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Achari RB, Chakraborty S, Ray S, Mahata A, Mandal S, Das J, Sarkar K, Mallick I, Bhaumik J, Chakraborti B, Ghosh A, Sen S, Chandra A, Chatterjee S, Arunsingh M, Bhattacharyya T. 18F-fluorodeoxyglucose PET-CT-guided pelvic chemoradiation therapy using helical tomotherapy for locally advanced carcinoma cervix without para-aortic nodal disease: Clinical and patient-reported outcomes from a prospective phase 2 study. J Med Imaging Radiat Oncol 2024. [PMID: 38874192 DOI: 10.1111/1754-9485.13667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 04/23/2024] [Indexed: 06/15/2024]
Abstract
INTRODUCTION Locally advanced carcinoma cervix (LACC) is a heterogeneous disease with variable combinations of primary tumour extensions with or without nodal involvement. Metabolic information from 18 fluro-deoxyglucose positron emission tomography combined with contrast-enhanced computerized tomography (FDG PET-CT) may potentially augment treatment decision-making for LACC. This study ascertained FDG-PET CT influence on chemoradiation therapy (CTRT) decisions in LACC. We report oncologic and patient-reported outcome measures (PROMs). METHODS FDG PET-CT scans were reviewed independently by two nuclear medicine specialists and two radiation oncologists. Pelvic CTRT plan digressions were documented and therapy was adapted accordingly. Pelvis radiation (50 Gy/25#/5 weeks) using tomotherapy with weekly cisplatin was used in node-negative disease. Dose-escalated simultaneous integrated boost (SIB) 60 Gy/25#/5 weeks was delivered to involved pelvic nodes. All received brachytherapy. Post-treatment PET-CT scans were at 6 months. Functional assessment of cancer therapy scores were calculated at baseline, treatment completion, 3 months, 1 year and 3 years. RESULTS Between November 2015 and January 2018, 85 patients were screened, and 77 consented. Extrapelvic disease was seen in 12 (16%) patients (9 para-aortic nodes, 2 distant metastases and 1 synchronous carcinoma breast); 60 patients were included in the final analysis. Decision changes were seen in 10/77 (13%) screened, 8/60 (13%) included and 32 (53.3%) received SIB. Post-treatment, 27 (45%) had grade 2 GI/GU/GYN toxicity, one (2%) had grade 3 GI and five (8.3%) had grade 3 neutropenia. At median overall survival of 54.2 months (95% CI 52.8-58.3), 5-year local failure, pelvic nodal and para-aortic nodal-free survival were 86.8% (95% CI 78.0-96.6), 85.2% (95% CI 76.1-95.3) and 85.2% (95% CI 76.2-95.4). Functional assessment of cancer therapy trial outcome index (FACT TOI) improved by 10.43 at 3 months with no further decline. Grade 3 toxicity was noted for abdominal pain in one (1.7%), cystitis in four (6.7%) and lymphoedema in one (1.7%) at 5 years. CONCLUSION PET-CT resulted in major decision changes in 13%. PET-adapted CTRT was associated with acceptable toxicity, encouraging long-term survival and improvement in PROMS.
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Affiliation(s)
- Rimpa Basu Achari
- Department of Radiation Oncology and Medical Physics, Tata Medical Center, Kolkata, India
| | - Santam Chakraborty
- Department of Radiation Oncology and Medical Physics, Tata Medical Center, Kolkata, India
| | | | - Anurupa Mahata
- Department of Radiation Oncology and Medical Physics, Tata Medical Center, Kolkata, India
| | - Samar Mandal
- Department of Radiation Oncology and Medical Physics, Tata Medical Center, Kolkata, India
| | - Jayanta Das
- Department of Nuclear Medicine, Tata Medical Center, Kolkata, India
| | - Kanishka Sarkar
- Department of Radiation Oncology and Medical Physics, Tata Medical Center, Kolkata, India
| | - Indranil Mallick
- Department of Radiation Oncology and Medical Physics, Tata Medical Center, Kolkata, India
| | - Jaydip Bhaumik
- Department of Gynecologic Oncosurgery, Tata Medical Center, Kolkata, India
| | | | - Anik Ghosh
- Department of Gynecologic Oncosurgery, Tata Medical Center, Kolkata, India
| | - Saugata Sen
- Department of Radiology, Tata Medical Center, Kolkata, India
| | - Aditi Chandra
- Department of Radiology, Tata Medical Center, Kolkata, India
| | - Sanjoy Chatterjee
- Department of Radiation Oncology and Medical Physics, Tata Medical Center, Kolkata, India
| | - Moses Arunsingh
- Department of Radiation Oncology and Medical Physics, Tata Medical Center, Kolkata, India
| | - Tapesh Bhattacharyya
- Department of Radiation Oncology and Medical Physics, Tata Medical Center, Kolkata, India
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Rørtveit ØL, Hysing LB, Stordal AS, Pilskog S. An organ deformation model using Bayesian inference to combine population and patient-specific data. Phys Med Biol 2023; 68. [PMID: 36735964 DOI: 10.1088/1361-6560/acb8fc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 02/03/2023] [Indexed: 02/05/2023]
Abstract
Objective.Organ deformation models have the potential to improve delivery and reduce toxicity of radiotherapy, but existing data-driven motion models are based on either patient-specific or population data. We propose to combine population and patient-specific data using a Bayesian framework. Our goal is to accurately predict individual motion patterns while using fewer scans than previous models.Approach.We have derived and evaluated two Bayesian deformation models. The models were applied retrospectively to the rectal wall from a cohort of prostate cancer patients. These patients had repeat CT scans evenly acquired throughout radiotherapy. Each model was used to create coverage probability matrices (CPMs). The spatial correlations between these estimated CPMs and the ground truth, derived from independent scans of the same patient, were calculated.Main results.Spatial correlation with ground truth were significantly higher for the Bayesian deformation models than both patient-specific and population-derived models with 1, 2 or 3 patient-specific scans as input. Statistical motion simulations indicate that this result will also hold for more than 3 scans.Significance.The improvement over previous models means that fewer scans per patient are needed to achieve accurate deformation predictions. The models have applications in robust radiotherapy planning and evaluation, among others.
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Affiliation(s)
- Øyvind Lunde Rørtveit
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway.,Department of Technology and Physics, University of Bergen, Norway
| | - Liv Bolstad Hysing
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway.,Department of Technology and Physics, University of Bergen, Norway
| | - Andreas Størksen Stordal
- NORCE Norwegian Research Centre, Bergen, Norway.,Department of Mathematics, University of Bergen, Norway
| | - Sara Pilskog
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway.,Department of Technology and Physics, University of Bergen, Norway
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Mohamed S, Assenholt MS, Fokdal L, Kallehauge J, Lindegaard JC, Tanderup K. Coverage probability planning for simultaneously integrated boosts of inguinal lymph nodes in vulvar cancer. Acta Oncol 2022; 61:1406-1411. [DOI: 10.1080/0284186x.2022.2134735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Sandy Mohamed
- Department of Radiotherapy and Nuclear Medicine, National Cancer Institute, Cairo University, Cairo, Egypt
| | | | - Lars Fokdal
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Kari Tanderup
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Dose Accumulation for Multicourse Gynaecological Reirradiation: A Methodological Narrative and Clinical Examples. Int J Radiat Oncol Biol Phys 2022; 113:1085-1090. [DOI: 10.1016/j.ijrobp.2022.04.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/15/2022] [Accepted: 04/30/2022] [Indexed: 11/23/2022]
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Kedves A, Gulyban A, Glavak C, Toller G, Völgyi Z, Faour A, Bálint A, Petrási B, Rák T, Lakosi F. Retrospective validation of coverage probability based simultaneous integrated nodal boost in locally advanced cervical cancer: a mono-institutional analysis. Acta Oncol 2022; 61:202-205. [PMID: 34460340 DOI: 10.1080/0284186x.2021.1971293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Andras Kedves
- Dr József Baka Center, Department of Radiation Oncology, Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
- Doctoral School of Health Sciences, University of Pécs, Pécs, Hungary
- Institute of Diagnostics, Faculty of Health Sciences, University of Pécs, Pécs, Hungary
| | - Akos Gulyban
- Medical Physics Department, Jules Bordet Institut, Brussels, Belgium
| | - Csaba Glavak
- Dr József Baka Center, Department of Radiation Oncology, Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
| | - Gabor Toller
- Dr József Baka Center, Department of Radiation Oncology, Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
| | - Zoltán Völgyi
- Dr József Baka Center, Department of Radiation Oncology, Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
| | - Amer Faour
- Dr József Baka Center, Department of Radiation Oncology, Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
| | - András Bálint
- Department of Clinical Oncology, Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
| | - Bernadett Petrási
- Dr József Baka Center, Department of Radiation Oncology, Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
| | - Tibor Rák
- Department of Gynecology, Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
| | - Ferenc Lakosi
- Dr József Baka Center, Department of Radiation Oncology, Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
- Doctoral School of Health Sciences, University of Pécs, Pécs, Hungary
- Institute of Diagnostics, Faculty of Health Sciences, University of Pécs, Pécs, Hungary
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Jensen GL, Mezera MA, Hasan S, Hammonds KP, Swanson GP, El-Ghamry MN. Dose escalated simultaneous integrated boost of gross nodal disease in gynecologic cancers: a multi-institutional retrospective analysis and review of the literature. Radiat Oncol J 2021; 39:219-230. [PMID: 34610661 PMCID: PMC8497864 DOI: 10.3857/roj.2020.00948] [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: 11/07/2020] [Accepted: 03/16/2021] [Indexed: 11/03/2022] Open
Abstract
PURPOSE Typical doses of 45-50.4 Gy used to treat regional nodes have demonstrated inadequate control of gross nodal disease (GND) in gynecologic cancer, and accelerated repopulation may limit the efficacy of a sequential boost. We reviewed outcomes of patients treated with a simultaneous integrated boost (SIB) at 2.25 Gy per fraction to positron emission tomography (PET) avid GND to evaluate toxicity and tumor control using this dose-escalated regimen. MATERIALS AND METHODS A total of 83 patients with gynecologic cancer and PET avid inguinal, pelvic, or para-aortic lymphadenopathy were treated using intensity-modulated radiation therapy (IMRT) with SIB. Primary cancers were mostly cervical (51%) and endometrial (34%), and included patients who received concurrent chemotherapy (59%) and/or brachytherapy boost (78%). RESULTS Median follow-up from radiation completion was 12.6 months (range, 2.7 to 92.9 months). Median dose to elective lymphatics was 50.4 Gy (range, 45 to 50.4 Gy) at 1.8 Gy/fraction. Median SIB dose and volume were 63 Gy (range, 56.3 to 63 Gy) and 72.8 mL (range, 6.8 to 1,134 mL) at 2-2.25 Gy/fraction. Nodal control was 97.6% in the SIB area while 90.4% in the low dose area (p = 0.013). SIB radiotherapy (RT) field failure-free, non-SIB RT field failure-free, and out of RT field failure-free survival at 4 years were 98%, 86%, and 51%, respectively. Acute and late grade ≥3 genitourinary toxicity rates were 0%. Acute and late grade ≥3 gastrointestinal toxicity rates were 7.2% and 12.0%, respectively. CONCLUSION Dose escalated SIB to PET avid adenopathy results in excellent local control with acceptable toxicity.
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Affiliation(s)
- Garrett Lee Jensen
- Department of Radiation Oncology, Baylor Scott & White Health, Temple, TX, USA
| | - Megan Ann Mezera
- Department of Radiation Oncology, MD Anderson Cancer Center at Cooper University Hospital, Camden, NJ, USA
| | - Salman Hasan
- Department of Radiation Oncology, Ascension Via Christi Cancer Center, Wichita, KS, USA
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Peters M, de Leeuw AAC, Nomden CN, Tanderup K, Kirchheiner K, Lindegaard JC, Kirisits C, Haie-Meder C, Sturdza A, Fokdal L, Mahantshetty U, Hoskin P, Segedin B, Bruheim K, Rai B, Huang F, Cooper R, van der Steen-Banasik E, van Limbergen E, Pieters BR, Tan LT, van Rossum PSN, Nesvacil N, Nout R, Schmid MP, Pötter R, Jürgenliemk-Schulz IM. Risk factors for nodal failure after radiochemotherapy and image guided brachytherapy in locally advanced cervical cancer: An EMBRACE analysis. Radiother Oncol 2021; 163:150-158. [PMID: 34480958 DOI: 10.1016/j.radonc.2021.08.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 07/22/2021] [Accepted: 08/26/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To assess risk factors for nodal failure (NF) after definitive (chemo)radiotherapy and image-guided brachytherapy for locally advanced cervical cancer (LACC) for patients treated in the EMBRACE I study. MATERIALS AND METHODS Data for pelvic NF and para-aortic (PAO) NF (NFPAO) were analysed. After multiple imputation, univariable and multivariable Cox-regression was performed for clinical and treatment-related variables. For patients with affected pelvic nodes but no PAO nodes at diagnosis, additional analyses were performed for two subgroups: 1. 'small pelvis' nodes in internal and external iliac, obturator, parametrial, presacral and/or common iliac (CI) region and 2. any CI nodes (subgroup of 1). RESULTS 1338 patients with 152 NF and 104 NFPAO events were analysed with a median follow-up of 34.2 months (IQR 16.4-52.7). For the entire group, larger tumour width, nodal risk groups (in particular any CI nodes without PAO nodes), local failure, and lower Hb-nadir increased the risk of NF. Elective PAO-irradiation was independently associated with a decreased risk of NFPAO (HR 0.53, 95%-CI 0.28-1.00, p = 0.05). For subgroup 1, having 'any CI nodes without PAO nodes' and local failure significantly increased NF risk. Additionally, elective PAO-irradiation was associated with less risk of NFPAO (HR 0.38, 95%-CI 0.17-0.86, p = 0.02). For subgroup 2 only local failure was associated with higher risk of NF. CONCLUSION In this patient cohort, nodal disease and tumour width at diagnosis, as well as local failure, are risk factors for NF after definitive treatment. Having either 'any PAO nodes' (with or without pelvic nodes) or 'any CI nodes' (without PAO nodes) are stronger risk factors than involvement of nodes in the small pelvis alone. Elective PAO-irradiation was associated with significantly less NFPAO, particularly in patients with nodal disease in the 'small pelvis' and/or CI region at time of diagnosis.
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Affiliation(s)
- Max Peters
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands.
| | - Astrid A C de Leeuw
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | - Christel N Nomden
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | - Kari Tanderup
- Aarhus University Hospital, Department of Oncology, Aarhus, Denmark
| | - Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | | | - Christian Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | | | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | - Lars Fokdal
- Aarhus University Hospital, Department of Oncology, Aarhus, Denmark
| | | | - Peter Hoskin
- Mount Vernon Cancer Centre, Northwood, United Kingdom
| | - Barbara Segedin
- Institute of Oncology Ljubljana, Department of Radiotherapy, Ljubljana, Slovenia
| | - Kjersti Bruheim
- The Norwegian Radium Hospital-Oslo University Hospital, Department of Oncology, Oslo, Norway
| | - Bhavana Rai
- Postgraduate Institute of Medical Education and Research, Department of Radiotherapy and Oncology, Chandigarh, India
| | - Fleur Huang
- Department of Oncology, Cross Cancer Institute and University of Alberta, Edmonton, Canada
| | - Rachel Cooper
- St James's University Hospital, Leeds Cancer Centre, Leeds, United Kingdom
| | | | | | - Bradley R Pieters
- Department of Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, the Netherlands
| | - Li Tee Tan
- Department of Oncology, Addenbrooke's Hospital, Cambridge University Hospitals, United Kingdom
| | - Peter S N van Rossum
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | - Nicole Nesvacil
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | - Remi Nout
- Leiden University Medical Center, Department of Radiation Oncology, Leiden, the Netherlands
| | - Maximilian P Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | - Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
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Musunuru HB, Pifer PM, Mohindra P, Albuquerque K, Beriwal S. Advances in management of locally advanced cervical cancer. Indian J Med Res 2021; 154:248-261. [PMID: 35142642 PMCID: PMC9131769 DOI: 10.4103/ijmr.ijmr_1047_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Globally, cervical cancer has the fourth highest cancer incidence and mortality in women. Cervical cancer is unique because it has effective prevention, screening, and treatment options. This review discusses the current cervical cancer advances with a focus on locally advanced cervical cancer. Topics discussed include diagnostic imaging principles, surgical management with adjuvant therapy and definitive concurrent chemoradiotherapy. Emphasis is given on current advances and future research directions in radiation therapy (RT) with an emphasis on three-dimensional brachytherapy, intensity-modulated RT, image-guided RT, proton RT and hyperthermia.
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Affiliation(s)
- Hima Bindu Musunuru
- Department of Radiation Oncology, University of Pittsburgh Medical Center Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - Phillip M Pifer
- Department of Radiation Oncology, University of Pittsburgh Medical Center Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Maryland Proton Treatment Center, Baltimore, Maryland, USA
| | - Kevin Albuquerque
- Department of Radiation Oncology, Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sushil Beriwal
- Department of Radiation Oncology, University of Pittsburgh Medical Center Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
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Tan LT, Tanderup K, Nappa A, Petric P, Jürgenliemk-Schulz IM, Serban M, Swamidas JV, Palmu M, Duke SL, Mahantshetty U, Nesvacil N, Pötter RC, Nout RA. Impact of transitioning to an online course - A report from the ESTRO gyn teaching course. Clin Transl Radiat Oncol 2021; 29:85-92. [PMID: 34189283 PMCID: PMC8220299 DOI: 10.1016/j.ctro.2021.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 06/09/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction In 2020, the ESTRO course on image-guided radiotherapy and chemotherapy in gynaecological cancer was converted into an online version due to the COVID-19 pandemic. This paper describes the change process and evaluates the impact on participants compared with previous live courses. Methods and materials The 2019 live course contained 41 h of educational content, comprising 33 h of synchronous activities (lectures, interactive activities, videos) and 8 h of homework (contouring, dose planning). For the online course, the lectures were provided as pre-course material (11 mandatory, 22 optional). Contouring/dose planning homework was unchanged. The synchronous sessions were reconfigured as six 2-hour webinars (total educational content ~38 h).Participant numbers/characteristics, engagement and satisfaction for six live courses and the online course were compared. Results Participant numbers for the online and live courses were similar (90 vs. mean 96). There were more participants from outside Europe (28% vs. mean 18%) and more non-doctors (47% vs. mean 33%). Proportion of participants responding to the pre-course questionnaire was similar (77% vs. mean 78%) but post-course questionnaire response was lower (62% vs. mean 92%).43% participants viewed ≥75% of mandatory lectures before the webinars. 86% viewed the optional lectures. Submissions of contouring and dose planning homework was higher (contouring 77%-90% vs. 56%-69%, dose planning 74%-89% vs. 29%-57%).96% (47/49) participants rated the online course as Excellent (43%) or Good (53%). Overall satisfaction was similar (4.4 vs. mean 4.6). Conclusion Participant satisfaction and engagement with the online course remained high despite less contact time with faculty.
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Affiliation(s)
- L T Tan
- Cambridge University Hospitals NHS Trust, United Kingdom
| | | | - A Nappa
- European Society of Radiotherapy and Oncology (ESTRO), Brussels, Belgium
| | - P Petric
- Institute of Oncology, Ljubljana, Slovenia
| | | | - M Serban
- McGill University Health Center, Montreal, Canada
| | | | - M Palmu
- European Society of Radiotherapy and Oncology (ESTRO), Brussels, Belgium
| | - S L Duke
- Cambridge University Hospitals NHS Trust, United Kingdom
| | | | | | | | - R A Nout
- Erasmus MC Cancer Institute, Rotterdam, the Netherlands
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Jayatilakebanda I, Tsang YM, Hoskin P. High dose simultaneous integrated boost for node positive cervical cancer. Radiat Oncol 2021; 16:92. [PMID: 34001158 PMCID: PMC8130443 DOI: 10.1186/s13014-021-01818-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 05/10/2021] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Lymph node metastases presenting with locally advanced cervical cancer are poor prognostic features. Modern radiotherapy approaches enable dose escalation to radiologically abnormal nodes. This study reports the results of a policy of a simultaneous integrated boost (SIB) in terms of treatment outcomes. MATERIALS AND METHODS Patients treated with radical chemoradiation with weekly cisplatin for locally advanced cervical cancer including an SIB to radiologically abnormal lymph nodes were analysed. All patients received a dose of 45 Gy in 25 fractions and a SIB dose of 60 Gy in 25 fractions using intensity modulated radiotherapy/volumetric modulated arc therapy, followed by high dose rate brachytherapy of 28 Gy in 4 fractions. A control cohort with radiologically negative lymph nodes was used to compare impact of the SIB in node positive patients. Treatment outcomes were measured by overall survival (OS), post treatment tumour response and toxicities. The tumour response was based on cross sectional imaging at 3 and 12 months and recorded as local recurrence free survival (LRFS), regional recurrence free survival (RRFS) and distant recurrence free survival (DRFS). RESULTS In between January 2015 and June 2017, a total of 69 patients with a median follow up of 30.9 months (23 SIB patients and 46 control patients) were identified. The complete response rate at 3 months was 100% in the primary tumour and 83% in the nodal volume receiving SIB. The OS, LRFS, RRFS and DRFS at 3 years of the SIB cohort were 69%, 91%, 79% and 77% respectively. High doses can be delivered to regional pelvic lymph nodes using SIB without excessive toxicity. CONCLUSION Using a SIB, a total dose of 60 Gy in 25 fractions chemoradiation can be delivered to radiologically abnormal pelvic nodes with no increase in toxicity compared to node negative patients. The adverse impact of positive nodal status may be negated by high dose deposition using SIB, but larger prospective studies are required to confirm this observation.
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Affiliation(s)
| | - Yat Man Tsang
- Mount Vernon Cancer Centre, Rickmansworth Road, Northwood, Middlesex, HA6 2RN, UK
| | - Peter Hoskin
- Mount Vernon Cancer Centre, Rickmansworth Road, Northwood, Middlesex, HA6 2RN, UK.
- University of Manchester, Manchester, UK.
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Pötter R, Tanderup K, Schmid MP, Jürgenliemk-Schulz I, Haie-Meder C, Fokdal LU, Sturdza AE, Hoskin P, Mahantshetty U, Segedin B, Bruheim K, Huang F, Rai B, Cooper R, van der Steen-Banasik E, Van Limbergen E, Pieters BR, Tan LT, Nout RA, De Leeuw AAC, Ristl R, Petric P, Nesvacil N, Kirchheiner K, Kirisits C, Lindegaard JC. MRI-guided adaptive brachytherapy in locally advanced cervical cancer (EMBRACE-I): a multicentre prospective cohort study. Lancet Oncol 2021; 22:538-547. [PMID: 33794207 DOI: 10.1016/s1470-2045(20)30753-1] [Citation(s) in RCA: 260] [Impact Index Per Article: 86.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/10/2020] [Accepted: 12/11/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND The concept of the use of MRI for image-guided adaptive brachytherapy (IGABT) in locally advanced cervical cancer was introduced 20 years ago. Here, we report on EMBRACE-I, which aimed to evaluate local tumour control and morbidity after chemoradiotherapy and MRI-based IGABT. METHODS EMBRACE-I was a prospective, observational, multicentre cohort study. Data from patients from 24 centres in Europe, Asia, and North America were prospectively collected. The inclusion criteria were patients older than 18 years, with biopsy-proven squamous cell carcinoma, adenocarcinoma, or adenosquamous carcinoma of the uterine cervix, The International Federation of Gynecology and Obstetrics (FIGO) stage IB-IVA disease or FIGO stage IVB disease restricted to paraaortic lymph metastasis below the L1-L2 interspace, suitable for curative treatment. Treatment consisted of chemoradiotherapy (weekly intravenous cisplatin 40 mg/m2, 5-6 cycles, 1 day per cycle, plus 45-50 Gy external-beam radiotherapy delivered in 1·8-2 Gy fractions) followed by MRI-based IGABT. The MRI-based IGABT target volume definition and dose reporting was according to Groupe Européen de Curiethérapie European Society for Radiation Oncology recommendations. IGABT dose prescription was open according to institutional practice. Local control and late morbidity were selected as primary endpoints in all patients available for analysis. The study was registered with ClinicalTrials.gov, NCT00920920. FINDINGS Patient accrual began on July 30, 2008, and closed on Dec 29, 2015. A total of 1416 patients were registered in the database. After exclusion for not meeting patient selection criteria before treatment, being registered but not entered in the database, meeting the exclusion criteria, and being falsely excluded, data from 1341 patients were available for analysis of disease and data from 1251 patients were available for assessment of morbidity outcome. MRI-based IGABT including dose optimisation was done in 1317 (98·2%) of 1341 patients. Median high-risk clinical target volume was 28 cm3 (IQR 20-40) and median minimal dose to 90% of the clinical target volume (D90%) was 90 Gy (IQR 85-94) equi-effective dose in 2 Gy per fraction. At a median follow-up of 51 months (IQR 20-64), actuarial overall 5-year local control was 92% (95% CI 90-93). Actuarial cumulative 5-year incidence of grade 3-5 morbidity was 6·8% (95% CI 5·4-8·6) for genitourinary events, 8·5% (6·9-10·6) for gastrointestinal events, 5·7% (4·3-7·6) for vaginal events, and 3·2% (2·2-4·5) for fistulae. INTERPRETATION Chemoradiotherapy and MRI-based IGABT result in effective and stable long-term local control across all stages of locally advanced cervical cancer, with a limited severe morbidity per organ. These results represent a positive breakthrough in the treatment of locally advanced cervical cancer, which might be used as a benchmark for clinical practice and all future studies. FUNDING Medical University of Vienna, Aarhus University Hospital, Elekta AB, and Varian Medical Systems.
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Affiliation(s)
- Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Maximilian Paul Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria.
| | - Ina Jürgenliemk-Schulz
- Department of Radiation Oncology, University Medical Centre Utrecht, Utrecht, Netherlands
| | | | | | - Alina Emiliana Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Peter Hoskin
- Mount Vernon Hospital, Mount Vernon Cancer Centre, Northwood, London, UK; Division of Cancer Sciences, University of Manchester, Manchester, UK
| | | | - Barbara Segedin
- Department of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Kjersti Bruheim
- Department of Oncology, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Fleur Huang
- Department of Oncology, Cross Cancer Institute and University of Alberta, Edmonton, AB, Canada
| | - Bhavana Rai
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rachel Cooper
- St James's University Hospital, Leeds Cancer Centre, Leeds, UK
| | | | | | - Bradley Rumwell Pieters
- Department of Radiation Oncology, Amsterdam University Medical Center, Academic Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Li-Tee Tan
- Department of Oncology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Remi Abubakar Nout
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, Netherlands; Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Robin Ristl
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Primoz Petric
- Department of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Nicole Nesvacil
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Christian Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
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12
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K Jensen NB, Pötter R, Spampinato S, Fokdal LU, Chargari C, Lindegaard JC, Schmid MP, Sturdza A, Jürgenliemk-Schulz IM, Mahantshetty U, Segedin B, Bruheim K, Hoskin P, Rai B, Wiebe E, Cooper R, Van der Steen-Banasik E, Van Limbergen E, Sundset M, Pieters BR, Nout RA, Kirisits C, Kirchheiner K, Tanderup K. Dose-Volume Effects and Risk Factors for Late Diarrhea in Cervix Cancer Patients After Radiochemotherapy With Image Guided Adaptive Brachytherapy in the EMBRACE I Study. Int J Radiat Oncol Biol Phys 2020; 109:688-700. [PMID: 33068689 DOI: 10.1016/j.ijrobp.2020.10.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 09/30/2020] [Accepted: 10/06/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate patient- and treatment-related risk factors associated with incidence and persistence of late diarrhea after radiochemotherapy and image guided adaptive brachytherapy (IGABT) in locally advanced cervical cancer. MATERIALS AND METHODS Of 1416 patients from the EMBRACE I study, 1199 were prospectively evaluated using physician-reported (Common Terminology Criteria for Adverse Events version 3 [CTCAEv3]) assessment for diarrhea; median follow-up 48 months. Patient-reported outcome (EORTC) was available in 900 patients. Incidence of CTCAE G≥2, G≥3, and EORTC "very much" diarrhea was analyzed with Cox proportional hazards regression. Binary logistic regression was used for analysis of persistent G≥1 and EORTC "quite a bit" - "very much" (≥"quite a bit") diarrhea, defined if present in at least half of all follow-ups. RESULTS Crude incidences of G≥2 and G≥3 diarrhea were 8.3% and 1.5%, respectively, and 8% of patients reported "very much" diarrhea. Persistent G≥1 and ≥"quite a bit" diarrhea was present in 16% and 7%, respectively. Patient-related risk factors were baseline diarrhea, smoking, and diabetes with hazard ratios of 1.4 to 7.3. Treatment-related risk factors included prescribed dose, V43 Gy, V57 Gy (lymph node boost), and para-aortic irradiation for external beam radiation therapy (EBRT). G≥2 diarrhea at 3 years increased from 9.5% to 19.9% with prescribed dose 45 Gy versus 50 Gy, 8.7% to 14.0% with V43 Gy <2500 cm3 versus >3000 cm3 and 9.4% to 19.0% with V57 Gy <165 cm3 versus ≥165 cm3. Brachytherapy-related bowel and rectum D2cm3 were also associated with diarrhea. CONCLUSION Dose and volume effects have been established for late diarrhea after radiochemotherapy and IGABT in both CTCAE and EORTC reporting. The risk of diarrhea was lower with a pelvic EBRT prescription of 45 Gy, and higher with larger lymph node boosts volumes (ie, ≥165 cm3). The importance of EBRT volumes as determinants of late toxicity underline the need for continuous quality assurance of target contouring, dose planning, and conformity. The findings of brachytherapy dosimetric factors related to the intestines may become more important with highly conformal EBRT.
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Affiliation(s)
- Nina B K Jensen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark.
| | - Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Sofia Spampinato
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Lars U Fokdal
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Cyrus Chargari
- Department of Radiotherapy, Gustave-Roussy, Villejuif, France
| | | | - Maximilian P Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | | | - Umesh Mahantshetty
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Homi Bhabha National Institute, India
| | - Barbara Segedin
- Department of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Kjersti Bruheim
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Peter Hoskin
- Mount Vernon Cancer Centre, Mount Vernon Hospital, Northwood, United Kingdom
| | - Bhavana Rai
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ericka Wiebe
- Department of Oncology, Cross Cancer Institute and University of Alberta, Edmonton, Canada
| | - Rachel Cooper
- Leeds Cancer Centre, St James's University Hospital, Leeds, United Kingdom
| | | | - Erik Van Limbergen
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Marit Sundset
- Clinic of Oncology and Women's Clinic, St. Olavs Hospital, Trondheim, Norway
| | - Bradley R Pieters
- Department of Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
| | - Remi A Nout
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands; Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Christian Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
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13
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Shinde A, Li R, Amini A, Chen YJ, Cristea M, Wang W, Wakabyashi M, Han E, Yashar C, Albuquerque K, Beriwal S, Glaser S. Role of Locoregional Treatment in Vulvar Cancer With Pelvic Lymph Node Metastases: Time to Reconsider FIGO Staging? J Natl Compr Canc Netw 2020; 17:922-930. [PMID: 31390593 DOI: 10.6004/jnccn.2019.7288] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 02/21/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Vulvar cancer with pelvic nodal involvement is considered metastatic (M1) disease per AJCC staging. The role of definitive therapy and its resulting impact on survival have not been defined. PATIENTS AND METHODS Patients with pelvic lymph node-positive vulvar cancer diagnosed in 2009 through 2015 were evaluated from the National Cancer Database. Patients with known distant metastatic disease were excluded. Logistic regression was used to evaluate use of surgery and radiation therapy (RT). Overall survival (OS) was evaluated with log-rank test and Cox proportional hazards modeling (multivariate analysis [MVA]). A 2-month conditional landmark analysis was performed. RESULTS A total of 1,304 women met the inclusion criteria. Median follow-up was 38 months for survivors. Chemotherapy, RT, and surgery were used in 54%, 74%, and 62% of patients, respectively. Surgery was associated with prolonged OS (hazard ratio [HR], 0.58; P<.001) but had multiple significant differences in baseline characteristics compared with nonsurgical patients. In patients managed nonsurgically, RT was associated with prolonged OS (HR, 0.66; P=.019) in MVA. In patients undergoing surgery, RT was associated with better OS (3-year OS, 55% vs 48%; P=.033). Factors predicting use of RT were identified. MVA revealed that RT was associated with prolonged OS (HR, 0.75; P=.004). CONCLUSIONS In this cohort of women with vulvar cancer and positive pelvic lymph nodes, use of RT was associated with prolonged survival in those who did not undergo surgery. Surgery followed by adjuvant RT was associated with prolonged survival compared with surgery alone.
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Affiliation(s)
| | | | | | | | | | | | - Mark Wakabyashi
- Department of Gynecologic Oncology, City of Hope National Medical Center, Duarte, California
| | - Ernest Han
- Department of Gynecologic Oncology, City of Hope National Medical Center, Duarte, California
| | - Catheryn Yashar
- Department of Radiation Oncology, University of California San Diego, La Jolla, California
| | - Kevin Albuquerque
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, Texas; and
| | - Sushil Beriwal
- Department of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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14
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McComas KN, Torgeson AM, Ager BJ, Hellekson C, Burt LM, Maurer KA, Werner TL, Gaffney DK. The variable impact of positive lymph nodes in cervical cancer: Implications of the new FIGO staging system. Gynecol Oncol 2020; 156:85-92. [DOI: 10.1016/j.ygyno.2019.10.025] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 10/15/2019] [Accepted: 10/21/2019] [Indexed: 02/06/2023]
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15
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Lindegaard JC, Petric P, Lindegaard AM, Tanderup K, Fokdal LU. Evaluation of a New Prognostic Tumor Score in Locally Advanced Cervical Cancer Integrating Clinical Examination and Magnetic Resonance Imaging. Int J Radiat Oncol Biol Phys 2019; 106:754-763. [PMID: 31794837 DOI: 10.1016/j.ijrobp.2019.11.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 11/08/2019] [Accepted: 11/25/2019] [Indexed: 01/04/2023]
Abstract
PURPOSE The integral results of clinical examination and magnetic resonance imaging (MRI) of patients with locally advanced cervical cancer may provide prognostic information that cannot readily be placed in current staging systems, such as proximal versus distal parametrial invasion, unilateral versus bilateral involvement, or organ infiltration on MRI. The aim was to develop and investigate the performance of a simple but comprehensive tumor score for reporting and prognostication. METHODS AND MATERIALS In the present study, 400 consecutive patients with locally advanced cervical cancer treated 2005 to 2018 with chemoradiation and image guided adaptive brachytherapy (IGABT) were analyzed. The diagnostic workup included clinical examination, positron emission tomography/computed tomography, and MRI. International Federation of Gynecology and Obstetrics 2009 stage distribution was IB to IIA 9%, IIB 61%, and III to IV 30%. Involvement of 8 anatomic locations (cervix, left parametrium, right parametrium, vagina, bladder, ureter, rectum, and uterine corpus) was scored according to a ranked ordinal scale with 0 to 3 points. The total sum of points constituted the tumor score (T-score). RESULTS The median T-score was 6 (range, 0-20). Based on the frequency distribution of the T-score, 4 equally sized groups were formed: 0 to 4, 5 to 6, 7 to 9, and >9 points. The T-score grouping was highly significant in both univariate and multivariable analysis and outperformed International Federation of Gynecology and Obstetrics stage for both survival and local control enabling also intrastage prognostication. Used as a linear variable, the T-score was correlated with IGABT target volume (high-risk clinical target volume, CTVHR), use of interstitial needles, dose (D90 of CTVHR), and total reference air kerma. CONCLUSIONS The T-score is a simple instrument for combining clinical findings and imaging into a powerful prognostic factor for survival and local control with capabilities surpassing traditional staging. In addition, the T-score may already at diagnosis predict essential IGABT parameters and may be used for audit and comparison of results in multicenter settings.
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Affiliation(s)
| | - Primoz Petric
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
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16
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Affiliation(s)
- Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Ludvig Paul Muren
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Morten Høyer
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Cai Grau
- Department of Oncology and Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
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17
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Berger T, Seppenwoolde Y, Pötter R, Assenholt MS, Lindegaard JC, Nout RA, de Leeuw A, Jürgenliemk-Schulz I, Tan LT, Georg D, Kirisits C, Dumas I, Nesvacil N, Swamidas J, Hudej R, Lowe G, Hellebust TP, Menon G, Fokdal L, Tanderup K. Importance of Technique, Target Selection, Contouring, Dose Prescription, and Dose-Planning in External Beam Radiation Therapy for Cervical Cancer: Evolution of Practice From EMBRACE-I to II. Int J Radiat Oncol Biol Phys 2019; 104:885-894. [PMID: 30904706 DOI: 10.1016/j.ijrobp.2019.03.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 03/05/2019] [Accepted: 03/10/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE To describe the evolution of external beam radiation therapy (EBRT) from EMBRACE-I (general guidelines for EBRT) to the initial phase of the EMBRACE-II study (detailed protocol for EBRT). METHODS AND MATERIALS EMBRACE-I enrolled 1416 locally advanced cervical cancer patients treated with chemoradiation including image-guided adaptive brachytherapy during 2008 to 2015. From March 2016 until March 2018, 153 patients were enrolled in the ongoing EMBRACE-II study, which involves a comprehensive detailed strategy and accreditation procedure for EBRT target contouring, treatment planning, and image guidance. EBRT planning target volumes (PTVs), treated volumes (V43 Gy), and conformity index (CI; V43 Gy/PTV) were evaluated in both studies and compared. RESULTS For EMBRACE-I, conformal radiation therapy (60% of patients) or intensity-modulated radiation therapy (IMRT) and volumetric arc therapy (VMAT; 40%) was applied with 45 to 50 Gy over 25 to 30 fractions to the elective clinical target volume (CTV). For pelvic CTVs (82%), median PTV and V43 Gy volumes were 1549 and 2390 mL, respectively, and CI was 1.54. For pelvic plus paraortic nodal (PAN) CTVs (15%), median PTV and V43 Gy volumes were 1921 and 2895 mL, and CI was 1.51. For pelvic CTVs treated with 45 to 46 Gy, the use of conformal radiation therapy was associated with a median V43 Gy volume that was 546 mL larger than with IMRT/VMAT. For pelvic CTVs treated with IMRT, the use of a dose prescription ≥48 Gy was associated with a median V43 Gy volumes that was 428 mL larger than with a dose prescription of 45 to 46 Gy. For EMBRACE-II, all patients were treated with: IMRT/VMAT, daily IGRT, 45 Gy over 25 fractions for the elective CTV, and simultaneously integrated boost for pathologic lymph nodes. For pelvic CTVs (61%), median PTV and V43 Gy volumes were 1388 and 1418 mL, and CI was 1.02. For pelvic plus PAN CTVs (32%), median PTV and V43 Gy volumes were 1720 and 1765 mL, and CI was 1.03. From EMBRACE-I to initial II, median V43 Gy was decreased by 972 mL (41%) and 1130 mL (39%), and median CI decreased from 1.54 to 1.02 and 1.51 to 1.03 for pelvic and pelvic plus PAN irradiation, respectively. CONCLUSIONS Application of IMRT/VMAT, IGRT, and a 45-Gy dose provides the potential of higher conformality inducing significant reduction of treated volume. Adherence to a detailed protocol including comprehensive accreditation, as in EMBRACE-II, reduces considerably V43 Gy and V50 Gy and improves conformality and interinstitutional consistency.
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Affiliation(s)
- Thomas Berger
- Department of Oncology, Aarhus University Hospital, Denmark.
| | - Yvette Seppenwoolde
- Department of Radiation Oncology, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | - Richard Pötter
- Department of Radiation Oncology, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | | | | | - Remi A Nout
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Astrid de Leeuw
- Department of Radiation Oncology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Ina Jürgenliemk-Schulz
- Department of Radiation Oncology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Li Tee Tan
- Departments of Oncology, Radiology and Gynae-oncology, Addenbrooke's Hospital, Cambridge University Hospitals National Health Service Trust, United Kingdom
| | - Dietmar Georg
- Department of Radiation Oncology, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | - Christian Kirisits
- Department of Radiation Oncology, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | - Isabelle Dumas
- Department of Radiotherapy, Gustave-Roussy, Villejuif, France
| | - Nicole Nesvacil
- Department of Radiation Oncology, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | - Jamema Swamidas
- Department of Radiation Oncology, ACTREC, Tata Memorial Centre, Navi Mumbai, India
| | - Robert Hudej
- Department of Radiotherapy, Institute of Oncology Ljubljana, Slovenia
| | - Gerry Lowe
- Cancer Centre, Mount Vernon Hospital, London, United Kingdom
| | - Taran Paulsen Hellebust
- Department of Medical Physics, Oslo University Hospital, Oslo, Norway; Department of Physics, University of Oslo, Oslo, Norway
| | - Geetha Menon
- Department of Oncology, Cross Cancer Institute, University of Alberta, Edmonton, Canada
| | - Lars Fokdal
- Department of Oncology, Aarhus University Hospital, Denmark
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Denmark
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18
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Berger T, Fokdal LU, Assenholt MS, Jensen NB, Petersen JB, Nyvang L, Korreman S, Lindegaard JC, Tanderup K. Robustness of elective lymph node target coverage with shrinking Planning Target Volume margins in external beam radiotherapy of locally advanced cervical cancer. Phys Imaging Radiat Oncol 2019; 11:9-15. [PMID: 33458270 PMCID: PMC7807569 DOI: 10.1016/j.phro.2019.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 06/06/2019] [Accepted: 06/06/2019] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND AND PURPOSE Image-Guidance decreases set-up uncertainties, which may allow for Planning Target Volume (PTV) margins reduction. This study evaluates the robustness of the elective lymph node target coverage to translational and rotational set-up errors in combination with shrinking PTV margins and determines the gain for the Organs At Risk (OARs). MATERIAL AND METHODS Ten cervix cancer patients who underwent external beam radiotherapy with 45 Gy/25Fx were analysed. Daily Image-Guidance was based on bony registration of Cone Beam CT (CBCT) to planning CT (pCT) and daily couch correction (translation and yaw). On each pCT, four Volumetric Modulated Arc Therapy dose-plans were generated with PTV margins of 0, 3, 5 and 8 mm. The elective clinical target volume (CTV-E) was propagated from daily CBCTs to the pCT to evaluate daily CTV-E dose. Additional systematic translational isocenter shifts of 2 mm were simulated. D98% (dose received by 98% of the volume of interest) and D99.9% were extracted from each CTV-E for all dose-plans and scenarios. Total dose was accumulated by Dose-Volume Histogram addition. The dosimetric impact of PTV margin reduction on the OARs was evaluated through V30Gy (volume included within the 30 Gy isodose), V40Gy and body V43Gy. RESULTS When decreasing the PTV margin from 5 to 0 mm, bowel V30Gy was decreased by 13% (from 247 cm3 to 214 cm3), body V43Gy by 19% (from 1462 cm3 to 1188 cm3) and PTV by 39% (from 1416 to 870 cm3). The dosimetric impact of combined systematic shifts and residual rotations on the elective target with a 0 mm PTV margin was a decrease of D98% (mean ± SD) from 44.1 Gy ± 0.4 Gy to 43.7 Gy ± 0.8 Gy and a minimum of 42.4 Gy. CONCLUSION PTV margin reduction from 5 to 0 mm induced significant OARs dosimetric gains while elective target coverage remained robust to positioning uncertainties.
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Affiliation(s)
- Thomas Berger
- Department of Oncology, Aarhus University Hospital, Denmark
| | - Lars U. Fokdal
- Department of Oncology, Aarhus University Hospital, Denmark
| | | | | | | | - Lars Nyvang
- Department of Oncology, Aarhus University Hospital, Denmark
| | - Stine Korreman
- Department of Oncology, Aarhus University Hospital, Denmark
| | | | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Denmark
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19
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Draghini L, Costantini S, Vicenzi L, Italiani M, Loreti F, Trippa F, Arcidiacono F, Casale M, Mantello G, Maranzano E. Positron emission tomography for staging locally advanced cervical cancer and assessing intensity modulated radiotherapy approach. Radiol Med 2019; 124:819-825. [PMID: 30904982 DOI: 10.1007/s11547-019-01023-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 03/11/2019] [Indexed: 12/13/2022]
Abstract
AIMS To evaluate toxicity and outcome of concomitant chemotherapy and intensity modulated radiotherapy (IMRT) with 18-fluorodeoxyglucose positron emission tomography/computed tomography (18FDG-PET/CT) based simultaneous integrated boost (SIB) of locally advanced cervical cancer (LACC). METHODS Patients with LACC underwent chemo-radiation with IMRT and SIB. Staging and follow-up were performed with clinical evaluation and CT, MRI, 18FDG-PET/CT. SIB was done on positive nodes with 18FDG-PET/CT based planning. CT-based planning high-dose-rate brachytherapy (HDR-BT) was delivered as subsequent boost to the primary tumor. Cisplatin concomitant chemotherapy was administered during IMRT. RESULTS Fourteen patients with cervical cancer were prospectively recruited between August 2014 and June 2017, 13 (93%) had a LACC, one (7%) patient was not evaluable because 18FDG-PET/CT evidenced metastases to the liver undetected by previous CT/MRI. Patients had a median age of 59 years, a median Karnofsky performance status of 100%, and a prevalence of squamous cell carcinoma histology (85%). SIB was delivered on 23 positive lymph nodes. IMRT median dose to the pelvis was 48.6 Gy in 27 fractions, SIB median dose 54 Gy in 27 fractions, HDR-BT boost median dose 21 Gy in 3 fractions. After a median follow-up of 30 months, 2-year local control and distant control were 86% and 86%, respectively. There were no grade 4 acute and/or late toxicities. CONCLUSIONS The 18FDG-PET/CT influenced stage assessment and RT treatment planning due to its high specificity in distant metastases and nodal involvement detection. The IMRT with SIB for positive nodes was an effective therapy with acceptable toxicity in LACC.
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Affiliation(s)
- Lorena Draghini
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Terni, Italy
| | - Sara Costantini
- Radiation Oncology Centre, Ospedali Riuniti Umberto I°, Ancona, Italy
| | - Lisa Vicenzi
- Radiation Oncology Centre, Ospedali Riuniti Umberto I°, Ancona, Italy
| | - Marco Italiani
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Terni, Italy
| | - Fabio Loreti
- Nuclear Medicine Service, "S. Maria" Hospital, Terni, Italy
| | - Fabio Trippa
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Terni, Italy
| | | | | | - Giovanna Mantello
- Radiation Oncology Centre, Ospedali Riuniti Umberto I°, Ancona, Italy
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De Leeuw AA, Nout RA, Van Leeuwen RG, Mans A, Verhoef LG, Jürgenliemk-Schulz IM. Implementation of state-of-the-art (chemo)radiation for advanced cervix cancer in the Netherlands: A quality improvement program. Tech Innov Patient Support Radiat Oncol 2019; 9:1-7. [PMID: 32095588 PMCID: PMC7033811 DOI: 10.1016/j.tipsro.2018.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 10/09/2018] [Accepted: 10/15/2018] [Indexed: 11/04/2022] Open
Abstract
PURPOSE To report on the "Dutch Quality Improvement Project" regarding external beam (EBRT) and brachytherapy (BT) contouring and treatment planning for locally advanced cervical cancer (LACC). MATERIAL AND METHODS Two rounds of three workshops were organized. Data from two patients with LACC were made available for homework exercises. Contouring and treatment planning was asked for according to the EMBRACE-II protocol. The submissions were analysed and the results were addressed during the workshops. RESULTS Almost all invited centres participated. EBRT contouring guidelines were followed within acceptable range, with major effort needed with regard to the ITV concept. BT contouring was of good quality, with especially small discrepancies for centres already participating in EMBRACE.EBRT treatment planning results improved between workshops with more centres being able to fulfil the planning aims. Guidance was especially necessary to improve the coverage probability planning for affected nodes.For BT planning prioritizing between target coverage and OAR sparing improved over time; the variation in dose to vaginal points remained considerable, as did variation in loading patterns and spatial dose distribution.The project was highly appreciated by all participants. CONCLUSION Homework and workshop activities provide a suitable platform for discussion, exchange of experience and improvement of quality and conformity. Due to this project, radiotherapy for LACC can be administered with better and more comparable quality throughout the Netherlands.
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Affiliation(s)
- Astrid A.C. De Leeuw
- Department of Radiation Oncology, University Medical Center Utrecht, P.O. Box 85500, Utrecht 3508GA, The Netherlands
| | - Remi A. Nout
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ruud G.H. Van Leeuwen
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anton Mans
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Lia G. Verhoef
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ina Maria Jürgenliemk-Schulz
- Department of Radiation Oncology, University Medical Center Utrecht, P.O. Box 85500, Utrecht 3508GA, The Netherlands
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Jensen NBK, Assenholt MS, Fokdal LU, Vestergaard A, Schouboe A, Kjaersgaard EB, Boejen A, Nyvang L, Lindegaard JC, Tanderup K. Cone beam computed tomography-based monitoring and management of target and organ motion during external beam radiotherapy in cervical cancer. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2018; 9:14-20. [PMID: 33458421 PMCID: PMC7807672 DOI: 10.1016/j.phro.2018.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 12/03/2018] [Accepted: 12/05/2018] [Indexed: 12/18/2022]
Abstract
Background and purpose Organ motion is a challenge during high-precision external beam radiotherapy in cervical cancer, and improved strategies for treatment adaptation and monitoring of target dose coverage are needed. This study evaluates a cone beam computed tomography (CBCT)-based approach. Materials and methods In twenty-three patients, individualized internal target volumes (ITVs) were generated from pre-treatment MRI and CT scans with full and empty bladders. The target volumes encompassed high-risk clinical target volume (CTV-T HR) (gross tumor volume + remaining cervix) and low risk (LR) CTV-T (CTV-T HR + uterus + parametriae + upper vagina). Volumetric Modulated Arc Therapy (VMAT) was used to deliver a dose of 45 Gy in 25 fractions. CBCTs were used for setup and for radiation therapists (RTTs) to evaluate the target coverage (inside/outside the planning target volume). CBCTs were reviewed offline. Estimates of the dose delivered with minimum (point) doses across all fractions to CTV-T HR (aim 42.75 Gy) and CTV-T LR (aim 40 Gy) were assessed. In patients with insufficient dose coverage, re-plans were generated based on previous imaging. Results Median (range) of the ITV-margins (mean of anterior-posterior margins) related to uterus and cervix was 1.2 (0.5–2.2 and 1.0–2.1) cm. RTTs were able to assess the target coverage in 90% of all CBCTs (505/563). With re-planning, one patient had considerable benefit (12.7 Gy increase of minimum dose) to CTV-T LR_vagina, four patients had improved dose to the CTV-T LR_uterus (1.2–1.8 Gy), and 3 patients did not benefit from re-planning. Conclusions Daily CBCT-based monitoring of target coverage by the RTTs has proven safe with limited workload. It allows for reduction in the treated volumes without compromising the target dose coverage.
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Affiliation(s)
| | | | - Lars Ulrik Fokdal
- Department of Oncology, Aarhus University Hospital, Dk-8000 Aarhus C., Denmark
| | - Anne Vestergaard
- Danish Centre for Particle Therapy, Aarhus University Hospital, Dk-8000 Aarhus C., Denmark
| | - Annette Schouboe
- Danish Centre for Particle Therapy, Aarhus University Hospital, Dk-8000 Aarhus C., Denmark
| | | | - Annette Boejen
- Department of Oncology, Aarhus University Hospital, Dk-8000 Aarhus C., Denmark
| | - Lars Nyvang
- Department of Medical Physics, Aarhus University Hospital, Dk-8000 Aarhus C., Denmark
| | | | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Dk-8000 Aarhus C., Denmark
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Unkelbach J, Alber M, Bangert M, Bokrantz R, Chan TCY, Deasy JO, Fredriksson A, Gorissen BL, van Herk M, Liu W, Mahmoudzadeh H, Nohadani O, Siebers JV, Witte M, Xu H. Robust radiotherapy planning. ACTA ACUST UNITED AC 2018; 63:22TR02. [DOI: 10.1088/1361-6560/aae659] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Pötter R, Tanderup K, Kirisits C, de Leeuw A, Kirchheiner K, Nout R, Tan LT, Haie-Meder C, Mahantshetty U, Segedin B, Hoskin P, Bruheim K, Rai B, Huang F, Van Limbergen E, Schmid M, Nesvacil N, Sturdza A, Fokdal L, Jensen NBK, Georg D, Assenholt M, Seppenwoolde Y, Nomden C, Fortin I, Chopra S, van der Heide U, Rumpold T, Lindegaard JC, Jürgenliemk-Schulz I. The EMBRACE II study: The outcome and prospect of two decades of evolution within the GEC-ESTRO GYN working group and the EMBRACE studies. Clin Transl Radiat Oncol 2018; 9:48-60. [PMID: 29594251 PMCID: PMC5862686 DOI: 10.1016/j.ctro.2018.01.001] [Citation(s) in RCA: 391] [Impact Index Per Article: 65.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 01/09/2018] [Accepted: 01/09/2018] [Indexed: 02/07/2023] Open
Abstract
The publication of the GEC-ESTRO recommendations one decade ago was a significant step forward for reaching international consensus on adaptive target definition and dose reporting in image guided adaptive brachytherapy (IGABT) in locally advanced cervical cancer. Since then, IGABT has been spreading, particularly in Europe, North America and Asia, and the guidelines have proved their broad acceptance and applicability in clinical practice. However, a unified approach to volume contouring and reporting does not imply a unified administration of treatment, and currently both external beam radiotherapy (EBRT) and IGABT are delivered using a large variety of techniques and prescription/fractionation schedules. With IGABT, local control is excellent in limited and well-responding tumours. The major challenges are currently loco-regional control in advanced tumours, treatment-related morbidity, and distant metastatic disease. Emerging evidence from the RetroEMBRACE and EMBRACE I studies has demonstrated that clinical outcome is related to dose prescription and technique. The next logical step is to demonstrate excellent clinical outcome with the most advanced EBRT and brachytherapy techniques based on an evidence-based prospective dose and volume prescription protocol. The EMBRACE II study is an interventional and observational multicentre study which aims to benchmark a high level of local, nodal and systemic control while limiting morbidity, using state of the art treatment including an advanced target volume selection and contouring protocol for EBRT and brachytherapy, a multi-parametric brachytherapy dose prescription protocol (clinical validation of dose constraints), and use of advanced EBRT (IMRT and IGRT) and brachytherapy (IC/IS) techniques (clinical validation). The study also incorporates translational research including imaging and tissue biomarkers.
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Affiliation(s)
- Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Denmark
| | - Christian Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | - Astrid de Leeuw
- Department of Radiation Oncology, University Medical Centre Utrecht, The Netherlands
| | - Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | - Remi Nout
- Department of Radiation Oncology, Leiden University Medical Center, The Netherlands
| | - Li Tee Tan
- Departments of Oncology, Radiology and Gynae-oncology, Addenbrooke’s Hospital, Cambridge University Hospitals National Health Service Trust, United Kingdom
| | | | | | - Barbara Segedin
- Department of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia
| | - Peter Hoskin
- Cancer Centre, Mount Vernon Cancer Centre, United Kingdom
| | - Kjersti Bruheim
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Bhavana Rai
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Fleur Huang
- Department of Oncology, Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Erik Van Limbergen
- Department of Radiation Oncology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Max Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | - Nicole Nesvacil
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | - Lars Fokdal
- Department of Oncology, Aarhus University Hospital, Denmark
| | | | - Dietmar Georg
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | | | - Yvette Seppenwoolde
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | - Christel Nomden
- Department of Radiation Oncology, University Medical Centre Utrecht, The Netherlands
| | - Israel Fortin
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
- Department of Radiation Oncology, Centre Hospitalier de l’Université de Montréal, Montreal University, Montreal, Canada
| | - Supriya Chopra
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, India
| | - Uulke van der Heide
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Tamara Rumpold
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
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