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Wang D, Yin Y, Zhou Q, Li Z, Ma X, Yin Y, Li B, Bai T, Li D, Zhu J. Dosimetric predictors and Lyman normal tissue complication probability model of hematological toxicity in cervical cancer patients with treated with pelvic irradiation. Med Phys 2022; 49:756-767. [PMID: 34800297 PMCID: PMC9299660 DOI: 10.1002/mp.15365] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 11/01/2021] [Accepted: 11/07/2021] [Indexed: 12/25/2022] Open
Abstract
PURPOSE To identify dosimetric parameters associated with acute hematological toxicity (HT) and identify the corresponding normal tissue complication probability (NTCP) model in cervical cancer patients receiving helical tomotherapy (Tomo) or fixed-field intensity-modulated radiation therapy (ff-IMRT) in combination with chemotherapy, that is, concurrent chemoradiotherapy (CCRT) using the Lyman-Kutcher-Burman normal tissue complication probability (LKB-NTCP) model. METHODS Data were collected from 232 cervical cancer patients who received Tomo or ff-IMRT from 2015 to 2018. The pelvic bone marrow (PBM) (including the ilium, pubes, ischia, acetabula, proximal femora, and lumbosacral spine) was contoured from the superior boundary (usually the lumbar 5 vertebra) of the planning target volume (PTV) to the proximal end of the femoral head (the lower edge of the ischial tubercle). The parameters of the LKB model predicting ≥grade 2 hematological toxicity (Radiation Therapy Oncology Group [RTOG] grading criteria) (TD50 (1), m, and n) were determined using maximum likelihood analyses. Univariate and multivariate logistic regression analyses were used to identify correlations between dose-volume parameters and the clinical factors of HT. RESULTS In total, 212 (91.37%) patients experienced ≥grade 2 hematological toxicity. The fitted normal tissue complication probability model parameters were TD50 (1) = 38.90 Gy (95%CI, [36.94, 40.96]), m = 0.13 (95%CI [0.12, 0.16]), and n = 0.04 (95%CI [0.02, 0.05]). Per the univariate analysis, the NTCP (the use of LKB-NTCP with the set of model parameters found, p = 0.023), maximal PBM dose (p = 0.01), mean PBM dose (p = 0.021), radiation dose (p = 0.001), and V16-53 (p < 0. 05) were associated with ≥grade 2 HT. The NTCP (the use of LKB-NTCP with the set of model parameters found, p = 0.023; AUC = 0.87), V16, V17, and V18 ≥ 79.65%, 75.68%, and 72.65%, respectively (p < 0.01, AUC = 0.66∼0.68), V35 and V36 ≥ 30.35% and 28.56%, respectively (p < 0.05; AUC = 0.71), and V47 ≥ 13.43% (p = 0.045; AUC = 0.80) were significant predictors of ≥grade 2 hematological toxicity from the multivariate logistic regression analysis. CONCLUSIONS The volume of the PBM of patients treated with concurrent chemoradiotherapy and subjected to both low-dose (V16-18 ) and high-dose (V35,36 and V47 ) irradiation was associated with hematological toxicity, depending on the fractional volumes receiving the variable degree of dosage. The NTCP were stronger predictors of toxicity than V16-18 , V35, 36 , and V47 . Hence, avoiding radiation hot spots on the PBM could reduce the incidence of severe HT.
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Affiliation(s)
- Dandan Wang
- Department of Radiation Oncology Physics and TechnologyShandong Cancer Hospital and InstituteShandong First Medical University and Shandong Academy of Medical SciencesJinanP. R. China
| | - Yueju Yin
- Department of Gynecological OncologyShandong Cancer Hospital and InstituteShandong First Medical University and Shandong Academy of Medical SciencesJinanP. R. China
| | - Qichao Zhou
- Manteia Technologies Co., LtdXiamenP. R. China
| | - Zirong Li
- Manteia Technologies Co., LtdXiamenP. R. China
| | - Xingmin Ma
- Department of Radiation Oncology Physics and TechnologyShandong Cancer Hospital and InstituteShandong First Medical University and Shandong Academy of Medical SciencesJinanP. R. China
| | - Yong Yin
- Department of Radiation Oncology Physics and TechnologyShandong Cancer Hospital and InstituteShandong First Medical University and Shandong Academy of Medical SciencesJinanP. R. China
| | - Baosheng Li
- Shandong Medical Imaging and Radiotherapy Engineering CenterJinanP. R. China
| | - Tong Bai
- Department of Radiation Oncology Physics and TechnologyShandong Cancer Hospital and InstituteShandong First Medical University and Shandong Academy of Medical SciencesJinanP. R. China
| | - Dapeng Li
- Department of Gynecological OncologyShandong Cancer Hospital and InstituteShandong First Medical University and Shandong Academy of Medical SciencesJinanP. R. China
| | - Jian Zhu
- Department of Radiation Oncology Physics and TechnologyShandong Cancer Hospital and InstituteShandong First Medical University and Shandong Academy of Medical SciencesJinanP. R. China
- Shandong Medical Imaging and Radiotherapy Engineering CenterJinanP. R. China
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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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von Reibnitz D, Yorke ED, Oh JH, Apte AP, Yang J, Pham H, Thor M, Wu AJ, Fleisher M, Gelb E, Deasy JO, Rimner A. Predictive Modeling of Thoracic Radiotherapy Toxicity and the Potential Role of Serum Alpha-2-Macroglobulin. Front Oncol 2020; 10:1395. [PMID: 32850450 PMCID: PMC7423838 DOI: 10.3389/fonc.2020.01395] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 07/02/2020] [Indexed: 12/25/2022] Open
Abstract
Background: To investigate the impact of alpha-2-macroglobulin (A2M), a suspected intrinsic radioprotectant, on radiation pneumonitis and esophagitis using multifactorial predictive models. Materials and Methods: Baseline A2M levels were obtained for 258 patients prior to thoracic radiotherapy (RT). Dose-volume characteristics were extracted from treatment plans. Spearman's correlation (Rs) test was used to correlate clinical and dosimetric variables with toxicities. Toxicity prediction models were built using least absolute shrinkage and selection operator (LASSO) logistic regression on 1,000 bootstrapped datasets. Results: Grade ≥2 esophagitis and pneumonitis developed in 61 (23.6%) and 36 (14.0%) patients, respectively. The median A2M level was 191 mg/dL (range: 94-511). Never/former/current smoker status was 47 (18.2%)/179 (69.4%)/32 (12.4%). We found a significant negative univariate correlation between baseline A2M levels and esophagitis (Rs = -0.18/p = 0.003) and between A2M and smoking status (Rs = 0.13/p = 0.04). Further significant parameters for grade ≥2 esophagitis included age (Rs = -0.32/p < 0.0001), chemotherapy use (Rs = 0.56/p < 0.0001), dose per fraction (Rs = -0.57/p < 0.0001), total dose (Rs = 0.35/p < 0.0001), and several other dosimetric variables with Rs > 0.5 (p < 0.0001). The only significant non-dosimetric parameter for grade ≥2 pneumonitis was sex (Rs = -0.32/p = 0.037) with higher risk for women. For pneumonitis D15 (lung) (Rs = 0.19/p = 0.006) and D45 (heart) (Rs = 0.16/p = 0.016) had the highest correlation. LASSO models applied on the validation data were statistically significant and resulted in areas under the receiver operating characteristic curve of 0.84 (esophagitis) and 0.78 (pneumonitis). Multivariate predictive models did not require A2M to reach maximum predictive power. Conclusion: This is the first study showing a likely association of higher baseline A2M values with lower risk of radiation esophagitis and with smoking status. However, the baseline A2M level was not a significant risk factor for radiation pneumonitis.
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Affiliation(s)
- Donata von Reibnitz
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Ellen D Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Jung Hun Oh
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Aditya P Apte
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Jie Yang
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Hai Pham
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Maria Thor
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Martin Fleisher
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Emily Gelb
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Joseph O Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
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Meijers A, Seller OC, Free J, Bondesson D, Seller Oria C, Rabe M, Parodi K, Landry G, Langendijk JA, Both S, Kurz C, Knopf AC. Assessment of range uncertainty in lung-like tissue using a porcine lung phantom and proton radiography. ACTA ACUST UNITED AC 2020; 65:155014. [DOI: 10.1088/1361-6560/ab91db] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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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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Wang Z, Chen M, Sun J, Jiang S, Wang L, Wang X, Sahoo N, Gunn GB, Frank SJ, Nguyen QN, Liao Z, Chang JY, Zhu XR, Zhang X. Lyman-Kutcher-Burman normal tissue complication probability modeling for radiation-induced esophagitis in non-small cell lung cancer patients receiving proton radiotherapy. Radiother Oncol 2020; 146:200-204. [PMID: 32220701 PMCID: PMC10035357 DOI: 10.1016/j.radonc.2020.03.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/31/2020] [Accepted: 03/02/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE To develop and test an Lyman-Kutcher-Burman (LKB) normal tissue complication probability (NTCP) model to predict radiation-induced esophagitis (RE) in non-small cell lung cancer (NSCLC) patients receiving passive-scattering proton therapy (PSPT). MATERIAL AND METHODS We retrospectively reviewed 328 NSCLC patients receiving PSPT at our institution. Esophagitis severity was graded by physicians according to the Common Toxicity Criteria for Adverse Events version 3.0, and the primary endpoint was grade ≥2 RE within 6 months from the first treatment. LKB model parameters (n, m, and TD50) were determined using maximum likelihood estimation. Overall performance of the model was quantified by Nagelkerke's R2 and the scaled Brier score. Discriminative ability was evaluated using the area under the receiver operating curve (AUC), and calibration was assessed with the Hosmer-Lemeshow goodness-of-fit test. Bootstrap internal validation was performed to assess the model uncertainty and generalizability. RESULTS Grade 2-3 RE was observed in 136 (41.5%) patients, and no grade 4-5 RE was reported. The optimal LKB parameters were: n = 0.24, m = 0.51, and TD50 = 44.83 Gy (relative biological effectiveness). The optimism-corrected AUC was 0.783, and the Hosmer-Lemeshow test showed significant agreement between predicted and observed morbidity. Bootstrap validation verified that the model was robust to similar future populations. CONCLUSION Our LKB NTCP model to predict grade ≥2 RE in NSCLC patients who received PSPT showed good predictive performance and robustness to similar future populations, and a smaller volume effect than the previously observed in photon-treated populations. External validation of the model is warranted.
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Affiliation(s)
- Zeming Wang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Mei Chen
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, USA; Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jian Sun
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA; Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Shengpeng Jiang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, USA; Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Li Wang
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Xiaochun Wang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Narayan Sahoo
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - G Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Joe Y Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - X Ronald Zhu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Xiaodong Zhang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, USA.
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Li Z, Dong Y, Fan M, Yin Y, Zhu J, Li B, Huang W. Analysis of Hepatitis B Virus Reactivation After Radiotherapy in Patients With Hepatocellular Carcinoma Using the Lyman NTCP Model. Technol Cancer Res Treat 2020; 18:1533033819875136. [PMID: 31526114 PMCID: PMC6749789 DOI: 10.1177/1533033819875136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Purpose: To analyze the correlation of hepatitis B virus reactivation with patient-related and treatment-related dose–volume factors and to describe the feasibility of hepatitis B virus reactivation analyzed by a normal tissue complication probability model for patients with hepatocellular carcinoma treated with radiotherapy. Materials and Methods: Ninety patients with hepatitis B virus-related hepatocellular carcinoma treated with radiotherapy were enrolled in this retrospective study and were followed from June 2009 to December 2015. Of the 90 patients, 78 had received conventional fractionation radiotherapy to a mean dose of 39.6 to 50.4 Gy and 12 patients were scheduled to receive hypofractionation. The physical doses were converted into 2 Gy equivalents for analysis. The parameters, TD50 (1), n, and m, of the Lyman-Kutcher-Burman normal tissue complication probability model were derived using maximum likelihood estimation. Bootstrap and leave-one-out were employed to against model overfitting and improve the model stability. Results: Radiation-induced liver diseases were 17.8%, hepatitis B virus reactivation was 22.2%, and hepatitis B virus reactivation-induced hepatitis was 21.1%, respectively. In multivariate analysis, the V5Gy was associated with hepatitis B virus reactivation; TD50 (1), m, and n were 32.3, 0.55, and 0.71 Gy, respectively, for hepatitis B virus reactivation. Bootstrap and leave-one-out results showed that the hepatitis B virus parameter fits were extremely robust. Conclusion: A Lyman-Kutcher-Burman normal tissue complication probability model has been established to predict hepatitis B virus reactivation for patients with hepatocellular carcinoma who received radiotherapy.
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Affiliation(s)
- Zhenjiang Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Yinping Dong
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China.,School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Min Fan
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Yong Yin
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Jian Zhu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Baosheng Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Wei Huang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
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Zhao H, Jia L, Chen G, Li X, Meng X, Zhao X, Xing L, Zhu W. A prospective, three-arm, randomized trial of EGCG for preventing radiation-induced esophagitis in lung cancer patients receiving radiotherapy. Radiother Oncol 2019; 137:186-191. [PMID: 30898322 DOI: 10.1016/j.radonc.2019.02.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 02/09/2019] [Accepted: 02/27/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE This trial investigated whether epigallocatechin-3-gallate (EGCG), a radioprotector, could be effective in the prevention and treatment of acute radiation-induced esophagitis (ARIE). METHODS AND MATERIALS This is a phase II study of EGCG combined with chemoradiation in unresectable stage III non-small-cell lung cancer or limited stage small cell lung cancer. Patients were randomized into a prophylactic EGCG group (arm A), a therapeutic EGCG group after the occurrence of esophagitis (arm B) or conventional therapy group (arm C). Esophagitis grades, pain and dysphagia scores were recorded weekly. Adjusted esophagitis index (AEI), pain index (API) and dysphagia index (ADI) were calculated to reflect changes in esophagitis grade, pain score and dysphagia score throughout treatment. RESULTS A total of 83 patients were eligible for toxicity analysis (arm A vs arm B vs arm C: N = 28:27:28). There was no significant difference in the baseline characteristics among three arms of the patients. The difference in the maximum esophagitis grade among three groups was statistically significant (P = 0.004). The maximum ARIE for patients with EGCG was significantly lower than for those with conventional therapy. The mean AEI of arm A was lower than that of arm B, while the mean AEI of arm C was the highest (arm A vs arm B, P = 0.028; arm B vs arm C, P = 0.002). Furthermore, API and ADI were significantly lower in patients receiving EGCG than in conventionally treated patients. CONCLUSION The application of EGCG could effectively alleviate acute radiation esophagitis in advanced lung cancer without obvious side effects. Prophylactic application of EGCG had a slight advantage over therapeutic use in treatment of acute esophagitis.
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Affiliation(s)
- Hanxi Zhao
- Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, China
| | - Li Jia
- Department of Radiation Oncology, Jinan Fourth People's Hospital, Jinan, China
| | - Guanxuan Chen
- Shandong Key Laboratory of Radiation Oncology, Jinan, China
| | - Xiaolin Li
- Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, China
| | - Xiangjiao Meng
- Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, China
| | - Xianguang Zhao
- Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, China
| | - Ligang Xing
- Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, China.
| | - Wanqi Zhu
- Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, China.
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Huang J, He T, Yang R, Ji T, Li G. Clinical, dosimetric, and position factors for radiation-induced acute esophagitis in intensity-modulated (chemo)radiotherapy for locally advanced non-small-cell lung cancer. Onco Targets Ther 2018; 11:6167-6175. [PMID: 30288052 PMCID: PMC6160279 DOI: 10.2147/ott.s174561] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Purpose The purpose of this study was to estimate the relation between acute esophagitis (AE) and clinical, dosimetric, and position factors in patients with locally advanced non-small-cell lung cancer (NSCLC) receiving intensity-modulated (chemo)radiotherapy. Materials and methods A retrospective cohort analysis was performed to identify factors associated with Common Toxicity Criteria for Adverse Events grade 2 or worse AE (AE2+). A multivariable model was established including patient- and treatment-related variables and esophageal dose–volume histogram parameters. The esophagus was divided according to physiological anatomy, and logistic regression was used to analyze the position parameter for its correlation with AE2+. Results The incidence of AE2+ was 27.5%. All models included gender, concurrent chemo-radiotherapy (CCRT), position parameter, and one of the dosimetric variables. The model with mean dose showed the best goodness of fit. Gender (OR=2.47, P=0.014), CCRT (OR=3.67, P=0.015), mean dose (OR=1.33, P<0.001), and maximum radiation position (OR=1.65, P=0.016) were significantly related to AE2+. Conclusion Gender, concurrent chemotherapy, maximum radiation position, and mean dose were independent risk factors for AE2+. The upper part of the esophagus showed a higher sensitivity to radiation toxicity.
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Affiliation(s)
- Jin Huang
- Department of Radiotherapy, The First Hospital of China Medical University, Shenyang 110001, China,
| | - Tianyu He
- Department of Radiotherapy, The First Hospital of China Medical University, Shenyang 110001, China,
| | - Ronghui Yang
- Department of Hematology, Shengjing Hospital of China Medical University, Shenyang 110000, China
| | - Tianlong Ji
- Department of Radiotherapy, The First Hospital of China Medical University, Shenyang 110001, China,
| | - Guang Li
- Department of Radiotherapy, The First Hospital of China Medical University, Shenyang 110001, China,
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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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Niedzielski JS, Yang J, Mohan R, Titt U, Mirkovic D, Stingo F, Liao Z, Gomez DR, Martel MK, Briere TM, Court LE. Differences in Normal Tissue Response in the Esophagus Between Proton and Photon Radiation Therapy for Non-Small Cell Lung Cancer Using In Vivo Imaging Biomarkers. Int J Radiat Oncol Biol Phys 2017; 99:1013-1020. [PMID: 29063837 DOI: 10.1016/j.ijrobp.2017.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 06/26/2017] [Accepted: 07/01/2017] [Indexed: 01/21/2023]
Abstract
PURPOSE To determine whether there exists any significant difference in normal tissue toxicity between intensity modulated radiation therapy (IMRT) or proton therapy for the treatment of non-small cell lung cancer. METHODS AND MATERIALS A total of 134 study patients (n=49 treated with proton therapy, n=85 with IMRT) treated in a randomized trial had a previously validated esophageal toxicity imaging biomarker, esophageal expansion, quantified during radiation therapy, as well as esophagitis grade (Common Terminology Criteria for Adverse Events version 3.0), on a weekly basis during treatment. Differences between the 2 modalities were statically analyzed using the imaging biomarker metric value (Kruskal-Wallis analysis of variance), as well as the incidence and severity of esophagitis grade (χ2 and Fisher exact tests, respectively). The dose-response of the imaging biomarker was also compared between modalities using esophageal equivalent uniform dose, as well as delivered dose to an isotropic esophageal subvolume. RESULTS No statistically significant difference in the distribution of esophagitis grade, the incidence of grade ≥3 esophagitis (15 and 11 patients treated with IMRT and proton therapy, respectively), or the esophageal expansion imaging biomarker between cohorts (P>.05) was found. The distribution of imaging biomarker metric values had similar distributions between treatment arms, despite a slightly higher dose volume in the proton arm (P>.05). Imaging biomarker dose-response was similar between modalities for dose quantified as esophageal equivalent uniform dose and delivered esophageal subvolume dose. Regardless of treatment modality, there was high variability in imaging biomarker response, as well as esophagitis grade, for similar esophageal doses between patients. CONCLUSIONS There was no significant difference in esophageal toxicity from either proton- or photon-based radiation therapy as quantified by esophagitis grade or the esophageal expansion imaging biomarker.
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Affiliation(s)
- Joshua S Niedzielski
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas; University of Texas-Houston Health Science Center, Graduate School of Biomedical Science, Houston, Texas.
| | - Jinzhong Yang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas; University of Texas-Houston Health Science Center, Graduate School of Biomedical Science, Houston, Texas
| | - Radhe Mohan
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas; University of Texas-Houston Health Science Center, Graduate School of Biomedical Science, Houston, Texas
| | - Uwe Titt
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas; University of Texas-Houston Health Science Center, Graduate School of Biomedical Science, Houston, Texas
| | - Dragan Mirkovic
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas; University of Texas-Houston Health Science Center, Graduate School of Biomedical Science, Houston, Texas
| | - Francesco Stingo
- Department of Statistics, Computer Science, Applications "G. Parenti," University of Florence, Florence, Italy
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Daniel R Gomez
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Mary K Martel
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas; University of Texas-Houston Health Science Center, Graduate School of Biomedical Science, Houston, Texas
| | - Tina M Briere
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas; University of Texas-Houston Health Science Center, Graduate School of Biomedical Science, Houston, Texas
| | - Laurence E Court
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas; University of Texas-Houston Health Science Center, Graduate School of Biomedical Science, Houston, Texas
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Radiomic analysis in contrast-enhanced CT: predict treatment response to chemoradiotherapy in esophageal carcinoma. Oncotarget 2017; 8:104444-104454. [PMID: 29262652 PMCID: PMC5732818 DOI: 10.18632/oncotarget.22304] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 10/05/2017] [Indexed: 01/04/2023] Open
Abstract
Objectives To investigate the capability of computed-tomography (CT) radiomic features to predict the therapeutic response of Esophageal Carcinoma (EC) to chemoradiotherapy (CRT). Methods Pretreatment contrast-enhanced CT images of 49 EC patients (33 responders, 16 nonresponders) who received with CRT were retrospectively analyzed. The region of tumor was contoured by two radiologists. A total of 214 features were extracted from the tumor region. Kruskal-Wallis test and receiver operating characteristic (ROC) analysis were performed to evaluate the capability of each feature on treatment response classification. Support vector machine (SVM) and artificial neural network (ANN) algorithms were used to build models for prediction of the treatment response. The statistical difference between the performances of the models was assessed using McNemar's test. Results Radiomic-based classification showed significance in differentiating responders from nonresponders. Five features were found to discriminate nonresponders from responders (AUCs from 0.686 to 0.727). Considering these features, two features (Histogram2D_skewness: P = 0.015. Histogram2D_kurtosis: P = 0.039) were significant for differentiating SDs (stable disease) from PRs (partial response) and one feature (Histogram2D_skewness: P = 0.027) for differentiating SDs from CRs (complete response). Both classifiers showed potential in predicting the treatment response with higher accuracy (ANN: 0.972, SVM: 0.891). No statistically significant difference was observed in the performance of the two classifiers (P = 0.250). Conclusions CT-based radiomic features can be used as imaging biomarkers to predict tumor response to CRT in EC patients.
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Dankers F, Wijsman R, Troost EGC, Monshouwer R, Bussink J, Hoffmann AL. Esophageal wall dose-surface maps do not improve the predictive performance of a multivariable NTCP model for acute esophageal toxicity in advanced stage NSCLC patients treated with intensity-modulated (chemo-)radiotherapy. Phys Med Biol 2017; 62:3668-3681. [DOI: 10.1088/1361-6560/aa5e9e] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Feng Z, Tao C, Zhu J, Chen J, Yu G, Qin S, Yin Y, Li D. An integrated strategy of biological and physical constraints in biological optimization for cervical carcinoma. Radiat Oncol 2017; 12:64. [PMID: 28376900 PMCID: PMC5379684 DOI: 10.1186/s13014-017-0784-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 02/22/2017] [Indexed: 01/19/2023] Open
Abstract
Background For cervical carcinoma cases, this study aimed to evaluate the quality of intensity-modulated radiation therapy (IMRT) plans optimized by biological constraints. Furthermore, a new integrated strategy in biological planning module was proposed and verified. Methods Twenty patients of advanced stage cervical carcinoma were enrolled in this study. For each patient, dose volume optimization (DVO), biological model optimization (BMO) and integrated strategy optimization (ISO) plans were created using same treatment parameters. Different biological models were also used for organ at risk (OAR) in BMO plans, which include the LKB and Poisson models. Next, BMO plans were compared with their corresponding DVO plans, in order to evaluate BMO plan quality. ISO plans were also compared with DVO and BMO plans, in order to verify the performance of the integrated strategy. Results BMO plans produced slightly inhomogeneity and less coverage of planning target volume (PTV) (V95=96.79, HI = 0.10: p < 0.01). However, the tumor control probability (TCP) value, both from DVO and BMO plans, were comparable. For the OARs, BMO plans produced lower normal tissue complication probability (NTCP) of rectum (NTCP = 0.11) and bladder (NTCP = 0.14) than in the corresponding DVO plans (NTCP = 0.19 and 0.18 for rectum and bladder; p < 0.01 for rectum and p = 0.03 for bladder). V95, D98, CI and HI values that were produced by ISO plans (V95 = 98.31, D98 = 54.18Gy, CI = 0.76, HI = 0.09) were greatly better than BMO plans (V95 = 96.79, D98 = 53.42Gy, CI = 0.71, HI = 0.10) with significant differences. Furthermore, ISO plans produced lower NTCP values of rectum (NTCP = 0.14) and bladder (NTCP = 0.16) than DVO plans (NTCP = 0.19 and 0.18 for rectum and bladder, respectively) with significant differences. Conclusions BMO plans produced lower NTCP values of OARs compared to DVO plans for cervical carcinoma cases, and resulted in slightly less target coverage and homogeneity. The integrated strategy, proposed in this study, could improve the coverage, conformity and homogeneity of PTV greater than the BMO plans, as well as reduce the NTCP values of OARs greater than the DVO plans.
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Affiliation(s)
- Ziwei Feng
- Shandong Province Key Laboratory of Medical Physics and Image Processing Technology, Institute of Biomedical Sciences, School of Physics and Electronics, Shandong Normal University, No.88, Wenhua East Road, Lixia District, Jinan, 250014, China
| | - Cheng Tao
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, No.440, Jiyan Road, Jinan, 250117, China
| | - Jian Zhu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, No.440, Jiyan Road, Jinan, 250117, China
| | - Jinhu Chen
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, No.440, Jiyan Road, Jinan, 250117, China
| | - Gang Yu
- Shandong Province Key Laboratory of Medical Physics and Image Processing Technology, Institute of Biomedical Sciences, School of Physics and Electronics, Shandong Normal University, No.88, Wenhua East Road, Lixia District, Jinan, 250014, China
| | - Shaohua Qin
- Shandong Province Key Laboratory of Medical Physics and Image Processing Technology, Institute of Biomedical Sciences, School of Physics and Electronics, Shandong Normal University, No.88, Wenhua East Road, Lixia District, Jinan, 250014, China
| | - Yong Yin
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, No.440, Jiyan Road, Jinan, 250117, China
| | - Dengwang Li
- Shandong Province Key Laboratory of Medical Physics and Image Processing Technology, Institute of Biomedical Sciences, School of Physics and Electronics, Shandong Normal University, No.88, Wenhua East Road, Lixia District, Jinan, 250014, China.
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Huang BT, Huang RH, Zhang WZ, Lin W, Guo LJ, Xu LY, Lin PX, Chen JZ, Li DR, Chen CZ. Different definitions of esophagus influence esophageal toxicity prediction for esophageal cancer patients administered simultaneous integrated boost versus standard-dose radiation therapy. Sci Rep 2017; 7:120. [PMID: 28273921 PMCID: PMC5427902 DOI: 10.1038/s41598-017-00168-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 02/13/2017] [Indexed: 02/05/2023] Open
Abstract
We aim to evaluate whether different definitions of esophagus (DEs) impact on the esophageal toxicity prediction for esophageal cancer (EC) patients administered intensity-modulated radiation therapy with simultaneous integrated boost (SIB-IMRT) vs. standard-dose IMRT (SD-IMRT). The esophagus for 21 patients diagnosed with primary EC were defined in the following four ways: the whole esophagus, including the tumor (ESOwhole); ESOwhole within the treatment field (ESOinfield); ESOinfield, excluding the tumor (ESOinfield-tumor) and ESOwhole, excluding the tumor (ESOwhole-tumor). The difference in the dose variation, acute esophageal toxicity (AET) and late esophageal toxicity (LET) of four DEs were compared. We found that the mean esophageal dose for ESOwhole, ESOinfield, ESOinfield-tumor and ESOwhole-tumor were increased by 7.2 Gy, 10.9 Gy, 4.6 Gy and 2.0 Gy, respectively, in the SIB-IMRT plans. Radiobiological models indicated that a grade ≥ 2 AET was 2.9%, 3.1%, 2.2% and 1.6% higher on average with the Kwint model and 14.6%, 13.2%, 7.2% and 3.4% higher with the Wijsman model for the four DEs. A grade ≥ 3 AET increased by 4.3%, 7.2%, 4.2% and 1.2%, respectively. Additionally, the predicted LET increased by 0.15%, 0.39%, 1.2 × 10−2% and 1.5 × 10−3%. Our study demonstrates that different DEs influence the esophageal toxicity prediction for EC patients administered SIB-IMRT vs. SD-IMRT treatment.
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Affiliation(s)
- Bao-Tian Huang
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, Shantou, China
| | - Rui-Hong Huang
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, Shantou, China
| | - Wu-Zhe Zhang
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, Shantou, China
| | - Wen Lin
- Department of Respiratory Medical Oncology, Cancer Hospital of Shantou University Medical College, Shantou, China
| | - Long-Jia Guo
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, Shantou, China
| | - Liang-Yu Xu
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, Shantou, China
| | - Pei-Xian Lin
- Department of Nosocomial Infection Management, The Second Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Jian-Zhou Chen
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, Shantou, China.,CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, UK
| | - De-Rui Li
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, Shantou, China
| | - Chuang-Zhen Chen
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, Shantou, China.
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Huang BT, Wu LL, Guo LJ, Xu LY, Huang RH, Lin PX, Chen JZ, Li DR, Chen CZ. Radiobiological evaluation of simultaneously dose-escalated versus non-escalated intensity-modulated radiation therapy for patients with upper thoracic esophageal cancer. Onco Targets Ther 2017; 10:2209-2217. [PMID: 28458564 PMCID: PMC5403125 DOI: 10.2147/ott.s132388] [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] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To compare the radiobiological response between simultaneously dose-escalated and non-escalated intensity-modulated radiation therapy (DE-IMRT and NE-IMRT) for patients with upper thoracic esophageal cancer (UTEC) using radiobiological evaluation. METHODS Computed tomography simulation data sets for 25 patients pathologically diagnosed with primary UTEC were used in this study. DE-IMRT plan with an escalated dose of 64.8 Gy/28 fractions to the gross tumor volume (GTV) and involved lymph nodes from 25 patients pathologically diagnosed with primary UTEC, was compared to an NE-IMRT plan of 50.4 Gy/28 fractions. Dose-volume metrics, tumor control probability (TCP), and normal tissue complication probability for the lung and spinal cord were compared. In addition, the risk of acute esophageal toxicity (AET) and late esophageal toxicity (LET) were also analyzed. RESULTS Compared with NE-IMRT plan, we found the DE-IMRT plan resulted in a 14.6 Gy dose escalation to the GTV. The tumor control was predicted to increase by 31.8%, 39.1%, and 40.9% for three independent TCP models. The predicted incidence of radiation pneumonitis was similar (3.9% versus 3.6%), and the estimated risk of radiation-induced spinal cord injury was extremely low (<0.13%) in both groups. Regarding the esophageal toxicities, the estimated grade ≥2 and grade ≥3 AET predicted by the Kwint model were increased by 2.5% and 3.8%. Grade ≥2 AET predicted using the Wijsman model was increased by 14.9%. The predicted incidence of LET was low (<0.51%) in both groups. CONCLUSION Radiobiological evaluation reveals that the DE-IMRT dosing strategy is feasible for patients with UTEC, with significant gains in tumor control and minor or clinically acceptable increases in radiation-induced toxicities.
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Affiliation(s)
- Bao-Tian Huang
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, Shantou
| | - Li-Li Wu
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, Shantou
| | - Long-Jia Guo
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, Shantou
| | - Liang-Yu Xu
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, Shantou
| | - Rui-Hong Huang
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, Shantou
| | - Pei-Xian Lin
- Department of Nosocomial Infection Management, The Second Affiliated Hospital of Shantou University Medical College, Shantou, People’s Republic of China
| | - Jian-Zhou Chen
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, Shantou
- CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, United Kingdom
| | - De-Rui Li
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, Shantou
| | - Chuang-Zhen Chen
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, Shantou
- Correspondence: Chuang-Zhen Chen, Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, 7 Raoping Road, Shantou, Guangdong Province, 515031, People’s Republic of China, Tel/fax +86 754 8855 5844, Email
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Zhu J, Simon A, Haigron P, Lafond C, Acosta O, Shu H, Castelli J, Li B, De Crevoisier R. The benefit of using bladder sub-volume equivalent uniform dose constraints in prostate intensity-modulated radiotherapy planning. Onco Targets Ther 2016; 9:7537-7544. [PMID: 28003767 PMCID: PMC5161391 DOI: 10.2147/ott.s116508] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background To assess the benefits of bladder wall sub-volume equivalent uniform dose (EUD) constraints in prostate cancer intensity-modulated radiotherapy (IMRT) planning. Methods Two IMRT plans, with and without EUD constraints on the bladder wall, were generated using beams that deliver 80 Gy to the prostate and 46 Gy to the seminal vesicles and were compared in 53 prostate cancer patients. The bladder wall was defined as the volume between the external manually delineated wall and a contraction of 7 mm apart from it. The bladder wall was then separated into two parts: the internal-bladder wall (bla-in) represented by the portion of the bladder wall that intersected with the planning target volume (PTV) plus 5 mm extension; the external-bladder wall (bla-ex) represented by the remaining part of the bladder wall. In the IMRT plan with EUD constraints, the values of “a” parameter for the EUD models were 10.0 for bla-in and 2.3 for bla-ex. The plans with and without EUD constraints were compared in terms of dose–volume histograms, 5-year bladder and rectum normal tissue complication probability values, as well as tumor control probability (TCP) values. Results The use of bladder sub-volume EUD constraints decreased both the doses to the bladder wall (V70: 22.76% vs 19.65%, Dmean: 39.82 Gy vs 35.45 Gy) and the 5-year bladder complication probabilities (≥LENT/SOMA Grade 2: 20.35% vs 17.96%; bladder bleeding: 10.63% vs 8.64%). The doses to the rectum wall and the rectum complication probabilities were also slightly decreased by the EUD constraints compared to physical constraints only. The minimal dose and the V76Gy of PTVprostate were, however, slightly decreased by EUD optimization, nevertheless without significant difference in TCP values between the two plans, and the PTV parameters finally respected the Groupe d’Etude des Tumeurs Uro-Génitales recommendations. Conclusion Separating the bladder wall into two parts with appropriate EUD optimization may reduce bladder toxicity in prostate IMRT. Combining biological constraints with physical constraints in the organs at risk at the inverse planning step of IMRT may improve the dose distribution.
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Affiliation(s)
- Jian Zhu
- Laboratory of Image Science and Technology, Southeast University, Nanjing, Jiangsu; Department of Radiation Oncology, Shandong Cancer Hospital & Institute, Jinan; Centre de Recherche en Information Biomédicale Sino-français, Nanjing, People's Republic of China
| | - Antoine Simon
- Centre de Recherche en Information Biomédicale Sino-français, Nanjing, People's Republic of China; Institut National de la Sante et de la Recherche Medicale, U1099; Laboratory of Signal and Image Processing (LTSI), University of Rennes 1
| | - Pascal Haigron
- Centre de Recherche en Information Biomédicale Sino-français, Nanjing, People's Republic of China; Institut National de la Sante et de la Recherche Medicale, U1099; Laboratory of Signal and Image Processing (LTSI), University of Rennes 1
| | - Caroline Lafond
- Institut National de la Sante et de la Recherche Medicale, U1099; Laboratory of Signal and Image Processing (LTSI), University of Rennes 1; Department of Radiotherapy, Centre Eugène Marquis, Rennes, France
| | - Oscar Acosta
- Institut National de la Sante et de la Recherche Medicale, U1099; Laboratory of Signal and Image Processing (LTSI), University of Rennes 1
| | - Huazhong Shu
- Laboratory of Image Science and Technology, Southeast University, Nanjing, Jiangsu; Centre de Recherche en Information Biomédicale Sino-français, Nanjing, People's Republic of China
| | - Joel Castelli
- Institut National de la Sante et de la Recherche Medicale, U1099; Laboratory of Signal and Image Processing (LTSI), University of Rennes 1; Department of Radiotherapy, Centre Eugène Marquis, Rennes, France
| | - Baosheng Li
- Laboratory of Image Science and Technology, Southeast University, Nanjing, Jiangsu; Department of Radiation Oncology, Shandong Cancer Hospital & Institute, Jinan; Centre de Recherche en Information Biomédicale Sino-français, Nanjing, People's Republic of China
| | - Renaud De Crevoisier
- Centre de Recherche en Information Biomédicale Sino-français, Nanjing, People's Republic of China; Institut National de la Sante et de la Recherche Medicale, U1099; Laboratory of Signal and Image Processing (LTSI), University of Rennes 1; Department of Radiotherapy, Centre Eugène Marquis, Rennes, France
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18
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Yu Y, Guan H, Dong Y, Xing L, Li X. Advances in dosimetry and biological predictors of radiation-induced esophagitis. Onco Targets Ther 2016; 9:597-603. [PMID: 26869804 PMCID: PMC4734814 DOI: 10.2147/ott.s97019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE To summarize the research progress about the dosimetry and biological predictors of radiation-induced esophagitis. METHODS We performed a systematic literature review addressing radiation esophagitis in the treatment of lung cancer published between January 2009 and May 2015 in the PubMed full-text database index systems. RESULTS Twenty-eight eligible documents were included in the final analysis. Many clinical factors were related to the risk of radiation esophagitis, such as elder patients, concurrent chemoradiotherapy, and the intense radiotherapy regimen (hyperfractionated radiotherapy or stereotactic body radiotherapy). The parameters including Dmax, Dmean, V20, V30, V50, and V55 may be valuable in predicting the occurrence of radiation esophagitis in patients receiving concurrent chemoradiotherapy. Genetic variants in inflammation-related genes are also associated with radiation-induced toxicity. CONCLUSION Dosimetry and biological factors of radiation-induced esophagitis provide clinical information to decrease its occurrence and grade during radiotherapy. More prospective studies are warranted to confirm their prediction efficacy.
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Affiliation(s)
- Yang Yu
- School of Medicine and Life Sciences, Shandong Academy of Medical Sciences, University of Jinan, Jinan, People's Republic of China
| | - Hui Guan
- School of Medicine and Life Sciences, Shandong Academy of Medical Sciences, University of Jinan, Jinan, People's Republic of China
| | - Yuanli Dong
- School of Medicine and Life Sciences, Shandong Academy of Medical Sciences, University of Jinan, Jinan, People's Republic of China
| | - Ligang Xing
- Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong Province, People's Republic of China
| | - Xiaolin Li
- Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong Province, People's Republic of China
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Wijsman R, Dankers F, Troost EGC, Hoffmann AL, van der Heijden EHFM, de Geus-Oei LF, Bussink J. Multivariable normal-tissue complication modeling of acute esophageal toxicity in advanced stage non-small cell lung cancer patients treated with intensity-modulated (chemo-)radiotherapy. Radiother Oncol 2015; 117:49-54. [PMID: 26341608 DOI: 10.1016/j.radonc.2015.08.010] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 08/10/2015] [Accepted: 08/11/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE The majority of normal-tissue complication probability (NTCP) models for acute esophageal toxicity (AET) in advanced stage non-small cell lung cancer (AS-NSCLC) patients treated with (chemo-)radiotherapy are based on three-dimensional conformal radiotherapy (3D-CRT). Due to distinct dosimetric characteristics of intensity-modulated radiation therapy (IMRT), 3D-CRT based models need revision. We established a multivariable NTCP model for AET in 149 AS-NSCLC patients undergoing IMRT. MATERIALS AND METHODS An established model selection procedure was used to develop an NTCP model for Grade ⩾2 AET (53 patients) including clinical and esophageal dose-volume histogram parameters. RESULTS The NTCP model predicted an increased risk of Grade ⩾2 AET in case of: concurrent chemoradiotherapy (CCR) [adjusted odds ratio (OR) 14.08, 95% confidence interval (CI) 4.70-42.19; p<0.001], increasing mean esophageal dose [Dmean; OR 1.12 per Gy increase, 95% CI 1.06-1.19; p<0.001], female patients (OR 3.33, 95% CI 1.36-8.17; p=0.008), and ⩾cT3 (OR 2.7, 95% CI 1.12-6.50; p=0.026). The AUC was 0.82 and the model showed good calibration. CONCLUSIONS A multivariable NTCP model including CCR, Dmean, clinical tumor stage and gender predicts Grade ⩾2 AET after IMRT for AS-NSCLC. Prior to clinical introduction, the model needs validation in an independent patient cohort.
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Affiliation(s)
- Robin Wijsman
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Frank Dankers
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Esther G C Troost
- Institute of Radiooncology, Helmholtz-Zentrum Dresden-Rossendorf, Germany; Department of Radiotherapy and Radiooncology, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Germany; OncoRay, National Center for Radiation Research in Oncology, Dresden, Germany
| | - Aswin L Hoffmann
- Institute of Radiooncology, Helmholtz-Zentrum Dresden-Rossendorf, Germany; Department of Radiotherapy and Radiooncology, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Germany
| | | | - Lioe-Fee de Geus-Oei
- Department of Radiology, Leiden University Medical Center, The Netherlands; Biomedical Photonic Imaging Group, MIRA Institute, University of Twente, Enschede, The Netherlands
| | - Johan Bussink
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
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Coates J, Jeyaseelan AK, Ybarra N, David M, Faria S, Souhami L, Cury F, Duclos M, El Naqa I. Contrasting analytical and data-driven frameworks for radiogenomic modeling of normal tissue toxicities in prostate cancer. Radiother Oncol 2015; 115:107-13. [PMID: 25818395 DOI: 10.1016/j.radonc.2015.03.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2014] [Revised: 01/25/2015] [Accepted: 03/09/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE We explore analytical and data-driven approaches to investigate the integration of genetic variations (single nucleotide polymorphisms [SNPs] and copy number variations [CNVs]) with dosimetric and clinical variables in modeling radiation-induced rectal bleeding (RB) and erectile dysfunction (ED) in prostate cancer patients. MATERIALS AND METHODS Sixty-two patients who underwent curative hypofractionated radiotherapy (66 Gy in 22 fractions) between 2002 and 2010 were retrospectively genotyped for CNV and SNP rs5489 in the xrcc1 DNA repair gene. Fifty-four patients had full dosimetric profiles. Two parallel modeling approaches were compared to assess the risk of severe RB (Grade⩾3) and ED (Grade⩾1); Maximum likelihood estimated generalized Lyman-Kutcher-Burman (LKB) and logistic regression. Statistical resampling based on cross-validation was used to evaluate model predictive power and generalizability to unseen data. RESULTS Integration of biological variables xrcc1 CNV and SNP improved the fit of the RB and ED analytical and data-driven models. Cross-validation of the generalized LKB models yielded increases in classification performance of 27.4% for RB and 14.6% for ED when xrcc1 CNV and SNP were included, respectively. Biological variables added to logistic regression modeling improved classification performance over standard dosimetric models by 33.5% for RB and 21.2% for ED models. CONCLUSION As a proof-of-concept, we demonstrated that the combination of genetic and dosimetric variables can provide significant improvement in NTCP prediction using analytical and data-driven approaches. The improvement in prediction performance was more pronounced in the data driven approaches. Moreover, we have shown that CNVs, in addition to SNPs, may be useful structural genetic variants in predicting radiation toxicities.
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Affiliation(s)
- James Coates
- Medical Physics Unit, Department of Oncology, McGill University Health Center, Montreal, Canada
| | - Asha K Jeyaseelan
- Medical Physics Unit, Department of Oncology, McGill University Health Center, Montreal, Canada
| | - Norma Ybarra
- Medical Physics Unit, Department of Oncology, McGill University Health Center, Montreal, Canada
| | - Marc David
- Radiation Oncology Division, Department of Oncology, McGill University Health Centre, Montreal, Canada
| | - Sergio Faria
- Radiation Oncology Division, Department of Oncology, McGill University Health Centre, Montreal, Canada
| | - Luis Souhami
- Radiation Oncology Division, Department of Oncology, McGill University Health Centre, Montreal, Canada
| | - Fabio Cury
- Radiation Oncology Division, Department of Oncology, McGill University Health Centre, Montreal, Canada
| | - Marie Duclos
- Radiation Oncology Division, Department of Oncology, McGill University Health Centre, Montreal, Canada
| | - Issam El Naqa
- Medical Physics Unit, Department of Oncology, McGill University Health Center, Montreal, Canada.
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Bai T, Zhu J, Yin Y, Lu J, Shu H, Wang L, Yang B. How does four-dimensional computed tomography spare normal tissues in non-small cell lung cancer radiotherapy by defining internal target volume? Thorac Cancer 2014; 5:537-42. [PMID: 26767049 DOI: 10.1111/1759-7714.12126] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 04/14/2014] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND To investigate how the four-dimensional computed tomography (4DCT) technique spares normal tissues in non-small cell lung cancer (NSCLC) radiotherapy by defining individualized internal target volume (ITV). MATERIALS AND METHODS Gross tumor volume (GTV) and clinical target volume (CTV) were contoured on all 10 respiratory phases of 4DCT scans in 10 patients with peripheral NSCLC. Both 3D and 4D treatment plans were performed for each patient using planning target volume (PTV)3D (derived from a single CTV plus conventional margins) and PTV4D (derived from 4D internal target volume, which included all 10 CTVs plus setup margins). Dose volume histogram and normal tissue complication probability (NTCP) values were compared for the lung, heart, and spinal cord between 3D and 4D treatment plans. RESULTS The average PTV of the 4D (127.56 ± 70.79) was less than the 3D plans (147.65 ± 76.89). The 4D spared more surrounding normal tissues than the 3D plans, especially in the lung. Compared with 3D plans, V5, V10, V20 and V30 of the total lung decreased from 41.25%, 37.75%, 24.25%, 17.00% to 38.13%, 33.00%, 21.25%, 15.13%, respectively. Without increasing the NTCP of the lung significantly, the 4D plans allowed us to increase the average prescription dose from 60 Gy to 66.00 ± 4.62 Gy. CONCLUSIONS 4DCT based plans can reduce the target volumes, spare more normal tissues, and allow dose escalation compared with 3D plans in NSCLC radiotherapy.
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Affiliation(s)
- Tong Bai
- Department of Radiation Physics, Shandong Cancer Hospital and Institute Jinan, China; Shandong Provincial Key Laboratory of Radiation Oncology Jinan, China
| | - Jian Zhu
- Department of Radiation Physics, Shandong Cancer Hospital and Institute Jinan, China; Shandong Provincial Key Laboratory of Radiation Oncology Jinan, China
| | - Yong Yin
- Department of Radiation Physics, Shandong Cancer Hospital and Institute Jinan, China; Shandong Provincial Key Laboratory of Radiation Oncology Jinan, China
| | - Jie Lu
- Department of Radiation Physics, Shandong Cancer Hospital and Institute Jinan, China; Shandong Provincial Key Laboratory of Radiation Oncology Jinan, China
| | - Huazhong Shu
- Laboratory of Image Science and Technology, Southeast University Nanjing, China
| | - Lin Wang
- Shandong Provincial Key Laboratory of Network based Intelligent Computing, University of Jinan Jinan, China
| | - Bo Yang
- Shandong Provincial Key Laboratory of Network based Intelligent Computing, University of Jinan Jinan, China
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Acute phase response before treatment predicts radiation esophagitis in non-small cell lung cancer. Radiother Oncol 2014; 110:493-8. [PMID: 24560756 DOI: 10.1016/j.radonc.2014.01.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Revised: 01/14/2014] [Accepted: 01/16/2014] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND PURPOSE Radiation esophagitis (RE) represents an inflammatory reaction to radiation therapy (RT). We hypothesized that aspects of the physiologic acute phase response (APR) predicts RE. MATERIAL AND METHODS We retrospectively analyzed 285 patients with non-small cell lung cancer (NSCLC) treated with definitive radiation. The primary analysis was the association of pretreatment lab values reflective of the APR with symptomatic (grade ⩾ 2) RE. Univariate and multivariate odds ratios (ORs) were calculated to test associations of clinical and pretreatment lab values with RE. Optimal cutpoints and multivariable risk stratification groupings were determined via recursive partitioning analysis. RESULTS Pretreatment platelet counts were higher and hemoglobin levels lower in patients who developed RE (P<0.05). Based on these two pre-treatment risk factors, an APR score was defined as 0 (no risk factors), 1 (either risk factor), or 2 (both risk factors). APR score was significantly associated with RE in both univariate (OR = 2.3 for each point, 95% confidence interval [CI] 1.5-3.4, P = 0.001) and multivariate (OR = 2.1, 95% CI 1.3-3.4, P = 0.002) analyses. CONCLUSIONS The APR score may represent a novel metric to predict RE. However, pending validation in an independent dataset, caution is advised when interpreting these results given their retrospective and thus exploratory nature.
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Zhao H, Zhu W, Xie P, Li H, Zhang X, Sun X, Yu J, Xing L. A phase I study of concurrent chemotherapy and thoracic radiotherapy with oral epigallocatechin-3-gallate protection in patients with locally advanced stage III non-small-cell lung cancer. Radiother Oncol 2014; 110:132-6. [PMID: 24444526 DOI: 10.1016/j.radonc.2013.10.014] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 09/22/2013] [Accepted: 10/03/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND PURPOSE Patients with unresectable stage III non-small-cell lung cancer receiving concurrent chemoradiotherapy often develop esophagitis that may lead to unplanned treatment interruptions, which may severely reduce rates of locoregional tumor control and survival. No effectivetreatment that would reduce the incidence and severity of this complication has been identified up to now. Although acceleration of normal tissue protection using epigallocatechin-3-gallate (EGCG) has been reported, its actual clinical practicability remains obscure. METHODS AND MATERIALS This is a phase I study of EGCG in combination with standard chemoradiation in surgically unresectable stage III non-small-cell lung cancer. Chemotherapy (cisplatin and etoposide) was given concurrently with radiation. EGCG solution was swallowed three times a day after the occurrence of grade 2 esophagitis at six concentration levels and dose escalation followed a standard phase I design. Esophageal toxicity and patient-reported pain was recorded weekly. RESULTS Twenty-four patients with AJCC stage IIIA (six) and IIIB (eighteen) completed the course of therapy. Twelve had squamous histology, ten adenocarcinoma, and two not specified. Patients were treated in six cohorts at six dose levels of EGCG. RT was not interrupted with a median dose of 64 Gy. There were no dose-limiting toxicities reported in all EGCG dosing tiers. Dramatic regression of esophagitis to grade 0/1 was observed in 22 of 24 patients, whereas grade 2 esophagitis persisted in 2 of 24 patients at the end of radiotherapy. The pain score was also reduced from a mean of 4.58 (N=24), 1.29 (N=24), 1.42 (N=24), 0.96 (N=23) to 1.13 (N=16) every week in turn. CONCLUSION We conclude that the oral administration of EGCG is feasible, safe and effective. The phase II recommended concentration is 440 μmol/L.
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Affiliation(s)
- Hanxi Zhao
- Department of Radiation Oncology, Shandong Cancer Hospital, Shandong Academy of Medical Sciences, Jinan, China.
| | - Wanqi Zhu
- Department of Radiation Oncology, Shandong Cancer Hospital, Shandong Academy of Medical Sciences, Jinan, China.
| | - Peng Xie
- Department of Radiation Oncology, Shandong Cancer Hospital, Shandong Academy of Medical Sciences, Jinan, China
| | - Huiqin Li
- Department of Radiation Oncology, Shandong Cancer Hospital, Shandong Academy of Medical Sciences, Jinan, China
| | - Xiqin Zhang
- Department of Radiation Oncology, Shandong Cancer Hospital, Shandong Academy of Medical Sciences, Jinan, China
| | - Xiaorong Sun
- Provincial Key Laboratory of Radiation Oncology, Shandong Cancer Hospital, Jinan, China
| | - Jinming Yu
- Department of Radiation Oncology, Shandong Cancer Hospital, Shandong Academy of Medical Sciences, Jinan, China
| | - Ligang Xing
- Department of Radiation Oncology, Shandong Cancer Hospital, Shandong Academy of Medical Sciences, Jinan, China.
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Kuroda Y, Sekine I, Sumi M, Sekii S, Takahashi K, Inaba K, Horinouchi H, Nokihara H, Yamamoto N, Kubota K, Murakami N, Morota M, Mayahara H, Ito Y, Tamura T, Nemoto K, Itami J. Acute radiation esophagitis caused by high-dose involved field radiotherapy with concurrent cisplatin and vinorelbine for stage III non-small cell lung cancer. Technol Cancer Res Treat 2013; 12:333-9. [PMID: 23369154 DOI: 10.7785/tcrt.2012.500319] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Purpose of this study is to obtain dose-volume histogram (DVH) predictors and threshold values for radiation esophagitis caused by high-dose involved field radiotherapy (IFRT) with concurrent chemotherapy in patients with stage III non-small cell lung cancer (NSCLC). Thirty-two patients treated by 66 Gy/33 Fr, 72 Gy/36 Fr, and 78 Gy/39 Fr thoracic radiotherapy without elective nodal irradiation plus concurrent cisplatin and vinorelvine were reviewed. Acute radiation esophagitis was evaluated according to common terminology criteria for adverse events version 4.0, and correlations between grade 2 or worse radiation esophagitis and DVH parameters were investigated. Grade 0-1, 2, 3, and 4-5 of radiation esophagitis were seen in 11 (34.4%), 20 (62.5%), 1 (3.1%), and 0 (0%) of the patients, respectively. Multivariate analysis revealed that whole esophagus V35 is a predictor of radiation esophagitis (OR = 0.74 [95%CI; 0.60-0.91], p = 0.006). There is a significant difference (38.4% vs. 89.4%, p = 0.027) in the cumulative rates of acute esophagitis according to V35 values of more than 20% versus less. As compared with other factors concerning patient and tumor and treatment factors, V35 ≤ 20% of the esophagus was an independent predictor (HR 5 0.29 [95%CI; 0.09-0.85], p 5 0.025). In conclusion, whole esophagus V35 < 20% is proposed in high-dose IFRT with concurrent chemotherapy for stage III NSCLC patients.
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Affiliation(s)
- Yuuki Kuroda
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan.
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Mantini G, Valentini V, Meduri B, Margaritora S, Balducci M, Micciché F, Nardone L, De Rose F, Cesario A, Larici AR, Maggi F, Calcagni ML, Granone P. Low-dose radiotherapy as a chemo-potentiator of a chemotherapy regimen with pemetrexed for recurrent non-small-cell lung cancer: A prospective phase II study. Radiother Oncol 2012; 105:161-6. [DOI: 10.1016/j.radonc.2012.09.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2010] [Revised: 07/08/2012] [Accepted: 09/06/2012] [Indexed: 12/25/2022]
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Challand T, Thureau S, Dubray B, Giraud P. [Esophageal toxicity of radiation therapy: clinical risk factors and management]. Cancer Radiother 2012; 16:364-71. [PMID: 22925486 DOI: 10.1016/j.canrad.2012.07.180] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Accepted: 07/05/2012] [Indexed: 12/25/2022]
Abstract
Acute radiation-induced esophagitis includes all clinical symptoms (odynophagia, dysphagia) occurring within 90 days after thoracic irradiation start. Its severity can be graded using RTOG and CTCAE scales. The clinical risk factors are: age, female gender, initial performance status, pre-therapeutic body mass index, pre-therapeutic dysphagia, tumoral and nodal stage, delivered dose, accelerated hyperfractionned radiotherapy, concomitant association of chemotherapy to radiotherapy and response to the treatment. The dosimetric parameters predictive of esophagitis are: mean dose, V(20Gy), V(30Gy), V(40Gy), V(45Gy) and V(50Gy). Amifostine is the only drug to have a proven radioprotective efficacy (evidence level C, ESMO recommendation grade III). The medical management of esophagitis associates a diet excluding irritant food, medication against gastroesophageal reflux, analgesic treatment according to the WHO scale and management of dehydration and denutrition by enteral feeding.
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Affiliation(s)
- T Challand
- Département de radiothérapie et de physique médicale, QuantIF, Litis, centre Henri-Becquerel, Rouen, France.
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Ren S, Ren G. External beam radiation therapy is safe and effective in treating primary pulmonary amyloidosis. Respir Med 2012; 106:1063-9. [DOI: 10.1016/j.rmed.2012.02.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2010] [Revised: 01/04/2012] [Accepted: 02/20/2012] [Indexed: 11/16/2022]
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