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Liu XC, Zhou PK. Tissue Reactions and Mechanism in Cardiovascular Diseases Induced by Radiation. Int J Mol Sci 2022; 23:ijms232314786. [PMID: 36499111 PMCID: PMC9738833 DOI: 10.3390/ijms232314786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 11/16/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022] Open
Abstract
The long-term survival rate of cancer patients has been increasing as a result of advances in treatments and precise medical management. The evidence has accumulated that the incidence and mortality of non-cancer diseases have increased along with the increase in survival time and long-term survival rate of cancer patients after radiotherapy. The risk of cardiovascular disease as a radiation late effect of tissue damage reactions is becoming a critical challenge and attracts great concern. Epidemiological research and clinical trials have clearly shown the close association between the development of cardiovascular disease in long-term cancer survivors and radiation exposure. Experimental biological data also strongly supports the above statement. Cardiovascular diseases can occur decades post-irradiation, and from initiation and development to illness, there is a complicated process, including direct and indirect damage of endothelial cells by radiation, acute vasculitis with neutrophil invasion, endothelial dysfunction, altered permeability, tissue reactions, capillary-like network loss, and activation of coagulator mechanisms, fibrosis, and atherosclerosis. We summarize the most recent literature on the tissue reactions and mechanisms that contribute to the development of radiation-induced cardiovascular diseases (RICVD) and provide biological knowledge for building preventative strategies.
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Yan D, Ning L, Chen Y, Ke S, Huang H, Wang L, Yan S. Analysis of deep inspiration breath-hold technique to improve dosimetric and clinical advantages in postoperative intensity-modulated radiation therapy for thymomas. Quant Imaging Med Surg 2022; 12:4239-4247. [PMID: 35919039 PMCID: PMC9338384 DOI: 10.21037/qims-21-1101] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 04/28/2022] [Indexed: 11/10/2022]
Abstract
Background Radiation therapy is one of the essential treatment modalities for invasive thymomas. Clinically, respiratory motion poses a challenge for the radiotherapy of thoracic tumors. One method to address this issue is to train patients to hold their breath at the end of deep inspiration. The purpose of this retrospective cohort study was to investigate the dosimetric and clinical advantages of the deep inspiration breath-hold (DIBH) technique in postoperative intensity-modulated radiation therapy (IMRT) for thymomas. Methods Thymoma patients undergoing postoperative IMRT were included. Each patient underwent two computed tomography (CT) scans, one under free breath (FB) and the other under DIBH. Dosimetric parameters of organs at risk (OARs) were evaluated in three series plans. Dose analysis and volume comparisons were conducted during FB-3 mm (FB with 3 mm internal target volume margin), FB-10 mm (FB with 10 mm internal target volume margin), and DIBH and compared using a paired sample Student’s t-test. Normal tissue complication probabilities (NTCP) for lungs and heart were calculated and compared. Results The total lung volume significantly increased by 31% (4,216±198 vs. 2,884±166 mL) and the heart volume reduced by 12% (552±25 vs. 636±35 mL) between DIBH acquisitions compared to FB. A significant improvement was observed in all the dosimetric parameters (Dmean, V20, V5) of the lung on DIBH compared to FB-3 mm (54%±2.85% vs. 47%±2.90%, P<0.001; 15%±1.37% vs. 12%±1.32%, P=0.004; and 10.28±0.58 vs. 8.76±0.57 Gy, P<0.001, respectively), as well as in the Dmax and D2% of the esophagus and spine. The lung volume increment was related to a reduction in the mean dose of lungs, with a correlation coefficient of r=0.27, P=0.03. The NTCP values for pneumonitis significantly reduced with DIBH compared to the FB state (0.6% vs. 1.1%, P<0.001). Conclusions The radiation dose to the OARs can be significantly reduced by using the DIBH technique in postoperative IMRT for thymomas. The increased volume of lungs using DIBH acquisitions can significantly reduce the incidence of pneumonitis.
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Affiliation(s)
- Danfang Yan
- Department of Radiation Oncology, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Lihua Ning
- Department of Radiation Oncology, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Ying Chen
- Department of Radiation Oncology, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Shanbao Ke
- Cancer Center, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Huijie Huang
- Department of Radiation Oncology, Yili Friendship Hospital, Xinjiang, China
| | - Lihong Wang
- Department of Radiation Oncology, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Senxiang Yan
- Department of Radiation Oncology, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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Socha J, Rygielska A, Uziębło-Życzkowska B, Chałubińska-Fendler J, Jurek A, Maciorowska M, Mielniczuk M, Pawłowski P, Tyc-Szczepaniak D, Krzesiński P, Kepka L. Contouring cardiac substructures on average intensity projection 4D-CT for lung cancer radiotherapy: a proposal of a heart valve contouring atlas. Radiother Oncol 2022; 167:261-268. [PMID: 34990727 DOI: 10.1016/j.radonc.2021.12.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 12/21/2021] [Accepted: 12/27/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE A detailed contouring atlas of the heart valves is lacking. Existing heart contouring atlases have not been evaluated on average intensity projection four-dimensional non-contrast computed tomography (AVE-4D-CT) scans, routinely used for organ-at-risk delineation in lung cancer radiotherapy. We aimed to develop the heart valve contouring atlas and to assess inter-observer variation in delineation of the heart, its substructures, and coronary arteries on AVE-4D-CT scans, along with its impact on radiotherapy doses. MATERIALS AND METHODS A heart valve contouring atlas was developed. Five radiation oncologists and four cardiologists delineated the valves according to this atlas, and the remaining heart substructures according to the existing atlases, on AVE-4D-CT scans of ten patients who underwent radio(chemo)therapy for NSCLC. The observer contours were then compared to the collectively defined "reference" contours. Spatial variation was assessed using the Sørensen-Dice similarity coefficient (DSC), directed average Hausdorff distance (DAH), directed Hausdorff distance (HD), and the mean distance to agreement (MDA). The effect of spatial variation on radiotherapy doses was assessed using the patients' treatment plans. RESULTS Inter-observer contour overlap (mean DSC) was 0.68, 0.49, 0.45 and 0.45, and inter-observer contour separation (mean DAH) was 2.1, 3.4, 2.6 and 2.9 mm for the pulmonic (PV), aortic (AV), mitral (MV) and tricuspid valve (TV), respectively. Mean HD was higher for TV and MV (13.3 and 11.7mm) than for AV and PV (7.8 and 7mm). The highest mean MDA of 3.1mm was found for AV, and the lowest (1.9mm) for PV. Inter-observer agreement was the lowest for the coronary arteries, but statistically significant dose variation was found mainly in the left ventricular septal and anterior segments. CONCLUSION Our atlas enables reproducible delineation of the heart valves. Delineation of the heart and its substructures on AVE-4D-CT scans is feasible, with inter-observer variability similar to that reported on conventional non-contrast CT scans.
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Affiliation(s)
- Joanna Socha
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland; Department of Radiotherapy, Regional Oncology Centre, Czestochowa, Poland.
| | - Anna Rygielska
- Department of Radiotherapy, Medical Physics Unit, Military Institute of Medicine, Warsaw, Poland
| | | | | | - Agnieszka Jurek
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | - Małgorzata Maciorowska
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | - Marta Mielniczuk
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | - Paweł Pawłowski
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland
| | | | - Paweł Krzesiński
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | - Lucyna Kepka
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland
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Perspectives on the model-based approach to proton therapy trials: A retrospective study of a lung cancer randomized trial. Radiother Oncol 2020; 147:8-14. [PMID: 32224318 DOI: 10.1016/j.radonc.2020.02.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 02/25/2020] [Accepted: 02/27/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE The goal of this study was to assess whether a model-based approach applied retrospectively to a completed randomized controlled trial (RCT) would have significantly altered the selection of patients of the original trial, using the same selection criteria and endpoint for testing the potential clinical benefit of protons compared to photons. METHODS AND MATERIALS A model-based approach, based on three widely used normal tissue complication probability (NTCP) models for radiation pneumonitis (RP), was applied retrospectively to a completed non-small cell lung cancer RCT (NCT00915005). It was assumed that patients were selected by the model-based approach if their expected ΔNTCP value was above a threshold of 5%. The endpoint chosen matched that of the original trial, the first occurrence of severe (grade ≥3) RP. RESULTS Our analysis demonstrates that NTCP differences between proton and photon therapy treatments may be too small to support a model-based trial approach for lung cancer using RP as the normal tissue endpoint. The analyzed lung trial showed that less than 19% (32/165) of patients enrolled in the completed trial would have been enrolled in a model-based trial, prescribing photon therapy to all other patients. The number of patients enrolled was also found to be dependent on the type of NTCP model used for evaluating RP, with the three models enrolling 3%, 13% or 19% of patients. This result does show limitations in NTCP models which would affect the success of a model-based trial approach. No conclusion regarding the development of RP in patients randomized by the model-based approach could statistically be made. CONCLUSIONS Uncertainties in the outcome models to predict NTCP are the inherent drawback of a model-based approach to clinical trials. The impact of these uncertainties on enrollment in model-based trials depends on the predicted difference between the two treatment arms and on the set threshold for patient stratification. Our analysis demonstrates that NTCP differences between proton and photon therapy treatments may be too small to support a model-based trial approach for specific treatment sites, such as lung cancer, depending on the chosen normal tissue endpoint.
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Alexandrian AN, Mavroidis P, Narayanasamy G, McConnell KA, Kabat CN, George RB, Defoor DL, Kirby N, Papanikolaou N, Stathakis S. Incorporating biological modeling into patient‐specific plan verification. J Appl Clin Med Phys 2020; 21:94-107. [PMID: 32101368 PMCID: PMC7075379 DOI: 10.1002/acm2.12831] [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: 10/22/2019] [Revised: 01/13/2020] [Accepted: 01/14/2020] [Indexed: 11/17/2022] Open
Abstract
Purpose Dose–volume histogram (DVH) measurements have been integrated into commercially available quality assurance systems to provide a metric for evaluating accuracy of delivery in addition to gamma analysis. We hypothesize that tumor control probability and normal tissue complication probability calculations can provide additional insight beyond conventional dose delivery verification methods. Methods A commercial quality assurance system was used to generate DVHs of treatment plan using the planning CT images and patient‐specific QA measurements on a phantom. Biological modeling was performed on the DVHs produced by both the treatment planning system and the quality assurance system. Results The complication‐free tumor control probability, P+, has been calculated for previously treated intensity modulated radiotherapy (IMRT) patients with diseases in the following sites: brain (−3.9% ± 5.8%), head‐neck (+4.8% ± 8.5%), lung (+7.8% ± 1.3%), pelvis (+7.1% ± 12.1%), and prostate (+0.5% ± 3.6%). Conclusion Dose measurements on a phantom can be used for pretreatment estimation of tumor control and normal tissue complication probabilities. Results in this study show how biological modeling can be used to provide additional insight about accuracy of delivery during pretreatment verification.
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Affiliation(s)
- Ara N. Alexandrian
- Department of Radiation Oncology University of Texas Health Sciences Center San Antonio TX USA
| | - Panayiotis Mavroidis
- Department of Radiation Oncology University of North Carolina Chapel Hill NC USA
| | - Ganesh Narayanasamy
- Department of Radiation Oncology University of Arkansas for Medical Sciences Little Rock AR USA
| | - Kristen A. McConnell
- Department of Radiation Oncology University of Texas Health Sciences Center San Antonio TX USA
| | - Christopher N. Kabat
- Department of Radiation Oncology University of Texas Health Sciences Center San Antonio TX USA
| | - Renil B. George
- Department of Radiation Oncology University of Texas Health Sciences Center San Antonio TX USA
| | - Dewayne L. Defoor
- Department of Radiation Oncology University of Texas Health Sciences Center San Antonio TX USA
| | - Neil Kirby
- Department of Radiation Oncology University of Texas Health Sciences Center San Antonio TX USA
| | - Nikos Papanikolaou
- Department of Radiation Oncology University of Texas Health Sciences Center San Antonio TX USA
| | - Sotirios Stathakis
- Department of Radiation Oncology University of Texas Health Sciences Center San Antonio TX USA
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Boyne DJ, Mickle AT, Brenner DR, Friedenreich CM, Cheung WY, Tang KL, Wilson TA, Lorenzetti DL, James MT, Ronksley PE, Rabi DM. Long-term risk of cardiovascular mortality in lymphoma survivors: A systematic review and meta-analysis. Cancer Med 2018; 7:4801-4813. [PMID: 30112841 PMCID: PMC6143935 DOI: 10.1002/cam4.1572] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 04/30/2018] [Accepted: 05/01/2018] [Indexed: 12/15/2022] Open
Abstract
Cardiovascular disease has been identified as one of the late complications of cancer therapy. The purpose of this study was to quantify the long-term risk of cardiovascular mortality among lymphoma survivors relative to that of the general population. A systematic review and meta-analysis were conducted. Articles were identified in November 2016 by searching EMBASE, MEDLINE, and CINAHL databases. Observational studies were included if they assessed cardiovascular mortality in patients with lymphoma who survived for at least 5 years from time of diagnosis or if they had a median follow-up of 10 years. A pooled standardized mortality ratio (SMR) was estimated using a DerSimonian and Laird random-effects model. The Q and I2 statistics were used to assess heterogeneity. Funnel plots and Begg's and Egger's tests were used to evaluate publication bias. Of the 7450 articles screened, 27 studies were included in the systematic review representing 46 829 Hodgkin and 14 764 non-Hodgkin lymphoma survivors. The pooled number of deaths attributable to cardiovascular disease among Hodgkin and non-Hodgkin disease was estimated to be 7.31 (95% CI: 5.29-10.10; I2 = 95.4%) and 5.35 (95% CI: 2.55-11.24; I2 = 94.0%) times that of the general population, respectively. This association was greater among Hodgkin lymphoma survivors treated before the age of 21 (pooled SMR = 13.43; 95% CI: 9.22-19.57; I2 = 78.9%). There was a high degree of heterogeneity and a high risk of bias due to confounding in this body of literature. Lymphoma survivors have an increased risk of fatal cardiovascular events compared to the general population and should be targeted for cardiovascular screening and prevention campaigns.
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Affiliation(s)
- Devon J. Boyne
- Department of Cancer Epidemiology and Prevention ResearchCancer Control AlbertaAlberta Health ServicesCalgaryABCanada
- Department of Community Health SciencesCumming School of MedicineUniversity of CalgaryCalgaryABCanada
| | - Alexis T. Mickle
- Department of Cancer Epidemiology and Prevention ResearchCancer Control AlbertaAlberta Health ServicesCalgaryABCanada
- Department of Community Health SciencesCumming School of MedicineUniversity of CalgaryCalgaryABCanada
| | - Darren R. Brenner
- Department of Cancer Epidemiology and Prevention ResearchCancer Control AlbertaAlberta Health ServicesCalgaryABCanada
- Department of Community Health SciencesCumming School of MedicineUniversity of CalgaryCalgaryABCanada
- Department of OncologyCumming School of MedicineUniversity of CalgaryCalgaryABCanada
| | - Christine M. Friedenreich
- Department of Cancer Epidemiology and Prevention ResearchCancer Control AlbertaAlberta Health ServicesCalgaryABCanada
- Department of Community Health SciencesCumming School of MedicineUniversity of CalgaryCalgaryABCanada
- Department of OncologyCumming School of MedicineUniversity of CalgaryCalgaryABCanada
| | - Winson Y. Cheung
- Department of Community Health SciencesCumming School of MedicineUniversity of CalgaryCalgaryABCanada
- Department of OncologyCumming School of MedicineUniversity of CalgaryCalgaryABCanada
| | - Karen L. Tang
- Department of MedicineCumming School of MedicineUniversity of CalgaryCalgaryABCanada
| | - Todd A. Wilson
- Department of Community Health SciencesCumming School of MedicineUniversity of CalgaryCalgaryABCanada
| | - Diane L. Lorenzetti
- Department of Community Health SciencesCumming School of MedicineUniversity of CalgaryCalgaryABCanada
| | - Matthew T. James
- Department of Community Health SciencesCumming School of MedicineUniversity of CalgaryCalgaryABCanada
- Department of MedicineCumming School of MedicineUniversity of CalgaryCalgaryABCanada
| | - Paul E. Ronksley
- Department of Community Health SciencesCumming School of MedicineUniversity of CalgaryCalgaryABCanada
| | - Doreen M. Rabi
- Department of Community Health SciencesCumming School of MedicineUniversity of CalgaryCalgaryABCanada
- Department of MedicineCumming School of MedicineUniversity of CalgaryCalgaryABCanada
- Department of Cardiac SciencesCumming School of MedicineUniversity of CalgaryCalgaryABCanada
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Corradini S, Ballhausen H, Weingandt H, Freislederer P, Schönecker S, Niyazi M, Simonetto C, Eidemüller M, Ganswindt U, Belka C. Left-sided breast cancer and risks of secondary lung cancer and ischemic heart disease : Effects of modern radiotherapy techniques. Strahlenther Onkol 2017; 194:196-205. [PMID: 28916844 DOI: 10.1007/s00066-017-1213-y] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 08/30/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE Modern breast cancer radiotherapy techniques, such as respiratory-gated radiotherapy in deep-inspiration breath-hold (DIBH) or volumetric-modulated arc radiotherapy (VMAT) have been shown to reduce the high dose exposure of the heart in left-sided breast cancer. The aim of the present study was to comparatively estimate the excess relative and absolute risks of radiation-induced secondary lung cancer and ischemic heart disease for different modern radiotherapy techniques. METHODS Four different treatment plans were generated for ten computed tomography data sets of patients with left-sided breast cancer, using either three-dimensional conformal radiotherapy (3D-CRT) or VMAT, in free-breathing (FB) or DIBH. Dose-volume histograms were used for organ equivalent dose (OED) calculations using linear, linear-exponential, and plateau models for the lung. A linear model was applied to estimate the long-term risk of ischemic heart disease as motivated by epidemiologic data. Excess relative risk (ERR) and 10-year excess absolute risk (EAR) for radiation-induced secondary lung cancer and ischemic heart disease were estimated for different representative baseline risks. RESULTS The DIBH maneuver resulted in a significant reduction of the ERR and estimated 10-year excess absolute risk for major coronary events compared to FB in 3D-CRT plans (p = 0.04). In VMAT plans, the mean predicted risk reduction through DIBH was less pronounced and not statistically significant (p = 0.44). The risk of radiation-induced secondary lung cancer was mainly influenced by the radiotherapy technique, with no beneficial effect through DIBH. VMAT plans correlated with an increase in 10-year EAR for radiation-induced lung cancer as compared to 3D-CRT plans (DIBH p = 0.007; FB p = 0.005, respectively). However, the EARs were affected more strongly by nonradiation-associated risk factors, such as smoking, as compared to the choice of treatment technique. CONCLUSION The results indicate that 3D-CRT plans in DIBH pose the lowest risk for both major coronary events and secondary lung cancer.
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Affiliation(s)
- Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany.
| | - Hendrik Ballhausen
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Helmut Weingandt
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Philipp Freislederer
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Stephan Schönecker
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Cristoforo Simonetto
- Institute of Radiation Protection, Helmholtz Zentrum München, Neuherberg, Germany
| | - Markus Eidemüller
- Institute of Radiation Protection, Helmholtz Zentrum München, Neuherberg, Germany
| | - Ute Ganswindt
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
- Department of Radiation Oncology, Medical University, Innsbruck, Austria
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
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Abuodeh Y, Naghavi AO, Echevarria M, DeMarco M, Tonner B, Feygelman V, Stevens CW, Perez BA, Dilling TJ. Quantitatively Excessive Normal Tissue Toxicity and Poor Target Coverage in Postoperative Lung Cancer Radiotherapy Meta-analysis. Clin Lung Cancer 2017; 19:e123-e130. [PMID: 29107487 DOI: 10.1016/j.cllc.2017.06.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 06/16/2017] [Accepted: 06/20/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND A previous meta-analysis (MA) found postoperative radiotherapy (PORT) in lung cancer patients to be detrimental in N0/N1 patients and equivocal in the N2 setting. We hypothesized that treatment plans generated using MA protocols had worse dosimetric outcomes compared to modern plans. PATIENTS AND METHODS We retrieved plans for 13 patients who received PORT with modern planning. A plan was recreated for each patient using the 8 protocols included in MA. Dosimetric values were then compared between the modern and simulated MA plans. RESULTS A total of 104 MA plans were generated. Median prescribed dose was 50.4 (range, 50-60) Gy in the modern plans and 53.2 (30-60) Gy in the MA protocols. Median planning volume coverage was 96% (93%-100%) in the modern plans, versus 58% (0%-100%) in the MA plans (P < .001). Internal target volume coverage was 100% (99%-100%) versus 65% (0%-100%), respectively (P < .001). Organs at risk received the following doses: spinal cord maximum dose, 36.8 (4.6-50.4) Gy versus 46.8 (2.9-74.0) Gy (P < .001); esophageal mean dose, 22.9 (5.5-35) Gy versus 30.5 (11.1-52.5) Gy (P = .003); heart V30 (percentage of volume of an organ receiving at least a dose of 30 Gy), 16% (0%-45%) versus 35% (0%-79%) (P = .047); mean lung dose, 12.4 (3.4-24.3) Gy versus 14.8 (4.1-27.4) Gy (P = .008); and lung V20, 18% (4%-34%) versus 25% (8%-67%) (P = .023). CONCLUSION We quantitatively confirm the inferiority of the techniques used in the PORT MA. Our analysis showed a lower therapeutic ratio in the MA plans, which may explain the poor outcomes in the MA. The findings of the MA are not relevant in the era of modern treatment planning.
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Affiliation(s)
- Yazan Abuodeh
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Arash O Naghavi
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Michelle Echevarria
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - MaryLou DeMarco
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Brian Tonner
- Department of Radiation Oncology, Eastern Carolina University, Greenville, NC
| | - Vladimir Feygelman
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Craig W Stevens
- Department of Radiation Oncology, William Beaumont Cancer Institute, Detroit, MI
| | - Bradford A Perez
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Thomas J Dilling
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL.
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Goto S, Murakami M, Kawabe M, Iwasaki R, Heishima K, Sakai H, Mori T. Hypofractionated radiation therapy in the treatment of canine thymoma: Retrospective study of eight cases. Vet Radiol Ultrasound 2017; 58:613-620. [DOI: 10.1111/vru.12525] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 04/10/2017] [Accepted: 04/14/2017] [Indexed: 12/25/2022] Open
Affiliation(s)
- Sho Goto
- Animal Medical Center; Gifu University; Yanagido Gifu-shi Gifu 501-1193 Japan
| | - Mami Murakami
- Department of Veterinary Clinical Oncology; Gifu University; Yanagido Gifu-shi Gifu 501-1193 Japan
| | - Mifumi Kawabe
- Department of Veterinary Clinical Oncology; Gifu University; Yanagido Gifu-shi Gifu 501-1193 Japan
| | - Ryota Iwasaki
- Animal Medical Center; Gifu University; Yanagido Gifu-shi Gifu 501-1193 Japan
| | - Kazuki Heishima
- Department of Veterinary Clinical Oncology; Gifu University; Yanagido Gifu-shi Gifu 501-1193 Japan
| | - Hiroki Sakai
- Department of Pathology; Gifu University; Yanagido Gifu-shi Gifu 501-1193 Japan
| | - Takashi Mori
- Department of Veterinary Clinical Oncology; Gifu University; Yanagido Gifu-shi Gifu 501-1193 Japan
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Spewak MB, Williamson RS, Mertens AC, Border WL, Meacham LR, Wasilewski-Masker KJ. Yield of screening echocardiograms during pediatric follow-up in survivors treated with anthracyclines and cardiotoxic radiation. Pediatr Blood Cancer 2017; 64. [PMID: 27966803 DOI: 10.1002/pbc.26367] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 10/25/2016] [Accepted: 10/26/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Guidelines published by the Children's Oncology Group recommend screening echocardiograms for childhood cancer survivors exposed to anthracyclines and/or cardiotoxic radiation. This study aims to assess risk factors for cardiac late effects while evaluating the overall yield of screening echocardiograms. PROCEDURE Demographics, exposures, and echocardiogram results were abstracted from the medical records of survivors diagnosed at ≤ 21 years old and ≥ 2 years off therapy who were exposed to anthracyclines and/or potentially cardiotoxic radiotherapy. Descriptive statistics and logistic regressions were performed and the yield of screening echocardiograms was calculated. RESULTS Of 853 patients, 1,728 screening echocardiograms were performed, and 37 patients had an abnormal echocardiogram (overall yield 2.1%). Yields were only somewhat higher in more frequently screened patients. Risk factors for an abnormal result included anthracycline dose of ≥300 mg/m2 (adjusted odds ratio [aOR] 3.1; 95% confidence interval [CI]: 1.3-7.2; P < 0.01) with a synergist relationship in patients who also received radiation doses ≥30 Gy (aOR 7.0; 95% CI: 1.6-31.9; P = 0.01), as well as autologous bone marrow transplant (OR 3.3; 95% CI: 1.3-8.5; P = 0.01). Sex, race, age at diagnosis, and cyclophosphamide exposure were not statistically significant risk factors, and no patient receiving <100 mg/m2 anthracycline dose without concomitant radiation had an abnormal echocardiogram. CONCLUSIONS Dose-dependent and synergist anthracycline and cardiotoxic radiotherapy risks for developing cardiomyopathy were confirmed. However, previously identified risk factors including female sex, black race, and early age at diagnosis were not replicated in this cohort. The yields showed weak correlation across frequency categories. Echocardiographic screening recommendations for low-risk pediatric patients may warrant re-evaluation.
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Affiliation(s)
- Michael B Spewak
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Rebecca S Williamson
- The Aflac Cancer & Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Ann C Mertens
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,The Aflac Cancer & Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - William L Border
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,The Sibley Heart Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Lillian R Meacham
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,The Aflac Cancer & Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Karen J Wasilewski-Masker
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,The Aflac Cancer & Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
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11
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Gonzalez VJ. Role of Radiation Therapy in the Treatment of Hodgkin Lymphoma. Curr Hematol Malig Rep 2017; 12:244-250. [DOI: 10.1007/s11899-017-0385-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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12
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Moiseenko V, Einck J, Murphy J, Ödén J, Bjöhle J, Uzan J, Gagliardi G. Clinical evaluation of QUANTEC guidelines to predict the risk of cardiac mortality in breast cancer patients. Acta Oncol 2016; 55:1506-1510. [PMID: 27732122 DOI: 10.1080/0284186x.2016.1234067] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Vitali Moiseenko
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
| | - John Einck
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
| | - James Murphy
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
| | - Jakob Ödén
- Department of Medical Physics, Karolinska University Hospital, Stockholm, Sweden
| | - Judith Bjöhle
- Department of Oncology-Pathology, Karolinska University Hospital, Stockholm, Sweden
| | - Julien Uzan
- Department of Medical Physics, Karolinska University Hospital, Stockholm, Sweden
- RaySearch Laboratories AB, Stockholm, Sweden
| | - Giovanna Gagliardi
- Department of Medical Physics, Karolinska University Hospital, Stockholm, Sweden
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13
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Woodford K, Panettieri V, Ruben JD, Senthi S. Limiting the risk of cardiac toxicity with esophageal-sparing intensity modulated radiotherapy for locally advanced lung cancers. J Thorac Dis 2016; 8:942-9. [PMID: 27162670 DOI: 10.21037/jtd.2016.03.64] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intensity modulated radiotherapy (IMRT) is routinely utilized in the treatment of locally advanced non-small cell lung cancer (NSCLC). RTOG 0617 found that overall survival was impacted by increased low (5 Gy) and intermediate (30 Gy) cardiac doses. We evaluated the impact of esophageal-sparing IMRT on cardiac doses with and without the heart considered in the planning process and predicted toxicity compared to 3D-conventional radiotherapy (3DCRT). METHODS Ten consecutive patients with N2 Stage III NSCLC treated to 60 Gy in 30 fractions, between February 2012 and September 2014, were evaluated. For each patient, 3DCRT and esophageal-sparing IMRT plans were generated. IMRT plans were then created with and without the heart considered in the optimization process. To compare plans, the dose delivered to 95% and 99% of the target (D95% and D99%), and doses to the esophagus, lung and heart were compared by determining the volume receiving X dose (VXGy) and the normal tissue complication probability (NTCP) calculated. RESULTS IMRT reduced maximum esophagus dose to below 60 Gy in all patients and produced significant reductions to V50Gy, V40Gy and esophageal NTCP. The cost of this reduction was a non-statistically, non-clinically significant increase in low dose (5 Gy) lung exposure that did not worsen lung NTCP. IMRT plans produced significant cardiac sparing, with the amount of improvement correlating to the amount of heart overlapping with the target. When included in plan optimization, for selected patients further sparing of the heart and improvement in heart NTCP was possible. CONCLUSIONS Esophageal-sparing IMRT can significantly spare the heart even if it is not considered in the optimization process. Further sparing can be achieved if plan optimization constrains low and intermediate heart doses, without compromising lung doses.
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Affiliation(s)
- Katrina Woodford
- 1 Alfred Health Radiation Oncology, The Alfred Hospital, Melbourne, Victoria, Australia ; 2 Central Clinical School, Monash University, Clayton, Victoria, Australia
| | - Vanessa Panettieri
- 1 Alfred Health Radiation Oncology, The Alfred Hospital, Melbourne, Victoria, Australia ; 2 Central Clinical School, Monash University, Clayton, Victoria, Australia
| | - Jeremy D Ruben
- 1 Alfred Health Radiation Oncology, The Alfred Hospital, Melbourne, Victoria, Australia ; 2 Central Clinical School, Monash University, Clayton, Victoria, Australia
| | - Sashendra Senthi
- 1 Alfred Health Radiation Oncology, The Alfred Hospital, Melbourne, Victoria, Australia ; 2 Central Clinical School, Monash University, Clayton, Victoria, Australia
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14
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Huang YJ, Harrison A, Sarkar V, Rassiah-Szegedi P, Zhao H, Szegedi M, Huang L, Wilson B, Gaffney DK, Salter BJ. Detection of late radiation damage on left atrial fibrosis using cardiac late gadolinium enhancement magnetic resonance imaging. Adv Radiat Oncol 2016; 1:106-114. [PMID: 28740877 PMCID: PMC5506699 DOI: 10.1016/j.adro.2016.04.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 04/15/2016] [Accepted: 04/19/2016] [Indexed: 12/25/2022] Open
Abstract
Purpose This is a proof-of-principle study investigating the feasibility of using late gadolinium enhancement magnetic resonance imaging (LGE-MRI) to detect left atrium (LA) radiation damage. Methods and materials LGE-MRI data were acquired for 7 patients with previous external beam radiation therapy (EBRT) histories. The enhancement in LA scar was delineated and fused to the computed tomography images used in dose calculation for radiation therapy. Dosimetric and normal tissue complication probability analyses were performed to investigate the relationship between LA scar enhancement and radiation doses. Results The average LA scar volume for the subjects was 2.5 cm3 (range, 1.2-4.1 cm3; median, 2.6 cm3). The overall average of the mean dose to the LA scar was 25.9 Gy (range, 5.8-49.2 Gy). Linear relationships were found between the amount of radiation dose (mean dose) (R2 = 0.8514, P = .03) to the LA scar-enhanced volume. The ratio of the cardiac tissue change (LA scar/LA wall) also demonstrated a linear relationship with the level of radiation received by the cardiac tissue (R2 = 0.9787, P < .01). Last, the normal tissue complication probability analysis suggested a dose response function to the LA scar enhancement. Conclusions With LGE-MRI and 3-dimensional dose mapping on the treatment planning system, it is possible to define subclinical cardiac damage and distinguish intrinsic cardiac tissue change from radiation induced cardiac tissue damage. Imaging myocardial injury secondary to EBRT using MRI may be a useful modality to follow cardiac toxicity from EBRT and help identify individuals who are more susceptible to EBRT damage. LGE-MRI may provide essential information to identify early screening strategy for affected cancer survivors after EBRT treatment.
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Affiliation(s)
- Y Jessica Huang
- Department of Radiation Oncology, University of Utah, Salt Lake City, Utah
| | - Alexis Harrison
- Cardiovascular Center, University of Utah, Salt Lake City, Utah.,Comprehensive Arrhythmia Research and Management Center, University of Utah, Salt Lake City, Utah
| | - Vikren Sarkar
- Department of Radiation Oncology, University of Utah, Salt Lake City, Utah
| | | | - Hui Zhao
- Department of Radiation Oncology, University of Utah, Salt Lake City, Utah
| | - Martin Szegedi
- Department of Radiation Oncology, University of Utah, Salt Lake City, Utah
| | - Long Huang
- Department of Radiation Oncology, University of Utah, Salt Lake City, Utah
| | - Brent Wilson
- Cardiovascular Center, University of Utah, Salt Lake City, Utah.,Comprehensive Arrhythmia Research and Management Center, University of Utah, Salt Lake City, Utah
| | - David K Gaffney
- Department of Radiation Oncology, University of Utah, Salt Lake City, Utah
| | - Bill J Salter
- Department of Radiation Oncology, University of Utah, Salt Lake City, Utah
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15
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Toltz A, Shin N, Mitrou E, Laude C, Freeman CR, Seuntjens J, Parker W, Roberge D. Late radiation toxicity in Hodgkin lymphoma patients: proton therapy's potential. J Appl Clin Med Phys 2015; 16:167–178. [PMID: 26699298 PMCID: PMC5690189 DOI: 10.1120/jacmp.v16i5.5386] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 05/20/2015] [Accepted: 05/03/2015] [Indexed: 12/22/2022] Open
Abstract
In 2010, all young patients treated for intrathoracic Hodgkin lymphoma (HL) at one of 10 radiotherapy centers in the province of Quebec received 3D conformal photon therapy. These patients may now be at risk for late effects of their treatment, notably secondary malignancies and cardiac toxicity. We hypothesized that more complex radiotherapy, including intensity‐modulated proton therapy (IMPT) and possibly IMRT (in the form of helical tomotherapy (HT)), could benefit these patients. With institutional review board approval at 10 institutions, all treatment plans for patients under the age of 30 treated for HL during a six‐month consecutive period of 2010 were retrieved. Twenty‐six patients were identified, and after excluding patients with extrathoracic radiation or treatment of recurrence, 20 patients were replanned for HT and IMPT. Neutron dose for IMPT plans was estimated from published measurements. The relative seriality model was used to predict excess risk of cardiac mortality. A modified linear quadratic model was used to predict the excess absolute risk for induction of lung cancer and, in female patients, breast cancer. Model parameters were derived from published data. Predicted risk for cardiac mortality was similar among the three treatment techniques (absolute excess risk of cardiac mortality was not reduced for HT or IMPT (p>0.05,p>0.05) as compared to 3D CRT). Predicted risks were increased for HT and reduced for IMPT for secondary lung cancer (p<0.001,p<0.001) and breast cancers (p<0.001,p<0.001) as compared to 3D CRT. PACS numbers: 87.55.dh, 87.55.dk
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16
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Nitsche M, Pahl R, Huber K, Eilf K, Dunst J. Cardiac Toxicity after Radiotherapy for Breast Cancer: Myths and Facts. Breast Care (Basel) 2015. [PMID: 26195942 DOI: 10.1159/000376560] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Radiotherapy is an important component in the multidisciplinary treatment of breast cancer. In recent years, the cardiac risks of radiation have been discussed several times. This problem has long been known and resolved from the radiotherapeutic point of view. The current data is briefly described here.
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Affiliation(s)
- Mirko Nitsche
- Zentrum für Strahlentherapie und Radioonkologie, Bremen/Westerstede, Germany ; Klinik für Strahlentherapie, Karl-Lennert-Krebscentrum, Universität Kiel, Germany
| | - René Pahl
- Klinik für Strahlentherapie, Karl-Lennert-Krebscentrum, Universität Kiel, Germany
| | - Karen Huber
- Klinik für Strahlentherapie, Karl-Lennert-Krebscentrum, Universität Kiel, Germany
| | - Kirsten Eilf
- Klinik für Strahlentherapie, Karl-Lennert-Krebscentrum, Universität Kiel, Germany
| | - Juergen Dunst
- Klinik für Strahlentherapie, Karl-Lennert-Krebscentrum, Universität Kiel, Germany
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17
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Cella L, Palma G, Deasy JO, Oh JH, Liuzzi R, D’Avino V, Conson M, Pugliese N, Picardi M, Salvatore M, Pacelli R. Complication probability models for radiation-induced heart valvular dysfunction: do heart-lung interactions play a role? PLoS One 2014; 9:e111753. [PMID: 25360627 PMCID: PMC4216137 DOI: 10.1371/journal.pone.0111753] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 09/30/2014] [Indexed: 12/25/2022] Open
Abstract
Purpose The purpose of this study is to compare different normal tissue complication probability (NTCP) models for predicting heart valve dysfunction (RVD) following thoracic irradiation. Methods All patients from our institutional Hodgkin lymphoma survivors database with analyzable datasets were included (n = 90). All patients were treated with three-dimensional conformal radiotherapy with a median total dose of 32 Gy. The cardiac toxicity profile was available for each patient. Heart and lung dose-volume histograms (DVHs) were extracted and both organs were considered for Lyman-Kutcher-Burman (LKB) and Relative Seriality (RS) NTCP model fitting using maximum likelihood estimation. Bootstrap refitting was used to test the robustness of the model fit. Model performance was estimated using the area under the receiver operating characteristic curve (AUC). Results Using only heart-DVHs, parameter estimates were, for the LKB model: D50 = 32.8 Gy, n = 0.16 and m = 0.67; and for the RS model: D50 = 32.4 Gy, s = 0.99 and γ = 0.42. AUC values were 0.67 for LKB and 0.66 for RS, respectively. Similar performance was obtained for models using only lung-DVHs (LKB: D50 = 33.2 Gy, n = 0.01, m = 0.19, AUC = 0.68; RS: D50 = 24.4 Gy, s = 0.99, γ = 2.12, AUC = 0.66). Bootstrap result showed that the parameter fits for lung-LKB were extremely robust. A combined heart-lung LKB model was also tested and showed a minor improvement (AUC = 0.70). However, the best performance was obtained using the previously determined multivariate regression model including maximum heart dose with increasing risk for larger heart and smaller lung volumes (AUC = 0.82). Conclusions The risk of radiation induced valvular disease cannot be modeled using NTCP models only based on heart dose-volume distribution. A predictive model with an improved performance can be obtained but requires the inclusion of heart and lung volume terms, indicating that heart-lung interactions are apparently important for this endpoint.
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Affiliation(s)
- Laura Cella
- Institute of Biostructure and Bioimaging, National Council of Research (CNR), Naples, Italy
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy
- * E-mail:
| | - Giuseppe Palma
- Institute of Biostructure and Bioimaging, National Council of Research (CNR), Naples, Italy
| | - Joseph O. Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, United States of America
| | - Jung Hun Oh
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, United States of America
| | - Raffaele Liuzzi
- Institute of Biostructure and Bioimaging, National Council of Research (CNR), Naples, Italy
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy
| | - Vittoria D’Avino
- Institute of Biostructure and Bioimaging, National Council of Research (CNR), Naples, Italy
| | - Manuel Conson
- Institute of Biostructure and Bioimaging, National Council of Research (CNR), Naples, Italy
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy
| | - Novella Pugliese
- Department of Clinical Medicine and Surgery, Federico II University School of Medicine, Naples, Italy
| | - Marco Picardi
- Department of Clinical Medicine and Surgery, Federico II University School of Medicine, Naples, Italy
| | - Marco Salvatore
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy
| | - Roberto Pacelli
- Institute of Biostructure and Bioimaging, National Council of Research (CNR), Naples, Italy
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy
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18
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Myers PA, Mavroidis P, Papanikolaou N, Stathakis S. Comparing conformal, arc radiotherapy and helical tomotherapy in craniospinal irradiation planning. J Appl Clin Med Phys 2014; 15:4724. [PMID: 25207562 PMCID: PMC5711087 DOI: 10.1120/jacmp.v15i5.4724] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 06/11/2014] [Accepted: 05/23/2014] [Indexed: 12/16/2022] Open
Abstract
Currently, radiotherapy treatment plan acceptance is based primarily on dosimetric performance measures. However, use of radiobiological analysis to assess benefit in terms of tumor control and harm in terms of injury to normal tissues can be advantageous. For pediatric craniospinal axis irradiation (CSI) patients, in particular, knowing the technique that will optimize the probabilities of benefit versus injury can lead to better long-term outcomes. Twenty-four CSI pediatric patients (median age 10) were retrospectively planned with three techniques: three-dimensional conformal radiation therapy (3D CRT), volumetric-modulated arc therapy (VMAT), and helical tomotherapy (HT). VMAT plans consisted of one superior and one inferior full arc, and tomotherapy plans were created using a 5.02cm field width and helical pitch of 0.287. Each plan was normalized to 95% of target volume (whole brain and spinal cord) receiving prescription dose 23.4Gy in 13 fractions. Using an in-house MATLAB code and DVH data from each plan, the three techniques were evaluated based on biologically effective uniform dose (D=), the complication-free tumor control probability (P+), and the width of the therapeutically beneficial range. Overall, 3D CRT and VMAT plans had similar values of D= (24.1 and 24.2 Gy), while HT had a D= slightly lower (23.6 Gy). The average values of the P+ index were 64.6, 67.4, and 56.6% for 3D CRT, VMAT, and HT plans, respectively, with the VMAT plans having a statistically significant increase in P+. Optimal values of D= were 28.4, 33.0, and 31.9 Gy for 3D CRT, VMAT, and HT plans, respectively. Although P+ values that correspond to the initial dose prescription were lower for HT, after optimizing the D= prescription level, the optimal P+ became 94.1, 99.5, and 99.6% for 3D CRT, VMAT, and HT, respectively, with the VMAT and HT plans having statistically significant increases in P+. If the optimal dose level is prescribed using a radiobiological evaluation method, as opposed to a purely dosimetric one, the two IMRT techniques, VMAT and HT, will yield largest overall benefit to CSI patients by maximizing tumor control and limiting normal tissue injury. Using VMAT or HT may provide these pediatric patients with better long-term outcomes after radiotherapy.
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Affiliation(s)
- Pamela A Myers
- University of Texas Health Science Center at San Antonio.
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19
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Davis M, Witteles RM. Radiation-induced heart disease: an under-recognized entity? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:317. [PMID: 24756471 DOI: 10.1007/s11936-014-0317-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OPINION STATEMENT Radiation-induced heart disease (RIHD) represents a spectrum of cardiovascular disease in patients who have undergone mediastinal, thoracic, or breast radiotherapy (RT). RIHD may involve any cardiac structure and is a major cause of morbidity and mortality in cancer survivors. While large cohort studies have demonstrated that symptomatic RIHD is a common late finding in this population, the incidence of asymptomatic disease is likely to be even higher. Long-term follow-up with regular screening for RIHD plays an important role in the management of cancer survivors who have undergone RT. Aggressive modification of traditional cardiovascular risk factors such as hypertension, dyslipidemia, and cigarette smoking is essential in patients at risk for RIHD, as these have been shown to potentiate the risks of radiation. In patients with symptomatic RIHD, medical and/or percutaneous therapies are often preferable to surgical interventions in view of the increased surgical risk associated with radiation damage to surrounding tissues. Percutaneous revascularization should generally be favored over surgical revascularization. Transcatheter valve replacements have not been widely used in this population but may offer an alternative to high-risk surgical valve procedures. Pericardiectomy is usually associated with extremely poor short-term and long-term outcomes in patients with RIHD and should be avoided in most cases. Heart transplantation is also higher risk in patients with RIHD than in patients with other etiologies of heart failure, but may be considered in young patients without other comorbidities.
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Affiliation(s)
- Margot Davis
- Division of Cardiovascular Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Falk Cardiovascular Research Center #273, Stanford, CA, 94305-5406, USA
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20
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Komisopoulos G, Mavroidis P, Rodriguez S, Stathakis S, Papanikolaou N, Nikiforidis GC, Sakellaropoulos GC. Radiobiologic comparison of helical tomotherapy, intensity modulated radiotherapy, and conformal radiotherapy in treating lung cancer accounting for secondary malignancy risks. Med Dosim 2014; 39:337-47. [DOI: 10.1016/j.meddos.2014.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 05/31/2014] [Accepted: 06/12/2014] [Indexed: 12/25/2022]
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21
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Bruzzaniti V, Abate A, Pinnarò P, D'Andrea M, Infusino E, Landoni V, Soriani A, Giordano C, Ferraro A, Strigari L. Dosimetric and clinical advantages of deep inspiration breath-hold (DIBH) during radiotherapy of breast cancer. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2013; 32:88. [PMID: 24423396 PMCID: PMC3826503 DOI: 10.1186/1756-9966-32-88] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 10/29/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND To investigate the potential dosimetric and clinical benefits of Deep Inspiration Breath-Hold (DIBH) technique during radiotherapy of breast cancer compared with Free Breathing (FB). METHODS Eight left-sided breast cancer patients underwent a supervised breath hold during treatment. For each patient, two CT scans were acquired with and without breath hold, and virtual simulation was performed for conventional tangential fields, utilizing 6 or 15 MV photon fields. The resulting dose-volume histograms were calculated, and the volumes of heart/lung irradiated to given doses were assessed. The left anterior descending coronary artery (LAD) mean and maximum doses were calculated, together with tumour control probability (TCP) and normal tissue complication probabilities (NTCP) for lung and heart. RESULTS For all patients a reduction of at least 16% in lung mean dose and at least 20% in irradiated pulmonary volumes was observed when DIBH was applied. Heart and LAD maximum doses were decreased by more than 78% with DIBH. The NTCP values for pneumonitis and long term cardiac mortality were also reduced by about 11% with DIBH. The NTCP values for pericarditis were zero for both DIBH and FB. CONCLUSION Delivering radiation in DIBH conditions the dose to the surrounding normal structures could be reduced, in particular heart, LAD and lung, due to increased distance between target and heart, and to reduced lung density.
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Ionizing radiation regulates cardiac Ca handling via increased ROS and activated CaMKII. Basic Res Cardiol 2013; 108:385. [PMID: 24068185 PMCID: PMC3898380 DOI: 10.1007/s00395-013-0385-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 08/29/2013] [Accepted: 08/30/2013] [Indexed: 11/08/2022]
Abstract
Ionizing radiation (IR) is an integral part of modern multimodal anti-cancer therapies. IR involves the formation of reactive oxygen species (ROS) in targeted tissues. This is associated with subsequent cardiac dysfunction when applied during chest radiotherapy. We hypothesized that IR (i.e., ROS)-dependently impaired cardiac myocytes’ Ca handling might contribute to IR-dependent cardiocellular dysfunction. Isolated ventricular mouse myocytes and the mediastinal area of anaesthetized mice (that included the heart) were exposed to graded doses of irradiation (sham 4 and 20 Gy) and investigated acutely (after ~1 h) as well as chronically (after ~1 week). IR induced a dose-dependent effect on myocytes’ systolic function with acutely increased, but chronically decreased Ca transient amplitudes, which was associated with an acutely unaltered but chronically decreased sarcoplasmic reticulum (SR) Ca load. Likewise, in vivo echocardiography of anaesthetized mice revealed acutely enhanced left ventricular contractility (strain analysis) that declined after 1 week. Irradiated myocytes showed persistently increased diastolic SR Ca leakage, which was acutely compensated by an increase in SR Ca reuptake. This was reversed in the chronic setting in the face of slowed relaxation kinetics. As underlying cause, acutely increased ROS levels were identified to activate Ca/calmodulin-dependent protein kinase II (CaMKII). Accordingly, CaMKII-, but not PKA-dependent phosphorylation sites of the SR Ca release channels (RyR2, at Ser-2814) and phospholamban (at Thr-17) were found to be hyperphosphorylated following IR. Conversely, ROS-scavenging as well as CaMKII-inhibition significantly attenuated CaMKII-activation, disturbed Ca handling, and subsequent cellular dysfunction upon irradiation. Targeted cardiac irradiation induces a biphasic effect on cardiac myocytes Ca handling that is associated with chronic cardiocellular dysfunction. This appears to be mediated by increased oxidative stress and persistently activated CaMKII. Our findings suggest impaired cardiac myocytes Ca handling as a so far unknown mediator of IR-dependent cardiac damage that might be of relevance for radiation-induced cardiac dysfunction.
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23
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Mavroidis P, Ferreira BC, Papanikolaou N, Lopes MDC. Analysis of fractionation correction methodologies for multiple phase treatment plans in radiation therapy. Med Phys 2013; 40:031715. [PMID: 23464310 DOI: 10.1118/1.4792636] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE Radiation therapy is often delivered by multiple sequential treatment plans. For an accurate radiobiological evaluation of the overall treatment, fractionation corrections to each dose distribution must be applied before summing the three-dimensional dose matrix of each plan since the simpler approach of performing the fractionation correction to the total dose-volume histograms, obtained by the arithmetical sum of the different plans, becomes inaccurate for more heterogeneous dose patterns. In this study, the differences between these two fractionation correction methods, named here as exact (corrected before) and approximate (after summation), respectively, are assessed for different cancer types. METHODS Prostate, breast, and head and neck (HN) tumor patients were selected to quantify the differences between two fractionation correction methods (the exact vs the approximate). For each cancer type, two different treatment plans were developed using uniform (CRT) and intensity modulated beams (IMRT), respectively. The responses of the target and normal tissue were calculated using the Poisson linear-quadratic-time model and the relative seriality model, respectively. All treatments were radiobiologically evaluated and compared using the complication-free tumor control probability (P+), the biologically effective uniform dose (D) together with common dosimetric criteria. RESULTS For the prostate cancer patient, an underestimation of around 14%-15% in P+ was obtained when the fractionation correction was applied after summation compared to the exact approach due to significant biological and dosimetric variations obtained between the two fractionation correction methods in the involved lymph nodes. For the breast cancer patient, an underestimation of around 3%-4% in the maximum dose in the heart was obtained. Despite the dosimetric differences in this organ, no significant variations were obtained in treatment outcome. For the HN tumor patient, an underestimation of about 5% in treatment outcome was obtained for the CRT plan as a result of an underestimation of the planning target volume control probability by about 10%. An underestimation of about 6% in the complication probability of the right parotid was also obtained. For all the other organs at risk, dosimetric differences of up to 4% were obtained but with no significant impact in the expected clinical outcome. However, for the IMRT plan, an overestimation in P+ of 4.3% was obtained mainly due to an underestimation of the complication probability of the left and right parotids (2.9% and 5.8%, respectively). CONCLUSIONS The use of the exact fractionation correction method, which is applying fractionation correction on the separate dose distributions of a multiple phase treatment before their summation was found to have a significant expected clinical impact. For regions of interest that are irradiated with very heterogeneous dose distributions and significantly different doses per fraction in the different treatment phases, the exact fractionation correction method needs to be applied since a significant underestimation of the true patient outcome can be introduced otherwise.
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Affiliation(s)
- Panayiotis Mavroidis
- Department of Radiation Oncology, University of Texas Health Sciences Center, San Antonio, Texas 78229, USA.
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Zhang R, Howell RM, Homann K, Giebeler A, Taddei PJ, Mahajan A, Newhauser WD. Predicted risks of radiogenic cardiac toxicity in two pediatric patients undergoing photon or proton radiotherapy. Radiat Oncol 2013; 8:184. [PMID: 23880421 PMCID: PMC3751146 DOI: 10.1186/1748-717x-8-184] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 07/21/2013] [Indexed: 01/12/2023] Open
Abstract
Background Hodgkin disease (HD) and medulloblastoma (MB) are common malignancies found in children and young adults, and radiotherapy is part of the standard treatment. It was reported that these patients who received radiation therapy have an increased risk of cardiovascular late effects. We compared the predicted risk of developing radiogenic cardiac toxicity after photon versus proton radiotherapies for a pediatric patient with HD and a pediatric patient with MB. Methods In the treatment plans, each patient’s heart was contoured in fine detail, including substructures of the pericardium and myocardium. Risk calculations took into account both therapeutic and stray radiation doses. We calculated the relative risk (RR) of cardiac toxicity using a linear risk model and the normal tissue complication probability (NTCP) values using relative seriality and Lyman models. Uncertainty analyses were also performed. Results The RR values of cardiac toxicity for the HD patient were 7.27 (proton) and 8.37 (photon), respectively; the RR values for the MB patient were 1.28 (proton) and 8.39 (photon), respectively. The predicted NTCP values for the HD patient were 2.17% (proton) and 2.67% (photon) for the myocardium, and were 2.11% (proton) and 1.92% (photon) for the whole heart. The predicted ratios of NTCP values (proton/photon) for the MB patient were much less than unity. Uncertainty analyses revealed that the predicted ratio of risk between proton and photon therapies was sensitive to uncertainties in the NTCP model parameters and the mean radiation weighting factor for neutrons, but was not sensitive to heart structure contours. The qualitative findings of the study were not sensitive to uncertainties in these factors. Conclusions We conclude that proton and photon radiotherapies confer similar predicted risks of cardiac toxicity for the HD patient in this study, and that proton therapy reduced the predicted risk for the MB patient in this study.
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Affiliation(s)
- Rui Zhang
- The University of Texas Graduate School of Biomedical Sciences at Houston, Houston, TX, USA.
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Bufacchi A, Nardiello B, Capparella R, Begnozzi L. Clinical implications in the use of the PBC algorithm versus the AAA by comparison of different NTCP models/parameters. Radiat Oncol 2013; 8:164. [PMID: 23826854 PMCID: PMC3750611 DOI: 10.1186/1748-717x-8-164] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2012] [Accepted: 06/13/2013] [Indexed: 12/25/2022] Open
Abstract
Purpose Retrospective analysis of 3D clinical treatment plans to investigate qualitative, possible, clinical consequences of the use of PBC versus AAA. Methods The 3D dose distributions of 80 treatment plans at four different tumour sites, produced using PBC algorithm, were recalculated using AAA and the same number of monitor units provided by PBC and clinically delivered to each patient; the consequences of the difference on the dose-effect relations for normal tissue injury were studied by comparing different NTCP model/parameters extracted from a review of published studies. In this study the AAA dose calculation is considered as benchmark data. The paired Student t-test was used for statistical comparison of all results obtained from the use of the two algorithms. Results In the prostate plans, the AAA predicted lower NTCP value (NTCPAAA) for the risk of late rectal bleeding for each of the seven combinations of NTCP parameters, the maximum mean decrease was 2.2%. In the head-and-neck treatments, each combination of parameters used for the risk of xerostemia from irradiation of the parotid glands involved lower NTCPAAA, that varied from 12.8% (sd=3.0%) to 57.5% (sd=4.0%), while when the PBC algorithm was used the NTCPPBC’s ranging was from 15.2% (sd=2.7%) to 63.8% (sd=3.8%), according the combination of parameters used; the differences were statistically significant. Also NTCPAAA regarding the risk of radiation pneumonitis in the lung treatments was found to be lower than NTCPPBC for each of the eight sets of NTCP parameters; the maximum mean decrease was 4.5%. A mean increase of 4.3% was found when the NTCPAAA was calculated by the parameters evaluated from dose distribution calculated by a convolution-superposition (CS) algorithm. A markedly different pattern was observed for the risk relating to the development of pneumonitis following breast treatments: the AAA predicted higher NTCP value. The mean NTCPAAA varied from 0.2% (sd = 0.1%) to 2.1% (sd = 0.3%), while the mean NTCPPBC varied from 0.1% (sd = 0.0%) to 1.8% (sd = 0.2%) depending on the chosen parameters set. Conclusions When the original PBC treatment plans were recalculated using AAA with the same number of monitor units provided by PBC, the NTCPAAA was lower than the NTCPPBC, except for the breast treatments. The NTCP is strongly affected by the wide-ranging values of radiobiological parameters.
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Affiliation(s)
- Antonella Bufacchi
- Medical Physics, PioXI Clinic and UOC Medical Physics, S Giovanni Calibita Fatebenefratelli Hospital, Rome, Italy.
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Abstract
Improvements in cancer therapy have led to increasing numbers of cancer survivors, and the long-term complications of these treatments are now becoming apparent. This article presents the current knowledge of adverse cardiovascular effects of radiotherapy to the chest. Medline literature searches relating to the cardiac complications of radiotherapy and subsequent prognosis were conducted. Potential adverse effects of mediastinal irradiation are numerous and can include coronary artery disease, pericarditis, cardiomyopathy, and valvular disease. Damage seems to be related to radiation dose, volume of irradiated heart, age at exposure, technique of chest irradiation, and patient-specific factors. The advent of technology and the newer sophisticated techniques in treatment planning and delivery are expected to decrease the incidence of cardiovascular diseases after radiation of the mediastinal structures. In any case, patients subjected to irradiation of the mediastinal structures require close multidisciplinary clinical monitoring.
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Women at increased risk for cardiac toxicity following chemoradiation therapy for esophageal carcinoma. Pract Radiat Oncol 2013; 3:e149-55. [PMID: 24674412 DOI: 10.1016/j.prro.2013.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Revised: 01/23/2013] [Accepted: 02/06/2013] [Indexed: 12/26/2022]
Abstract
PURPOSE The purpose of this study was to identify factors associated with cardiac toxicity in patients treated with chemoradiation therapy (CRT) for esophageal carcinoma. METHODS AND MATERIALS One hundred twenty-seven patients with adenocarcinoma or squamous cell carcinoma of the esophagus treated from July 2002 to June 2011 at 2 academic institutions with preoperative or definitive CRT were retrospectively reviewed. Association of cardiac toxicity with a number of variables was investigated, including heart disease, cardiac bypass and angioplasty, diabetes, insulin use, smoking, chemotherapy regimen, and tumor location. T test assessed risk of cardiac toxicity secondary to age. Dose volume histograms (DVH) were evaluated for percentage of heart volume receiving >20, 30, 40, and 50 Gy (V20-V50). The Fisher exact test analyzed for an association between dose volume parameters and cardiac toxicity. RESULTS Patient population included 100 men and 27 women with a mean age of 64 years. Median follow-up was 12.7 months (range, 0.3-99.6 months). Any cardiac toxicity occurred in 28 patients, the majority of which were pericardial effusion (23/28). Odds ratio for toxicity in women was 4.15 (95% confidence interval [CI], 1.63-10.50; P = .0017) and time to cardiac toxicity by sex was significant (P = .0003). Patients above the median cutoff for V20, V30, and V40 had increased odds of developing cardiac toxicity (P = .03, .008, .002). There was 4.0 increased odds of developing cardiac toxicity with V40 >57% (95% CI, 1.5-10.3, P = .002). On multivariable logistic regression analysis, sex was the only variable associated with any cardiac toxicity and pericardial effusion (P = .0016, P = .0038). None of the other investigated variables were associated with increased risk of cardiac toxicity. CONCLUSIONS Female patients and dose greater than the median for V20-V40 were associated with the development of cardiac toxicity, specifically pericardial effusion. These data suggest exercising increased care when designing radiation fields in women undergoing CRT for esophageal carcinoma, as pericardial effusion may be a long-term complication.
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Cooper SL, Russo JK, Chin S. Definitive chemoradiotherapy for esophageal carcinoma. Surg Clin North Am 2012; 92:1213-48. [PMID: 23026279 DOI: 10.1016/j.suc.2012.07.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Radiation therapy plays an important role in the treatment of esophageal cancer. Radiation therapy may be combined with chemotherapy, used as a component of induction therapy, used in the adjuvant setting, or used for palliation of advanced disease. Chemotherapy is also occasionally used as a solitary treatment modality for patients with esophageal cancer. Current treatment protocols include multiple agents, and agents directed against specific molecular targets have been investigated in clinical trials. This article discusses future directions related to the selection of radiation treatment protocols, novel targeted chemotherapeutic agents, and the selection of patients for surgery.
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Affiliation(s)
- S Lewis Cooper
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, SC 29425, USA
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Roland T, Tryggestad E, Mavroidis P, Hales R, Papanikolaou N. The radiobiological P(+) index for pretreatment plan assessment with emphasis on four-dimensional radiotherapy modalities. Med Phys 2012; 39:6420-30. [PMID: 23039677 DOI: 10.1118/1.4754653] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Radiation treatment modalities will continue to emerge that promise better clinical outcomes albeit technologically challenging to implement. An important question facing the radiotherapy community then is the need to justify the added technological effort for the clinical return. Mobile tumor radiotherapy is a typical example, where 4D tumor tracking radiotherapy (4DTRT) has been proposed over the simpler conventional modality for better results. The modality choice per patient can depend on a wide variety of factors. In this work, we studied the complication-free tumor control probability (P(+)) index, which combines the physical complexity of the treatment plan with the radiobiological characteristics of the clinical case at hand and therefore found to be useful in evaluating different treatment techniques and estimating the expected clinical effectiveness of different radiation modalities. METHODS 4DCT volumes of 18 previously treated lung cancer patients with tumor motion and size ranging from 2 mm to 15 mm and from 4 cc to 462 cc, respectively, were used. For each patient, 4D treatment plans were generated to extract the 4D dose distributions, which were subsequently used with clinically derived radiobiological parameters to compute the P(+) index per modality. RESULTS The authors observed, on average, a statistically significant increase in P(+) of 3.4% ± 3.8% (p < 0.003) in favor of 4DTRT. There was high variability among the patients with a <0.5% up to 13.4% improvement in P(+). CONCLUSIONS The observed variability in the improvement of the clinical effectiveness suggests that the relative benefit of tracking should be evaluated on a per patient basis. Most importantly, this variability could be effectively captured in the computed P(+). The index can thus be useful to discriminate and hence point out the need for a complex modality like 4DTRT over another. Besides tumor mobility, a wide range of other factors, e.g., size, location, fractionation, etc., can affect the relative benefits. Application of the P(+) objective is a simple and effective way to combine these factors in the evaluation of a treatment plan.
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Affiliation(s)
- Teboh Roland
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA.
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Chen KH, Chou YH, Cheng AL. Primary Squamous Cell Carcinoma of the Thyroid With Cardiac Metastases and Right Ventricle Outflow Tract Obstruction. J Clin Oncol 2012; 30:e260-3. [DOI: 10.1200/jco.2011.39.9808] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Ann-Lii Cheng
- National Taiwan University Hospital; National Taiwan University College of Medicine, Taipei; and National Health Research Institutes, Hsinchu, Taiwan
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Siegel R, DeSantis C, Virgo K, Stein K, Mariotto A, Smith T, Cooper D, Gansler T, Lerro C, Fedewa S, Lin C, Leach C, Cannady RS, Cho H, Scoppa S, Hachey M, Kirch R, Jemal A, Ward E. Cancer treatment and survivorship statistics, 2012. CA Cancer J Clin 2012; 62:220-41. [PMID: 22700443 DOI: 10.3322/caac.21149] [Citation(s) in RCA: 2039] [Impact Index Per Article: 169.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Although there has been considerable progress in reducing cancer incidence in the United States, the number of cancer survivors continues to increase due to the aging and growth of the population and improvements in survival rates. As a result, it is increasingly important to understand the unique medical and psychosocial needs of survivors and be aware of resources that can assist patients, caregivers, and health care providers in navigating the various phases of cancer survivorship. To highlight the challenges and opportunities to serve these survivors, the American Cancer Society and the National Cancer Institute estimated the prevalence of cancer survivors on January 1, 2012 and January 1, 2022, by cancer site. Data from Surveillance, Epidemiology, and End Results (SEER) registries were used to describe median age and stage at diagnosis and survival; data from the National Cancer Data Base and the SEER-Medicare Database were used to describe patterns of cancer treatment. An estimated 13.7 million Americans with a history of cancer were alive on January 1, 2012, and by January 1, 2022, that number will increase to nearly 18 million. The 3 most prevalent cancers among males are prostate (43%), colorectal (9%), and melanoma of the skin (7%), and those among females are breast (41%), uterine corpus (8%), and colorectal (8%). This article summarizes common cancer treatments, survival rates, and posttreatment concerns and introduces the new National Cancer Survivorship Resource Center, which has engaged more than 100 volunteer survivorship experts nationwide to develop tools for cancer survivors, caregivers, health care professionals, advocates, and policy makers.
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Affiliation(s)
- Rebecca Siegel
- Surveillance Information, Surveillance Research, American Cancer Society, Atlanta, GA 30303, USA.
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Sardaro A, Petruzzelli MF, D'Errico MP, Grimaldi L, Pili G, Portaluri M. Radiation-induced cardiac damage in early left breast cancer patients: risk factors, biological mechanisms, radiobiology, and dosimetric constraints. Radiother Oncol 2012; 103:133-42. [PMID: 22391054 DOI: 10.1016/j.radonc.2012.02.008] [Citation(s) in RCA: 149] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Revised: 01/30/2012] [Accepted: 02/04/2012] [Indexed: 01/29/2023]
Abstract
Today there is general awareness of the potential damage to the heart in left-sided (more than in right-sided) breast cancer radiotherapy (RT). Historical changes in tumor and heart doses are presented here along with the impact of different RT techniques and volumes. Individual and pharmacological risk factors are also examined with respect to radiation damage. The biological mechanisms of harm are only partially understood, such as the radiobiology of heart damage due to the presence of various radiosensitive structures and their topographic heterogeneity. Furthermore, individual variability may expose patients to higher or lower risks of late cardiac damage or death. Damage mechanisms and radiobiological characteristics in heart irradiation are presented in relation to dosimetric and biological parameters.
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Affiliation(s)
- Angela Sardaro
- University Institute of Radiation Oncology Policlinico di Bari, Italy
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Breast cancer and funnel chest. Strahlenther Onkol 2012; 188:127-35. [DOI: 10.1007/s00066-011-0022-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 10/04/2011] [Indexed: 02/02/2023]
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Cella L, Liuzzi R, Conson M, Torre G, Caterino M, De Rosa N, Picardi M, Camera L, Solla R, Farella A, Salvatore M, Pacelli R. Dosimetric predictors of asymptomatic heart valvular dysfunction following mediastinal irradiation for Hodgkin's lymphoma. Radiother Oncol 2011; 101:316-21. [PMID: 21925755 DOI: 10.1016/j.radonc.2011.08.040] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Revised: 08/04/2011] [Accepted: 08/08/2011] [Indexed: 12/25/2022]
Abstract
PURPOSE To identify dose-heart-volume constraints that correlate with the risk of developing asymptomatic valvular defects (VD) in Hodgkin's lymphoma (HL) patients treated with three-dimensional radiotherapy (RT). PATIENTS AND METHODS Fifty-six patients undergoing cytotoxic chemotherapy (CHT) and involved-field radiation treatment for HL were retrospectively analyzed. Electro-echocardiography was performed before CHT, after CHT, and after RT. For the entire heart, for right and left ventricle (RV, LV), right and left atrium (RA, LA) percentage of volume exceeding 5-30Gy in increment of 5Gy (V(x)), and dosimetric parameters were calculated using 1.6Gy fraction as reference. To evaluate clinical and dosimetric factors possibly associated with VD, univariate and multivariate logistic regression analyses were performed. RESULTS At a median follow up of 70.5 months, 32.1% of patients developed VD (regurgitation and/or stenosis): 25.0% developed mitral, 5.4% developed aortic, and 14.3% tricuspid VD. In particular the percentage of LA exceeding 25Gy (LA-V(25)) and the percentage of LV exceeding 30Gy (LV-V(30)) correlated with mitral and aortic VD with an odds ratio (OR) of 5.7 (LA-V(25)>63.0% vs. LA-V(25)≤63.0%) and OR of 4.4 (LV-V(30)>25% vs. LV-V(30)≤25%), respectively. RV-V(30) correlated with tricuspid VD (OR=7.2, RV-V(30)>65% vs. RV-V(30)≤65%). CONCLUSION LA-V(25), LV- and RV-V(30) prove to be predictors of asymptomatic alteration of valve functionality.
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Affiliation(s)
- Laura Cella
- Institute of Biostructure and Bioimaging, National Research Council of Italy, Naples, Italy
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Mavroidis P, Ferreira BC, Lopes MDC. Response-probability volume histograms and iso-probability of response charts in treatment plan evaluation. Med Phys 2011; 38:2382-97. [PMID: 21776773 DOI: 10.1118/1.3570613] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE This study aims at demonstrating a new method for treatment plan evaluation and comparison based on the radiobiological response of individual voxels. This is performed by applying them on three different cancer types and treatment plans of different conformalities. Furthermore, their usefulness is examined in conjunction with traditionally applied radiobiological and dosimetric treatment plan evaluation criteria. METHODS Three different cancer types (head and neck, breast and prostate) were selected to quantify the benefits of the proposed treatment plan evaluation method. In each case, conventional conformal radiotherapy (CRT) and intensity modulated radiotherapy (IMRT) treatment configurations were planned. Iso-probability of response charts was produced by calculating the response probability in every voxel using the linear-quadratic-Poisson model and the dose-response parameters of the corresponding structure to which this voxel belongs. The overall probabilities of target and normal tissue responses were calculated using the Poisson and the relative seriality models, respectively. The 3D dose distribution converted to a 2 Gy fractionation, D2(GY) and iso-BED distributions are also shown and compared with the proposed methodology. Response-probability volume histograms (RVH) were derived and compared with common dose volume histograms (DVH). The different dose distributions were also compared using the complication-free tumor control probability, P+, the biologically effective uniform dose, D, and common dosimetric criteria. RESULTS 3D Iso-probability of response distributions is very useful for plan evaluation since their visual information focuses on the doses that are likely to have a larger clinical effect in that particular organ. The graphical display becomes independent of the prescription dose highlighting the local radiation therapy effect in each voxel without the loss of important spatial information. For example, due to the exponential nature of the Poisson distribution, cold spots in the target volumes or hot spots in the normal tissues are much easier to be identified. Response-volume histograms, as DVH, can also be derived and used for plan comparison. RVH are advantageous since by incorporating the radiobiological properties of each voxel they summarize the 3D distribution into 2D without the loss of relevant information. Thus, more clinically relevant radiobiological objectives and constraints could be defined and used in treatment planning optimization. These measures become increasingly important when dose distributions need to be designed according to the microscopic biological properties of tumor and normal tissues. CONCLUSIONS The proposed methods do not aim to replace quantifiers like the probabilities of total tissue response, which ultimately are the quantities of interest to evaluate treatment success. However, iso-probability of response charts and response-probability volume histograms illustrates more clearly the difference in effectiveness between different treatment plans than the information provided by alternative dosimetric data. The use of 3D iso-probability of response distributions could serve as a good descriptor of the effectiveness of a dose distribution indicating primarily the regions in a tissue that dominate its response.
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Affiliation(s)
- Panayiotis Mavroidis
- Department of Medical Radiation Physics, Karolinska Institutet and Stockholm University, S-17176 Stockholm, Sweden.
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Abstract
Patients diagnosed with Hodgkin lymphoma have a high cure rate. However, long-term survivors of the disease are at significantly increased risk for a number of late effects, with cardiovascular disease being the most common non-malignant cause of death in these patients. This review summarizes the available data regarding the types of cardiac complications, timing of their onset in relationship to initial treatment, associated risk factors, and available studies on the role of screening for subclinical cardiac disease. Given the known correlation between the extent of Hodgkin lymphoma therapy and subsequent cardiac risks, current trials investigating treatment reduction, including using lower radiation dose, smaller radiation field size and abbreviated chemotherapy will hopefully help in limiting cardiac toxicity. Screening for and aggressive management of traditional cardiac risk factors are also important strategies in reducing risks of cardiac disease in long-term Hodgkin lymphoma survivors.
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Affiliation(s)
- Andrea K Ng
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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Hawkins MA, Bedford JL, Warrington AP, Tait DM. Volumetric modulated arc therapy planning for distal oesophageal malignancies. Br J Radiol 2011; 85:44-52. [PMID: 21427179 DOI: 10.1259/bjr/25428720] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES Volumetric modulated arc therapy (VMAT) is a novel form of intensity-modulated radiation therapy that allows the radiation dose to be delivered in a single gantry rotation using conformal or modulated fields. The capability of VMAT to reduce heart and cord dose, while maintaining lung receiving 20 Gy <20%, was evaluated for chemoradiation for oesophageal cancer. METHODS An optimised forward-planned four-field arrangement was compared with inverse-planned coplanar VMAT arcs with 35 control points for 10 patients with lower gastro-oesophageal tumours prescribed 54 Gy in 30 fractions. Conformal (cARC) and intensity-modulated (VMATi) arcs were considered. Plans were assessed and compared using the planning target volume (PTV) irradiated to 95% of the prescription dose (V95), volumes of lung irradiated to 20 Gy (V20), heart irradiated to 30 Gy (V30), spinal cord maximum dose and van't Riet conformation number (CN). The monitor units per fraction and delivery time were recorded for a single representative plan. RESULTS VMATi provided a significant reduction in the heart V30 (31% vs 55%; p=0.02) with better CN (0.72 vs 0.65; p=0.01) than the conformal plan. The treatment delivery was 1 min 28 s for VMAT compared with 3 min 15 s. CONCLUSION For similar PTV coverage, VMATi delivers a lower dose to organs at risk than conformal plans in a shorter time, and this has warranted clinical implementation.
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Affiliation(s)
- M A Hawkins
- Department of Clinical Oncology, The Royal Marsden NHS Foundation Trust, Sutton, UK.
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Mavroidis P, Su FC, Giantsoudi D, Stathakis S, Komisopoulos G, Shi C, Swanson G, Papanikolaou N. Radiobiological and Dosimetric Analysis of Daily Megavoltage CT Registration on Adaptive Radiotherapy with Helical Tomotherapy. Technol Cancer Res Treat 2011; 10:1-13. [DOI: 10.7785/tcrt.2012.500175] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Pre-treatment patient repositioning in highly conformal image-guided radiation therapy modalities is a prerequisite for reducing setup uncertainties. In Helical Tomotherapy (HT) treatment, a megavoltage CT (MVCT) image is usually acquired to evaluate daily changes in the patient's internal anatomy and setup position. This MVCT image is subsequently compared to the kilovoltage CT (kVCT) study that was used for dosimetric planning, by applying a registration process. This study aims at investigating the expected effect of patient setup correction using the Hi-Art tomotherapy system by employing radiobiological measures such as the biologically effective uniform dose ([Formula: see text]) and the complication-free tumor control probability ( P+). A new module of the Tomotherapy software (TomoTherapy, Inc, Madison, WI) called Planned Adaptive is employed in this study. In this process the delivered dose can be calculated by using the sinogram for each delivered fraction and the registered MVCT image set that corresponds to the patient's position and anatomical distribution for that fraction. In this study, patients treated for lung, pancreas and prostate carcinomas are evaluated by this method. For each cancer type, a Helical Tomotherapy plan was developed. In each cancer case, two dose distributions were calculated using the MVCT image sets before and after the patient setup correction. The fractional dose distributions were added and renormalized to the total number of fractions planned. The dosimetric and radiobiological differences of the dose distributions with and without patient setup correction were calculated. By using common statistical measures of the dose distributions and the P+ and [Formula: see text] concepts and plotting the tissue response probabilities vs. [Formula: see text] a more comprehensive comparison was performed based on radiobiological measures. For the lung cancer case, at the clinically prescribed dose levels of the dose distributions, with and without patient setup correction, the complication-free tumor control probabilities, P+ are 48.5% and 48.9% for a [Formula: see text] of 53.3 Gy. The respective total control probabilities, PB are 56.3% and 56.5%, whereas the corresponding total complication probabilities, PI are 7.9% and 7.5%. For the pancreas cancer case, at the prescribed dose levels of the two dose distributions, the P+ values are 53.7% and 45.7% for a [Formula: see text] of 54.7 Gy and 53.8 Gy, respectively. The respective PB values are 53.7% and 45.8%, whereas the corresponding PI values are ~0.0% and 0.1%. For the prostate cancer case, at the prescribed dose levels of the two dose distributions, the P+ values are 10.9% for a [Formula: see text] of 75.2 Gy and 11.9% for a [Formula: see text] of 75.4 Gy, respectively. The respective PB values are 14.5% and 15.3%, whereas the corresponding PI values are 3.6% and 3.4%. Our analysis showed that the very good daily patient setup and dose delivery were very close to the intended ones. With the exception of the pancreas cancer case, the deviations observed between the dose distributions with and without patient setup correction were within ±2% in terms of P+. In the radiobiologically optimized dose distributions, the role of patient setup correction using MVCT images could appear to be more important than in the cases of dosimetrically optimized treatment plans were the individual tissue radiosensitivities are not precisely considered.
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Affiliation(s)
- P. Mavroidis
- Department of Medical Radiation Physics, Karolinska Institutet and Stockholm University, Sweden
- University Hospital of Larissa, Greece
| | - F-C. Su
- Department of Radiological Sciences, University of Texas Health Science Center, San Antonio, Texas, USA
| | - D. Giantsoudi
- Department of Radiological Sciences, University of Texas Health Science Center, San Antonio, Texas, USA
| | - S. Stathakis
- Department of Radiological Sciences, University of Texas Health Science Center, San Antonio, Texas, USA
| | | | - C. Shi
- Department of Radiological Sciences, University of Texas Health Science Center, San Antonio, Texas, USA
| | - G. Swanson
- Department of Radiological Sciences, University of Texas Health Science Center, San Antonio, Texas, USA
| | - N. Papanikolaou
- Department of Radiological Sciences, University of Texas Health Science Center, San Antonio, Texas, USA
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Mavroidis P, Shi C, Plataniotis GA, Delichas MG, Ferreira BC, Rodriguez S, Lind BK, Papanikolaou N. Comparison of the helical tomotherapy against the multileaf collimator-based intensity-modulated radiotherapy and 3D conformal radiation modalities in lung cancer radiotherapy. Br J Radiol 2011; 84:161-72. [PMID: 20858664 PMCID: PMC3473851 DOI: 10.1259/bjr/89275085] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2009] [Revised: 01/26/2010] [Accepted: 03/03/2010] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES The aim of this study was to compare three-dimensional (3D) conformal radiotherapy and the two different forms of IMRT in lung cancer radiotherapy. METHODS Cases of four lung cancer patients were investigated by developing a 3D conformal treatment plan, a linac MLC-based step-and-shoot IMRT plan and an HT plan for each case. With the use of the complication-free tumour control probability (P(+)) index and the uniform dose concept as the common prescription point of the plans, the different treatment plans were compared based on radiobiological measures. RESULTS The applied plan evaluation method shows the MLC-based IMRT and the HT treatment plans are almost equivalent over the clinically useful dose prescription range; however, the 3D conformal plan inferior. At the optimal dose levels, the 3D conformal treatment plans give an average P(+) of 48.1% for a effective uniform dose to the internal target volume (ITV) of 62.4 Gy, whereas the corresponding MLC-based IMRT treatment plans are more effective by an average ΔP(+) of 27.0% for a Δ effective uniform dose of 16.3 Gy. Similarly, the HT treatment plans are more effective than the 3D-conformal plans by an average ΔP(+) of 23.8% for a Δ effective uniform dose of 11.6 Gy. CONCLUSION A radiobiological treatment plan evaluation can provide a closer association of the delivered treatment with the clinical outcome by taking into account the dose-response relations of the irradiated tumours and normal tissues. The use of P - effective uniform dose diagrams can complement the traditional tools of evaluation to compare and effectively evaluate different treatment plans.
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Affiliation(s)
- P Mavroidis
- Department of Medical Radiation Physics, Karolinska Institutet, Stockholm University, Sweden.
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Mavroidis P, Tzikas A, Papanikolaou N, Lind BK. Toolkit for determination of dose-response relations, validation of radiobiological parameters and treatment plan optimization based on radiobiological measures. Technol Cancer Res Treat 2010; 9:523-37. [PMID: 20815424 DOI: 10.1177/153303461000900511] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Accurately determined dose-response relations of the different tumors and normal tissues should be estimated and used in the clinic. The aim of this study is to demonstrate developed tools that are necessary for determining the dose-response parameters of tumors and normal tissues, for clinically verifying already published parameter sets using local patient materials and for making use of all this information in the optimization and comparison of different treatment plans and radiation techniques. One of the software modules (the Parameter Determination Module) is designed to determine the dose-response parameters of tumors and normal tissues. This is accomplished by performing a maximum likelihood fitting to calculate the best estimates and confidence intervals of the parameters used by different radiobiological models. Another module of this software (the Parameter Validation Module) concerns the validation and compatibility of external or reported dose-response parameters describing tumor control and normal tissue complications. This is accomplished by associating the expected response rates, which are calculated using different models and published parameter sets, with the clinical follow-up records of the local patient population. Finally, the last module of the software (the Radiobiological Plan Evaluation Module) is used for estimating and optimizing the effectiveness a treatment plan in terms of complication-free tumor control, P(+). The use of the Parameter Determination Module is demonstrated by deriving the dose-response relation of proximal esophagus from head and neck cancer radiotherapy. The application of the Parameter Validation Module is illustrated by verifying the clinical compatibility of those dose-response parameters with the examined treatment methodologies. The Radiobiological Plan Evaluation Module is demonstrated by evaluating and optimizing the effectiveness of head and neck cancer treatment plans. The results of the radiobiological evaluation are compared against dosimetric criteria. The presented toolkit appears to be very convenient and efficient for clinical implementation of radiobiological modeling. It can also be used for the development of a clinical data and health information database for assisting the performance of epidemiological studies and the collaboration between different institutions within research and clinical frameworks.
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Affiliation(s)
- Panayiotis Mavroidis
- Department of Medical Radiation Physics, Karolinska Institutet and Stockholm University, Sweden.
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Ng A, Constine LS, Advani R, Das P, Flowers C, Friedberg J, Hodgson DC, Schwartz CL, Wilder RB, Wilson LD, Yunes MJ. ACR Appropriateness Criteria: follow-up of Hodgkin's lymphoma. Curr Probl Cancer 2010; 34:211-27. [PMID: 20541059 DOI: 10.1016/j.currproblcancer.2010.04.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
In the follow-up of Hodgkin's lymphoma patients, the focus in the first 5 years is to detect recurrence, while after 5 years, the focus is on limiting and detecting late effects of treatment. In the first 5 years post-treatment, routine history and physical and computed tomography (CT) imaging (more frequent in the first 2 years) are generally appropriate. However, there are limited data to support the role of positron emission tomography scanning as routine follow-up. Beyond 5 years post-treatment, annual history and physical is appropriate, although there is no longer a role for routine imaging for recurrences. Women irradiated to the chest area at a young age (<35) would benefit from annual mammogram screening given the increased breast cancer risk. Magnetic resonance imaging can be considered, although there is a lack of data supporting its role in this population. Low-dose chest CT for lung cancer screening in patients with history of mediastinal irradiation and/or alkylating chemotherapy exposures and a smoking history can be considered, although data on its utility is lacking. Cardiac screening with echocardiogram and exercise tolerance tests in patients with history of mediastinal irradiation and/or adriamycin exposure may be appropriate, although the optimal screening interval would depend on mediastinal dose, adriamycin dose, presence of other cardiac risk factors and findings at the baseline screening. Patients at risk for cardiac disease due to treatment exposure would also benefit from lipid screening every 1-3 years.
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Doyen J, Giraud P, Belkacemi Y. Dose de tolérance des tissus sains : le cœur. Cancer Radiother 2010; 14:319-26. [DOI: 10.1016/j.canrad.2010.02.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2010] [Accepted: 02/02/2010] [Indexed: 10/19/2022]
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Gagliardi G, Constine LS, Moiseenko V, Correa C, Pierce LJ, Allen AM, Marks LB. Radiation dose-volume effects in the heart. Int J Radiat Oncol Biol Phys 2010; 76:S77-85. [PMID: 20171522 DOI: 10.1016/j.ijrobp.2009.04.093] [Citation(s) in RCA: 464] [Impact Index Per Article: 33.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2008] [Revised: 04/16/2009] [Accepted: 04/16/2009] [Indexed: 11/27/2022]
Abstract
The literature is reviewed to identify the main clinical and dose-volume predictors for acute and late radiation-induced heart disease. A clear quantitative dose and/or volume dependence for most cardiac toxicity has not yet been shown, primarily because of the scarcity of the data. Several clinical factors, such as age, comorbidities and doxorubicin use, appear to increase the risk of injury. The existing dose-volume data is presented, as well as suggestions for future investigations to better define radiation-induced cardiac injury.
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Affiliation(s)
- Giovanna Gagliardi
- Department of Medical Physics, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden.
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Quaranta BP, Das SK, Shafman TD, Light KL, Marks LB. The utility of non-axial treatment beam orientations for lower lobe lung cancers. J Appl Clin Med Phys 2010; 11:3010. [PMID: 20160689 PMCID: PMC5719787 DOI: 10.1120/jacmp.v11i1.3010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Accepted: 10/22/2009] [Indexed: 11/23/2022] Open
Abstract
Traditional treatment beams for non‐small–cell lung cancer are limited to the axial plane. For many tumor geometries, non‐axial orientations appear to reduce the dose to normal tissues (e.g. heart, liver). We hypothesize that non‐axial beams provide a significant reduction in incidental irradiation of the heart and liver, while maintaining adequate target coverage. CT scans of twenty‐four patients with lower lobe lung cancers were studied. For each patient, an opposed oblique axial beam pair and a competing non‐axial opposed oblique pair were generated, both off‐cord. The competing plans delivered comparable doses/margins to the GTV. DVHs and integral doses were computed for all structures of interest for the two competing plans. The integral dose was compared for axial and non‐axial beams for each contoured organ using a paired t‐test. Dose to the heart was significantly lower for the non‐axial plans (p=.0001). For 20/24 patients, the integral heart dose was reduced by using non‐axial beams. In those patients with tumors located in the inferior right lower lobe, a lower dose to the liver was achieved when non‐axial beams were used. There were no meaningful differences in dose to the GTV, lungs, or skin between axial and non‐axial beams. Non‐axial beams can reduce the dose to the heart and liver in patients with lower lobe lung cancers. Non‐axial beams may be clinically beneficial in these patients and should be considered as an option during planning. PACS number: 87.55.de
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Coon AB, Dickler A, Kirk MC, Liao Y, Shah AP, Strauss JB, Chen S, Turian J, Griem KL. Tomotherapy and multifield intensity-modulated radiotherapy planning reduce cardiac doses in left-sided breast cancer patients with unfavorable cardiac anatomy. Int J Radiat Oncol Biol Phys 2009; 78:104-10. [PMID: 20004529 DOI: 10.1016/j.ijrobp.2009.07.1705] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2009] [Revised: 07/21/2009] [Accepted: 07/22/2009] [Indexed: 12/21/2022]
Abstract
PURPOSE For patients with left-sided breast cancers, radiation treatment to the intact breast results in high doses to significant volumes of the heart, increasing the risk of cardiac morbidity, particularly in women with unfavorable cardiac anatomy. We compare helical tomotherapy (TOMO) and inverse planned intensity modulated radiation therapy (IMRT) with three-dimensional conformal radiotherapy using opposed tangents (3D-CRT) for reductions in cardiac volumes receiving high doses. METHODS AND MATERIALS Fifteen patients with left-sided breast cancers and unfavorable cardiac anatomy, determined by a maximum heart depth (MHD) of >or=1.0 cm within the tangent fields, were planned for TOMO and IMRT with five to seven beam angles, in addition to 3D-CRT. The volumes of heart and left ventricle receiving >or=35 Gy (V35) were compared for the plans, as were the mean doses to the contralateral breast and the volume receiving >or=20 Gy (V20) for the ipsilateral lung. RESULTS The mean MHD was 1.7 cm, and a significant correlation was observed between MHD and both heart and left ventricle V35. The V35s for IMRT (0.7%) and TOMO (0.5%) were significantly lower than for 3D-CRT (3.6%). The V20 for IMRT (22%) was significantly higher than for 3D-CRT (15%) or TOMO (18%), but the contralateral breast mean dose for TOMO (2.48 Gy) was significantly higher than for 3D-CRT (0.93 Gy) or IMRT (1.38 Gy). CONCLUSIONS Both TOMO and IMRT can significantly reduce cardiac doses, with modest increases in dose to other tissues in left-sided breast cancer patients with unfavorable cardiac anatomy.
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Affiliation(s)
- Alan B Coon
- Department of Radiation Oncology, Rush University Medical Center, Chicago, IL 60612, USA.
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Abstract
Long-term survivors of Hodgkin's lymphoma are at increased risk for a number of late complications, including development of second malignancies and cardiovascular disease. Treatment-related factors and other modifying risk factors contributing to the risk of late effects have been identified. Survivors deemed at increased risk based on their treatment history and other exposures may benefit from early detection for late complications and risk reduction strategies. However, the optimal screening tests and prevention program, and their timing and frequency are not clear. It should be noted that treatment for Hodgkin's lymphoma has undergone considerable changes over the last several decades. Most of the current data on late effects after Hodgkin's lymphoma are based on patients treated with outdated chemotherapy and radiation therapy. As Hodgkin's lymphoma therapy evolve over time, continued documentation of late effects associated with newer treatment will be important for the follow-up of patients treated in the modern era.
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Mavroidis P, Stathakis S, Gutierrez A, Esquivel C, Shi C, Papanikolaou N. Expected clinical impact of the differences between planned and delivered dose distributions in helical tomotherapy for treating head and neck cancer using helical megavoltage CT images. J Appl Clin Med Phys 2009; 10:125-139. [PMID: 19692977 PMCID: PMC5720549 DOI: 10.1120/jacmp.v10i3.2969] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2008] [Revised: 01/04/2009] [Accepted: 04/23/2009] [Indexed: 11/23/2022] Open
Abstract
Helical Tomotherapy (HT) has become increasingly popular over the past few years. However, its clinical efficacy and effectiveness continues to be investigated. Pre-treatment patient repositioning in highly conformal image-guided radiation therapy modalities is a prerequisite for reducing setup uncertainties. A MVCT image set has to be acquired to account for daily changes in the patient's internal anatomy and setup position. Furthermore, a comparison should be performed to the kVCT study used for dosimetric planning, by a registration process which results in repositioning the patient according to specific transitional and rotational shifts. Different image registration techniques may lead to different repositioning of the patient and, as a result, to varying delivered doses. This study aims to investigate the expected effect of patient setup correction using the Hi-Art tomotherapy system by employing radiobiological measures such as the biologically effective uniform dose (BEUD) and the complication-free tumor control probability (P+). In this study, a typical case of lung cancer with metastatic head & neck disease was investigated by developing a Helical Tomotherapy plan. For the Tomotherapy HiArt plan, the dedicated Tomotherapy treatment planning station was used. Three dose distributions (planned and delivered with and without patient setup correction) were compared based on radiobiological measures by using the P+ index and the BEUD concept as the common prescription point of the plans and plotting the tissue response probabilities against the mean target dose for a range of prescription doses. The applied plan evaluation method shows that in this cancer case the planned and delivered dose distributions with and without patient setup correction give a P+ of 81.6%, 80.9% and 72.2%, for a BEUD to the planning target volume (PTV) of 78.0Gy, 77.7Gy and 75.4Gy, respectively. The corresponding tumor control probabilities are 86.3%, 85.1% and 75.1%, whereas the total complication probabilities are 4.64%, 4.20% and 2.89%, respectively. HT can encompass the often large PTV required while minimizing the volume of the organs at risk receiving high dose. However, the effectiveness of a HT treatment plan can be considerably deteriorated if an accurate patient setup system is not available. Taking into account the dose-response relations of the irradiated tumors and normal tissues, a radiobiological treatment plan evaluation can be performed, which may provide a closer association of the delivered treatment with the clinical outcome. In such situations, for effective evaluation and comparison of different treatment plans, traditional dose based evaluation tools can be complemented by the use of P+,BEUD diagrams.
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Affiliation(s)
- Panayiotis Mavroidis
- Department of Medical Radiation PhysicsKarolinska Institutet and Stockholm UniversityStockholmSweden
- Department of Medical PhysicsLarissa University HospitalLarissaGreece
| | - Sotirios Stathakis
- Department of Radiological SciencesUniversity of Texas Health Sciences CenterSan AntonioTXUSA
| | - Alonso Gutierrez
- Department of Radiological SciencesUniversity of Texas Health Sciences CenterSan AntonioTXUSA
| | - Carlos Esquivel
- Department of Radiological SciencesUniversity of Texas Health Sciences CenterSan AntonioTXUSA
| | - Chenyu Shi
- Department of Radiological SciencesUniversity of Texas Health Sciences CenterSan AntonioTXUSA
| | - Nikos Papanikolaou
- Department of Radiological SciencesUniversity of Texas Health Sciences CenterSan AntonioTXUSA
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Adamus-Górka M, Brahme A, Mavroidis P, Lind BK. Variation in radiation sensitivity and repair kinetics in different parts of the spinal cord. Acta Oncol 2009; 47:928-36. [PMID: 18568487 DOI: 10.1080/02841860701864668] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The spinal cord, known for its strongly serial character and high sensitivity to radiation even when a small segment is irradiated, is one of the most critical organs at risk to be spared during radiation therapy. To compare the sensitivity of different parts of the spinal cord, data for radiation myelopathy have been used. MATERIAL AND METHODS In the present study, the relative seriality model was fitted to two different datasets of clinical radiation myelitis concerning cervical spinal cord after treating 248 patients for head and neck cancer and thoracic spinal cord after treating 43 patients with lung carcinoma. The maximum likelihood method was applied to fit the clinical data. The model parameters and their 68% confidence intervals were calculated for each dataset. The alpha/beta ratio for the thoracic cord was also was also found to be 0.9 (0-3.0) Gy. RESULTS The dose-response curve for the more sensitive cervical myelopathy is well described by the parameters D(50)=55.9 (54.8-57.1) Gy, gamma=6.9 (5.0-9.2), s=0.13 (0.07-0.24), whereas the thoracic myelopathy is described by the parameters D(50)=75.5 (70.5-80.8) Gy, gamma=1.1 (0.6-1.6), s=36 (3.3-infinity). DISCUSSION AND CONCLUSIONS Large differences in radiation response between the cervical and thoracic region of spinal cord are thus observed: cervical myelopathy seems to be characterized by medium seriality, while thoracic spinal cord is characterized by a highly serial dose-response. The much steeper dose-response curve for cervical spinal cord myelopathy can be interpreted as a higher number of functional subunits consistent with a higher amount of white matter close to the brain.
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Lohr F, Heggemann F, Papavassiliu T, El-Haddad M, Tomé O, Dinter D, Dobler B, Kraus-Tiefenbacher U, Borggrefe M, Wenz F. [Is cardiotoxicity still an issue after breast-conserving surgery and could it be reduced by multifield IMRT?]. Strahlenther Onkol 2009; 185:222-30. [PMID: 19370424 DOI: 10.1007/s00066-009-1892-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2008] [Accepted: 01/09/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Postoperative radiotherapy after breast cancer surgery effectively reduces local relapses. A survival benefit after breast conservation, however, has only been proven recently which was in part due to excessive cardiac mortality of patients who had been treated with radiotherapy in the past. MATERIAL AND METHODS The literature on postoperative radiotherapy for breast cancer was reviewed with regard to cardiac toxicity as the basis for hypothesis generation. RESULTS From numerous publications on cardiac toxicity of breast cancer radiotherapy, the following pattern emerges: in series where a high radiation dose was applied to a significant percentage of the heart (postmastectomy and postlumpectomy series) cardiac toxicity/mortality was increased versus a nonexposed cohort or for left over right disease. If, however, a relevant exposure of cardiac muscle could be more or less excluded based on the technique used (mainly more recent postlumpectomy radiotherapy), no cardiac toxicity was observed. Series for which individual dose exposure varied or could not be clarified also came to varying conclusions. Also due to retrospectively unclear dose distributions, an exact quantification of tolerance doses/effects of different geographic dose distribution patterns could not be performed to date. A particularly difficult question to answer is the threshold volume for clinically relevant cardiotoxicity with tangential radiotherapy at prescription doses. As a consequence, this precludes an estimate in which situations multifield intensity-modulated radiotherapy (IMRT) with its characteristic dose distribution pattern of a larger volume exposed to intermediate doses and higher mean/median heart doses (as shown in Figure 1) might be preferable. CONCLUSION This review updates the database on cardiac toxicity of breast cancer radiotherapy with special emphasis regarding the issues related to the clinical use of IMRT. Multifield IMRT may reduce the cardiac risk for a small subset of patients at excessive risk with conventional tangential radiotherapy due to unfavorable thoracic geometry, for whom partial-breast radiotherapy is not an option. Due to further concern about the effects of intermediate doses to larger heart volumes, potentially increased contralateral cancer risk and the long latency of clinically apparent toxicity, the introduction of breast IMRT should be closely followed. Accompanying functional studies may have the potential to detect cardiac toxicity at an earlier time.
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Affiliation(s)
- Frank Lohr
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Mannheim, Germany.
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Mavroidis P, Ferreira BC, Shi C, Delichas MG, Lind BK, Papanikolaou N. Comparison of the helical tomotherapy and MLC-based IMRT radiation modalities in treating brain and cranio-spinal tumors. Technol Cancer Res Treat 2009; 8:3-14. [PMID: 19166237 DOI: 10.1177/153303460900800102] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
The investigation of the clinical efficacy and effectiveness of Intensity Modulated Radiotherapy (IMRT) using Multileaf Collimators (MLC) and Helical Tomotherapy (HT) has been an issue of increasing interest over the past few years. In order to assess the suitability of a treatment plan, dosimetric criteria such as dose-volume histograms (DVH), maximum, minimum, mean, and standard deviation of the dose distribution are typically used. Nevertheless, the radiobiological parameters of the different tumors and normal tissues are often not taken into account. The use of the biologically effective uniform dose (D=) together with the complication-free tumor control probability (P(+)) were applied to evaluate the two radiation modalities. Two different clinical cases of brain and cranio-spinal axis cancers have been investigated by developing a linac MLC-based step-and-shoot IMRT plan and a Helical Tomotherapy plan. The treatment plans of the MLC-based IMRT were developed on the Philips treatment planning station using the Pinnacle 7.6 software release while the dedicated Tomotherapy treatment planning station was used for the HT plan. With the use of the P(+) index and the D(=) concept as the common prescription point, the different treatment plans were compared based on radiobiological measures. The tissue response probabilities were plotted against D(=) for a range of prescription doses. The applied plan evaluation method shows that in the brain cancer, the HT treatment gives slightly better results than the MLC-based IMRT in terms of optimum expected clinical outcome (P(+) of 66.1% and 63.5% for a D(=) to the PTV of 63.0 Gy and 62.0 Gy, respectively). In the cranio-spinal axis cancer, the HT plan is significantly better compared to the MLC-based IMRT plan over the clinically useful dose prescription range (P(+) of 84.1% and 28.3% for a D(=) to the PTV of 50.6 Gy and 44.0 Gy, respectively). If a higher than 5% risk for complications could be allowed, the complication-free tumor control could be increased by almost 30% compared to the initial dose prescription. In comparison to MLC based-IMRT, HT can better encompass the often large PTV while minimizing the volume of the OARs receiving high dose. A radiobiological treatment plan evaluation can provide a closer association of the delivered treatment with the clinical outcome by taking into account the dose-response relations of the irradiated tumors and normal tissues. The use of P - (D=) diagrams can complement the traditional tools of evaluation such as DVHs, in order to compare and effectively evaluate different treatment plans.
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Affiliation(s)
- Panayiotis Mavroidis
- Department of Medical Radiation Physics, Karolinska Institutet and Stockholm University, Stockholm, Sweden.
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