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Zhang YH, Martin S, Liu H, Todor D, Sohn JJ, Quinn B, Francis LE, Roach M, Fields EC. Utilizing a novel hybrid brachytherapy technique FINITO (Freehand Interstitial Needles in addition to Tandem and Ovoid) for locally advanced cervical cancer. Brachytherapy 2023; 22:746-752. [PMID: 37722989 DOI: 10.1016/j.brachy.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 05/31/2023] [Accepted: 06/06/2023] [Indexed: 09/20/2023]
Abstract
PURPOSE We aimed to assess the clinical feasibility and advantages of using a novel hybrid brachytherapy technique by placing Freehand Interstitial Needles in addition to the Tandem and Ovoid applicator (FINITO) for the treatment of locally advanced cervical cancer (LAC). METHODS AND MATERIALS A retrospective analysis was performed on two cohorts of patients with LACC treated at our institution: 29 patients in the FINITO group and 17 patients in the control group using T&O only approach. Clinical outcomes of interest included local control (LC), progression-free survival (PFS), overall survival (OS), and rates of acute and late toxicities. Kaplan-Meier methodology was used to estimate OS, PFS, and LC. Wilcoxon signed-rank test was used to compare the median values for dosimetry parameters. A p-value of ≤ 0.05 was considered statistically significant. All statistical analyses were performed using RStudio. RESULTS At a median of 2 years there was no difference in rates of OS, PFS or LC between the FINITO and the control group of patients. The 2-year OS, PFS, and LC for the FINITO group were 59% (95% CI 34%-100%), 58% (95% CI 38%-89%), and 84% (95% CI 69%-100%), respectively. Late toxicities were significantly lower in the FINITO group for both gastrointestinal and genitourinary symptoms (p = 0.001 and 0.01, respectively) as compared to the T&O group. CONCLUSION Based on the equivalent LC rate and lower toxicity profile, our FINITO technique appears to be an excellent alternative to the standard intracavitary brachytherapy in patients with advanced disease, especially in resource-limited settings.
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Affiliation(s)
- Yue H Zhang
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, VA
| | - Sara Martin
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, VA
| | - Han Liu
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, VA
| | - Dorin Todor
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, VA
| | - James J Sohn
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Bridget Quinn
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, VA
| | - Louise E Francis
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, VA
| | - Melinda Roach
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, VA
| | - Emma C Fields
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, VA.
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Yoshimoto Y, Murata K, Irie D, Ando K, Adachi A, Aoki H, Hirakawa T, Noda SE, Nakano T, Ohno T. A retrospective study of small-pelvis radiotherapy plus image-guided brachytherapy in stage I-II non-bulky cervical squamous cell carcinoma. JOURNAL OF RADIATION RESEARCH 2022; 63:290-295. [PMID: 35152292 PMCID: PMC8944301 DOI: 10.1093/jrr/rrac001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/18/2021] [Indexed: 06/14/2023]
Abstract
We herein report a retrospective analysis of the efficacy of a combination therapy of pelvic irradiation that excluded the common iliac lymph nodes region and image-guided brachytherapy (IGBT) for non-bulky (≤4 cm) cervical cancer. Thirty-three patients with stage I-II cervical squamous cell carcinoma (≤4 cm) and without pelvic/para-aortic lymphadenopathy who were treated with definitive radiotherapy alone between February 2009 and September 2016 were included. The radiotherapy consisted of CT-based small-pelvis irradiation (whole pelvis minus common iliac lymph node area) of 20 Gy/10 fractions followed by pelvic irradiation with a midline block of 30 Gy/15 fractions and IGBT of 24 Gy/4 fractions (6 Gy/fraction for high-risk [HR] clinical target volume [CTV] D90%). In-room computed tomography (CT) imaging with applicator insertion was used for brachytherapy planning, with physical examinations and diagnostic magnetic resonance imaging (MRI) also being referred to for determination of HR CTV. Over a median follow-up of 60.5 months (range, 7-89), two patients developed distant recurrence and one developed local and distant recurrence. Two patients died from cervical cancer, one from hepatocellular carcinoma and one from non-cancerous disease. The 2/5-year local control (LC), progression-free survival (PFS) and overall survival (OS) rates were 100%/96.7%, 93.8%/90.6% and 93.9%/93.9%, respectively. No pelvic/para-aortic lymph node recurrence was observed. There were no late complications of grade 3 or higher in the small bowel, large bowel/rectum, or bladder. Our results suggest that a combination therapy of IGBT plus small-pelvis irradiation excluding common iliac lymph nodes provides reasonable clinical outcomes and can be a treatment option in non-bulky (≤4 cm) cervical squamous cell carcinoma.
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Affiliation(s)
| | | | - Daisuke Irie
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Ken Ando
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Akiko Adachi
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Hiroshi Aoki
- Department of Obstetrics and Gynecology, National Hospital Organization Takasaki General Medical Center, 36 Takamatsu-cho. Takasaki, Gunma 370-0829, Japan
| | - Takashi Hirakawa
- Department of Obstetrics and Gynecology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Shin-ei Noda
- Department of Radiation Oncology, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama 350-1298, Japan
| | - Takashi Nakano
- Quantum Life and Medical Science Directorate, National Institute for Quantum Science and Technology (QST), 4-9-1 Anagawa, Inage-ku, Chiba 263-8555, Japan
| | - Tatsuya Ohno
- Corresponding author. Tatsuya Ohno, Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan. Tel: +81-27-220-8383; Fax: +81-27-220-8397; E-mail:
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3
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Chopra S, Gupta S, Kannan S, Dora T, Engineer R, Mangaj A, Maheshwari A, Shylasree TS, Ghosh J, Paul SN, Phurailatpam R, Charnalia M, Alone M, Swamidas J, Mahantshetty U, Deodhar K, Kerkar R, Shrivastava SK. Late Toxicity After Adjuvant Conventional Radiation Versus Image-Guided Intensity-Modulated Radiotherapy for Cervical Cancer (PARCER): A Randomized Controlled Trial. J Clin Oncol 2021; 39:3682-3692. [PMID: 34506246 DOI: 10.1200/jco.20.02530] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Postoperative Adjuvant Radiation in Cervical Cancer (PARCER), a phase III randomized trial, compared late toxicity after image-guided intensity-modulated radiotherapy (IG-IMRT) with three-dimensional conformal radiation therapy (3D-CRT) in women with cervical cancer undergoing postoperative radiation. METHODS Patients were randomly assigned to receive either IG-IMRT or 3D-CRT after stratification for the type of hysterectomy and use of concurrent chemotherapy. The primary end point was 3-year grade ≥ 2 late GI toxicity assessed using Common Toxicity Criteria for Adverse Events v 3.0 and estimated using time-to-event, intention-to-treat analysis, with a study level type I error of 0.05 and a nominal α of .047 after accounting for one interim analysis. Secondary end points included acute toxicity, health-related quality of life, and pelvic relapse-free, disease-free, and overall survival. RESULTS Between 2011 and 2019, 300 patients were randomly assigned (IG-IMRT 151 and 3D-CRT 149). At a median follow-up of 46 (interquartile range 20-72) months, the 3-year cumulative incidence of grade ≥ 2 late GI toxicity in the IG-IMRT and 3D-CRT arms were 21.1% versus 42.4% (hazard ratio [HR] 0.46; 95% CI, 0.29 to 0.73; P < .001). The cumulative incidence of grade ≥ 2 any late toxicity was 28.1% versus 48.9% (HR 0.50; 95% CI, 0.33 to 0.76; P < .001), respectively. Patients reported reduced diarrhea (P = .04), improved appetite (P = .008), and lesser bowel symptoms (P = .002) with IG-IMRT. However, no difference was observed in the time by treatment interaction. The 3-year pelvic relapse-free survival and disease-free survival in the IG-IMRT versus the 3D-CRT arm were 81.8% versus 84% (HR 1.17; 95% CI, 0.68 to 1.99; P = .55) and 76.9% versus 81.2% (HR 1.03; 95% CI, 0.62 to 1.71; P = .89), respectively. CONCLUSION IG-IMRT results in reduced toxicity with no difference in disease outcomes.
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Affiliation(s)
- Supriya Chopra
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Kharghar, Navi Mumbai, Maharashtra, India
| | - Sudeep Gupta
- Department of Medical Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Kharghar, Navi Mumbai, Maharashtra, India
| | - Sadhana Kannan
- Epidemiology and Clinical Trials Unit, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Kharghar, Navi Mumbai, Maharashtra, India
| | - Tapas Dora
- Department of Radiation Oncology, Homi Bhabha Cancer Hospital, Tata Memorial Centre, Sangrur, Punjab, India
| | - Reena Engineer
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Akshay Mangaj
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Amita Maheshwari
- Department of Gynecologic Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - T Surappa Shylasree
- Department of Gynecologic Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Jaya Ghosh
- Department of Medical Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Kharghar, Navi Mumbai, Maharashtra, India
| | - Siji N Paul
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Kharghar, Navi Mumbai, Maharashtra, India
| | - Reena Phurailatpam
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Kharghar, Navi Mumbai, Maharashtra, India
| | - Mayuri Charnalia
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Kharghar, Navi Mumbai, Maharashtra, India
| | - Mitali Alone
- Clinical Research Secretariat, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Jamema Swamidas
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Kharghar, Navi Mumbai, Maharashtra, India
| | - Umesh Mahantshetty
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Kedar Deodhar
- Department of Pathology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Rajendra Kerkar
- Department of Gynecologic Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Shyam K Shrivastava
- Department of Radiation Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
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Kobayashi T, Isohashi F, Eino D, Tanaka K, Sawada K, Ueda Y, Kobayashi E, Tomimatsu T, Kimura T, Ogawa K. Correlation Between the Transient Elevation of Peripheral Eosinophil Count During Radiotherapy and Acute Diarrhea. CANCER DIAGNOSIS & PROGNOSIS 2021; 1:331-337. [PMID: 35403139 PMCID: PMC8988959 DOI: 10.21873/cdp.10044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 07/06/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND/AIM This study aimed to evaluate the association between the change in peripheral eosinophil count during postoperative pelvic radiotherapy and gastrointestinal (GI) toxicities in patients with cervical cancer. PATIENTS AND METHODS The medical records of 163 patients with cervical cancer who underwent postoperative concurrent chemoradiotherapy between 2000 and 2016 were analyzed. RESULTS Among the peripheral blood cell counts, transient elevation of the eosinophil count was observed during radiotherapy. Of the 163 patients, 117 developed grade ≥2 diarrhea during radiotherapy, and 25 patients developed grade ≥2 late GI toxicities. In multivariate analysis, the maximum eosinophil count and age emerged as independent predictors of grade ≥2 acute diarrhea during radiotherapy, while bowel bag V 40 Gy and age were predictive of grade ≥2 late GI toxicities. CONCLUSION Early detection of transient elevation of eosinophil may facilitate early treatment of acute diarrhea during radiotherapy.
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Affiliation(s)
- Takako Kobayashi
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Fumiaki Isohashi
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Daisuke Eino
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Kazunori Tanaka
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Kenjiro Sawada
- Department of Gynecology and Obstetrics, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yutaka Ueda
- Department of Gynecology and Obstetrics, Osaka University Graduate School of Medicine, Suita, Japan
| | - Eiji Kobayashi
- Department of Gynecology and Obstetrics, Osaka University Graduate School of Medicine, Suita, Japan
| | - Takuji Tomimatsu
- Department of Gynecology and Obstetrics, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tadashi Kimura
- Department of Gynecology and Obstetrics, Osaka University Graduate School of Medicine, Suita, Japan
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Japan
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Clarke E, Howells R, Beasley M, Murray L. Restricted bowel loop contouring: Improving efficiency in radiotherapy contouring for abdomino-pelvic Stereotactic Ablative Radiotherapy (SABR). Clin Transl Radiat Oncol 2020; 24:60-64. [PMID: 32637661 PMCID: PMC7327863 DOI: 10.1016/j.ctro.2020.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 05/05/2020] [Accepted: 06/09/2020] [Indexed: 11/28/2022] Open
Abstract
We present a time-saving alternative to individual bowel loop delineation for abdomino-pelvic Stereotactic Ablative Radiotherapy. Here, individual bowel loop contouring is only performed within a 3 cm circumferential and 2 cm superio-inferior expansion of the PTV. A bowel bag structure represents distal bowel. No relevant doses are 'missed' with this time-saving strategy.
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Affiliation(s)
| | | | | | - Louise Murray
- Leeds Cancer Centre, Leeds Teaching Hospitals, Leeds, UK
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
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Kashihara T, Kobayashi K, Iijima K, Murakami N, Yoshida K, Okuma K, Nakamura S, Takahashi K, Inaba K, Igaki H, Nakayama Y, Kato T, Uno T, Itami J. A case report of a patient with bulky uterine cervical neoplasm who achieved complete response with "intentional internal high-dose policy" high-dose-rate interstitial brachytherapy. Medicine (Baltimore) 2020; 99:e20860. [PMID: 32629674 PMCID: PMC7337609 DOI: 10.1097/md.0000000000020860] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Gynecological high-dose-rate (HDR) brachytherapy has progressed for years, but it remains difficult for bulky tumors to be controlled locally. Dose limitations to organs at risk (OARs) are invariably obstacles in increasing the prescription dose. Additionally, it is controversial that the excessive hyperdose sleeve, the volume receiving a dose equal to or greater than twice the reference dose, should be eliminated in gynecological HDR brachytherapy. On the other hand, the technique of simultaneous integrated protection was reported for large hepatocellular carcinoma treatment, and similarly, internal high-dose brachytherapy could be used for treating bulky cervical carcinoma. PATIENT CONCERNS A 54-year-old female had irregular genital bleeding and lost 13 kg in one year. DIAGNOSIS She was diagnosed with T3bN1M0 cervical cancer in another hospital. The transverse diameter of the primary tumor was 10.5 cm. INTERVENTIONS The whole pelvis and para-aortic lymph node were irradiated with a total of 50 Gy in 25 fractions, but the size of the tumor showed only a slight decrease to 8.9 cm. After external beam radiotherapy, first-time high-dose-rate interstitial brachytherapy (HDR-ISBT) was administered without "intentional internal high-dose (IIHD) policy," the technique of high-dose administration to only the inside of the tumor. Considering the rectum dose limitation, in the additional 2 times of brachytherapy, "IIHD policy" HDR-ISBT was applied. In the second and third HDR-ISBT, the percentage of the volume exposed to 200% of the prescribed dose for high-risk clinical target volume increased by 241% and 204% compared with the first HDR-ISBT, while the doses to OARs were not significantly higher than those of the first-time HDR-ISBT. OUTCOMES Complete response was obtained, and no recurrence findings and side effects caused by HDR-ISBT have been detected for 2 years and 9 months. LESSONS To our knowledge, this is the first report of IIHD HDR-ISBT for bulky cervical cancer. This technique can be the solution for treating bulky cervical cancer.
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Affiliation(s)
- Tairo Kashihara
- Department of Radiation Therapy, National Cancer Center Hospital, Tokyo
| | - Kazuma Kobayashi
- Department of Radiation Therapy, National Cancer Center Hospital, Tokyo
| | - Kotaro Iijima
- Department of Radiation Therapy, National Cancer Center Hospital, Tokyo
| | - Naoya Murakami
- Department of Radiation Therapy, National Cancer Center Hospital, Tokyo
| | - Ken Yoshida
- Department of Radiology, Osaka Medical College Hospital, Osaka
| | - Kae Okuma
- Department of Radiation Therapy, National Cancer Center Hospital, Tokyo
| | - Satoshi Nakamura
- Department of Radiation Therapy, National Cancer Center Hospital, Tokyo
| | - Kana Takahashi
- Department of Radiation Therapy, National Cancer Center Hospital, Tokyo
| | - Koji Inaba
- Department of Radiation Therapy, National Cancer Center Hospital, Tokyo
| | - Hiroshi Igaki
- Department of Radiation Therapy, National Cancer Center Hospital, Tokyo
| | - Yuko Nakayama
- Department of Radiation Therapy, National Cancer Center Hospital, Tokyo
| | - Tomoyasu Kato
- Department of Gynecologic Oncology, National Cancer Center Hospital, Tokyo
| | - Takashi Uno
- Department of Radiology, Chiba University Hospital, Chiba, Japan
| | - Jun Itami
- Department of Radiation Therapy, National Cancer Center Hospital, Tokyo
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Ling A, Furhang E, Ryemon SN, Ennis RD. Late small bowel toxicity after aggressive abdominopelvic intensity modulated radiation therapy. Adv Radiat Oncol 2017; 2:615-623. [PMID: 29204529 PMCID: PMC5707426 DOI: 10.1016/j.adro.2017.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 08/17/2017] [Accepted: 09/06/2017] [Indexed: 12/24/2022] Open
Abstract
Purpose We retrospectively analyzed late small bowel toxicity in patients who received abdominal or pelvic intensity modulated radiation therapy (IMRT) to the small bowel with a maximum dose greater than the generally accepted maximal tolerable dose of 45 Gy. Methods and materials All patients (N = 94) who received IMRT with a point dose of at least 45 Gy to tightly contoured small bowel between 2005 and 2014 at our institution were included. The median prescribed treatment dose was 70.2 Gy. The median follow-up was 20.1 months. Late small bowel toxicity was assessed using the Common Terminology Criteria for Adverse Events Version 3.0. Dosimetric variables and clinical factors were assessed for their relationship to small bowel toxicity. Results The median maximal small bowel point dose (Dmax) was 6546.5 cGy. The estimated 5-year rates of freedom from at least grade 1, at least grade 2, and at least grade 3 late small bowel toxicity were 72.4% (95% confidence interval [CI], 60.7%-86.5%), 91.9% (95% CI, 84.1%-100%), and 93.6% (95% CI, 86.2%-100%), respectively. One patient (1.1%) developed grade 3 late toxicity, and 2 patients (2.1%) developed grade 4 late toxicity. Use of capecitabine/5-fluorouracil treatment was a significant predictor (P < 0.001) of at least grade 1 and at least grade 2 small bowel toxicity. No other clinical factors were associated with toxicity. None of the dose-volume parameters were significant predictors of small bowel toxicity. Conclusion It may be possible with IMRT to deliver high doses to small volumes of small bowel with low rates of significant long-term complications. Further studies should explore tolerable dose-volume relationships in cases in which aggressive abdominal or pelvic treatment may be warranted to treat the underlying malignancy.
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Affiliation(s)
- Andrew Ling
- Department of Radiation Oncology, Mount Sinai West Hospital, New York, New York
| | - Eli Furhang
- Department of Radiation Oncology, Mount Sinai West Hospital, New York, New York
| | - Shannon N Ryemon
- Department of Radiation Oncology, Mount Sinai West Hospital, New York, New York
| | - Ronald D Ennis
- Department of Radiation Oncology, Mount Sinai West Hospital, New York, New York.,Icahn School of Medicine at Mount Sinai, New York, New York
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