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Dong Q, Xue T, Yan H, Liu F, Liu R, Zhang K, Chong Y, Du J, Zhang H. Radiotherapy combined with nano-biomaterials for cancer radio-immunotherapy. J Nanobiotechnology 2023; 21:395. [PMID: 37899463 PMCID: PMC10614396 DOI: 10.1186/s12951-023-02152-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 10/09/2023] [Indexed: 10/31/2023] Open
Abstract
Radiotherapy (RT) plays an important role in tumor therapy due to its noninvasiveness and wide adaptation. In recent years, radiation therapy has been discovered to induce an anti-tumor immune response, which arouses widespread concern among scientists and clinicians. In this review, we highlight recent advances in the applications of nano-biomaterials for radiotherapy-activated immunotherapy. We first discuss the combination of different radiosensitizing nano-biomaterials and immune checkpoint inhibitors to enhance tumor immune response and improve radiotherapy efficacy. Subsequently, various nano-biomaterials-enabled tumor oxygenation strategies are introduced to alleviate the hypoxic tumor environment and amplify the immunomodulatory effect. With the aid of nano-vaccines and adjuvants, radiotherapy refreshes the host's immune system. Additionally, ionizing radiation responsive nano-biomaterials raise innate immunity-mediated anti-tumor immunity. At last, we summarize the rapid development of immune modulatable nano-biomaterials and discuss the key challenge in the development of nano-biomaterials for tumor radio-immunotherapy. Understanding the nano-biomaterials-assisted radio-immunotherapy will maximize the benefits of clinical radiotherapy and immunotherapy and facilitate the development of new combinational therapy modality.
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Affiliation(s)
- Qingrong Dong
- Department of Medical Imaging, First Hospital of Shanxi Medical University, Intelligent Imaging Big Data and Functional Nano-Imaging Engineering Research Center of Shanxi Province, Taiyuan, 030001, People's Republic of China
| | - Tingyu Xue
- Department of Medical Imaging, First Hospital of Shanxi Medical University, Intelligent Imaging Big Data and Functional Nano-Imaging Engineering Research Center of Shanxi Province, Taiyuan, 030001, People's Republic of China
| | - Haili Yan
- Department of Medical Imaging, First Hospital of Shanxi Medical University, Intelligent Imaging Big Data and Functional Nano-Imaging Engineering Research Center of Shanxi Province, Taiyuan, 030001, People's Republic of China
| | - Fang Liu
- College of Pharmacy, Shanxi Medical University, Jinzhong, 030619, People's Republic of China
| | - Ruixue Liu
- Department of Medical Imaging, First Hospital of Shanxi Medical University, Intelligent Imaging Big Data and Functional Nano-Imaging Engineering Research Center of Shanxi Province, Taiyuan, 030001, People's Republic of China
| | - Kun Zhang
- College of Pharmacy, Shanxi Medical University, Jinzhong, 030619, People's Republic of China
| | - Yu Chong
- State Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection School for Radiological and Interdisciplinary Sciences (RAD-X) Collaborative Innovation Center of Radiation Medicine of Jiangsu Higher Education Institutions, Soochow University, Suzhou, 215123, People's Republic of China.
| | - Jiangfeng Du
- Department of Medical Imaging, First Hospital of Shanxi Medical University, Intelligent Imaging Big Data and Functional Nano-Imaging Engineering Research Center of Shanxi Province, Taiyuan, 030001, People's Republic of China.
- College of Pharmacy, Shanxi Medical University, Jinzhong, 030619, People's Republic of China.
- Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Shanxi Medical University, Taiyuan, 030001, People's Republic of China.
| | - Hui Zhang
- Department of Medical Imaging, First Hospital of Shanxi Medical University, Intelligent Imaging Big Data and Functional Nano-Imaging Engineering Research Center of Shanxi Province, Taiyuan, 030001, People's Republic of China.
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Li C, Chen J, Zhu J, Gong G, Tao C, Li Z, Lu J, Yin Y. Plan quality comparison for cervical carcinoma treated with Halcyon and Trilogy intensity-modulated radiotherapy. J Cancer 2019; 10:6135-6141. [PMID: 31762823 PMCID: PMC6856582 DOI: 10.7150/jca.32500] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 08/18/2019] [Indexed: 11/09/2022] Open
Abstract
Purpose: Varian Halcyon is a novel machine with dual-layer leaves, single flattening filter free (FFF) energy and an enclosed bore. The purpose of this study was to compare the differences in dosimetry and plan parameters of intensity-modulated radiation therapy (IMRT) plans between the Halcyon and Trilogy accelerators. Methods and Materials: A total of 30 IMRT plans from cervical carcinoma patients were retrospectively analyzed on the Trilogy and Eclipse v13.5 treatment planning systems (TPSs). For each patient, a new plan based on Halcyon was created with the same planning parameters and optimization constraints using the Eclipse Version 15.1 TPS. To compare plan qualities, dosimetry parameters regarding planning target volume (PTV), organs at risk (OARs), monitor unit (MU) efficiency, segment size and treatment time were evaluated. Evaluation of the helical diode array system was performed with gamma-index analysis. Results: The dose distribution of the target volume of the Halcyon and Trilogy plans showed no significant difference (p > 0.05). The mean doses of rectum and both femoral heads for Halcyon plans were significantly reduced compared to those for Trilogy plans (p < 0.05). Compared to Trilogy, Halcyon increased the number of MUs from 1542.9±248.3 MU to 2514.9±328.2 MU (p = 0.00) and decreased the delivery time from 11.28±1.36 min to 3.26±0.26 min (p = 0.00). The average segment areas of Halcyon plans for proximal and distal multileaf collimators (MLCs) were 42.1 ± 31.2 cm2 and 28.4 ± 23.7 cm2, respectively, and that of Trilogy plans was 27.3 ± 16.9 cm2. The mean gamma index (3 mm/3%) results for the Halcyon and Trilogy plans were 99.41±0.26 and 99.76±0.32 (p > 0.05), respectively. Conclusions: All Halcyon treatment plans were recognized as clinically acceptable and had statistically better OAR sparing with higher delivery efficiency. The Halcyon system exhibited fast treatment delivery of IMRT with good dosimetric agreement using ArcCHECK.
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Affiliation(s)
| | | | | | | | | | | | | | - Yong Yin
- Department of Radiation Oncology Physics, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan 250117, China
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Chen Q, Chen J, Yang Z, Xu J, Xu L, Liang C, Han X, Liu Z. Nanoparticle-Enhanced Radiotherapy to Trigger Robust Cancer Immunotherapy. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2019; 31:e1802228. [PMID: 30663118 DOI: 10.1002/adma.201802228] [Citation(s) in RCA: 377] [Impact Index Per Article: 75.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 10/15/2018] [Indexed: 05/17/2023]
Abstract
External radiotherapy is extensively used in clinic to destruct tumors by locally applied ionizing-radiation beams. However, the efficacy of radiotherapy is usually limited by tumor hypoxia-associated radiation resistance. Moreover, as a local treatment technique, radiotherapy can hardly control tumor metastases, the major cause of cancer death. Herein, core-shell nanoparticles based poly(lactic-co-glycolic) acid (PLGA) are fabricate, by encapsulating water-soluble catalase (Cat), an enzyme that can decompose H2 O2 to generate O2 , inside the inner core, and loading hydrophobic imiquimod (R837), a Toll-like-receptor-7 agonist, within the PLGA shell. The formed PLGA-R837@Cat nanoparticles can greatly enhance radiotherapy efficacy by relieving the tumor hypoxia and modulating the immune-suppressive tumor microenvironment. The tumor-associated antigens generated postradiotherapy-induced immunogenic cell death in the presence of such R837-loaded adjuvant nanoparticles will induce strong antitumor immune responses, which together with cytotoxic T-lymphocyte associated protein 4 (CTLA-4) checkpoint blockade will be able to effectively inhibit tumor metastases by a strong abscopal effect. Moreover, a long term immunological memory effect to protect mice from tumor rechallenging is observed post such treatment. This work thus presents a unique nanomedicine approach as a next-generation radiotherapy strategy to enable synergistic whole-body therapeutic responses after local treatment, greatly promising for clinical translation.
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Affiliation(s)
- Qian Chen
- Institute of Functional Nano and Soft Materials (FUNSOM), Jiangsu Key Laboratory for Carbon-based Functional Materials and Devices, Soochow University, Suzhou, Jiangsu, 215123, China
| | - Jiawen Chen
- Institute of Functional Nano and Soft Materials (FUNSOM), Jiangsu Key Laboratory for Carbon-based Functional Materials and Devices, Soochow University, Suzhou, Jiangsu, 215123, China
| | - Zhijuan Yang
- Institute of Functional Nano and Soft Materials (FUNSOM), Jiangsu Key Laboratory for Carbon-based Functional Materials and Devices, Soochow University, Suzhou, Jiangsu, 215123, China
| | - Jun Xu
- Institute of Functional Nano and Soft Materials (FUNSOM), Jiangsu Key Laboratory for Carbon-based Functional Materials and Devices, Soochow University, Suzhou, Jiangsu, 215123, China
| | - Ligeng Xu
- Institute of Functional Nano and Soft Materials (FUNSOM), Jiangsu Key Laboratory for Carbon-based Functional Materials and Devices, Soochow University, Suzhou, Jiangsu, 215123, China
| | - Chao Liang
- Institute of Functional Nano and Soft Materials (FUNSOM), Jiangsu Key Laboratory for Carbon-based Functional Materials and Devices, Soochow University, Suzhou, Jiangsu, 215123, China
| | - Xiao Han
- Institute of Functional Nano and Soft Materials (FUNSOM), Jiangsu Key Laboratory for Carbon-based Functional Materials and Devices, Soochow University, Suzhou, Jiangsu, 215123, China
| | - Zhuang Liu
- Institute of Functional Nano and Soft Materials (FUNSOM), Jiangsu Key Laboratory for Carbon-based Functional Materials and Devices, Soochow University, Suzhou, Jiangsu, 215123, China
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Chen Q, Chen M, Liu Z. Local biomaterials-assisted cancer immunotherapy to trigger systemic antitumor responses. Chem Soc Rev 2019; 48:5506-5526. [DOI: 10.1039/c9cs00271e] [Citation(s) in RCA: 129] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Cancer immunotherapy by educating or stimulating patients’ own immune systems to attack cancer cells has demonstrated promising therapeutic responses in the clinic.
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Affiliation(s)
- Qian Chen
- Institute of Functional Nano & Soft Materials (FUNSOM)
- Jiangsu Key Laboratory for Carbon-Based Functional Materials & Devices
- Soochow University
- Suzhou
- P. R. China
| | - Muchao Chen
- Institute of Functional Nano & Soft Materials (FUNSOM)
- Jiangsu Key Laboratory for Carbon-Based Functional Materials & Devices
- Soochow University
- Suzhou
- P. R. China
| | - Zhuang Liu
- Institute of Functional Nano & Soft Materials (FUNSOM)
- Jiangsu Key Laboratory for Carbon-Based Functional Materials & Devices
- Soochow University
- Suzhou
- P. R. China
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Brito Delgado A, Cohen D, Eng T, Stanley D, Shi Z, Charlton M, Gutiérrez A. Modeling the target dose fall-off in IMRT and VMAT planning techniques for cervical SBRT. Med Dosim 2018; 43:1-10. [DOI: 10.1016/j.meddos.2017.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 07/17/2017] [Accepted: 07/19/2017] [Indexed: 10/18/2022]
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Feng Z, Tao C, Zhu J, Chen J, Yu G, Qin S, Yin Y, Li D. An integrated strategy of biological and physical constraints in biological optimization for cervical carcinoma. Radiat Oncol 2017; 12:64. [PMID: 28376900 PMCID: PMC5379684 DOI: 10.1186/s13014-017-0784-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 02/22/2017] [Indexed: 01/19/2023] Open
Abstract
Background For cervical carcinoma cases, this study aimed to evaluate the quality of intensity-modulated radiation therapy (IMRT) plans optimized by biological constraints. Furthermore, a new integrated strategy in biological planning module was proposed and verified. Methods Twenty patients of advanced stage cervical carcinoma were enrolled in this study. For each patient, dose volume optimization (DVO), biological model optimization (BMO) and integrated strategy optimization (ISO) plans were created using same treatment parameters. Different biological models were also used for organ at risk (OAR) in BMO plans, which include the LKB and Poisson models. Next, BMO plans were compared with their corresponding DVO plans, in order to evaluate BMO plan quality. ISO plans were also compared with DVO and BMO plans, in order to verify the performance of the integrated strategy. Results BMO plans produced slightly inhomogeneity and less coverage of planning target volume (PTV) (V95=96.79, HI = 0.10: p < 0.01). However, the tumor control probability (TCP) value, both from DVO and BMO plans, were comparable. For the OARs, BMO plans produced lower normal tissue complication probability (NTCP) of rectum (NTCP = 0.11) and bladder (NTCP = 0.14) than in the corresponding DVO plans (NTCP = 0.19 and 0.18 for rectum and bladder; p < 0.01 for rectum and p = 0.03 for bladder). V95, D98, CI and HI values that were produced by ISO plans (V95 = 98.31, D98 = 54.18Gy, CI = 0.76, HI = 0.09) were greatly better than BMO plans (V95 = 96.79, D98 = 53.42Gy, CI = 0.71, HI = 0.10) with significant differences. Furthermore, ISO plans produced lower NTCP values of rectum (NTCP = 0.14) and bladder (NTCP = 0.16) than DVO plans (NTCP = 0.19 and 0.18 for rectum and bladder, respectively) with significant differences. Conclusions BMO plans produced lower NTCP values of OARs compared to DVO plans for cervical carcinoma cases, and resulted in slightly less target coverage and homogeneity. The integrated strategy, proposed in this study, could improve the coverage, conformity and homogeneity of PTV greater than the BMO plans, as well as reduce the NTCP values of OARs greater than the DVO plans.
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Affiliation(s)
- Ziwei Feng
- Shandong Province Key Laboratory of Medical Physics and Image Processing Technology, Institute of Biomedical Sciences, School of Physics and Electronics, Shandong Normal University, No.88, Wenhua East Road, Lixia District, Jinan, 250014, China
| | - Cheng Tao
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, No.440, Jiyan Road, Jinan, 250117, China
| | - Jian Zhu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, No.440, Jiyan Road, Jinan, 250117, China
| | - Jinhu Chen
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, No.440, Jiyan Road, Jinan, 250117, China
| | - Gang Yu
- Shandong Province Key Laboratory of Medical Physics and Image Processing Technology, Institute of Biomedical Sciences, School of Physics and Electronics, Shandong Normal University, No.88, Wenhua East Road, Lixia District, Jinan, 250014, China
| | - Shaohua Qin
- Shandong Province Key Laboratory of Medical Physics and Image Processing Technology, Institute of Biomedical Sciences, School of Physics and Electronics, Shandong Normal University, No.88, Wenhua East Road, Lixia District, Jinan, 250014, China
| | - Yong Yin
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, No.440, Jiyan Road, Jinan, 250117, China
| | - Dengwang Li
- Shandong Province Key Laboratory of Medical Physics and Image Processing Technology, Institute of Biomedical Sciences, School of Physics and Electronics, Shandong Normal University, No.88, Wenhua East Road, Lixia District, Jinan, 250014, China.
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Mazzola R, Ricchetti F, Fiorentino A, Levra NG, Fersino S, Di Paola G, Ruggieri R, Alongi F. Weekly Cisplatin and Volumetric-Modulated Arc Therapy With Simultaneous Integrated Boost for Radical Treatment of Advanced Cervical Cancer in Elderly Patients: Feasibility and Clinical Preliminary Results. Technol Cancer Res Treat 2016; 16:310-315. [PMID: 27402633 DOI: 10.1177/1533034616655055] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND To evaluate the feasibility and clinical preliminary results of weekly cisplatin and volumetric-modulated arc therapy to the pelvis with simultaneous integrated boost to macroscopic disease in a cohort of elderly patients. MATERIALS AND METHODS Inclusion criteria of this prospective study were age ≥70 years, Karnofsky performance status 70 to 100, locally advanced histologically proven squamous cervical carcinoma, and patients unable to undergo brachytherapy. Radiation doses prescribed were 66 Gy to the macroscopic disease and 54 Gy to the pelvic nodes in 30 fractions. Weekly cisplatin dose was 40 mg/mq. RESULTS A total of 30 patients were recruited. Median follow-up was 32 months (range: 8-48 months). Median age was 72 years (range: 70-84 years). The 3-year overall survival and local control were 93% and 80%, respectively. The median time to progression was 24 months (range: 6-30 months). Analyzing clinical outcome grouping based on the stage of disease, II versus III, the 3-year overall survival was 100% and 85%, respectively. The 3-year local control was 91% for stage II and 67% for stage III. Acute and late toxicities were acceptable without severe events. CONCLUSION Weekly cisplatin and volumetric-modulated arc therapy-simultaneous integrated boost for radical treatment of advanced cervical cancer in the current cohort of elderly patients were feasible. Long-term results and prospective randomized trials are advocated.
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Affiliation(s)
- Rosario Mazzola
- 1 Radiation Oncology, Sacro Cuore Don Calabria-Cancer Care Center, Negrar, Verona, Italy
| | - Francesco Ricchetti
- 1 Radiation Oncology, Sacro Cuore Don Calabria-Cancer Care Center, Negrar, Verona, Italy
| | - Alba Fiorentino
- 1 Radiation Oncology, Sacro Cuore Don Calabria-Cancer Care Center, Negrar, Verona, Italy
| | - Niccolò Giaj Levra
- 1 Radiation Oncology, Sacro Cuore Don Calabria-Cancer Care Center, Negrar, Verona, Italy
| | - Sergio Fersino
- 1 Radiation Oncology, Sacro Cuore Don Calabria-Cancer Care Center, Negrar, Verona, Italy
| | | | - Ruggero Ruggieri
- 1 Radiation Oncology, Sacro Cuore Don Calabria-Cancer Care Center, Negrar, Verona, Italy
| | - Filippo Alongi
- 1 Radiation Oncology, Sacro Cuore Don Calabria-Cancer Care Center, Negrar, Verona, Italy
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Al Feghali KA, Elshaikh MA. Why brachytherapy boost is the treatment of choice for most women with locally advanced cervical carcinoma? Brachytherapy 2016; 15:191-9. [DOI: 10.1016/j.brachy.2015.12.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 11/23/2015] [Accepted: 12/07/2015] [Indexed: 10/22/2022]
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An assessment of interfractional bladder, rectum and vagina motion in postoperative cervical cancer based on daily cone-beam computed tomography. Mol Clin Oncol 2015; 4:271-277. [PMID: 26893874 DOI: 10.3892/mco.2015.704] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 09/08/2015] [Indexed: 02/05/2023] Open
Abstract
Interfractional variations of the bladder, rectum and vagina may affect the accuracy of postoperative intensity-modulated radiotherapy in patients with cervical cancer. This study aimed to assess the interfractional variations with daily kV cone-beam computed tomography (CBCT). All the patients were instructed to control the filling status of the bladder and rectum. CBCT images were obtained daily after set-up and the bladder, rectum and vagina were contoured on each CBCT scan. All the contours were transferred to the planning CT following image fusion. Interfractional variations in pelvic organs were assessed with CBCT based on two reference lines, which were identified as A (the midsaggital line across the superior border of pubic symphysis) and B (a parallel line 1.5 cm above line A). The mean volume (range) of the bladder and rectum was 156.5 (1.7-626.5) and 48.2 (11.3-139.7) ml, respectively. The uniform planning target volume (PTV) margin of 10 mm failed to encompass the vagina in 17.3 and 18.1% of the fractions on lines A and B, respectively. The motion of the vagina (standard deviation) was 0.3 (0.3) and 0.1 (0.5) cm on lines A and B, respectively. The anteroposterior dimension and position of the vagina were significantly affected by the filling status of the bladder (P<0.05), but not by that of the rectum. Although instructions were given, the interfractional variations of the vagina and other pelvic organs were significant, which may exceed the uniform PTV margin; therefore, more effective methods to decrease these variations should be investigated.
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Cihoric N, Tsikkinis A, Tapia C, Aebersold DM, Zlobec I, Lössl K. Dose escalated intensity modulated radiotherapy in the treatment of cervical cancer. Radiat Oncol 2015; 10:240. [PMID: 26597282 PMCID: PMC4657246 DOI: 10.1186/s13014-015-0551-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Accepted: 11/18/2015] [Indexed: 02/01/2023] Open
Abstract
PURPOSE Standard dose of external beam radiotherapy seems to be insufficient for satisfactory control of loco-regionally advanced cervical cancer. Aim of our study is to evaluate the outcome as well as early and chronic toxicities in patients with loco-regionally advanced cervical cancer, treated with dose escalated intensity modulated radiotherapy (IMRT) combined with cisplatin chemotherapy. MATERIAL AND METHODS Thirty-nine patients with cervical carcinoma FIGO stage IB2 - IVA were treated with curative intent between 2006 and 2010. The dose of 50.4 Gy was prescribed to the elective pelvic nodal volume. Primary tumors < 4 cm in diameter (n = 6; 15.4 %) received an external beam radiotherapy (EBRT) boost of 5.4 Gy, primary tumors > 4 cm in diameter (n = 33; 84.6 %) received an EBRT boost of 9 Gy. Patients with positive lymph nodes detected with (18)FDG-PET/CT (n = 22; 56.4 %) received a boost to a total dose of 59.4 - 64.8 Gy. The para-aortic region was included in the radiation volume in 8 (20.5 %) patients and in 5 (12.8 %) patients the para-aortic macroscopic lymph nodes received an EBRT boost. IMRT was followed with a 3D planned high dose rate intrauterine brachytherapy given to 36 (92.3 %) patients with a total dose ranging between 15-18 Gy in three fractions (single fraction: 4-6.5 Gy). Patients without contraindications (n = 31/79.5 %) received concomitantly a cisplatin-based chemotherapy (40 mg/kg) weekly. Toxicities were graded according to the common terminology criteria for adverse events (CTCAE v 4.0). RESULTS Mean overall survival for the entire cohort was 61.1 months (±3.5 months). Mean disease free survival was 47.2 months (±4.9 months) and loco-regional disease free survival was 55.2 months (±4.4 months). 65 % of patients developed radiotherapy associated acute toxicities grade 1, ca. 30 % developed toxicities grade 2 and just two (5.2 %) patients developed grade 3 toxicities, one acute diarrhea and one acute cystitis. 16 % of patients had chronic toxicities grade 1, 9 % grade 2 and one patient (2.6 %) toxicities grade 3 in the form of vaginal dryness. CONCLUSION Dose escalated IMRT appears to have a satisfactory outcome with regards to mean overall survival, disease free and loco-regional disease free survival, whereas the treatment-related toxicities remain reasonably low.
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Affiliation(s)
- Nikola Cihoric
- Department of Radiation Oncology, Bern University Hospital & University of Bern, Bern, Switzerland.
| | - Alexandros Tsikkinis
- Department of Radiation Oncology, Bern University Hospital & University of Bern, Bern, Switzerland.
| | - Coya Tapia
- University of Bern, Institute for Pathology, Murtenstrasse 31, Bern, 3010, Switzerland. .,Department of Translational Molecular Pathology, University of Texas MD Anderson Cancer Center Life Science Plaza, 2130 W. Holcombe, Blvd. Unit 2951, Houston, 77030, TX, USA.
| | - Daniel M Aebersold
- Department of Radiation Oncology, Bern University Hospital & University of Bern, Bern, Switzerland.
| | - Inti Zlobec
- University of Bern, Institute for Pathology, Murtenstrasse 31, Bern, 3010, Switzerland.
| | - Kristina Lössl
- Department of Radiation Oncology, Bern University Hospital & University of Bern, Bern, Switzerland.
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Upasani MN, Chopra S, Engineer R, Mahantshetty U, Medhi S, Mehta Z, Shrivastava SK. Internal target volume for post-hysterectomy vaginal recurrences of cervical cancers during image-guided radiotherapy. Br J Radiol 2015; 88:20140783. [PMID: 26248870 DOI: 10.1259/bjr.20140783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE The outcome of post-surgical recurrences of cervical cancer may be improved through radiation dose escalation, which hinges on accurate identification and treatment of the target. The present study quantifies target motion during course of image-guided radiotherapy (IGRT) for vault cancers. METHODS All patients underwent planning CT simulation after bladder-filling protocol. A daily pre-treatment megavoltage CT was performed. All translations and rotations were recorded. Post-registration displacement of gross tumour volume (GTV) and centre of mass (COM) of GTV was independently recorded by two observers for fractions one to seven. Day 1 image sets served as reference images against which the displacements of COM were measured. We calculated the displacements of common volume (CV) and encompassing volume (EV) of GTV for both the observers. RESULTS A total of 90 image data sets of 15 patients were available for evaluation. Individual patient GTV and average GTV by both the observers were comparable. The average shifts for EV were 2.4 mm [standard deviation (SD) ±1.2] in the mediolateral, 4.2 mm (SD ±2.8) in the anteroposterior and 4.0 mm (SD ±2.1) in superoinferior directions. Similarly, the average shifts for CV were 1.9 mm (SD ±0.6) in the mediolateral, 3.7 mm (SD ±2.7) in the anteroposterior and 4.4 mm (SD ±2.7) in superoinferior directions. Using Stroom's/van Herk's formula, the minimum recommended margins would be 4.5/5.2, 8.2/9.4 and 7.3/8.3 mm, respectively, for lateral, anteroposterior and superoinferior directions. CONCLUSION Differential directional internal margin is recommended in patients undergoing IGRT for post-surgical recurrence of cervical cancers. ADVANCES IN KNOWLEDGE Internal organ motion of vault cancers can be accounted for by a directional margin to the gross tumour.
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Affiliation(s)
| | - Supriya Chopra
- 2 Department of Radiation Oncology, Advanced Centre for Treatment, Education and Research in Cancer, Tata Memorial Centre, Mumbai, India
| | - Reena Engineer
- 1 Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, India
| | - Umesh Mahantshetty
- 1 Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, India
| | - Seema Medhi
- 3 Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Zubin Mehta
- 2 Department of Radiation Oncology, Advanced Centre for Treatment, Education and Research in Cancer, Tata Memorial Centre, Mumbai, India
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IMRT with ¹⁸FDG-PET\CT based simultaneous integrated boost for treatment of nodal positive cervical cancer. Radiat Oncol 2014; 9:83. [PMID: 24661323 PMCID: PMC4014138 DOI: 10.1186/1748-717x-9-83] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 03/16/2014] [Indexed: 12/11/2022] Open
Abstract
Background To evaluate toxicity and outcome of intensity modulated radiotherapy (IMRT) with simultaneous integrated boost (SIB) to the positive lymph nodes in patients with loco-regional advanced cervical cancer (LRACC). Methods The study population comprised ten patients with 18FDG-PET\CT positive lymph nodes (LNs), who underwent chemoradiation with IMRT and SIB. A dose of 50.4 Gy, in daily fractions of 1.8 Gy, was delivered to primary tumor and draining LNs. Primary tumor received an additional external beam boost to a total dose of 55.8 Gy. A SIB of 62 Gy, in daily fractions of 2 Gy, was delivered to the 18FDG-PET\CT positive LNs. Finally, a high dose rate brachytherapy (HDRB) boost (15 – 18 Gy) was administered to the primary tumor. The primary goal of this study was to evaluate acute and early late toxicity and loco-regional control. Results The median number of irradiated LNs per patient was 3 (range: 1–6) with a median middle nodal SIB-volume of 26.10 cm3 (range, 11.9-82.50 cm3). Median follow-up was 20 months (range, 12 to 30 months). Acute and late grade 3 toxicity was observed in 1 patient. Three of the patients developed a recurrence, one in the form of a local tumor relapse, one had a paraaortic LN metastasis outside the treated volume and the last one developed a distant metastasis. Conclusion IMRT with SIB in the region of 18FDG-PET positive lymph nodes appears to be an effective therapy with acceptable toxicity and might be useful in the treatment of patients with locally advanced cervical cancer.
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Predictors of Grade 3 or Higher Late Bowel Toxicity in Patients Undergoing Pelvic Radiation for Cervical Cancer: Results From a Prospective Study. Int J Radiat Oncol Biol Phys 2014; 88:630-5. [DOI: 10.1016/j.ijrobp.2013.11.214] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 09/19/2013] [Accepted: 11/08/2013] [Indexed: 11/22/2022]
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Ohno T, Kakinuma S, Kato S, Tsujii H, Shimada Y. Risk of second cancers after radiotherapy for cervical cancer. Expert Rev Anticancer Ther 2014; 6:49-57. [PMID: 16375644 DOI: 10.1586/14737140.6.1.49] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Radiotherapy for cervical cancer has both beneficial and detrimental effects: improvement of patient survival and potential induction of a second cancer among long-term survivors. Large epidemiological studies have demonstrated small, but significant, increases of second cancers with radiotherapy compared with the general population. The risk of second cancer has been characterized by organ sites, dose, time since radiotherapy and age at the time of radiotherapy. Analyses of genetic susceptibility and molecular carcinogenesis can be used to develop more appropriate strategies for radiation therapy for cervical cancers.
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Affiliation(s)
- Tatsuya Ohno
- Research Center for Charged Particle Therapy, National Institute of Radiological Sciences, 4-9-1 Anagawa, Chiba, Japan.
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Fernandez-Ots A, Crook J. The role of intensity modulated radiotherapy in gynecological radiotherapy: Present and future. Rep Pract Oncol Radiother 2013; 18:363-70. [PMID: 24416580 DOI: 10.1016/j.rpor.2013.08.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 07/13/2013] [Accepted: 08/02/2013] [Indexed: 10/26/2022] Open
Abstract
AIM This manuscript reviews the English language literature on the use of intensity modulated radiation therapy (IMRT) for gynecologic malignancies, focusing on the treatment cervical cancer. BACKGROUND Radiation therapy plays a key role in both definitive and adjuvant treatment of these patients, although efforts continue to minimize acute and chronic toxicity. IMRT is an attractive option because of the potential to dose escalate to the target while sparing organs at risk. METHODS AND MATERIALS The English language literature was reviewed for relevant studies. RESULTS Multiple heterogeneous studies have showed dosimetric and clinical benefits with reduction in acute and late gastrointestinal, genitourinary and hematologic toxicity, especially in the post hysterectomy scenario and for dose escalation to para-aortic nodes. Consensus is evolving regarding necessary margins and target delineation in the context of organ movement and tumor shrinkage during the course of radiotherapy. Protocols with daily soft-tissue visualization are being investigated. CONCLUSIONS Consistency in approach and reporting are vital in order to acquire the data to justify the considerable increased expense of IMRT.
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Affiliation(s)
- Ana Fernandez-Ots
- British Columbia Cancer Agency, Center for the Southern Interior, 399 Royal Avenue, Kelowna, British Columbia, Canada V1Y 5L3
| | - Juanita Crook
- British Columbia Cancer Agency, Center for the Southern Interior, 399 Royal Avenue, Kelowna, British Columbia, Canada V1Y 5L3
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Affiliation(s)
- Ericka Wiebe
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Shrivastava SK, Mahantshetty U, Narayan K. Principles of radiation therapy in low-resource and well-developed settings, with particular reference to cervical cancer. Int J Gynaecol Obstet 2013; 119 Suppl 2:S155-9. [PMID: 22999507 DOI: 10.1016/s0020-7292(12)60029-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Franckena M. Review of radiotherapy and hyperthermia in primary cervical cancer. Int J Hyperthermia 2012; 28:543-8. [DOI: 10.3109/02656736.2012.670835] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
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Mizowaki T, Hatano K, Hiraoka M. Surveillance on interfacility differences in dose-prescription policy of intensity-modulated radiation therapy plans for prostate cancer. JOURNAL OF RADIATION RESEARCH 2012; 53:608-14. [PMID: 22843627 PMCID: PMC3393351 DOI: 10.1093/jrr/rrs016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 03/25/2012] [Accepted: 03/29/2012] [Indexed: 05/24/2023]
Abstract
Intensity-modulated radiation therapy (IMRT) has recently become popular in Japan. Prostate cancer is indisputably one of the main targets of IMRT. However, the current status and interfacility differences in dose-prescription policies for prostate IMRT are unknown. Therefore, a nationwide survey of 43 institutions that had implemented prostate IMRT was conducted by sending a questionnaire regarding the above-mentioned issues. Thirty-three institutions (77%) had responded to the questionnaire by the end of October 2010. A total of 5245 patients with localized prostate cancer had been treated with IMRT by the end of 2009. Regular multileaf collimator-based techniques were the most common beam delivery method. Dose-prescription policies were divided into four major categories: isocenter-based (@isocenter), dose delivered to 95% of the planning target volume (PTV) (D95)-based (D95@PTV), mean dose to the PTV-based (Mean@PTV), and mean dose to the clinical target volume (CTV)-based (@CTV). The mean doses of the CTV and PTV, and the volume of the PTV receiving 95% of the dose (V95) were significantly higher with the D95@PTV policy than with the other prescription policies. Low-dose areas and hot spots were observed within the PTV in plans with @isocenter and @CTV policies. In conclusion, there are currently considerable differences among institutions in Japan regarding target doses for prostate IMRT. The D95@PTV prescription policy resulted in significant dose escalation compared with the other policies. These differences should be taken into consideration when interpreting treatment outcomes and creating multi-institutional protocols in the future.
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Affiliation(s)
- Takashi Mizowaki
- Department of Radiation Oncology and Image-applied Therapy, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, Japan.
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Gouy S, Morice P, Narducci F, Uzan C, Gilmore J, Kolesnikov-Gauthier H, Querleu D, Haie-Meder C, Leblanc E. Nodal-staging surgery for locally advanced cervical cancer in the era of PET. Lancet Oncol 2012; 13:e212-20. [PMID: 22554549 DOI: 10.1016/s1470-2045(12)70011-6] [Citation(s) in RCA: 140] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Chemoradiation therapy is deemed the standard treatment by many North American and European teams for treatment of locally advanced cervical cancer. The prevalence of para-aortic nodal metastasis in these tumours is 10-25%. PET (with or without CT) is the most accurate imaging modality to assess extrapelvic disease in such tumours. The true-positive rate of PET is high, suggesting that surgical staging is not necessary if uptake takes place in the para-aortic region. Nevertheless, false-negative results (in the para-aortic region) have been recorded in 12% of patients, rising to 22% in those with uptake during PET of the pelvic nodes. In such situations, laparoscopic surgical para-aortic staging still has an important role for detection of patients with occult para-aortic spread misdiagnosed on PET or PET-CT, allowing optimisation of treatment (extension of radiation therapy fields to include the para-aortic area). Complications of the laparoscopic procedure were noted in 0-7% of patients. Survival of individuals (missed by PET) with para-aortic nodal metastasis of 5 mm or less (and managed by extended field chemoradiation therapy) seems to be similar to survival of those without para-aortic spread, suggesting a positive therapeutic effect of the addition of staging surgery. Nevertheless, the effect on survival of potential delay of chemoradiation owing to use of PET and staging surgery, and acute and late complications of surgery followed by chemoradiation therapy (particularly in case of extended field chemoradiation to para-aortic area), need to be studied.
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Affiliation(s)
- Sebastien Gouy
- Department of Gynaecological Surgery, Institut Gustave Roussy, Villejuif, France
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Chen CC, Lin JC, Jan JS, Ho SC, Wang L. Definitive intensity-modulated radiation therapy with concurrent chemotherapy for patients with locally advanced cervical cancer. Gynecol Oncol 2011; 122:9-13. [DOI: 10.1016/j.ygyno.2011.03.034] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 03/18/2011] [Accepted: 03/26/2011] [Indexed: 10/18/2022]
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Postoperative Intensity-Modulated Radiotherapy in Low-Risk Endometrial Cancers: Final Results of a Phase I Study. Int J Radiat Oncol Biol Phys 2010; 76:1390-5. [DOI: 10.1016/j.ijrobp.2009.04.091] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Revised: 04/07/2009] [Accepted: 04/07/2009] [Indexed: 11/22/2022]
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Vandecasteele K, De Neve W, De Gersem W, Delrue L, Paelinck L, Makar A, Fonteyne V, De Wagter C, Villeirs G, De Meerleer G. Intensity-modulated arc therapy with simultaneous integrated boost in the treatment of primary irresectable cervical cancer. Treatment planning, quality control, and clinical implementation. Strahlenther Onkol 2009; 185:799-807. [PMID: 20013089 DOI: 10.1007/s00066-009-1986-8] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2008] [Accepted: 09/30/2009] [Indexed: 12/25/2022]
Abstract
PURPOSE To report on the planning procedure, quality control, and clinical implementation of intensity-modulated arc therapy (IMAT) delivering a simultaneous integrated boost (SIB) in patients with primary irresectable cervix carcinoma. PATIENTS AND METHODS Six patients underwent PET-CT (positron emission tomography-computed tomography) and MRI (magnetic resonance imaging) before treatment planning. Prescription (25 fractions) was (1) a median dose (D(50)) of 62, 58 and 56 Gy to the primary tumor (GTV_cervix), primary clinical target volume (CTV_cervix) and its planning target volume (PTV_cervix), respectively; (2) a D(50) of 60 Gy to the PET-positive lymph nodes (GTV_nodes); (3) a minimal dose (D(98)) of 45 Gy to the planning target volume of the elective lymph nodes (PTV_nodes). IMAT plans were generated using an anatomy-based exclusion tool with the aid of weight and leaf position optimization. The dosimetric delivery of IMAT was validated preclinically using radiochromic film dosimetry. RESULTS Five to nine arcs were needed to create valid IMAT plans. Dose constraints on D(50) were not met in two patients (both GTV_cervix: 1 Gy and 3 Gy less). D(98) for PTV_nodes was not met in three patients (1 Gy each). Film dosimetry showed excellent gamma evaluation. There were no treatment interruptions. CONCLUSION IMAT allows delivering an SIB to the macroscopic tumor without compromising the dose to the elective lymph nodes or the organs at risk. The clinical implementation is feasible.
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Kidd EA, Siegel BA, Dehdashti F, Rader JS, Mutic S, Mutch DG, Powell MA, Grigsby PW. Clinical outcomes of definitive intensity-modulated radiation therapy with fluorodeoxyglucose-positron emission tomography simulation in patients with locally advanced cervical cancer. Int J Radiat Oncol Biol Phys 2009; 77:1085-91. [PMID: 19880262 DOI: 10.1016/j.ijrobp.2009.06.041] [Citation(s) in RCA: 154] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2009] [Revised: 06/11/2009] [Accepted: 06/12/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE This study aimed to evaluate the toxicity and clinical outcomes for cervical cancer patients treated definitively with intensity-modulated radiation therapy (IMRT) compared with non-IMRT treatment. METHODS AND MATERIALS This prospective cohort study included 452 patients with newly diagnosed cervical cancer treated with curative intent (135 IMRT and 317 non-IMRT). Treatment involved external irradiation and brachytherapy, and 85% of patients received concurrent chemotherapy. All IMRT patients underwent an F-18 fluorodeoxyglucose positron emission tomography (FDG-PET/CT) simulation. A 3-month post-therapy PET was obtained to evaluate treatment response. Toxicity was scored by the Common Terminology Criteria for Adverse Events Version 3.0. RESULTS The IMRT and non-IMRT groups had similar stage distribution and histology. For all patients, the post-therapy FDG-PET response correlated with overall recurrence risk (p < 0.0001) and cause-specific survival (p < 0.0001). Post-treatment FDG-PET findings were not significantly different between the IMRT and non-IMRT patients (p = 0.9774). The mean follow-up for all patients alive at the time of last follow-up was 52 months (72 months non-IMRT, 22 months IMRT). At last follow-up, 178 patients (39 IMRT, 139 non-IMRT) had developed a recurrence. The difference in recurrence-free survival between the two groups did not reach statistical significance (p = 0.0738), although the IMRT group showed better overall and cause-specific survivals (p < 0.0001). Of the patients, 62 patients (8 IMRT and 54 non-IMRT) developed Grade 3 or greater bowel or bladder complications, and by cumulative hazard function analysis the risk was significantly less for patients treated with IMRT (p = 0.0351). CONCLUSION Cervical cancer patients treated with FDG-PET/CT-guided IMRT have improved survival and less treatment-related toxicity compared with patients treated with non-IMRT radiotherapy.
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Affiliation(s)
- Elizabeth A Kidd
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO 63110, USA
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26
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Barillot I. Les cancers du col utérin : place de la radiothérapie avec modulation d’intensité. Cancer Radiother 2009; 13:507-10. [DOI: 10.1016/j.canrad.2009.05.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2009] [Revised: 04/23/2009] [Accepted: 05/01/2009] [Indexed: 10/20/2022]
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Intensity modulated radiotherapy (IMRT) the white, black and grey: a clinical perspective. Rep Pract Oncol Radiother 2009. [DOI: 10.1016/s1507-1367(10)60101-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Yu CX, Amies CJ, Svatos M. Planning and delivery of intensity-modulated radiation therapy. Med Phys 2009; 35:5233-41. [PMID: 19175082 DOI: 10.1118/1.3002305] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Intensity modulated radiation therapy (IMRT) is an advanced form of external beam radiation therapy. IMRT offers an additional dimension of freedom as compared with field shaping in three-dimensional conformal radiation therapy because the radiation intensities within a radiation field can be varied according to the preferences of locations within a given beam direction from which the radiation is directed to the tumor. This added freedom allows the treatment planning system to better shape the radiation doses to conform to the target volume while sparing surrounding normal structures. The resulting dosimetric advantage has shown to translate into clinical advantages of improving local and regional tumor control. It also offers a valuable mechanism for dose escalation to tumors while simultaneously reducing radiation toxicities to the surrounding normal tissue and sensitive structures. In less than a decade, IMRT has become common practice in radiation oncology. Looking forward, the authors wonder if IMRT has matured to such a point that the room for further improvement has diminished and so it is pertinent to ask what the future will hold for IMRT. This article attempts to look from the perspective of the current state of the technology to predict the immediate trends and the future directions. This article will (1) review the clinical experience of IMRT; (2) review what we learned in IMRT planning; (3) review different treatment delivery techniques; and finally, (4) predict the areas of advancements in the years to come.
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Affiliation(s)
- Cedric X Yu
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.
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29
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Franckena M, Lutgens LC, Koper PC, Kleynen CE, van der Steen-Banasik EM, Jobsen JJ, Leer JW, Creutzberg CL, Dielwart MF, van Norden Y, Canters RAM, van Rhoon GC, van der Zee J. Radiotherapy and hyperthermia for treatment of primary locally advanced cervix cancer: results in 378 patients. Int J Radiat Oncol Biol Phys 2008; 73:242-50. [PMID: 18990505 DOI: 10.1016/j.ijrobp.2008.03.072] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2007] [Revised: 03/26/2008] [Accepted: 03/27/2008] [Indexed: 11/18/2022]
Abstract
PURPOSE To report response rate, pelvic tumor control, survival, and late toxicity after treatment with combined radiotherapy and hyperthermia (RHT) for patients with locally advanced cervical carcinoma (LACC) and compare the results with other published series. METHODS AND MATERIALS From 1996 to 2005, a total of 378 patients with LACC (International Federation of Gynecology and Obstetrics Stage IB2-IVA) were treated with RHT. External beam radiotherapy (RT) was applied to 46-50.4 Gy and combined with brachytherapy. The hyperthermia (HT) was prescribed once weekly. Primary end points were complete response (CR) and local control. Secondary end points were overall survival, disease-specific survival, and late toxicity. Patient, tumor, and treatment characteristics predictive for the end points were identified in univariate and multivariate analyses. RESULTS Overall, a CR was achieved in 77% of patients. At 5 years, local control, disease-specific survival, and incidence of late toxicity Common Terminology Criteria for Adverse Events Grade 3 or higher were 53%, 47%, and 12%, respectively. In multivariate analysis, number of HT treatments emerged as a predictor of outcome in addition to commonly identified prognostic factors. CONCLUSIONS The CR, local control, and survival rates are similar to previously observed results of RHT in the randomized Dutch Deep Hyperthermia Trial. Reported treatment results for currently applied combined treatment modalities (i.e., RT with chemotherapy and/or HT) do not permit definite conclusions about which combination is superior. The present results confirm previously shown beneficial effects from adding HT to RT and justify the application of RHT as first-line treatment in patients with LACC as an alternative to chemoradiation.
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Affiliation(s)
- Martine Franckena
- Department of Radiation Oncology, Erasmus Medical Center, Rotterdam, The Netherlands
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Innovations in chemotherapy and radiation therapy: Implications and opportunities for the Asia-Pacific Rim. Biomed Imaging Interv J 2008; 4:e40. [PMID: 21611006 PMCID: PMC3097728 DOI: 10.2349/biij.4.3.e40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2008] [Accepted: 10/17/2008] [Indexed: 11/18/2022] Open
Abstract
New cases of invasive cancer in the United States occur among nearly 1.5 million people annually. In 2007, more than 1,500 people died per day with this diagnosis. Cancer is responsible for nearly one in every four deaths reported in the country. Enormous amounts of money and research have been, and are being spent, in an attempt to improve these numbers. While prevention and early detection remain the key to long-term success, treatment in the neo-adjuvant, adjuvant and metastatic settings still centre around two main treatment modalities – radiation therapy and chemotherapy. This article will review the advances that have been made in both areas that are making these treatments more precise and convenient, as well as less toxic, for the patient. In the field of radiation therapy this involves the development of new therapy planning and delivery systems, such as intensity-modulated radiation therapy (IMRT), and positron emission and computed tomography, PET-CT. Chemotherapy has also evolved with the development of targeted chemotherapy for the treatment of specific malignancies as well as improved supportive care agents which allow for the administration of dose-dense chemotherapy when appropriate.
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Conformal and intensity-modulated radiotherapy for cervical cancer. Clin Oncol (R Coll Radiol) 2008; 20:417-25. [PMID: 18558480 DOI: 10.1016/j.clon.2008.04.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2008] [Revised: 04/01/2008] [Accepted: 04/17/2008] [Indexed: 12/28/2022]
Abstract
Three-dimensional radiotherapy planning techniques, including conformal radiotherapy and intensity-modulated radiotherapy, have potential for improving outcomes in cervical cancer. Accurate target volume definition is essential in order to maximise normal tissue sparing while minimising the risk of a geographical miss. This reduction in toxicity provides the option of dose escalation, particularly with simultaneous integrated boost intensity-modulated radiotherapy. The evidence for the current use and potential applications of these techniques in the treatment of cervical cancer are discussed.
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An assessment of interfractional uterine and cervical motion: implications for radiotherapy target volume definition in gynaecological cancer. Radiother Oncol 2008; 88:250-7. [PMID: 18538873 DOI: 10.1016/j.radonc.2008.04.016] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2007] [Revised: 04/20/2008] [Accepted: 04/26/2008] [Indexed: 11/22/2022]
Abstract
PURPOSE To assess interfractional movement of the uterus and cervix in patients with gynaecological cancer to aid selection of the internal margin for radiotherapy target volumes. METHODS AND MATERIALS Thirty-three patients with gynaecological cancer had an MRI scan performed on two consecutive days. The two sets of T2-weighted axial images were co-registered, and the uterus and cervix outlined on each scan. Points were identified on the anterior uterine body (Point U), posterior cervix (Point C) and upper vagina (Point V). The displacement of each point in the antero-posterior (AP), superior-inferior (SI) and lateral directions between the two scans was measured. The changes in point position and uterine body angle were correlated with bladder volume and rectal diameter. RESULTS The mean difference (+/-1 SD) in Point U position was 7 mm (+/-9.0) in the AP direction, 7.1 mm (+/-6.8) SI and 0.8 mm (+/-1.3) laterally. Mean Point C displacement was 4.1 mm (+/-4.4) SI, 2.7 mm (+/-2.8) AP, 0.3 (+/-0.8) laterally, and Point V was 2.6 mm (+/-3.0) AP and 0.3 mm (+/-1.0) laterally. There was correlation for uterine SI movement in relation to bladder filling, and for cervical and vaginal AP movement in relation to rectal filling. CONCLUSION Large movements of the uterus can occur, particularly in the superior-inferior and anterior-posterior directions, but cervical displacement is less marked. Rectal filling may affect cervical position, while bladder filling has more impact on uterine body position, highlighting the need for specific instructions on bladder and rectal filling for treatment. We propose an asymmetrical margin with CTV-PTV expansion of the uterus, cervix and upper vagina of 15 mm AP, 15 mm SI and 7 mm laterally and expansion of the nodal regions and parametria by 7 mm in all directions.
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Smith RP, Heron DE, Huq MS, Yue NJ. Modern radiation treatment planning and delivery--from Röntgen to real time. Hematol Oncol Clin North Am 2006; 20:45-62. [PMID: 16580556 DOI: 10.1016/j.hoc.2006.01.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The field of radiation oncology has advanced exponentially since the discovery of X-rays just over 100 years ago. With the advent of three-dimensional treatment planning, the therapeutic index was increased by dose escalation and more accurate shielding of normal tissues. Now, even greater advances are under way with IMRT, image-guided radiation therapy, delineation and control of organ motion, and real-time imaging. Similarly, the use of particle therapies such as protons has the potential to effect even more accurate dose distributions. Clinical studies investigating these modalities will likely further increase the efficacy of radiation in years to come.
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Affiliation(s)
- Ryan P Smith
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, UPMC Cancer Pavilion, 5150 Centre Avenue, Suite 545, Pittsburgh, PA 15232, USA
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Gerszten K, Colonello K, Heron DE, Lalonde RJ, Fitian ID, Comerci JT, Selvaraj RN, Varlotto JM. Feasibility of concurrent cisplatin and extended field radiation therapy (EFRT) using intensity-modulated radiotherapy (IMRT) for carcinoma of the cervix. Gynecol Oncol 2006; 102:182-8. [PMID: 16516281 DOI: 10.1016/j.ygyno.2005.12.044] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2005] [Revised: 12/09/2005] [Accepted: 12/16/2005] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To assess the acute tolerance of delivering concurrent cisplatin and extended field radiotherapy (EFRT) using intensity-modulated radiotherapy technique (IMRT) for cancer of the cervix. METHODS All patients receiving definitive treatment for cervical cancer were treated with EFRT using IMRT technique and concurrent cisplatin. The treatment volume included the cervix, uterus, parametria, presacral space, upper vagina, pelvic, common iliac, and paraaortic nodes to the top of L1. All regions received 45 Gy (25 fractions) with a simultaneous boost to involved nodes (55 Gy/25 fractions). Patients were assessed weekly for toxicity and response. RESULTS Twenty-two consecutive patients underwent treatment. All patients completed the prescribed course of EFRT. Median treatment length was 39.5 days (range 36-53). Treatment breaks of 2 and 3 days were required for bone marrow toxicity in 2 patients. The final week of chemotherapy was held in 2 patients because of neutropenia. No patient suffered acute or subacute grade 3 or 4 GI or GU toxicity. CONCLUSION In this clinical study, an IMRT technique was used to successfully deliver EFRT with concurrent chemosensitization for cervical cancer. The technique was associated with an acceptable acute toxicity without significant treatment protraction. This new role for IMRT merits further evaluation with larger patient numbers and longer follow-up.
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Affiliation(s)
- Kristina Gerszten
- Department of Radiation Oncology, UPMC Cancer Pavillon (POB II), 5150 Centre Avenue, 5th Floor, Room 544B, Pittsburgh, PA 15232, USA.
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Kato S, Ohno T, Tsujii H, Nakano T, Mizoe JE, Kamada T, Miyamoto T, Tsuji H, Kato H, Yamada S, Kandatsu S, Yoshikawa K, Ezawa H, Suzuki M. Dose escalation study of carbon ion radiotherapy for locally advanced carcinoma of the uterine cervix. Int J Radiat Oncol Biol Phys 2006; 65:388-97. [PMID: 16626894 DOI: 10.1016/j.ijrobp.2005.12.050] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2005] [Revised: 12/09/2005] [Accepted: 12/09/2005] [Indexed: 10/24/2022]
Abstract
PURPOSE To evaluate the toxicity and efficacy of carbon ion radiotherapy (CIRT) for locally advanced cervical cancer by two phase I/II clinical trials. METHODS AND MATERIALS Between June 1995 and January 2000, 44 patients were treated with CIRT. Thirty patients had Stage IIIB disease, and 14 patients had Stage IVA disease. Median tumor size was 6.5 cm (range, 4.2-11.0 cm). The treatment consisted of 16 fractions of whole pelvic irradiation and 8 fractions of local boost. In the first study, the total dose ranged from 52.8 to 72.0 gray equivalents (GyE) (2.2-3.0 GyE per fraction). In the second study, the whole pelvic dose was fixed at 44.8 GyE, and an additional 24.0 or 28.0 GyE was given to the cervical tumor (total dose, 68.8 or 72.8 GyE). RESULTS No patient developed severe acute toxicity. In contrast, 8 patients developed major late gastrointestinal complications. The doses resulting in major complications were > or =60 GyE. All patients with major complications were surgically salvaged. The 5-year local control rate for patients in the first and second studies was 45% and 79%, respectively. When treated with > or =62.4 GyE, the local control was favorable even for the patients with stage IVA disease (69%) or for those with tumors > or =6.0 cm (64%). CONCLUSIONS In CIRT for advanced cervical cancer, the dose to the intestines should be limited to <60 GyE to avoid major complications. Although the number of patients in this study was small, the results support continued investigation to confirm therapeutic efficacy.
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Affiliation(s)
- Shingo Kato
- Research Center Hospital for Charged Particle Therapy, National Institute of Radiological Sciences, Chiba, Japan.
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Saibishkumar EP, Patel FD, Sharma SC, Karunanidhi G, Sankar AS, Mallick I. Results of External-beam Radiotherapy Alone in Invasive Cancer of the Uterine Cervix: A Retrospective Analysis. Clin Oncol (R Coll Radiol) 2006; 18:46-51. [PMID: 16477919 DOI: 10.1016/j.clon.2005.10.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
AIMS In this retrospective audit, we describe the results of external-beam radiotherapy (EBRT) alone in patients with invasive cancer of the cervix treated at our centre. MATERIAL AND METHODS We included 146 patients with invasive cancer of the cervix who were treated with EBRT to a total dose of 60-66 Gy between January 1996 and December 2001. None of these patients were suitable for intracavitary radiotherapy (ICRT) after a median dose of 46 Gy. A boost dose of 14-20 Gy was given after a gap of 2-4 weeks. Most patients belonged to stage IIIB (n = 124). RESULTS Follow-up of patients at risk ranged from 19 to 89 months (median 48 months). One hundred and thirty-six patients (93.2%) received EBRT to a dose of 66 Gy, and 10 patients (6.8%) received 60 Gy. Overall treatment time (OTT) ranged from 56 to 160 days (median 78 days). At completion of 46 Gy of EBRT, 63 patients achieved partial response and 83 patients had stable disease. Five-year overall survival, disease-free survival (DFS) and pelvic control were 15.1% (median 9 months), 11.6% (median 5 months) and 21.9% (median 6 months), respectively. Factors found to affect 5-year pelvic control in univariate analysis by Kaplan-Meier method were response to EBRT at 46 Gy (partial response 36.5% and stable disease 10.8%), age (> or = 50 years 28.8% and < 50 years 13.6%) and OTT (< 90 days 26.5% and > or = 90 days 12.5%). For DFS and overall survival, response to EBRT was the only factor that was significant in univariate analysis. In multivariate analysis by Cox's proportional hazard model, response to EBRT was the only factor to influence pelvic control (P = 0.007), DFS (P = 0.01) and overall survival (P < 0.001). CONCLUSIONS Overall outcome of patients in whom ICRT was not given remains less than satisfactory. Response to EBRT emerged as the most important factor to predict all clinical outcomes. To improve upon the dismal results of EBRT alone, we will have to decrease the OTT and consider concurrent chemo-radiation with cisplatin.
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Affiliation(s)
- E P Saibishkumar
- Department of Radiotherapy, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
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Saibishkumar EP, Patel FD, Ghoshal S, Kumar V, Karunanidhi G, Sharma SC. Results of salvage radiotherapy after inadequate surgery in invasive cervical carcinoma patients: A retrospective analysis. Int J Radiat Oncol Biol Phys 2005; 63:828-33. [PMID: 15950400 DOI: 10.1016/j.ijrobp.2005.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2004] [Revised: 02/15/2005] [Accepted: 04/05/2005] [Indexed: 11/24/2022]
Abstract
PURPOSE To evaluate the results of salvage radiotherapy (RT) after inadequate surgery in patients with invasive carcinoma of the cervix. METHODS AND MATERIALS Between 1996 and 2001, 105 invasive cervical carcinoma patients were treated at our center with external beam RT with or without intracavitary RT after having undergone total/subtotal hysterectomy at outside institutions. RESULTS The median follow-up was 34 months. The gap between surgery and RT was 23-198 days (median, 80). Clinically visible residual disease was present in 81 patients (77.1%). Total hysterectomy had been done in 82 patients (78%) and subtotal hysterectomy in 23 patients (22%). The 5-year overall survival, disease-free survival, and pelvic control rates of all patients were 55.2%, 53.3%, and 72.4%, respectively. On univariate analysis, older age, total hysterectomy, hemoglobin level >10 g% before RT, nonsquamous histologic type, use of intracavitary RT, a shorter gap between surgery and RT, and the absence of, or a small volume of, residual disease favorably affected the outcome. The 5-year actuarial rate of late toxicity (Radiation Therapy Oncology Group Criteria) was 19% in the rectum, 4.8% in the bladder, 24.8% in the skin, and 14.3% in the small intestine. CONCLUSIONS Inadequate and inappropriate surgery in invasive cervical cancer with resulting gross residual disease is common in India. Factors such as the use of intracavitary RT, the correction of anemia, and a shorter gap between surgery and RT will enable postoperative RT to achieve acceptable results with minimal morbidity.
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Affiliation(s)
- Elantholi P Saibishkumar
- Department of Radiotherapy, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
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Dragun AE, Harmon JF, Aguero EG. Defining targets and protecting normal tissues in inverse-planned IMRT for prostate, head and neck, and gynecologic cancers: a comparative review. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/s1548-5315(11)70898-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Guerrero M, Li XA, Ma L, Linder J, Deyoung C, Erickson B. Simultaneous integrated intensity-modulated radiotherapy boost for locally advanced gynecological cancer: Radiobiological and dosimetric considerations. Int J Radiat Oncol Biol Phys 2005; 62:933-9. [PMID: 15936580 DOI: 10.1016/j.ijrobp.2004.11.040] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2004] [Revised: 11/19/2004] [Accepted: 11/29/2004] [Indexed: 11/19/2022]
Abstract
PURPOSE Whole-pelvis irradiation (WPI) followed by a boost to the tumor site is the standard of practice for the radiotherapeutic management of locally advanced gynecologic cancers. The boost is frequently administered by use of brachytherapy or, occasionally, external-beam radiotherapy (EBRT) when brachytherapy does not provide sufficient coverage because of the size of the tumor or the geometry of the patient. In this work, we propose using an intensity-modulated radiotherapy (IMRT) simultaneous integrated boost (SIB), which is a single-phase process, to replace the conventional two-phase process involving WPI plus a boost. Radiobiological modeling is used to design appropriate regimens for the IMRT SIB. To demonstrate feasibility, a dosimetric study is carried out on an example patient. METHODS AND MATERIALS The standard linear-quadratic (LQ) model is used to calculate the biologically effective dose (BED) and equivalent uniform dose (EUD). A series of regimens that are biologically equivalent to those conventional two-phase treatments is calculated for the proposed SIB. A commercial inverse planning system (Corvus) was used to generate IMRT SIB plans for a sample patient case that used the newly designed fractionations. The dose-volume histogram (DVH) and EUD of both the target and normal structures for conventional treatments and the SIB are compared. A sparing factor was introduced to characterize the sparing of normal structures. RESULTS Fractionation regimes that are equivalent to the conventional treatments and are suitable for the IMRT SIB are deduced. For example, a SIB plan with 25 x 3.1 Gy (77.5 Gy) to a tumor is equivalent to a conventional treatment of EBRT of 45 Gy to the whole pelvis in 25 fractions plus a high-dose rate (HDR) brachytherapy boost with 30 Gy in 5 fractions. The normal tissue BED is found to be lower for the SIB plan than for the whole-pelvis plus HDR scheme when a sparing factor for the critical structures is considered. This finding suggests that the IMRT SIB has a better therapeutic ratio. Three IMRT SIB plans with 25 x 1.8 Gy to the pelvic nodes and 25 x 2.4 Gy (60 Gy), 25 x 2.8 Gy (70 Gy), and 25 x 3.2 Gy (80 Gy) to the tumor site were generated for the example patient case. The target coverage ranged from 94% to 95.5%. The sparing of bladder and rectum is significantly improved with the 60 to 70 Gy SIB treatments, as compared with the conventional treatments. The proposed SIB treatment can reduce the treatment time to 5 weeks. CONCLUSIONS An IMRT simultaneous integrated boost to replace the conventional two-phase treatments (whole pelvic irradiation followed by brachytherapy or EBRT boost) is radiobiologically and dosimetricaly feasible for locally advanced gynecological cancers that may not be amenable to brachytherapy for anatomic or medical reasons. In addition to its shorter treatment time, the proposed IMRT SIB can provide significant sparing to normal structures, which offers potential for dose escalation. Issues such as organ motion and changing anatomy as tumor responds still must be addressed.
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Affiliation(s)
- Mariana Guerrero
- Department of Radiation Oncology, University of Maryland, Baltimore, MD, USA
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Wong E, D'Souza DP, Chen JZ, Lock M, Rodrigues G, Coad T, Trenka K, Mulligan M, Bauman GS. Intensity-modulated arc therapy for treatment of high-risk endometrial malignancies. Int J Radiat Oncol Biol Phys 2005; 61:830-41. [PMID: 15708263 DOI: 10.1016/j.ijrobp.2004.06.253] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2004] [Revised: 06/14/2004] [Accepted: 06/30/2004] [Indexed: 11/18/2022]
Abstract
PURPOSE We developed an intensity-modulated arc therapy (IMAT) technique for the treatment of women with high-risk endometrial malignancies. In the context of multimodality therapy, nodal and tumor bed irradiation was delivered while respecting tolerance doses for critical structures. METHODS AND MATERIALS Five patients were planned and treated with the IMAT technique after hysterectomy. Computed tomographic (CT) scans for treatment planning were acquired with the tumor bed contoured as the clinical target volume (CTV(tumor_bed)) and the iliac and presacral vessels contoured as the gross tumor volume (GTV). In 2 patients the lower para-aortic nodes were included into the GTV. The small bowel, iliac crests, femoral heads, bladder, and rectum were contoured as critical organs. For the nodes, a CTV(nodes) was generated with a 7-10-mm margin around the vessels, and the planning target volume (PTV(nodes)) was generated by a further 5-mm expansion. For the tumor bed, the PTV(tumor_bed) was generated with a margin of 7-10 mm around CTV(tumor_bed). Planning constraints included adequate coverage of the tumor bed (>95% receiving > or =45 Gy) and nodes (> or =95% receiving > or =40 Gy). Arc combinations with different extents were tested, and the final plan was generated based on the balance between complexity (number of arcs), PTV coverage, and critical structure sparing. Conventional and 8-field intensity-modulated radiation therapy (IMRT) plans were generated for each patient for comparison purposes. All patients were treated with IMAT. RESULTS We found that two anterior intensity-modulated arcs (300 degrees to 30 degrees and 330 degrees to 60 degrees ) adequately treated the PTVs. Furthermore, this IMAT technique allowed sparing of small bowel and the iliac crests (marrow space) to a similar degree as the 8-field IMRT. The 8-field IMRT yielded better dose uniformity than IMAT in the target volumes; however, neither technique was as uniform as the conventional plan. In the 5 patients, IMAT treatment was well tolerated and completed as planned. CONCLUSIONS We successfully piloted an optimized intensity-modulated arc technique to treat 5 high-risk endometrial cancer patients undergoing multimodality treatment. This allowed a significant reduction in dose to bone marrow and small bowel compared with conventional techniques and was simpler to deliver than multifield IMRT.
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Affiliation(s)
- Eugene Wong
- Department of Oncology, University of Western Ontario, and London Regional Cancer Centre, 790 Commissioners Road East, London, Ontario N6A 4L6, Canada.
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Abstract
Radiation therapy has been a major therapeutic modality for eradicating malignant tumors over the past century. In fact, it was not long after the discovery of radium that the first woman with cervical cancer underwent intracavitary brachytherapy. Progress in the way that this cytotoxic agent is manipulated and delivered has seen an explosive growth over the past two decades with technological developments in physics, computing capabilities, and imaging. Although radiation oncologists are educated in and familiar with the wealth of new revolutionary techniques, it is not easy for other key members of the team to keep up with the rapid progress and its significance. However, to fully exploit these enormous gains and to communicate effectively, medical and gynecological oncologists are expected to be aware of state-of-the-art radiation oncology. Here, we elucidate and illustrate contemporary techniques in radiation oncology, with particular attention paid to the external beam radiotherapy used for adjuvant and primary definitive management of malignancies of the female pelvis.
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Affiliation(s)
- A Ahamad
- Department of Radiation Oncology, The University of Texas, M. D. Anderson Cancer Center, Houston, TX, USA
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Salama JK, Roeske JC, Mehta N, Mundt AJ. Intensity-modulated radiation therapy in gynecologic malignancies. Curr Treat Options Oncol 2004; 5:97-108. [PMID: 14990204 DOI: 10.1007/s11864-004-0042-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Radiation therapy occupies an important role in the treatment of gynecologic malignancies. Unfortunately, traditional approaches result in the irradiation of large volumes of normal tissues exposing patients to many toxicities and precluding dose escalation in select patients. A novel approach to the planning and delivery of radiation therapy, known as intensity-modulated radiation therapy (IMRT), has been introduced. Unlike conventional approaches, IMRT conforms the prescription dose to the shape of the target in three dimensions, thus sparing the surrounding normal tissues. Multiple studies have demonstrated the clear superiority of IMRT planning in these patients in terms of normal tissue sparing. Promising clinical results have also been published, suggesting that IMRT reduces the incidence of acute and chronic toxicity in these women. Ongoing studies are focusing on tumor control and patient outcome. Although further work is needed, these results suggest that IMRT may represent a major advancement in the planning and delivery of radiation therapy in patients with gynecologic malignancies.
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Affiliation(s)
- Joseph K Salama
- Department of Radiation and Cellular Oncology, University of Chicago, 5758 South Maryland Avenue, MC 9006, Chicago, IL 60637, USA
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Wahab SH, Malyapa RS, Mutic S, Grigsby PW, Deasy JO, Miller TR, Zoberi I, Low DA. A treatment planning study comparing HDR and AGIMRT for cervical cancer. Med Phys 2004; 31:734-43. [PMID: 15124990 DOI: 10.1118/1.1645678] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The customization of brachytherapy dose distributions for gynecologic malignancies is limited by the spatial positioning of the applicators. We tested the hypothesis that applicator-guided intensity modulated radiation therapy (AGIMRT) has the potential to deliver highly conformal dose distributions to cervical tumors, representing improvement over distributions obtained with intracavitary brachytherapy. A commercial three-dimensional (3-D) treatment planning system was used to create plans for ten cervical cancer patients treated at our institution. Dose distributions of conventionally designed high dose rate (HDR) plans were compared against those of AGIMRT. Tumor delineation was based on a previously published binary threshold technique, using image intensity on positron emission tomography (PET) scans. AGIMRT treatment schedules were designed using two fraction sizes: 6.5 Gy, to directly reproduce the HDR fractionation, and 1.8 Gy, to simulate traditional external beam fractionation. The average minimum tumor dose was significantly greater for the AGIMRT dose distributions than for the HDR distributions (64.2 Gy vs 33.6 Gy; p = 0.005). The mean percent tumor volume at the prescription dose was higher for the AGIMRT plans (90.0% vs 58.2%; p = 0.005). Using AGIMRT, the mean percent volume at the tolerance limit was decreased for the bladder (6.1% vs 16.6%; p = 0.047) but increased for the rectum (4.1% vs 2.2%; p = 0.646). Our study suggests that there may be conceptual and dosimetric advantages to replacing HDR with AGIMRT for patients with large-volume cervical tumors. This investigation is being expanded using sequential PET images to model tumor regression and compare brachytherapy and AGIMRT throughout the course of therapy.
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Affiliation(s)
- Sasha H Wahab
- Department of Radiation Oncology, Mallinckrodt Institute, Washington University School of Medicine, Box 8224, 660 South Euclid Avenue, St. Louis, Missouri 63110, USA
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Mundt AJ, Roeske JC. Can intensity-modulated radiation therapy replace brachytherapy in the management of cervical cancer? Counterpoint. Brachytherapy 2004; 1:192-4. [PMID: 15062166 DOI: 10.1016/s1538-4721(03)00002-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Arno J Mundt
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, USA
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Lee CM, Shrieve DC, Gaffney DK. Rapid involution and mobility of carcinoma of the cervix. Int J Radiat Oncol Biol Phys 2004; 58:625-30. [PMID: 14751536 DOI: 10.1016/j.ijrobp.2003.09.060] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To quantitatively describe the involution and mobility of carcinoma of the cervix while under treatment with chemoradiotherapy (both with external beam radiation [EBRT] and high-dose-rate [HDR] intracavitary therapy). These data have implications for conformal or intensity modulated radiation therapy boost to the cervix. METHODS AND MATERIALS Seventeen patients underwent HDR brachytherapy boost to the cervix and were evaluated by repeat clinical examinations. In most cases, 5 weekly HDR brachytherapy insertions were performed after approximately 2 to 3 weeks of the initiation of EBRT. Sequential clinical tumor sizes were recorded in the chart for each patient under treatment. Linear regression analyses were performed to analyze tumor size as a function of total dose of external beam plus brachytherapy and number of elapsed days during the treatment course. In addition, the mobility of the cervix was documented by placement of a uterine sleeve for HDR brachytherapy before the initiation of therapy, and changes in sleeve position were identified on portal films relative to the midline of the pubic symphysis, in three dimensions. The anatomic position of the cervix was also identified at the time of simulation for HDR brachytherapy. RESULTS Seventeen patients were identified and selected to receive HDR brachytherapy at our institution. Sixteen of the 17 patients received concurrent chemotherapy. The median dose at which tumor was no longer clinically evident was 61.5 Gy (95% confidence interval [CI]: 50.7-72.3 Gy) by linear regression analysis. This indicates that the median dose to achieve a 50% reduction in tumor size is approximately 30.8 Gy. Similarly, the median number of elapsed days for a complete response was 42 days (95% CI: 34-50 elapsed days). This indicates that it takes 21 days to achieve a 50% clinical complete response for patients undergoing concurrent cisplatin-based chemoradiotherapy and HDR brachytherapy. In addition, the mobility of the cervix during EBRT was noted by serial measurements of the location of a metallic ring in the uterine sleeve, as seen on port films. The median and maximum ranges for change in the position of the cervix in the lateral (x), superior/inferior (y), and anterior/posterior (z) planes were 10, 8, and 16 mm and 24, 36, and 23 mm, respectively. Also, 85 brachytherapy procedures were performed, and the positions of the cervix on 170 orthogonal films were evaluated. The median and maximum ranges for the position of the cervix at the time of HDR brachytherapy in the lateral (x), superior/inferior (y), and anterior/posterior (z) planes were 5, 12, and 10 mm and 11, 25, and 32 mm, respectively. CONCLUSIONS Carcinoma of the cervix involutes rapidly with EBRT, concurrent cisplatin-based chemotherapy, and HDR brachytherapy. The time for 50% tumor regression was calculated to be 21 days and occurs after 30.8 Gy. In addition, uterine sleeve placement allowed us to document the median and maximum ranges of cervical mobility during the treatment course of EBRT to be 8-16 mm and 23-36 mm, and at the time of HDR brachytherapy to be 5-12 mm and 11-32 mm, respectively. These data indicate that the cervix gross tumor volume changes rapidly in a systematic fashion during chemoradiotherapy and, together with the mobility of the cervix, urge caution in nonbrachytherapy boost planning.
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Affiliation(s)
- Christopher M Lee
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, 50 N. Medical Drive, Salt Lake City, UT 84132, USA
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Capp A, Metcalfe P. IMRT: is it Nirvana? PROGRESS IN PALLIATIVE CARE 2004. [DOI: 10.1179/096992604225004561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Roeske JC, Bonta D, Mell LK, Lujan AE, Mundt AJ. A dosimetric analysis of acute gastrointestinal toxicity in women receiving intensity-modulated whole-pelvic radiation therapy. Radiother Oncol 2003; 69:201-7. [PMID: 14643959 DOI: 10.1016/j.radonc.2003.05.001] [Citation(s) in RCA: 147] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE To identify dosimetric factors correlated with acute gastrointestinal (GI) toxicity in gynecology patients undergoing intensity-modulated whole pelvic radiation therapy (IM-WPRT). MATERIAL AND METHODS Fifty gynecology patients received IM-WPRT (45-1.8Gy/fraction) between 2/00 and 3/02. All patients were treated to a clinical target volume (CTV) consisting of the upper vagina, parametria, uterus, presacral region and pelvic lymph nodes. Grade 2 acute GI toxicity requiring frequent medications and grade 3-5 toxicities were designated as clinically significant and analyzed as a function of patient and dosimetric variables. The most significant volumetric factors were fit to a normal tissue complication probability (NTCP) function. RESULTS Fourteen women (28%) developed clinically significant acute GI toxicity. None of the patient factors were correlated with acute GI toxicity. In addition, the volume of rectum receiving 25, 50, 75, 90, 100 and 110% of the prescription dose did not reach statistical significance. In contrast, a correlation was observed between the volume of small bowel (SB) irradiated and acute GI toxicity, particularly the SB volumes receiving 90 and 100% of the prescription dose (p=0.009 and p=0.009, respectively). Controlling for patient and other dosimetric factors, the SB volume receiving the 100% (Vol(SB,100)) of the prescription dose remained the sole significant factor on multivariate analysis (p=0.012). Subsequently, a NTCP curve, quantifying the risk of acute GI toxicity, was generated based on the Vol(SB,100). CONCLUSIONS The most significant factor correlated acute GI toxicity in gynecology patients undergoing IM-WPRT is Vol(SB,100).
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Affiliation(s)
- John C Roeske
- Department of Radiation and Cellular Oncology, The University of Chicago, 5758 S. Maryland Ave MC 9006, Chicago, IL 60637, USA
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Mundt AJ, Mell LK, Roeske JC. Preliminary analysis of chronic gastrointestinal toxicity in gynecology patients treated with intensity-modulated whole pelvic radiation therapy. Int J Radiat Oncol Biol Phys 2003; 56:1354-60. [PMID: 12873680 DOI: 10.1016/s0360-3016(03)00325-0] [Citation(s) in RCA: 243] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE To provide a preliminary analysis of chronic gastrointestinal (GI) toxicity in gynecology patients treated with intensity-modulated whole pelvic radiation therapy (IM-WPRT). METHODS AND MATERIALS Between February 2000 and August 2001, 36 gynecology patients received IM-WPRT. All patients underwent a contrast-enhanced computed tomography scan, and a clinical target volume (CTV) was contoured consisting of the upper vagina, parametria, uterus (if present), and presacral and pelvic lymph node regions. The CTV was expanded by 1 cm to create a planning target volume (PTV). Seven or 9-field IM-WPRT plans were generated. IM-WPRT plans were highly conformal, providing excellent coverage of the PTV and considerable sparing of normal tissues, including the small bowel and rectum. Chronic GI toxicity was scored: 0 (no symptoms), 1 (mild symptoms, no medications required), 2 (moderate symptoms, medications required), and 3 (severe symptoms, hospitalization, surgery required). Chronic GI toxicity in 30 gynecology patients treated with conventional WPRT patients before the implementation of IM-WPRT was also evaluated. Median follow-up in the IM-WPRT and WPRT groups were 19.6 and 30.2 months, respectively. RESULTS The IM-WPRT and WPRT groups were well balanced in terms of most patient and treatment factors, including age, site, stage, chemotherapy, WPRT dose, and brachytherapy, except for a higher frequency of surgery (75 vs. 54%, p = 0.02) in the IM-WPRT group. Overall, IM-WPRT patients had a lower rate of chronic GI toxicity (11.1 vs. 50.0%, p = 0.001) than WPRT patients. The percentage of IM-WPRT patients with Grade 1, 2, and 3 toxicity were 8.3%, 2.8%, and 0%, respectively. Corresponding percentages in the WPRT group were 30.0%, 16.7%, and 3.3%, respectively. The only other factor correlated with chronic GI toxicity was age (p = 0.02). On multivariate (logistic regression) analysis controlling for age and other clinical factors, IM-WPRT retained its statistical significance (p = 0.01; odds ratio 0.16; 95% confidence interval 0.04, 0.67) CONCLUSIONS Our results suggest that IM-WPRT is associated with less chronic GI toxicity than conventional WPRT in patients with gynecologic malignancies. However, longer follow-up and more patients are clearly needed to ascertain whether the benefits of IM-WPRT treatment seen here translate into true long-term reductions in chronic GI toxicity.
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Affiliation(s)
- Arno J Mundt
- Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, IL 60637, USA.
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Mell LK, Roeske JC, Mundt AJ. A survey of intensity-modulated radiation therapy use in the United States. Cancer 2003; 98:204-11. [PMID: 12833473 DOI: 10.1002/cncr.11489] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The objective of this study was to assess the current level of intensity-modulated radiation therapy (IMRT) use in the United States. METHODS Three-hundred thirty-three randomly selected radiation oncologists were sent a 13-question survey regarding IMRT use. IMRT users were asked about the number of patients and sites treated, their reasons for adopting IMRT, and future plans for its use. Physicians who did not use IMRT were asked about their reasons for not using IMRT; whether they intended to adopt it in the future; and, if so, their reasons. RESULTS One-hundred sixty-eight responses (50.5%) were received. Fifty-four respondents (32.1%) stated that they currently used IMRT. Most IMRT users (79.6%) had adopted IMRT since 2000. Academic physicians were more likely to use IMRT (P = 0.003) compared with private practitioners. The percent of physicians using IMRT in practices comprised of 1 physician, 2-4 physicians, or > 4 physicians were 15.4%, 28.4%, and 44.2%, respectively (P = 0.02). The most common sites treated were head and neck malignancies and genitourinary tumors. Of the 114 IMRT nonusers, 96.5% planned to use IMRT in the future, with 91.8% planning to use IMRT within 3 years. Among IMRT nonusers, the most common reason cited for not using IMRT was lack of necessary equipment. The most common reasons for adopting IMRT (users) or wanting to adopt IMRT (nonusers) were to improve delivery of conventional doses and to escalate dose. CONCLUSIONS Approximately one-third of radiation oncologists in the United States use IMRT. However, this number appears to be growing rapidly. Efforts to ensure the safe and appropriate application of this new technology are warranted.
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Affiliation(s)
- Loren K Mell
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, Illinois 60637, USA
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