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Minimizing the Risk of Acute Skin Toxicity Due to Hip Prosthesis Avoidance in Prostate Radiation Therapy. Pract Radiat Oncol 2023; 13:66-70. [PMID: 35907615 DOI: 10.1016/j.prro.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 07/18/2022] [Indexed: 01/10/2023]
Abstract
Limiting the entrance dose through hip prostheses to improve dosimetric accuracy can result in unfavorable skin toxicity. We propose a volumetric modulated arc therapy solution that strikes a better balance between dose accuracy and skin dosimetry. Our current planning strategy limits the entrance dose through hip prostheses using stringent optimization objectives on an avoidance structure. Avoidance efficiency is evaluated by recalculating the plan with prosthesis density set at 20 g/cc, and evaluating the loss of target coverage from increased attenuation. We require this loss to be ≤5% of the original values. This approach has resulted in an uncommon skin toxicity for a prostate-bed patient with bilateral hip prostheses. Thus, the dosimetric tradeoffs between skin dose and prosthesis avoidance were investigated by incrementally reducing prosthesis avoidance to achieve maximum skin doses (Dmax) between 30 and 50 Gy. When prosthesis avoidance is prioritized, the skin dose increases and the target dose coverage and conformity decrease. A large degradation in target coverage for plans with the lowest skin Dmax of 30 to 35 Gy indicates that a significant proportion of the target dose arises from beams entering the prostheses. The plan with a skin Dmax of 40 Gy provides a better compromise between skin and prosthesis entrance doses, with a <20% reduction in target coverage at an increased prosthesis density of 20 g/cm3. Skin dose needs to be considered when using prosthesis avoidance planning strategies. Allowing for a minimal dose through the prosthesis may be required to restrict skin dose and reduce the risk of toxicity.
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ECOG-ACRIN Guideline for Contouring and Treatment of Early Stage Anal Cancer Using IMRT/IGRT. Pract Radiat Oncol 2022; 12:335-347. [PMID: 35717050 DOI: 10.1016/j.prro.2022.01.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 11/22/2022]
Abstract
PURPOSE Previous anal cancer guidelines delineate target volumes similarly for all patients with squamous cell carcinoma of the anal canal and/or perianal skin (SCCA), regardless of disease stage. The purpose of this guideline is to provide customized radiation treatment recommendations for early stage (T1-2 N0 M0) anal cancer treated with intensity modulated and image guided radiation therapy (RT). METHODS AND MATERIALS A contouring atlas and radiation treatment recommendations for the ongoing, randomized phase II trial of deintensified chemoradiation for early stage SCCA (EA2182) was created by an expert panel of radiation oncologists. A literature search was conducted to update and expand these recommendations into a guideline for routine clinical use. RESULTS For the majority of cases, we recommend treatment in the supine, frog leg position with the use of a customized immobilization device and daily image guided RT to ensure optimal bone and soft tissue alignment. Vaginal dilators can be used daily during RT to maximize genitalia sparing. We recommend use of a 10-mm margin on the gross tumor plus including the anal complex to create the primary clinical target volume. To define the elective lymph node clinical target volume, we recommend starting with a 7-mm expansion on blood vessels, but then further refining these volumes based on the anatomic location. A 5- to 10-mm planning target volume (PTV) margin is suggested based on institutional setup and patient-specific factors. When using a simultaneous integrated boost technique, a dose of 50.4 Gy to primary PTV and 42 Gy to lymph node PTV, both delivered over 28 fractions, with chemotherapy is appropriate for early stage anal cancer. CONCLUSIONS This guideline provides anatomic, clinical, and technical instructions to guide radiation oncologists in the planning and delivery of intensity modulated and image guided RT for early stage SCCA.
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Glicksman RM, Davidson M, Wong A, Binda S, Reinhart R, Loblaw A. Moving Unfavorable Small-Bowel Anatomy Away From the Prostate to Optimize Radiation Therapy Plans With the GU-Lok. Pract Radiat Oncol 2021; 11:510-514. [PMID: 34237473 DOI: 10.1016/j.prro.2021.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 05/06/2021] [Accepted: 06/27/2021] [Indexed: 11/16/2022]
Abstract
Patients with localized prostate cancer comprise a large volume of treatments in radiation therapy centers. Occasionally, individual patient anatomy makes the safe delivery of an effective dose of radiation therapy challenging. We describe 2 cases of patients with a small bowel deep in the pelvis within the planning target volume with subsequent suboptimal radiation therapy treatment plans. We explore how we used the GU-Lok, a prostate immobilization device, to move the small bowel away from the prostate, and tighten target volume margins to help facilitate safe and effective treatment.
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Affiliation(s)
- Rachel M Glicksman
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Melanie Davidson
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Department of Medical Physics, Odette Cancer Centre, Sunnybrook Health Sciences Centres, Toronto, Ontario, Canada
| | - Andrew Wong
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Shawn Binda
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Rebecca Reinhart
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Andrew Loblaw
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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Prone treatment position as a novel option for head and neck cancer patients with unmanageable secretions. JOURNAL OF RADIOTHERAPY IN PRACTICE 2020. [DOI: 10.1017/s146039692000059x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractBackground:Supine orientation is the standard treatment position for radiation therapy for head and neck cancer. Some patients, however, cannot tolerate this due to pooling of secretions and airway concerns, and theoretically, treatment would be better tolerated in a prone position. Here, we described the first prone treatment setup and delivery for a patient with head and neck cancer.Methods:A 68-year-old male patient with inoperable locally advanced, T4aN0M0, squamous cell carcinoma of the maxillary sinus was simulated, planned, and treated in prone position due to sinus congestion.Results:Prone position was well tolerated by the patient, who then did not require daily anaesthesia for airway secretion management. The prone dosimetry demonstrated good target coverage and normal tissue sparing. His treatment setup was found to be reproducible throughout the course of therapy.Conclusions:We successfully demonstrated the feasibility of prone treatment position for patients with head and neck cancer who are unable to tolerate supine position due to unmanageable secretions. Consideration should be given to prone treatment when designing both radiation therapy protocols and individual treatment plans.
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Hoffmann M, Waller K, Last A, Westhuyzen J. A critical literature review on the use of bellyboard devices to control small bowel dose for pelvic radiotherapy. Rep Pract Oncol Radiother 2020; 25:598-605. [PMID: 32518531 PMCID: PMC7267681 DOI: 10.1016/j.rpor.2020.04.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 04/10/2020] [Accepted: 04/23/2020] [Indexed: 11/16/2022] Open
Abstract
Delivering curative radiotherapy doses for rectal and gynaecological tumours has historically been complicated by the dose tolerance of the small bowel. Acute radiation-induced small bowel toxicity includes side effects such as abdominal pain, nausea and diarrhoea. With the advent of new treatment delivery modalities, such as IMRT (Intensity modulated radiotherapy) and VMAT (Volumetric modulated Arc radiotherapy), there has been an expectation that small bowel doses can be better controlled with the use of these technologies. These capabilities enable the creation of treatment plans that can better avoid critical radiosensitive organs. The purpose of this review is to look beyond advances in linear accelerator technology in seeking improvements to small bowel dose and toxicity. This review examines whether an alternative prone patient positioning approach using a bellyboard device in conjunction with IMRT and VMAT treatment delivery can reduce small bowel doses further than using these technologies with the patient in a traditional supine position.
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Affiliation(s)
- Matthew Hoffmann
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Port Macquarie, New South Wales, Australia
| | - Kim Waller
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Port Macquarie, New South Wales, Australia
| | - Andrew Last
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Port Macquarie, New South Wales, Australia
| | - Justin Westhuyzen
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
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Ollivier L, Guilloit JM, Dos Santos M, Guillemette L, Florescu C, M'vondo CM, Meyer E, Galais MP, Corbinais S, Parzy A, Varatharajah S, Lesueur P. Implantation of tissue expander prior to irradiation in the era of intensity modulated radiotherapy: impact on the management of patients with pelvic digestive cancers. Int J Colorectal Dis 2020; 35:559-564. [PMID: 31853620 DOI: 10.1007/s00384-019-03475-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Before the introduction of intensity-modulated radiation therapy (IMRT), few teams used to implant a pelvic tissue expander to keep the bowel away from the radiation field, so as to reduce the risk of acute and late enteritis. However, this unexpected surgery could impact patient's overall treatment and may be no more necessary in the era of modern radiotherapy. MATERIAL AND METHODS This is a retrospective cross-sectional study including 13 patients who underwent tissue expander implantation before radiotherapy or chemoradiotherapy for rectal or anal carcinoma between November 2008 and March 2019. First, we aim to show that IMRT could sometimes be insufficient to respect dosimetric constraints, and then we aim to report the impact of tissue expander implantation on the global strategy of care of patients with anal and rectal cancers. RESULTS Seventy-seven percent of the included patients were treated for anal neoplasms, while the remaining 23% had locally advanced rectal cancer. The median follow-up since implantation of the expander was 51 months [3.7-115]. Three patients recurred. One patient developed grade III toxicity related to the implantation of a tissue expander. The delay between diagnosis and the start of irradiation was significantly prolonged (median of 3 months), requiring unusual induction chemotherapy. CONCLUSION Implantation of tissue expander prior to chemoradiotherapy should be considered, even in the era of IMRT, when irradiated peritoneal cavity volume (V15Gy-V45Gy) far exceeds usual dose constraints. However, it impacts the global strategy of care by delaying the start of irradiation, by introducing induction chemotherapy, and rarely by causing post-operative complications.
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Affiliation(s)
- Luc Ollivier
- Centre François Baclesse, Radiation oncology Department, 3 avenue du general Harris, 14000, Caen, France
- CHRU de Brest, Radiation oncology department, 29200, Brest, France
| | | | - Mélanie Dos Santos
- Centre François Baclesse, Medical Oncology Department, 14000, Caen, France
- Normandy University, Université de Caen Basse Normandie, 14000, Caen, France
| | - Laura Guillemette
- Centre François Baclesse, Radiation oncology Department, 3 avenue du general Harris, 14000, Caen, France
| | - Carmen Florescu
- Centre François Baclesse, Radiation oncology Department, 3 avenue du general Harris, 14000, Caen, France
| | - Che Mabubu M'vondo
- Centre François Baclesse, Radiation oncology Department, 3 avenue du general Harris, 14000, Caen, France
| | - Emmanuel Meyer
- Centre François Baclesse, Radiation oncology Department, 3 avenue du general Harris, 14000, Caen, France
| | | | - Stéphane Corbinais
- Centre François Baclesse, Medical Oncology Department, 14000, Caen, France
| | - Aurelie Parzy
- Centre François Baclesse, Medical Oncology Department, 14000, Caen, France
| | | | - Paul Lesueur
- Centre François Baclesse, Radiation oncology Department, 3 avenue du general Harris, 14000, Caen, France.
- Normandy University, Université de Caen Basse Normandie, 14000, Caen, France.
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Sawayanagi S, Yamashita H, Ogita M, Kiritoshi T, Nakamoto T, Abe O, Nakagawa K. Volumetric and dosimetric comparison of organs at risk between the prone and supine positions in postoperative radiotherapy for prostate cancer. Radiat Oncol 2018; 13:70. [PMID: 29665832 PMCID: PMC5905127 DOI: 10.1186/s13014-018-1023-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 04/11/2018] [Indexed: 11/23/2022] Open
Abstract
Background The aim of this study was to evaluate the effects of patient positioning on the volume of organs at risk (OARs) in or near the planning target volume (PTV) and the dose distribution in adjuvant or salvage radiotherapy for prostate cancer after prostatectomy. Methods Seventeen patients who received intensity-modulated radiation therapy (66 Gy in 33 fractions) as adjuvant or salvage therapy after prostatectomy were evaluated. All patients underwent CT scans in both the prone (on a belly board) and supine positions. The target volumes and OARs were delineated on each CT series. The planning target volume (PTV) was extended in every direction to generate the PTV + 0.5 cm, PTV + 1 cm, PTV + 2 cm, PTV + 3 cm, and PTV + 4 cm values. The volumes of the OARs overlapping with the PTV and the extended target volumes in the prone and supine position were compared using the Wilcoxon signed-rank test. Dose-volume histogram (DVH) parameters in the prone and supine position were compared using the paired t-test. Results The mean overlapping volumes of the small intestine for each of the PTV values were as follows (prone position vs. supine position [mean ± SD]): PTV, 1.5 ± 5.5 cm3 vs. 7.9 ± 15.7 cm3 (P = 0.028); PTV + 0.5 cm, 2.6 ± 8.9 cm3 vs. 12.1 ± 22.6 cm3 (P = 0.028); PTV + 1 cm, 3.5 ± 11.4 cm3 vs. 17.1 ± 29.8 cm3 (P = 0.028); PTV + 2 cm, 5.6 ± 14.5 cm3 vs. 26.8 ± 46.9 cm3 (P = 0.028); and PTV + 3 cm, 9.0 ± 17.4 cm3 vs. 36.5 ± 63.2 cm3 (P = 0.019), respectively. Some of the overlapping volumes of the rectum and bladder were significantly smaller in the prone position. On the other hand, when the target volume was extended by ≥2 cm, the overlapping volumes of the femurs were significantly larger in the prone position. V15 of the rectum and mean dose and V65 of the bladder were significantly lower in the prone position. Conclusions This study indicated that the volumes of the small intestine, rectum, and bladder in or near the PTV decreased when the patient was placed in the prone position on a belly board in postoperative radiotherapy for prostate cancer. The dose distribution seemed superior in the prone position to the supine position.
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Affiliation(s)
- Subaru Sawayanagi
- Departments of Radiology, University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hideomi Yamashita
- Departments of Radiology, University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Mami Ogita
- Departments of Radiology, University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Tomoki Kiritoshi
- Departments of Radiology, University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Takahiro Nakamoto
- Departments of Radiology, University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Osamu Abe
- Departments of Radiology, University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Keiichi Nakagawa
- Departments of Radiology, University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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