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Mohanty S, Patil D, Joshi K, Gamre P, Mishra A, Khairnar S, Kakoti S, Nayak L, Punatar S, Jain J, Phurailatpam R, Goda JS. Dosimetric Impact of Voluntary Deep Inspiration Breath Hold (DIBH) in Mediastinal Hodgkin Lymphomas: A Comparative Evaluation of Three Different Intensity Modulated Radiation Therapy (IMRT) Delivery Methods Using Voluntary DIBH and Free Breathing Techniques. Cancers (Basel) 2024; 16:690. [PMID: 38398081 PMCID: PMC10886974 DOI: 10.3390/cancers16040690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 12/26/2023] [Accepted: 01/08/2024] [Indexed: 02/25/2024] Open
Abstract
Hodgkin lymphomas are radiosensitive and curable tumors that often involve the mediastinum. However, the application of radiation therapy to the mediastinum is associated with late effects including cardiac and pulmonary toxicities and secondary cancers. The adoption of conformal IMRT and deep inspiration breath- hold (DIBH) can reduce the dose to healthy normal tissues (lungs, heart and breast). We compared the dosimetry of organs at risk (OARs) using different IMRT techniques for two breathing conditions, i.e., deep inspiration breath hold (DIBH) and free breathing. Twenty-three patients with early-stage mediastinal Hodgkin lymphomas were accrued in the prospective study. The patients were given treatment plans which utilized full arc volumetric modulated arc therapy (F-VMAT), Butterfly VMAT (B-VMAT), and fixed field IMRT (FF-IMRT) techniques for both DIBH and free breathing methods, respectively. All the plans were optimized to deliver 95% of the prescription dose which was 25.2 Gy to 95% of the PTV volume. The mean dose and standard error of the mean for each OAR, conformity index (CI), and homogeneity index (HI) for the target using the three planning techniques were calculated and compared using Student's t-test for parametric data and Wilcoxon signed-rank test for non-parametric data. The HI and CI of the target was not compromised using the DIBH technique for mediastinal lymphomas. The mean values of CI and HI for both DIBH and FB were comparable. The mean heart doses were reduced by 2.1 Gy, 2.54 Gy, and 2.38 Gy in DIBH compared to FB for the F-VMAT, B-VMAT, and IMRT techniques, respectively. There was a significant reduction in V5Gy, V10Gy, and V15Gy to the heart (p < 0.005) with DIBH. DIBH reduced the mean dose to the total lung by 1.19 Gy, 1.47 Gy, and 1.3 Gy, respectively. Among the 14 female patients, there was a reduction in the mean right breast dose with DIBH compared to FB (4.47 Gy vs. 3.63 Gy, p = 0.004). DIBH results in lower heart, lung, and breast doses than free breathing in mediastinal Hodgkin Lymphoma. Among the different IMRT techniques, FF-IMRT, B-VMAT, and F-VMAT showed similar PTV coverage, with similar conformity and homogeneity indices. However, the time taken for FF-IMRT was much longer than for the F-VMAT and B-VMAT techniques for both breathing methods. B-VMAT and F-VMAT emerged as the optimal planning techniques able to achieve the best target coverage and lower doses to the OARs, with less time required to deliver the prescribed dose.
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Affiliation(s)
- Samarpita Mohanty
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai 410210, India; (S.M.); (D.P.); (K.J.); (P.G.); (A.M.); (S.K.); (S.K.); (J.J.); (R.P.)
| | - Divya Patil
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai 410210, India; (S.M.); (D.P.); (K.J.); (P.G.); (A.M.); (S.K.); (S.K.); (J.J.); (R.P.)
| | - Kishore Joshi
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai 410210, India; (S.M.); (D.P.); (K.J.); (P.G.); (A.M.); (S.K.); (S.K.); (J.J.); (R.P.)
| | - Poonam Gamre
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai 410210, India; (S.M.); (D.P.); (K.J.); (P.G.); (A.M.); (S.K.); (S.K.); (J.J.); (R.P.)
| | - Ajay Mishra
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai 410210, India; (S.M.); (D.P.); (K.J.); (P.G.); (A.M.); (S.K.); (S.K.); (J.J.); (R.P.)
| | - Sunil Khairnar
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai 410210, India; (S.M.); (D.P.); (K.J.); (P.G.); (A.M.); (S.K.); (S.K.); (J.J.); (R.P.)
| | - Sangeeta Kakoti
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai 410210, India; (S.M.); (D.P.); (K.J.); (P.G.); (A.M.); (S.K.); (S.K.); (J.J.); (R.P.)
| | - Lingaraj Nayak
- Department of Hemato Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai 410210, India; (L.N.); (S.P.)
| | - Sachin Punatar
- Department of Hemato Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai 410210, India; (L.N.); (S.P.)
| | - Jeevanshu Jain
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai 410210, India; (S.M.); (D.P.); (K.J.); (P.G.); (A.M.); (S.K.); (S.K.); (J.J.); (R.P.)
| | - Reena Phurailatpam
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai 410210, India; (S.M.); (D.P.); (K.J.); (P.G.); (A.M.); (S.K.); (S.K.); (J.J.); (R.P.)
| | - Jayant S. Goda
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai 410210, India; (S.M.); (D.P.); (K.J.); (P.G.); (A.M.); (S.K.); (S.K.); (J.J.); (R.P.)
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Ollivier L, Laprie A, Jouglar E, Claude L, Martin V, Muracciole X, Padovani L, Supiot S, Escande A. [Characteristics of radiotherapy for adolescents and young adults]. Cancer Radiother 2023; 27:736-745. [PMID: 38652674 DOI: 10.1016/j.canrad.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 04/25/2024]
Abstract
Radiotherapy for adolescents and young adults is complex in several aspects. The population is very heterogeneous and has characteristics derived from both paediatric and adult populations both in terms of pathology (anatomical pathology, response to treatment) and the patient's physical, biological and psychological characteristics. This article reviews the characteristics to be taken into account in adolescent and young adult patients radiotherapy and more particularly in some of the most common diseases.
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Affiliation(s)
- L Ollivier
- Département de radiothérapie, institut de cancérologie de l'Ouest (ICO), Saint-Herblain, France
| | - A Laprie
- Département d'oncologie-radiothérapie, oncopole institut Claudius-Regaud, institut universitaire du cancer de Toulouse, université Toulouse III, Toulouse, France
| | - E Jouglar
- Département de radiothérapie, institut Curie, université Paris Science et Lettres, Paris, France
| | - L Claude
- Département de radiothérapie, centre Léon-Bérard, Lyon, France
| | - V Martin
- Département d'oncologie-radiothérapie, Gustave-Roussy, Villejuif, France
| | - X Muracciole
- Département d'oncologie-radiothérapie, Assistance publique-hôpitaux de Marseille, CHU La Timone, CHU Nord, Marseille, France
| | - L Padovani
- Département d'oncologie-radiothérapie, Assistance publique-hôpitaux de Marseille, CHU La Timone, CHU Nord, Marseille, France
| | - S Supiot
- Département de radiothérapie, institut de cancérologie de l'Ouest (ICO), Saint-Herblain, France
| | - A Escande
- Département de radiothérapie, centre Léonard-de-Vinci, Dechy, France; Laboratoire CRIStAL, UMR 9186, université de Lille, Villeneuve-d'Ascq, France.
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Hoffmann L, Ehmsen ML, Hansen J, Hansen R, Knap MM, Mortensen HR, Poulsen PR, Ravkilde T, Rose HK, Schmidt HH, Worm ES, Møller DS. Repeated deep-inspiration breath-hold CT scans at planning underestimate the actual motion between breath-holds at treatment for lung cancer and lymphoma patients. Radiother Oncol 2023; 188:109887. [PMID: 37659663 DOI: 10.1016/j.radonc.2023.109887] [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: 06/25/2023] [Revised: 08/04/2023] [Accepted: 08/23/2023] [Indexed: 09/04/2023]
Abstract
PURPOSE/OBJECTIVE Deep-inspiration breath-hold (DIBH) during radiotherapy may reduce dose to the lungs and heart compared to treatment in free breathing. However, intra-fractional target shifts between several breath-holds may decrease target coverage. We compared target shifts between four DIBHs at the planning-CT session with those measured on CBCT-scans obtained pre- and post-DIBH treatments. MATERIAL/METHODS Twenty-nine lung cancer and nine lymphoma patients were treated in DIBH. An external gating block was used as surrogate for the DIBH-level with a window of 2 mm. Four DIBH CT-scans were acquired: one for planning (CTDIBH3) and three additional (CTDIBH1,2,4) to assess the intra-DIBH target shifts at scanning by registration to CTDIBH3. During treatment, pre-treatment (CBCTpre) and post-treatment (CBCTpost) scans were acquired. For each pair of CBCTpre/post, the target intra-DIBH shift was determined. For lung cancer, tumour (GTV-Tlung) and lymph nodes (GTV-Nlung) were analysed separately. Group mean (GM), systematic and random errors, and GM for the absolute maximum shifts (GMmax) were calculated for the shifts between CTDIBH1,2,3,4 and between CBCTpre/post. RESULTS For GTV-Tlung, GMmax was larger at CBCT than CT in all directions. GMmax in cranio-caudal direction was 3.3 mm (CT)and 6.1 mm (CBCT). The standard deviations of the shifts in the left-right and cranio-caudal directions were larger at CBCT than CT. For GTV-Nlung and CTVlymphoma, no difference was found in GMmax or SD. CONCLUSION Intra-DIBH shifts at planning-CT session are generally smaller than intra-DIBH shifts observed at CBCTpre/post and therefore underestimate the intra-fractional DIBH uncertainty during treatment. Lung tumours show larger intra-fractional variations than lymph nodes and lymphoma targets.
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Affiliation(s)
- Lone Hoffmann
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - M L Ehmsen
- Danish Center for Proton Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - J Hansen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - R Hansen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - M M Knap
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - H R Mortensen
- Danish Center for Proton Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - P R Poulsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Danish Center for Proton Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - T Ravkilde
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - H K Rose
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - H H Schmidt
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - E S Worm
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - D S Møller
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Canters R, Vaassen F, Lubken I, Cobben M, Murrer L, Peeters S, Berbee M, Ta B. Radiotherapy for mediastinal lymphoma in breath hold using surface monitoring and nasal high flow oxygen: Clinical experiences and breath hold stability. Radiother Oncol 2023; 183:109594. [PMID: 36870610 DOI: 10.1016/j.radonc.2023.109594] [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: 07/04/2022] [Revised: 02/11/2023] [Accepted: 02/26/2023] [Indexed: 03/06/2023]
Abstract
PURPOSE In this study we describe the clinical introduction and evaluation of radiotherapy in mediastinal lymphoma in breath hold using surface monitoring combined with nasal high flow therapy (NHFT) to prolong breath hold duration. MATERIALS AND METHODS 11 Patients with mediastinal lymphoma were evaluated. 6 Patients received NHFT, 5 patients were treated in breath hold without NHFT. Breath hold stability as measured by a surface scanning system was evaluated, as well as internal movement based on cone beam computed tomography (CBCT) before and after treatment. Based on internal movement, margins were determined. In a parallel planning study we compared free breathing plans with breath hold plans using the determined margins. RESULTS Average inter breath hold stability was 0.6 mm for NHFT treatments, and 0.5 mm for non-NHFT treatments (p > 0.1). Intra breath hold stability was 0.8 vs. 0.6 mm (p > 0.1) on average. Using NHFT, average breath hold duration increased from 34 s to 60 s (p < 0.01). Residual CTV motion derived from CBCTs before and after each fraction was 2.0 mm for NHFT vs 2.2 mm for non-NHFT (p > 0.1). Combined with inter-fraction motion, a uniform mediastinal margin of 5 mm appears to be sufficient. In breath hold, mean lung dose is reduced by 2.6 Gy (p < 0.001), while mean heart dose is reduced by 2.0 Gy (p < 0.001). CONCLUSION Treatment of mediastinal lymphoma in breath hold is feasible and safe. The addition of NHFT approximately increases breath hold durations with a factor two while stability is maintained. By reducing breathing motion, margins can be decreased to 5 mm. A considerable dose reduction in heart, lungs, esophagus, and breasts can be achieved with this method.
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Affiliation(s)
- Richard Canters
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Reproduction, Maastricht University Medical Center, the Netherlands.
| | - Femke Vaassen
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Reproduction, Maastricht University Medical Center, the Netherlands
| | - Indra Lubken
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Reproduction, Maastricht University Medical Center, the Netherlands
| | - Maud Cobben
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Reproduction, Maastricht University Medical Center, the Netherlands
| | - Lars Murrer
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Reproduction, Maastricht University Medical Center, the Netherlands
| | - Stephanie Peeters
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Reproduction, Maastricht University Medical Center, the Netherlands
| | - Maaike Berbee
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Reproduction, Maastricht University Medical Center, the Netherlands
| | - Bastiaan Ta
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Reproduction, Maastricht University Medical Center, the Netherlands
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Houlihan OA, Ntentas G, Cutter DJ, Daly P, Gillham C, McArdle O, Duane FK. Predicted cardiac and second cancer risks for patients undergoing VMAT for mediastinal Hodgkin lymphoma. Clin Transl Oncol 2022; 25:1368-1377. [PMID: 36585562 PMCID: PMC10119211 DOI: 10.1007/s12094-022-03034-z] [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: 10/06/2022] [Accepted: 11/29/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE To predict treatment-related cardiovascular disease (CVD) and second cancer 30-year absolute mortality risks (AMR30) for patients with mediastinal Hodgkin lymphoma in a large multicentre radiation oncology network in Ireland. MATERIAL AND METHODS This study includes consecutive patients treated for mediastinal lymphoma using chemotherapy and involved site radiotherapy (RT) 2016-2019. Radiation doses to heart, left ventricle, cardiac valves, lungs, oesophagus, carotid arteries and female breasts were calculated. Individual CVD and second cancer AMR30 were predicted using Irish background population rates and dose-response relationships. RESULTS Forty-four patients with Hodgkin lymphoma were identified, 23 females, median age 28 years. Ninety-eight percent received anthracycline, 80% received 4-6 cycles ABVD. Volumetric modulated arc therapy (VMAT) ± deep inspiration breath hold (DIBH) was delivered, median total prescribed dose 30 Gy. Average mean heart dose 9.8 Gy (range 0.2-23.8 Gy). Excess treatment-related mean AMR30 from CVD was 2.18% (0.79, 0.90, 0.01, 0.13 and 0.35% for coronary disease, heart failure, valvular disease, stroke and other cardiac diseases), 1.07% due to chemotherapy and a further 1.11% from RT. Excess mean AMR30 for second cancers following RT were: lung cancer 2.20%, breast cancer in females 0.34%, and oesophageal cancer 0.28%. CONCLUSION For patients with mediastinal lymphoma excess mortality risks from CVD and second cancers remain clinically significant despite contemporary chemotherapy and photon-RT. Efforts to reduce the toxicity of combined modality treatment, for example, using DIBH, reduced margins and advanced RT, e.g. proton beam therapy, should be continued to further reduce potentially fatal treatment effects.
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Affiliation(s)
- Orla A Houlihan
- St Luke's Radiation Oncology Network, Dublin, Ireland. .,Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7AE, UK.
| | - Georgios Ntentas
- Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Department of Medical Physics, Guy's and St Thomas' NHS Foundation Trust, London, UK.,School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - David J Cutter
- Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Oxford Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Patricia Daly
- St Luke's Radiation Oncology Network, Dublin, Ireland.,Trinity St James's Cancer Institute, St. James's Hospital, Dublin, Ireland.,School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Charles Gillham
- St Luke's Radiation Oncology Network, Dublin, Ireland.,Trinity St James's Cancer Institute, St. James's Hospital, Dublin, Ireland.,School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Orla McArdle
- St Luke's Radiation Oncology Network, Dublin, Ireland
| | - Frances K Duane
- St Luke's Radiation Oncology Network, Dublin, Ireland.,Trinity St James's Cancer Institute, St. James's Hospital, Dublin, Ireland.,School of Medicine, Trinity College Dublin, Dublin, Ireland
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Patel CG, Peterson J, Aznar M, Tseng YD, Lester S, Pafundi D, Flampouri S, Mohindra P, Parikh RR, Mailhot Vega R, Konig L, Plastaras JP, Bates JE, Loap P, Kirova YM, Orlandi E, Lütgendorf-Caucig C, Ntentas G, Hoppe B. Systematic review for deep inspiration breath hold in proton therapy for mediastinal lymphoma: A PTCOG Lymphoma Subcommittee report and recommendations. Radiother Oncol 2022; 177:21-32. [PMID: 36252635 DOI: 10.1016/j.radonc.2022.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 09/14/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE To systematically review all dosimetric studies investigating the impact of deep inspiration breath hold (DIBH) compared with free breathing (FB) in mediastinal lymphoma patients treated with proton therapy as compared to IMRT (intensity-modulated radiation therapy)-DIBH. MATERIALS AND METHODS We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline using the PubMed database to identify studies of mediastinal lymphoma patients with dosimetric comparisons of proton-FB and/or proton-DIBH with IMRT-DIBH. Parameters included mean heart (MHD), lung (MLD), and breast (MBD) doses, among other parameters. Case reports were excluded. Absolute differences in mean doses > 1 Gy between comparators were considered to be clinically meaningful. RESULTS As of April 2021, eight studies fit these criteria (n = 8), with the following comparisons: proton-FB vs IMRT-DIBH (n = 5), proton-DIBH vs proton-FB (n = 5), and proton-DIBH vs IMRT-DIBH (n = 8). When comparing proton-FB with IMRT-DIBH in 5 studies, MHD was reduced with proton-FB in 2 studies, was similar (<1 Gy difference) in 2 studies, and increased in 1 study. On the other hand, MLD and MBD were reduced with proton-FB in 3 and 4 studies, respectively. When comparing proton-DIBH with proton-FB, MHD and MLD were reduced with proton DIBH in 4 and 3 studies, respectively, while MBD remained similar. Compared with IMRT-DIBH in 8 studies, proton-DIBH reduced the MHD in 7 studies and was similar in 1 study. Furthermore, MLD and MBD were reduced with proton-DIBH in 8 and 6 studies respectively. Integral dose was similar between proton-FB and proton-DIBH, and both were substantially lower than IMRT-DIBH. CONCLUSION Accounting for heart, lung, breast, and integral dose, proton therapy (FB or DIBH) was superior to IMRT-DIBH. Proton-DIBH can lower dose to the lungs and heart even further compared with proton-FB, depending on disease location in the mediastinum, and organ-sparing and target coverage priorities.
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Affiliation(s)
- Chirayu G Patel
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, USA.
| | | | - Marianne Aznar
- University of Manchester, Division of Cancer Sciences, Manchester, United Kingdom
| | - Yolanda D Tseng
- Department of Radiation Oncology, University of Washington, Seattle, USA
| | | | | | - Stella Flampouri
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, USA
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Rahul R Parikh
- Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, New Brunswick, NJ, USA
| | - Raymond Mailhot Vega
- Department of Radiation Oncology, University of Florida, Gainsville, Florida, USA
| | - Laila Konig
- Department of Radiation Oncology, Heidelberg University Hospital; Heidelberg Ion Beam Therapy Centre (HIT); National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - John P Plastaras
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - James E Bates
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, USA
| | - Pierre Loap
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Youlia M Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Ester Orlandi
- National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | | | - Georgios Ntentas
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; Guy's and St Thomas' NHS Foundation Trust, Department of Medical Physics, London, United Kingdom
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Jones KS, Webster A, Ntentas G, Brady JL, Mikhaeel NG. Deep inspiration breath-hold for mediastinal lymphoma patients: Evaluation of a 5-year service. Tech Innov Patient Support Radiat Oncol 2022; 22:26-29. [PMID: 35450274 PMCID: PMC9018138 DOI: 10.1016/j.tipsro.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/22/2022] [Accepted: 04/05/2022] [Indexed: 11/25/2022] Open
Abstract
There is little published data on the use of DIBH and Butterfly volumetric arc therapy for the treatment of mediastinal lymphoma. Experience of a 5 year service was analysed looking into immobilisaiton, IGRT, patient compliance, and completion of the patient pathway without interruption. It is noted that a successful service has been implemented with minimal disruption to the patient pathway and optimal treatment delivered.
Deep inspiration breath-hold (DIBH) is an advanced radiotherapy technique that has been shown to have dosimetric benefits in the treatment of patients with mediastinal lymphoma. Whilst there is much published data on the use of DIBH in breast radiotherapy, reports on the use of the technique in mediastinal lymphoma patients remain limited. As the first NHS centre in the UK to implement DIBH in this pt group, we have evaluated our experience and success in using this technique over a 5 year period.
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Introduction of deep inspirational breath-hold and Butterfly-VMAT techniques into clinical practice for the treatment of mediastinal lymphoma – Lessons learned from an experienced centre. Tech Innov Patient Support Radiat Oncol 2022; 22:22-25. [PMID: 35434387 PMCID: PMC9010782 DOI: 10.1016/j.tipsro.2022.04.002] [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: 01/12/2022] [Revised: 02/22/2022] [Accepted: 04/05/2022] [Indexed: 11/24/2022] Open
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Shbib Dabaja B, Boyce-Fappiano D, Dong W, Damron E, Fang P, Gunther J, Rodriguez MA, Strati P, Steiner R, Nair R, Lee H, Abou Yehia Z, Shihadeh F, Pinnix C, Ng AK. Second Malignancies in Patients with Hodgkin’s Lymphoma: Half a Century of Experience. Clin Transl Radiat Oncol 2022; 35:64-69. [PMID: 35601797 PMCID: PMC9121058 DOI: 10.1016/j.ctro.2022.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 04/07/2022] [Accepted: 04/25/2022] [Indexed: 12/05/2022] Open
Abstract
Purpose Therapeutic improvements for Hodgkin’s Lymphoma (HL) has resulted in excellent survival outcomes. Thus, patients are increasing susceptible to developing secondary malignancy (SM) a feared iatrogenic complication. Materials & Methods We evaluated the SM risk in a cohort of patients with HL treated over a 50-year period. In total, 1653 patients were treated for HL from 1956 to 2009 at a tertiary-cancer-center. A cumulative incidence function was used to quantify SM risk and the Fine and Gray competing risk model was used to identify disease and treatment related correlates. Results Two-hundred-ninety patients (19%) developed SMs. Paradoxically, SM risk was higher in the modern era with 20-year cumulative incidence rates of 11.1%, 11.9%, 17% and 21.8%, for patients treated <1970, 1971–1986, 1986–1995 and 1996–2009, respectively. We hypothesized that the disproportionately high rate of early deaths in the early era may skew the assessment of SM risks, a much-delayed event. When the analysis was restricted to patients with early-stage favorable HL treated >1980, we found a reversal of the trend, especially on the risk of solid tumor, with a hazard ratio of 0.57 (p = 0.0651) in patients treated after 1996. Conclusion Our findings highlight the limitations of comparing the risk of a late event between groups with disparate rates of early deaths, despite the use of a competing risk model. When partially corrected for, patients treated in the more recent time period experienced a lower solid tumor risk.
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Affiliation(s)
- Bouthaina Shbib Dabaja
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Corresponding author at: Department of Radiation Oncology, Division of Radiation Oncology Incident Commander, University of Texas MD Anderson Cancer Center, Director of Research of the International Lymphoma Radiation Oncology Group (ILROG), 1515 Holcombe Blvd., Houston, TX 77030, USA.
| | - David Boyce-Fappiano
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wenli Dong
- Departments of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ethan Damron
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Penny Fang
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jill Gunther
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maria A. Rodriguez
- Departments of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paolo Strati
- Departments of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Raphael Steiner
- Departments of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ranjit Nair
- Departments of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hun Lee
- Departments of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zeinab Abou Yehia
- Department of Radiation Oncology, Rutgers Robertwood Johnson Medical Center, Houston, TX, USA
| | - Ferial Shihadeh
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Chelsea Pinnix
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrea K. Ng
- Department of Radiation Oncology, Dana-Farber/Brigham and Women’s Cancer Center, Harvard Medical School, Houston, TX, USA
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10
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Ntentas G, Dedeckova K, Andrlik M, Aznar MC, Shakir R, Ramroth J, Begum R, Kubeš J, Darby SC, Mikhaeel NG, Cutter DJ. Proton Therapy in Supradiaphragmatic Lymphoma: Predicting Treatment-Related Mortality to Help Optimize Patient Selection. Int J Radiat Oncol Biol Phys 2022; 112:913-925. [PMID: 34762970 PMCID: PMC8865523 DOI: 10.1016/j.ijrobp.2021.10.151] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 09/28/2021] [Accepted: 10/28/2021] [Indexed: 11/15/2022]
Abstract
PURPOSE In some patients with Hodgkin lymphoma (HL), proton beam therapy (PBT) may reduce the risk of radiation-related cardiovascular disease (CVD) and second cancers (SC) compared with photon radiation therapy (RT). Our aim was to identify patients who benefit the most from PBT in terms of predicted 30-year absolute mortality risks (AMR30) from CVD and SC, taking into account individual background, chemotherapy, radiation, and smoking-related risks. METHODS AND MATERIALS Eighty patients with supradiaphragmatic HL treated with PBT between 2015 and 2019 were replanned using optimal photon RT. To identify patients predicted to derive the greatest benefit from PBT compared with photon RT, doses and AMR30 from CVD and SC of the lung, breast, and esophagus were compared for all patients and across patient subgroups. RESULTS For patients with mediastinal disease below the origin of the left main coronary artery (n = 66; 82%), PBT reduced the mean dose to the heart, left ventricle, and heart valves by 1.0, 2.7, and 3.6 Gy, respectively. Based on U.S. mortality rates, PBT reduced CVD AMR30 by 0.2%, from 5.9% to 5.7%. The benefit was larger if the mediastinal disease overlapped longitudinally with the heart by ≥40% (n = 23; 29%). PBT reduced the mean dose to the heart, left ventricle, and heart valves by 3.2, 5.6, and 5.1 Gy, respectively, and reduced CVD AMR30 by 0.8%, from 7.0% to 6.2%. For patients with axillary disease (n = 25; 31%), PBT reduced the mean lung dose by 2.8 Gy and lung cancer AMR30 by 0.6%, from 2.7% to 2.1%. Breast and esophageal doses were also lower with PBT, but the effects on AMR30 were negligible. The effect of smoking on CVD and lung cancer AMR30 was much larger than radiation and chemotherapy and the differences between radiation modalities. CONCLUSIONS The predicted benefit of PBT is not universal and limited to certain categories of patients with lymphoma and lower mediastinal or axillary disease. Smoking cessation should be strongly encouraged in smokers who require thoracic RT.
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Affiliation(s)
- Georgios Ntentas
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; Guy's and St Thomas' NHS Foundation Trust, Department of Medical Physics, London, United Kingdom.
| | - Katerina Dedeckova
- Proton Therapy Center Czech, Prague, Czech Republic; Department of Oncology, 2nd Faculty of Medicine Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | | | - Marianne C Aznar
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; Manchester Cancer Research Centre, University of Manchester, Manchester, United Kingdom
| | - Rebecca Shakir
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; Oxford Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Johanna Ramroth
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Rubina Begum
- Guy's and St Thomas' NHS Foundation Trust, Department of Medical Physics, London, United Kingdom
| | - Jiří Kubeš
- Proton Therapy Center Czech, Prague, Czech Republic; Department of Oncology, 2nd Faculty of Medicine Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Sarah C Darby
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - N George Mikhaeel
- Guy's & St Thomas' NHS Foundation Trust and School of Cancer & Pharmaceutical Sciences, King's College London, London, United Kingdom
| | - David J Cutter
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; Oxford Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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11
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Laprie A, Bernier V, Padovani L, Martin V, Chargari C, Supiot S, Claude L. Guide for paediatric radiotherapy procedures. Cancer Radiother 2021; 26:356-367. [PMID: 34969622 DOI: 10.1016/j.canrad.2021.11.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
A third of children with cancer receive radiotherapy as part of their initial treatment, which represents 800 paediatric irradiations per year in France carried out in 15 specialized centres approved on the recommendations of the French national cancer institute in decreasing order of frequency, the types of cancer that require irradiation are: brain tumours, neuroblastomas, Ewing's sarcomas, Hodgkin's lymphomas, soft tissue sarcomas including rhabdomyosarcomas, and nephroblastomas. The treatment guidelines follow the recommendations of the French society for childhood cancers (SFCE) or the French and European prospective protocols. The therapeutic indications, the technical and/and ballistic choices of complex cases are frequently discussed during bimonthly paediatric radiotherapy technical web-conferences. All cancers combined, overall survival being 80%, long-term toxicity logically becomes an important concern, making the preparation of treatments complex. The irradiation methods include all the techniques currently available: 3D conformational irradiation, intensity modulation radiation therapy, irradiation under normal or hypofractionated stereotaxic conditions, brachytherapy and proton therapy. We present the update of the recommendations of the French society for radiation oncology on the indications, the technical methods of realization and the organisation and the specificities of paediatric radiation oncology.
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Affiliation(s)
- A Laprie
- Département d'oncologie radiothérapie, Institut universitaire du cancer de Toulouse-Oncopole (IUCT-oncopole), université Paul-Sabatier Toulouse III, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex 9, France.
| | - V Bernier
- Département d'oncologie radiothérapie, Institut de cancérologie de Lorraine centre Alexis-Vautrin, 6, avenue de Bourgogne, CS 30519, 54519 Vandœuvre-lès-Nancy cedex, France
| | - L Padovani
- Département de cancérologie radiothérapie, CHU, 13000 Marseille, France; Université Aix-Marseille, 13000 Marseille, France
| | - V Martin
- Département de cancérologie radiothérapie, institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif cedex, France
| | - C Chargari
- Département d'oncologie radiothérapie, institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif cedex, France; Service de santé des armées, 75000 Paris, France
| | - S Supiot
- Département de radiothérapie, Institut de cancérologie de l'Ouest (ICO) centre René-Gauducheau, 44800 Saint-Herblain, France; Université de Nantes, 44000 Nantes, France
| | - L Claude
- Département d'oncologie radiothérapie, centre Léon-Bérard, 28, rue Laennec, 69373 Lyon cedex 08, France
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12
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Cutter DJ, Ramroth J, Diez P, Buckle A, Ntentas G, Popova B, Clifton-Hadley L, Hoskin PJ, Darby SC, Radford J, Illidge T. Predicted Risks of Cardiovascular Disease Following Chemotherapy and Radiotherapy in the UK NCRI RAPID Trial of Positron Emission Tomography-Directed Therapy for Early-Stage Hodgkin Lymphoma. J Clin Oncol 2021; 39:3591-3601. [PMID: 34388007 PMCID: PMC8577686 DOI: 10.1200/jco.21.00408] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 06/21/2021] [Accepted: 06/30/2021] [Indexed: 01/07/2023] Open
Abstract
PURPOSE The contemporary management of early-stage Hodgkin lymphoma (ES-HL) involves balancing the risk of late adverse effects of radiotherapy against the increased risk of relapse if radiotherapy is omitted. This study provides information on the risk of radiation-related cardiovascular disease to help personalize the delivery of radiotherapy in ES-HL. METHODS We predicted 30-year absolute cardiovascular risk from chemotherapy and involved field radiotherapy in patients who were positron emission tomography (PET)-negative following three cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine chemotherapy within a UK randomized trial of PET-directed therapy for ES-HL. Cardiac and carotid radiation doses and chemotherapy exposure were combined with established dose-response relationships and population-based mortality and incidence rates. RESULTS Average mean heart dose was 4.0 Gy (range 0.1-24.0 Gy) and average bilateral common carotid artery dose was 21.5 Gy (range 0.6-38.1 Gy), based on individualized cardiovascular dosimetry for 144 PET-negative patients receiving involved field radiotherapy. The average predicted 30-year radiation-related absolute excess overall cardiovascular mortality was 0.56% (range 0.01%-6.79%; < 0.5% in 67% of patients and > 1% in 15%), whereas average predicted 30-year excess incidence was 6.24% (range 0.31%-31.09%; < 5% in 58% of patients and > 10% in 24%). For cardiac disease, the average predicted 30-year radiation-related absolute excess mortality was 0.42% (0.79% with mediastinal involvement and 0.05% without) and for stroke, it was 0.14%. CONCLUSION Predicted excess cardiovascular risk is small for most patients, so radiotherapy may provide net benefit. However, for a minority of patients receiving high doses of radiation to cardiovascular structures, it may be preferable to consider advanced radiotherapy techniques to reduce doses or to omit radiotherapy and accept the increased relapse risk. Individual assessment of cardiovascular and other risks before treatment would allow personalized decision making about radiotherapy in ES-HL.
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Affiliation(s)
- David J. Cutter
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Oxford Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, United Kingdom
| | - Johanna Ramroth
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Patricia Diez
- National Radiotherapy Trials Quality Assurance Group, Mount Vernon Cancer Centre, Northwood, United Kingdom
| | - Andy Buckle
- Oxford Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, United Kingdom
| | - Georgios Ntentas
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Department of Medical Physics, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Bilyana Popova
- Cancer Research UK, UCL Cancer Trials Centre, London, United Kingdom
| | | | - Peter J. Hoskin
- National Radiotherapy Trials Quality Assurance Group, Mount Vernon Cancer Centre, Northwood, United Kingdom
- Manchester Academic Health Science Centre, Manchester Cancer Research Centre, University of Manchester, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Sarah C. Darby
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - John Radford
- Manchester Academic Health Science Centre, Manchester Cancer Research Centre, University of Manchester, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Tim Illidge
- Manchester Academic Health Science Centre, Manchester Cancer Research Centre, University of Manchester, The Christie NHS Foundation Trust, Manchester, United Kingdom
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13
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Role of radiotherapy to bulky sites of advanced Hodgkin lymphoma treated with ABVD: final results of FIL HD0801 trial. Blood Adv 2021; 5:4504-4514. [PMID: 34597375 PMCID: PMC8579271 DOI: 10.1182/bloodadvances.2021005150] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 08/15/2021] [Indexed: 11/20/2022] Open
Abstract
The role of consolidation radiotherapy (RT) for bulky lesions is controversial in patients with advanced-stage Hodgkin lymphoma who achieve complete metabolic response (CMR) after doxorubicin, bleomycin, vinblastine, dacarbazine (ABVD)-based chemotherapy. We present the final results of the Fondazione Italiana Linfomi HD0801 trial, which investigated the potential benefit of RT in that setting. In this phase 3 randomized study, patients with a bulky lesion at baseline (a mass with largest diameter ≥5 cm) who have CMR after 2 and 6 ABVD cycles were randomly assigned 1:1 to RT vs observation (OBS) with a primary endpoint of event-free survival (EFS) at 2 years. The sample size was calculated estimating an EFS improvement for RT of 20% (from 60% to 80%). The secondary end point was progression-free survival (PFS). One hundred sixteen patients met the inclusion criteria and were randomly assigned to RT or OBS. Intention-to-treat (ITT) analysis showed a 2-year EFS of 87.8% vs 85.8% for RT vs OBS (hazard ratio [HR], 1.5; 95% confidence interval [CI], 0.6-3.5; P = .34). At 2 years, ITT-PFS was 91.3% vs 85.8% (HR, 1.2; 95% CI, 0.5-3; P = .7). Patients in CMR randomly assigned to OBS had a good outcome, and the primary end point of a 20% benefit in EFS for RT was not met. However, the sample size was underpowered to detect a benefit of 10% or less, keeping open the question of a potential, more limited role of RT in this setting. This trial was registered at www.clinicaltrials.gov as #NCT00784537.
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14
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Aznar M, Ntentas G, Enmark M, Flampouri S, Meidhal Petersen P, Ricardi U, Levis M. The role of motion management and position verification in lymphoma radiotherapy. Br J Radiol 2021; 94:20210618. [PMID: 34677090 PMCID: PMC8553184 DOI: 10.1259/bjr.20210618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 09/09/2021] [Accepted: 09/10/2021] [Indexed: 12/17/2022] Open
Abstract
In the last decades, the substantial technical progress in radiation oncology offered the opportunity for more accurate planning and delivery of treatment. At the same time, the evolution of systemic treatment and the advent of modern diagnostic tools allowed for more accurate staging and consequently a safe reduction of radiotherapy (RT) target volumes and RT doses in the treatment of lymphomas. As a result, incidental irradiation of organs at risk was reduced, with a consequent reduction of severe late toxicity in long-term lymphoma survivors. Nevertheless, these innovations warrant that professionals pay attention to concurrently ensure precise planning and dose delivery to the target volume and safe sparing of the organs at risk. In particular, target and organ motion should be carefully managed in order to prevent any compromise of treatment efficacy. Several aspects should be taken into account during the treatment pathway to minimise uncertainties and to apply a valuable motion management strategy, when needed. These include: reliable image registration between diagnostic and planning radiologic exams to facilitate the contouring process, image guidance to limit positioning uncertainties and to ensure the accuracy of dose delivery and management of lung motion through procedures of respiratory gating and breath control. In this review, we will cover the current clinical approaches to minimise these uncertainties in patients treated with modern RT techniques, with a particular focus on mediastinal lymphoma. In addition, since uncertainties have a different impact on the dose deposition of protons compared to conventional x-rays, the role of motion management and position verification in proton beam therapy (PBT) will be discussed in a separate section.
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Affiliation(s)
| | | | | | - Stella Flampouri
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | | | | | - Mario Levis
- Department of Oncology, University of Torino, Turin, Italy
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15
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Petersen PM, Mikhaeel NG, Ricardi U, Brady JL. Harnessing benefit of highly conformal RT techniques for lymphoma patients. Br J Radiol 2021; 94:20210469. [PMID: 34379521 DOI: 10.1259/bjr.20210469] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
This status article describes current state-of-the-art radiotherapy for lymphomas and new emerging techniques. Current state-of-the-art radiotherapy is sophisticated, individualised, CT-based, intensity-modulated treatment, using PET/CT to define the target. The concept of involved site radiotherapy should be used, delineating the target using the exact same principles as for solid tumours. The optimal treatment delivery includes motion management and online treatment verification systems, which reduce intra- and interfractional anatomical variation. Emerging radiotherapy techniques in lymphomas include adaptive radiotherapy in MR- and CT-based treatment systems and proton therapy. The next generation linear accelerators have the capability to deliver adaptive treatment and allow relatively quick online adaptation to the daily variations of the anatomy. The computer systems use machine leaning to facilitate rapid automatic contouring of the target and organs-at-risk. Moreover, emerging MR-based planning and treatment facilities allow target definition directly from MR scans and allow intra-fractional tracking of structures recognisable on MR. Proton facilities are now being widely implemented. The benefits of proton therapy are due to the physical properties of protons, which in many cases allow sparing of normal tissue. The variety of techniques in modern radiotherapy means that the radiation oncologist must be able to choose the right technique for each patient. The choice is mainly based on experience and standard protocols, but new systems calculating risks for the patients with a specific treatment plan and also systems integrating clinical factors and risk factors into the planning process itself are emerging.
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Affiliation(s)
- Peter Meidahl Petersen
- Department of Oncology, The Finsen Centre, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - N George Mikhaeel
- Guy's Cancer Centre, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | | | - Jessica L Brady
- Guy's Cancer Centre, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
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16
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Buglione M, Guerini AE, Filippi AR, Spiazzi L, Pasinetti N, Magli A, Toraci C, Borghetti P, Triggiani L, Alghisi A, Costantino G, Bertagna F, Giaj Levra N, Pegurri L, Magrini SM. A Systematic Review on Intensity Modulated Radiation Therapy for Mediastinal Hodgkin's Lymphoma. Crit Rev Oncol Hematol 2021; 167:103437. [PMID: 34358649 DOI: 10.1016/j.critrevonc.2021.103437] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 05/20/2021] [Accepted: 07/28/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Secondary malignant neoplasms (SMNs) and cardiovascular diseases induced by chemotherapy and radiotherapy represent the main cause of excess mortality for early-stage Hodgkin lymphoma patients, especially when the mediastinum is involved. Conformal radiotherapy techniques such as Intensity-Modulated Radiation Therapy (IMRT) could allow a reduction of the dose to the organs-at-risk (OARs) and therefore limit long-term toxicity. METHODS We performed a systematic review of the current literature regarding comparisons between IMRT and conventional photon beam radiotherapy, or between different IMRT techniques, for the treatment of mediastinal lymphoma. RESULTS AND CONCLUSIONS IMRT allows a substantial reduction of the volumes of OARs exposed to high doses, reducing the risk of long-term toxicity. This benefit is conterbalanced by the increase of volumes receiving low doses, that could potentially increase the risk of SMNs. Treatment planning should be personalized on patient and disease characteristics. Dedicated techniques such as "butterfly" VMAT often provide the best trade-off.
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Affiliation(s)
- Michela Buglione
- Università degli Studi di Brescia, Department of Radiation Oncology, Brescia University, P.le Spedali Civili 1, 25123 Brescia, Italy.
| | - Andrea Emanuele Guerini
- Università degli Studi di Brescia, Department of Radiation Oncology, Brescia University, P.le Spedali Civili 1, 25123 Brescia, Italy.
| | - Andrea Riccardo Filippi
- Radiation Oncology, Fondazione IRCCS Policlinico San Matteo and University of Pavia, Pavia, Italy.
| | - Luigi Spiazzi
- Department of Radiation Oncology, ASST Spedali Civili di Brescia, P.le Spedali Civili 1, 25123 Brescia, Italy.
| | - Nadia Pasinetti
- Università degli Studi di Brescia, Department of Radiation Oncology, Brescia University, P.le Spedali Civili 1, 25123 Brescia, Italy; Radiation Oncology Service, ASST Valcamonica Esine, Italy.
| | - Alessandro Magli
- Department of Radiation Oncology, Udine General Hospital, Udine, Italy.
| | - Cristian Toraci
- Department of Radiation Oncology, ASST Spedali Civili di Brescia, P.le Spedali Civili 1, 25123 Brescia, Italy.
| | - Paolo Borghetti
- Department of Radiation Oncology, ASST Spedali Civili di Brescia, P.le Spedali Civili 1, 25123 Brescia, Italy.
| | - Luca Triggiani
- Università degli Studi di Brescia, Department of Radiation Oncology, Brescia University, P.le Spedali Civili 1, 25123 Brescia, Italy.
| | - Alessandro Alghisi
- Department of Radiation Oncology, Alessandro Manzoni Hospital, Lecco, Italy.
| | | | - Francesco Bertagna
- Nuclear Medicine Department, University of Brescia and Spedali Civili of Brescia, Brescia, Italy.
| | - Niccolò Giaj Levra
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Italy.
| | - Ludovica Pegurri
- Department of Radiation Oncology, ASST Spedali Civili di Brescia, P.le Spedali Civili 1, 25123 Brescia, Italy.
| | - Stefano Maria Magrini
- Università degli Studi di Brescia, Department of Radiation Oncology, Brescia University, P.le Spedali Civili 1, 25123 Brescia, Italy.
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17
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Advanced Radiotherapy Techniques for Mediastinal Lymphomas: Results from an Italian Survey. HEMATO 2021. [DOI: 10.3390/hemato2030031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background: Multiple methods have been implemented to limit the impact of radiotherapy on patients affected by mediastinal lymphoma, including breathing control techniques, image-guided radiotherapy (IGRT) and intensity-modulated radiotherapy (IMRT), although the actual diffusion of such techniques is unclear. No surveys have been published to date evaluating the techniques adopted at different centers. Methods: A survey with a dedicated questionnaire was submitted to 195 Italian radiotherapy centers, assessing items regarding the characteristics of the center and clinical practice in the treatment of mediastinal lymphomas. Results: A total of 43 centers (22%) responded, the majority of which were university hospitals (37.2%) or cancer care centers (27.9%). In 95.4% of the centers, IMRT was used in the clinical practice, and the most frequently employed techniques were VMAT (48.8% of centers) and non-rotational IMRT (31.7%). Comparison of multiple plans was performed by 66.7% of the responding centers. Dose constraints for organs at risk were consistently prescribed. IGRT techniques were adopted by 93% of the centers, while breathing control or gating techniques were routinely used by only 25.6% of the centers. A necessity to standardize OAR constraints and define guidelines was perceived by almost all participants. Conclusions: Modern radiotherapy techniques are widely used in the Italian centers, although with heterogeneous characteristics.
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18
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Houlihan OA, Rangaswamy G, Dunne M, Rohan C, O'Neill L, Chalke S, Daly P, Gillham C, McArdle O. Deep inspiration breath hold versus free breathing technique in mediastinal radiotherapy for lymphoma. BJR Open 2021; 3:20200067. [PMID: 33718767 PMCID: PMC7931409 DOI: 10.1259/bjro.20200067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/26/2021] [Accepted: 01/26/2021] [Indexed: 12/12/2022] Open
Abstract
Objective: Radiotherapy plays an important role in the management of lymphoma and many patients with lymphoma are cured with treatment. Risk of secondary malignancy and long-term cardiac and pulmonary toxicity from mediastinal radiotherapy exists. Delivery of radiotherapy using a deep inspiration breath-hold (DIBH) technique increases lung volume and has the potential to reduce dose to heart and lungs. We undertook a prospective study to assess the dosimetric differences in DIBH and free breathing (FB) plans in patients requiring mediastinal radiotherapy in clinical practice. Methods: We performed both FB and DIBH planning scans on 35 consecutive patients with mediastinal lymphoma needing radiotherapy. Contours and plans were generated for both data sets and dosimetric data were compared. All patients were planned using volumetric modulated arc therapy (VMAT). Data were compared for FB and DIBH plans with each patient acting as their own control using the related-samples Wilcoxon signed rank test. Results: DIBH significantly reduced lung doses (mean 10.6 vs 11.4Gy, p < 0.0005; V20 16.8 vs 18.3%, p = 0.001) and spinal cord maximum dose (20.6 vs 22.8Gy, p = 0.001). DIBH increased breast V4 (38.5% vs 31.8%, p = 0.006) and mean right breast dose (4.2 vs 3.6Gy, p = 0.010). There was no significant difference in heart doses when the entire study cohort was considered, however, mean heart dose tended to be lower with DIBH for upper mediastinal (UM) tumours (4.3 vs 4.9Gy, p = 0.05). Conclusion: Our study describes the potential benefit of DIBH in a population reflective of clinical practice. DIBH can decrease radiation dose to lungs, heart and spinal cord, however, may increase dose to breasts. DIBH is not always superior to FB, and the clinical significance of differences in dose to organs at risk in addition to the time required to treat patients with DIBH must be considered when deciding the most appropriate radiotherapy technique for each patient. Advances in knowledge: To our knowledge, this is the largest study comparing DIBH and FB planning for patients with lymphoma receiving mediastinal radiotherapy in clinical practice. It demonstrates the impact of an increasingly common radiotherapy technique on dose to organs at risk and the subsequent potential for long-term radiotherapy side-effects.
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Affiliation(s)
| | | | - Mary Dunne
- St. Luke's Radiation Oncology Network, Dublin, Ireland
| | | | | | | | - Patricia Daly
- St. Luke's Radiation Oncology Network, Dublin, Ireland
| | | | - Orla McArdle
- St. Luke's Radiation Oncology Network, Dublin, Ireland
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19
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Pinnix CC, Gunther JR, Fang P, Bankston ME, Milgrom SA, Boyce D, Lee HJ, Nair R, Steiner R, Strati P, Ahmed S, Iyer SP, Westin J, Parmar S, Rodriguez MA, Nastoupil L, Neelapu S, Flowers C, Dabaja BS. Assessment of Radiation Doses Delivered to Organs at Risk Among Patients With Early-Stage Favorable Hodgkin Lymphoma Treated With Contemporary Radiation Therapy. JAMA Netw Open 2020; 3:e2013935. [PMID: 32990738 PMCID: PMC7525355 DOI: 10.1001/jamanetworkopen.2020.13935] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE Response-adapted randomized trials have used positron emission tomography-computed tomography to attempt to identify patients with early-stage favorable Hodgkin lymphoma (ESFHL) who could be treated with doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) without radiation therapy (RT). While maximal efficacy is demonstrated with combined modality therapy, RT is often omitted in fear of late adverse effects; however, the application of modern RT could limit these toxic effects. OBJECTIVE To determine the radiation doses delivered to organs at risk with modern involved-site RT among patients with ESFHL treated with 20 Gy after 2 cycles of ABVD. DESIGN, SETTING, AND PARTICIPANTS This case series included 42 adult patients with ESFHL (according to the German Hodgkin Study Group criteria) who were treated between 2010 and 2019, achieved complete response by positron emission tomography-computed tomography (1-3 on 5-point scale) following 2 cycles of ABVD, and then received consolidative RT. The study was conducted at a single comprehensive cancer center. EXPOSURES 2 cycles of chemotherapy followed by 20-Gy involved-site RT. MAIN OUTCOMES AND MEASURES The medical records of patients with ESFHL were examined. Organs at risk were contoured, and doses were calculated. Progression-free survival, defined from date of diagnosis to disease progression, relapse, or death, and overall survival were estimated using the Kaplan-Meier method. RESULTS The cohort comprised 42 patients with ESFHL (median [range] age at diagnosis, 35 [18-74] years; 18 [43%] women; 24 [57%] with stage II disease). At a median follow-up of 44.6 (95% CI, 27.6-61.6) months, the 3-year progression-free survival and overall survival rates were 91.2% (95% CI, 74.9%-97.1%) and 97.0% (95% CI, 80.4%-99.6%), respectively. The mean heart dose was less than 5 Gy (mean, 0.8 Gy; SD, 1.5 Gy; range, 0-4.8 Gy) in all patients. The mean (SD) breast dose for both breasts was 0.1 (0.2) Gy (left breast range, 0-1.0 Gy; right breast range, 0-0.9 Gy). CONCLUSIONS AND RELEVANCE In this study, combined modality therapy with 2 cycles of ABVD and 20 Gy for ESFHL was highly effective and avoided excess doses to organs at risk, which may limit long-term toxic effects.
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Affiliation(s)
- Chelsea C. Pinnix
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Jillian R. Gunther
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Penny Fang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Mikaela E Bankston
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Sarah A. Milgrom
- Department of Radiation Oncology, University of Colorado, Denver
| | - David Boyce
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Hun Ju Lee
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston
| | - Ranjit Nair
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston
| | - Raphael Steiner
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston
| | - Paolo Strati
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston
| | - Sairah Ahmed
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston
| | - Swaminathan P. Iyer
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston
| | - Jason Westin
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston
| | - Simrit Parmar
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston
| | - M. Alma Rodriguez
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston
| | - Loretta Nastoupil
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston
| | - Sattva Neelapu
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston
| | - Christopher Flowers
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston
| | - Bouthaina S. Dabaja
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
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20
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De Luca V, Gallio E, Bartoncini S, Giglioli FR, Sardo A, Cavallin C, Iorio GC, Orlandi E, Parise R, Palladino C, Buonavita A, Fiandra C, Levis M, Ricardi U. Adoption of Expansion Margins to Reduce the Dose Received by the Coronary Arteries and the Risk of Cardiovascular Events in Lymphoma Patients. Pract Radiat Oncol 2020; 11:66-73. [PMID: 32565414 DOI: 10.1016/j.prro.2020.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 04/28/2020] [Accepted: 06/04/2020] [Indexed: 02/09/2023]
Abstract
PURPOSE Mediastinal radiation therapy (RT) in patients with lymphoma implies involuntary coronary artery (CA) exposure, resulting in an increased risk of coronary artery disease (CAD). Accurate delineation of CAs may spare them from higher RT doses. However, heart motion affects the estimation of the dose received by CAs. An expansion margin (planning organ at risk volume [PRV]), encompassing the nearby area where CAs displace, may compensate for these uncertainties, reducing CA dose and CAD risk. Our study aimed to evaluate if a planning process optimized on CA-specific PRVs, rather than just on CAs, could provide any dosimetric or clinical benefit. METHODS AND MATERIALS Forty patients receiving RT for mediastinal lymphomas were included. We contoured left main trunk, left anterior descending, left circumflex, and right coronary arteries. An isotropic PRV was then applied to all CAs, in accordance with literature data. A comparison was then performed by optimizing treatment plans either on CAs or on PRVs, to detect any difference in CA sparing in terms of maximum (Dmax), median (Dmed), and mean (Dmean) dose. We then investigated, through risk modeling, if any dosimetric benefit obtained with the PRV-related optimization process could translate to a lower risk of ischemic complications. RESULTS Plan optimization on PRVs demonstrated a significant dose reduction (range, 7%-9%) in Dmax, Dmed, and Dmean for the whole coronary tree, and even higher dose reductions when vessels were located 5- to 20-mm from PTV (range, 13%-15%), especially for left main trunk and left circumflex (range, 16%-21%). This translated to a mean risk reduction of developing CAD of 12% (P < .01), which increased to 17% when CAs were located 5- to 20-mm from PTV. CONCLUSIONS Integration of CA-related PRVs in the optimization process reduces the dose received by CAs and translates to a meaningful prevention of CAD risk in patients with lymphoma treated with mediastinal RT.
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Affiliation(s)
- Viola De Luca
- Department of Oncology, University of Torino, Torino, Italy
| | - Elena Gallio
- Medical Physics Unit, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Torino, Italy
| | | | - Francesca Romana Giglioli
- Medical Physics Unit, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Torino, Italy
| | - Anna Sardo
- Medical Physics Unit, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Torino, Italy
| | | | | | - Erika Orlandi
- Department of Oncology, University of Torino, Torino, Italy
| | - Ramona Parise
- Department of Oncology, University of Torino, Torino, Italy
| | | | | | | | - Mario Levis
- Department of Oncology, University of Torino, Torino, Italy.
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21
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Abstract
Radiation therapy plays a critical role in the management of a wide range of hematologic malignancies. The optimal radiation dose and target volume, and safe and effective ways of integrating radiation with systemic agents, vary depending on the histologic subtypes, stage at presentation, patient performance status, response to systemic therapy if given, treatment intent, and patient preferences. Limiting doses to surrounding organs without sacrificing disease control is of paramount importance. Reducing radiation doses and treatment volume in selected cases, and the use of advanced radiotherapy technology, can improve the therapeutic ratio of patients receiving radiation therapy for hematologic malignancies.
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Affiliation(s)
- Yolanda D Tseng
- Department of Radiation Oncology, Seattle Cancer Care Alliance Proton Therapy Center, University of Washington School of Medicine, 1570 North 115th Street, Seattle, WA 98133, USA
| | - Andrea K Ng
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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22
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The Optimal Use of Imaging in Radiation Therapy for Lymphoma: Guidelines from the International Lymphoma Radiation Oncology Group (ILROG). Int J Radiat Oncol Biol Phys 2019; 104:501-512. [DOI: 10.1016/j.ijrobp.2019.02.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 01/28/2019] [Accepted: 02/03/2019] [Indexed: 12/21/2022]
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