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Turcas A, Homorozeanu B, Gheara C, Balan C, Cosnarovici R, Diaconu O, Fekete Z, Mihut E, Olteanu D, Pruteanu P, Tipcu A, Turcas A, Cernea D, Leucuta D, Achimas-Cadariu P. Dynamics and predictors of hematologic toxicity during cranio-spinal irradiation. Rep Pract Oncol Radiother 2024; 29:362-372. [PMID: 39144265 PMCID: PMC11321791 DOI: 10.5603/rpor.101094] [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: 11/17/2023] [Accepted: 05/31/2024] [Indexed: 08/16/2024] Open
Abstract
Background Craniospinal irradiation (CSI) is a complex radiotherapy (RT) technique required for treating specific brain tumors and some hematologic malignancies. With large volumes of hematogenous bone marrow (BM) being irradiated, CSI could cause acute hematologic toxicity, leading to treatment interruptions or severe complications. We report on the dynamics and dose/volume predictors of hematologic toxicity during CSI. Materials and methods Pediatric patients (≤ 18years) undergoing CSI in a tertiary cancer center were included. Medical records were retrospectively reviewed for clinical data and blood parameters were collected at baseline and weekly, until four weeks after the end of RT. The BM substructures were contoured, and dose-volume parameters were extracted. We used Wilcoxon rank-sum test to compare quantitative data, Chi square test for qualitative data and receiver operating characteristics (ROC) curves for dose/volume thresholds. Results Fifty-one patients were included. Severe toxicities (grade 3-4) were recorded as follows: 2% anemia, 8% thrombocytopenia, 25% leukopenia, 24% neutropenia. Ninety-eight percent of patients had lymphopenia (grade 1-4) at some point. Twenty-nine percent required granulocyte-colony stimulating factor, 50% had an infection and 8% required a blood transfusion. Dmean > 3.6 Gy and V15 Gy > 10.6% for Pelvic Bones were associated with a higher risk of developing any ≥ G3 toxicities. Dmean > 30-35 Gy to the thoracic and lumbar spine was predictive for G3-4 anemia and thrombocytopenia, and Cervical Spine Dmean > 30 Gy was associated with ≥ G3 neutropenia. Conclusion CSI was well tolerated, without life-threatening complications in our cohort, but hematologic toxicity was frequent, with severity increasing with higher mean doses delivered to the hematogenous BM and larger volumes of BM receiving 30-35 Gy.
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Affiliation(s)
- Andrada Turcas
- Radiotherapy Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
- Oncology Department, The University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
| | - Bianca Homorozeanu
- Radiotherapy Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
- Oncology Department, The University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
| | - Cristina Gheara
- Radiotherapy Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
- Faculty of Physics, “Babes-Bolyai” University, Cluj-Napoca, Romania
| | - Cristina Balan
- Radiotherapy Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
- Faculty of Physics, “Babes-Bolyai” University, Cluj-Napoca, Romania
| | - Rodica Cosnarovici
- Paediatric Oncology Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
| | - Oana Diaconu
- Radiotherapy Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
- Faculty of Physics, “Babes-Bolyai” University, Cluj-Napoca, Romania
| | - Zsolt Fekete
- Radiotherapy Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
- Oncology Department, The University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
| | - Emilia Mihut
- Paediatric Oncology Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
| | - Diana Olteanu
- Paediatric Oncology Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
| | - Paula Pruteanu
- Paediatric Oncology Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
| | - Alexandru Tipcu
- Radiotherapy Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
- Oncology Department, The University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
| | - Adrian Turcas
- Oncology Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
| | - Dana Cernea
- Radiotherapy Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
| | - Daniel Leucuta
- Department of Medical Informatics and Biostatistics, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
| | - Patriciu Achimas-Cadariu
- Oncology Department, The University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
- Surgical Oncology Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
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Liu KX, Haas-Kogan DA, Elhalawani H. Radiotherapy for Primary Pediatric Central Nervous System Malignancies: Current Treatment Paradigms and Future Directions. Pediatr Neurosurg 2023; 58:356-366. [PMID: 37703864 DOI: 10.1159/000533777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 08/21/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Central nervous system tumors are the most common solid tumors in childhood. Treatment paradigms for pediatric central nervous system malignancies depend on elements including tumor histology, age of patient, and stage of disease. Radiotherapy is an important modality of treatment for many pediatric central nervous system malignancies. SUMMARY While radiation contributes to excellent overall survival rates for many patients, radiation also carries significant risks of long-term side effects including neurocognitive decline, hearing loss, growth impairment, neuroendocrine dysfunction, strokes, and secondary malignancies. In recent decades, clinical trials have demonstrated that with better imaging and staging along with more sophisticated radiation planning and treatment set-up verification, smaller treatment volumes can be utilized without decrement in survival. Furthermore, the development of intensity-modulated radiotherapy and proton-beam radiotherapy has greatly improved conformality of radiation. KEY MESSAGES Recent changes in radiation treatment paradigms have decreased risks of short- and long-term toxicity for common histologies and in different age groups. Future studies will continue to develop novel radiation regimens to improve outcomes in aggressive central nervous system tumors, integrate molecular subtypes to tailor radiation treatment, and decrease radiation-associated toxicity for long-term survivors.
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Affiliation(s)
- Kevin X Liu
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Daphne A Haas-Kogan
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hesham Elhalawani
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Pulmonary toxicity of craniospinal irradiation using helical tomotherapy. Sci Rep 2022; 12:3221. [PMID: 35217707 PMCID: PMC8881492 DOI: 10.1038/s41598-022-07224-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 02/11/2022] [Indexed: 11/28/2022] Open
Abstract
Craniospinal irradiation using helical tomotherapy (HT-CSI) has advantages in aspects of homogeneous dose distribution. Physicians, however, still have concerns of pulmonary toxicity due to HT-CSI’s relatively large, low-dose irradiated volume from continuous and 360° rotation delivery. In this study, we investigated the pulmonary toxicity of HT-CSI. We retrospectively reviewed 105 patients who received HT-CSI between January 2014 and December 2019. Grade 2 + pulmonary toxicities were evaluated. Intensive systemic treatment was defined as systemic treatment administration before, during, and after HT-CSI. VX Gy was defined as % volume receiving ≥ X Gy. Thirteen patients (12.4%) presented with grade 2 + pulmonary toxicities after HT-CSI. Of these patients, only one experienced grade 2 radiation pneumonitis combined with pembrolizumab-induced pneumonitis. Conversely, pneumonia was observed in 12 patients. Intensive systemic treatment (p = 0.004), immunosuppressive drugs (p = 0.031), and bilateral lung V5 Gy ≥ 65% (p = 0.031) were identified as independent risk factors for pneumonia. The risk factor for pneumonia in pediatric patients were immunosuppressive drugs (p = 0.035) and bilateral lung V5 Gy ≥ 65% (p = 0.047). HT-CSI can be a safe treatment modality with tolerable pulmonary toxicities. Intensive systemic treatment, immunosuppressive drugs, and bilateral lung V5 Gy ≥ 65% were significantly associated with pneumonia. In these patients, close follow-up should be considered for proper management of pneumonia.
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Prabhu RS, Dhakal R, Piantino M, Bahar N, Meaders KS, Fasola CE, Ward MC, Heinzerling JH, Sumrall AL, Burri SH. Volumetric Modulated Arc Therapy (VMAT) Craniospinal Irradiation (CSI) for Children and Adults: A Practical Guide for Implementation. Pract Radiat Oncol 2021; 12:e101-e109. [PMID: 34848379 DOI: 10.1016/j.prro.2021.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/28/2021] [Accepted: 11/08/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE Volumetric modulated arc therapy (VMAT) craniospinal irradiation (CSI) has been shown to have significant dosimetric advantages compared to 3D-conformal therapy, but is a technically complex process. We sought to develop a guide for all aspects of the VMAT CSI process and report patient dosimetry results. METHODS AND MATERIALS We initiated VMAT CSI in 2017 and have regularly revised our standard operating procedure (SOP) for this process since then. Herein, we report a detailed template for the entire VMAT CSI process from initial patient setup and immobilization at time of CT simulation to contouring and treatment planning, quality assurance, and therapy delivery. The records of 12 patients who were treated with VMAT CSI were also retrospectively reviewed. RESULTS Patient age ranged from 2 to 59 years with 5 pediatric patients (age<18 years), 5 young adults (age 18-35 years) and 2 older adults (age>35 years). The majority of patients (67%) had medulloblastoma. CSI dose ranged from 21.6 Gy to 36 Gy, with a median of 36 Gy. The median CSI planning target volume (PTV) was 2383cc with a median V95% of 99.8% and median 0.03 cc hotspot of 112.5%. The average V107% was 7.4% and the average conformality index was 1.01. CONCLUSIONS VMAT CSI has potentially significant dosimetric and acute toxicity advantages compared to 3D-conformal. However, proper procedures need to be in place throughout the process in order to be able to realize these potential advantages. We herein describe our detailed SOP for VMAT CSI. Recognizing the scarcity of proton beam centers in many areas, VMAT CSI represents a feasible treatment with more widespread availability.
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Affiliation(s)
- Roshan S Prabhu
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina; Southeast Radiation Oncology Group, Charlotte, North Carolina.
| | - Reshika Dhakal
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Melanie Piantino
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Nina Bahar
- St. Peter's Health Partners, Albany, New York
| | | | - Carolina E Fasola
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina; Southeast Radiation Oncology Group, Charlotte, North Carolina
| | - Matthew C Ward
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina; Southeast Radiation Oncology Group, Charlotte, North Carolina
| | - John H Heinzerling
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina; Southeast Radiation Oncology Group, Charlotte, North Carolina
| | - Ashley L Sumrall
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Stuart H Burri
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina; Southeast Radiation Oncology Group, Charlotte, North Carolina
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