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Bates JE, Rancati T, Keshavarz H, Gagliardi G, Aznar MC, Howell RM, Shrestha S, Moiseenko V, Yorke E, Armenian S, Kremer L, Chen MH, van der Pal HJ, Cutter DJ, Constine LS, Hodgson D. Cardiac Disease in Childhood Cancer Survivors Treated With Radiation Therapy: A PENTEC Comprehensive Review. Int J Radiat Oncol Biol Phys 2024; 119:522-532. [PMID: 37061912 DOI: 10.1016/j.ijrobp.2023.03.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 02/10/2023] [Accepted: 03/10/2023] [Indexed: 04/17/2023]
Abstract
PURPOSE Radiation therapy (RT) is an essential component in the treatment of many pediatric malignancies. Thoracic RT may expose the heart to radiation dose and thereby increase the risk of late cardiac disease. This comprehensive review from the Pediatric Normal Tissue Effects in the Clinic (PENTEC) initiative focused on late cardiac disease in survivors of childhood cancer treated with RT. METHODS AND MATERIALS This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. We identified 1496 articles; 4 were included for dose-response modeling between mean cardiac radiation dose and risk of late coronary artery disease, heart failure (HF), valvular disease, and any cardiac disease. RESULTS For each 10-Gy increase in corrected mean cardiac radiation dose in 1.8- to 2.0-Gy fractions, we estimated a hazard ratio of 2.01 (95% confidence interval [CI], 1.79-2.25) for coronary artery disease, of 1.87 (95% CI, 1.70-2.06) for HF, of 1.87 (95% CI, 1.78-1.96) for valvular disease, and of 1.88 (95% CI, 1.75-2.03) for any cardiac disease. From the same model, for each 100-mg/m2 increase in cumulative anthracycline dose, the hazard ratio for the development of HF was 1.93 (95% CI, 1.58-2.36), equivalent to an increase in mean heart dose of approximately 10.5 Gy. Other nontreatment factors were inconsistently reported in the analyzed articles. CONCLUSIONS Radiation dose to the heart increases the risk of late cardiac disease, but survivors of childhood cancer who receive a mean dose <10 Gy at standard fractionation are at low absolute risk (<∼2% approximately 30 years after exposure) of late cardiac disease in the absence of anthracycline exposure. Minimizing cardiac radiation dose is especially relevant in children receiving anthracyclines. When cardiac sparing is not possible, we recommend prioritizing target coverage. It is likely that individual cardiac substructure doses will be a better predictor of specific cardiac diseases than mean dose, and we urge the pediatric oncology community to further study these relationships.
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Affiliation(s)
- James E Bates
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia.
| | - Tiziana Rancati
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Giovanna Gagliardi
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Marianne C Aznar
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Rebecca M Howell
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas; Graduate School of Biomedical Sciences, MD Anderson UT Health, Houston, Texas
| | - Suman Shrestha
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas; Graduate School of Biomedical Sciences, MD Anderson UT Health, Houston, Texas
| | - Vitali Moiseenko
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Saro Armenian
- Department of Pediatrics, City of Hope, Duarte, California
| | - Leontien Kremer
- Princess Maxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Ming Hui Chen
- Departments of Cardiology and Pediatrics, Boston Children's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | | | - David J Cutter
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Louis S Constine
- Departments of Radiation Oncology and Pediatrics, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - David Hodgson
- Department of Radiation Oncology, Princess Margaret Hospital, Toronto, Ontario, Canada
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Olch AJ, van Luijk P, Hua CH, Avanzo M, Howell RM, Yorke E, Aznar MC, Kry SF. Physics Considerations for Evaluation of Dose for Dose-Response Models of Pediatric Late Effects From Radiation Therapy: A PENTEC Introductory Review. Int J Radiat Oncol Biol Phys 2024; 119:360-368. [PMID: 37003845 DOI: 10.1016/j.ijrobp.2023.02.060] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 02/17/2023] [Accepted: 02/25/2023] [Indexed: 04/01/2023]
Abstract
PURPOSE We describe the methods used to estimate the accuracy of dosimetric data found in literature sources used to construct the Pediatric Normal Tissue Effects in the Clinic (PENTEC) dose-response models, summarize these findings of each organ-specific task force, describe some of the dosimetric challenges and the extent to which these efforts affected the final modeling results, and provide guidance on the interpretation of the dose-response results given the various dosimetric uncertainties. METHODS AND MATERIALS Each of the PENTEC task force medical physicists reviewed all the journal articles used for dose-response modeling to identify, categorize, and quantify dosimetric uncertainties. These uncertainties fell into 6 broad categories. A uniform nomenclature was developed for describing the "dosimetric quality" of the articles used in the PENTEC reviews. Among the multidisciplinary experts in the PENTEC effort, the medical physicists were charged with the dosimetric evaluation, as they are most expert in this subject. RESULTS The percentage dosimetric uncertainty was estimated for each late effect endpoint for all PENTEC organ reports. Twelve specific sources of dose uncertainty were identified related to the 6 broad categories. The most common reason for organ dose uncertainty was that prescribed dose rather than organ dose was reported. Percentage dose uncertainties ranged from 5% to 200%. Systematic uncertainties were used to correct the dose component of the models. Random uncertainties were also described in each report and in some cases used to modify dose axis error bars. In addition, the potential effects of dose binning were described. CONCLUSIONS PENTEC reports are designed to provide guidance to radiation oncologists and treatment planners for organ dose constraints. It is critical that these dose constraint recommendations are as accurate as possible, acknowledging the large error bars for many. Achieving this accuracy is important as it enables clinicians to better balance target dose coverage with risk of late effects. Evidence-based dose constraints for pediatric patients have been lacking and, in this regard, PENTEC fills an important unmet need. One must be aware of the limitations of our recommendations, and that for some organ systems, large uncertainties exist in the dose-response model because of clinical endpoint uncertainty, dosimetric uncertainty, or both.
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Affiliation(s)
- Arthur J Olch
- Department of Radiation Oncology, University of Southern California and Children's Hospital Los Angeles, Los Angeles, California.
| | - Peter van Luijk
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Chia-Ho Hua
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Michele Avanzo
- Department of Medical Physics, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Rebecca M Howell
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marianne C Aznar
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Stephen F Kry
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
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Lo AC, Liu A, Liu Q, Yasui Y, Castellino SM, Kelly KM, Hererra AF, Friedberg JW, Friedman DL, Schwartz CL, Pei Q, Kessel S, Bergeron-Gravel S, Dama H, Roberts K, Constine LS, Hodgson DC. Late Cardiac Toxic Effects Associated With Treatment Protocols for Hodgkin Lymphoma in Children. JAMA Netw Open 2024; 7:e2351062. [PMID: 38241048 PMCID: PMC10799264 DOI: 10.1001/jamanetworkopen.2023.51062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 11/20/2023] [Indexed: 01/22/2024] Open
Abstract
Importance Contemporary North American trials for children with Hodgkin lymphoma (HL) have decreased radiation therapy (RT) use and increased pharmacologic cardioprotection but also increased the cumulative doxorubicin dose, making overall treatment consequences for late cardiac toxic effects uncertain. Objective To estimate the risk of cardiac toxic effects associated with treatments used in modern pediatric HL clinical trials. Design, Setting, and Participants For this cohort study, Fine and Gray models were fitted using survivors in the Childhood Cancer Survivor Study who were diagnosed with HL between January 1, 1970, and December 31, 1999, and were followed for a median of 23.5 (range, 5.0-46.3) years. These models were applied to the exposures in the study population to estimate the 30-year cumulative incidence of cardiac disease. The study population comprised patients with intermediate-risk or high-risk HL treated in 4 consecutive Children's Oncology Group clinical trials from September 2002 to October 2022: AHOD0031, AHOD0831, AHOD1331, and S1826. Data analysis was performed from April 2020 to February 2023. Exposures All patients received chemotherapy including doxorubicin, and some patients received mediastinal RT, dexrazoxane, or mediastinal RT and dexrazoxane. Main Outcomes and Measures Estimated 30-year cumulative incidence of grade 3 to 5 cardiac disease. Results The study cohort comprised 2563 patients, with a median age at diagnosis of 15 (range, 1-22) years. More than half of the patients were male (1357 [52.9%]). All 2563 patients received doxorubicin, 1362 patients (53.1%) received mediastinal RT, and 307 patients (12.0%) received dexrazoxane. Radiation therapy use and the median mean heart dose among patients receiving RT decreased, whereas the planned cumulative dose of doxorubicin and use of dexrazoxane cardioprotection increased. For patients treated at age 15 years, the estimated 30-year cumulative incidence of severe or fatal cardiac disease was 9.6% (95% CI, 4.2%-16.4%) in the AHOD0031 standard treatment group (enrolled 2002-2009), 8.6% (95% CI, 3.8%-14.9%) in the AHOD0831 trial (enrolled 2009-2012), 8.2% (95% CI, 3.6%-14.3%) in the AHOD1331 trial (enrolled 2015-2019), and 6.2% (95% CI, 2.7%-10.9%) in the S1826 trial (enrolled 2019-2022), whereas the expected rate in an untreated population was 5.0% (95% CI, 2.1%-9.3%). Despite the estimated reduction in late cardiac morbidity, the frequency of recommended echocardiographic screening among survivors will increase based on current guidelines. Conclusions and Relevance In this cohort study of sequential HL trials, reductions in the proportion of children receiving mediastinal RT and increases in dexrazoxane use were estimated to offset the increased doxorubicin dose and produce a net reduction in late cardiac disease. Further studies on dexrazoxane are warranted to confirm whether its role in reducing cardiac toxic effects is maintained long term. These findings suggest that survivorship follow-up guidelines should be refined to align with the risks associated with treatment.
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Affiliation(s)
- Andrea C Lo
- Department of Radiation Oncology, BC Cancer, University of British Columbia, Vancouver, British Columbia, Canada
| | - Amy Liu
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Qi Liu
- Department of Public Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Yutaka Yasui
- Epidemiology and Cancer Control Department, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Sharon M Castellino
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Kara M Kelly
- Department of Pediatric Oncology, Roswell Park Cancer Institute and Oishei Children's Hospital, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York
| | - Alex F Hererra
- Department of Hematology, City of Hope, Duarte, California
| | | | - Debra L Friedman
- Division of Pediatric Hematology/Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cindy L Schwartz
- Department of Pediatrics, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee
| | - Qinglin Pei
- Children's Oncology Group, Statistics and Data Center, Department of Biostatistics, University of Florida, Gainesville
| | - Sandy Kessel
- Imaging and Radiation Oncology Core, Lincoln, Rhode Island
| | | | - Hitesh Dama
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Kenneth Roberts
- Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Louis S Constine
- Department of Radiation Oncology, Wilmot Cancer Institute, University of Rochester, Rochester, New York
| | - David C Hodgson
- Department of Radiation Oncology, Princess Margaret Cancer Centre-University Health Network, Toronto, Ontario, Canada
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Bates JE, Shrestha S, Liu Q, Smith SA, Mulrooney DA, Leisenring W, Gibson T, Robison LL, Chow EJ, Oeffinger KC, Armstrong GT, Constine LS, Hoppe BS, Lee C, Yasui Y, Howell RM. Cardiac Substructure Radiation Dose and Risk of Late Cardiac Disease in Survivors of Childhood Cancer: A Report From the Childhood Cancer Survivor Study. J Clin Oncol 2023; 41:3826-3838. [PMID: 37307512 PMCID: PMC10419575 DOI: 10.1200/jco.22.02320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 04/11/2023] [Accepted: 04/18/2023] [Indexed: 06/14/2023] Open
Abstract
PURPOSE Radiation-associated cardiac disease is a major cause of morbidity/mortality among childhood cancer survivors. Radiation dose-response relationships for cardiac substructures and cardiac diseases remain unestablished. METHODS Using the 25,481 5-year survivors of childhood cancer treated from 1970 to 1999 in the Childhood Cancer Survivor Study, we evaluated coronary artery disease (CAD), heart failure (HF), valvular disease (VD), and arrhythmia. We reconstructed radiation doses for each survivor to the coronary arteries, chambers, valves, and whole heart. Excess relative rate (ERR) models and piecewise exponential models evaluated dose-response relationships. RESULTS The cumulative incidence 35 years from diagnosis was 3.9% (95% CI, 3.4 to 4.3) for CAD, 3.8% (95% CI, 3.4 to 4.2) for HF, 1.2% (95% CI, 1.0 to 1.5) for VD, and 1.4% (95% CI, 1.1 to 1.6) for arrhythmia. A total of 12,288 survivors (48.2%) were exposed to radiotherapy. Quadratic ERR models improved fit compared with linear ERR models for the dose-response relationship between mean whole heart and CAD, HF, and arrhythmia, suggesting a potential threshold dose; however, such departure from linearity was not observed for most cardiac substructure end point dose-response relationships. Mean doses of 5-9.9 Gy to the whole heart did not increase the risk of any cardiac diseases. Mean doses of 5-9.9 Gy to the right coronary artery (rate ratio [RR], 2.6 [95% CI, 1.6 to 4.1]) and left ventricle (RR, 2.2 [95% CI, 1.3 to 3.7]) increased risk of CAD, and to the tricuspid valve (RR, 5.5 [95% CI, 2.0 to 15.1]) and right ventricle (RR, 8.4 [95% CI, 3.7 to 19.0]) increased risk of VD. CONCLUSION Among children with cancer, there may be no threshold dose below which radiation to the cardiac substructures does not increase the risk of cardiac diseases. This emphasizes their importance in modern treatment planning.
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Affiliation(s)
- James E. Bates
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Suman Shrestha
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Qi Liu
- Department of Public Health Sciences, University of Alberta, Edmonton, AB
| | - Susan A. Smith
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Daniel A. Mulrooney
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Wendy Leisenring
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Todd Gibson
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD
| | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Eric J. Chow
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Louis S. Constine
- Department of Radiation Oncology, Wilmot Cancer Institute, University of Rochester, Rochester, NY
- Department of Pediatrics, University of Rochester, Rochester, NY
| | - Bradford S. Hoppe
- Department of Radiation Oncology, Mayo Clinic-Jacksonville, Jacksonville, FL
| | - Choonsik Lee
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Rebecca M. Howell
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
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Owens CA, Rigaud B, Ludmir EB, Gupta AC, Shrestha S, Paulino AC, Smith SA, Peterson CB, Kry SF, Lee C, Henderson TO, Armstrong GT, Brock KK, Howell RM. Development and validation of a population-based anatomical colorectal model for radiation dosimetry in late effects studies of survivors of childhood cancer. Radiother Oncol 2022; 176:118-126. [PMID: 36063983 PMCID: PMC9845018 DOI: 10.1016/j.radonc.2022.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 08/10/2022] [Accepted: 08/24/2022] [Indexed: 01/19/2023]
Abstract
PURPOSE The purposes of this study were to develop and integrate a colorectal model that incorporates anatomical variations of pediatric patients into the age-scalable MD Anderson Late Effects (MDA-LE) computational phantom, and validate the model for pediatric radiation therapy (RT) dose reconstructions. METHODS Colorectal contours were manually derived from whole-body non-contrast computed tomography (CT) scans of 114 pediatric patients (age range: 2.1-21.6 years, 74 males, 40 females). One contour was used for an anatomical template, 103 for training and 10 for testing. Training contours were used to create a colorectal principal component analysis (PCA)-based statistical shape model (SSM) to extract the population's dominant deformations. The SSM was integrated into the MDA-LE phantom. Geometric accuracy was assessed between patient-specific and SSM contours using several overlap metrics. Two alternative colorectal shapes were generated using the first 17 dominant modes of the PCA-based SSM. Dosimetric accuracy was assessed by comparing colorectal doses from test patients' CT-based RT plans (ground truth) with reconstructed doses for the mean and two alternative models in age-matched MDA-LE phantoms. RESULTS When using all 103 PCA modes, the mean (min-max) Dice similarity coefficient, distance-to-agreement and Hausdorff distance between the patient-specific and reconstructed contours for the test patients were 0.89 (0.85-0.91), 2.1 mm (1.7-3.0), and 8.6 mm (5.7-14.3), respectively. The average percent difference between reconstructed and ground truth mean and maximum colorectal doses for the mean (alternative 1, 2) model were 6.3% (8.1%, 6.1%) and 4.4% (4.3%, 4.7%), respectively. CONCLUSIONS We developed, validated and integrated a colorectal PCA-based SSM into the MDA-LE phantom and demonstrated its dosimetric performance for accurate pediatric RT dose reconstruction.
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Affiliation(s)
- Constance A Owens
- The University of Texas MD Anderson Cancer Center, Department of Radiation Physics, Houston, TX, USA; MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Graduate Program in Medical Physics, Houston, TX, USA.
| | - Bastien Rigaud
- The University of Texas MD Anderson Cancer Center, Department of Imaging Physics, Houston, TX, USA
| | - Ethan B Ludmir
- The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, TX, USA; The University of Texas MD Anderson Cancer Center, Department of Biostatistics, Houston, TX, USA
| | - Aashish C Gupta
- The University of Texas MD Anderson Cancer Center, Department of Radiation Physics, Houston, TX, USA; MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Graduate Program in Medical Physics, Houston, TX, USA
| | - Suman Shrestha
- The University of Texas MD Anderson Cancer Center, Department of Radiation Physics, Houston, TX, USA; MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Graduate Program in Medical Physics, Houston, TX, USA
| | - Arnold C Paulino
- The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, TX, USA
| | - Susan A Smith
- The University of Texas MD Anderson Cancer Center, Department of Radiation Physics, Houston, TX, USA
| | - Christine B Peterson
- The University of Texas MD Anderson Cancer Center, Department of Biostatistics, Houston, TX, USA
| | - Stephen F Kry
- The University of Texas MD Anderson Cancer Center, Department of Radiation Physics, Houston, TX, USA; MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Graduate Program in Medical Physics, Houston, TX, USA
| | - Choonsik Lee
- National Cancer Institute, Division of Cancer Epidemiology and Genetics, Bethesda, MD, USA
| | - Tara O Henderson
- The University of Chicago, Department of Pediatrics, Chicago, IL, USA
| | - Gregory T Armstrong
- St. Jude Children's Research Hospital, Department of Epidemiology and Cancer Control, Memphis, TN, USA
| | - Kristy K Brock
- The University of Texas MD Anderson Cancer Center, Department of Radiation Physics, Houston, TX, USA; The University of Texas MD Anderson Cancer Center, Department of Imaging Physics, Houston, TX, USA
| | - Rebecca M Howell
- The University of Texas MD Anderson Cancer Center, Department of Radiation Physics, Houston, TX, USA; MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Graduate Program in Medical Physics, Houston, TX, USA.
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Gupta AC, Owens CA, Shrestha S, Lee C, Smith SA, Weathers RE, Netherton T, Balter PA, Kry SF, Followill DS, Griffin KT, Long JP, Armstrong GT, Howell RM. Body region-specific 3D age-scaling functions for scaling whole-body computed tomography anatomy for pediatric late effects studies. Biomed Phys Eng Express 2022; 8:10.1088/2057-1976/ac3f4e. [PMID: 34874300 PMCID: PMC9547666 DOI: 10.1088/2057-1976/ac3f4e] [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: 07/01/2021] [Accepted: 12/02/2021] [Indexed: 02/03/2023]
Abstract
Purpose.Radiation epidemiology studies of childhood cancer survivors treated in the pre-computed tomography (CT) era reconstruct the patients' treatment fields on computational phantoms. For such studies, the phantoms are commonly scaled to age at the time of radiotherapy treatment because age is the generally available anthropometric parameter. Several reference size phantoms are used in such studies, but reference size phantoms are only available at discrete ages (e.g.: newborn, 1, 5, 10, 15, and Adult). When such phantoms are used for RT dose reconstructions, the nearest discrete-aged phantom is selected to represent a survivor of a specific age. In this work, we (1) conducted a feasibility study to scale reference size phantoms at discrete ages to various other ages, and (2) evaluated the dosimetric impact of using exact age-scaled phantoms as opposed to nearest age-matched phantoms at discrete ages.Methods.We have adopted the University of Florida/National Cancer Institute (UF/NCI) computational phantom library for our studies. For the feasibility study, eight male and female reference size UF/NCI phantoms (5, 10, 15, and 35 years) were downscaled to fourteen different ages which included next nearest available lower discrete ages (1, 5, 10 and 15 years) and the median ages at the time of RT for Wilms' tumor (3.9 years), craniospinal (8.0 years), and all survivors (9.1 years old) in the Childhood Cancer Survivor Study (CCSS) expansion cohort treated with RT. The downscaling was performed using our in-house age scaling functions (ASFs). To geometrically validate the scaling, Dice similarity coefficient (DSC), mean distance to agreement (MDA), and Euclidean distance (ED) were calculated between the scaled and ground-truth discrete-aged phantom (unscaled UF/NCI) for whole-body, brain, heart, liver, pancreas, and kidneys. Additionally, heights of the scaled phantoms were compared with ground-truth phantoms' height, and the Centers for Disease Control and Prevention (CDC) reported 50th percentile height. Scaled organ masses were compared with ground-truth organ masses. For the dosimetric assessment, one reference size phantom and seventeen body-size dependent 5-year-old phantoms (9 male and 8 female) of varying body mass indices (BMI) were downscaled to 3.9-year-old dimensions for two different radiation dose studies. For the first study, we simulated a 6 MV photon right-sided flank field RT plan on a reference size 5-year-old and 3.9-year-old (both of healthy BMI), keeping the field size the same in both cases. Percent of volume receiving dose ≥15 Gy (V15) and the mean dose were calculated for the pancreas, liver, and stomach. For the second study, the same treatment plan, but with patient anatomy-dependent field sizes, was simulated on seventeen body-size dependent 5- and 3.9-year-old phantoms with varying BMIs. V15, mean dose, and minimum dose received by 1% of the volume (D1), and by 95% of the volume (D95) were calculated for pancreas, liver, stomach, left kidney (contralateral), right kidney, right and left colons, gallbladder, thoracic vertebrae, and lumbar vertebrae. A non-parametric Wilcoxon rank-sum test was performed to determine if the dose to organs of exact age-scaled and nearest age-matched phantoms were significantly different (p < 0.05).Results.In the feasibility study, the best DSCs were obtained for the brain (median: 0.86) and whole-body (median: 0.91) while kidneys (median: 0.58) and pancreas (median: 0.32) showed poorer agreement. In the case of MDA and ED, whole-body, brain, and kidneys showed tighter distribution and lower median values as compared to other organs. For height comparison, the overall agreement was within 2.8% (3.9 cm) and 3.0% (3.2 cm) of ground-truth UF/NCI and CDC reported 50th percentile heights, respectively. For mass comparison, the maximum percent and absolute differences between the scaled and ground-truth organ masses were within 31.3% (29.8 g) and 211.8 g (16.4%), respectively (across all ages). In the first dosimetric study, absolute difference up to 6% and 1.3 Gy was found for V15and mean dose, respectively. In the second dosimetric study, V15and mean dose were significantly different (p < 0.05) for all studied organs except the fully in-beam organs. D1and D95were not significantly different for most organs (p > 0.05).Conclusion.We have successfully evaluated our ASFs by scaling UF/NCI computational phantoms from one age to another age, which demonstrates the feasibility of scaling any CT-based anatomy. We have found that dose to organs of exact age-scaled and nearest aged-matched phantoms are significantly different (p < 0.05) which indicates that using the exact age-scaled phantoms for retrospective dosimetric studies is a better approach.
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Affiliation(s)
- Aashish C. Gupta
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX USA,The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX USA
| | - Constance A. Owens
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX USA,The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX USA
| | - Suman Shrestha
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX USA,The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX USA
| | - Choonsik Lee
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD USA
| | - Susan A. Smith
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Rita E. Weathers
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Tucker Netherton
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Peter A. Balter
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX USA,The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX USA
| | - Stephen F. Kry
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX USA,The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX USA
| | - David S. Followill
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX USA,The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX USA
| | - Keith T. Griffin
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD USA,George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, GA USA
| | - James P. Long
- The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX USA,Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN USA
| | - Rebecca M. Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX USA,The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX USA,Address for correspondence: Rebecca M. Howell, Director, Radiation Dosimetry Services, Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, 8060 El Rio St., Unit 605, Houston, TX 77054,
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Shrestha S, Bates JE, Liu Q, Smith SA, Oeffinger KC, Chow EJ, Gupta AC, Owens CA, Constine LS, Hoppe BS, Leisenring WM, Qiao Y, Weathers RE, Court LE, Pinnix CC, Kry SF, Mulrooney DA, Armstrong GT, Yasui Y, Howell RM. Radiation therapy related cardiac disease risk in childhood cancer survivors: Updated dosimetry analysis from the Childhood Cancer Survivor Study. Radiother Oncol 2021; 163:199-208. [PMID: 34454975 PMCID: PMC9036604 DOI: 10.1016/j.radonc.2021.08.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND PURPOSE We previously evaluated late cardiac disease in long-term survivors in the Childhood Cancer Survivor Study (CCSS) based on heart radiation therapy (RT) doses estimated from an age-scaled phantom with a simple atlas-based heart model (HAtlas). We enhanced our phantom with a high-resolution CT-based anatomically realistic and validated age-scalable cardiac model (HHybrid). We aimed to evaluate how this update would impact our prior estimates of RT-related late cardiac disease risk in the CCSS cohort. METHODS We evaluated 24,214 survivors from the CCSS diagnosed from 1970 to 1999. RT fields were reconstructed on an age-scaled phantom with HHybrid and mean heart dose (Dm), percent volume receiving ≥ 20 Gy (V20) and ≥ 5 Gy with V20 = 0 ( [Formula: see text] ) were calculated. We reevaluated cumulative incidences and adjusted relative rates of grade 3-5 Common Terminology Criteria for Adverse Events outcomes for any cardiac disease, coronary artery disease (CAD), and heart failure (HF) in association with Dm, V20, and [Formula: see text] (as categorical variables). Dose-response relationships were evaluated using piecewise-exponential models, adjusting for attained age, sex, cancer diagnosis age, race/ethnicity, time-dependent smoking history, diagnosis year, and chemotherapy exposure and doses. For relative rates, Dm was also considered as a continuous variable. RESULTS Consistent with previous findings with HAtlas, reevaluation using HHybrid dosimetry found that, Dm ≥ 10 Gy, V20 ≥ 0.1%, and [Formula: see text] ≥ 50% were all associated with increased cumulative incidences and relative rates for any cardiac disease, CAD, and HF. While updated risk estimates were consistent with previous estimates overall without statistically significant changes, there were some important and significant (P < 0.05) increases in risk with updated dosimetry for Dm in the category of 20 to 29.9 Gy and V20 in the category of 30% to 79.9%. When changes in the linear dose-response relationship for Dm were assessed, the slopes of the dose response were steeper (P < 0.001) with updated dosimetry. Changes were primarily observed among individuals with chest-directed RT with prescribed doses ≥ 20 Gy. CONCLUSION These findings present a methodological advancement in heart RT dosimetry with improved estimates of RT-related late cardiac disease risk. While results are broadly consistent with our prior study, we report that, with updated cardiac dosimetry, risks of cardiac disease are significantly higher in two dose and volume categories and slopes of the Dm-specific RT-response relationships are steeper. These data support the use of contemporary RT to achieve lower heart doses for pediatric patients, particularly those requiring chest-directed RT.
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Affiliation(s)
- Suman Shrestha
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, United States; The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, United States
| | - James E Bates
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, United States
| | - Qi Liu
- University of Alberta, Canada
| | - Susan A Smith
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, United States
| | - Kevin C Oeffinger
- Department of Medicine, Duke University School of Medicine, United States
| | - Eric J Chow
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Research Center, United States
| | - Aashish C Gupta
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, United States; The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, United States
| | - Constance A Owens
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, United States; The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, United States
| | - Louis S Constine
- Department of Radiation Oncology and Pediatrics, University of Rochester Medical Center, United States
| | - Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic Florida, United States
| | - Wendy M Leisenring
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Research Center, United States
| | - Ying Qiao
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, United States
| | - Rita E Weathers
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, United States
| | - Laurence E Court
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, United States; The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, United States
| | - Chelsea C Pinnix
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, United States
| | - Stephen F Kry
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, United States; The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, United States
| | - Daniel A Mulrooney
- Oncology Department, St. Jude Children's Research Hospital, United States; Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, United States
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, United States
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, United States
| | - Rebecca M Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, United States; The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, United States.
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