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Jahng JWS, Little MP, No HJ, Loo BW, Wu JC. Consequences of ionizing radiation exposure to the cardiovascular system. Nat Rev Cardiol 2024:10.1038/s41569-024-01056-4. [PMID: 38987578 DOI: 10.1038/s41569-024-01056-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/11/2024] [Indexed: 07/12/2024]
Abstract
Ionizing radiation is widely used in various industrial and medical applications, resulting in increased exposure for certain populations. Lessons from radiation accidents and occupational exposure have highlighted the cardiovascular and cerebrovascular risks associated with radiation exposure. In addition, radiation therapy for cancer has been linked to numerous cardiovascular complications, depending on the distribution of the dose by volume in the heart and other relevant target tissues in the circulatory system. The manifestation of symptoms is influenced by numerous factors, and distinct cardiac complications have previously been observed in different groups of patients with cancer undergoing radiation therapy. However, in contemporary radiation therapy, advances in treatment planning with conformal radiation delivery have markedly reduced the mean heart dose and volume of exposure, and these variables are therefore no longer sole surrogates for predicting the risk of specific types of heart disease. Nevertheless, certain cardiac substructures remain vulnerable to radiation exposure, necessitating close monitoring. In this Review, we provide a comprehensive overview of the consequences of radiation exposure on the cardiovascular system, drawing insights from various cohorts exposed to uniform, whole-body radiation or to partial-body irradiation, and identify potential risk modifiers in the development of radiation-associated cardiovascular disease.
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Affiliation(s)
- James W S Jahng
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - Mark P Little
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD, USA
- Faculty of Health and Life Sciences, Oxford Brookes University, Headington Campus, Oxford, UK
| | - Hyunsoo J No
- Department of Radiation Oncology, Southern California Permanente Medical Group, Los Angeles, CA, USA
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Billy W Loo
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Joseph C Wu
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.
- Greenstone Biosciences, Palo Alto, CA, USA.
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2
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Rosenbrock J, Kaul H, Oertel M, Celik E, Linde P, Fan J, Eichenauer DA, Bröckelmann PJ, von Tresckow B, Kobe C, Dietlein M, Fuchs M, Borchmann P, Eich HT, Baues C. Involved-site Radiation Therapy is Equally Effective and Less Toxic Than Involved-field Radiation Therapy in Patients Receiving Combined Modality Treatment for Early-stage Unfavorable Hodgkin Lymphoma-An Analysis of the Randomized Phase 3 HD17 Trial of the German Hodgkin Study Group. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00514-5. [PMID: 38631539 DOI: 10.1016/j.ijrobp.2024.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 04/01/2024] [Accepted: 04/10/2024] [Indexed: 04/19/2024]
Abstract
PURPOSE Combined modality treatment with chemotherapy followed by consolidation radiation therapy (RT) provides excellent outcomes for patients with early-stage Hodgkin lymphoma. The international standard of care for consolidation RT, involved-site/involved-node radiation therapy (ISRT/INRT), has never been evaluated in a randomized phase 3 trial against the former standard involved-field radiation therapy (IFRT). METHODS AND MATERIALS In the multicenter phase 3 GHSG (German Hodgkin Study Group) HD17 trial, patients with early-stage unfavorable Hodgkin lymphoma were randomized between the standard Combined modality treatment group and a positron-emission tomography (PET)-guided group. In the standard group, patients received 2 cycles of escalated bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone (eBEACOPP) and 2 cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) followed by 30 Gy IFRT. In the experimental group, patients received no further therapy if postchemotherapy PET was negative and 30 Gy GHSG INRT, comparable to and therefore termed here ISRT, if PET was positive. Here, we analyze the interim PET-positive patients in a post hoc analysis, and therefore the randomized comparison of IFRT versus INRT/ISRT. RESULTS A total of 1100 patients were randomized, of which 311 had a positive PET after chemotherapy. Kaplan-Meier estimates of 4-year progression-free survival were 96.8% (95% CI, 91.6%-98.8%) in the IFRT group and 95.4% (95% CI, 89.9%-97.9%; HR, 1.40; 95% CI, 0.44-4.42) in the ISRT group. The pattern of recurrence analyses indicated that none of the cases of disease progression or recurrence in the ISRT group would have been prevented by the use of IFRT. Acute grade 3/4 toxicities occurred in 8.5% of IFRT patients and 2.6% of ISRT patients (P = .03). CONCLUSIONS For the first time, consolidation INRT/ISRT was randomly compared with IFRT in a phase 3 trial. Regarding progression-free survival, no advantage of IFRT could be demonstrated. In summary, our data confirm the status of INRT/ISRT as the current standard of care.
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Affiliation(s)
- Johannes Rosenbrock
- German Hodgkin Study Group (GHSG); Department of Radiation Oncology and Cyberknife Center, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.
| | - Helen Kaul
- German Hodgkin Study Group (GHSG); Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Michael Oertel
- German Hodgkin Study Group (GHSG); Department of Radiation Oncology, University Hospital Muenster, Muenster, Germany
| | - Eren Celik
- Department of Radiation Oncology and Cyberknife Center, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Philipp Linde
- Department of Radiation Oncology and Cyberknife Center, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Jiaqi Fan
- Department of Radiation Oncology and Cyberknife Center, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Dennis A Eichenauer
- German Hodgkin Study Group (GHSG); Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Paul J Bröckelmann
- German Hodgkin Study Group (GHSG); Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Bastian von Tresckow
- German Hodgkin Study Group (GHSG); Department of Hematology and Stem Cell Transplantation, West German Cancer Center (WTZ), University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Carsten Kobe
- German Hodgkin Study Group (GHSG); Department of Nuclear Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Markus Dietlein
- German Hodgkin Study Group (GHSG); Department of Nuclear Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Michael Fuchs
- German Hodgkin Study Group (GHSG); Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Peter Borchmann
- German Hodgkin Study Group (GHSG); Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Hans Theodor Eich
- German Hodgkin Study Group (GHSG); Department of Radiation Oncology, University Hospital Muenster, Muenster, Germany
| | - Christian Baues
- German Hodgkin Study Group (GHSG); Department of Radiation Oncology, Marienhospital Herne, Ruhr University Bochum, Bochum, Germany
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3
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Frechette KM, Lester SC, Taparra K, Breen WG, Martenson JA, Hoppe BS, Peterson JL, Rule WG, Stafford SL, Stish BJ, Habermann TM, Young JR, Harmsen WS, Laack NN. Outcomes of patients with stage I-II Hodgkin lymphoma who had uniform pre-treatment staging with PET/CT and treatment with limited field radiation therapy after chemotherapy. Blood Cancer J 2022; 12:121. [PMID: 35995767 PMCID: PMC9395516 DOI: 10.1038/s41408-022-00711-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 07/08/2022] [Accepted: 07/22/2022] [Indexed: 11/09/2022] Open
Affiliation(s)
| | - Scott C Lester
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Kekoa Taparra
- Department of Radiation Oncology, Stanford Medicine, Palo Alto, CA, USA
| | - William G Breen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | | | - William G Rule
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, AZ, USA
| | - Scott L Stafford
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Bradley J Stish
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Jason R Young
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - William S Harmsen
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA.
| | - Nadia N Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA.
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Coutte A, Pointreau Y. [Hematological pathologies: the most successful model of de-escalation in radiotherapy]. Cancer Radiother 2022; 26:925-930. [PMID: 35965244 DOI: 10.1016/j.canrad.2022.06.003] [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: 05/31/2022] [Revised: 06/13/2022] [Accepted: 06/14/2022] [Indexed: 10/15/2022]
Abstract
The proportion of patients irradiated in the context of malignant hematological pathologies decreased over the last decades. The main causes are the late side effects of the historical series and the new therapeutic strategies aiming to relay radiotherapy to the rank of option. At the same time, radiotherapy has been modernised, target volumes and total doses have been drastically reduced. Hodgkin's lymphomas, indolent follicular lymphomas and primary cerebral lymphomas are the main witnesses of this therapeutic deflation.
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Affiliation(s)
- A Coutte
- Service de radiothérapie, CHU Amiens Picardie, 1, rond-point du Professeur Christian Cabrol, 80054 Amiens, France.
| | - Y Pointreau
- Institut inter-régionaL de Cancérologie (ILC) - Centre Jean Bernard, 9, Rue Beauverger, 72000 Le Mans, France; Service de radiothérapie, centre régional universitaire de cancérologie Henry-S.-Kaplan, hôpital Bretonneau, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours, France; COLIB, Club des Oncologues LIBéraux, 72000 Le Mans, France
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Milgrom SA, Bakst RL, Campbell BA. Clinical Outcomes Confirm Conjecture: Modern Radiation Therapy Reduces the Risk of Late Toxicity in Survivors of Hodgkin Lymphoma. Int J Radiat Oncol Biol Phys 2021; 111:841-850. [PMID: 34655558 DOI: 10.1016/j.ijrobp.2021.06.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 06/21/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Sarah A Milgrom
- University of Colorado, Department of Radiation Oncology, Aurora, Colorado.
| | - Richard L Bakst
- Mount Sinai Hospital, Department of Radiation Oncology, New York, New York
| | - Belinda A Campbell
- Peter MacCallum Cancer Centre, Department of Radiation Oncology, Melbourne, Victoria, Australia; University of Melbourne, Department of Clinical Pathology, Parkville, Victoria, Australia; University of Melbourne, The Sir Peter MacCallum Department of Oncology, Parkville, Victoria, Australia
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6
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Potre O, Pescaru M, Sima A, Ionita I, Tudor R, Borsi E, Samfireag M, Potre C. Evaluation of the Relapse Risk and Survival Rate in Patients with Hodgkin Lymphoma: A Monocentric Experience. ACTA ACUST UNITED AC 2021; 57:medicina57101026. [PMID: 34684063 PMCID: PMC8540813 DOI: 10.3390/medicina57101026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/17/2021] [Accepted: 09/22/2021] [Indexed: 11/16/2022]
Abstract
Background and objectives: Hodgkin lymphoma (HL) is characterized by the presence of malignant Reed Sternberg cells. Although the current curability rate in patients with HL has increased, up to 30% of those in the advanced stages and 5% to 10% of those in limited stages of the disease, relapse. According to the studies, the relapse risk in HL decreases after 2 years. The purpose of this study is to evaluate the relapse risk and event free survival (EFS) in patients with HL treated with Doxorubicin, Bleomycin, Vinblastine and Dacarbazine (ABVD), or treated with Bleomycin, Etoposide, Doxorubicin, Cyclophosphamide, Vincristine, Procarbazine, and Prednisone (BEACOPP) regimens. Material and methods: In an observational, consecutive-case scenario, 71 patients (median age 32 years; range 16 to 80 years) diagnosed within a 4-year timeframe were enrolled; all patients were treated according to standards of care. The average follow-up duration was 26 months. Results: The risk of relapse, in patients older than 40 years, decreased after 1 year, OR = 0.707 (95% CI 0.506 to 0.988), and 2 years, OR = 0.771 (95% CI 0.459 to 1.295), respectively. Patients in the advanced stages had a higher International Prognostic Score (IPS) (score ≥ 4). The overall survival at 2 years was 57.74% and the disease-specific survival at 2 years was 71.83%. Regardless, the chemotherapy regimen and the EFS time, advanced stage, high IPS and bulky disease were still associated with an increased relapse risk in patients with HL. Conclusions: The use of ABVD chemotherapy regimen followed by 2 years EFS was associated with a reduced relapse risk.
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Affiliation(s)
- Ovidiu Potre
- Department of Internal Medicine, Hematology, Victor Babes University of Medicine and Pharmacy, 300041 Timisoara, Romania; (O.P.); (M.P.); (I.I.); (E.B.); (C.P.)
- Hematology Clinic, Timisoara’s Emergency City Hospital, 300723 Timisoara, Romania
| | - Monica Pescaru
- Department of Internal Medicine, Hematology, Victor Babes University of Medicine and Pharmacy, 300041 Timisoara, Romania; (O.P.); (M.P.); (I.I.); (E.B.); (C.P.)
- Hematology Clinic, Timisoara’s Emergency City Hospital, 300723 Timisoara, Romania
| | - Alexandra Sima
- Second Department of Internal Medicine, Diabetes, Nutrition, Metabolic Diseases and Systemic Rheumatology, Victor Babes University of Medicine and Pharmacy, 300041 Timisoara, Romania
- 3rd Medical Clinic, Pius Brinzeu Emergency Hospital, 300041 Timisoara, Romania
- Correspondence:
| | - Ioana Ionita
- Department of Internal Medicine, Hematology, Victor Babes University of Medicine and Pharmacy, 300041 Timisoara, Romania; (O.P.); (M.P.); (I.I.); (E.B.); (C.P.)
- Hematology Clinic, Timisoara’s Emergency City Hospital, 300723 Timisoara, Romania
| | - Raluca Tudor
- Department of Neurology, Victor Babes University of Medicine and Pharmacy, 300041 Timisoara, Romania;
| | - Ema Borsi
- Department of Internal Medicine, Hematology, Victor Babes University of Medicine and Pharmacy, 300041 Timisoara, Romania; (O.P.); (M.P.); (I.I.); (E.B.); (C.P.)
- Hematology Clinic, Timisoara’s Emergency City Hospital, 300723 Timisoara, Romania
| | - Miruna Samfireag
- Department of Internal Medicine, Clinical Practical Skills, Victor Babes University of Medicine and Pharmacy, 300041 Timisoara, Romania;
| | - Cristina Potre
- Department of Internal Medicine, Hematology, Victor Babes University of Medicine and Pharmacy, 300041 Timisoara, Romania; (O.P.); (M.P.); (I.I.); (E.B.); (C.P.)
- Hematology Clinic, Timisoara’s Emergency City Hospital, 300723 Timisoara, Romania
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Outcome of limited-stage nodular lymphocyte-predominant Hodgkin lymphoma and the impact of a PET-adapted approach. Blood Adv 2021; 5:3647-3655. [PMID: 34438445 PMCID: PMC8945586 DOI: 10.1182/bloodadvances.2021004375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 04/29/2021] [Indexed: 01/05/2023] Open
Abstract
Radiotherapy (RT) is typically incorporated into the treatment of limited-stage nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL), although it remains unknown whether chemotherapy alone may be suitable in select patients. We evaluated outcomes of limited-stage NLPHL at BC Cancer on the basis of era-specific guidelines: routine RT era, 1995 to 2005 (n = 36), combined modality with 2 cycles of doxorubicin, bleomycin, vinblastine, dacarbazine (ABVD) chemotherapy followed by RT or RT alone; positron emission tomography (PET) era, after 2005 (n = 63), ABVD alone (4 cycles) if the PET scan after the second cycle of ABVD (PET2) is negative, or treatment is changed to RT if PET2 is positive. Median age of patients was 38 years (range, 16-82 years), 73% were male, and 43% had stage II. With a median follow-up of 10.5 years for all patients, 5-year progression-free survival (PFS) was 91% [corrected] and was 97% for overall survival (OS), with no difference by treatment era (PFS, P = .15; [corrected] OS, P = .35). For the 49 patients who had a PET2 scan, 86% were PET negative and 14% were PET positive by Deauville criteria with 5-year PFS rates of 92% and 80% (P = .87) [corrected], respectively. This is the largest study of a PET-adapted approach in NLPHL and supports that ABVD alone may be a viable option in select patients with a negative PET2 scan, with consideration of acute and long-term toxicities.
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Cochrane T, Campbell BA, Gangatharan SA, Latimer M, Khor R, Christie DRH, Gilbertson M, Ratnasingam S, Palfreyman E, Lee HP, Trotman J, Hertzberg M, Dickinson M. Assessment and management of newly diagnosed classical Hodgkin lymphoma: a consensus practice statement from the Australasian Lymphoma Alliance. Intern Med J 2021; 51:2119-2128. [PMID: 34505342 DOI: 10.1111/imj.15503] [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: 05/07/2021] [Revised: 08/25/2021] [Accepted: 08/26/2021] [Indexed: 11/28/2022]
Abstract
The management of Hodgkin lymphoma (HL) has undergone significant changes in recent years. Due to the predilection of HL to affect younger patients, balancing cure and treatment-related morbidity is a constant source of concern for physicians and patients alike. Positron emission tomography adapted therapy has been developed for both early and advanced stage HL to try and improve the outcome of treatment, while minimising toxicities. The aim of this review is to digest the plethora of studies recently conducted and provide some clear, evidence-based practice statements to simplify the management of HL.
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Affiliation(s)
- Tara Cochrane
- Department of Haematology, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,School of Medicine, Griffiths University, Gold Coast, Queensland, Australia
| | - Belinda A Campbell
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Clinical Pathology, University of Melbourne, Parkville, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Shane A Gangatharan
- Fiona Stanley Hospital, Perth, Western Australia, Australia.,University of Western Australia, Perth, Western Australia, Australia
| | - Maya Latimer
- ACT Pathology and Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | | | - David R H Christie
- Genesiscare, Gold Coast, Queensland, Australia.,Bond University, Gold Coast, Queensland, Australia
| | - Michael Gilbertson
- Monash Health, Melbourne, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,Department of Haematology and Oncology, Western Health, Melbourne, Victoria, Australia
| | - Sumita Ratnasingam
- Andrew Love Cancer Centre, University Hospital Geelong, Geelong, Victoria, Australia
| | - Emma Palfreyman
- Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Hui-Peng Lee
- Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Judith Trotman
- Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Mark Hertzberg
- Department of Haematology, Prince of Wales Hospital, Sydney, New South Wales, Australia.,University of NSW, Sydney, New South Wales, Australia
| | - Michael Dickinson
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Victoria, Australia
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9
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Bergom C, Bradley JA, Ng AK, Samson P, Robinson C, Lopez-Mattei J, Mitchell JD. Past, Present, and Future of Radiation-Induced Cardiotoxicity: Refinements in Targeting, Surveillance, and Risk Stratification. JACC CardioOncol 2021; 3:343-359. [PMID: 34604796 PMCID: PMC8463722 DOI: 10.1016/j.jaccao.2021.06.007] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 06/07/2021] [Accepted: 06/09/2021] [Indexed: 12/13/2022] Open
Abstract
Radiation therapy is an important component of cancer therapy for many malignancies. With improvements in cardiac-sparing techniques, radiation-induced cardiac dysfunction has decreased but remains a continued concern. In this review, we provide an overview of the evolution of radiotherapy techniques in thoracic cancers and associated reductions in cardiac risk. We also highlight data demonstrating that in some cases radiation doses to specific cardiac substructures correlate with cardiac toxicities and/or survival beyond mean heart dose alone. Advanced cardiac imaging, cardiovascular risk assessment, and potentially even biomarkers can help guide post-radiotherapy patient care. In addition, treatment of ventricular arrhythmias with the use of ablative radiotherapy may inform knowledge of radiation-induced cardiac dysfunction. Future efforts should explore further personalization of radiotherapy to minimize cardiac dysfunction by coupling knowledge derived from enhanced dosimetry to cardiac substructures, post-radiation regional dysfunction seen on advanced cardiac imaging, and more complete cardiac toxicity data.
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Key Words
- CAC, coronary artery calcium
- CAD, coronary artery disease
- CMRI, cardiac magnetic resonance imaging
- CT, computed tomography
- HL, Hodgkin lymphoma
- LAD, left anterior descending artery
- LV, left ventricular
- MHD, mean heart dose
- NSCLC, non–small cell lung cancer
- RICD, radiation-induced cardiovascular disease
- RT, radiation therapy
- SBRT, stereotactic body radiation therapy
- breast cancer
- cancer survivorship
- childhood cancer
- esophageal cancer
- imaging
- lung cancer
- lymphoma
- radiation physics
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Affiliation(s)
- Carmen Bergom
- Department of Radiation Oncology, Washington University, Saint Louis, Missouri, USA
- Cardio-Oncology Center of Excellence, Washington University, St. Louis, Missouri, USA
- Alvin J. Siteman Center, Washington University, St. Louis, Missouri, USA
| | - Julie A. Bradley
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida, USA
| | - Andrea K. Ng
- Department of Radiation Oncology, Dana-Farber/Brigham and Women’s Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Pamela Samson
- Department of Radiation Oncology, Washington University, Saint Louis, Missouri, USA
- Alvin J. Siteman Center, Washington University, St. Louis, Missouri, USA
| | - Clifford Robinson
- Department of Radiation Oncology, Washington University, Saint Louis, Missouri, USA
- Alvin J. Siteman Center, Washington University, St. Louis, Missouri, USA
- Division of Cardiology, Department of Medicine, Washington University, St. Louis, Missouri, USA
| | - Juan Lopez-Mattei
- Departments of Cardiology and Thoracic Imaging, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Joshua D. Mitchell
- Cardio-Oncology Center of Excellence, Washington University, St. Louis, Missouri, USA
- Alvin J. Siteman Center, Washington University, St. Louis, Missouri, USA
- Division of Cardiology, Department of Medicine, Washington University, St. Louis, Missouri, USA
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10
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Long-term outcomes for patients with limited-stage follicular lymphoma: update of a population-based study. Blood 2021; 136:1006-1010. [PMID: 32321165 DOI: 10.1182/blood.2019004588] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
With a median follow-up of 16.6 years, Lo and colleagues report excellent long-term outcomes with primary radiotherapy for limited-stage follicular lymphoma in this month’s CME article.
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11
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Filippi AR, Meregalli S, DI Russo A, Levis M, Ciammella P, Buglione M, Guerini AE, De Marco G, De Sanctis V, Vagge S, Ricardi U, Simontacchi G. Fondazione Italiana Linfomi (FIL) expert consensus on the use of intensity-modulated and image-guided radiotherapy for Hodgkin's lymphoma involving the mediastinum. Radiat Oncol 2020; 15:62. [PMID: 32164700 PMCID: PMC7066773 DOI: 10.1186/s13014-020-01504-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 02/21/2020] [Indexed: 12/14/2022] Open
Abstract
Aim Advances in therapy have resulted in improved cure rates and an increasing number of long-term Hodgkin's lymphoma (HL) survivors. However, radiotherapy (RT)-related late effects are still a significant issue, particularly for younger patients with mediastinal disease (secondary cancers, heart diseases). In many Centers, technological evolution has substantially changed RT planning and delivery. This consensus document aims to analyze the current knowledge of Intensity-Modulated Radiation Therapy (IMRT) and Image-Guided Radiation Therapy (IGRT) for mediastinal HL and formulate practical recommendations based on scientific evidence and expert opinions. Methods A dedicated working group was set up within the Fondazione Italiana Linfomi (FIL) Radiotherapy Committee in May 2018. After a first meeting, the group adopted a dedicated platform to share retrieved articles and other material. Two group coordinators redacted a first document draft, that was further discussed and finalized in two subsequent meetings. Topics of interest were: 1) Published data comparing 3D-conformal radiotherapy (3D-CRT) and IMRT 2) dose objectives for the organs at risk 3) IGRT protocols and motion management. Results Data review showed that IMRT might allow for an essential reduction in the high-dose regions for all different thoracic OAR. As very few studies included specific dose constraints for lungs and breasts, the low-dose component for these OAR resulted slightly higher with IMRT vs. 3D-CRT, depending on the technique used. We propose a set of dose objectives for the heart, breasts, lungs, and thyroid. The use of IGRT is advised for margin reduction without specific indications, such as the use of breath-holding techniques. An individual approach, including comparative planning and considering different risk factors for late morbidity, is recommended for each patient. Conclusions As HL therapy continues to evolve, with an emphasis on treatment reduction, radiation oncologists should use at best all the available tools to minimize the dose to organs at risk and optimize treatment plans. This document provides indications on the use of IMRT/IGRT based on expert consensus, providing a basis for clinical implementation and future development.
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Affiliation(s)
- Andrea Riccardo Filippi
- Radiation Oncology Department, Fondazione IRCCS Policlinico S. Matteo, Viale Golgi 19, 27100, Pavia, Italy.
| | | | - Anna DI Russo
- Fondazione IRCCS Policlinico San Matteo and University of Pavia, Viale Golgi 19, 27100, Pavia, Italy
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Volume de-escalation in radiation therapy: state of the art and new perspectives. J Cancer Res Clin Oncol 2020; 146:909-924. [PMID: 32072318 DOI: 10.1007/s00432-020-03152-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 02/10/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE New RT techniques and data emerging from follow-up for several tumor sites suggest that treatment volume de-escalation may permit to minimize therapy-related side effects and/or obtain better clinical outcomes. Here, we summarize the main evidence about volume de-escalation in RT. METHOD The relevant literature from PubMed was reviewed in this article. The ClinicalTrials.gov database was searched for clinical trials related to the specific topic. RESULTS In Lymphoma, large-volume techniques (extended- and involved-field RT) are being successfully replaced by involved-site RT and involved-node RT. In head and neck carcinoma, spare a part of elective neck is controversial. In early breast cancer, partial breast irradiation has been established as a treatment option in low-risk patients. In pancreatic cancer stereotactic body radiotherapy may be used to dose escalation. Stereotactic radiosurgery should be the treatment choice for patients with oligometastatic brain disease and a life expectancy of more than 3 months, and it should be considered an alternative to WBRT for patients with multiple brain metastases. CONCLUSION Further clinical trials are necessary to improve the identification of suitable patient cohorts and the extent of possible volume de-escalation that does not compromise tumor control.
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A comparison of selected dosimetric parameters of two Hodgkin Lymphoma radiotherapy techniques with reference to potential risk of radiation induced heart disease. POLISH JOURNAL OF MEDICAL PHYSICS AND ENGINEERING 2018. [DOI: 10.2478/pjmpe-2018-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract
Purpose: Hodgkin lymphoma (HL) is one of the most frequent malignancies among pediatric patients. One of the common causes of death in HL survivors after radiation therapy (RT), is radiation-induced heart disease (RIHD). The aim of this study was to compare several dosimetric parameters for two methods of early stage Hodgkin lymphoma radiotherapy with reference to potential risk of RIHD.
Materials and Methods: Using a series of computed tomography slices of 40 young patients, treatment planning was done in two methods of HL RT, including involved field (IFRT) and involved site (ISRT) in doses of 20, 30, and 35 Gy. Contouring of clinical target volume as well as the organs at risk, including the heart, was performed by a radiation oncologist. The mean and maximum dose of heart (Dheart-mean and Dheart-max), the volume of heart receiving a dose more than 25 Gy (V25), and the standard deviation of dose as a dose homogeneity index in heart, were used to compare the RIHD risk.
Results: The mean value for Dheart-mean in ISRT method in all doses was less compare to IFRT. Maximum reduction in mean value of Dheart-mean occurred at moving from 30 Gy IFRT to ISRT by 9.53 Gy (p < 0.001) and minimum was between 35 Gy IFRT and ISRT. The mean value for Dheart-max was fewer in IFRT rather than ISRT and the maximum difference was between 35 Gy IFRT and ISRT (1.35 Gy). The mean of V25 of heart was 26.66% and 23.74% in 35 Gy IFRT and ISRT, respectively, and dose distribution was more homogeneous in IFRT.
Conclusions: If Dheart-max and V25 of heart or homogeneity of dose distribution in heart are considered as determining factors in RIHD, then IFRT can be considered optimum, especially in 35 Gy IFRT; while, assuming the Dheart-mean as the most important factor in RIHD, superiority of ISRT over IFRT is observed.
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Villa D, Sehn LH, Aquino-Parsons C, Tonseth P, Scott DW, Gerrie AS, Wilson D, Bénard F, Gascoyne RD, Slack GW, Farinha P, Morris J, Pickles T, Connors JM, Savage KJ. Interim PET-directed therapy in limited-stage Hodgkin lymphoma initially treated with ABVD. Haematologica 2018; 103:e590-e593. [PMID: 30002124 DOI: 10.3324/haematol.2018.196782] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Diego Villa
- BC Cancer Centre for Lymphoid Cancer and Division of Medical Oncology
| | - Laurie H Sehn
- BC Cancer Centre for Lymphoid Cancer and Division of Medical Oncology
| | | | | | - David W Scott
- BC Cancer Centre for Lymphoid Cancer and Division of Medical Oncology
| | - Alina S Gerrie
- BC Cancer Centre for Lymphoid Cancer and Division of Medical Oncology
| | | | | | - Randy D Gascoyne
- Department of Pathology and Laboratory Medicine, BC Cancer and the University of British Columbia, Vancouver, BC, Canada
| | - Graham W Slack
- Department of Pathology and Laboratory Medicine, BC Cancer and the University of British Columbia, Vancouver, BC, Canada
| | - Pedro Farinha
- Department of Pathology and Laboratory Medicine, BC Cancer and the University of British Columbia, Vancouver, BC, Canada
| | | | | | - Joseph M Connors
- BC Cancer Centre for Lymphoid Cancer and Division of Medical Oncology
| | - Kerry J Savage
- BC Cancer Centre for Lymphoid Cancer and Division of Medical Oncology
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15
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Carella AM, Corradini P, Mussetti A, Ricardi U, Vitolo U, Viviani S. Treatment of classical Hodgkin lymphoma in the era of brentuximab vedotin and immune checkpoint inhibitors. Ann Hematol 2018; 97:1301-1315. [PMID: 29802458 DOI: 10.1007/s00277-018-3366-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 05/06/2018] [Indexed: 12/19/2022]
Abstract
The majority of Hodgkin lymphoma patients are now cured with conventional first-line therapy; however, 10-15% of early-stage disease and less than 30% of advanced-stage patients are refractory(rare) or relapsed. Salvage second-line therapy combined with high-dose therapy and autologous stem-cell transplantation can cure 40-50% of patients. Recently novel agents (Brentuximab Vedotin and Immune Checkpoint inhibitors) have demonstrated evidence of therapeutic activity and are potential bridge to an allogeneic stem-cell transplantation. The review is aimed to present not only salvage strategies; indeed, the paper contains paragraphs about therapy and new treatment options at diagnosis.
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Affiliation(s)
- A M Carella
- Division of Hematology and BMT Unit, Ospedale Policlinico San Martino, Genoa, Italy.
| | - P Corradini
- Division of Hematology and BMT Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - A Mussetti
- Division of Hematology and BMT Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - U Ricardi
- Department of Oncology, Università di Torino, Turin, Italy
| | - U Vitolo
- AOU Citta' della Salute e della Scienza, Turin, Italy
| | - S Viviani
- Division of Hematology and BMT Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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16
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Pinnix CC, Wirth A, Milgrom SA, Andraos TY, Aristophanous M, Pham M, Hancock D, Ludmir EB, Gunther JR, Fanale MA, Oki Y, Nastoupil L, Chuang HH, Mikhaeel NG, Dabaja BS. Omitting cardiophrenic lymph nodes in the treatment of patients with Hodgkin lymphoma via modified involved-site radiation therapy. Leuk Lymphoma 2018; 59:2650-2659. [PMID: 29616834 DOI: 10.1080/10428194.2018.1452211] [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] [Indexed: 12/25/2022]
Abstract
Cardiophrenic lymph nodes (CPLNs) are occasionally involved in Hodgkin lymphoma (HL). We characterized the incidence of CPLN involvement among 169 HL patients and evaluated outcomes after treatment with omission of the CPLN region from the involved-site radiation therapy (ISRT) field. Three types of RT fields were used: standard (S)-ISRT, reduced-dose (RD)-ISRT (lower dose to CPLNs, standard to other sites), or modified (M)-ISRT (omission of CPLNs). CPLNs were involved at diagnosis in 29 patients (17%). Of the 20 patients who received RT after complete response to chemotherapy, 4(20%) received S-ISRT, 8(40%) RD-ISRT, and 8(40%) M-ISRT. The four-year progression-free survival was 94.7%. One relapse occurred at a non-CPLN site after RD-ISRT. The mean heart dose and volume of the heart that received 25 Gy was higher for S-ISRT patients compared to M-ISRT (p = .043 and p = .025, respectively). Re-planning the M-ISRT cases as S-ISRT resulted in significant increase in cardiac doses.
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Affiliation(s)
- Chelsea C Pinnix
- a Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Andrew Wirth
- b Department of Radiation Oncology , Peter MacCallum Cancer Institute , Melbourne , Australia
| | - Sarah A Milgrom
- a Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Therese Y Andraos
- a Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Michalis Aristophanous
- a Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Mary Pham
- a Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Donald Hancock
- a Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Ethan B Ludmir
- a Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Jillian R Gunther
- a Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Michelle A Fanale
- c Department of Lymphoma/Myeloma , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Yasuhiro Oki
- c Department of Lymphoma/Myeloma , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Loretta Nastoupil
- c Department of Lymphoma/Myeloma , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Hubert H Chuang
- d Department of Nuclear Medicine , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - N George Mikhaeel
- e Department of Clinical Oncology , Guy's and St. Thomas' Hospital , London , UK
| | - Bouthaina S Dabaja
- a Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
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17
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Kamran SC, Jacene HA, Chen YH, Mauch PM, Ng AK. Clinical outcome of patients with early stage favorable Hodgkin lymphoma treated with ABVD × two cycles followed by FDG-PET/CT restaging and 20 Gy of involved-site radiotherapy. Leuk Lymphoma 2017; 59:1384-1390. [PMID: 28937297 DOI: 10.1080/10428194.2017.1376745] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Our purpose was to assess outcome of patients with early-stage, favorable (per GHSG criteria) Hodgkin Lymphoma (HL) staged with FDG-PET/CT and treated with two cycles of adriamycin, bleomycin, vincristine, and dacarbazine (ABVD) followed by PET/CT assessment and involved-site radiotherapy (ISRT) to 20 Gy. Records of 23 patients who met eligibility criteria, treated between 2008 and 2016, were reviewed. PET response after two cycles of ABVD was independently assessed by a nuclear medicine physician. After two cycles of ABVD, 91.3% of patients had a Deauville score of 1-2; 1 patient had a score of 3. Median follow-up was 45.3 months. As of this analysis, all patients are alive without disease. One patient had an out-of-field relapse, yielding a 4-year relapse-free survival rate of 92.9% (95%CI [59.1, 99.0]). Our results showed that with careful patient selection by initial disease characteristics and FDG-PET response to chemotherapy, the use of a more restricted treatment volume of ISRT to 20 Gy following ABVD × 2 is associated with excellent outcomes.
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Affiliation(s)
- Sophia C Kamran
- a Harvard Radiation Oncology Program , Dana-Farber Cancer Institute/Brigham and Women's Hospital , Boston , MA , USA
| | - Heather A Jacene
- b Department of Radiology , Dana-Farber Cancer Institute/Brigham and Women's Hospital , Boston , MA , USA
| | - Yu-Hui Chen
- c Department of Biostatistics and Computational Biology , Dana-Farber Cancer Institute/Brigham and Women's Hospital , Boston , MA , USA
| | - Peter M Mauch
- d Department of Radiation Oncology , Dana-Farber Cancer Institute/Brigham and Women's Hospital , Boston , MA , USA
| | - Andrea K Ng
- d Department of Radiation Oncology , Dana-Farber Cancer Institute/Brigham and Women's Hospital , Boston , MA , USA
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18
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Abstract
This topic addresses the treatment of newly diagnosed patients with favorable prognosis stage I and II Hodgkin lymphoma. In most cases, combined modality therapy (chemotherapy followed by involved site radiation therapy) constitutes the current standard of care. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment. By combining the most recent medical literature and expert opinion, this revised guideline can aid clinicians in the appropriate use of combined modality therapy for favorable prognosis stage I and II Hodgkin lymphoma. Increasing information about the late effects of treatment has led to attempts to decrease toxicity by using less chemotherapy (decreased duration and/or intensity or different agents) and less radiation therapy (reduced volume and/or dose) while maintaining excellent efficacy.
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19
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Stewart MH, Jahangir E, Polin NM. Valvular Heart Disease in Cancer Patients: Etiology, Diagnosis, and Management. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:53. [PMID: 28547673 DOI: 10.1007/s11936-017-0550-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OPINION STATEMENT Cardiac valvular disease as consequence of radiation and chemotherapy during treatment for malignancy is growing in its awareness. While the overwhelming emphasis in this population has been on the monitoring and preservation of left ventricular systolic function, we are now developing a greater appreciation for the plethora of cardiac sequelae beyond this basic model. To this end many institutions across the country have developed cardio-oncology programs, which are collaborative practices between oncologists and cardiologists in order to minimize a patient's cardiovascular risk while allowing them to receive the necessary treatment for their cancer. These programs also help to recognize early nuanced treatment complications such as valvular heart disease, and provide consultation for the most appropriate course of action. In this article we will discuss the etiology, prevalence, diagnosis, and current treatment options of valvular heart disease as the result of chemotherapy and radiation.
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Affiliation(s)
- Merrill H Stewart
- John Ochsner Heart and Vascular Institute, University of Queensland School of Medicine, 1514 Jefferson Highway, New Orleans, LA, 70121, USA.
| | - Eiman Jahangir
- Division of Cardiology, Kaiser Permanente Northern California, 401 Bicentennial Drive, Santa Rosa, CA, 95403, USA
| | - Nichole M Polin
- John Ochsner Heart and Vascular Institute, University of Queensland School of Medicine, 1514 Jefferson Highway, New Orleans, LA, 70121, USA
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20
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Filippi AR, Levis M, Parikh R, Hoppe B. Optimal Therapy for Early-Stage Hodgkin's Lymphoma: Risk Adapting, Response Adapting, and Role of Radiotherapy. Curr Oncol Rep 2017; 19:34. [PMID: 28365830 DOI: 10.1007/s11912-017-0592-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE OF REVIEW The aim of this article is to discuss the current role of radiotherapy (RT) for early-stage Hodgkin's lymphoma (HL) in the context of risk-adapted and response-adapted treatment strategy, and describe changes in RT technical approach. RECENT FINDINGS In low-risk patients, RT could be omitted but, at the price of a lower progression-free survival, and its role is still debated. Ongoing trials are combining new agents with chemotherapy alone or response-adapted combined modality therapy, and results are awaited. Modern RT incorporates lower doses and smaller fields, together with the implementation of sophisticated delivery techniques aimed to reducing the dose to critical structures such as the heart. The role of RT for early-stage HL is still under debate, and new combinations are emerging; an individualized approach should be recommended, considering all RT technical opportunities to minimize toxicity while maintaining efficacy.
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Affiliation(s)
- Andrea Riccardo Filippi
- Department of Oncology, San Luigi Gonzaga University Hospital, University of Torino, Regione Gonzole 10, 10043, Orbassano, Turin, Italy.
| | - Mario Levis
- Department of Oncology, San Luigi Gonzaga University Hospital, University of Torino, Regione Gonzole 10, 10043, Orbassano, Turin, Italy
| | - Rahul Parikh
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, USA
| | - Bradford Hoppe
- Department of Radiation Oncology, University of Florida, Gainesville, USA.,University of Florida Health Proton Therapy Institute, Jacksonville, USA
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21
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Secondary Breast Cancer Risk by Radiation Volume in Women With Hodgkin Lymphoma. Int J Radiat Oncol Biol Phys 2016; 97:35-41. [PMID: 27979454 DOI: 10.1016/j.ijrobp.2016.10.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 09/12/2016] [Accepted: 10/04/2016] [Indexed: 11/23/2022]
Abstract
PURPOSE To determine whether the risk of secondary breast cancer (SBC) is reduced in women with Hodgkin lymphoma (HL) treated with smaller field radiation therapy (SFRT) versus mantle field radiation therapy (MRT). METHODS AND MATERIALS We used the BC Cancer Agency (BCCA) Lymphoid Cancer Database to identify female patients treated for HL between January 1961 and December 2009. Radiation therapy volumes were categorized as MRT or SFRT, which included involved field, involved site, or involved nodal radiation therapy. SBC risk estimates were compared using competing risk analysis and Fine and Gray multivariable model: MRT ± chemotherapy, SFRT ± chemotherapy, or chemotherapy-only. RESULTS Of 734 eligible patients, 75% of the living patients have been followed up for more than 10 years, SBC has developed in 54, and 15 have died of breast cancer. The 20-year estimated risks (competing risk cumulative incidence) for SBC differed significantly: MRT 7.5% (95% confidence interval [CI] 4.4%-11.5%), SFRT 3.1% (95% CI 1.0%-7.7%), and chemotherapy-only 2.2% (95% CI 1.0%-4.8%) (P=.01). Using a Fine and Gray model to control for death and patients lost to follow-up, MRT was associated with a higher risk of SBC (hazard ratio [HR] = 2.9; 95% CI 1.4%-6.0%; P=.004) compared with chemotherapy-only and with SFRT (HR = 3.3; 95% CI 1.3%-8.4%; P=.01). SFRT was not associated with a greater risk of SBC compared with chemotherapy-only (HR = 0.87; 95% CI 0.28%-2.66%; P=.80). CONCLUSION This study confirms that large-volume MRT is associated with a markedly increased risk of SBC; however, more modern small-volume RT is not associated with a greater risk of SBC than chemotherapy alone.
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22
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Russell RR, Alexander J, Jain D, Poornima IG, Srivastava AV, Storozynsky E, Schwartz RG. The role and clinical effectiveness of multimodality imaging in the management of cardiac complications of cancer and cancer therapy. J Nucl Cardiol 2016; 23:856-84. [PMID: 27251147 DOI: 10.1007/s12350-016-0538-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 04/13/2016] [Indexed: 12/24/2022]
Abstract
With the increasing number of individuals living with a current or prior diagnosis of cancer, it is important for the cardiovascular specialist to recognize the various complications of cancer and its therapy on the cardiovascular system. This is true not only for established cancer therapies, such as anthracyclines, that have well established cardiovascular toxicities, but also for the new targeted therapies that can have "off target" effects in the heart and vessels. The purpose of this informational statement is to provide cardiologists, cardiac imaging specialists, cardio-oncologists, and oncologists an understanding of how multimodality imaging may be used in the diagnosis and management of the cardiovascular complications of cancer therapy. In addition, this document is meant to provide useful general information concerning the cardiovascular complications of cancer and cancer therapy as well as established recommendations for the monitoring of specific cardiotoxic therapies.
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Affiliation(s)
- Raymond R Russell
- Rhode Island Cardiovascular Institute, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, 593 Eddy Street, APC 737, Providence, RI, 02903, USA.
| | - Jonathan Alexander
- Cardiology Division, Western Connecticut Medical Center at Danbury Hospital, Danbury, CT, USA
| | - Diwakar Jain
- Section of Cardiovascular Medicine, New York Medical College and Westchester Medical Center, Valhalla, NY, USA
| | - Indu G Poornima
- Division of Cardiology, Allegheny Health Network, Pittsburgh, PA, USA
| | - Ajay V Srivastava
- Division of Cardiovascular Medicine, Scripps Clinic, La Jolla, CA, USA
| | - Eugene Storozynsky
- Cardiology Division, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Ronald G Schwartz
- Cardiology Division, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
- Nuclear Medicine Division, Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
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23
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Hapgood G, Zheng Y, Sehn LH, Villa D, Klasa R, Gerrie AS, Shenkier T, Scott DW, Gascoyne RD, Slack GW, Parsons C, Morris J, Pickles T, Connors JM, Savage KJ. Evaluation of the Risk of Relapse in Classical Hodgkin Lymphoma at Event-Free Survival Time Points and Survival Comparison With the General Population in British Columbia. J Clin Oncol 2016; 34:2493-500. [DOI: 10.1200/jco.2015.65.4194] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Studies in classical Hodgkin lymphoma (cHL) typically measure the time to events from diagnosis. We evaluated the risk of relapse at event-free survival time points in cHL and compared the risk of death to expected mortality rates in British Columbia (BC). Methods The BC Cancer Agency Lymphoid Cancer Database was screened to identify all patients age 16 to 69 years diagnosed with cHL between 1989 and 2012 treated with the chemotherapy regimen of doxorubicin, bleomycin, vinblastine, and dacarbazine (or equivalent). We compared the observed mortality to the general population using age-, sex-, and calendar period–generated expected mortality rates from BC life-tables. Relative survival was calculated using a conditional approach and expressed as a standardized mortality ratio of observed-to-expected deaths. Results One thousand four hundred two patients were identified; 749 patients were male (53%), the median age was 32 years, and 68% had advanced-stage disease. The median follow-up time was 8.4 years. Seventy-two percent of relapses occurred within the first 2 years of diagnosis. For all patients, the 5-year risk of relapse from diagnosis was 18.1% but diminished to 5.6% for patients remaining event free at 2 years. For advanced-stage patients who were event free at 2 years, the 5-year risk of relapse was only 7.6%, and for those who were event free at 3 years, it was comparable to that of limited-stage patients (4.1% v 2.5%, respectively; P = .07). Furthermore, international prognostic score ≥ 4 and bulky disease were no longer prognostic in patients who were event free at 1 year. Although the relative survival improved as patients remained in remission, it did not normalize compared with the general population. Conclusion Patients with cHL who are event free at 2 years have an excellent outcome regardless of baseline prognostic factors. All patients with cHL had an enduring increased risk of death compared with the general population.
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Affiliation(s)
- Greg Hapgood
- Greg Hapgood, Laurie H. Sehn, Diego Villa, Richard Klasa, Alina S. Gerrie, Tamara Shenkier, David W. Scott, Randy D. Gascoyne, Graham W. Slack, Joseph M. Connors, and Kerry J. Savage, British Columbia Cancer Agency Centre for Lymphoid Cancer; Yvonne Zheng, Cancer Surveillance and Outcomes, Population Oncology; Christina Parsons, James Morris, and Tom Pickles, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Yvonne Zheng
- Greg Hapgood, Laurie H. Sehn, Diego Villa, Richard Klasa, Alina S. Gerrie, Tamara Shenkier, David W. Scott, Randy D. Gascoyne, Graham W. Slack, Joseph M. Connors, and Kerry J. Savage, British Columbia Cancer Agency Centre for Lymphoid Cancer; Yvonne Zheng, Cancer Surveillance and Outcomes, Population Oncology; Christina Parsons, James Morris, and Tom Pickles, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Laurie H. Sehn
- Greg Hapgood, Laurie H. Sehn, Diego Villa, Richard Klasa, Alina S. Gerrie, Tamara Shenkier, David W. Scott, Randy D. Gascoyne, Graham W. Slack, Joseph M. Connors, and Kerry J. Savage, British Columbia Cancer Agency Centre for Lymphoid Cancer; Yvonne Zheng, Cancer Surveillance and Outcomes, Population Oncology; Christina Parsons, James Morris, and Tom Pickles, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Diego Villa
- Greg Hapgood, Laurie H. Sehn, Diego Villa, Richard Klasa, Alina S. Gerrie, Tamara Shenkier, David W. Scott, Randy D. Gascoyne, Graham W. Slack, Joseph M. Connors, and Kerry J. Savage, British Columbia Cancer Agency Centre for Lymphoid Cancer; Yvonne Zheng, Cancer Surveillance and Outcomes, Population Oncology; Christina Parsons, James Morris, and Tom Pickles, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Richard Klasa
- Greg Hapgood, Laurie H. Sehn, Diego Villa, Richard Klasa, Alina S. Gerrie, Tamara Shenkier, David W. Scott, Randy D. Gascoyne, Graham W. Slack, Joseph M. Connors, and Kerry J. Savage, British Columbia Cancer Agency Centre for Lymphoid Cancer; Yvonne Zheng, Cancer Surveillance and Outcomes, Population Oncology; Christina Parsons, James Morris, and Tom Pickles, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Alina S. Gerrie
- Greg Hapgood, Laurie H. Sehn, Diego Villa, Richard Klasa, Alina S. Gerrie, Tamara Shenkier, David W. Scott, Randy D. Gascoyne, Graham W. Slack, Joseph M. Connors, and Kerry J. Savage, British Columbia Cancer Agency Centre for Lymphoid Cancer; Yvonne Zheng, Cancer Surveillance and Outcomes, Population Oncology; Christina Parsons, James Morris, and Tom Pickles, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Tamara Shenkier
- Greg Hapgood, Laurie H. Sehn, Diego Villa, Richard Klasa, Alina S. Gerrie, Tamara Shenkier, David W. Scott, Randy D. Gascoyne, Graham W. Slack, Joseph M. Connors, and Kerry J. Savage, British Columbia Cancer Agency Centre for Lymphoid Cancer; Yvonne Zheng, Cancer Surveillance and Outcomes, Population Oncology; Christina Parsons, James Morris, and Tom Pickles, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - David W. Scott
- Greg Hapgood, Laurie H. Sehn, Diego Villa, Richard Klasa, Alina S. Gerrie, Tamara Shenkier, David W. Scott, Randy D. Gascoyne, Graham W. Slack, Joseph M. Connors, and Kerry J. Savage, British Columbia Cancer Agency Centre for Lymphoid Cancer; Yvonne Zheng, Cancer Surveillance and Outcomes, Population Oncology; Christina Parsons, James Morris, and Tom Pickles, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Randy D. Gascoyne
- Greg Hapgood, Laurie H. Sehn, Diego Villa, Richard Klasa, Alina S. Gerrie, Tamara Shenkier, David W. Scott, Randy D. Gascoyne, Graham W. Slack, Joseph M. Connors, and Kerry J. Savage, British Columbia Cancer Agency Centre for Lymphoid Cancer; Yvonne Zheng, Cancer Surveillance and Outcomes, Population Oncology; Christina Parsons, James Morris, and Tom Pickles, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Graham W. Slack
- Greg Hapgood, Laurie H. Sehn, Diego Villa, Richard Klasa, Alina S. Gerrie, Tamara Shenkier, David W. Scott, Randy D. Gascoyne, Graham W. Slack, Joseph M. Connors, and Kerry J. Savage, British Columbia Cancer Agency Centre for Lymphoid Cancer; Yvonne Zheng, Cancer Surveillance and Outcomes, Population Oncology; Christina Parsons, James Morris, and Tom Pickles, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Christina Parsons
- Greg Hapgood, Laurie H. Sehn, Diego Villa, Richard Klasa, Alina S. Gerrie, Tamara Shenkier, David W. Scott, Randy D. Gascoyne, Graham W. Slack, Joseph M. Connors, and Kerry J. Savage, British Columbia Cancer Agency Centre for Lymphoid Cancer; Yvonne Zheng, Cancer Surveillance and Outcomes, Population Oncology; Christina Parsons, James Morris, and Tom Pickles, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - James Morris
- Greg Hapgood, Laurie H. Sehn, Diego Villa, Richard Klasa, Alina S. Gerrie, Tamara Shenkier, David W. Scott, Randy D. Gascoyne, Graham W. Slack, Joseph M. Connors, and Kerry J. Savage, British Columbia Cancer Agency Centre for Lymphoid Cancer; Yvonne Zheng, Cancer Surveillance and Outcomes, Population Oncology; Christina Parsons, James Morris, and Tom Pickles, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Tom Pickles
- Greg Hapgood, Laurie H. Sehn, Diego Villa, Richard Klasa, Alina S. Gerrie, Tamara Shenkier, David W. Scott, Randy D. Gascoyne, Graham W. Slack, Joseph M. Connors, and Kerry J. Savage, British Columbia Cancer Agency Centre for Lymphoid Cancer; Yvonne Zheng, Cancer Surveillance and Outcomes, Population Oncology; Christina Parsons, James Morris, and Tom Pickles, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Joseph M. Connors
- Greg Hapgood, Laurie H. Sehn, Diego Villa, Richard Klasa, Alina S. Gerrie, Tamara Shenkier, David W. Scott, Randy D. Gascoyne, Graham W. Slack, Joseph M. Connors, and Kerry J. Savage, British Columbia Cancer Agency Centre for Lymphoid Cancer; Yvonne Zheng, Cancer Surveillance and Outcomes, Population Oncology; Christina Parsons, James Morris, and Tom Pickles, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Kerry J. Savage
- Greg Hapgood, Laurie H. Sehn, Diego Villa, Richard Klasa, Alina S. Gerrie, Tamara Shenkier, David W. Scott, Randy D. Gascoyne, Graham W. Slack, Joseph M. Connors, and Kerry J. Savage, British Columbia Cancer Agency Centre for Lymphoid Cancer; Yvonne Zheng, Cancer Surveillance and Outcomes, Population Oncology; Christina Parsons, James Morris, and Tom Pickles, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
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Krebs L, Amorin S, Brice P, Guillerm S, Menard J, Hennequin C, Quéro L. Analyses of patterns-of-failure and prognostic factors according to radiation fields in early-stage Hodgkin lymphoma. Strahlenther Onkol 2016; 193:116-124. [PMID: 27316376 DOI: 10.1007/s00066-016-0969-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 03/09/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Doses and volumes of radiation therapy (RT) for early stages of Hodgkin lymphoma (HL) have been reduced over the last 30 years. Combined modality therapy (CMT) is currently the standard treatment for most patients with early-stage HL. The aim of this study was to analyze the site of relapse after RT according to the extent of radiation fields. PATIENTS AND METHODS Between 1987 and 2011, 427 patients were treated at our institution with RT ± chemotherapy for stage-I/II HL. Among these, 65 patients who experienced a relapse were retrospectively analyzed. Most patients had nodular sclerosis histology (86 %) and stage-II disease (75.9 %). Bulky disease was present in 21 % and 56 % of patients belonged to the unfavorable risk group according to European Organization for Research and Treatment of Cancer (EORTC)/The Lymphoma Study Association (LYSA) definitions. CMT was delivered to 91 % of patients. All patients received RT with doses ranging from 20 to 45 Gy (mean = 34 ± 5.3 Gy). The involved-field RT technique was used in 59 % of patients. RESULTS The mean time between diagnosis and relapse was 4.2 years (range 0.3-24.5). Out-of-field relapses were suffered by 53 % of patients. Relapses occurred more frequently at out-of-field sites in patients with a favorable disease status, whereas in-field relapses were associated with bulky mediastinal disease. Relapses occurred later for favorable compared with the unfavorable risk group (3.5 vs. 2.9 years, p = 0.5). From multivariate analyses, neither RT dose nor RT field size were predictive for an in-field relapse (p = 0.25 and p = 0.8, respectively), only bulky disease was predictive (p = 0.018). CONCLUSION In patients with bulky disease, RT dose and RT field size were not predictive for an in-field relapse. In this subgroup of patients, chemotherapy should be intensified. We confirmed the bad prognosis of early relapses.
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Affiliation(s)
- Lorraine Krebs
- Radiation Oncology Department, Saint Louis Hospital, 1, Avenue Claude Vellefaux, 75010, Paris, France
| | - Sandy Amorin
- Hematooncology Department, Saint Louis Hospital, AP-HP, Paris, France
| | - Pauline Brice
- Hematooncology Department, Saint Louis Hospital, AP-HP, Paris, France
| | - Sophie Guillerm
- Radiation Oncology Department, Saint Louis Hospital, 1, Avenue Claude Vellefaux, 75010, Paris, France
| | - Jean Menard
- Radiation Oncology Department, Saint Louis Hospital, 1, Avenue Claude Vellefaux, 75010, Paris, France
| | - Christophe Hennequin
- Radiation Oncology Department, Saint Louis Hospital, 1, Avenue Claude Vellefaux, 75010, Paris, France
| | - Laurent Quéro
- Radiation Oncology Department, Saint Louis Hospital, 1, Avenue Claude Vellefaux, 75010, Paris, France.
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25
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Abstract
Hodgkin's lymphoma (HL) is a relatively rare disease accounting for 15 % of all lymphoma. This disease has developed from an incurable disease to the adult malignancy with the most favorable prognosis. With current therapeutic approaches consisting of polychemo- and small-field radiotherapy, up to 80 % of all patients can be cured long term. In refractory or relapsed HL, intensified treatment including high-dose chemotherapy (HDCT) and autologous stem cell transplantation (ASCT) is associated with progression-free survival (PFS) of 50 %. Evaluation of novel drugs in multiple relapsed or refractory cases, better treatment options for elderly patients and reducing treatment-related side effects are the main focus of current research. Recent clinical developments and future approaches in the treatment of HL will be discussed in this review.
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Abstract
Nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL) is a rare subtype of Hodgkin lymphoma with distinct clinicopathologic features. It is typified by the presence of lymphocyte predominant (LP) cells, which are CD20(+) but CD15(-) and CD30(-) and are found scattered amongst small B lymphocytes arranged in a nodular pattern. Despite frequent and often late or multiple relapses, the prognosis of NLPHL is very favorable. There is an inherent risk of secondary aggressive non-Hodgkin lymphoma (NHL) and studies support that risk is highest in those with splenic involvement at presentation. Given disease rarity, the optimal management is unclear and opinions differ as to whether treatment paradigms should be similar to or differ from those for classical Hodgkin lymphoma (CHL). This review provides an overview of the existing literature describing pathological subtypes, outcome and treatment approaches for NLPHL.
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Affiliation(s)
- Kerry J Savage
- Department of Medical Oncology, Centre for Lymphoid Cancer, British Columbia Cancer Agency, Vancouver, BC, Canada.
| | - Anja Mottok
- Centre for Lymphoid Cancer, British Columbia Cancer Agency, Vancouver, BC, Canada
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Gunther JR, Fanale MA, Reddy JP, Akhtari M, Smith GL, Pinnix CC, Milgrom SA, Yehia ZA, Allen PK, Osborne EM, Mawlawi O, Dabaja BS. Treatment of Early-Stage Unfavorable Hodgkin Lymphoma: Efficacy and Toxicity of 4 Versus 6 Cycles of ABVD Chemotherapy With Radiation. Int J Radiat Oncol Biol Phys 2016; 96:110-8. [PMID: 27325479 DOI: 10.1016/j.ijrobp.2016.03.052] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 03/28/2016] [Accepted: 03/30/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE The German Hodgkin Study Group HD11 trial validated 4 cycles of doxorubicin, bleomycin, vinblastine, dacarbazine (ABVD) chemotherapy followed by involved field radiation therapy (IFRT) for early unfavorable Hodgkin lymphoma (HL) patients. However, practitioners often recommend 6 cycles followed by RT, especially for bulky disease. We compared patient outcomes after treatment with 4 or 6 cycles of ABVD followed by RT (IFRT and involved site RT [ISRT]). METHODS AND MATERIALS We identified 128 patients treated for early unfavorable HL (GHSG criteria) between 2000 and 2013. Clinical outcomes (overall survival [OS] and freedom from relapse [FFR]) were estimated using Kaplan-Meier analysis. Toxicities were evaluated. RESULTS The median follow-up time was 5.0 years. Patients received 4 (70 patients, 55%) or 6 (58 patients, 45%) cycles of chemotherapy. Bulky disease was present in 22 patients (31%; 0 stage IA, 3 stage IB, 19 stage IIA) of the 4-cycle group and 42 patients (72%; 5 stage IA, 3 stage IB, 34 stage IIA) of the 6-cycle group. For patients receiving 4 and 6 cycles, the 6-year OS was 100% and 97% (P=.35), respectively, and the 6 year FFR was 100% and 98% (P=.28), respectively. More patients received 6 cycles if they were treated before 2010 (HD11 report) (P=.01) and if they had bulky disease (P<.01). Sixty-eight percent of patients received ISRT. The 6-year FFR was 99% and 100% for patients receiving ISRT and IFRT, respectively (P=.58). More patients experienced bleomycin pulmonary toxicity in the 6-cycle group (20% vs 31%, P=.16). For patients with bulky disease, the 4-year FFR was similar with receipt of 4 (100%) or 6 (98%) cycles (P=.48) and IFRT (100%) or ISRT (98%) (P=.52). There were no deaths among patients with bulky disease. CONCLUSIONS Patients with early unfavorable HL have excellent outcomes with 4 cycles of ABVD chemotherapy followed by ISRT. Six cycles of chemotherapy does not appear superior for disease control, even for bulky disease.
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Affiliation(s)
- Jillian R Gunther
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michelle A Fanale
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jay P Reddy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mani Akhtari
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Radiation Oncology, The University of Texas Medical Branch at Galveston, Galveston, Texas
| | - Grace L Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Chelsea C Pinnix
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sarah A Milgrom
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Zeinab Abou Yehia
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Pamela K Allen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eleanor M Osborne
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Osama Mawlawi
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bouthaina S Dabaja
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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Gujral DM, Lloyd G, Bhattacharyya S. Radiation-induced valvular heart disease. Heart 2015; 102:269-76. [PMID: 26661320 DOI: 10.1136/heartjnl-2015-308765] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 11/03/2015] [Indexed: 12/15/2022] Open
Abstract
Radiation to the mediastinum is a key component of treatment with curative intent for a range of cancers including Hodgkin's lymphoma and breast cancer. Exposure to radiation is associated with a risk of radiation-induced heart valve damage characterised by valve fibrosis and calcification. There is a latent interval of 10-20 years between radiation exposure and development of clinically significant heart valve disease. Risk is related to radiation dose received, interval from exposure and use of concomitant chemotherapy. Long-term outlook and the risk of valve surgery are related to the effects of radiation on mediastinal structures including pulmonary fibrosis and pericardial constriction. Dose prediction models to predict the risk of heart valve disease in the future and newer radiation techniques to reduce the radiation dose to the heart are being developed. Surveillance strategies for this cohort of cancer survivors at risk of developing significant heart valve complications are required.
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Affiliation(s)
- Dorothy M Gujral
- Department of Clinical Oncology, Imperial College Healthcare NHS Trust, London, UK
| | - Guy Lloyd
- Echocardiography Laboratory, Bart's Heart Centre, St Bartholomew's Hospital, London, UK Valvular Heart Disease Clinic, Bart's Heart Centre, St Bartholomew's Hospital, London, UK
| | - Sanjeev Bhattacharyya
- Echocardiography Laboratory, Bart's Heart Centre, St Bartholomew's Hospital, London, UK Valvular Heart Disease Clinic, Bart's Heart Centre, St Bartholomew's Hospital, London, UK
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Portlock CS. Involved site radiation therapy for the treatment of early-stage Hodgkin lymphoma in adolescents and young adults. CLINICAL ONCOLOGY IN ADOLESCENTS AND YOUNG ADULTS 2015; 5:97-102. [PMID: 26767184 PMCID: PMC4708267 DOI: 10.2147/coaya.s70370] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Radiation therapy technology has permitted the development of new treatment planning techniques. Involved field, involved node, and involved site radiotherapy fields are discussed and compared. Indications for and implications of combined modality therapy are examined, particularly as pertinent to the adolescent and young adult population.
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Affiliation(s)
- Carol S Portlock
- Division of Hematologic Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
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30
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The concept and evolution of involved site radiation therapy for lymphoma. Int J Clin Oncol 2015; 20:849-54. [DOI: 10.1007/s10147-015-0863-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 06/14/2015] [Indexed: 01/22/2023]
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31
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Involved Node, Site, Field and Residual Volume Radiotherapy for Lymphoma: A Comparison of Organ at Risk Dosimetry and Second Malignancy Risks. Clin Oncol (R Coll Radiol) 2015; 27:401-10. [DOI: 10.1016/j.clon.2015.03.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 02/04/2015] [Accepted: 03/12/2015] [Indexed: 12/25/2022]
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32
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Filippi AR, Ragona R, Piva C, Scafa D, Fiandra C, Fusella M, Giglioli FR, Lohr F, Ricardi U. Optimized volumetric modulated arc therapy versus 3D-CRT for early stage mediastinal Hodgkin lymphoma without axillary involvement: a comparison of second cancers and heart disease risk. Int J Radiat Oncol Biol Phys 2015; 92:161-8. [PMID: 25863763 DOI: 10.1016/j.ijrobp.2015.02.030] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 02/08/2015] [Accepted: 02/17/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the risks of second cancers and cardiovascular diseases associated with an optimized volumetric modulated arc therapy (VMAT) planning solution in a selected cohort of stage I/II Hodgkin lymphoma (HL) patients treated with either involved-node or involved-site radiation therapy in comparison with 3-dimensional conformal radiation therapy (3D-CRT). METHODS AND MATERIALS Thirty-eight patients (13 males and 25 females) were included. Disease extent was mediastinum alone (n=8, 21.1%); mediastinum plus unilateral neck (n=19, 50%); mediastinum plus bilateral neck (n=11, 29.9%). Prescription dose was 30 Gy in 2-Gy fractions. Only 5 patients had mediastinal bulky disease at diagnosis (13.1%). Anteroposterior 3D-CRT was compared with a multiarc optimized VMAT solution. Lung, breast, and thyroid cancer risks were estimated by calculating a lifetime attributable risk (LAR), with a LAR ratio (LAR(VMAT)-to-LAR(3D-CRT)) as a comparative measure. Cardiac toxicity risks were estimated by calculating absolute excess risk (AER). RESULTS The LAR ratio favored 3D-CRT for lung cancer induction risk in mediastinal alone (P=.004) and mediastinal plus unilateral neck (P=.02) presentations. LAR ratio for breast cancer was lower for VMAT in mediastinal plus bilateral neck presentations (P=.02), without differences for other sites. For thyroid cancer, no significant differences were observed, regardless of anatomical presentation. A significantly lower AER of cardiac (P=.038) and valvular diseases (P<.0001) was observed for VMAT regardless of disease extent. CONCLUSIONS In a cohort of patients with favorable characteristics in terms of disease extent at diagnosis (large prevalence of nonbulky presentations without axillary involvement), optimized VMAT reduced heart disease risk with comparable risks of thyroid and breast cancer, with an increase in lung cancer induction probability. The results are however strongly influenced by the different anatomical presentations, supporting an individualized approach.
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Affiliation(s)
| | - Riccardo Ragona
- Department of Oncology, Radiation Oncology, University of Torino, Torino, Italy
| | - Cristina Piva
- Department of Oncology, Radiation Oncology, University of Torino, Torino, Italy
| | - Davide Scafa
- Department of Oncology, Radiation Oncology, University of Torino, Torino, Italy
| | - Christian Fiandra
- Department of Oncology, Radiation Oncology, University of Torino, Torino, Italy
| | - Marco Fusella
- Medical Physics, AOU Città della Salute e della Scienza Hospital, Torino, Italy
| | | | - Frank Lohr
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Umberto Ricardi
- Department of Oncology, Radiation Oncology, University of Torino, Torino, Italy
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33
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Affiliation(s)
- Joseph M Connors
- British Columbia Cancer Agency Centre for Lymphoid Cancer, The University of British Columbia, Vancouver, BC, Canada
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34
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Maraldo MV, Dabaja BS, Filippi AR, Illidge T, Tsang R, Ricardi U, Petersen PM, Schut DA, Garcia J, Headley J, Parent A, Guibord B, Ragona R, Specht L. Radiation therapy planning for early-stage Hodgkin lymphoma: experience of the International Lymphoma Radiation Oncology Group. Int J Radiat Oncol Biol Phys 2015; 92:144-52. [PMID: 25670544 DOI: 10.1016/j.ijrobp.2014.12.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 11/26/2014] [Accepted: 12/04/2014] [Indexed: 12/25/2022]
Abstract
PURPOSE Early-stage Hodgkin lymphoma (HL) is a rare disease, and the location of lymphoma varies considerably between patients. Here, we evaluate the variability of radiation therapy (RT) plans among 5 International Lymphoma Radiation Oncology Group (ILROG) centers with regard to beam arrangements, planning parameters, and estimated doses to the critical organs at risk (OARs). METHODS Ten patients with stage I-II classic HL with masses of different sizes and locations were selected. On the basis of the clinical information, 5 ILROG centers were asked to create RT plans to a prescribed dose of 30.6 Gy. A postchemotherapy computed tomography scan with precontoured clinical target volume (CTV) and OARs was provided for each patient. The treatment technique and planning methods were chosen according to each center's best practice in 2013. RESULTS Seven patients had mediastinal disease, 2 had axillary disease, and 1 had disease in the neck only. The median age at diagnosis was 34 years (range, 21-74 years), and 5 patients were male. Of the resulting 50 treatment plans, 15 were planned with volumetric modulated arc therapy (1-4 arcs), 16 with intensity modulated RT (3-9 fields), and 19 with 3-dimensional conformal RT (2-4 fields). The variations in CTV-to-planning target volume margins (5-15 mm), maximum tolerated dose (31.4-40 Gy), and plan conformity (conformity index 0-3.6) were significant. However, estimated doses to OARs were comparable between centers for each patient. CONCLUSIONS RT planning for HL is challenging because of the heterogeneity in size and location of disease and, additionally, to the variation in choice of treatment techniques and field arrangements. Adopting ILROG guidelines and implementing universal dose objectives could further standardize treatment techniques and contribute to lowering the dose to the surrounding OARs.
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Affiliation(s)
- Maja V Maraldo
- Departments of Clinical Oncology and Hematology, Rigshospitalet, University of Copenhagen, Denmark.
| | | | - Andrea R Filippi
- Department of Oncology, University of Torino School of Medicine, Torino, Italy
| | - Tim Illidge
- Department of Oncology, Christie Hospital, Manchester, United Kingdom
| | - Richard Tsang
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Umberto Ricardi
- Department of Oncology, University of Torino School of Medicine, Torino, Italy
| | - Peter M Petersen
- Departments of Clinical Oncology and Hematology, Rigshospitalet, University of Copenhagen, Denmark
| | - Deborah A Schut
- Departments of Clinical Oncology and Hematology, Rigshospitalet, University of Copenhagen, Denmark
| | - John Garcia
- Department of Radiation Oncology, MD Anderson Cancer Center, Texas
| | - Jayne Headley
- Department of Oncology, Christie Hospital, Manchester, United Kingdom
| | - Amy Parent
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Benoit Guibord
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Riccardo Ragona
- Department of Oncology, University of Torino School of Medicine, Torino, Italy
| | - Lena Specht
- Departments of Clinical Oncology and Hematology, Rigshospitalet, University of Copenhagen, Denmark
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The role of radiotherapy in Hodgkin's lymphoma: what has been achieved during the last 50 years? BIOMED RESEARCH INTERNATIONAL 2015; 2015:485071. [PMID: 25705661 PMCID: PMC4331316 DOI: 10.1155/2015/485071] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 10/18/2014] [Indexed: 12/23/2022]
Abstract
Currently, Hodgkin's lymphoma (HL) has an excellent clinical outcome, with overall survival of approximately 90% in early stages of the disease. Based on young age of the majority of patients at the time of diagnosis and their long survival time, increased attention has been focused on long-term toxicity of therapy. While novel, directly targeting antitumor agents, with an excellent safety profile, have been developed for HL treatment, the role of radiotherapy is still debated. Radiotherapy may induce cardiovascular disease and impairment of thyroid or pulmonary function and, most importantly, may lead to development of secondary cancers. As a consequence, the current radiation therapy planning paradigm is mainly focused on a reduction of field size. As it was investigated in clinical trials regional therapy is as effective as extended field radiotherapy, but less toxic. Although chemotherapy is the mainstay of HL treatment, consolidative involved field radiation therapy is still considered to be the standard of care in both early and advanced stages. Recently, further field reduction has been investigated to further decrease the late radiation-induced toxicity. In this paper we describe the role and safety profile of radiotherapy in the past and present and hope for the novel techniques in the future.
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Maraldo MV, Specht L. A Decade of Comparative Dose Planning Studies for Early-Stage Hodgkin Lymphoma: What Can We Learn? Int J Radiat Oncol Biol Phys 2014; 90:1126-35. [DOI: 10.1016/j.ijrobp.2014.06.069] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 06/13/2014] [Accepted: 06/26/2014] [Indexed: 01/20/2023]
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Pieters RS, Wagner H, Baker S, Morano K, Ulin K, Cicchetti MG, Bishop-Jodoin M, FitzGerald TJ. The impact of protocol assignment for older adolescents with hodgkin lymphoma. Front Oncol 2014; 4:317. [PMID: 25506581 PMCID: PMC4246660 DOI: 10.3389/fonc.2014.00317] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 10/24/2014] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND PURPOSE Hodgkin lymphoma (HL) treatment has evolved to reduce or avoid radiotherapy (RT) dose and volume and minimize the potential for late effects. Some older adolescents are treated on adult protocols. The purpose of this study is to examine the protocol assignment of older adolescents and its impact on radiation dose to relevant thoracic structures. MATERIALS AND METHODS Cooperative group data were reviewed and 12 adolescents were randomly selected from a pediatric HL protocol. Treatment plans were generated per one pediatric and two adult protocols. Dose volume histograms for heart, lung, and breast allowed comparison of radiation dose to these sites across these three protocols. RESULTS A total of 15.2% of adolescents were treated on adult HL protocols and received significantly higher radiation dosage to heart and lung compared to pediatric HL protocols. Adolescents treated on either pediatric or adult protocols received similar RT dose to breast. CONCLUSION Older adolescents treated on adult HL protocols received higher RT dose to thoracic structures except breast. Level of nodal involvement may impact overall RT dose to breast. The impact of varying field design and RT dose on survival, local, and late effects needs further study for this vulnerable age group. Adolescents, young adults, Hodgkin lymphoma, RT, clinical trials.
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Affiliation(s)
- Richard S Pieters
- Department of Radiation Oncology, University of Massachusetts Medical School, University of Massachusetts Memorial Health Care System , Worcester, MA , USA
| | - Henry Wagner
- Division of Radiation Oncology, Milton S. Hershey Medical Center, Pennsylvania State University , Hershey, PA , USA
| | - Stephen Baker
- Department of Quantitative Health Sciences and Cell Biology, University of Massachusetts Medical School , Worcester, MA , USA
| | - Karen Morano
- Department of Radiation Oncology, Quality Assurance Review Center, University of Massachusetts Medical School , Lincoln, RI , USA
| | - Kenneth Ulin
- Department of Radiation Oncology, University of Massachusetts Medical School, University of Massachusetts Memorial Health Care System , Worcester, MA , USA ; Department of Radiation Oncology, Quality Assurance Review Center, University of Massachusetts Medical School , Lincoln, RI , USA
| | - Maria Giulia Cicchetti
- Department of Radiation Oncology, University of Massachusetts Medical School, University of Massachusetts Memorial Health Care System , Worcester, MA , USA ; Department of Radiation Oncology, Quality Assurance Review Center, University of Massachusetts Medical School , Lincoln, RI , USA
| | - Maryann Bishop-Jodoin
- Department of Radiation Oncology, Quality Assurance Review Center, University of Massachusetts Medical School , Lincoln, RI , USA
| | - Thomas J FitzGerald
- Department of Radiation Oncology, University of Massachusetts Medical School, University of Massachusetts Memorial Health Care System , Worcester, MA , USA ; Department of Radiation Oncology, Quality Assurance Review Center, University of Massachusetts Medical School , Lincoln, RI , USA
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Lohr F, Georg D, Cozzi L, Eich HT, Weber DC, Koeck J, Knäusl B, Dieckmann K, Abo-Madyan Y, Fiandra C, Mueller RP, Engert A, Ricardi U. Novel radiotherapy techniques for involved-field and involved-node treatment of mediastinal Hodgkin lymphoma: when should they be considered and which questions remain open? Strahlenther Onkol 2014; 190:864-6, 868-71. [PMID: 25209551 DOI: 10.1007/s00066-014-0719-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 07/01/2014] [Indexed: 01/10/2023]
Abstract
PURPOSE Hodgkin lymphoma (HL) is a highly curable disease. Reducing late complications and second malignancies has become increasingly important. Radiotherapy target paradigms are currently changing and radiotherapy techniques are evolving rapidly. DESIGN This overview reports to what extent target volume reduction in involved-node (IN) and advanced radiotherapy techniques, such as intensity-modulated radiotherapy (IMRT) and proton therapy-compared with involved-field (IF) and 3D radiotherapy (3D-RT)- can reduce high doses to organs at risk (OAR) and examines the issues that still remain open. RESULTS Although no comparison of all available techniques on identical patient datasets exists, clear patterns emerge. Advanced dose-calculation algorithms (e.g., convolution-superposition/Monte Carlo) should be used in mediastinal HL. INRT consistently reduces treated volumes when compared with IFRT with the exact amount depending on the INRT definition. The number of patients that might significantly benefit from highly conformal techniques such as IMRT over 3D-RT regarding high-dose exposure to organs at risk (OAR) is smaller with INRT. The impact of larger volumes treated with low doses in advanced techniques is unclear. The type of IMRT used (static/rotational) is of minor importance. All advanced photon techniques result in similar potential benefits and disadvantages, therefore only the degree-of-modulation should be chosen based on individual treatment goals. Treatment in deep inspiration breath hold is being evaluated. Protons theoretically provide both excellent high-dose conformality and reduced integral dose. CONCLUSION Further reduction of treated volumes most effectively reduces OAR dose, most likely without disadvantages if the excellent control rates achieved currently are maintained. For both IFRT and INRT, the benefits of advanced radiotherapy techniques depend on the individual patient/target geometry. Their use should therefore be decided case by case with comparative treatment planning.
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Affiliation(s)
- Frank Lohr
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany,
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Chiaravalloti A, Danieli R, Caracciolo CR, Travascio L, Cantonetti M, Gallamini A, Guazzaroni M, Orlacchio A, Simonetti G, Schillaci O. Initial staging of Hodgkin's disease: role of contrast-enhanced 18F FDG PET/CT. Medicine (Baltimore) 2014; 93:e50. [PMID: 25121354 PMCID: PMC4602442 DOI: 10.1097/md.0000000000000050] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The objective of this study was to compare the diagnostic accuracy of positron emission tomography/low-dose computed tomography (PET/ldCT) versus the same technique implemented by contrast-enhanced computed tomography (ceCT) in staging Hodgkin's disease (HD).Forty patients (18 men and 22 women, mean age 30 ± 9.6) with biopsy-proven HD underwent a PET/ldCT study for initial staging including an unenhanced low-dose computed tomography for attenuation correction with positron emission tomography acquisition and a ceCT, performed at the end of the PET/ldCT scan, in the same exam session. A detailed datasheet was generated for illness locations for separate imaging modality comparison and then merged in order to compare the separate imaging method results (PET/ldCT and ceCT) versus merged results positron emission tomography/contrast-enhanced computed tomography (PET/ceCT). The nodal and extranodal lesions detected by each technique were then compared with follow-up data that served as the reference standard.No significant differences were found at staging between PET/ldCT and PET/ceCT in our series. One hundred and eighty four stations of nodal involvement have been found with no differences in both modalities. Extranodal involvement was identified in 26 sites by PET/ldCT and in 28 by PET/ceCT. We did not find significant differences concerning the stage (Ann Arbor).Our study shows a good concordance and conjunction between PET/ldCT and ceCT in both nodal and extranodal sites in the initial staging of HD, suggesting that PET/ldCT could suffice in most of these patients.
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Affiliation(s)
- Agostino Chiaravalloti
- Department of Biomedicine and Prevention, University Tor Vergata, Rome (AC, RD, CRC, LT, MC, MG, AO, GS, OS); Azienda Ospedaliera S. Coce e Carle, Hematology, Cuneo (AG); and IRCCS Neuromed, Pozzilli (OS), Italy
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Role of FDG-PET in the Implementation of Involved-Node Radiation Therapy for Hodgkin Lymphoma Patients. Int J Radiat Oncol Biol Phys 2014; 89:1047-1052. [DOI: 10.1016/j.ijrobp.2014.04.026] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 04/10/2014] [Accepted: 04/15/2014] [Indexed: 11/17/2022]
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Mulvihill DJ, McMichael K, Goyal S, Drachtman R, Weiss A, Khan AJ. Involved-nodal radiation therapy leads to lower doses to critical organs-at-risk compared to involved-field radiation therapy. Radiother Oncol 2014; 112:279-83. [PMID: 25082095 DOI: 10.1016/j.radonc.2014.06.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 06/25/2014] [Accepted: 06/30/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND Involved field radiotherapy (IFRT) after cytotoxic chemotherapy has become the standard of care in treating pediatric patients with Hodgkin lymphoma. However, recent interest in shrinking the treatment volume to involved node radiotherapy (INRT) may allow lower doses to critical organ structures. We dosimetrically compared IFRT and INRT treatment approaches. METHODS INRT treatment plans were retrospectively constructed from 17 consecutively treated pediatric patients identified with Hodgkin lymphoma who had been previously treated with conventional IFRT. The radiation doses delivered to organs-at-risk (OARs) with virtual INRT treatment plans based on INRT field design were then compared to the original IFRT treatment plans. Metrics for comparison included mean doses to organs and volumes of organ receiving at least 50% of the original prescription dose (V50%). A one-tailed, paired t-test was then performed to verify statistical significance at an alpha level of 0.05. RESULTS All organs at risk compared in this investigation (kidneys, heart, thyroid, parotids, and lungs) had significantly lower doses of radiation with INRT when compared to IFRT (p<0.05). Furthermore, the volume of the breast receiving at least 50% of the initial prescription dose was statistically lower in the INRT plans. CONCLUSIONS Utilizing the concept of INRT results in a reduction of radiation dose to critical organ structures in pediatric patients with Hodgkin lymphoma when compared to the more traditional method of IFRT.
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Affiliation(s)
- David J Mulvihill
- Dept of Radiation Oncology, Rutgers Cancer Institute of NJ, New Brunswick, United States
| | - Kevin McMichael
- Dept of Radiation Oncology, Rutgers Cancer Institute of NJ, New Brunswick, United States
| | - Sharad Goyal
- Dept of Radiation Oncology, Rutgers Cancer Institute of NJ, New Brunswick, United States
| | - Richard Drachtman
- Dept of Pediatric Oncology, Rutgers Cancer Institute of NJ, New Brunswick, United States
| | - Aaron Weiss
- Dept of Pediatric Oncology, Rutgers Cancer Institute of NJ, New Brunswick, United States
| | - Atif J Khan
- Dept of Radiation Oncology, Rutgers Cancer Institute of NJ, New Brunswick, United States.
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Hay AE, Meyer RM. Balancing risks and benefits of therapy for patients with favorable-risk limited-stage Hodgkin lymphoma: the role of doxorubicin, bleomycin, vinblastine, and dacarbazine chemotherapy alone. Hematol Oncol Clin North Am 2014; 28:49-63. [PMID: 24287067 DOI: 10.1016/j.hoc.2013.10.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Because long-term survival of patients with nonbulky stage IA to IIA Hodgkin lymphoma is dependent on disease control and avoidance of late toxic effects associated with the treatment received, the initial choice of treatment can be associated with trade-offs that balance optimum disease control with avoidance of these late effect risks. Health professionals and patients face the dilemma of making treatment decisions without the benefit of completely understanding the risk-benefit balances associated with how current treatments affect all outcomes of interest. Optimum management of these patients requires careful multidisciplinary evaluation and communication strategies that account for patient preferences.
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Affiliation(s)
- Annette E Hay
- NCIC Clinical Trials Group, Queen's University, 10 Stuart Street, Kingston, Ontario K7L 3N6, Canada
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Terezakis SA, Metzger ML, Hodgson DC, Schwartz CL, Advani R, Flowers CR, Hoppe BS, Ng A, Roberts KB, Shapiro R, Wilder RB, Yunes MJ, Constine LS. ACR Appropriateness Criteria Pediatric Hodgkin Lymphoma. Pediatr Blood Cancer 2014; 61:1305-12. [PMID: 24616347 DOI: 10.1002/pbc.24983] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 12/26/2013] [Indexed: 11/06/2022]
Abstract
Pediatric Hodgkin lymphoma is a highly curable malignancy and potential long-term effects of therapy need to be considered in optimizing clinical care. An expert panel was convened to reach consensus on the most appropriate approach to evaluation and treatment of pediatric Hodgkin lymphoma. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. Four clinical variants were developed to assess common clinical scenarios and render recommendations for evaluation and treatment approaches to pediatric Hodgkin lymphoma. We provide a summary of the literature as well as numerical ratings with commentary. By combining available data in published literature and expert medical opinion, we present a consensus to the approach for management of pediatric Hodgkin lymphoma.
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Affiliation(s)
- Stephanie A Terezakis
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Hospital, Baltimore, Maryland
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The Evolving Role of Radiotherapy in Early Stage Hodgkin's Lymphoma. Mediterr J Hematol Infect Dis 2014; 6:e2014035. [PMID: 24959332 PMCID: PMC4063609 DOI: 10.4084/mjhid.2014.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Accepted: 04/27/2014] [Indexed: 11/26/2022] Open
Abstract
Radiation therapy has a key role in the combined modality treatment of early-stage Hodgkin’s Lymphoma (HL). Nevertheless, late toxicity still remains an issue. A modern approach in HL radiotherapy includes lower doses and smaller fields, together with the implementation of sophisticated and dedicated delivery techniques. Aim of the present review is to discuss the current role of radiotherapy and its potential future developments, with a focus on major clinical trials, technological advances and their repercussion in the clinical management of HL patients.
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Chemotherapy only in early stage Hodgkin lymphoma: more relapses but the same survival--what to do? Curr Hematol Malig Rep 2014; 9:217-21. [PMID: 24838494 DOI: 10.1007/s11899-014-0214-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Limited-stage Hodgkin lymphoma can almost always be cured with combined-modality chemotherapy plus involved-field or involved-nodal radiation, at the cost of exposing all patients--many unnecessarily--to radiation. Large prospective randomized clinical trials, including a total of over 1,200 patients, indicate that at least 95% of patients with limited-extent Hodgkin lymphoma are cured. The data also demonstrate that more than 80% of patients treated with two to three cycles of ABVD chemotherapy reach a positron emission tomography (PET)-negative state. Such patients need only one to two additional cycles of ABVD to reach an anticipated 95% cure rate. The remaining 20% of patients, with a positive PET, should be given radiation to reach the same 95% cure rate. The above approach leads to the same overall cure rate as one comprising combined chemotherapy and radiation, but avoids radiation for 80% of patients. Treatment outcome for limited-stage Hodgkin lymphoma is best optimized--considering cost, inconvenience, toxicity, and efficacy--using interim PET assessment to minimize exposure to radiation.
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Filippi AR, Ciammella P, Piva C, Ragona R, Botto B, Gavarotti P, Merli F, Vitolo U, Iotti C, Ricardi U. Involved-site image-guided intensity modulated versus 3D conformal radiation therapy in early stage supradiaphragmatic Hodgkin lymphoma. Int J Radiat Oncol Biol Phys 2014; 89:370-5. [PMID: 24613810 DOI: 10.1016/j.ijrobp.2014.01.041] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 12/16/2013] [Accepted: 01/25/2014] [Indexed: 11/16/2022]
Abstract
PURPOSE Image-guided intensity modulated radiation therapy (IG-IMRT) allows for margin reduction and highly conformal dose distribution, with consistent advantages in sparing of normal tissues. The purpose of this retrospective study was to compare involved-site IG-IMRT with involved-site 3D conformal RT (3D-CRT) in the treatment of early stage Hodgkin lymphoma (HL) involving the mediastinum, with efficacy and toxicity as primary clinical endpoints. METHODS AND MATERIALS We analyzed 90 stage IIA HL patients treated with either involved-site 3D-CRT or IG-IMRT between 2005 and 2012 in 2 different institutions. Inclusion criteria were favorable or unfavorable disease (according to European Organization for Research and Treatment of Cancer criteria), complete response after 3 to 4 cycles of an adriamycin- bleomycin-vinblastine-dacarbazine (ABVD) regimen plus 30 Gy as total radiation dose. Exclusion criteria were chemotherapy other than ABVD, partial response after ABVD, total radiation dose other than 30 Gy. Clinical endpoints were relapse-free survival (RFS) and acute toxicity. RESULTS Forty-nine patients were treated with 3D-CRT (54.4%) and 41 with IG-IMRT (45.6%). Median follow-up time was 54.2 months for 3D-CRT and 24.1 months for IG-IMRT. No differences in RFS were observed between the 2 groups, with 1 relapse each. Three-year RFS was 98.7% for 3D-CRT and 100% for IG-IMRT. Grade 2 toxicity events, mainly mucositis, were recorded in 32.7% of 3D-CRT patients (16 of 49) and in 9.8% of IG-IMRT patients (4 of 41). IG-IMRT was significantly associated with a lower incidence of grade 2 acute toxicity (P=.043). CONCLUSIONS RFS rates at 3 years were extremely high in both groups, albeit the median follow-up time is different. Acute tolerance profiles were better for IG-IMRT than for 3D-CRT. Our preliminary results support the clinical safety and efficacy of advanced RT planning and delivery techniques in patients affected with early stage HL, achieving complete response after ABVD-based chemotherapy.
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Affiliation(s)
| | - Patrizia Ciammella
- Radiation Therapy Unit, Department of Oncology and Advanced Technology, ASMN Hospital IRCCS, Reggio Emilia, Italy
| | - Cristina Piva
- Department of Oncology, University of Torino, Torino, Italy
| | | | - Barbara Botto
- Hematology, Città della Salute e della Scienza, Torino, Italy
| | - Paolo Gavarotti
- Hematology, University of Torino and Città della Salute e della Scienza, Torino, Italy
| | | | - Umberto Vitolo
- Hematology, Città della Salute e della Scienza, Torino, Italy
| | - Cinzia Iotti
- Radiation Therapy Unit, Department of Oncology and Advanced Technology, ASMN Hospital IRCCS, Reggio Emilia, Italy
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Abstract
Abstract
Although radiotherapy is highly effective for the treatment of Hodgkin lymphoma, the realization of its potential long-term toxicity and the demonstration of excellent results from combination chemotherapy have led to a retreat from its use in early-stage disease. Recent trials using functional imaging may allow better identification of those patients for whom radiotherapy may be safely omitted without compromising cure rates and this review examines the evidence for this.
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Abstract
Hematology Oncology has a rich history including few crucial therapeutic innovations. These were possible because of the evolution of the cell and molecular biology allowing a better understanding of basic mechanisms of cancerogenesis. We propose here to summarize the most important therapeutic innovations since the beginning of Hematology/Oncology history. We also describe evolution of therapeutic strategies themselves. New insights and therapeutic perspectives for next future are also discussed.
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Prabhu RS, Kandula S, Crocker I. In Reply to Marks. Int J Radiat Oncol Biol Phys 2013; 86:808-9. [DOI: 10.1016/j.ijrobp.2013.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 03/15/2013] [Indexed: 11/16/2022]
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The Role of Radiation Therapy in the Treatment of Stage I-II Diffuse Large B-Cell Lymphoma. Curr Hematol Malig Rep 2013; 8:236-42. [DOI: 10.1007/s11899-013-0170-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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