department of Radiation Oncology, Northwestern University, Chicago, Illinois
| | - Arnold C Paulino
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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17
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Hua CH, Mascia AE, Servalli E, Lomax AJ, Seiersen K, Ulin K. Advances in radiotherapy technology for pediatric cancer patients and roles of medical physicists: COG and SIOP Europe perspectives. Pediatr Blood Cancer 2021; 68 Suppl 2:e28344. [PMID: 33818892 PMCID: PMC8030241 DOI: 10.1002/pbc.28344] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/27/2020] [Accepted: 04/02/2020] [Indexed: 11/11/2022]
Abstract
Over the last two decades, rapid technological advances have dramatically changed radiation delivery to children with cancer, enabling improved normal-tissue sparing. This article describes recent advances in photon and proton therapy technologies, image-guided patient positioning, motion management, and adaptive therapy that are relevant to pediatric cancer patients. For medical physicists who are at the forefront of realizing the promise of technology, challenges remain with respect to ensuring patient safety as new technologies are implemented with increasing treatment complexity. The contributions of medical physicists to meeting these challenges in daily practice, in the conduct of clinical trials, and in pediatric oncology cooperative groups are highlighted. Representing the perspective of the physics committees of the Children's Oncology Group (COG) and the European Society for Paediatric Oncology (SIOP Europe), this paper provides recommendations regarding the safe delivery of pediatric radiotherapy. Emerging innovations are highlighted to encourage pediatric applications with a view to maximizing the therapeutic ratio.
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Affiliation(s)
- Chia-ho Hua
- Department of Radiation Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Anthony E. Mascia
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Enrica Servalli
- Department of Radiotherapy, University Medical Center Utrecht, The Netherlands
| | - Antony J. Lomax
- Center for Proton Therapy, Paul Scherrer Institute, PSI Villigen, Switzerland
| | | | - Kenneth Ulin
- Department of Radiation Oncology, University of Massachusetts, Worcester, Massachusetts, USA
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18
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Mul J, van Grotel M, Seravalli E, Bosman ME, van Tinteren H, Roy P, Dávila Fajardo R, Tytgat GAM, Mavinkurve-Groothuis AMC, van de Ven CP, Wijnen MHWA, de Krijger RR, Littooij AS, van den Heuvel-Eibrink MM, Janssens GO. Locoregional control using highly conformal flank target volumes and volumetric-modulated arc therapy in pediatric renal tumors: Results from the Dutch national cohort. Radiother Oncol 2021; 159:249-254. [PMID: 33845042 DOI: 10.1016/j.radonc.2021.04.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 03/24/2021] [Accepted: 04/01/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE In pediatric renal tumors, conventional two opposing photon beams have been used to cover the postoperative flank target volume for decades. This single center study describes the locoregional outcome using highly conformal flank target volumes adjusted for postoperative changes and intra-fraction motion combined with Volumetric-Modulated Arc Therapy (VMAT). MATERIALS AND METHODS Between 01-2015 and 12-2019, 36/161 newly diagnosed patients with renal tumors underwent flank only irradiation (n = 30) or flank + whole lung irradiation (n = 6) using highly conformal target volumes in line with the SIOP-RTSG consensus statement. VMAT consisted of full-arc 10MV photon beams optimized for constraints of the organs at risk. In case of locoregional relapses, image co-registration and dose reconstruction was performed. Each relapse was classified as either 'infield' (V95%relapse: ≥99.0%), 'marginal' (V95%relapse: 20.0-98.9%) or 'outfield' (V95%relapse: 0-19.9%). RESULTS At a median follow-up from diagnosis of 3.1 years (range:0.4-5.7), the estimated 2-year Locoregional Control Rate, Disease-Free Interval and Overall Survival were 94%, 91% and 94%, respectively. Locoregional relapse was observed in two patients. One patient had a combined tumor bed and regional recurrence, classified as infield (V95%relapse: 100%) and outfield (V95%relapse: 1.2%). The second patient had a regional relapse in the inferior vena cava classified as marginal recurrence (V95%relapse: 93%). Relapses would not have been adequately covered by conventional beams. CONCLUSIONS This single center analysis provides encouraging evidence that excellent locoregional control can be obtained by using highly conformal flank target volumes with VMAT in pediatric renal tumors. The safety of this approach will be validated in a prospective multicenter study.
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Affiliation(s)
- Joeri Mul
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands; Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | | | - Enrica Seravalli
- Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Mirjam E Bosman
- Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Harm van Tinteren
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Prakriti Roy
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Raquel Dávila Fajardo
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands; Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | | | | | | | - Marc H W A Wijnen
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Ronald R de Krijger
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands; Department of Pathology, University Medical Center Utrecht, The Netherlands
| | - Annemieke S Littooij
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands; Department of Radiology, University Medical Center Utrecht, The Netherlands
| | | | - Geert O Janssens
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands; Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands.
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19
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Wong RX, Faught J, Gargone M, Myers W, Krasin M, Faught A, Acharya S. Cardiac-Sparing and Breast-Sparing Whole Lung Irradiation Using Intensity-Modulated Proton Therapy. Int J Part Ther 2021; 7:65-73. [PMID: 33829074 PMCID: PMC8019572 DOI: 10.14338/ijpt-20-00079.1] [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: 10/23/2020] [Accepted: 01/12/2021] [Indexed: 11/24/2022] Open
Abstract
PURPOSE Whole lung irradiation (WLI) is indicated for certain pediatric patients with lung metastases. This study investigated whether WLI delivered as intensity-modulated proton therapy (IMPT) could significantly spare the heart and breasts when compared with conventional WLI delivered with anteroposterior/posteroanterior photon fields and with intensity-modulated photon therapy (IMRT) WLI. MATERIALS AND METHODS Conventional, IMRT, and IMPT plans were generated for 5 patients (aged 5-22 years). The prescription dose was 16.5 GyRBE in 1.5-GyRBE fractions. Conventional plans used 6-MV photons prescribed to the midline and a field-in-field technique to cover the planning target volume (the internal target volume [ITV] + 1 cm). IMRT plans used 6-MV photons with a 7-beam arrangement with dose prescribed to the planning target volume. IMPT plans used scenario-based optimization with 5% range uncertainty and 5-mm positional uncertainty to cover the ITV robustly. Monte Carlo dose calculation was used for all IMPT plans. Doses were compared with paired Student t test. RESULTS The ITV Dmean was similar for the IMPT, conventional, and IMRT plans, but the IMPT plans had a lower Dmin and a higher Dmax at tissue interfaces than conventional plans (Dmean ratio: 0.96, P > .05; Dmin ratio: 0.9, P < .001; Dmax ratio: 1.1, P = .014). Dmeans for breast and heart substructures were lower with IMPT plans than with conventional/IMRT plans (heart ratios, 0.63:0.73; left ventricle ratios, 0.61:0.72; right ventricle ratios, 0.45:0.57; left atrium ratios, 0.79:0.85; right atrium ratios, 0.81:0.86; left breast ratios, 0.40:0.51; right breast ratio, 0.46:0.52; all P < .05). CONCLUSIONS IMPT resulted in comparable ITV coverage and lower mean doses to the heart and breasts when compared with other techniques. Whole lung irradiation delivered as IMPT warrants prospective evaluation in pediatric patients.
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Affiliation(s)
- Ru Xin Wong
- Department of Radiation Oncology, National Cancer Centre, Singapore
| | - Jacqueline Faught
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Melissa Gargone
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - William Myers
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Matthew Krasin
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Austin Faught
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Sahaja Acharya
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
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Sha X, Duan J, Lin X, Zhu J, Zhang R, Sun T, Wang H, Meng X, Yin Y. A New Proton Therapy Solution Provides Superior Cardiac Sparing Compared With Photon Therapy in Whole Lung Irradiation for Pediatric Tumor Patients. Front Oncol 2021; 10:611514. [PMID: 33604292 PMCID: PMC7884855 DOI: 10.3389/fonc.2020.611514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 12/14/2020] [Indexed: 11/21/2022] Open
Abstract
Objective Whole lung irradiation (WLI) plays a crucial role in local control in pediatric patients with lung metastases and improves patient survival. The intention of this research was to explore the advantage of cardiac sparing between photons and protons during WLI. We also propose a new solution for cardiac sparing with proton techniques. Methods Eleven patients with pediatric tumors and pulmonary metastasis treated with 12 Gy WLI (all received volumetric-modulated arc therapy (VMAT)) in our institute between 2010 and 2019 were retrospectively selected. Each patient was replanned with intensity-modulated radiation therapy (IMRT), helical tomotherapy (HT), and two intensity-modulated proton radiotherapy (IMPT) plans (IMPT-1 and IMPT-2). IMPT-1 considered the whole lung as the planning target volume (PTV), utilizing the anteroposterior technique (0/180°). IMPT-2 was a new proton solution that we proposed in this research. This approach considered the unilateral lung as the PTV, and 3 ipsilateral fields were designed for each lung. Then, IMPT-2 was generated by summing two unilateral lung plans. The primary objective was to obtain adequate coverage (95% of the prescription dose to the PTV) while maximally sparing the dose to the heart. The PTV coverage, conformity index (CI), homogeneity index (HI), and dose–volume statistics of the heart and substructures were assessed by means of the averages of each comparison parameter. Results All treatment techniques achieved the target volume coverage required by clinical practice. HT yielded the best coverage and homogeneity for the target structure compared with other techniques. The CI from IMRT was excellent. For photon radiation therapy, the HT plan afforded superior dose sparing for the V5, V6, V7, V8, and Dmean of the heart and Dmean of the right ventricle (RV). IMRT displayed the most notable dose reductions in the V9, V10, V11, and V12 of the heart and Dmean of the right atrium (RA). The VMAT plan was the least effective on the heart and substructures. However, compared with photon radiation therapy, IMPT-1 did not show an advantage for heart protection. Interestingly, IMPT-2 provided significant superiority in cardiac sparing, including maximum dose sparing for the V5, V6, V7, V8, V9 and Dmean of the heart and Dmean of the RA, RV, left atrium (LA) and left ventricle (LV) compared to all other techniques. Conclusions Considering the complex anatomical relation between target volumes and organs at risk (OARs), IMPT can provide a dose advantage for organs located outside of the target area rather than within or surrounding the area. It is hoped that advances in proton therapy (PT) plan design will lead to further improvements in radiotherapy approaches and provide the best treatment choice for individual patients.
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Affiliation(s)
- Xue Sha
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Jinghao Duan
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Xiutong Lin
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Jian Zhu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China.,Shandong Provincial Key Laboratory of Digital Medicine and Computer-Assisted Surgery, Qingdao, China
| | - Ruohui Zhang
- Department of Radiation Oncology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Tao Sun
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Hui Wang
- Department of Radiation Oncology, Qingdao Central Hospital, Qingdao, China
| | - Xiangjuan Meng
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Yong Yin
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
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21
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Mul J, van de Ven CP, Seravalli E, Littooij AS, Wijnen MHWA, van Grotel M, van den Heuvel-Eibrink MM, Janssens GO. The contribution of surgical clips for optimizing highly-conformal image-guided flank irradiation in pediatric renal tumors: A single center experience. Radiother Oncol 2020; 156:62-68. [PMID: 33310005 DOI: 10.1016/j.radonc.2020.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 11/17/2020] [Accepted: 12/01/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND AIMS Two-opposing photon beams are considered standard of care for flank irradiation in pediatric patients with renal tumors. Nowadays, Image-Guided Radiotherapy (IGRT) techniques allow high-precision dose delivery to complex flank target volumes taking into account postoperative organ shifts and tumor bed motion. This study examines the contribution of a lateral and superior surgical clip on flank target volume delineation intended for IGRT. METHODS Between 01-2015 and 09-2019, 30/162 newly-diagnosed pediatric patients with renal tumors, lateral/superior surgical clips (n = 30/30) and available 4D-CT-scans (n = 27/30), underwent postoperative flank irradiation. The lateral and superior clip, as respective markers for the lateral tumor extension and intrafraction motion, were analyzed. The positive and negative values depict the lateral/dorsal/cranial or the medial/ventral/caudal direction, respectively. Planning target volumes (PTV) were generated based on lateral clips (PTVlatclip), superior clips with 4D-CT technology (PTVsupclip), and both clips combined (PTVcombined), and compared to an approach without clips (PTVnoclip). RESULTS Indicated by clips, the mean lateral tumor bed extension along the posterior wall was 74° (range: 50°-93°), while mean intrafraction motion was +1.2 mm (range: -1.8/+4.8 mm), +0.6 mm (range: +0.6/+4.9 mm), -0.3 mm (range: -3.8/+0.7 mm) in craniocaudal, ventrodorsal, mediolateral direction, respectively. The median PTVnoclip (556 mL) was statistically different from the median PTVlatclip (454 mL, p = <0.01), median PTVsupclip (373 mL, p = <0.01) and median PTVcombined (348 mL p = <0.01). CONCLUSION In pediatric patients with renal tumors, surgical clips at the lateral and superior border of the tumor bed can optimize flank target volume delineation and, consequently, reduce the normal tissue volume receiving high-dose irradiation when IGRT techniques are applied.
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Affiliation(s)
- Joeri Mul
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands; Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | | | - Enrica Seravalli
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Annemieke S Littooij
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands; Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marc H W A Wijnen
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | | | | | - Geert O Janssens
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands; Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
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The SIOP-Renal Tumour Study Group consensus statement on flank target volume delineation for highly conformal radiotherapy. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 4:846-852. [PMID: 33068550 DOI: 10.1016/s2352-4642(20)30183-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/22/2020] [Accepted: 05/29/2020] [Indexed: 12/20/2022]
Abstract
For decades, radiotherapy with two opposing photon beams has been the standard technique used to cover the flank target volume in paediatric patients with renal tumours. Nowadays, many institutes are implementing advanced radiotherapy techniques that spare healthy tissue. To decrease the radiotherapy dose to healthy structures while preserving oncological efficacy, the conventional approach of flank irradiation has been adapted into a guideline for highly conformal flank target-volume delineation by paediatric radiation oncologists and representatives of the International Society of Paediatric Oncology's Renal Tumour Study Group (SIOP-RTSG) board during four live international consensus meetings. The consensus was refined by delineation exercises and videoconferences by ten collaborating paediatric radiation oncologists. The final guideline includes eight chronological steps to generate the tumour bed and clinical, internal, and planning target volumes, and it describes the optional use of surgical clips to optimise treatment planning. This guideline will be added into the radiotherapy guideline of the UMBRELLA SIOP-RTSG protocol for paediatric renal tumours to improve international consistency of highly conformal flank target-volume delineation.
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Suzuki G, Ogata T, Aibe N, Yamazaki H, Yagyu S, Iehara T, Hosoi H, Yamada K. Effective heart-sparing whole lung irradiation using volumetric modulated arc therapy: a case report. J Med Case Rep 2019; 13:277. [PMID: 31474226 PMCID: PMC6717977 DOI: 10.1186/s13256-019-2209-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 07/30/2019] [Indexed: 01/04/2023] Open
Abstract
Background Late cardiovascular disease-related adverse events are one of the most common causes of premature mortality among long-term survivors of childhood cancer. As it is difficult to reduce the heart dose with traditional anteroposterior–posteroanterior field whole lung irradiation for pulmonary metastasis, improved radiation techniques are highly desirable. We report a case treated with whole lung irradiation using volumetric modulated arc therapy. Case presentation A 3-year-old Japanese girl with pulmonary metastases of Wilms’ tumor received 12 Gy in 8 fractions of whole lung irradiation using volumetric modulated arc therapy. The treatment was well tolerated, and the course was completed as planned without any toxicity. We found statistically significant reduced volumetric modulated arc therapy irradiation doses to organs at risk relative to those of the standard anteroposterior–posteroanterior field technique. The mean heart dose was 8.5 Gy for volumetric modulated arc therapy and 12.3 Gy for the anteroposterior–posteroanterior field. The doses to liver and thyroid were also more favorable with volumetric modulated arc therapy than with the anteroposterior–posteroanterior field technique. We confirmed the dosimetric advantages of volumetric modulated arc therapy over anteroposterior–posteroanterior field in whole lung irradiation in terms of superior normal organ protection. Conclusions Effective heart sparing is possible for whole lung irradiation using volumetric modulated arc therapy. Large-scale studies using standardized procedures should be conducted to validate our results.
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Affiliation(s)
- Gen Suzuki
- Department of Radiology, Kyoto Prefectural University Graduate School of Medical Science, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan.
| | - Toshiyuki Ogata
- Department of Radiology, Kyoto Prefectural University Graduate School of Medical Science, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Norihiro Aibe
- Department of Radiology, Kyoto Prefectural University Graduate School of Medical Science, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Hideya Yamazaki
- Department of Radiology, Kyoto Prefectural University Graduate School of Medical Science, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Shigeki Yagyu
- Department of Pediatrics, Kyoto Prefectural University Graduate School of Medical Science, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Tomoko Iehara
- Department of Pediatrics, Kyoto Prefectural University Graduate School of Medical Science, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Hajime Hosoi
- Department of Pediatrics, Kyoto Prefectural University Graduate School of Medical Science, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Kei Yamada
- Department of Radiology, Kyoto Prefectural University Graduate School of Medical Science, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
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Kalapurakal JA, Lee B, Bautista J, Rigsby C, Helenowski I, Gopalakrishnan M. Cardiac-Sparing Whole Lung Intensity Modulated Radiation Therapy in Children With Wilms Tumor: Final Report on Technique and Abdominal Field Matching to Maximize Normal Tissue Protection. Pract Radiat Oncol 2018; 9:e62-e73. [PMID: 30096378 DOI: 10.1016/j.prro.2018.07.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 07/23/2018] [Accepted: 07/28/2018] [Indexed: 11/15/2022]
Abstract
PURPOSE Cardiac-sparing whole lung intensity modulated radiation therapy (WL IMRT) has been shown to improve cardiac protection and lung volume dose coverage compared with standard anteroposterior techniques. This dosimetry study had 2 aims: To determine the dosimetric advantages of a modified WL IMRT (M-WL IMRT) technique, designed to reduce radiation exposure to the thyroid gland and breast tissues, compared with standard WL IMRT (S-WL IMRT) and to determine the dosimetric advantages of M-WL IMRT and dosimetrically matched abdomen and flank radiation therapy (RT) fields designed to reduce normal tissue exposure compared with standard field matching techniques. METHODS AND MATERIALS Computed tomography scans of the chest and abdomen that were obtained during computed tomography simulation of 10 female children were used. For Aim 1, for S-WL IMRT, the planning target volume (PTV) was obtained with a 1-cm expansion of the 4-dimensional lung volume (internal target volume). For M-WL IMRT, the PTV was reduced around the breast and thyroid gland to facilitate thyroid and breast sparing. For Aim 2, standard matching techniques for 3-dimensional anterior/posterior-posterior/anteriorwhole lung and abdominal RT fields were compared with a new dosimetric matching technique for WL IMRT and abdomen and flank fields. For both aims, the dose coverage of the lungs and radiation exposure to normal tissues (heart, thyroid, breasts) were statistically compared. RESULTS Compared with S-WL IMRT, the M-WL IMRT technique provided similar lung PTV dose coverage and a significantly superior reduction in mean breast and thyroid doses, without compromising cardiac protection. The M-WL IMRT technique combined with a dosimetrically matched abdomen and flank fields showed significantly superior normal tissue protection compared with standard matched anterior/posterior-posterior/anteriorlung and abdomen and flank RT fields. CONCLUSIONS This study has shown that the M-WL IMRT technique can reduce radiation exposure to the thyroid gland and breast tissue without compromising cardiac protection and 4-dimensional lung volume dose coverage. This report also describes a new dosimetric matching technique between WL IMRT and abdomen and flank fields that will improve normal tissue sparing compared with standard techniques.
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Affiliation(s)
- John A Kalapurakal
- Northwestern University, Chicago, Illinois; Northwestern Memorial Hospital, Chicago, Illinois.
| | - Bryan Lee
- Northwestern Memorial Hospital, Chicago, Illinois
| | | | - Cynthia Rigsby
- Northwestern Memorial Hospital, Chicago, Illinois; Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois
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