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Bamneshin K, Rabi Mahdavi S, Bitarafan-Rajabi A, Geramifar P, Hejazi P, Koosha F, Jadidi M. Evaluation of Dose-Painting in the Dominant Intraprostatic Lesions by Radiobiological Parameters using 68Ga- PSMA PET/CT. J Biomed Phys Eng 2022; 12:369-376. [PMID: 36059285 PMCID: PMC9395631 DOI: 10.31661/jbpe.v0i0.1912-1006] [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: 12/16/2019] [Accepted: 02/03/2020] [Indexed: 06/15/2023]
Abstract
BACKGROUND Patients diagnosed with dominant intraprostatic lesions (DIL) may need radiation doses over than 80 Gy. Dose-painting by contours (DPC) is a useful technique which helps the patients. Dose-painting approach need to be evaluated. OBJECTIVE To evaluate the DCP technique in the case of boosting the DILs by radiobiological parameters, tumor control probability (TCP), and normal tissue complication probability (NTCP) via PET/CT images traced by 68Ga-PSMA. MATERIAL AND METHODS In this analytical study, 68Ga-PSMA PET/CT images were obtained from patients with DILs that were delineated using the Fuzzy c-mean (FCM) algorithm and thresholding methods. The protocol of therapy included two phases; at the first phase (ph1), a total dose of 72 Gy in 36 fractions were delivered to the planning target volume (PTV1); the seconds phase consisted of the application of variable doses to the PTV2. Moreover, two concepts were also considered to calculate the TCP using the Zaider-Minerbo model. RESULTS The lowest volume in DILs belonged to the DIL1 extracted by the FCM method. According to dose-volume parameters of the rectum and bladder, by the increase in the PTV dose higher than 92 Gy, the amounts of rectum and bladder doses are increased. There was no difference between the TCPs of DILs at doses higher than 86 Gy and 100 Gy for ordinary and high clone density, respectively. CONCLUSION Consequently, our dose-painting approach for DILs, extracted by the FCM method via PET/CT images, can reduce the total dose for prostate radiation with 100% tumor control and less normal tissue complications.
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Affiliation(s)
- Khadijeh Bamneshin
- PhD, Department of Medical Physics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
- PhD, Student Research Committee, Iran University of Medical Sciences, Tehran, Iran
| | - Seied Rabi Mahdavi
- PhD, Radiation Biology Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ahmad Bitarafan-Rajabi
- PhD, Echocardiography Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Parham Geramifar
- PhD, Department of Nuclear Medicine, Shariati Hospital Tehran University of Medical Sciences, Tehran, Iran
| | - Payman Hejazi
- PhD, Department of Medical Physics, Faculty of Medicine, Semnan University of Medical Sciences, Semnan, Iran
| | - Fereshteh Koosha
- PhD, Department of Radiology Technology, Faculty of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Majid Jadidi
- PhD, Department of Medical Physics, Faculty of Medicine, Semnan University of Medical Sciences, Semnan, Iran
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Pedersen J, Liang X, Bryant C, Mendenhall N, Li Z, Muren LP. Normal tissue complication probability models for prospectively scored late rectal and urinary morbidity after proton therapy of prostate cancer. Phys Imaging Radiat Oncol 2021; 20:62-68. [PMID: 34805558 PMCID: PMC8590075 DOI: 10.1016/j.phro.2021.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 10/02/2021] [Accepted: 10/11/2021] [Indexed: 12/25/2022] Open
Abstract
Background and purpose Photons and protons have fundamentally different properties, i.e. protons have a reduced dose bath but a higher relative biological effectiveness. Photon-based normal tissue complication probability (NTCP) models may therefore not immediately be applicable to proton therapy (PT). The aim was to derive parameters of the Lyman-Kutcher-Burman (LKB) NTCP model using prospectively recorded late morbidity data from PT, focusing on rectal morbidity and prostate cancer. Materials and methods Prospectively collected data were available for 1151 prostate cancer patients treated with passive scattering PT and prescribed target doses of 78–82 Gy (RBE = 1.1) in 2 Gy fractions. Morbidity data (CTCAE v3.0) consisted of two alternative late grade 2 rectal bleeding endpoints: Medical Grade2A (GR2A) and procedural Grade2B (GR2B), as well as late grade 3 + urinary morbidity. GR2A + 2B were observed in 156/1047 patients (15%), GR2B in 45/1047 patients (4%), and urinary grade 3 + in 51/1151 patients (4%). LKB NTCP model parameters (D50, m, and n) were derived by maximum likelihood estimation. Results For the rectum/rectal wall the volume parameter n was low (0.07–0.14) for both GR2A + 2B and GR2B, as was the m parameter (range: 0.16–0.20). For the bladder/bladder wall both parameters were high (n-range: 0.20–0.36; m-range: 0.32–0.36). D50 parameters were higher for GR2B of the rectum/rectal wall (95.9–98.0 Gy) and bladder/bladder wall (118.1–119.9 Gy), but lower for GR2A2B (71.7–73.6 Gy). Conclusion PT specific LKB NTCP model parameters were derived from a population of more than 1000 patients. The D50 parameter differed for all structures and endpoints and deviated from typical photon-based LKB model values.
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Affiliation(s)
- Jesper Pedersen
- Danish Centre for Particle Therapy, Aarhus University Hospital/Aarhus University, Aarhus, Denmark
| | - Xiaoying Liang
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Curtis Bryant
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Nancy Mendenhall
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Zuofeng Li
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Ludvig P Muren
- Danish Centre for Particle Therapy, Aarhus University Hospital/Aarhus University, Aarhus, Denmark
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McDonald J, Chuang CY, Hicks JK, Berry DK, Imanirad I, Rishi A, Frakes JM, Hoffe SE, Felder S. FANCD2 Mutation in a Patient With Early Rectal Cancer Receiving Definitive Chemoradiation. Adv Radiat Oncol 2021; 6:100717. [PMID: 34258475 PMCID: PMC8260782 DOI: 10.1016/j.adro.2021.100717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 04/13/2021] [Accepted: 04/20/2021] [Indexed: 02/07/2023] Open
Affiliation(s)
| | | | | | | | | | | | | | | | - Seth Felder
- Surgical Oncology, Moffitt Cancer Center, Tampa, Florida
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Ebert MA, Gulliford S, Acosta O, de Crevoisier R, McNutt T, Heemsbergen WD, Witte M, Palma G, Rancati T, Fiorino C. Spatial descriptions of radiotherapy dose: normal tissue complication models and statistical associations. Phys Med Biol 2021; 66:12TR01. [PMID: 34049304 DOI: 10.1088/1361-6560/ac0681] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 05/28/2021] [Indexed: 12/20/2022]
Abstract
For decades, dose-volume information for segmented anatomy has provided the essential data for correlating radiotherapy dosimetry with treatment-induced complications. Dose-volume information has formed the basis for modelling those associations via normal tissue complication probability (NTCP) models and for driving treatment planning. Limitations to this approach have been identified. Many studies have emerged demonstrating that the incorporation of information describing the spatial nature of the dose distribution, and potentially its correlation with anatomy, can provide more robust associations with toxicity and seed more general NTCP models. Such approaches are culminating in the application of computationally intensive processes such as machine learning and the application of neural networks. The opportunities these approaches have for individualising treatment, predicting toxicity and expanding the solution space for radiation therapy are substantial and have clearly widespread and disruptive potential. Impediments to reaching that potential include issues associated with data collection, model generalisation and validation. This review examines the role of spatial models of complication and summarises relevant published studies. Sources of data for these studies, appropriate statistical methodology frameworks for processing spatial dose information and extracting relevant features are described. Spatial complication modelling is consolidated as a pathway to guiding future developments towards effective, complication-free radiotherapy treatment.
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Affiliation(s)
- Martin A Ebert
- School of Physics, Mathematics and Computing, University of Western Australia, Crawley, Western Australia, Australia
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
- 5D Clinics, Claremont, Western Australia, Australia
| | - Sarah Gulliford
- Department of Radiotherapy Physics, University College Hospitals London, United Kingdom
- Department of Medical Physics and Bioengineering, University College London, United Kingdom
| | - Oscar Acosta
- Univ Rennes, CLCC Eugène Marquis, INSERM, LTSI-UMR 1099, F-35000 Rennes, France
| | | | - Todd McNutt
- Johns Hopkins University, Baltimore, Maryland, United States of America
| | | | - Marnix Witte
- The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Giuseppe Palma
- Institute of Biostructures and Bioimaging, National Research Council, Napoli, Italy
| | - Tiziana Rancati
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Claudio Fiorino
- Medical Physics, San Raffaele Scientific Institute, Milano, Italy
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Sargos P, Faye MD, Bacci M, Supiot S, Latorzeff I, Azria D, Niazi TM, Vuong T, Vendrely V, de Crevoisier R. Late Gastrointestinal Tolerance After Prostate Radiotherapy: Is the Anal Canal the Culprit? A Narrative Critical Review. Front Oncol 2021; 11:666962. [PMID: 34221983 PMCID: PMC8242201 DOI: 10.3389/fonc.2021.666962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 05/13/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Late gastro-intestinal toxicities (LGIT) secondary to pelvic radiotherapy (RT) are well described in the literature. LGIT are mainly related to rectal or ano-rectal irradiation; however, involvement of the anal canal (AC) in the occurrence of LGIT remains poorly described and understood. MATERIALS AND METHODS The aim of this work was to explore the potential role of the AC in the development of LGIT after prostate irradiation and identify predictive factors that could be optimized in order to limit these toxicities. This narrative literature review was realized using the Pubmed database. We identified original articles published between June 1997 and July 2019, relating to LGIT after RT for localized prostate cancer and for which AC was identified independently. Articles defining the AC as part of an anorectal or rectal volume only were excluded. RESULTS A history of abdominal surgery or cardio-vascular risk, anticoagulant or tobacco use, and the occurrence of acute GIT during RT increases the risk of LGIT. A dose-effect relationship was identified between dose to the AC and development of LGIT. Identification and contouring of the AC and adjacent anatomical structures (muscles or nerves) are justified to apply specific dose constraints. As a limitation, our review mainly considered on 3DCRT which is no longer the standard of care nowadays; we did not identify any reports in the literature using moderately hypofractionated RT for the prostate and AC specific dosimetry. CONCLUSION These results suggest that the AC may have an important role in the development of LGIT after pelvic RT for prostate cancer. The individualization of the AC during planning should be recommended in prospective studies.
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Affiliation(s)
- Paul Sargos
- Department of Radiation Oncology, Institut Bergonié, Bordeaux Cedex, France
| | - Mame Daro Faye
- Department of Radiation Oncology, Jewish General Hospital, Montreal, QC, Canada
| | - Manon Bacci
- Department of Radiation Oncology, Institut Bergonié, Bordeaux Cedex, France
| | - Stéphane Supiot
- Department of Radiation Oncology, Institut de Cancérologie de l'Ouest, Saint-Herblain, France
| | - Igor Latorzeff
- Department of Radiation Oncology, Clinique Pasteur, Toulouse, France
| | - David Azria
- Department of Radiation Oncology, Institut de Cancérologie de Montpellier, Montpellier, France
| | - Tamim M Niazi
- Department of Radiation Oncology, Jewish General Hospital, Montreal, QC, Canada
| | - Te Vuong
- Department of Radiation Oncology, Jewish General Hospital, Montreal, QC, Canada
| | - Véronique Vendrely
- Department of Radiation Oncology, Bordeaux University Hospital, Bordeaux, France
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Jadon R, Hanna L, Parsons P, Staffurth J. Dose-Volume Predictors for Patient-reported Late Diarrhoea, Faecal Incontinence and Urgency after Pelvic Radiotherapy. Clin Oncol (R Coll Radiol) 2021; 33:536-545. [PMID: 33875359 DOI: 10.1016/j.clon.2021.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 02/09/2021] [Accepted: 03/15/2021] [Indexed: 11/30/2022]
Abstract
AIMS Pelvic radiotherapy adds significantly to the curative treatment of many pelvic malignancies. However, this cure comes at a cost for many patients, where late bowel toxicities, such as faecal incontinence, urgency and diarrhoea, adversely affect quality of life. Despite the implementation of advanced radiotherapy techniques in many centres, there are deficiencies in our knowledge of how to make best use of these techniques to minimise these late toxicities, with dose-volume constraints specifically for late effects needing definition. The aims of this study were to establish dose-volume predictors for patient-reported late bowel toxicities and derive constraints for clinical use to reduce the risk of these toxicities. MATERIALS AND METHODS All radiotherapy patients treated in our institution between 2012 and 2014 for gynaecological and urological cancers (bladder, prostate where pelvic nodes are treated) were identified. Patients were sent patient-reported toxicity questionnaires at 12 and 24 months after treatment. Planning computed tomography scans were retrospectively contoured with different definitions of bowel as organs at risk (OARs). Dose-volume data for each OAR were collected and predictors of these toxicities found using multivariate analysis. For those dose-volume predictors found to be significant on multivariate analysis, statistically significant and clinically relevant dose-volume constraints were derived. Furthermore, data collected were used to validate constraints from published studies. RESULTS Faecal urgency, incontinence and diarrhoea rates were found in 52, 23.5 and 18.7% of the 203 patients included at 12 months following radiotherapy. Dose-volume parameters for sigmoid colon and large bowel were significant for these toxicities, and constraints for these OARs were derived, which are promising. A previously published constraint for bowel loops was validated with our data. CONCLUSIONS The sigmoid colon and large bowel are important OARs for the development of faecal urgency, incontinence and diarrhoea. Promising constraints for these OARs were derived, which require further validation before prospective clinical use.
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Affiliation(s)
- R Jadon
- Department of Clinical Oncology, Velindre Cancer Centre, Cardiff, UK; Department of Clinical Oncology, Addenbrooke's Hospital, Cambridge, UK.
| | - L Hanna
- Department of Clinical Oncology, Velindre Cancer Centre, Cardiff, UK
| | - P Parsons
- Department of Medical Physics, Velindre Cancer Centre, Cardiff, UK
| | - J Staffurth
- Department of Clinical Oncology, Velindre Cancer Centre, Cardiff, UK; School of Medicine, Institute of Cancer and Genetics, Cardiff University, Velindre Cancer Centre, Cardiff, UK
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Wang X, Zhang B, He Q, Kong Y, Dai Z, Meng H, Huang F, Zhang S, Zhu Y, Tan X, Zhen X. Rectum Protection by Rectal Gel Injection in Cervical Cancer Brachytherapy: A Dosimetric Study via Deformable Surface Dose Accumulation and Machine-Learning-Based Discriminative Modeling. Front Oncol 2021; 11:657208. [PMID: 33937068 PMCID: PMC8085420 DOI: 10.3389/fonc.2021.657208] [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: 01/22/2021] [Accepted: 03/29/2021] [Indexed: 11/13/2022] Open
Abstract
PURPOSE This retrospective study aimed to evaluate the dosimetric effects of a rectal insertion of Kushen Ningjiao on rectal protection using deformable dose accumulation and machine learning-based discriminative modelling. MATERIALS AND METHODS Sixty-two patients with cervical cancer enrolled in a clinical trial, who received a Kushen Ningjiao injection of 20 g into their rectum for rectal protection via high-dose rate brachytherapy (HDR-BT, 6 Gy/f), were studied. The cumulative equivalent 2-Gy fractional rectal surface dose was deformably summed using an in-house-developed topography-preserved point-matching deformable image registration method. The cumulative three-dimensional (3D) dose was flattened and mapped to a two-dimensional (2D) plane to obtain the rectal surface dose map (RSDM). For analysis, the rectal dose (RD) was further subdivided as follows: whole, anterior, and posterior 3D-RD and 2D-RSDM. The dose-volume parameters (DVPs) were extracted from the 3D-RD, while the dose geometric parameters (DGPs) and textures were extracted from the 2D-RSDM. These features were fed into 192 classification models (built with 8 classifiers and 24 feature selection methods) for discriminating the dose distributions between pre-Kushen Ningjiao and pro-Kushen Ningjiao. RESULTS The rectal insertion of Kushen Ningjiao dialated the rectum in the ambilateral direction, with the rectal column increased from pre-KN 15 cm3 to post-KN 18 cm3 (P < 0.001). The characteristics of DGPs accounted for the largest portions of the top-ranked features. The top-ranked dosimetric features extracted from the posterior rectum were more reliable indicators of the dosimetric effects/changes introduced by the rectal insertion of Kushen Ningjiao. A significant dosimetric impact was found on the dose-volume parameters D1.0cc-D2.5cc extracted on the posterior rectal wall. CONCLUSIONS The rectal insertion of Kushen Ningjiao incurs significant dosimetric changes on the posterior rectal wall. Whether this effect is eventually translated into clinical gains requires further long-term follow-up and more clinical data for confirmation.
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Affiliation(s)
- Xuetao Wang
- Radiation Oncology Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Bailin Zhang
- Radiation Oncology Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qiang He
- Radiation Oncology Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yilin Kong
- Radiation Oncology Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhenhui Dai
- Radiation Oncology Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Haoyu Meng
- Radiation Oncology Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Fangjun Huang
- School of Biomedical Engineering, Southern Medical University, Guangzhou, China
| | - Shengfeng Zhang
- Radiation Oncology Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yuanhu Zhu
- Radiation Oncology Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xiang Tan
- Radiation Oncology Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xin Zhen
- School of Biomedical Engineering, Southern Medical University, Guangzhou, China
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8
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Kronborg CJS, Christensen P, Pedersen BG, Spindler KLG. Anorectal function and radiation dose to pelvic floor muscles after primary treatment for anal cancer. Radiother Oncol 2021; 157:141-146. [PMID: 33545256 DOI: 10.1016/j.radonc.2021.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/05/2021] [Accepted: 01/17/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND PURPOSE Chemoradiotherapy is the primary treatment for localized anal cancer (AC). This treatment offers high rates of cure and organ preservation. Radiotherapy can however, result in late persisting anorectal dysfunction, with anal incontinence, urge and clustering. Correlation of radiation doses to pelvic substructures and functional outcome is not well described in AC. We correlated patient reported anorectal function to radiation doses to sphincters and pelvic floor muscles. MATERIALS AND METHODS Patients treated with (chemo)radiotherapy for AC were asked to fill out LARS (lower anterior resection syndrome) questionnaires at follow-up. We compared patients with no LARS (score 0-19) and patients with major LARS (30-42) as well as individual LARS questions to specific radiation doses to sphincters, levators and puborectal muscles. RESULTS Thirty-six patients were included, 18 with no LARS and 18 with major LARS. Gender, age, TNM stage, PTV, chemotherapy, time to LARS score (mean 660 and 749 days) were comparable between the two groups. LARS symptoms, occurring at least once per week, were reported between 25-55.7%, and poorer LARS outcome was associated to worse quality of life. Dose to sphincter complex (Dmean, V50Gy and D90%) differed significantly between patients with no and major LARS (p = 0.048, 0.035 and 0.02 respectively). Further, D90% to the sphincter complex was significantly higher in patients who had accidental leakage of stool, (p = 0.044). CONCLUSION Patients treated with (chemo)radiotherapy for AC show high frequency of patient reported anorectal dysfunction. Specific doses to the sphincters could become a useful predictor of anal incontinence and major LARS and incorporated into future radiotherapy planning studies.
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Pedersen J, Liang X, Casares-Magaz O, Bryant C, Mendenhall N, Li Z, Muren LP. Multivariate normal tissue complication probability models for rectal and bladder morbidity in prostate cancer patients treated with proton therapy. Radiother Oncol 2020; 153:279-288. [PMID: 33096166 DOI: 10.1016/j.radonc.2020.10.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 10/14/2020] [Accepted: 10/15/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND PURPOSE Normal tissue complication probability (NTCP) models applied for model-based patient selection to proton therapy (PT) have usually been derived using dose/volume histogram (DVH) parameters from photon-based radiotherapy. This study aimed to derive PT-specific multivariate NTCP models that also accounted for the spatial dose distribution (rectum only) as well as non-dose/volume related factors. MATERIALS AND METHODS The study included rectum and bladder DVHs, 2D rectal dose maps and relevant patient/treatment characteristics from 1151 prostate cancer cases treated with PT. Prospectively scored Grade 2 late rectal bleeding (CTCAE v3.0, also procedural interventions separately) (n = 156 (15%)) and Grade 3+ GU morbidity (n = 51 (4%)) were entered into a multivariate logistic regression analysis. Model evaluation included assessment of the area under the receiver operating characteristic curve (AUC). RESULTS Anticoagulant use was a dominant predictor, chosen in four of the six rectum models and in the bladder model. Age was a dominant predictor in all procedural only rectum models while prostate volume, bladder D5% and V75Gy were predictors in the bladder model. The selection frequency of the dose/volume predictors varied widely, where the percentage of the anterior rectum surface receiving >=75 Gy was the most robust. AUC values ranged from 0.58 to 0.70 across all models, with no clear difference between the DVH- and spatial-based models for the rectum. CONCLUSION Anticoagulant use and age were the most prominent predictors in the NTCP models. V75Gy of the rectal wall and the bladder was a predictor in the DVH-based models of the rectum and bladder respectively.
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Affiliation(s)
- Jesper Pedersen
- Danish Centre for Particle Therapy, Aarhus University Hospital/Aarhus University, Denmark.
| | - Xiaoying Liang
- University of Florida Health Proton Therapy Institute, Jacksonville, USA
| | - Oscar Casares-Magaz
- Danish Centre for Particle Therapy, Aarhus University Hospital/Aarhus University, Denmark
| | - Curtis Bryant
- University of Florida Health Proton Therapy Institute, Jacksonville, USA
| | - Nancy Mendenhall
- University of Florida Health Proton Therapy Institute, Jacksonville, USA
| | - Zuofeng Li
- University of Florida Health Proton Therapy Institute, Jacksonville, USA
| | - Ludvig P Muren
- Danish Centre for Particle Therapy, Aarhus University Hospital/Aarhus University, Denmark
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Ibragimov B, Toesca DA, Chang DT, Yuan Y, Koong AC, Xing L. Automated hepatobiliary toxicity prediction after liver stereotactic body radiation therapy with deep learning-based portal vein segmentation. Neurocomputing 2020. [DOI: 10.1016/j.neucom.2018.11.112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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11
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Heemsbergen WD, Incrocci L, Pos FJ, Heijmen BJM, Witte MG. Local Dose Effects for Late Gastrointestinal Toxicity After Hypofractionated and Conventionally Fractionated Modern Radiotherapy for Prostate Cancer in the HYPRO Trial. Front Oncol 2020; 10:469. [PMID: 32346534 PMCID: PMC7169424 DOI: 10.3389/fonc.2020.00469] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 03/16/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose: Late gastrointestinal (GI) toxicity after radiotherapy for prostate cancer may have significant impact on the cancer survivor's quality of life. To date, little is known about local dose-effects after modern radiotherapy including hypofractionation. In the current study we related the local spatial distribution of radiation dose in the rectum to late patient-reported gastrointestinal (GI) toxicities for conventionally fractionated (CF) and hypofractionated (HF) modern radiotherapy in the randomized HYPRO trial. Material and Methods: Patients treated to 78 Gy in 2 Gy fractions (n = 298) or 64.6 Gy in 3.4 Gy fractions (n = 295) with available late toxicity questionnaires (n ≥ 2 within 1-5 years post-treatment) and available 3D planning data were eligible for this study. The majority received intensity modulated radiotherapy (IMRT). We calculated two types of dose surface maps: (1) the total delineated rectum with its central axis scaled to unity, and (2) the delineated rectum with a length of 7 cm along its central axis aligned on the prostate's half-height point (prostate-half). For each patient-reported GI symptom, dose difference maps were constructed by subtracting average co-registered EQD2 (equivalent dose in 2 Gy) dose maps of patients with and without the symptom of interest, separately for HF and CF. P-values were derived from permutation tests. We evaluated patient-reported moderate to severe GI symptoms. Results: Observed incidences of rectal bleeding and increased stool frequency were significantly higher in the HF group. For rectal bleeding (p = 0.016), mucus discharge (p = 0.015), and fecal incontinence (p = 0.001), significant local dose-effects were observed in HF patients but not in CF patients. For rectal pain, similar local dose-effects (p < 0.05) were observed in both groups. No significant local dose-effects were observed for increased stool frequency. Total rectum mapping vs. prostate-half mapping showed similar results. Conclusion: We demonstrated significant local dose-effect relationships for patient-reported late GI toxicity in patients treated with modern RT. HF patients were at higher risk for increased stool frequency and rectal bleeding, and showed the most pronounced local dose-effects in intermediate-high dose regions. These findings suggest that improvement of current treatment optimization protocols could lead to clinical benefit, in particular for HF treatment.
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Affiliation(s)
- Wilma D Heemsbergen
- Department of Radiation Oncology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Luca Incrocci
- Department of Radiation Oncology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Floris J Pos
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Ben J M Heijmen
- Department of Radiation Oncology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Marnix G Witte
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
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12
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Wilkins A, Naismith O, Brand D, Fernandez K, Hall E, Dearnaley D, Gulliford S. Derivation of Dose/Volume Constraints for the Anorectum from Clinician- and Patient-Reported Outcomes in the CHHiP Trial of Radiation Therapy Fractionation. Int J Radiat Oncol Biol Phys 2020; 106:928-938. [PMID: 31987974 DOI: 10.1016/j.ijrobp.2020.01.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 12/20/2019] [Accepted: 01/03/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE The CHHiP trial randomized 3216 men with localized prostate cancer (1:1:1) to 3 radiation therapy fractionation schedules: 74 Gy in 37 fractions over 7.4 weeks; 60 Gy in 20 fractions over 4 weeks; and 57 Gy in 19 fractions over 3.8 weeks. Literature-based dose constraints were applied with arithmetic adjustment for the hypofractionated arms. This study aimed to derive anorectal dose constraints using prospectively collected clinician-reported outcomes (CROs) and patient-reported outcomes (PROs) and to assess the added predictive value of spatial dose metrics. METHODS AND MATERIALS A case-control study design was used; 7 CRO and 5 PRO bowel symptoms were evaluated. Cases experienced a moderate or worse symptom 1 to 5 years after-radiation therapy and did not have the symptom before radiation therapy. Controls did not experience the symptom at baseline or between 1 to 5 years after radiation therapy. The anorectum was recontoured from the anal verge to the rectosigmoid junction; dose/volume parameters were extracted. Univariate logistic regression, atlases of complication indices, and bootstrapped receiver-operating-characteristic analysis (1000 replicates, balanced outcomes) were used to derive dose constraints for the whole cohort (hypofractionated schedules were converted to 2-Gy equivalent schedules using α/β = 3 Gy) and separate hypofractionated/conventional fractionation cohorts. Only areas under the curve with 95% confidence interval lower limits >0.5 were considered statistically significant. Any constraint derived in <95% to 99% of bootstraps was excluded. RESULTS Statistically significant dose constraints were derived for CROs but not PROs. Intermediate to high doses were important for rectal bleeding, whereas intermediate doses were important for increased bowel frequency, fecal incontinence, and rectal pain. Spatial dose metrics did not improve prediction of CROs or PROs. A new panel of dose constraints for hypofractionated schedules to 60 Gy or 57 Gy are V20Gy <85%, V30Gy <57%, V40Gy <38%, V50Gy <22%, and V60Gy <0.01%. CONCLUSIONS Dose constraints differed among symptoms, indicating potentially different pathogenesis of radiation-induced side effects. Derived dose constraints were stricter than those used in CHHiP and may reduce bowel symptoms after radiation therapy.
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Affiliation(s)
- Anna Wilkins
- Division of Clinical Studies, Institute of Cancer Research, London, United Kingdom; The Royal Marsden Hospital, London, United Kingdom.
| | - Olivia Naismith
- The Royal Marsden Hospital, London, United Kingdom; Radiotherapy Trials Quality Assurance Group, London, United Kingdom
| | - Douglas Brand
- The Royal Marsden Hospital, London, United Kingdom; Division of Radiotherapy and Imaging, Institute of Cancer Research, London, United Kingdom
| | - Katie Fernandez
- Division of Radiotherapy and Imaging, Institute of Cancer Research, London, United Kingdom
| | - Emma Hall
- Division of Clinical Studies, Institute of Cancer Research, London, United Kingdom
| | - David Dearnaley
- The Royal Marsden Hospital, London, United Kingdom; Division of Radiotherapy and Imaging, Institute of Cancer Research, London, United Kingdom
| | - Sarah Gulliford
- Division of Radiotherapy and Imaging, Institute of Cancer Research, London, United Kingdom
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13
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Cross-modality applicability of rectal normal tissue complication probability models from photon- to proton-based radiotherapy. Radiother Oncol 2020; 142:253-260. [DOI: 10.1016/j.radonc.2019.09.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 09/20/2019] [Accepted: 09/21/2019] [Indexed: 11/21/2022]
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14
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Onjukka E, Fiorino C, Cicchetti A, Palorini F, Improta I, Gagliardi G, Cozzarini C, Degli Esposti C, Gabriele P, Valdagni R, Rancati T. Patterns in ano-rectal dose maps and the risk of late toxicity after prostate IMRT. Acta Oncol 2019; 58:1757-1764. [PMID: 31298076 DOI: 10.1080/0284186x.2019.1635267] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Purpose: The aim of this work was to determine how the spatial pattern of dose in the ano-rectal wall is related to late gastro-intestinal toxicity for prostate cancer patients treated with mainly IMRT.Patients and methods: Patients from the DUE-01 multicentre study with patient-reported (prospective) follow-up and available dosimetric data were included. Conventionally fractionated patients received 74-80 Gy and hypofractionated patients received 65-75.2 Gy. A large majority of the patients were treated with intensity-modulated radiotherapy (IMRT). Dose-surface maps (DSMs) for the anal canal and rectum as a single structure, and for the anal canal and the rectum separately, were co-registered rigidly in two dimensions and, for the patients with and without toxicity, respectively, the mean value of the dose in each pixel was calculated. A pixel-wise t-test was used to highlight the anatomical areas where there was a significant difference between the 'mean dose maps' of each group. Univariate models were also fitted to a range of spatial parameters. The endpoints considered were a mean grade ≥1 late fecal incontinence and a maximum grade ≥2 late rectal bleeding.Results: Twenty-six out of 213 patients had fecal incontinence, while 21/225 patients had rectal bleeding. Incontinence was associated with a higher dose in the caudal region of the anal canal; the most relevant spatial parameter was the lateral extent of the low and medium isodoses (5-49 Gy in EQD2). Bleeding was associated with high isodoses reaching the posterior rectal wall. The spatial dose parameters with the highest AUC value (.69) were the lateral extent of the 60-70 Gy isodoses.Conclusions: To avoid fecal incontinence it is important to limit the portion of the anal canal irradiated. Our analysis confirms that rectal bleeding is a function of similar spatial dose parameters for patients treated with IMRT, compared to previous studies on patients treated with three-dimensional conformal radiotherapy.
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Affiliation(s)
- Eva Onjukka
- Karolinska University Hospital, Stockholm, Sweden
| | | | | | | | | | | | | | | | - Pietro Gabriele
- Istituto di Candiolo - Fondazione del Piemonte per l'Oncologia IRCCS, Candiolo, Italy
| | | | - Tiziana Rancati
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
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15
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Casares-Magaz O, Bülow S, Pettersson NJ, Moiseenko V, Pedersen J, Thor M, Einck J, Hopper A, Knopp R, Muren LP. High accumulated doses to the inferior rectum are associated with late gastro-intestinal toxicity in a case-control study of prostate cancer patients treated with radiotherapy. Acta Oncol 2019; 58:1543-1546. [PMID: 31364905 DOI: 10.1080/0284186x.2019.1632476] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
| | - Steffen Bülow
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Niclas J. Pettersson
- Department of Medical Physics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Vitali Moiseenko
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
| | - Jesper Pedersen
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Maria Thor
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - John Einck
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
| | - Austin Hopper
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
| | - Rick Knopp
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
| | - Ludvig Paul Muren
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
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16
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Jadon R, Higgins E, Hanna L, Evans M, Coles B, Staffurth J. A systematic review of dose-volume predictors and constraints for late bowel toxicity following pelvic radiotherapy. Radiat Oncol 2019; 14:57. [PMID: 30943992 PMCID: PMC6448293 DOI: 10.1186/s13014-019-1262-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 03/27/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Advanced pelvic radiotherapy techniques aim to reduce late bowel toxicity which can severely impact the lives of pelvic cancer survivors. Although advanced techniques have been largely adopted worldwide, to achieve their aim, knowledge of which dose-volume parameters of which components of bowel predict late bowel toxicity is crucial to make best use of these techniques. The rectum is an extensively studied organ at risk (OAR), and dose-volume predictors of late toxicity for the rectum are established. However, for other components of bowel, there is a significant paucity of knowledge. The Quantitative Analyses of Normal Tissue Effects in the Clinic (QUANTEC) reviews recommend dose-volume constraints for acute bowel toxicity for peritoneal cavity and bowel loops, although no constraints are recommended for late toxicity, despite its relevance to our increasing number of survivors. This systematic review aims to examine the published literature to seek dose-volume predictors and constraints of late bowel toxicity for OARs (apart from the rectum) for use in clinical practice. METHODS A systematic literature search was performed using Medline, Embase, Cochrane Library, Web of Science, Cinahl and Pubmed. Studies were screened and included according to specific pre-defined criteria. Included studies were assessed for quality against QUANTEC-defined assessment criteria. RESULTS 101 studies were screened to find 30 relevant studies. Eight studies related to whole bowel, 11 to small bowel, and 21 to large bowel (including 16 of the anal canal). The anal canal is an important OAR for the development of late toxicity, and we recommend an anal canal Dmean <40Gy as a constraint to reduce late incontinence. For other components of bowel (sigmoid, large bowel, intestinal cavity, bowel loops), although individual studies found statistically significant parameters and constraints these findings were not corroborated in other studies. CONCLUSIONS The anal canal is an important OAR for the development of late bowel toxicity symptoms. Further validation of the constraints found for other components of bowel is needed. Studies that were more conclusive included those with patient-reported data, where individual symptom scores were assessed rather than an overall score, and those that followed statistical and endpoint criteria as defined by QUANTEC.
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Affiliation(s)
- Rashmi Jadon
- Department of Clinical Oncology, Velindre Cancer Centre, Velindre Road, Whitchurch, Cardiff, CF14 2TL, UK. .,Department of Clinical Oncology, Addenbrookes' Hospital, Box 193, Cambridge, CB2 0QQ, UK.
| | - Emma Higgins
- Department of Clinical Oncology, Velindre Cancer Centre, Velindre Road, Whitchurch, Cardiff, CF14 2TL, UK
| | - Louise Hanna
- Department of Clinical Oncology, Velindre Cancer Centre, Velindre Road, Whitchurch, Cardiff, CF14 2TL, UK
| | - Mererid Evans
- Department of Clinical Oncology, Velindre Cancer Centre, Velindre Road, Whitchurch, Cardiff, CF14 2TL, UK
| | - Bernadette Coles
- Cancer Research Wales Library, Velindre Cancer Centre, Velindre Road, Whitchurch, Cardiff, CF14 2TL, UK
| | - John Staffurth
- Department of Clinical Oncology, Velindre Cancer Centre, Velindre Road, Whitchurch, Cardiff, CF14 2TL, UK.,School of Medicine, Institute of Cancer and Genetics, Cardiff University, Velindre Cancer Centre, Velindre Road, Whitchurch, Cardiff, CF14 2TL, UK
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17
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Impact of radiotherapy on anorectal function in patients with rectal cancer following a watch and wait programme. Radiother Oncol 2019; 132:79-84. [DOI: 10.1016/j.radonc.2018.11.017] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 11/19/2018] [Accepted: 11/25/2018] [Indexed: 12/14/2022]
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18
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Vanneste BG, Buettner F, Pinkawa M, Lambin P, Hoffmann AL. Ano-rectal wall dose-surface maps localize the dosimetric benefit of hydrogel rectum spacers in prostate cancer radiotherapy. Clin Transl Radiat Oncol 2019; 14:17-24. [PMID: 30456317 PMCID: PMC6234617 DOI: 10.1016/j.ctro.2018.10.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/31/2018] [Accepted: 10/31/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND PURPOSE To evaluate spatial differences in dose distributions of the ano-rectal wall (ARW) using dose-surface maps (DSMs) between prostate cancer patients receiving intensity-modulated radiation therapy with and without implantable rectum spacer (IMRT+IRS; IMRT-IRS, respectively), and to correlate this with late gastro-intestinal (GI) toxicities using validated spatial and non-spatial normal-tissue complication probability (NTCP) models. MATERIALS AND METHODS For 26 patients DSMs of the ARW were generated. From the DSMs various shape-based dose measures were calculated at different dose levels: lateral extent, longitudinal extent, and eccentricity. The contiguity of the ARW dose distribution was assessed by the contiguous-DSH (cDSH). Predicted complication rates between IMRT+IRS and IMRT-IRS plans were assessed using a spatial NTCP model and compared against a non-spatial NTCP model. RESULTS Dose surface maps are generated for prostate radiotherapy using an IRS. Lateral extent, longitudinal extent and cDSH were significantly lower in IMRT+IRS than for IMRT-IRS at high-dose levels. Largest significant differences were observed for cDSH at dose levels >50 Gy, followed by lateral extent at doses >57 Gy, and longitudinal extent in anterior and superior-inferior directions. Significant decreases (p = 0.01) in median rectal and anal NTCPs (respectively, Gr 2 late rectal bleeding and subjective sphincter control) were predicted when using an IRS. CONCLUSIONS Local-dose effects are predicted to be significantly reduced by an IRS. The spatial NTCP model predicts a significant decrease in Gr 2 late rectal bleeding and subjective sphincter control. Dose constraints can be improved for current clinical treatment planning.
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Affiliation(s)
| | | | - Michael Pinkawa
- Department of Radiation Oncology, MediClin Robert Janker Klinik, Bonn, Germany
| | - Philippe Lambin
- The D-Lab, GROW – School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Aswin L. Hoffmann
- MAASTRO Clinic, Maastricht, The Netherlands
- Institute of Radiooncology, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- Department of Radiotherapy, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany
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19
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Dapper H, Rodríguez I, Münch S, Peeken JC, Borm K, Combs SE, Habermehl D. Impact of VMAT-IMRT compared to 3D conformal radiotherapy on anal sphincter dose distribution in neoadjuvant chemoradiation of rectal cancer. Radiat Oncol 2018; 13:237. [PMID: 30509284 PMCID: PMC6276230 DOI: 10.1186/s13014-018-1187-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 11/19/2018] [Indexed: 12/13/2022] Open
Abstract
Background Neoadjuvant radio- or chemoradiation (nIRT) therapy is the standard treatment for loco-regional advanced rectal cancer patients of the lower or middle third. Currently, intensity modulated radiation therapy (IMRT) is not the recommended radiation technique even though IMRT has advantages compared to 3D-radiation regarding dose sparing to organs at risk like small bowel and urinary bladder. So far, the benefit of IMRT concerning the anal sphincter complex is not examined. With this study we intended to evaluate the dose distribution on the anal sphincters of rectal cancer patients treated with IMRT in comparison with 3D-techniques. Methods We selected 16 patients for the IMRT-group and 16 patients for the 3D-group with rectal cancer of the middle third who were treated in our institute. All patients received 45 Gy in a chemoradiation protocol. Patients in both groups were matched regarding stage, primary tumor distance to the anal verge and size of the tumor. We delineated the internal and external anal sphincters, the addition of both sphincters and the levator ani muscle in all patients. Subsequently, we evaluated and compared dose parameters of the different sphincters in both groups and analysed the configuration of the isodoses in the area of the caudal radiation field, respectively. Results Most of the relevant dose parameters of the caudal sphincters (Dmean, Dmedian, V10–V40) were significantly reduced in the IMRT-group compared to the 3D-group. Accordingly, the isodoses at the caudal edge of the target volume in the IMRT group demonstrated a steep dose fall. The levator ani muscle always was included into the planned target volumes and received the full dose in both groups. Conclusions The modern VMAT-IMRT can significantly reduce the dose to the anal sphincters for rectal cancer patients of the middle third who were treated with conventional chemoradiation therapy.
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Affiliation(s)
- Hendrik Dapper
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Iván Rodríguez
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Stefan Münch
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Pettenkoferstr. 8a, 80336, Munich, Germany
| | - Jan C Peeken
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Kai Borm
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.,Institut für innovative Radiotherapie (iRT), Helmholtz Zentrum München, Ingolstädter Landstr. 1, 85764, Neuherberg, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Pettenkoferstr. 8a, 80336, Munich, Germany
| | - Daniel Habermehl
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
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20
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Olsson CE, Jackson A, Deasy JO, Thor M. A Systematic Post-QUANTEC Review of Tolerance Doses for Late Toxicity After Prostate Cancer Radiation Therapy. Int J Radiat Oncol Biol Phys 2018; 102:1514-1532. [PMID: 30125635 PMCID: PMC6652194 DOI: 10.1016/j.ijrobp.2018.08.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 07/27/2018] [Accepted: 08/04/2018] [Indexed: 12/25/2022]
Abstract
PURPOSE The aims of this study were to systematically review tolerance doses for late distinct gastrointestinal (GI), genitourinary (GU), and sexual dysfunction (SD) symptoms after external beam radiation therapy (EBRT) alone and treatments involving brachytherapy (BT) for prostate cancer after Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC) and ultimately to perform quantitative syntheses of identified dose/volume tolerances represented by dose-volume histogram (DVH) thresholds, that is, statistically significant (P ≤ .05) cutoff points between symptomatic and asymptomatic patients in a certain study. METHODS AND MATERIALS PubMed was scrutinized for full-text articles in English after QUANTEC (January 1, 2010). The inclusion criteria were randomized controlled trials, case-control studies, or cohort studies with tolerance doses for late distinct symptoms ≥3 months after primary radiation therapy for prostate cancer (N > 30). All DVH thresholds were converted into equivalent doses in 2-Gy fractions (EQD2α/β) and were fitted with a linear or linear-quadratic function (goodness of fit, R2). The review was registered on PROSPERO (CRD42016042464). RESULTS From 33 identified studies, which included 36 to 746 patients per symptom domain, the majority of dose/volume tolerances were derived for GI toxicity after EBRT alone (GI, 97 thresholds; GU, 8 thresholds; SD, 1 threshold). For 5 symptoms (defecation urgency, diarrhea, fecal incontinence, proctitis, and rectal bleeding), relationships between dose/volume tolerances across studies (R2 = 0.93 [0.82-1.00]), and across symptoms, leading to a curve for overall GI toxicity (R2 = 0.98), could be determined. For these symptoms, mainly rectal thresholds were found throughout low and high doses (10 Gy ≤ equivalent dose in 2-Gy fractions using α/β = 3Gy (EQD23) ≤ 50 Gy and 55 Gy ≤ EQD23 ≤ 78 Gy, respectively). For BT with or without EBRT, dose/volume tolerances were also mainly identified for GI toxicity (GI, 14 thresholds; GU, 4 thresholds; SD, 2 thresholds) with the largest number of DVH thresholds concerning rectal bleeding (5 thresholds). CONCLUSIONS Updated dose/volume tolerances after QUANTEC were found for 17 GI, GU, or SD symptoms. A DVH curve described the relationship between dose/volume tolerances across 5 GI symptoms after EBRT alone. Restricting treatments for EBRT alone using the lower boundaries of this curve is likely to limit overall GI toxicity, but this should be explored prospectively. Dose/volume tolerances for GU and SD toxicity after EBRT alone and after BT with or without EBRT were scarce and support further research including data-sharing initiatives to untangle the dose/volume relationships for these symptoms.
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Affiliation(s)
- Caroline E Olsson
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden; Regional Cancer Center West, Western Sweden Healthcare Region, Gothenburg, Sweden
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joseph O Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Maria Thor
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York.
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Pan YB, Maeda Y, Wilson A, Glynne-Jones R, Vaizey CJ. Late gastrointestinal toxicity after radiotherapy for anal cancer: a systematic literature review. Acta Oncol 2018; 57:1427-1437. [PMID: 30264638 DOI: 10.1080/0284186x.2018.1503713] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION There is a paucity of data on incidence and mechanisms of long-term gastrointestinal consequences after chemoradiotherapy for anal cancer. Most of the adverse effects reported were based on traditional external beam radiotherapy whilst only short-term follow-ups have been available for intensity-modulated radiotherapy, and there is lack of knowledge about consequences of dose-escalation radiotherapy. METHOD A systematic literature review. RESULTS Two thousand nine hundred and eighty-five titles (excluding duplicates) were identified through the search; 130 articles were included in this review. The overall incidence of late gastrointestinal toxicity was reported to be 7-64.5%, with Grade 3 and above (classified as severe) up to 33.3%. The most commonly reported late toxicities were fecal incontinence (up to 44%), diarrhea (up to 26.7%), and ulceration (up to 22.6%). Diarrhea, fecal incontinence and buttock pain were associated with lower scores in radiotherapy specific quality of life scales (QLQ-CR29, QLQ-C30, and QLQ-CR38) compared to healthy controls. Intensity-modulated radiation therapy appears to reduce late toxicity. CONCLUSION Late gastrointestinal toxicities are common with severe toxicity seen in one-third of the patients. These symptoms significantly impact on patients' quality of life. Prospective studies with control groups are needed to elucidate long-term toxicity.
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Affiliation(s)
- Yi Bin Pan
- Sir Alan Parks Physiology Unit, St. Mark’s Hospital, Harrow, UK
- Longhua Hospital, Shanghai University of TCM, Shanghai, China
| | - Yasuko Maeda
- Sir Alan Parks Physiology Unit, St. Mark’s Hospital, Harrow, UK
- Imperial College London, London, UK
| | - Ana Wilson
- Imperial College London, London, UK
- Wolfson Unit of Endoscopy, St. Mark’s Hospital, Harrow, UK
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Cicchetti A, Avuzzi B, Palorini F, Ballarini F, Stucchi C, Fellin G, Gabriele P, Vavassori V, Esposti CD, Cozzarini C, Fiorino C, Rancati T, Valdagni R. Predicting Late Fecal Incontinence Risk After Radiation Therapy for Prostate Cancer: New Insights From External Independent Validation. Int J Radiat Oncol Biol Phys 2018; 102:127-136. [PMID: 29970313 DOI: 10.1016/j.ijrobp.2018.05.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 03/30/2018] [Accepted: 05/02/2018] [Indexed: 12/24/2022]
Abstract
PURPOSE This study aimed to validate a previously published predictive model for late fecal incontinence (FI) in a contemporary population of prostate cancer patients treated with radical radiation therapy. METHODS AND MATERIALS The validation included patients treated with intensity-modulated radiation therapy (IMRT) (2010-2014). Prescribed dose range was 65-80 Gy, including conventional and moderate hypo-fractionated treatments. Rectal toxicity was scored using LENT/SOMA, a minimum 2-year follow up was considered. We chose to validate the model published by Rancati et al for predicting chronic FI, developed on a 3-dimensional conformal radiation therapy (3DCRT) population. It considered a longitudinal endpoint defined as the average toxicity grade during the follow up. This continuous endpoint was dichotomized using a cut-off value of mean FI grade >1. The model included mean rectal dose (Dmean), previous diseases of the colon (COLO) and previous abdominal surgery (SURG). Doses were corrected to 2 Gy/fraction using the linear-quadratic model and applying alpha/beta ratio = 4.8 Gy. RESULTS 228 patients constituted the validation population. A mean FI grade >1 was scored in 25 patients (11%). Logistic regression confirmed risk factors reported in the literature, with similar odds ratios (ORs) for Dmean (1.04 ± 0.03 vs 1.06 ± 0.04) and SURG (1.9 ± 1.7 vs 1.6 ± 1.45); COLO was not confirmed. Consequently, the predictive models including Dmean/Dmean + SURG were evaluated using calibration plots. Both showed a clear discriminative trend, but the absolute observed toxicity rates were underestimated (ie, absolute predicted rates were always lower than corresponding absolute observed rates). This result was consistent with an unexpected effect of hypofractionation (OR = 2.20, conventional = 8.1% vs hypofractionated = 17.4%) beyond the standard correction using linear-quadratic model. Nevertheless, the FI rate in the conventionally treated group was almost double the rate observed in the previously studied cohort (4.3% vs 8.1%). CONCLUSIONS The study confirms previously published results indicating that abdominal surgery and rectal mean dose are risk factors for late FI. Calibration plots highlight a possible role of hypofractionation beyond linear-quadratic correction.
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Affiliation(s)
- Alessandro Cicchetti
- Fondazione IRCCS Istituto Nazionale dei Tumori, Prostate Cancer Program, Milan, Italy; Università degli Studi di Pavia, Physics Department, Pavia, Italy
| | - Barbara Avuzzi
- Fondazione IRCCS Istituto Nazionale dei Tumori, Radiation Oncology 1, Milan, Italy
| | - Federica Palorini
- Fondazione IRCCS Istituto Nazionale dei Tumori, Prostate Cancer Program, Milan, Italy
| | - Francesca Ballarini
- Università degli Studi di Pavia, Physics Department, Pavia, Italy; INFN-Section of Pavia, Pavia, Italy
| | - Claudio Stucchi
- Fondazione IRCCS Istituto Nazionale dei Tumori, Medical Physics, Milan, Italy
| | | | - Pietro Gabriele
- Istituto di Candiolo- Fondazione del Piemonte per l'Oncologia IRCCS, Radiotherapy, Torino, Italy
| | | | | | - Cesare Cozzarini
- San Raffaele Scientific Institute, Radiation Oncology, Milan, Italy
| | - Claudio Fiorino
- San Raffaele Scientific Institute, Medical Physics, Milan, Italy
| | - Tiziana Rancati
- Fondazione IRCCS Istituto Nazionale dei Tumori, Prostate Cancer Program, Milan, Italy.
| | - Riccardo Valdagni
- Fondazione IRCCS Istituto Nazionale dei Tumori, Prostate Cancer Program, Milan, Italy; Fondazione IRCCS Istituto Nazionale dei Tumori, Radiation Oncology 1, Milan, Italy; Università degli Studi di Milano, Department of Oncology and Hemato-oncology, Milan, Italy
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Boladeras A, Ferrer F, Navarro V, De Blas R, Cunillera O, Mateo D, Gutierrez C, Martinez E, Villà S, Pera J, Ferrer M, Guedea F. Association between EBRT dose volume histograms and quality of life in prostate cancer patients. Rep Pract Oncol Radiother 2018; 23:360-368. [PMID: 30127676 DOI: 10.1016/j.rpor.2018.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 07/22/2018] [Indexed: 01/06/2023] Open
Abstract
Aim To evaluate the association between dose-volume histogram (DVH) values in organs at risk (OAR) and patient-reported HRQoL outcomes. Background Data on the association between DVHs and health-related quality of life (HRQoL) in prostate cancer (PCa) patients are limited. Materials and methods Five-year follow-up study of 154 patients with organ-confined (stage T1/T2) PCa treated with EBRT between January 2003 and November 2005. HRQoL was evaluated with the Expanded Prostate Cancer Index (EPIC). DVH for OARs (penile bulb, rectum and bladder) were created for all patients for whom data were available (119/154; 77%). The functional data analysis (FDA) statistical method was used. HRQoL data was collected prospectively and data analysis was performed retrospectively. Results Worsening of urinary incontinence and obstructive symptoms correlated with higher DVH dose distributions at 24 months. Increased rectal bleeding at months 24 and 60 correlated with higher DVH dose distributions in the 40-70 Gy range. Patients with deterioration in rectal incontinence presented a higher DVH distribution range than patients without rectal incontinence. Penile bulb DVH values and erectile dysfunction were not significantly associated. Conclusions DVH parameters and post-radiotherapy HRQoL appear to be closely correlated, underscoring the importance of assessing DVH values prior to initiating EBRT to determine the risk of developing HRQoL related adverse effects. Advanced treatment modalities may be appropriate in high risk cases to minimize treatment-related toxicity and to improve treatment outcomes and HRQoL. Future studies are needed to better elucidate the association between pre-treatment DVH parameters in organs at risk and subsequent HRQoL.
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Affiliation(s)
- Anna Boladeras
- Institut Català d'Oncologia (ICO), L'Hospitalet, Barcelona, Spain
| | - Ferran Ferrer
- Institut Català d'Oncologia (ICO), L'Hospitalet, Barcelona, Spain
| | - Valentin Navarro
- Institut Català d'Oncologia (ICO), L'Hospitalet, Barcelona, Spain
| | - Rodolfo De Blas
- Institut Català d'Oncologia (ICO), L'Hospitalet, Barcelona, Spain
| | - Oriol Cunillera
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain.,CIBER en Epidemiología y Salud Pública, CIBERESP, Spain
| | - David Mateo
- Institut Català d'Oncologia (ICO), L'Hospitalet, Barcelona, Spain
| | | | - Evelyn Martinez
- Institut Català d'Oncologia (ICO), L'Hospitalet, Barcelona, Spain
| | | | - Joan Pera
- Institut Català d'Oncologia (ICO), L'Hospitalet, Barcelona, Spain
| | - Montse Ferrer
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain.,CIBER en Epidemiología y Salud Pública, CIBERESP, Spain
| | - Ferran Guedea
- Institut Català d'Oncologia (ICO), L'Hospitalet, Barcelona, Spain
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Chen J, Chen H, Zhong Z, Wang Z, Hrycushko B, Zhou L, Jiang S, Albuquerque K, Gu X, Zhen X. Investigating rectal toxicity associated dosimetric features with deformable accumulated rectal surface dose maps for cervical cancer radiotherapy. Radiat Oncol 2018; 13:125. [PMID: 29980214 PMCID: PMC6035458 DOI: 10.1186/s13014-018-1068-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 06/18/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Better knowledge of the dose-toxicity relationship is essential for safe dose escalation to improve local control in cervical cancer radiotherapy. The conventional dose-toxicity model is based on the dose volume histogram, which is the parameter lacking spatial dose information. To overcome this limit, we explore a comprehensive rectal dose-toxicity model based on both dose volume histogram and dose map features for accurate radiation toxicity prediction. METHODS Forty-two cervical cancer patients treated with combined external beam radiotherapy (EBRT) and brachytherapy (BT) were retrospectively studied, including 12 with Grade ≥ 2 rectum toxicity and 30 patients with Grade 0-1 toxicity (non-toxicity patients). The cumulative equivalent 2-Gy rectal surface dose was deformably summed using the deformation vector fields obtained through a recent developed local topology preserved non-rigid point matching algorithm. The cumulative three-dimensional (3D) dose was flattened and mapped to a two-dimensional (2D) plane to obtain the rectum surface dose map (RSDM). The dose volume parameters (DVPs) were calculated from the 3D rectum surface, while the texture features and the dose geometric parameters (DGPs) were extracted from the 2D RSDM. Representative features further computed from DVPs, textures and DGPs by principle component analysis (PCA) and statistical analysis were respectively fed into a support vector machine equipped with a sequential feature selection procedure. The predictive powers of the representative features were compared with the GEC-ESTRO dosimetric parameters D0.1/1/2cm3. RESULTS Satisfactory predictive accuracy of sensitivity 74.75 and 84.75%, specificity 72.67 and 79.87%, and area under the receiver operating characteristic curve (AUC) 0.82 and 0.91 were respectively achieved by the PCA features and statistical significant features, which were superior to the D0.1/1/2cm3 (AUC 0.71). The relative area in dose levels of 64Gy, 67Gy, 68Gy, 87Gy, 88Gy and 89Gy, perimeters in dose levels of 89Gy, as well as two texture features were ranked as the important factors that were closely correlated with rectal toxicity. CONCLUSIONS Our extensive experimental results have demonstrated the feasibility of the proposed scheme. A future large patient cohort study is still needed for model validation.
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Affiliation(s)
- Jiawei Chen
- School of Biomedical Engineering, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Haibin Chen
- School of Biomedical Engineering, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Zichun Zhong
- Department of Computer Science, Wayne State University, Detroit, MI, 48202, USA
| | - Zhuoyu Wang
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 805 Sherbrooke Street West, Montreal, Quebec, H3A 0G4, Canada
| | - Brian Hrycushko
- Department of Radiation Oncology, The University of Texas, Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Linghong Zhou
- School of Biomedical Engineering, Southern Medical University, Guangzhou, 510515, Guangdong, China.
| | - Steve Jiang
- Department of Radiation Oncology, The University of Texas, Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Kevin Albuquerque
- Department of Radiation Oncology, The University of Texas, Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Xuejun Gu
- Department of Radiation Oncology, The University of Texas, Southwestern Medical Center, Dallas, TX, 75390, USA.
| | - Xin Zhen
- School of Biomedical Engineering, Southern Medical University, Guangzhou, 510515, Guangdong, China.
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Dean J, Wong K, Gay H, Welsh L, Jones AB, Schick U, Oh JH, Apte A, Newbold K, Bhide S, Harrington K, Deasy J, Nutting C, Gulliford S. Incorporating spatial dose metrics in machine learning-based normal tissue complication probability (NTCP) models of severe acute dysphagia resulting from head and neck radiotherapy. Clin Transl Radiat Oncol 2018; 8:27-39. [PMID: 29399642 PMCID: PMC5796681 DOI: 10.1016/j.ctro.2017.11.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 11/16/2017] [Accepted: 11/17/2017] [Indexed: 12/20/2022] Open
Abstract
Severe acute dysphagia commonly results from head and neck radiotherapy (RT). A model enabling prediction of severity of acute dysphagia for individual patients could guide clinical decision-making. Statistical associations between RT dose distributions and dysphagia could inform RT planning protocols aiming to reduce the incidence of severe dysphagia. We aimed to establish such a model and associations incorporating spatial dose metrics. Models of severe acute dysphagia were developed using pharyngeal mucosa (PM) RT dose (dose-volume and spatial dose metrics) and clinical data. Penalized logistic regression (PLR), support vector classification and random forest classification (RFC) models were generated and internally (173 patients) and externally (90 patients) validated. These were compared using area under the receiver operating characteristic curve (AUC) to assess performance. Associations between treatment features and dysphagia were explored using RFC models. The PLR model using dose-volume metrics (PLRstandard) performed as well as the more complex models and had very good discrimination (AUC = 0.82) on external validation. The features with the highest RFC importance values were the volume, length and circumference of PM receiving 1 Gy/fraction and higher. The volumes of PM receiving 1 Gy/fraction or higher should be minimized to reduce the incidence of severe acute dysphagia.
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Key Words
- pm, pharyngeal mucosa
- plr, penalized logistic regression
- svc, support vector classification
- rfc, random forest classification
- auc, area under the receiver operating characteristic curve
- ntcp, normal tissue complication probability
- rt, radiotherapy
- imrt, intensity modulated radiotherapy
- ctcae, common terminology criteria for adverse events
- peg, percutaneous endoscopic gastrostomy
- dvh, dose-volume histogram
- dlh, dose-length histogram
- dch, dose-circumference histogram
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Affiliation(s)
- Jamie Dean
- Joint Department of Physics at the Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London SM2 5NG, UK
| | - Kee Wong
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK
| | - Hiram Gay
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Liam Welsh
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK
| | - Ann-Britt Jones
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK
| | - Ulricke Schick
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK
| | - Jung Hun Oh
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Aditya Apte
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kate Newbold
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, Fulham Road, London SW3 6JJ, UK
| | - Shreerang Bhide
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, Fulham Road, London SW3 6JJ, UK
| | - Kevin Harrington
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, Fulham Road, London SW3 6JJ, UK
| | - Joseph Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Christopher Nutting
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, Fulham Road, London SW3 6JJ, UK
| | - Sarah Gulliford
- Joint Department of Physics at the Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London SM2 5NG, UK
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Gulliford S, Ghose S, Ebert M, Kennedy A, Dowling J, Mitra J, Joseph D, Denham J. Radiotherapy dose-distribution to the perirectal fat space (PRS) is related to gastrointestinal control-related complications. Clin Transl Radiat Oncol 2017; 7:62-70. [PMID: 29594231 PMCID: PMC5862665 DOI: 10.1016/j.ctro.2017.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 10/02/2017] [Accepted: 10/03/2017] [Indexed: 11/25/2022] Open
Abstract
Traditionally rectal symptoms following pelvic/prostate radiotherapy are correlated to the dosimetry of the anorectum or a substructure of this. It has been suggested that the perirectal fat space (PRS) surrounding the rectum may also be relevant. This study considers the delineation and dosimetry of the PRS related to both rectal bleeding and control-related toxicity. Initially, a case-control cohort of 100 patients from the RADAR study were chosen based on presence/absence of rectal control-related toxicity. Automated contouring was developed to delineate the PRS. 79 of the 100 auto-segmentations were considered successful. Balanced case-control cohorts were defined from these cases. Atlas of Complication Incidence (ACI) were generated to relate the DVH of the PRS with specific rectal symptoms; rectal bleeding and control-related symptoms (LENT/SOM). ACI demonstrated that control-related symptoms were related to the dose distribution to the PRS which was confirmed with Wilcoxon rank sum test (p < 0.05). To the authors knowledge this is the first study implicating the dose distribution to the PRS to the incidence of control-related symptoms of rectal toxicity.
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Affiliation(s)
- S.L. Gulliford
- Joint Department of Physics, Institute of Cancer Research and Royal Marsden National Health Service Foundation Trust, Sutton, United Kingdom
| | - S. Ghose
- Department of Biomedical Engineering, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106, USA
| | - M.A. Ebert
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Western Australia, Australia
- School of Physics, University of Western Australia, Western Australia, Australia
| | - A. Kennedy
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Western Australia, Australia
| | - J. Dowling
- Australian e-Health Research Centre, CSIRO, Brisbane, Queensland, Australia
| | - J. Mitra
- Department of Biomedical Engineering, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106, USA
| | - D.J. Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Western Australia, Australia
- School of Surgery, University of Western Australia, Western Australia, Australia
| | - J.W. Denham
- School of Medicine and Public Health, University of Newcastle, New South Wales, Australia
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Casares-Magaz O, Muren LP, Moiseenko V, Petersen SE, Pettersson NJ, Høyer M, Deasy JO, Thor M. Spatial rectal dose/volume metrics predict patient-reported gastro-intestinal symptoms after radiotherapy for prostate cancer. Acta Oncol 2017; 56:1507-1513. [PMID: 28885095 DOI: 10.1080/0284186x.2017.1370130] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Gastro-intestinal (GI) toxicity after radiotherapy (RT) for prostate cancer reduces patient's quality of life. In this study, we explored associations between spatial rectal dose/volume metrics and patient-reported GI symptoms after RT for localized prostate cancer, and compared these with those of dose-surface/volume histogram (DSH/DVH) metrics. MATERIAL AND METHODS Dose distributions and six GI symptoms (defecation urgency/emptying difficulties/fecal leakage, ≥Grade 2, median follow-up: 3.6 y) were extracted for 200 patients treated with image-guided RT in 2005-2007. Three hundred and nine metrics assessed from 2D rectal dose maps or DSHs/DVHs were subject to 50-times iterated five-fold cross-validated univariate and multivariate logistic regression analysis (UVA, MVA). Performance of the most frequently selected MVA models was evaluated by the area under the receiving-operating characteristics curve (AUC). RESULTS The AUC increased for dose-map compared to DSH/DVH-based models (mean SD: 0.64 ± 0.03 vs. 0.61 ± 0.01), and significant relations were found for six versus four symptoms. Defecation urgency and faecal leakage were explained by high doses at the central/upper and central areas, respectively; while emptying difficulties were explained by longitudinal extensions of intermediate doses. CONCLUSIONS Predictability of patient-reported GI toxicity increased using spatial metrics compared to DSH/DVH metrics. Novel associations were particularly identified for emptying difficulties using both approaches in which intermediate doses were emphasized.
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Affiliation(s)
| | - Ludvig Paul Muren
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Vitali Moiseenko
- Department of Radiation, Medicine and Applied Sciences, University of California San Diego, San Diego, CA, USA
| | - Stine E. Petersen
- Department of Radiation Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Niclas Johan Pettersson
- Department of Radiation, Medicine and Applied Sciences, University of California San Diego, San Diego, CA, USA
| | - Morten Høyer
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Joseph O. Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Maria Thor
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
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Zhen X, Chen J, Zhong Z, Hrycushko B, Zhou L, Jiang S, Albuquerque K, Gu X. Deep convolutional neural network with transfer learning for rectum toxicity prediction in cervical cancer radiotherapy: a feasibility study. Phys Med Biol 2017; 62:8246-8263. [PMID: 28914611 DOI: 10.1088/1361-6560/aa8d09] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Better understanding of the dose-toxicity relationship is critical for safe dose escalation to improve local control in late-stage cervical cancer radiotherapy. In this study, we introduced a convolutional neural network (CNN) model to analyze rectum dose distribution and predict rectum toxicity. Forty-two cervical cancer patients treated with combined external beam radiotherapy (EBRT) and brachytherapy (BT) were retrospectively collected, including twelve toxicity patients and thirty non-toxicity patients. We adopted a transfer learning strategy to overcome the limited patient data issue. A 16-layers CNN developed by the visual geometry group (VGG-16) of the University of Oxford was pre-trained on a large-scale natural image database, ImageNet, and fine-tuned with patient rectum surface dose maps (RSDMs), which were accumulated EBRT + BT doses on the unfolded rectum surface. We used the adaptive synthetic sampling approach and the data augmentation method to address the two challenges, data imbalance and data scarcity. The gradient-weighted class activation maps (Grad-CAM) were also generated to highlight the discriminative regions on the RSDM along with the prediction model. We compare different CNN coefficients fine-tuning strategies, and compare the predictive performance using the traditional dose volume parameters, e.g. D 0.1/1/2cc, and the texture features extracted from the RSDM. Satisfactory prediction performance was achieved with the proposed scheme, and we found that the mean Grad-CAM over the toxicity patient group has geometric consistence of distribution with the statistical analysis result, which indicates possible rectum toxicity location. The evaluation results have demonstrated the feasibility of building a CNN-based rectum dose-toxicity prediction model with transfer learning for cervical cancer radiotherapy.
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Affiliation(s)
- Xin Zhen
- Department of Radiation Oncology, The University of Texas, Southwestern Medical Center, Dallas, TX 75390, United States of America. Department of Biomedical Engineering, Southern Medical University, Guangzhou, Guangdong 510515, People's Republic of China
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30
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Joye I, Macq G, Vaes E, Roels S, Lambrecht M, Pelgrims A, Bussels B, Vancleef A, Stellamans K, Scalliet P, Weytjens R, Christian N, Boulanger AS, Donnay L, Van Brussel S, Moretti L, Van den Bergh L, Van Eycken E, Debucquoy A, Haustermans K. Do refined consensus guidelines improve the uniformity of clinical target volume delineation for rectal cancer? Results of a national review project. Radiother Oncol 2016; 120:202-6. [DOI: 10.1016/j.radonc.2016.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 06/06/2016] [Accepted: 06/13/2016] [Indexed: 12/22/2022]
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31
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Dean JA, Wong KH, Welsh LC, Jones AB, Schick U, Newbold KL, Bhide SA, Harrington KJ, Nutting CM, Gulliford SL. Normal tissue complication probability (NTCP) modelling using spatial dose metrics and machine learning methods for severe acute oral mucositis resulting from head and neck radiotherapy. Radiother Oncol 2016; 120:21-7. [PMID: 27240717 PMCID: PMC5021201 DOI: 10.1016/j.radonc.2016.05.015] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 04/18/2016] [Accepted: 05/12/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND PURPOSE Severe acute mucositis commonly results from head and neck (chemo)radiotherapy. A predictive model of mucositis could guide clinical decision-making and inform treatment planning. We aimed to generate such a model using spatial dose metrics and machine learning. MATERIALS AND METHODS Predictive models of severe acute mucositis were generated using radiotherapy dose (dose-volume and spatial dose metrics) and clinical data. Penalised logistic regression, support vector classification and random forest classification (RFC) models were generated and compared. Internal validation was performed (with 100-iteration cross-validation), using multiple metrics, including area under the receiver operating characteristic curve (AUC) and calibration slope, to assess performance. Associations between covariates and severe mucositis were explored using the models. RESULTS The dose-volume-based models (standard) performed equally to those incorporating spatial information. Discrimination was similar between models, but the RFCstandard had the best calibration. The mean AUC and calibration slope for this model were 0.71 (s.d.=0.09) and 3.9 (s.d.=2.2), respectively. The volumes of oral cavity receiving intermediate and high doses were associated with severe mucositis. CONCLUSIONS The RFCstandard model performance is modest-to-good, but should be improved, and requires external validation. Reducing the volumes of oral cavity receiving intermediate and high doses may reduce mucositis incidence.
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Affiliation(s)
- Jamie A Dean
- Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK.
| | - Kee H Wong
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Liam C Welsh
- The Royal Marsden NHS Foundation Trust, London, UK
| | | | | | - Kate L Newbold
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - Shreerang A Bhide
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - Kevin J Harrington
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - Christopher M Nutting
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - Sarah L Gulliford
- Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
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Schaake W, van der Schaaf A, van Dijk LV, Bongaerts AHH, van den Bergh ACM, Langendijk JA. Normal tissue complication probability (NTCP) models for late rectal bleeding, stool frequency and fecal incontinence after radiotherapy in prostate cancer patients. Radiother Oncol 2016; 119:381-7. [PMID: 27157889 DOI: 10.1016/j.radonc.2016.04.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 02/28/2016] [Accepted: 04/03/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND PURPOSE Curative radiotherapy for prostate cancer may lead to anorectal side effects, including rectal bleeding, fecal incontinence, increased stool frequency and rectal pain. The main objective of this study was to develop multivariable NTCP models for these side effects. MATERIAL AND METHODS The study sample was composed of 262 patients with localized or locally advanced prostate cancer (stage T1-3). Anorectal toxicity was prospectively assessed using a standardized follow-up program. Different anatomical subregions within and around the anorectum were delineated. A LASSO logistic regression analysis was used to analyze dose volume effects on toxicity. RESULTS In the univariable analysis, rectal bleeding, increase in stool frequency and fecal incontinence were significantly associated with a large number of dosimetric parameters. The collinearity between these predictors was high (VIF>5). In the multivariable model, rectal bleeding was associated with the anorectum (V70) and anticoagulant use, fecal incontinence was associated with the external sphincter (V15) and the iliococcygeal muscle (V55). Finally, increase in stool frequency was associated with the iliococcygeal muscle (V45) and the levator ani (V40). No significant associations were found for rectal pain. CONCLUSIONS Different anorectal side effects are associated with different anatomical substructures within and around the anorectum. The dosimetric variables associated with these side effects can be used to optimize radiotherapy treatment planning aiming at prevention of specific side effects and to estimate the benefit of new radiation technologies.
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Affiliation(s)
- Wouter Schaake
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, The Netherlands; Research Group Healthy Ageing, Allied Health Care and Nursing, Hanze University of Applied Sciences, Groningen, The Netherlands.
| | - Arjen van der Schaaf
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Lisanne V van Dijk
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Alfons H H Bongaerts
- Department of Radiology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Alfons C M van den Bergh
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Johannes A Langendijk
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, The Netherlands
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Landoni V, Fiorino C, Cozzarini C, Sanguineti G, Valdagni R, Rancati T. Predicting toxicity in radiotherapy for prostate cancer. Phys Med 2016; 32:521-32. [PMID: 27068274 DOI: 10.1016/j.ejmp.2016.03.003] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 02/15/2016] [Accepted: 03/02/2016] [Indexed: 02/08/2023] Open
Abstract
This comprehensive review addresses most organs at risk involved in planning optimization for prostate cancer. It can be considered an update of a previous educational review that was published in 2009 (Fiorino et al., 2009). The literature was reviewed based on PubMed and MEDLINE database searches (from January 2009 up to September 2015), including papers in press; for each section/subsection, key title words were used and possibly combined with other more general key-words (such as radiotherapy, dose-volume effects, NTCP, DVH, and predictive model). Publications generally dealing with toxicity without any association with dose-volume effects or correlations with clinical risk factors were disregarded, being outside the aim of the review. A focus was on external beam radiotherapy, including post-prostatectomy, with conventional fractionation or moderate hypofractionation (<4Gy/fraction); extreme hypofractionation is the topic of another paper in this special issue. Gastrointestinal and urinary toxicity are the most investigated endpoints, with quantitative data published in the last 5years suggesting both a dose-response relationship and the existence of a number of clinical/patient related risk factors acting as dose-response modifiers. Some results on erectile dysfunction, bowel toxicity and hematological toxicity are also presented.
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Affiliation(s)
- Valeria Landoni
- Medical Physics, Istituto Nazionale Tumori Regina Elena, Rome, Italy
| | - Claudio Fiorino
- Medical Physics, Raffaele Scientific Institute IRCCS, Milan, Italy
| | | | | | - Riccardo Valdagni
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Tiziana Rancati
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
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34
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First application of a pixel-wise analysis on bladder dose-surface maps in prostate cancer radiotherapy. Radiother Oncol 2016; 119:123-8. [PMID: 26993415 DOI: 10.1016/j.radonc.2016.02.025] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 02/08/2016] [Accepted: 02/17/2016] [Indexed: 01/26/2023]
Abstract
PURPOSE To develop a method for investigating local dose effects on the bladder after prostate cancer radiotherapy based on dose-surface maps (DSMs). BACKGROUND AND PURPOSE DSMs of patients included in a prospective study (DUE01) were generated by virtually cutting bladder contours at the points intersecting the sagittal plane passing through its center-of-mass: maps were laterally normalized and aligned at the posterior inferior point. The average DSMs of patients with/without toxicity, the DSMs of differences and t statistic were used to select regions better discriminating patients with toxicity. A total of 72 patients with no/mild urinary symptoms before radiotherapy and who were treated with moderate hypo-fractionation (2.5-2.65Gy/fr, 70-74Gy) were considered, and the endpoint was an International Prostate Symptoms Score (IPSS)⩾15 at the end of therapy (IPSSend⩾15, n=25/72). RESULTS The DSMs of patients with/without toxicity were significantly different (p<0.05). The percentage of bladder circumference receiving >50-70Gy at 5-7mm from the base was associated with an IPSSend⩾15 (odds ratios: 1.03-1.07). Different patterns were recognized for specific symptoms. With frequency/urgency, a quasi-threshold effect on the absolute posterior dose at 5-12mm from the base (2Gy equivalent doses=80-82Gy, α/β=3-5Gy) was observed. CONCLUSIONS Local-dose effects for acute symptoms were detected in a group of patients treated within a moderately hypo-fractionated protocol. The results for frequency/urgency were consistent with a threshold effect on the trigone.
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Abstract
Chemoradiotherapy is the standard-of-care treatment of squamous-cell carcinoma of the anus (SCCA), and this has not changed in decades. Radiation doses of 50-60 Gy, as used in many phase III trials, result in substantial late morbidities and fail to control larger and node-positive tumours. Technological advances in radiation therapy are improving patient outcomes and quality of life, and should be applied to patients with SCCA. Modern techniques such as intensity-modulated radiotherapy (IMRT), rotational IMRT, image-guided radiotherapy using cone-beam CT, and stereotactic techniques have enabled smaller margins and highly conformal plans, resulting in decreased radiation doses to the organs at risk and ensuring a shorter overall treatment time. In this Perspectives article, the use of novel approaches to target delineation, optimized radiotherapy techniques, adaptive radiotherapy, dose-escalation with external-beam radiotherapy (EBRT) or brachytherapy, and the potential for modified fractionation are discussed in the context of SCCA.
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Dose-surface maps identifying local dose-effects for acute gastrointestinal toxicity after radiotherapy for prostate cancer. Radiother Oncol 2015; 117:515-20. [PMID: 26522060 DOI: 10.1016/j.radonc.2015.10.020] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 10/05/2015] [Accepted: 10/20/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND PURPOSE We evaluated dose distributions in the anorectum and its relation to acute gastrointestinal toxicities using dose surface maps in an image-guided (IG) IMRT and 3D-conformal radiotherapy (3D-CRT) population. MATERIAL AND METHODS For patients treated to 78 Gy with IG-IMRT (n=260) or 3D-CRT (n=215), for whom acute toxicity data were available, three types of surface maps were calculated: (1) total anorectum using regular intervals along a central axis with perpendicular slices, (2) the rectum next to the prostate, and (3) the anal canal (horizontal slicing). For each toxicity, an average dose map was calculated for patients with and without the toxicity and subsequently dose difference maps were constructed, 3D-CRT and IG-IMRT separately. P-values were based on permutation tests. RESULTS Dose distributions in patients with grade ⩾2 acute proctitis were significantly different from dose distributions in patients without toxicity, for IG-IMRT and 3D-CRT. At the cranial and posterior rectal site, in areas receiving moderate dose levels (≈25-50 Gy), dose differences up to 10 Gy were identified for IG-IMRT. For pain, cramps, incontinence, diarrhea and mucus loss significant differences were found as well. CONCLUSIONS We demonstrated significant relationships between acute rectal toxicity and local dose distributions. This may serve as a basis for subsequent dose-effect modeling in IG-IMRT, and improved dose constraints in current clinical practice.
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Uzan J, Nahum AE, Syndikus I. Prostate Dose-painting Radiotherapy and Radiobiological Guided Optimisation Enhances the Therapeutic Ratio. Clin Oncol (R Coll Radiol) 2015; 28:165-70. [PMID: 26482453 DOI: 10.1016/j.clon.2015.09.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 08/12/2015] [Accepted: 09/03/2015] [Indexed: 11/25/2022]
Abstract
AIMS To describe the treatment of 11 patients with radiobiologically guided dose-painting radiotherapy and report on toxicity. MATERIALS AND METHODS Boost volumes were identified with functional magnetic resonance imaging scans in 11 patients with high-risk prostate cancer. Patients were treated using a dose-painting approach; the boost dose was limited to 86 Gy in 37 fractions, while keeping the rectal normal tissue complication probability to 5-6%. Rotational intensity-modulated radiotherapy was used with daily image guidance and fiducial markers. RESULTS The median dose to the prostate (outside the boost volume) and urethra was 75.4 Gy/37 fractions (range 75.1-75.8 Gy), whereas the median boost dose was 83.4 Gy (range 79.0-87.4 Gy). The tumour control probability (TCP) (Marsden model) increased from 71% for the standard plans to 83.6% [76.6-86.8%] for the dose-painting boost plans. The mean (Lyman-Kutcher-Burman) normal tissue complication probability for rectal bleeding was 5.2% (range 3.3-6.2%) and 5.2% for faecal incontinence (range 3.6-7.8%). All patients tolerated the treatment well, with a low acute toxicity profile. At a median follow-up of 36 months (range 24-50) there was no grade 3 late toxicity. Two patients had grade 2 late urinary toxicity (urethral stricture, urinary frequency and urgency), one patient had grade 1 and one grade 2 late rectal toxicity. The mean prostate-specific antigen at follow-up was 0.81 ng/ml after stopping hormone therapy; one patient relapsed biochemically at 32 months (2.70 ng/ml). CONCLUSIONS The toxicity for this radiobiological guided dose-painting protocol was low, but we have only treated a small cohort with limited follow-up time. The advantages of this treatment approach should be established in a clinical trial.
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Affiliation(s)
- J Uzan
- Physics Department, Clatterbridge Cancer Centre, Bebington, UK
| | - A E Nahum
- Physics Department, Clatterbridge Cancer Centre, Bebington, UK
| | - I Syndikus
- Radiotherapy Department, Clatterbridge Cancer Centre, Bebington, UK.
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Thor M, Olsson CE, Oh JH, Petersen SE, Alsadius D, Bentzen L, Pettersson N, Muren LP, Waldenström AC, Høyer M, Steineck G, Deasy JO. Relationships between dose to the gastro-intestinal tract and patient-reported symptom domains after radiotherapy for localized prostate cancer. Acta Oncol 2015; 54:1326-34. [PMID: 26340136 DOI: 10.3109/0284186x.2015.1063779] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Gastrointestinal (GI) morbidity after radiotherapy (RT) for prostate cancer is typically addressed by studying specific single symptoms. The aim of this study was to explore the interplay between domains of patient- reported outcomes (PROs) on GI morbidity, and to what extent these are explained by RT dose to the GI tract. MATERIAL AND METHODS The study included men from two Scandinavian studies (N = 211/277) who had undergone primary external beam radiotherapy (EBRT) for localized prostate cancer to 70-78 Gy (2 Gy/fraction). Factor analysis was applied to previously identified PRO-based symptom domains from two study-specific questionnaires. Number of questions: 43; median time to follow-up: 3.6-6.4 years) and dose-response outcome variables were defined from these domains. Dose/volume parameters of the anal sphincter (AS) or the rectum were tested as predictors for each outcome variable using logistic regression with 10-fold cross-validation. Performance was assessed using area under the receiver operating characteristic curve (Az) and model frequency. RESULTS Outcome variables from Defecation urgency (number of symptoms: 2-3), Fecal leakage (4-6), Mucous (4), and Pain (3-6) were defined. In both cohorts, intermediate rectal doses predicted Defecation urgency (mean Az: 0.53-0.54; Frequency: 70-75%), and near minimum and low AS doses predicted Fecal leakage (mean Az: 0.63-0.67; Frequency: 83-99%). In one cohort, high AS doses predicted Mucous (mean Az: 0.54; Frequency: 96%), whereas in the other, low AS doses and intermediate rectal doses predicted Pain (mean Az: 0.69; Frequency: 28-82%). CONCLUSION We have demonstrated that Defecation urgency, Fecal leakage, Mucous, and Pain following primary EBRT for localized prostate cancer primarily are predicted by intermediate rectal doses, low AS doses, high AS doses, or a combination of low AS and intermediate rectal doses, respectively. This suggests that there is a domain-specific dose-response for the GI tract. To reduce risk of GI morbidity, dose distributions of both the AS region and the rectum should, therefore, be considered when prescribing prostate cancer RT.
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Affiliation(s)
- Maria Thor
- a Department of Medical Physics , Memorial Sloan Kettering Cancer Center , New York , USA
| | - Caroline E Olsson
- b Division of Clinical Cancer Epidemiology, Department of Oncology , Institute of Clinical Sciences, the Sahlgrenska Academy at the University of Gothenburg , Sweden
| | - Jung Hun Oh
- a Department of Medical Physics , Memorial Sloan Kettering Cancer Center , New York , USA
| | - Stine E Petersen
- c Departments of Medical Physics and Oncology , Aarhus University Hospital , Aarhus , Denmark
| | - David Alsadius
- d Oncology, University of Gothenburg , Gothenburg , Sweden
| | - Lise Bentzen
- c Departments of Medical Physics and Oncology , Aarhus University Hospital , Aarhus , Denmark
| | - Niclas Pettersson
- e Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital , Gothenburg , Sweden
| | - Ludvig P Muren
- c Departments of Medical Physics and Oncology , Aarhus University Hospital , Aarhus , Denmark
| | - Ann-Charlotte Waldenström
- b Division of Clinical Cancer Epidemiology, Department of Oncology , Institute of Clinical Sciences, the Sahlgrenska Academy at the University of Gothenburg , Sweden
| | - Morten Høyer
- c Departments of Medical Physics and Oncology , Aarhus University Hospital , Aarhus , Denmark
| | - Gunnar Steineck
- b Division of Clinical Cancer Epidemiology, Department of Oncology , Institute of Clinical Sciences, the Sahlgrenska Academy at the University of Gothenburg , Sweden
| | - Joseph O Deasy
- a Department of Medical Physics , Memorial Sloan Kettering Cancer Center , New York , USA
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Hamlett LJ, McPartlin AJ, Maile EJ, Webster G, Swindell R, Rowbottom CG, Choudhury A, Aitkenhead AH. Parametrized rectal dose and associations with late toxicity in prostate cancer radiotherapy. Br J Radiol 2015; 88:20150110. [PMID: 26246172 DOI: 10.1259/bjr.20150110] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE We investigated possible associations between planned dose-volume parameters and rectal late toxicity in 170 patients having radical prostate cancer radiotherapy. METHODS For each patient, the rectum was outlined from anorectal junction to sigmoid colon, and rectal dose was parametrized using dose-volume (DVH), dose-surface (DSH) and dose-line (DLH) histograms. Generation of DLHs differed from previous studies in that the rectal dose was parametrized without first unwrapping onto 2-dimensional dose-surface maps. Patient-reported outcomes were collected using a validated Later Effects in Normal Tissues Subjective, Objective, Management and Analytic questionnaire. Associations between dose and toxicity were assessed using a one-sided Mann-Whitney U test. RESULTS Associations (p < 0.05) were found between equieffective dose (EQD23) and late toxicity as follows: overall toxicity with DVH and DSH at 13-24 Gy; proctitis with DVH and DSH at 25-36 Gy and with DVH, DSH and DLH at 61-67 Gy; bowel urgency with DVH and DSH at 10-20 Gy. None of these associations met statistical significance following the application of a Bonferroni correction. CONCLUSION Independently confirmed associations between rectal dose and late toxicity remain elusive. Future work to increase the accuracy of the knowledge of the rectal dose, either by accounting for interfraction and intrafraction rectal motion or via stabilization of the rectum during treatment, may be necessary to allow for improved dose-toxicity comparisons. ADVANCES IN KNOWLEDGE This study is the first to use parametrized DLHs to study associations with patient-reported toxicity for prostate radiotherapy showing that it is feasible to model rectal dose mapping in three dimensions.
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Affiliation(s)
- Lynsey J Hamlett
- 1 Manchester Academic Health Science Centre (MAHSC), Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK.,2 Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Andrew J McPartlin
- 3 Department of Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Edward J Maile
- 4 Oxford University Clinical Academic Graduate School, Medical Sciences Division, John Radcliffe Hospital, Oxford, UK
| | - Gareth Webster
- 5 Hall-Edwards Radiotherapy Research Group, Medical Physics, Queen Elizabeth Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ric Swindell
- 6 The Christie NHS Foundation Trust, Manchester, UK
| | - Carl G Rowbottom
- 7 Department of Medical Physics, Clatterbridge Cancer Centre, Liverpool, UK
| | - Ananya Choudhury
- 1 Manchester Academic Health Science Centre (MAHSC), Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK.,3 Department of Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Adam H Aitkenhead
- 1 Manchester Academic Health Science Centre (MAHSC), Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK.,2 Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
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Casares-Magaz O, Thor M, Liao D, Frøkjær JB, Kræmer P, Krogh K, Drewes AM, Gregersen H, Moiseenko V, Høyer M, Muren LP. An image-based method to quantify biomechanical properties of the rectum in radiotherapy of prostate cancer. Acta Oncol 2015. [PMID: 26198656 DOI: 10.3109/0284186x.2015.1066933] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Gastrointestinal morbidity after radiotherapy (RT) for prostate cancer may be related to the biomechanical properties of the rectum. In this study we present a magnetic resonance imaging (MRI)-based method to quantitate the thickness and elasticity of the rectal wall in prostate cancer patients treated with RT. MATERIAL AND METHODS Four patients previously treated with RT for prostate cancer underwent an MRI session with stepwise rectal bag deflation (from a maximum tolerable volume to 0 ml, in 50 ml steps), with a probe inserted inside the bag to monitor the internal rectal pressure. MRIs were acquired using Dixon sequences (4 mm axial slice thickness) at each deflation step. Rectal walls were defined from the recto-sigmoid junction to 3 cm above the anal canal as the space between the inner and outer wall surfaces. The wall thickness was determined and biomechanical properties (strain and stress) were calculated from the pressure measurements and the MRI-segmented rectal walls. RESULTS The integral rectal pressure varied for the maximum tolerable volume (range 150-250 ml) across patients and ranged from 1.3 to 4.0 kPa (SD = 1.2 kPa). Wall thickness was found to vary between patients and also across different rectum segments, with a mean (SD) thickness for the different segments at the 50 ml distension volume of 1.8-4.0 (0.6) mm. Stress showed larger variation than strain, with mean (SD) values for the different segments ranging between 1.5 and 7.0 (1.5) kPa. CONCLUSION We have developed a method to quantify biomechanical properties of the rectal wall. The resulting rectal wall thickness, strain and stress differed between patients, as well as across different rectal wall sections. These findings could provide guidance in future predictive outcome modelling in order to better understand the rectal dose-volume response relationship.
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Affiliation(s)
- Oscar Casares-Magaz
- a Department of Medical Physics , Aarhus University Hospital/Aarhus University , Denmark
| | - Maria Thor
- b Department of Medical Physics , Memorial Sloan Kettering Cancer Center , New York , USA
| | - Donghua Liao
- c GIOME Academia, Department of Clinical Medicine , Aarhus University , Denmark
| | - Jens B Frøkjær
- d Department of Clinical Medicine , Aalborg University Hospital , Denmark
- e Department of Radiology , Aalborg University Hospital , Denmark
| | - Pia Kræmer
- f Department of Oncology , Aarhus University Hospital/Aarhus University , Denmark
| | - Klaus Krogh
- g Department of Hepatology and Gastroenterology , Aarhus University Hospital/Aarhus University , Denmark
| | - Asbjørn M Drewes
- d Department of Clinical Medicine , Aalborg University Hospital , Denmark
- h Department of Gastroenterology , Aalborg University Hospital , Denmark
| | - Hans Gregersen
- i GIOME, College of Bioengineering, Chongqing University , Chongqing , China
| | - Vitali Moiseenko
- j Department of Radiation Medicine and Applied Science , University of California San Diego , San Diego , USA
| | - Morten Høyer
- f Department of Oncology , Aarhus University Hospital/Aarhus University , Denmark
| | - Ludvig P Muren
- a Department of Medical Physics , Aarhus University Hospital/Aarhus University , Denmark
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Use of bladder dose points for assessment of the spatial dose distribution in the posterior bladder wall in cervical cancer brachytherapy and the impact of applicator position. Brachytherapy 2015; 14:252-9. [DOI: 10.1016/j.brachy.2014.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Revised: 10/29/2014] [Accepted: 11/07/2014] [Indexed: 12/19/2022]
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Yamazaki H, Nakamura S, Nishimura T, Yoshida K, Yoshioka Y, Koizumi M, Ogawa K. Transitioning from conventional radiotherapy to intensity-modulated radiotherapy for localized prostate cancer: changing focus from rectal bleeding to detailed quality of life analysis. JOURNAL OF RADIATION RESEARCH 2014; 55:1033-1047. [PMID: 25204643 PMCID: PMC4229926 DOI: 10.1093/jrr/rru061] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 05/27/2014] [Accepted: 06/09/2014] [Indexed: 06/02/2023]
Abstract
With the advent of modern radiation techniques, we have been able to deliver a higher prescribed radiotherapy dose for localized prostate cancer without severe adverse reactions. We reviewed and analyzed the change of toxicity profiles of external beam radiation therapy (EBRT) from the literature. Late rectal bleeding is the main adverse effect, and an incidence of >20% of Grade ≥2 adverse events was reported for 2D conventional radiotherapy of up to 70 Gy. 3D conformal radiation therapy (3D-CRT) was found to reduce the incidence to ∼10%. Furthermore, intensity-modulated radiation therapy (IMRT) reduced it further to a few percentage points. However, simultaneously, urological toxicities were enhanced by dose escalation using highly precise external radiotherapy. We should pay more attention to detailed quality of life (QOL) analysis, not only with respect to rectal bleeding but also other specific symptoms (such as urinary incontinence and impotence), for two reasons: (i) because of the increasing number of patients aged >80 years, and (ii) because of improved survival with elevated doses of radiotherapy and/or hormonal therapy; age is an important prognostic factor not only for prostate-specific antigen (PSA) control but also for adverse reactions. Those factors shift the main focus of treatment purpose from survival and avoidance of PSA failure to maintaining good QOL, particularly in older patients. In conclusion, the focus of toxicity analysis after radiotherapy for prostate cancer patients is changing from rectal bleeding to total elaborate quality of life assessment.
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Affiliation(s)
- Hideya Yamazaki
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Satoaki Nakamura
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Takuya Nishimura
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Ken Yoshida
- Department of Radiology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki-City, Osaka, 569-8686, Japan
| | - Yasuo Yoshioka
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Yamadaoka 2-2, Suita, 565-0871 Osaka, Japan
| | - Masahiko Koizumi
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Yamadaoka 2-2, Suita, 565-0871 Osaka, Japan
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Yamadaoka 2-2, Suita, 565-0871 Osaka, Japan
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Glynne-Jones R, Kadalayil L, Meadows HM, Cunningham D, Samuel L, Geh JI, Lowdell C, James R, Beare S, Begum R, Ledermann JA, Sebag-Montefiore D. Tumour- and treatment-related colostomy rates following mitomycin C or cisplatin chemoradiation with or without maintenance chemotherapy in squamous cell carcinoma of the anus in the ACT II trial. Ann Oncol 2014; 25:1616-22. [PMID: 24827136 DOI: 10.1093/annonc/mdu188] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Squamous cell carcinoma of the anus (SCCA) is highly sensitive to chemoradiation (CRT) which achieves good loco-regional control and preserves anal function. However, some patients require permanent stoma formation either as a result of surgery on relapse, poor anal function or treatment-related symptoms. Our aim was to determine patient, tumour and treatment-related colostomy rates following CRT and maintenance chemotherapy in the ACT II trial. PATIENTS AND METHODS The ACT II trial recruited 940 patients comparing 5FU-based CRT using cisplatin (CisP) or mitomycin C (MMC) with or without additional maintenance chemotherapy. We investigated the association between colostomy-free survival (CFS) and progression-free survival (PFS) with age, gender, T-stage, N-stage, treatment and baseline haemoglobin. RESULTS The median follow-up was 5.1 years (n = 884 evaluable/940); tumour site canal (84%), margin (14%); stage T1/T2 (52%), T3/T4 (46%); N+ (32%), N0 (62%). Twenty out of 118 (17%) colostomies fashioned before CRT were reversed within 8 months. One hundred and twelve patients had a post-treatment colostomy due to persistent disease (98) or morbidity (14). Fifty-two per cent (61/118) of all pre-treatment colostomies were never reversed. The 5-year CFS rates were 68% MMC/Maint, 70% CisP/Maint, 68% MMC/No-maint and 65% CisP/No-maint. CRT with CisP did not improve CFS when compared with MMC (hazard ratio: 1.04, 95% confidence interval: 0.82-1.31, P = 0.74). The 5-year CFS rates were higher for T1/T2 (79%) than T3/T4 (54%) tumours and higher for node-negative (72%) than node-positive (60%) patients. Significant predictors of CFS were gender, T-stage and haemoglobin, while treatment factors had no impact on outcome. Similar associations were found between PFS and tumour/treatment-related factors. CONCLUSIONS The majority (52%) of pre-treatment colostomies were never reversed. Neither CRT with 5FU/CisP nor maintenance chemotherapy impacted on CFS. The low risk of colostomy for late effects (1.7%) is likely to be associated with the modest total radiotherapy dose. The predictive factors for CFS were T-stage, gender and baseline haemoglobin. CLINICAL TRIAL REGISTRATION NUMBER ISRCTN 26715889.
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Affiliation(s)
- R Glynne-Jones
- Department of Medical Oncology, Mount Vernon Centre for Cancer Treatment, Northwood
| | - L Kadalayil
- Cancer Research UK and University College London Cancer Trials Centre, London
| | - H M Meadows
- Cancer Research UK and University College London Cancer Trials Centre, London
| | | | - L Samuel
- Department of Clinical Oncology, Aberdeen Royal Infirmary, Aberdeen
| | - J I Geh
- Department of Oncology, Queen Elizabeth Hospital, Birmingham
| | - C Lowdell
- Department of Oncology, Imperial College Healthcare NHS Trust, London
| | - R James
- The Kent Cancer Centre, Tonbridge, Maidstone
| | - S Beare
- Cancer Research UK and University College London Cancer Trials Centre, London
| | - R Begum
- Cancer Research UK and University College London Cancer Trials Centre, London
| | - J A Ledermann
- Cancer Research UK and University College London Cancer Trials Centre, London
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Scher ED, Ahmed I, Yue NJ, Jabbour SK. Technical aspects of radiation therapy for anal cancer. J Gastrointest Oncol 2014; 5:198-211. [PMID: 24982768 DOI: 10.3978/j.issn.2078-6891.2014.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 05/22/2014] [Indexed: 01/26/2023] Open
Abstract
Historically treated with surgery, current practice recommends anal carcinoma to be treated with a combination of chemotherapy and radiation. This review will examine the anatomy, modes of disease spread and recurrence, and evaluate the existing evidence for treatment options for these tumors. An in-depth examination of specific radiation therapy (RT) techniques-such as conventional 3D-conformal RT and intensity-modulated RT-will be discussed along with modern dose constraints. RT field arrangement, patient setup, and recommended gross and clinical target volume (CTV) contours will be considered. Areas in need of further investigation, such as the role in treatment for positron emission tomography (PET) will be explored.
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Affiliation(s)
- Eli D Scher
- 1 Rowan University School of Osteopathic Medicine, Stratford, NJ 08084, USA ; 2 Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08903, USA
| | - Inaya Ahmed
- 1 Rowan University School of Osteopathic Medicine, Stratford, NJ 08084, USA ; 2 Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08903, USA
| | - Ning J Yue
- 1 Rowan University School of Osteopathic Medicine, Stratford, NJ 08084, USA ; 2 Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08903, USA
| | - Salma K Jabbour
- 1 Rowan University School of Osteopathic Medicine, Stratford, NJ 08084, USA ; 2 Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08903, USA
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Stenmark MH, Conlon AS, Johnson S, Daignault S, Litzenberg D, Marsh R, Ritter T, Vance S, Kazzi N, Feng FY, Sandler H, Sanda MG, Hamstra DA. Dose to the inferior rectum is strongly associated with patient reported bowel quality of life after radiation therapy for prostate cancer. Radiother Oncol 2014; 110:291-7. [DOI: 10.1016/j.radonc.2014.01.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 12/17/2013] [Accepted: 01/05/2014] [Indexed: 11/24/2022]
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Thor M, Apte A, Deasy JO, Karlsdóttir À, Moiseenko V, Liu M, Muren LP. Dose/volume-response relations for rectal morbidity using planned and simulated motion-inclusive dose distributions. Radiother Oncol 2013; 109:388-93. [PMID: 24231236 DOI: 10.1016/j.radonc.2013.10.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 10/10/2013] [Accepted: 10/19/2013] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND PURPOSE Many dose-limiting normal tissues in radiotherapy (RT) display considerable internal motion between fractions over a course of treatment, potentially reducing the appropriateness of using planned dose distributions to predict morbidity. Accounting explicitly for rectal motion could improve the predictive power of modelling rectal morbidity. To test this, we simulated the effect of motion in two cohorts. MATERIALS AND METHODS The included patients (232 and 159 cases) received RT for prostate cancer to 70 and 74 Gy. Motion-inclusive dose distributions were introduced as simulations of random or systematic motion to the planned dose distributions. Six rectal morbidity endpoints were analysed. A probit model using the QUANTEC recommended parameters was also applied to the cohorts. RESULTS The differences in associations using the planned over the motion-inclusive dose distributions were modest. Statistically significant associations were obtained with four of the endpoints, mainly at high doses (55-70 Gy), using both the planned and the motion-inclusive dose distributions, primarily when simulating random motion. The strongest associations were observed for GI toxicity and rectal bleeding (Rs=0.12-0.21; Rs=0.11-0.20). Applying the probit model, significant associations were found for tenesmus and rectal bleeding (Rs=0.13, p=0.02). CONCLUSION Equally strong associations with rectal morbidity were observed at high doses (>55 Gy), for the planned and the simulated dose distributions including in particular random rectal motion. Future studies should explore patient-specific descriptions of rectal motion to achieve improved predictive power.
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Affiliation(s)
- Maria Thor
- Departments of Medical Physics and Oncology, Aarhus University Hospital, Denmark; Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, USA.
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Brundage M, Danielson B, Pearcey R, Bass B, Pickles T, Bahary JP, Peng Y, Wallace D, Mackillop W. A criterion-based audit of the technical quality of external beam radiotherapy for prostate cancer. Radiother Oncol 2013; 107:339-45. [PMID: 23830469 DOI: 10.1016/j.radonc.2013.04.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Revised: 04/25/2013] [Accepted: 04/26/2013] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate the technical quality of external beam radiotherapy for prostate cancer in Canada. METHODS This was a multi-institution, retrospective study of a random sample of patients undergoing radiotherapy (RT) for prostate cancer in Canada. Patterns of care were determined by abstracting details of the patients' management from original records. The quality of patient's technical care was measured against a previously published, comprehensive suite of quality indicators. RESULTS 32 of the 37 RT centres participated. The total study population of 810 patients included 25% low-risk, 44% intermediate-risk, and 28% high-risk cases. 649 received external beam RT (EBRT) only, for whom compliance with 12 indicators of the quality of pre-treatment assessment ranged from 56% (sexual function documented) to 96% (staging bone scan obtained in high-risk patients). Compliance with treatment-related indicators ranged from 78% (dose to prostate ≥74 Gy in intermediate risk patients not receiving hormone therapy) to 100% (3DCRT or IMRT plan). Compliance varied among centres; no centre demonstrated 100% compliance on all indicators and every centre was 100% compliant on at least some indicators. The number of assessment-related indicators (n=13) with which a given centre was 100% compliant ranged from 4 to 11 (median 7) and the number of the treatment-specific indicators (n=8) with which a given centre was 100% compliant ranged from 6 to 8 (median 8). ADT therapy was utilised in most high-risk cases (191, 92.3%). CONCLUSIONS While patterns of prostate cancer care in Canada vary somewhat, compliance on the majority of quality indicators is very high. However, all centres showed room for improvement on several indicators and few individual patients received care that met target benchmarks on all quality measures. This variation is particularly important for indicators such as delivered dose where impact on disease outcome is known to exist, and suggests that quality improvement programmes have the potential to further improve quality of care.
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Affiliation(s)
- Michael Brundage
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada.
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Thor M, Bentzen L, Hysing LB, Ekanger C, Helle SI, Karlsdóttir Á, Muren LP. Prediction of rectum and bladder morbidity following radiotherapy of prostate cancer based on motion-inclusive dose distributions. Radiother Oncol 2013; 107:147-52. [PMID: 23684586 DOI: 10.1016/j.radonc.2013.03.029] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 03/19/2013] [Accepted: 03/26/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE In radiotherapy (RT) of prostate cancer the key organs at risk (ORs) - the rectum and the bladder - display considerable motion, which may influence the dose/volume parameters predicting for morbidity. In this study we compare motion-inclusive doses to planned doses for the rectum and bladder and explore their associations with prospectively recorded morbidity. MATERIALS AND METHODS The study included 38 prostate cancer patients treated with hypo-fractionated image-guided intensity-modulated RT that had an average of nine repeat CT scans acquired during treatment. These scans were registered to the respective treatment planning CT (pCT) followed by a new dose calculation from which motion-inclusive dose distributions were derived. The pCT volumes, the treatment course averaged volumes as well as the planned and motion-inclusive doses were associated with acute and late morbidity (morbidity cut-off: ≥ Grade 2). RESULTS Acute rectal morbidity (observed in 29% of cases) was significantly associated with both smaller treatment course averaged rectal volumes (population median: 75 vs. 94 cm(3)) and the motion-inclusive volume receiving doses close to the prescription dose (2 Gy-equivalent dose of 76 Gy). CONCLUSION Variation in rectum and bladder volumes leads to deviations between planned and delivered dose/volume parameters that should be accounted for to improve the ability to predict morbidity following RT.
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Affiliation(s)
- Maria Thor
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark.
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