1
|
Camarda AM, Vincini MG, Russo S, Comi S, Emiro F, Bazani A, Ingargiola R, Vischioni B, Vecchi C, Volpe S, Orecchia R, Jereczek-Fossa BA, Orlandi E, Alterio D. Dosimetric and NTCP analyses for selecting parotid gland cancer patients for proton therapy. TUMORI JOURNAL 2024; 110:273-283. [PMID: 38769916 PMCID: PMC11295422 DOI: 10.1177/03008916241252544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 03/25/2024] [Accepted: 04/17/2024] [Indexed: 05/22/2024]
Abstract
PURPOSE/OBJECTIVE To perform a dosimetric and a normal tissue complication probability (NTCP) comparison between intensity modulated proton therapy and photon volumetric modulated arc therapy in a cohort of patients with parotid gland cancers in a post-operative or radical setting. MATERIALS AND METHODS From May 2011 to September 2021, 37 parotid gland cancers patients treated at two institutions were eligible. Inclusion criteria were as follows: patients aged ⩾ 18 years, diagnosis of parotid gland cancers candidate for postoperative radiotherapy or definitive radiotherapy, presence of written informed consent for the use of anonymous data for research purposes. Organs at risk (OARs) were retrospectively contoured. Target coverage goal was defined as D95 > 98%. Six NTCP models were selected. NTCP profiles were calculated for each patient using an internally-developed Python script in RayStation TPS. Average differences in NTCP between photon and proton plans were tested for significance with a two-sided Wilcoxon signed-rank test. RESULTS Seventy-four plans were generated. A lower Dmean to the majority of organs at risk (inner ear, cochlea, oral cavity, pharyngeal constrictor muscles, contralateral parotid and submandibular gland) was obtained with intensity modulated proton therapy vs volumetric modulated arc therapy with statistical significance (p < .05). Ten (27%) patients had a difference in NTCP (photon vs proton plans) greater than 10% for hearing loss and tinnitus: among them, seven qualified for both endpoints, two patients for hearing loss only, and one for tinnitus. CONCLUSIONS In the current study, nearly one-third of patients resulted eligible for proton therapy and they were the most likely to benefit in terms of prevention of hearing loss and tinnitus.
Collapse
Affiliation(s)
- Anna Maria Camarda
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy, Pavia, Italy
- Division of Radiation Oncology, IEO European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Maria Giulia Vincini
- Division of Radiation Oncology, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Stefania Russo
- Medical Physics Unit, Clinical Department, National Center for Oncological Hadrontherapy, Pavia, Italy
| | - Stefania Comi
- Unit of Medical Physics, European Institute of Oncology IRCCS, Milan, Italy
| | - Francesca Emiro
- Unit of Medical Physics, European Institute of Oncology IRCCS, Milan, Italy
| | - Alessia Bazani
- Medical Physics Unit, Clinical Department, National Center for Oncological Hadrontherapy, Pavia, Italy
| | - Rossana Ingargiola
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy, Pavia, Italy
| | - Barbara Vischioni
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy, Pavia, Italy
| | | | - Stefania Volpe
- Division of Radiation Oncology, IEO European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Roberto Orecchia
- Scientific Directorate, European Institute of Oncology IRCCS, Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiation Oncology, IEO European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Ester Orlandi
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy, Pavia, Italy
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences,University of Pavia, Italy
| | - Daniela Alterio
- Division of Radiation Oncology, IEO European Institute of Oncology IRCCS, Milan, Italy
| |
Collapse
|
2
|
Hoeltgen L, Meixner E, Hoegen-Saßmannshausen P, Kim JY, Deng M, Seidensaal K, Held T, Herfarth K, Haberer T, Debus J, Mairani A, Harrabi S, Tessonnier T. Helium Ion Therapy for Advanced Juvenile Nasopharyngeal Angiofibroma. Cancers (Basel) 2024; 16:1993. [PMID: 38893114 PMCID: PMC11171253 DOI: 10.3390/cancers16111993] [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: 04/26/2024] [Revised: 05/17/2024] [Accepted: 05/18/2024] [Indexed: 06/21/2024] Open
Abstract
Helium ion therapy (HRT) is a promising modality for the treatment of pediatric tumors and those located close to critical structures due to the favorable biophysical properties of helium ions. This in silico study aimed to explore the potential benefits of HRT in advanced juvenile nasopharyngeal angiofibroma (JNA) compared to proton therapy (PRT). We assessed 11 consecutive patients previously treated with PRT for JNA in a definitive or postoperative setting with a relative biological effectiveness (RBE) weighted dose of 45 Gy (RBE) in 25 fractions at the Heidelberg Ion-Beam Therapy Center. HRT plans were designed retrospectively for dosimetric comparisons and risk assessments of radiation-induced complications. HRT led to enhanced target coverage in all patients, along with sparing of critical organs at risk, including a reduction in the brain integral dose by approximately 27%. In terms of estimated risks of radiation-induced complications, HRT led to a reduction in ocular toxicity, cataract development, xerostomia, tinnitus, alopecia and delayed recall. Similarly, HRT led to reduced estimated risks of radiation-induced secondary neoplasms, with a mean excess absolute risk reduction of approximately 30% for secondary CNS malignancies. HRT is a promising modality for advanced JNA, with the potential for enhanced sparing of healthy tissue and thus reduced radiation-induced acute and long-term complications.
Collapse
Affiliation(s)
- Line Hoeltgen
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (L.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Eva Meixner
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (L.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Philipp Hoegen-Saßmannshausen
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (L.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Ji-Young Kim
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (L.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Maximilian Deng
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (L.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Katharina Seidensaal
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (L.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Thomas Held
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (L.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Klaus Herfarth
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (L.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Thomas Haberer
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (L.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- Partner Site, German Cancer Consortium (DKTK), 69120 Heidelberg, Germany
| | - Andrea Mairani
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Centro Nazionale di Adroterapia Oncologica (CNAO), Medical Physics Department, 27100 Pavia, Italy
| | - Semi Harrabi
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (L.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Thomas Tessonnier
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| |
Collapse
|
3
|
Tajiki S, Joya M, Gharekhani V, Richeson D, Gholami S. A systematic review of the normal tissue complication probability models and parameters: Head and neck cancers treated with conformal radiotherapy. Head Neck 2023; 45:3146-3156. [PMID: 37767820 DOI: 10.1002/hed.27469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 07/05/2023] [Accepted: 07/06/2023] [Indexed: 09/29/2023] Open
Abstract
This systematic review study aims to provide comprehensive data on different radiobiological models, parameters, and endpoints used for calculating the normal tissue complication probability (NTCP) based on clinical data from head and neck cancer patients treated with conformal radiotherapy. A systematic literature search was carried out according to the PRISMA guideline for the identification of relevant publications in six electronic databases of Embase, PubMed, Scopus, and Google Scholar to July 2022 using specific keywords in the paper's title and abstract. The initial search resulted in 1368 articles for all organs for the review article about the NTCP parameters. One hundred and seventy-eight articles were accepted for all organs with complete parameters for the mentioned models and finally, 20 head and neck cancer articles were accepted for review. Analysis of the studies shows that the Lyman-Kutcher-Burman (LKB) model properly links the NTCP curve parameters to the postradiotherapy endpoints. In the LKB model for esophagus, the minimum, and maximum corresponding parameters were reported as TD50 = 2.61 Gy with grade ≥3 radiation-induced esophagitis endpoints as the minimum TD50 and TD50 = 68 Gy as the maximum ones. nmin = 0.06, nmax = 1.04, mmin = 0.1, and mmax = 0.65, respectively. Unfortunately, there was not a wide range of published articles on other organs at risk like ear or cauda equina except Burman et al. (Fitting of normal tissue tolerance data to an analytic function. Int J Radiat Oncol Biol Phys Ther. 1991;21:123-135). Findings suggest that the validation of different radiobiological models and their corresponding parameters need to be investigated in vivo and in vitro for developing a more accurate NTCP model to be used for radiotherapy treatment planning optimization.
Collapse
Affiliation(s)
- Sareh Tajiki
- Radiotherapy Oncology Research Centre, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Musa Joya
- Department of Medical Physics and Biomedical Engineering, Tehran University of Medical Sciences, Tehran, Iran
| | - Vahideh Gharekhani
- Department of Radiobiology, Faculty of Paramedical, Tehran University of Medical Sciences, Tehran, Iran
| | - Dylan Richeson
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Somayeh Gholami
- Department of Radiation Oncology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| |
Collapse
|
4
|
Hoeltgen L, Tessonnier T, Meixner E, Hoegen P, Kim JY, Deng M, Seidensaal K, Held T, Herfarth K, Debus J, Harrabi S. Proton Therapy for Advanced Juvenile Nasopharyngeal Angiofibroma. Cancers (Basel) 2023; 15:5022. [PMID: 37894389 PMCID: PMC10605854 DOI: 10.3390/cancers15205022] [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: 09/14/2023] [Revised: 10/12/2023] [Accepted: 10/13/2023] [Indexed: 10/29/2023] Open
Abstract
PURPOSE To provide the first report on proton radiotherapy (PRT) in the management of advanced nasopharyngeal angiofibroma (JNA) and evaluate potential benefits compared to conformal photon therapy (XRT). METHODS We retrospectively reviewed 10 consecutive patients undergoing PRT for advanced JNA in a definitive or postoperative setting with a relative biological effectiveness weighted dose of 45 Gy in 25 fractions between 2012 and 2022 at the Heidelberg Ion Beam Therapy Center. Furthermore, dosimetric comparisons and risk estimations for short- and long-term radiation-induced complications between PRT plans and helical XRT plans were conducted. RESULTS PRT was well tolerated, with only low-grade acute toxicities (CTCAE I-II) being reported. The local control rate was 100% after a median follow-up of 27.0 (interquartile range 13.3-58.0) months. PRT resulted in considerable tumor shrinkage, leading to complete remission in five patients and bearing the potential to provide partial or complete symptom relief. Favorable dosimetric outcomes in critical brain substructures by the use of PRT translated into reduced estimated risks for neurocognitive impairment and radiation-induced CNS malignancies compared to XRT. CONCLUSIONS PRT is an effective treatment option for advanced JNA with minimal acute morbidity and the potential for reduced radiation-induced long-term complications.
Collapse
Affiliation(s)
- Line Hoeltgen
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (S.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
- National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Thomas Tessonnier
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Eva Meixner
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (S.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
- National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Philipp Hoegen
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (S.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
- National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Ji-Young Kim
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (S.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
- National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Maximilian Deng
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (S.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
- National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Katharina Seidensaal
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (S.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
- National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Thomas Held
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (S.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
- National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Klaus Herfarth
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (S.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
- National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Juergen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (S.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
- National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK), Partner Site, 69120 Heidelberg, Germany
| | - Semi Harrabi
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany (S.H.)
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
- National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany
| |
Collapse
|
5
|
Momeni N, Broomand MA, Roozmand Z, Hamzian N. Estimating the Dose-Response Relationship for Ocular Pain after Radiotherapy of Head and Neck Cancers and Skull Base Tumors based on the LKB Radiobiological Model. J Biomed Phys Eng 2023; 13:411-420. [PMID: 37868939 PMCID: PMC10589689 DOI: 10.31661/jbpe.v0i0.2210-1554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 01/03/2023] [Indexed: 10/24/2023]
Abstract
Background Radiotherapy is considered a compromise between the amount of killed tumor cells and the damage caused to the healthy tissue. Regarding this, radiobiological modeling is performed to individualize and optimize treatment strategies. Objective This study aimed to determine the normal tissue complication probability (NTCP) of acute ocular pain following radiotherapy. Material and Methods In this prospective observational study, the clinical data were collected from 45 patients with head and neck cancers and skull-base tumors, and dosimetric data were recorded after contouring the eye globe. Acute ocular pain was prospectively assessed with a three-month follow-up. The Lyman-Kutcher-Berman (LKB) parameters were estimated using the Area Under Curve (AUC) of Receiver Operating Characteristic (ROC) maximization and Maximum Likelihood (MLH) methods, and the NTCP of acute ocular pain was then determined using generalized LKB radiobiological model. The model performance was evaluated with AUC, Brier score, and Hosmer-Lemeshow tests. Results Six out of 45 (13.33%) patients developed acute ocular pain (grade 1 or more). LKB model showed a weak dose-volume effect (n=0.09), tolerance dose for a 50% complication (TD50) of 27.54 Gy, and slope parameter (m) of 0.38. The LKB model showed high prediction performance. The LKB model predicted that NTCP would be less than 25% if the generalized equivalent uniform dose (gEUD) was kept below 20 Gy. Conclusion The LKB model showed a high performance in determining the NTCP of ocular pain so that the probability of ocular pain will be less than 25% if the eye globe mean dose is kept below 12 Gy.
Collapse
Affiliation(s)
- Nastaran Momeni
- Department of Medical Physics, School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mohammad Ali Broomand
- Department of Clinical Oncology, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Zahra Roozmand
- Department of Medical Physics, School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Nima Hamzian
- Department of Medical Physics, School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| |
Collapse
|
6
|
Bouter J, Reznik Y, Thariat J. Effects on the Hypothalamo-Pituitary Axis in Patients with CNS or Head and Neck Tumors following Radiotherapy. Cancers (Basel) 2023; 15:3820. [PMID: 37568636 PMCID: PMC10417001 DOI: 10.3390/cancers15153820] [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: 06/12/2023] [Revised: 07/23/2023] [Accepted: 07/26/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Knowledge about the precise effects of radiotherapy on hypothalamo-pituitary functions is limited. Reduction of side effects is a major goal of advanced radiotherapy modalities. We assessed strategies for monitoring and replacement of hormone deficiencies in irradiated patients. METHODS A search strategy was systematically conducted on PubMed®. Additional articles were retrieved to describe endocrine mechanisms. RESULTS 45 studies were evaluated from 2000 to 2022. They were predominantly retrospective and highly heterogeneous concerning patient numbers, tumor types, radiotherapy technique and follow-up. Endocrine deficiencies occurred in about 40% of patients within a median follow-up of 5.6 years without a clear difference between radiotherapy modalities. Somatotropic and thyrotropic axes were, respectively, the most and least radiosensitive. CONCLUSIONS Current pituitary gland dose constraints may underestimate radiation-induced endocrine deficiencies, thus impairing quality of life. Little difference might be expected between radiation techniques for PG tumors. For non-PG tumors, dose constraints should be applied more systematically.
Collapse
Affiliation(s)
- Jordan Bouter
- Radiotherapy Department, Centre François Baclesse, Avenue du Général Harris, 14000 Caen, France;
| | - Yves Reznik
- Department of Endocrinology, University Hospital of Caen, Avenue de la Côte de Nacre, 14033 Caen, France;
| | - Juliette Thariat
- Radiotherapy Department, Centre François Baclesse, Avenue du Général Harris, 14000 Caen, France;
- Corpuscular Physics Laboratory, ENSICAEN, Boulevard Maréchal Juin, 14050 Caen, France
- Unicaen—Normandie Université, 14050 Caen, France
| |
Collapse
|
7
|
Wickert R, Tessonnier T, Deng M, Adeberg S, Seidensaal K, Hoeltgen L, Debus J, Herfarth K, Harrabi SB. Radiotherapy with Helium Ions Has the Potential to Improve Both Endocrine and Neurocognitive Outcome in Pediatric Patients with Ependymoma. Cancers (Basel) 2022; 14:cancers14235865. [PMID: 36497348 PMCID: PMC9736041 DOI: 10.3390/cancers14235865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/10/2022] [Accepted: 11/15/2022] [Indexed: 11/30/2022] Open
Abstract
Ependymomas are the third most-frequent pediatric brain tumors. To prevent local recurrence, the resection site should be irradiated. Compared to photon radiation treatment, proton therapy often achieves even better results regarding target coverage and organ-sparing. Due to their physical properties, helium ions could further reduce side effects, providing better protection of healthy tissue despite similar target coverage. In our in silico study, 15 pediatric ependymoma patients were considered. All patients underwent adjuvant radiotherapeutic treatment with active-scanned protons at Heidelberg Ion Beam Therapy Center (HIT). Both helium ion and highly conformal IMRT plans were calculated to evaluate the potential dosimetric advantage of ion beam therapy compared to the current state-of-the-art photon-based treatments. To estimate the potential clinical benefit of helium ions, normal tissue complication probabilities (NTCP) were calculated. Target coverage was comparable in all three modalities. As expected, the integral dose absorbed by healthy brain tissue could be significantly reduced with protons by up to -48% vs. IMRT. Even compared to actively scanned protons, relative dose reductions for critical neuronal structures of up to another -39% were achieved when using helium ions. The dose distribution of helium ions is significantly superior when compared to proton therapy and IMRT due to the improved sparing of OAR. In fact, previous studies could clearly demonstrate that the dosimetric advantage of protons translates into a measurable clinical benefit for pediatric patients with brain tumors. Given the dose-response relationship of critical organs at risk combined with NTCP calculation, the results of our study provide a strong rationale that the use of helium ions has the potential to even further reduce the risk for treatment related sequelae.
Collapse
Affiliation(s)
- Ricarda Wickert
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Thomas Tessonnier
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Maximilian Deng
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Sebastian Adeberg
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Katharina Seidensaal
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Line Hoeltgen
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK), 69120 Heidelberg, Germany
| | - Klaus Herfarth
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Semi B. Harrabi
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Correspondence:
| |
Collapse
|
8
|
Bachtiary B, Veraguth D, Roos N, Pfiffner F, Leiser D, Pica A, Walser M, von Felten S, Weber DC. Hearing Loss in Cancer Patients with Skull Base Tumors Undergoing Pencil Beam Scanning Proton Therapy: A Retrospective Cohort Study. Cancers (Basel) 2022; 14:cancers14163853. [PMID: 36010847 PMCID: PMC9405884 DOI: 10.3390/cancers14163853] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/05/2022] [Accepted: 08/06/2022] [Indexed: 11/16/2022] Open
Abstract
To assess the incidence and severity of changes in hearing threshold in patients undergoing high-dose pencil-beam-scanning proton therapy (PBS-PT). This retrospective cohort study included fifty-one patients (median 50 years (range, 13–68)) treated with PBS-PT for skull base tumors. No chemotherapy was delivered. Pure tone averages (PTAs)were determined before (baseline) and after PBS-PT as the average hearing thresholds at frequencies of 0.5, 1, 2, and 4 kHz. Hearing changes were calculated as PTA differences between pre-and post-PBS-PT. A linear mixed-effects model was used to assess the relationship between the PTA at the follow-up and the baseline, the cochlea radiation dose intensity, the increased age, and the years after PBS-PT. Included patients were treated for chordoma (n = 24), chondrosarcoma (n = 9), head and neck tumors (n = 9), or meningioma (n = 3), with a mean tumor dose of 71.1 Gy (RBE) (range, 52.0–77.8), and a mean dose of 37 Gy (RBE) (range, 0.0–72.7) was delivered to the cochleas. The median time to the first follow-up was 11 months (IQR, 5.5–33.7). The PTA increased from a median of 15 dB (IQR 10.0–25) at the baseline to 23.8 (IQR 11.3–46.3) at the first follow-up. In the linear mixed-effect model, the baseline PTA (estimate 0.80, 95%CI 0.64 to 0.96, p ≤ 0.001), patient’s age (0.30, 0.03 to 0.57, p = 0.029), follow-up time (2.07, 0.92 to 3.23, p ≤ 0.001), and mean cochlear dose in Gy (RBE) (0.34, 0.21 to 0.46, p ≤ 0.001) were all significantly associated with an increase in PTA at follow-up. The applied cochlear dose and baseline PTA, age, and time after treatment were significantly associated with hearing loss after proton therapy.
Collapse
Affiliation(s)
- Barbara Bachtiary
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, 5232 Villigen, Switzerland
- Correspondence: ; Tel.: +41-56-310-2319
| | - Dorothe Veraguth
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Nicolaas Roos
- Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
| | - Flurin Pfiffner
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Dominic Leiser
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, 5232 Villigen, Switzerland
| | - Alessia Pica
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, 5232 Villigen, Switzerland
| | - Marc Walser
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, 5232 Villigen, Switzerland
| | - Stefanie von Felten
- Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, 8001 Zurich, Switzerland
| | - Damien C. Weber
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, 5232 Villigen, Switzerland
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- Department of Radiation Oncology, University Hospital of Zurich, University of Zurich, 8091 Zurich, Switzerland
| |
Collapse
|
9
|
Li Z, Zhao Q, Yin H, Ren H, Zhou Y, Zhou C. Dosimetric differences between intensity-modulated radiotherapy based on equivalent uniform dose and dose-volume optimization in stage III non-small cell lung cancer. Am J Transl Res 2022; 14:5195-5200. [PMID: 35958500 PMCID: PMC9360840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 02/18/2021] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To determine the dosimetric differences between biological and physical functions of equivalent uniform dose (EUD) and dose volume (DV) therapy in patients with phase III non-small cell lung cancer. METHODS Four different radiotherapy plans (DV+DV, DV-EUD+DV, EUD+EUD and EUD-DV+EUD) were developed for 15 patients with stage III NSCLC. To study physical function (DV+DV) the target area was optimized by introducing the conditions of biological function optimization, while the organs at risk were optimized by means of physical function (DV-EUD+DV). Biological function optimization (EUD+EUD) was performed for the target area by applying conditions of physical function optimization while biological function optimization (EUD-DV+DV) was conducted for the organs at risk to compare dosimetric parameters among the four groups of treatment plans. RESULTS PTV: D2%, D98%, D50%, V105% and Dmax of both the DV-EUD+DV group and EDU-DV+EUD group were the minimum (P<0.05). The minimum and average dose of the EUD+EUD group showed an increasing trend and high-dose area became observable. For homogeneity index (HI), DV-EUD+DV group and EUD-DV+EUD results were compared with the other groups (P<0.05), no significant difference was observed statistically between the DV-EUD+DV group and EUD DV+EUD (P=0.659). With regard to conformability index (CI), the results of the four groups showed no significant difference (P>0.05). For the organs at risk, the mean dose of lung tissue (MLD), V5, V10, V20, V30, heart V30, V40, and Dmean also revealed no significant difference (P>0.05). For the spinal cord, the D1 % of the EUD+EUD group and EUD-DV+EUD groups were significantly different (P<0.05) than the other groups. While no significant difference (P=0.32) was found between the EUD+EUD and EUD-DV+EUD groups. When comparing the number of machine unions (MU) no significant difference was revealed (P>0.05) among the results of the 4 groups. CONCLUSION The methods featuring optimization of physical and biological functions are effective in improving the uniformity of target area to have better outcome of the treatment. Biological function optimization or the combination of biological and physical function optimization is conducive to significantly reduce the required dose for the spinal cord.
Collapse
Affiliation(s)
- Zhenhu Li
- Department of Oncology, Jinshan Hospital of Fudan UniversityShanghai, China
| | - Qiuxia Zhao
- Department of Ultrasound, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and ScienceXiangyang, Hubei Province, China
| | - Haitao Yin
- Department of Radiotherapy, Xuzhou Central Hospital Affiliated to Xuzhou Medical UniversityXuzhou, Jiangsu Province, China
| | - Hongrong Ren
- Department of Radiotherapy, Xuzhou Central Hospital Affiliated to Xuzhou Medical UniversityXuzhou, Jiangsu Province, China
| | - Yun Zhou
- Department of Radiotherapy, Xuzhou Central Hospital Affiliated to Xuzhou Medical UniversityXuzhou, Jiangsu Province, China
| | - Chong Zhou
- Department of Radiotherapy, Xuzhou Central Hospital Affiliated to Xuzhou Medical UniversityXuzhou, Jiangsu Province, China
| |
Collapse
|
10
|
Evaluation of the Radiobiological Models predicting the Radiation-Induced Hypothyroidism in the Partially Irradiated Thyroid Gland of Patients with Breast Cancer. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2022. [DOI: 10.5812/ijcm-119445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Radiation-induced hypothyroidism (RHT) is one of the side effects that might have an impact on the quality of life of patients with breast cancer treated with radiotherapy. Objectives: The aim of the current study was to evaluate the performances of the Lyman-Kutcher-Burman (LKB) and Log-Logistic models in the prediction of hypothyroidism (HT) as well as the estimation of the model parameters for the incidence of RHT among patients with breast cancer. Methods: Fifty-two patients treated with radiation therapy (RT) for breast cancer were prospectively evaluated. Patients' serum samples [tri-iodothyronine, thyroxine, thyroid-stimulating hormone (TSH), free triiodothyronine, and free thyroxine] were measured before RT and also at a regular time interval until 1 year after the completion of RT. For each patient, dose-volume histograms (DVHs) of the thyroid gland were derived from their treatment planning dataset. Patients whose TSH levels were higher than normal with a decrease in FT4 levels were considered as cases with RHT. The LKB and Log-Logistic radiobiological models were evaluated by comparing them with the resultant follow-up data. The parameters for radiobiological models have been deduced by fitting the models to the follow-up data. The models were fitted in a Bayesian setting and compared according to the widely applicable information criterion (WAIC). Results: Twenty-one (40%) patients developed RHT at a follow-up of 1 year after the end of radiation treatment. The fitted values of D50 for the LKB and Log-Logistic models were 37.71 and 25.50 Gy, respectively for the partially irradiated thyroid of patients with breast cancer. The mean time to the incidence of RHT was obtained at 6.7 months in the studied group. Conclusions: A volumetric effect was found for the thyroid gland in the implemented normal tissue complication probability models. Compared to the follow-up data, the Log-Logistic model was ranked as the best model for predicting the rate of RHT in patients with breast cancer.
Collapse
|
11
|
Dell'Oro M, Wilson P, Short M, Hua CH, Merchant TE, Bezak E. Normal tissue complication probability modeling to guide individual treatment planning in pediatric cranial proton and photon radiotherapy. Med Phys 2021; 49:742-755. [PMID: 34796509 DOI: 10.1002/mp.15360] [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: 07/05/2021] [Revised: 11/05/2021] [Accepted: 11/09/2021] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Proton therapy (PT) is broadly accepted as the gold standard of care for pediatric patients with cranial cancer. The superior dose distribution of PT compared to photon radiotherapy reduces normal tissue complication probability (NTCP) for organs at risk. As NTCPs for pediatric organs are not well understood, clinics generally base radiation response on adult data. However, there is evidence that radiation response strongly depends on the age and even sex of a patient. Furthermore, questions surround the influence of individual intrinsic radiosensitivity (α/β ratio) on pediatric NTCP. While the clinical pediatric NTCP data is scarce, radiobiological modeling and sensitivity analyses can be used to investigate the NTCP trends and its dependence on individual modeling parameters. The purpose of this study was to perform sensitivity analyses of NTCP models to ascertain the dependence of radiosensitivity, sex, and age of a child and predict cranial side-effects following intensity-modulated proton therapy (IMPT) and intensity-modulated radiotherapy (IMRT). METHODS Previously, six sex-matched pediatric cranial datasets (5, 9, and 13 years old) were planned in Varian Eclipse treatment planning system (13.7). Up to 108 scanning beam IMPT plans and 108 IMRT plans were retrospectively optimized for a range of simulated target volumes and locations. In this work, dose-volume histograms were extracted and imported into BioSuite Software for radiobiological modeling. Relative-Seriality and Lyman-Kutcher-Burman models were used to calculate NTCP values for toxicity endpoints, where TD50, (based on reported adult clinical data) was varied to simulate sex dependence of NTCP. Plausible parameter ranges, based on published literature for adults, were used in modeling. In addition to sensitivity analyses, a 20% difference in TD50 was used to represent the radiosensitivity between the sexes (with females considered more radiosensitive) for ease of data comparison as a function of parameters such as α/β ratio. RESULTS IMPT plans resulted in lower NTCP compared to IMRT across all models (p < 0.0001). For medulloblastoma treatment, the risk of brainstem necrosis (> 10%) and cochlea tinnitus (> 20%) among females could potentially be underestimated considering a lower TD50 value for females. Sensitivity analyses show that the difference in NTCP between sexes was significant (p < 0.0001). Similarly, both brainstem necrosis and cochlea tinnitus NTCP varied significantly (p < 0.0001) across tested α/β as a function of TD50 values (assumption being that TD50 values are 20% lower in females). If the true α/β of these pediatric tissues is higher than expected (α/β ∼ 3), the risk of tinnitus for IMRT can significantly increase (p < 0.0001). CONCLUSION Due to the scarcity of pediatric NTCP data available, sensitivity analyses were performed using plausible ranges based on published adult data. In the clinical scenario where, if female pediatric patients were 20% more radiosensitive (lower TD50 value), they could be up to twice as likely to experience side-effects of brainstem necrosis and cochlea tinnitus compared to males, highlighting the need for considering the sex in NTCP models. Based on our sensitivity analyses, age and sex of a pediatric patient could significantly affect the resultant NTCP from cranial radiotherapy, especially at higher α/β values.
Collapse
Affiliation(s)
- Mikaela Dell'Oro
- Cancer Research Institute, University of South Australia, Adelaide, Australia.,Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, Australia
| | - Puthenparampil Wilson
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, Australia.,UniSA STEM, University of South Australia, Adelaide, Australia
| | - Michala Short
- Cancer Research Institute, University of South Australia, Adelaide, Australia
| | - Chia-Ho Hua
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Thomas E Merchant
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Eva Bezak
- Cancer Research Institute, University of South Australia, Adelaide, Australia.,Department of Physics, University of Adelaide, Adelaide, Australia
| |
Collapse
|
12
|
Partoune E, Virzi M, Vander Veken L, Renard L, Maiter D. Occurrence of pituitary hormone deficits in relation to both pituitary and hypothalamic doses after radiotherapy for skull base meningioma. Clin Endocrinol (Oxf) 2021; 95:460-468. [PMID: 34028837 DOI: 10.1111/cen.14499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/28/2021] [Accepted: 05/10/2021] [Indexed: 12/19/2022]
Abstract
CONTEXT Little accurate information is available regarding the risk of hypopituitarism after irradiation of skull base meningiomas. DESIGN Retrospective study in a single centre. PATIENTS 48 patients with a skull base meningioma and normal pituitary function at diagnosis, treated with radiotherapy (RXT) between 1998 and 2017 (median follow-up of 90 months). MEASUREMENTS The GH, TSH, LH/FSH and ACTH hormonal axes were evaluated yearly for the entire follow-up period. Mean doses delivered to the pituitary gland (PitD) and the hypothalamus (HypoD) were calculated, as well as the doses responsible for the development of deficits in 50% of patients after 5 years (TD50). RESULTS At least one hormone deficit was observed in 38% of irradiated patients and complete hypopituitarism in 13%. The GH (35%), TSH (32%) and LH/FSH axes (28%) were the most frequently affected, while ACTH secretion axis was less altered (13%). The risk of hypopituitarism was independently related to planning target volume (PTV) and to the PitD (threshold dose 45 Gy; TD50 between 50 and 54 Gy). In this series, the risk was less influenced by the HypoD, increasing steadily between doses of 15 and 70 Gy with no clear-cut dose threshold. CONCLUSIONS Over a median follow-up period of 7.5 years, hypopituitarism occurred in more than one third of patients irradiated for a skull base meningioma, and this prevalence was time- and dose-dependent. In this setting, the risk of developing hypopituitarism was mainly determined by the irradiated target volume and by the dose delivered to the pituitary gland.
Collapse
Affiliation(s)
- Eléonore Partoune
- Departments of Radiotherapy, Cliniques Universitaires Saint Luc, Université catholique de Louvain, Brussels, Belgium
| | - Maxime Virzi
- Departments of Radiotherapy, Cliniques Universitaires Saint Luc, Université catholique de Louvain, Brussels, Belgium
| | - Loïc Vander Veken
- Departments of Radiotherapy, Cliniques Universitaires Saint Luc, Université catholique de Louvain, Brussels, Belgium
| | - Laurette Renard
- Departments of Radiotherapy, Cliniques Universitaires Saint Luc, Université catholique de Louvain, Brussels, Belgium
| | - Dominique Maiter
- Endocrinology and Nutrition, Cliniques Universitaires Saint Luc, Université catholique de Louvain, Brussels, Belgium
| |
Collapse
|
13
|
Stieb S, Lee A, van Dijk LV, Frank S, Fuller CD, Blanchard P. NTCP Modeling of Late Effects for Head and Neck Cancer: A Systematic Review. Int J Part Ther 2021; 8:95-107. [PMID: 34285939 PMCID: PMC8270107 DOI: 10.14338/20-00092] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/08/2021] [Indexed: 12/23/2022] Open
Affiliation(s)
- Sonja Stieb
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Center for Radiation Oncology KSA-KSB, Kantonsspital Aarau, Aarau, Switzerland
| | - Anna Lee
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lisanne V. van Dijk
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Radiation Oncology, University Medical Center–Groningen, Groningen, the Netherlands
| | - Steven Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Clifton David Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pierre Blanchard
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Radiotherapy, Gustave Roussy Cancer Campus, Universite Paris-Saclay, Villejuif, France
| |
Collapse
|
14
|
Bäumer C, Plaude S, Khalil DA, Geismar D, Kramer PH, Kröninger K, Nitsch C, Wulff J, Timmermann B. Clinical Implementation of Proton Therapy Using Pencil-Beam Scanning Delivery Combined With Static Apertures. Front Oncol 2021; 11:599018. [PMID: 34055596 PMCID: PMC8149965 DOI: 10.3389/fonc.2021.599018] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 04/06/2021] [Indexed: 11/13/2022] Open
Abstract
Proton therapy makes use of the favorable depth-dose distribution with its characteristic Bragg peak to spare normal tissue distal of the target volume. A steep dose gradient would be desired in lateral dimensions, too. The widespread spot scanning delivery technique is based, however, on pencil-beams with in-air spot full-widths-at-half-maximum of typically 1 cm or more. This hampers the sparing of organs-at-risk if small-scale structures adjacent to the target volume are concerned. The trimming of spot scanning fields with collimating apertures constitutes a simple measure to increase the transversal dose gradient. The current study describes the clinical implementation of brass apertures in conjunction with the pencil-beam scanning delivery mode at a horizontal, clinical treatment head based on commercial hardware and software components. Furthermore, clinical cases, which comprised craniopharyngiomas, re-irradiations and ocular tumors, were evaluated. The dosimetric benefits of 31 treatment plans using apertures were compared to the corresponding plans without aperture. Furthermore, an overview of the radiation protection aspects is given. Regarding the results, robust optimization considering range and setup uncertainties was combined with apertures. The treatment plan optimizations followed a single-field uniform dose or a restricted multi-field optimization approach. Robustness evaluation was expanded to account for possible deviations of the center of the pencil-beam delivery and the mechanical center of the aperture holder. Supplementary apertures improved the conformity index on average by 15.3%. The volume of the dose gradient surrounding the PTV (evaluated between 80 and 20% dose levels) was decreased on average by 17.6%. The mean dose of the hippocampi could be reduced on average by 2.9 GyRBE. In particular cases the apertures facilitated a sparing of an organ-at-risk, e.g. the eye lens or the brainstem. For six craniopharyngioma cases the inclusion of apertures led to a reduction of the mean dose of 1.5 GyRBE (13%) for the brain and 3.1 GyRBE (16%) for the hippocampi.
Collapse
Affiliation(s)
- Christian Bäumer
- West German Proton Therapy Centre Essen, Essen, Germany
- West German Cancer Center (WTZ), University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
- Faculty of Physics, TU Dortmund University, Dortmund, Germany
| | - Sandija Plaude
- West German Proton Therapy Centre Essen, Essen, Germany
- West German Cancer Center (WTZ), University Hospital Essen, Essen, Germany
| | - Dalia Ahmad Khalil
- West German Proton Therapy Centre Essen, Essen, Germany
- West German Cancer Center (WTZ), University Hospital Essen, Essen, Germany
- Department of Particle Therapy, University Hospital Essen, Essen, Germany
| | - Dirk Geismar
- West German Proton Therapy Centre Essen, Essen, Germany
- West German Cancer Center (WTZ), University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
- Department of Particle Therapy, University Hospital Essen, Essen, Germany
| | - Paul-Heinz Kramer
- West German Proton Therapy Centre Essen, Essen, Germany
- West German Cancer Center (WTZ), University Hospital Essen, Essen, Germany
| | - Kevin Kröninger
- Faculty of Physics, TU Dortmund University, Dortmund, Germany
| | | | - Jörg Wulff
- West German Proton Therapy Centre Essen, Essen, Germany
- West German Cancer Center (WTZ), University Hospital Essen, Essen, Germany
| | - Beate Timmermann
- West German Proton Therapy Centre Essen, Essen, Germany
- West German Cancer Center (WTZ), University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
- Department of Particle Therapy, University Hospital Essen, Essen, Germany
| |
Collapse
|
15
|
Dutz A, Lühr A, Troost EGC, Agolli L, Bütof R, Valentini C, Baumann M, Vermeren X, Geismar D, Timmermann B, Krause M, Löck S. Identification of patient benefit from proton beam therapy in brain tumour patients based on dosimetric and NTCP analyses. Radiother Oncol 2021; 160:69-77. [PMID: 33872640 DOI: 10.1016/j.radonc.2021.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 03/17/2021] [Accepted: 04/08/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND The limited availability of proton beam therapy (PBT) requires individual treatment selection strategies, such as the model-based approach. In this study, we assessed the dosimetric benefit of PBT compared to photon therapy (XRT), analysed the corresponding changes in normal tissue complication probability (NTCP) on a variety of available models, and illustrated model-based patient selection in an in-silico study for patients with brain tumours. METHODS For 92 patients treated at two PBT centres, volumetric modulated arc therapy treatment plans were retrospectively created for comparison with the clinically applied PBT plans. Several dosimetric parameters for the brain excluding tumour and margins, cerebellum, brain stem, frontal and temporal lobes, hippocampi, cochleae, chiasm, optic nerves, lacrimal glands, lenses, pituitary gland, and skin were compared between both modalities using Wilcoxon signed-rank tests. NTCP differences (ΔNTCP) were calculated for 11 models predicting brain necrosis, delayed recall, temporal lobe injury, hearing loss, tinnitus, blindness, ocular toxicity, cataract, endocrine dysfunction, alopecia, and erythema. A patient was assumed to be selected for PBT if ΔNTCP exceeded a threshold of 10 percentage points for at least one of the side-effects. RESULTS PBT substantially reduced the dose in almost all investigated OARs, especially in the low and intermediate dose ranges and for contralateral organs. In general, NTCP predictions were significantly lower for PBT compared to XRT, in particular in ipsilateral organs. Considering ΔNTCP of all models, 80 patients (87.0%) would have been selected for PBT in this in-silico study, mainly due to predictions of a model on delayed recall (51 patients). CONCLUSION In this study, substantial dose reductions for PBT were observed, mainly in contralateral organs. However, due to the sigmoidal dose response, NTCP was particularly reduced in ipsilateral organs. This underlines that physical dose-volume parameters alone may not be sufficient to describe the clinical relevance between different treatment techniques and highlights potential benefits of NTCP models. Further NTCP models for different modern treatment techniques are mandatory and existing models have to be externally validated in order to implement the model-based approach in clinical practice for cranial radiotherapy.
Collapse
Affiliation(s)
- Almut Dutz
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Armin Lühr
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; Medical Physics and Radiotherapy, Faculty of Physics, TU Dortmund University, Germany
| | - Esther G C Troost
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Linda Agolli
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Rebecca Bütof
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Chiara Valentini
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Michael Baumann
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany; Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany
| | - Xavier Vermeren
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, Germany
| | - Dirk Geismar
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, Germany; Department of Particle Therapy, University Hospital Essen, Germany; West German Cancer Center (WTZ), University Hospital Essen, Germany
| | - Beate Timmermann
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, Germany; Department of Particle Therapy, University Hospital Essen, Germany; West German Cancer Center (WTZ), University Hospital Essen, Germany; German Cancer Consortium (DKTK), partner site Essen, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Mechthild Krause
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Steffen Löck
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
| |
Collapse
|
16
|
Lamaj E, Vu E, van Timmeren JE, Leonardi C, Marc L, Pytko I, Guckenberger M, Balermpas P. Cochlea sparing optimized radiotherapy for nasopharyngeal carcinoma. Radiat Oncol 2021; 16:64. [PMID: 33794949 PMCID: PMC8017833 DOI: 10.1186/s13014-021-01796-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 03/25/2021] [Indexed: 12/08/2022] Open
Abstract
BACKGROUND Definitive chemoradiotherapy (CRT) is standard of care for nasopharyngeal carcinoma. Due to the tumor localization and concomitant platinum-based chemotherapy, hearing impairment is a frequent complication, without defined dose-threshold. In this study, we aimed to achieve the maximum possible cochleae sparing. MATERIALS AND METHODS Treatment plans of 20 patients, treated with CRT (6 IMRT and 14 VMAT) based on the QUANTEC organs-at-risk constraints were investigated. The cochleae were re-delineated independently by two radiation oncologists, whereas target volumes and other organs at risk (OARs) were not changed. The initial plans, aiming to a mean cochlea dose < 45 Gy, were re-optimized with VMAT, using 2-2.5 arcs without compromising the dose coverage of the target volume. Mean cochlea dose, PTV coverage, Homogeneity Index, Conformity Index and dose to other OAR were compared to the reference plans. Wilcoxon signed-rank test was used to evaluate differences, a p value < 0.05 was considered significant. RESULTS The re-optimized plans achieved a statistically significant lower dose for both cochleae (median dose for left and right 14.97 Gy and 18.47 Gy vs. 24.09 Gy and 26.05 Gy respectively, p < 0.001) compared to the reference plans, without compromising other plan quality parameters. The median NTCP for tinnitus of the most exposed sites was 11.3% (range 3.52-91.1%) for the original plans, compared to 4.60% (range 1.46-90.1%) for the re-optimized plans (p < 0.001). For hearing loss, the median NTCP of the most exposed sites could be improved from 0.03% (range 0-99.0%) to 0.00% (range 0-98.5%, p < 0.001). CONCLUSIONS A significantly improved cochlea sparing beyond current QUANTEC constraints is feasible without compromising the PTV dose coverage in nasopharyngeal carcinoma patients treated with VMAT. As there appears to be no threshold for hearing toxicity after CRT, this should be considered for future treatment planning.
Collapse
Affiliation(s)
- Enkelejda Lamaj
- Department of Radiation Oncology, University Hospital Zurich (USZ), University of Zurich (UZH), Rämistrasse 100, 8091, Zurich, Switzerland
| | - Erwin Vu
- Department of Radiation Oncology, University Hospital Zurich (USZ), University of Zurich (UZH), Rämistrasse 100, 8091, Zurich, Switzerland
| | - Janita E van Timmeren
- Department of Radiation Oncology, University Hospital Zurich (USZ), University of Zurich (UZH), Rämistrasse 100, 8091, Zurich, Switzerland
| | - Chiara Leonardi
- Department of Radiation Oncology, University Hospital Zurich (USZ), University of Zurich (UZH), Rämistrasse 100, 8091, Zurich, Switzerland
| | - Louise Marc
- Department of Radiation Oncology, University Hospital Zurich (USZ), University of Zurich (UZH), Rämistrasse 100, 8091, Zurich, Switzerland
| | - Izabela Pytko
- Department of Radiation Oncology, University Hospital Zurich (USZ), University of Zurich (UZH), Rämistrasse 100, 8091, Zurich, Switzerland
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich (USZ), University of Zurich (UZH), Rämistrasse 100, 8091, Zurich, Switzerland
| | - Panagiotis Balermpas
- Department of Radiation Oncology, University Hospital Zurich (USZ), University of Zurich (UZH), Rämistrasse 100, 8091, Zurich, Switzerland.
| |
Collapse
|
17
|
Dutz A, Lühr A, Agolli L, Bütof R, Valentini C, Troost EG, Baumann M, Vermeren X, Geismar D, Lamba N, Lebow ES, Bussière M, Daly JE, Bussière MR, Krause M, Timmermann B, Shih HA, Löck S. Modelling of late side-effects following cranial proton beam therapy. Radiother Oncol 2021; 157:15-23. [DOI: 10.1016/j.radonc.2021.01.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 01/04/2021] [Accepted: 01/05/2021] [Indexed: 02/06/2023]
|
18
|
van der Weide HL, Kramer MCA, Scandurra D, Eekers DBP, Klaver YLB, Wiggenraad RGJ, Méndez Romero A, Coremans IEM, Boersma L, van Vulpen M, Langendijk JA. Proton therapy for selected low grade glioma patients in the Netherlands. Radiother Oncol 2020; 154:283-290. [PMID: 33197495 DOI: 10.1016/j.radonc.2020.11.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 11/06/2020] [Accepted: 11/08/2020] [Indexed: 12/12/2022]
Abstract
Proton therapy offers an attractive alternative to conventional photon-based radiotherapy in low grade glioma patients, delivering radiotherapy with equivalent efficacy to the tumour with less radiation exposure to the brain. In the Netherlands, patients with favourable prognosis based on tumour and patient characteristics can be offered proton therapy. Radiation-induced neurocognitive function decline is a major concern in these long surviving patients. Although level 1 evidence of superior clinical outcome with proton therapy is lacking, the Dutch National Health Care Institute concluded that there is scientific evidence to assume that proton therapy can have clinical benefit by reducing radiation-induced brain damage. Based on this decision, proton therapy is standard insured care for selected low grade glioma patients. Patients with other intracranial tumours can also qualify for proton therapy, based on the same criteria. In this paper, the evidence and considerations that led to this decision are summarised. Additionally, the eligibility criteria for proton therapy and the steps taken to obtain high-quality data on treatment outcome are discussed.
Collapse
Affiliation(s)
- Hiska L van der Weide
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, the Netherlands.
| | - Miranda C A Kramer
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, the Netherlands
| | - Daniel Scandurra
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, the Netherlands
| | - Daniëlle B P Eekers
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, the Netherlands
| | | | | | - Alejandra Méndez Romero
- Holland Proton Therapy Center, Delft, the Netherlands; Department of Radiation Oncology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ida E M Coremans
- Department of Radiation Oncology, Leiden University Medical Center, the Netherlands
| | - Liesbeth Boersma
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, the Netherlands
| | - Marco van Vulpen
- Holland Proton Therapy Center, Delft, the Netherlands; Department of Radiation Oncology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Radiation Oncology, Leiden University Medical Center, the Netherlands
| | - Johannes A Langendijk
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, the Netherlands
| | | |
Collapse
|
19
|
Generalizability assessment of head and neck cancer NTCP models based on the TRIPOD criteria. Radiother Oncol 2020; 146:143-150. [DOI: 10.1016/j.radonc.2020.02.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 02/06/2020] [Accepted: 02/17/2020] [Indexed: 12/23/2022]
|
20
|
Patient selection for proton therapy: a radiobiological fuzzy Markov model incorporating robust plan analysis. Phys Eng Sci Med 2020; 43:493-503. [PMID: 32524433 DOI: 10.1007/s13246-020-00849-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 02/01/2020] [Indexed: 01/20/2023]
Abstract
While proton therapy can offer increased sparing of healthy tissue compared with X-ray therapy, it can be difficult to predict whether a benefit can be expected for an individual patient. Predictive modelling may aid in this respect. However, the predictions of these models can be affected by uncertainties in radiobiological model parameters and in planned dose. The aim of this work is to present a Markov model that incorporates these uncertainties to compare clinical outcomes for individualised proton and X-ray therapy treatments. A time-inhomogeneous fuzzy Markov model was developed which estimates the response of a patient to a given treatment plan in terms of quality adjusted life years. These are calculated using the dose-dependent probabilities of tumour control and toxicities as transition probabilities in the model. Dose-volume data representing multiple isotropic patient set-up uncertainties and range uncertainties (for proton therapy) are included to model dose delivery uncertainties. The model was retrospectively applied to an example patient as a demonstration. When uncertainty in the radiobiological model parameter was considered, the model predicted that proton therapy would result in an improved clinical outcome compared with X-ray therapy. However, when dose delivery uncertainty was included, there was no difference between the two treatments. By incorporating uncertainties in the predictive modelling calculations, the fuzzy Markov concept was found to be well suited to providing a more holistic comparison of individualised treatment outcomes for proton and X-ray therapy. This may prove to be useful in model-based patient selection strategies.
Collapse
|
21
|
Austin AM, Douglass MJJ, Nguyen GT, Dalfsen R, Le H, Gorayski P, Tee H, Penniment M, Penfold SN. Cost-effectiveness of proton therapy in treating base of skull chordoma. AUSTRALASIAN PHYSICAL & ENGINEERING SCIENCES IN MEDICINE 2019; 42:1091-1098. [DOI: 10.1007/s13246-019-00810-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 10/16/2019] [Indexed: 12/11/2022]
|
22
|
Dose-response relationship and normal-tissue complication probability of conductive hearing loss in patients undergoing head-and-neck or cranial radiotherapy: A prospective study including 70 ears. Phys Med 2019; 61:64-69. [DOI: 10.1016/j.ejmp.2019.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 03/16/2019] [Accepted: 04/06/2019] [Indexed: 11/22/2022] Open
|
23
|
Dutz A, Lühr A, Agolli L, Troost EG, Krause M, Baumann M, Vermeren X, Geismar D, Schapira EF, Bussière M, Daly JE, Bussière MR, Timmermann B, Shih HA, Löck S. Development and validation of NTCP models for acute side-effects resulting from proton beam therapy of brain tumours. Radiother Oncol 2019; 130:164-171. [DOI: 10.1016/j.radonc.2018.06.036] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 06/19/2018] [Accepted: 06/22/2018] [Indexed: 11/27/2022]
|
24
|
Brodin NP, Tomé WA. Revisiting the dose constraints for head and neck OARs in the current era of IMRT. Oral Oncol 2018; 86:8-18. [PMID: 30409324 DOI: 10.1016/j.oraloncology.2018.08.018] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 08/20/2018] [Accepted: 08/25/2018] [Indexed: 12/25/2022]
Abstract
Head and neck cancer poses a particular challenge in radiation therapy, whilst being an effective treatment modality it requires very high doses of radiation to provide effective therapy. This is further complicated by the fact that the head and neck region contains a large number of radiosensitive tissues, often resulting in patients experiencing debilitating normal tissue complications. In the era of intensity-modulated radiation therapy (IMRT) treatments can be delivered using non-uniform dose distributions selectively aimed at reducing the dose to critical organs-at-risk while still adequately covering the tumor target. Dose-volume constraints for the different risk organs play a vital role in one's ability to devise the best IMRT treatment plan for a head and neck cancer patient. To this end, it is pivotal to have access to the latest and most relevant dose constraints available and as such the goal of this review is to provide a summary of suggested dose-volume constraints for head and neck cancer RT that have been published after the QUANTEC reports were made available in early 2010.
Collapse
Affiliation(s)
- N Patrik Brodin
- Institute for Onco-Physics, Albert Einstein College of Medicine, Bronx, NY 10461, USA; Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY 10461, USA
| | - Wolfgang A Tomé
- Institute for Onco-Physics, Albert Einstein College of Medicine, Bronx, NY 10461, USA; Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY 10461, USA; Department of Neurology, Albert Einstein College of Medicine, Bronx, NY 10461, USA.
| |
Collapse
|
25
|
Radiation dose constraints for organs at risk in neuro-oncology; the European Particle Therapy Network consensus. Radiother Oncol 2018; 128:26-36. [PMID: 29779919 DOI: 10.1016/j.radonc.2018.05.001] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 04/16/2018] [Accepted: 05/01/2018] [Indexed: 12/25/2022]
Abstract
PURPOSE For unbiased comparison of different radiation modalities and techniques, consensus on delineation of radiation sensitive organs at risk (OARs) and on their dose constraints is warranted. Following the publication of a digital, online atlas for OAR delineation in neuro-oncology by the same group, we assessed the brain OAR-dose constraints in a follow-up study. METHODS We performed a comprehensive search to identify the current papers on OAR dose constraints for normofractionated photon and particle therapy in PubMed, Ovid Medline, Cochrane Library, Embase and Web of Science. Moreover, the included articles' reference lists were cross-checked for potential studies that met the inclusion criteria. Consensus was reached among 20 radiation oncology experts in the field of neuro-oncology. RESULTS For the OARs published in the neuro-oncology literature, we summarized the available literature and recommended dose constraints associated with certain levels of normal tissue complication probability (NTCP) according to the recent ICRU recommendations. For those OARs with lacking or insufficient NTCP data, a proposal for effective and efficient data collection is given. CONCLUSION The use of the European Particle Therapy Network-consensus OAR dose constraints summarized in this article is recommended for the model-based approach comparing photon and proton beam irradiation as well as for prospective clinical trials including novel radiation techniques and/or modalities.
Collapse
|
26
|
Eekers DB, In 't Ven L, Roelofs E, Postma A, Alapetite C, Burnet NG, Calugaru V, Compter I, Coremans IEM, Høyer M, Lambrecht M, Nyström PW, Méndez Romero A, Paulsen F, Perpar A, de Ruysscher D, Renard L, Timmermann B, Vitek P, Weber DC, van der Weide HL, Whitfield GA, Wiggenraad R, Troost EGC. The EPTN consensus-based atlas for CT- and MR-based contouring in neuro-oncology. Radiother Oncol 2018; 128:37-43. [PMID: 29548560 DOI: 10.1016/j.radonc.2017.12.013] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 12/01/2017] [Accepted: 12/19/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE To create a digital, online atlas for organs at risk (OAR) delineation in neuro-oncology based on high-quality computed tomography (CT) and magnetic resonance (MR) imaging. METHODS CT and 3 Tesla (3T) MR images (slice thickness 1 mm with intravenous contrast agent) were obtained from the same patient and subsequently fused. In addition, a 7T MR without intravenous contrast agent was obtained from a healthy volunteer. Based on discussion between experienced radiation oncologists, the clinically relevant organs at risk (OARs) to be included in the atlas for neuro-oncology were determined, excluding typical head and neck OARs previously published. The draft atlas was delineated by a senior radiation oncologist, 2 residents in radiation oncology, and a senior neuro-radiologist incorporating relevant available literature. The proposed atlas was then critically reviewed and discussed by European radiation oncologists until consensus was reached. RESULTS The online atlas includes one CT-scan at two different window settings and one MR scan (3T) showing the OARs in axial, coronal and sagittal view. This manuscript presents the three-dimensional descriptions of the fifteen consensus OARs for neuro-oncology. Among these is a new OAR relevant for neuro-cognition, the posterior cerebellum (illustrated on 7T MR images). CONCLUSION In order to decrease inter- and intra-observer variability in delineating OARs relevant for neuro-oncology and thus derive consistent dosimetric data, we propose this atlas to be used in photon and particle therapy. The atlas is available online at www.cancerdata.org and will be updated whenever required.
Collapse
Affiliation(s)
- Daniëlle Bp Eekers
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, The Netherlands; Proton Therapy Department South-East Netherlands (ZON-PTC), Maastricht, The Netherlands.
| | - Lieke In 't Ven
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, The Netherlands
| | - Erik Roelofs
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, The Netherlands; The-D Lab: Decision Support for Precision Medicine, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre+, The Netherlands
| | - Alida Postma
- Department of Radiology and Nuclear Medicine MUMC+, Maastricht, The Netherlands
| | - Claire Alapetite
- Institut Curie, Radiation Oncology Department, Paris & Proton Center, Orsay, France
| | - Neil G Burnet
- University of Cambridge Department of Oncology, Addenbrooke's Hospital, United Kingdom
| | - Valentin Calugaru
- Institute Curie, Paris, France; Institute Curie, Centre de Protonthérapie d'Orsay, Orsay, France
| | - Inge Compter
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, The Netherlands
| | - Ida E M Coremans
- Leiden University Medical Centre, Department of Radiotherapy, The Netherlands; Holland Proton Therapy Centre, Delft, The Netherlands
| | - Morton Høyer
- Danish Center for Particle Therapy, Aarhus, Denmark
| | - Maarten Lambrecht
- Department of Radiotherapy-Oncology, Leuven Kanker Instituut, UZ Gasthuisberg, Belgium
| | - Petra Witt Nyström
- The Skandion Clinic, Uppsala, Sweden; Department of Immunology, Genetics and Pathology, Uppsala University, Sweden
| | - Alejandra Méndez Romero
- Holland Proton Therapy Centre, Delft, The Netherlands; Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Frank Paulsen
- Department of Radiation Oncology, Eberhard-Carls-Universität Tübingen, Germany
| | - Ana Perpar
- EBG MedAustron GmbH, Wiener Neustadt, Austria
| | - Dirk de Ruysscher
- Department of Radiation Oncology (MAASTRO), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, The Netherlands; Department of Radiotherapy-Oncology, Leuven Kanker Instituut, UZ Gasthuisberg, Belgium
| | - Laurette Renard
- Service de Radiothérapie Oncologique Cliniques universitaires St Luc, Brussels, Belgium
| | - Beate Timmermann
- Clinic for Particle Therapy, University Hospital Essen, West German Cancer Center (WTZ), Germany; West German Proton Therapy Center Essen (WPE), Germany; German Cancer Consortium (DKTK), partnersite Essen, Essen, Germany
| | - Pavel Vitek
- Proton Therapy Center Czech, Prague, Czech Republic
| | - Damien C Weber
- Paul Scherrer Institut med. Center for Proton Therapy, Switzerland
| | - Hiske L van der Weide
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Gillian A Whitfield
- The University of Manchester, Manchester Academic Health Science Centre, The Christie NHS Foundation Trust, United Kingdom; The Children's Brain Tumour Research Network, University of Manchester, Royal Manchester Children's Hospital, United Kingdom
| | - Ruud Wiggenraad
- Holland Proton Therapy Centre, Delft, The Netherlands; Haaglanden Medisch Centrum, Department of Radiotherapy, Leidschendam, The Netherlands
| | - Esther G C Troost
- Department of Radiation Oncology, Medical Faculty and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Institute of Radiooncology - OncoRay, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany; OncoRay - National Center for Radiation Research in Oncology, Dresden, Germany; German Cancer Consortium (DKTK), partnersite Dresden, Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; National Center for Tumor Diseases (NCT), partnersite Dresden, Dresden, Germany
| | | |
Collapse
|
27
|
Woods K, Lee P, Kaprealian T, Yang I, Sheng K. Cochlea-sparing acoustic neuroma treatment with 4π radiation therapy. Adv Radiat Oncol 2018; 3:100-107. [PMID: 29904732 PMCID: PMC6000182 DOI: 10.1016/j.adro.2018.01.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 12/28/2017] [Accepted: 01/31/2018] [Indexed: 11/04/2022] Open
Abstract
Purpose This study investigates whether 4π noncoplanar radiation therapy can spare the cochleae and consequently potentially improve hearing preservation in patients with acoustic neuroma who are treated with radiation therapy. Methods and materials Clinical radiation therapy plans for 30 patients with acoustic neuroma were included (14 stereotactic radiation surgery [SRS], 6 stereotactic radiation therapy [SRT], and 10 intensity modulated radiation therapy [IMRT]). The 4π plans were created for each patient with 20 optimal beams selected using a greedy column generation method and subsequently recalculated in Eclipse for comparison. Organ-at-risk (OAR) doses, homogeneity index, conformity, and tumor control probability (TCP) were compared. Normal tissue complication probability (NTCP) was calculated for sensorineural hearing loss (SNHL) at 3 and 5 years posttreatment. The dose for each plan was then escalated to achieve 99.5% TCP. Results 4π significantly reduced the mean dose to both cochleae by 2.0 Gy (32%) for SRS, 3.2 Gy (29%) for SRT, and 10.0 Gy (32%) for IMRT. The maximum dose to both cochleae was also reduced with 4π by 1.6 Gy (20%), 2.2 Gy (15%), and 7.1 Gy (18%) for SRS, SRT, and IMRT plans, respectively. The reductions in mean/maximum brainstem dose with 4π were also statistically significant. Mean doses to other OARs were reduced by 19% to 56% on average. 4π plans had a similar CN and TCP, with a significantly higher average homogeneity index (0.93 vs 0.92) and significantly lower average NTCP for SNHL at both 3 years (30.8% vs 40.8%) and 5 years (43.3% vs 61.7%). An average dose escalation of approximately 116% of the prescription dose achieved 99.5% TCP, which resulted in 32.6% and 43.4% NTCP for SNHL at 3 years and 46.4% and 64.7% at 5 years for 4π and clinical plans, respectively. Conclusions Compared with clinical planning methods, optimized 4π radiation therapy enables statistically significant sparing of the cochleae in acoustic neuroma treatment as well as lowering of other OAR doses, potentially reducing the risk of hearing loss.
Collapse
Affiliation(s)
- Kaley Woods
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Percy Lee
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Tania Kaprealian
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Isaac Yang
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California
| | - Ke Sheng
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| |
Collapse
|
28
|
Abdollahi H, Mostafaei S, Cheraghi S, Shiri I, Rabi Mahdavi S, Kazemnejad A. Cochlea CT radiomics predicts chemoradiotherapy induced sensorineural hearing loss in head and neck cancer patients: A machine learning and multi-variable modelling study. Phys Med 2018; 45:192-197. [DOI: 10.1016/j.ejmp.2017.10.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Revised: 10/05/2017] [Accepted: 10/14/2017] [Indexed: 12/30/2022] Open
|
29
|
Normal tissue complication probability modeling of radiation-induced sensorineural hearing loss after head-and-neck radiation therapy. Int J Radiat Biol 2017; 93:1327-1333. [DOI: 10.1080/09553002.2017.1385872] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
30
|
Brodin NP, Kabarriti R, Garg MK, Guha C, Tomé WA. Systematic Review of Normal Tissue Complication Models Relevant to Standard Fractionation Radiation Therapy of the Head and Neck Region Published After the QUANTEC Reports. Int J Radiat Oncol Biol Phys 2017; 100:391-407. [PMID: 29353656 DOI: 10.1016/j.ijrobp.2017.09.041] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 09/02/2017] [Accepted: 09/21/2017] [Indexed: 12/21/2022]
Abstract
There has recently been an increasing interest in model-based evaluation and comparison of different treatment options in radiation oncology studies. This is partly driven by the considerable technical advancements in radiation therapy of the last decade, leaving radiation oncologists with a multitude of options to consider. In lieu of randomized trials comparing all of these different treatment options for varying indications, which is unfeasible, treatment evaluations based on normal tissue complication probability (NTCP) models offer a practical alternative. The Quantitative Analyses of Normal Tissue Effects in the Clinic (QUANTEC) effort, culminating in a number of reports published in 2010, provided a basis for many of the since-implemented dose-response models and dose-volume constraints and was a key component for model-based treatment evaluations. Given that 7 years have passed since the QUANTEC publications and that patient-reported outcomes have emerged as an important consideration in recent years, an updated summary of the published radiation dose-response literature, which includes a focus on patient-reported quality of life outcomes, is warranted. Here we provide a systematic review of quantitative dose-response models published after January 1, 2010 for endpoints relevant to radiation therapy for head and neck cancer, because these patients are typically at risk for a variety of treatment-induced normal tissue complications.
Collapse
Affiliation(s)
- N Patrik Brodin
- Institute for Onco-Physics, Department of Radiation Oncology, Albert Einstein College of Medicine, Bronx, New York; Department of Radiation Oncology, Montefiore Medical Center, Bronx, New York
| | - Rafi Kabarriti
- Institute for Onco-Physics, Department of Radiation Oncology, Albert Einstein College of Medicine, Bronx, New York; Department of Radiation Oncology, Montefiore Medical Center, Bronx, New York
| | - Madhur K Garg
- Institute for Onco-Physics, Department of Radiation Oncology, Albert Einstein College of Medicine, Bronx, New York; Department of Radiation Oncology, Montefiore Medical Center, Bronx, New York; Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Bronx, New York; Department of Urology, Montefiore Medical Center, Bronx, New York
| | - Chandan Guha
- Institute for Onco-Physics, Department of Radiation Oncology, Albert Einstein College of Medicine, Bronx, New York; Department of Radiation Oncology, Montefiore Medical Center, Bronx, New York; Department of Urology, Montefiore Medical Center, Bronx, New York; Department of Pathology, Albert Einstein College of Medicine, Bronx, New York
| | - Wolfgang A Tomé
- Institute for Onco-Physics, Department of Radiation Oncology, Albert Einstein College of Medicine, Bronx, New York; Department of Radiation Oncology, Montefiore Medical Center, Bronx, New York; Department of Neurology, Albert Einstein College of Medicine, Bronx, New York.
| |
Collapse
|
31
|
Hall DC, Trofimov AV, Winey BA, Liebsch NJ, Paganetti H. Predicting Patient-specific Dosimetric Benefits of Proton Therapy for Skull-base Tumors Using a Geometric Knowledge-based Method. Int J Radiat Oncol Biol Phys 2017; 97:1087-1094. [PMID: 28332994 PMCID: PMC5377911 DOI: 10.1016/j.ijrobp.2017.01.236] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Indexed: 01/24/2023]
Abstract
PURPOSE To predict the organ at risk (OAR) dose levels achievable with proton beam therapy (PBT), solely based on the geometric arrangement of the target volume in relation to the OARs. A comparison with an alternative therapy yields a prediction of the patient-specific benefits offered by PBT. This could enable physicians at hospitals without proton capabilities to make a better-informed referral decision or aid patient selection in model-based clinical trials. METHODS AND MATERIALS Skull-base tumors were chosen to test the method, owing to their geometric complexity and multitude of nearby OARs. By exploiting the correlations between the dose and distance-to-target in existing PBT plans, the models were independently trained for 6 types of OARs: brainstem, cochlea, optic chiasm, optic nerve, parotid gland, and spinal cord. Once trained, the models could estimate the feasible dose-volume histogram and generalized equivalent uniform dose (gEUD) for OAR structures of new patients. The models were trained using 20 patients and validated using an additional 21 patients. Validation was achieved by comparing the predicted gEUD to that of the actual PBT plan. RESULTS The predicted and planned gEUD were in good agreement. Considering all OARs, the prediction error was +1.4 ± 5.1 Gy (mean ± standard deviation), and Pearson's correlation coefficient was 93%. By comparing with an intensity modulated photon treatment plan, the model could classify whether an OAR structure would experience a gain, with a sensitivity of 93% (95% confidence interval: 87%-97%) and specificity of 63% (95% confidence interval: 38%-84%). CONCLUSIONS We trained and validated models that could quickly and accurately predict the patient-specific benefits of PBT for skull-base tumors. Similar models could be developed for other tumor sites. Such models will be useful when an estimation of the feasible benefits of PBT is desired but the experience and/or resources required for treatment planning are unavailable.
Collapse
Affiliation(s)
- David C Hall
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Alexei V Trofimov
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Brian A Winey
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Norbert J Liebsch
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|