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Nervo A, Retta F, Ragni A, Piovesan A, Gallo M, Arvat E. Management of Progressive Radioiodine-Refractory Thyroid Carcinoma: Current Perspective. Cancer Manag Res 2022; 14:3047-3062. [PMID: 36275786 PMCID: PMC9584766 DOI: 10.2147/cmar.s340967] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 10/13/2022] [Indexed: 11/23/2022] Open
Abstract
Patients with thyroid cancer (TC) usually have an excellent prognosis; however, 5-10% of them develop an advanced disease. The prognosis of this subgroup is still favourable if the lesions respond to radioactive iodine (RAI) treatment. Nearly two-thirds of advanced TC patients become RAI-refractory (RAI-R), and their management is challenging. A multidisciplinary approach in the context of a tumour board is essential to define a personalized strategy. Systemic therapy is not always the best option. In case of slow neoplastic growth and low tumour burden, active surveillance may represent a valuable choice. Local approaches might be considered if the disease progression is limited to a single or few lesions, also in combination and during systemic therapy. Antiresorptive treatment may be started in presence of bone metastases. In case of rapid and/or symptomatic progression involving multiple lesions and/or organs, systemic therapy has to be considered, in absence of contraindications. The multi-kinase inhibitors (MKIs) lenvatinib and sorafenib are currently available as first-line treatment for advanced progressive RAI-R TC. Among second-line options, cabozantinib has been recently approved in RAI-R TC who progressed during MKIs targeting the vascular endothelial growth factor receptor (VEGFR). In the last few years, next-generation sequencing (NGS) assays have been increasingly employed, permitting identification of the genetic alterations harboured by TC, with a significant impact on patients' management. Novel selective targeted therapies have been introduced for the treatment of RAI-R TC in selected cases: REarranged during Transfection (RET) inhibitors (selpercatinib and pralsetinib) and Tropomyosin Receptor Kinase (TRK) inhibitors (larotrectinib and entrectinib) have recently expanded the panorama of the therapeutic options. Moreover, immune checkpoint inhibitors (ICIs) have shown promising results, and they are still under investigation.
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Affiliation(s)
- Alice Nervo
- Oncological Endocrinology Unit, Department of Medical Sciences, Città Della Salute e Della Scienza Hospital, University of Turin, Turin, Italy,Correspondence: Alice Nervo, Oncological Endocrinology Unit, Department of Medical Sciences, Città Della Salute e Della Scienza Hospital, University of Turin, Via Genova 3, Turin, 10126, Italy, Tel +390116336611, Fax +390116334703, Email
| | - Francesca Retta
- Oncological Endocrinology Unit, Department of Medical Sciences, Città Della Salute e Della Scienza Hospital, University of Turin, Turin, Italy
| | - Alberto Ragni
- Endocrinology and Metabolic Diseases Unit, AO SS. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Alessandro Piovesan
- Oncological Endocrinology Unit, Department of Medical Sciences, Città Della Salute e Della Scienza Hospital, University of Turin, Turin, Italy
| | - Marco Gallo
- Endocrinology and Metabolic Diseases Unit, AO SS. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Emanuela Arvat
- Oncological Endocrinology Unit, Department of Medical Sciences, Città Della Salute e Della Scienza Hospital, University of Turin, Turin, Italy
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Kuah T, Vellayappan BA, Makmur A, Nair S, Song J, Tan JH, Kumar N, Quek ST, Hallinan JTPD. State-of-the-Art Imaging Techniques in Metastatic Spinal Cord Compression. Cancers (Basel) 2022; 14:cancers14133289. [PMID: 35805059 PMCID: PMC9265325 DOI: 10.3390/cancers14133289] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/24/2022] [Accepted: 06/28/2022] [Indexed: 12/23/2022] Open
Abstract
Metastatic Spinal Cord Compression (MSCC) is a debilitating complication in oncology patients. This narrative review discusses the strengths and limitations of various imaging modalities in diagnosing MSCC, the role of imaging in stereotactic body radiotherapy (SBRT) for MSCC treatment, and recent advances in deep learning (DL) tools for MSCC diagnosis. PubMed and Google Scholar databases were searched using targeted keywords. Studies were reviewed in consensus among the co-authors for their suitability before inclusion. MRI is the gold standard of imaging to diagnose MSCC with reported sensitivity and specificity of 93% and 97% respectively. CT Myelogram appears to have comparable sensitivity and specificity to contrast-enhanced MRI. Conventional CT has a lower diagnostic accuracy than MRI in MSCC diagnosis, but is helpful in emergent situations with limited access to MRI. Metal artifact reduction techniques for MRI and CT are continually being researched for patients with spinal implants. Imaging is crucial for SBRT treatment planning and three-dimensional positional verification of the treatment isocentre prior to SBRT delivery. Structural and functional MRI may be helpful in post-treatment surveillance. DL tools may improve detection of vertebral metastasis and reduce time to MSCC diagnosis. This enables earlier institution of definitive therapy for better outcomes.
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Affiliation(s)
- Tricia Kuah
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
- Correspondence: ; Tel.: +65-6779-5555
| | - Balamurugan A. Vellayappan
- Department of Radiation Oncology, National University Cancer Institute Singapore, National University Hospital, Singapore 119074, Singapore;
| | - Andrew Makmur
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597, Singapore
| | - Shalini Nair
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
| | - Junda Song
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
| | - Jiong Hao Tan
- University Spine Centre, Department of Orthopaedic Surgery, National University Health System, 1E Lower Kent Ridge Road, Singapore 119228, Singapore; (J.H.T.); (N.K.)
| | - Naresh Kumar
- University Spine Centre, Department of Orthopaedic Surgery, National University Health System, 1E Lower Kent Ridge Road, Singapore 119228, Singapore; (J.H.T.); (N.K.)
| | - Swee Tian Quek
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597, Singapore
| | - James Thomas Patrick Decourcy Hallinan
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597, Singapore
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Kowalchuk RO, Cousins D, Spencer KM, Richardson KM, Larner JM, Showalter TN, McAllister WH, Sheehan JP, Kersh CR, Dutta SW. Local control of 1-5 fraction radiotherapy regimens for spinal metastases: an analysis of the impacts of biologically effective dose and primary histology. Rep Pract Oncol Radiother 2021; 26:883-891. [PMID: 34992859 PMCID: PMC8726428 DOI: 10.5603/rpor.a2021.0099] [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: 04/18/2021] [Accepted: 07/18/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND This analysis evaluates the impacts of biologically effective dose (BED) and histology on local control (LC) of spinal metastases treated with highly conformal radiotherapy to moderately-escalated doses. MATERIALS AND METHODS Patients were treated at two institutions from 2010-2020. Treatments with less than 5 Gy per fraction or 8 Gy in 1 fraction were excluded. The dataset was divided into three RPA classes predictive of survival (1). The primary endpoint was LC. RESULTS 223 patients with 248 treatments met inclusion criteria. Patients had a median Karnofsky Performance Status (KPS ) of 80, and common histologies included breast (29.4%), non-small cell lung cancer (15.7%), and prostate (13.3%). A median 24 Gy was delivered in 3 fractions (BED: 38.4 Gy) to a median planning target volume (PTV) of 37.3 cc. 2-year LC was 75.7%, and 2-year OS was 42.1%. Increased BED was predictive of improved LC for primary prostate cancer (HR = 0.85, 95% CI: 0.74-0.99). Patients with favorable survival (RPA class 1) had improved LC with BED ≥ 40 Gy (p = 0.05), unlike the intermediate and poor survival groups. No grade 3-5 toxicities were reported. CONCLUSIONS Moderately-escalated treatments were efficacious and well-tolerated. BED ≥ 40 Gy may improve LC, particularly for prostate cancer and patients with favorable survival.
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Affiliation(s)
| | - David Cousins
- Department of Radiation Oncology, University of Virginia, Charlottesville, United States
| | - Kelly M. Spencer
- Radiosurgery Center, University of Virginia/Riverside, Newport News, United States
| | - K. Martin Richardson
- Radiosurgery Center, University of Virginia/Riverside, Newport News, United States
| | - James M. Larner
- Department of Radiation Oncology, University of Virginia, Charlottesville, United States
| | - Timothy N. Showalter
- Department of Radiation Oncology, University of Virginia, Charlottesville, United States
| | - William H. McAllister
- Department of Neurosurgery, Riverside Regional Medical Center, Newport News, United States
| | - Jason P. Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, United States
| | - C. Ronald Kersh
- Radiosurgery Center, University of Virginia/Riverside, Newport News, United States
| | - Sunil W. Dutta
- Department of Radiation Oncology, Emory University, Atlanta, United States
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Li J, Zhang X, Pan Y, Zhuang H, Wang J, Yang R. Assessment of Delivery Quality Assurance for Stereotactic Radiosurgery With Cyberknife. Front Oncol 2021; 11:751922. [PMID: 34868957 PMCID: PMC8635503 DOI: 10.3389/fonc.2021.751922] [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: 08/02/2021] [Accepted: 10/26/2021] [Indexed: 11/25/2022] Open
Abstract
Purpose The purpose of this study is to establish and assess a practical delivery quality assurance method for stereotactic radiosurgery with Cyberknife by analyzing the geometric and dosimetric accuracies obtained using a PTW31016 PinPoint ionization chamber and EBT3 films. Moreover, this study also explores the relationship between the parameters of plan complexity, target volume, and deliverability parameters and provides a valuable reference for improving plan optimization and validation. Methods One hundred fifty cases of delivery quality assurance plans were performed on Cyberknife to assess point dose and planar dose distribution, respectively, using a PTW31016 PinPoint ionization chamber and Gafchromic EBT3 films. The measured chamber doses were compared with the planned mean doses in the sensitive volume of the chamber, and the measured planar doses were compared with the calculated dose distribution using gamma index analysis. The gamma passing rates were evaluated using the criteria of 3%/1 mm and 2%/2 mm. The statistical significance of the correlations between the complexity metrics, target volume, and the gamma passing rate were analyzed using Spearman’s rank correlation coefficient. Results For point dose comparison, the averaged dose differences (± standard deviations) were 1.6 ± 0.73% for all the cases. For planar dose distribution, the mean gamma passing rate for 3%/1 mm, and 2%/2 mm evaluation criteria were 94.26% ± 1.89%, and 93.86% ± 2.16%, respectively. The gamma passing rates were higher than 90% for all the delivery quality assurance plans with the criteria of 3%/1 mm and 2%/2 mm. The difference in point dose was lowly correlated with volume of PTV, number of beams, and treatment time for 150 DQA plans, and highly correlated with volume of PTV for 18 DQA plans of small target. DQA gamma passing rate (2%/2 mm) was a moderate significant correlation for the number of nodes, number of beams and treatment time, and a low correlation with MU. Conclusion PTW31016 PinPoint ionization chamber and EBT3 film can be used for routine Cyberknife delivery quality assurance. The point dose difference should be within 3%. The gamma passing rate should be higher than 90% for the criteria of 3%/1 mm and 2%/2 mm. In addition, the plan complexity and PTV volume were found to have some influence on the plan deliverability.
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Affiliation(s)
- Jun Li
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Xile Zhang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Yuxi Pan
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Hongqing Zhuang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Junjie Wang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Ruijie Yang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
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Qi Y, Li J, Zhang Y, Shao Q, Liu X, Li F, Wang J, Li Z, Wang W. Effect of abdominal compression on target movement and extension of the external boundary of peripheral lung tumours treated with stereotactic radiotherapy based on four-dimensional computed tomography. Radiat Oncol 2021; 16:173. [PMID: 34493303 PMCID: PMC8425044 DOI: 10.1186/s13014-021-01889-0] [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: 04/27/2021] [Accepted: 08/16/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study aimed to investigate the effect of abdominal compression on tumour motion and target volume and to determine suitable planning target volume (PTV) margins for patients treated with lung stereotactic body radiotherapy (SBRT) based on four-dimensional computed tomography (4DCT). METHODS Twenty-three patients diagnosed to have a peripheral pulmonary tumour were selected and divided into an all lesions group (group A), an upper middle lobe lesions group (group B), and a lower lobe lesions group (group C). Two 4DCT scans were performed in each patient, one with and one without abdominal compression. Cone beam computed tomography (CBCT) was performed before starting treatment. The gross target volumes (GTVs) were delineated and internal gross target volumes (IGTVs) were defined. IGTVs were generated using two methods: (1) the maximum intensity projections (MIPs) based on the 4DCT were reconstructed to form a single volume and defined as the IGTVMIP and (2) GTVs from all 10 phases were combined to form a single volume and defined as the IGTV10. A 5-mm, 4-mm, and 3-mm margin was added in all directions on the IGTVMIP and the volume was constructed as PTVMIP5mm, PTVMIP4mm, and PTVMIP3mm. RESULTS There was no significant difference in the amplitude of tumour motion in the left-right, anterior-posterior, or superior-inferior direction according to whether or not abdominal compression was applied (group A, p = 0.43, 0.27, and 0.29, respectively; group B, p = 0.46, 0.15, and 0.45; group C, p = 0.79, 0.86, and 0.37; Wilcoxon test). However, the median IGTVMIP without abdominal compression was 33.67% higher than that with compression (p = 0.00), and the median IGTV10 without compression was 16.08% higher than that with compression (p = 0.00). The median proportion of the degree of inclusion of the IGTVCBCT in PTVMIP5mm, PTVMIP4mm, and PTVMIP3mm ≥ 95% was 100%, 100%, and 83.33%, respectively. CONCLUSIONS Abdominal compression was useful for reducing the size of the IGTVMIP and IGTV10 and for decreasing the PTV margins based on 4DCT. In IGTVMIP with abdominal compression, adding a 4-mm margin to account for respiration is feasible in SBRT based on 4DCT.
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Affiliation(s)
- Yuanjun Qi
- Shandong First Medical University and Shandong Academy of Medical Sciences and Now Studies at Shandong Cancer Hospital and Institute , Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, China
| | - Jianbin Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, 440 Jiyan Road, Jinan, 250117, Shandong Province, China.
| | - Yingjie Zhang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, 440 Jiyan Road, Jinan, 250117, Shandong Province, China.
| | - Qian Shao
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, 440 Jiyan Road, Jinan, 250117, Shandong Province, China
| | - Xijun Liu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, 440 Jiyan Road, Jinan, 250117, Shandong Province, China
| | - Fengxiang Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, 440 Jiyan Road, Jinan, 250117, Shandong Province, China
| | - Jinzhi Wang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, 440 Jiyan Road, Jinan, 250117, Shandong Province, China
| | - Zhenxiang Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, 440 Jiyan Road, Jinan, 250117, Shandong Province, China
| | - Wei Wang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, 440 Jiyan Road, Jinan, 250117, Shandong Province, China
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Kroeze SGC, Schaule J, Fritz C, Kaul D, Blanck O, Kahl KH, Roeder F, Siva S, Verhoeff JJC, Adebahr S, Schymalla MM, Glatzer M, Szuecs M, Geier M, Skazikis G, Sackerer I, Lohaus F, Eckert F, Guckenberger M. Metastasis directed stereotactic radiotherapy in NSCLC patients progressing under targeted- or immunotherapy: efficacy and safety reporting from the 'TOaSTT' database. Radiat Oncol 2021; 16:4. [PMID: 33407611 PMCID: PMC7788768 DOI: 10.1186/s13014-020-01730-0] [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: 10/28/2020] [Accepted: 12/06/2020] [Indexed: 12/25/2022] Open
Abstract
Background Metastasis directed treatment (MDT) is increasingly performed with the attempt to improve outcome in non-small cell lung cancer (NSCLC) patients receiving targeted- or immunotherapy (TT/IT). This study aimed to assess the safety and efficacy of metastasis directed stereotactic radiotherapy (SRT) concurrent to TT/IT in NSCLC patients. Methods A retrospective multicenter cohort of stage IV NSCLC patients treated with TT/IT and concurrent (≤ 30 days) MDT was established. 56% and 44% of patients were treated for oligoprogressive disease (OPD) or polyprogressive disease (PPD) under TT/IT, polyprogressive respectively. Survival was analyzed using Kaplan–Meier and log rank testing. Toxicity was scored using CTCAE v4.03 criteria. Predictive factors for overall survival (OS), progression free survival (PFS) and time to therapy switch (TTS) were analyzed with uni- and multivariate analysis. Results MDT of 192 lesions in 108 patients was performed between 07/2009 and 05/2018. Concurrent TT/IT consisted of EGFR/ALK-inhibitors (60%), immune checkpoint inhibitors (31%), VEGF-antibodies (8%) and PARP-inhibitors (1%). 2y-OS was 51% for OPD and 25% for PPD. After 1 year, 58% of OPD and 39% of PPD patients remained on the same TT/IT. Second progression after MDT was oligometastatic (≤ 5 lesions) in 59% of patients. Severe acute and late toxicity was observed in 5.5% and 1.9% of patients. In multivariate analysis, OS was influenced by the clinical metastatic status (p = 0.002, HR 2.03, 95% CI 1.30–3.17). PFS was better in patients receiving their first line of systemic treatment (p = 0.033, HR 1.7, 95% CI 1.05–2.77) and with only one metastases-affected organ (p = 0.023, HR 2.04, 95% CI 1.10–3.79). TTS was 6 months longer in patients with one metastases-affected organ (p = 0.031, HR 2.53, 95% CI 1.09–5.89). Death was never therapy-related. Conclusions Metastases-directed SRT in NSCLC patients can be safely performed concurrent to TT/IT with a low risk of severe toxicity. To find the ideal sequence of the available multidisciplinary treatment options for NSCLC and determine what patients will benefit most, a further evaluated in a broader context within prospective clinical trials is needed continuation of TT/IT beyond progression combined with MDT for progressive lesions appears promising but requires prospective evaluation. Trial registration: retrospectively registered
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Affiliation(s)
- Stephanie G C Kroeze
- Department of Radiation Oncology, University Hospital Zürich, Rämistrasse 100, 8091, Zürich, Switzerland.
| | - Jana Schaule
- Department of Radiation Oncology, University Hospital Zürich, Rämistrasse 100, 8091, Zürich, Switzerland
| | - Corinna Fritz
- Department of Radiation Oncology, Marienhospital Stuttgart, Böheimstrasse 37, 70199, Stuttgart, Germany
| | - David Kaul
- Department of Radiation Oncology, Charité-University Hospital Berlin, Charitestraße 1, 10117, Berlin, Germany
| | - Oliver Blanck
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Arnold-Heller-Straße 3, Haus 50, 24105, Kiel, Germany
| | - Klaus H Kahl
- Department of Radiation Oncology, University Clinic Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany
| | - Falk Roeder
- Department of Radiation Oncology, University Hospital Munich, Georgenstraße 5, 80799, Munich, Germany
| | - Shankar Siva
- Department Or Radiation Oncology, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC, 3000, Australia
| | - Joost J C Verhoeff
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Sonja Adebahr
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg and German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Markus M Schymalla
- Department of Radiation Oncology, Philipps-University Marburg, Baldingerstraße, 35043, Marburg, Germany
| | - Markus Glatzer
- Department of Radiation Oncology, Saint Gallen Cantonal Hospital, Rorschacher Str. 95/Haus 03, 9007, St. Gallen, Switzerland
| | - Marcella Szuecs
- Department of Radiation Oncology, University Hospital Rostock, Südring 75, 18059, Rostock, Germany
| | - Michael Geier
- Department of Radiation Oncology, Ordensklinikum Linz, Fadingerstraße 1, 4020, Linz, Austria
| | - Georgios Skazikis
- Department of Radiation Oncology, Schwarzwald-Baar Klinikum, Klinikstraße 11, 78050, Villingen-Schwenningen, Germany
| | - Irina Sackerer
- Department of Radiation Oncology, Strahlentherapie Freising Und Dachau, Biberstraße 15, 85354, Freising, Germany
| | - Fabian Lohaus
- Department of Radiation Oncology, University Hospital Dresden, Händelallee 28, 01309, Dresden, Germany
| | - Franziska Eckert
- Department of Radiation Oncology, University Hospital Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zürich, Rämistrasse 100, 8091, Zürich, Switzerland
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Colombo C, Giancola N, Fugazzola L. Personalized treatment for differentiated thyroid cancer: current data and new perspectives. Minerva Endocrinol (Torino) 2020; 46:62-89. [PMID: 33213119 DOI: 10.23736/s2724-6507.20.03342-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
More conservative and personalized treatment options have been developed in recent years to face the rising diagnosis of low-risk differentiated thyroid carcinoma (DTC). The present review describes the change towards a more risk-adapted management either in the treatment or in the follow-up of DTC. Particular attention is given to the innovations introduced by the latest guidelines for low-risk tumors, starting from the most appropriate extension of surgery up to the postoperative management. The emerging role of active surveillance for low-risk microcarcinoma is discussed, as well as the development of percutaneous strategies in the setting of malignant thyroid disease. The recent use of approved new systemic target therapies for advanced radioiodine refractory thyroid cancer is reported, together with the description of new compounds in trial. Finally, we provide some considerations to improve the risk evaluation in a presurgical setting, especially related to the rising role of genetics, to enable better risk-based cancer management and personalized treatment choices.
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Affiliation(s)
- Carla Colombo
- Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy - .,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy -
| | - Noemi Giancola
- Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Laura Fugazzola
- Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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A single-institutional experience with low dose stereotactic body radiation therapy for liver metastases. Rep Pract Oncol Radiother 2020; 25:987-993. [PMID: 33100916 DOI: 10.1016/j.rpor.2020.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 08/07/2020] [Accepted: 09/10/2020] [Indexed: 12/25/2022] Open
Abstract
AIM This study reports a single-institutional experience treating liver metastases with stereotactic body radiation therapy (SBRT). MATERIALS AND METHODS 107 patients with 169 lesions were assessed to determine factors predictive for local control, radiographic response, and overall survival (OS). Machine learning techniques, univariate analysis, and the Kaplan-Meier method were utilized. RESULTS Patients were treated with a relatively low median dose of 30 Gy in 3 fractions. Fractions were generally delivered once weekly. Median biologically effective dose (BED) was 60 Gy, and the median gross tumor volume (GTV) was 12.16 cc. Median follow-up was 7.36 months. 1-year local control was 75% via the Kaplan-Meier method. On follow-up imaging, 43%, 40%, and 17% of lesions were decreased, stable, and increased in size, respectively. 1-year OS was 46% and varied by primary tumor, with median OS of 34.3, 25.1, 12.5, and 4.6 months for ovarian, breast, colorectal, and lung primary tumors, respectively. Breast and ovarian primary patients had better OS (p < 0.0001), and lung primary patients had worse OS (p = 0.032). Higher BED values, the number of hepatic lesions, and larger GTV were not predictive of local control, radiographic response, or OS. 21% of patients suffered from treatment toxicity, but no grade ≥3 toxicity was reported. CONCLUSION Relatively low-dose SBRT for liver metastases demonstrated efficacy and minimal toxicity, even for patients with large tumors or multiple lesions. This approach may be useful for patients in whom higher-dose therapy is contraindicated or associated with high risk for toxicity. OS depends largely on the primary tumor.
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Tjong MC, Moraes FY, Yamada Y, Brar S, Cederquist GY, Yorke E, Schmitt AM, Shultz DB. Radiation-induced Lumbosacral Plexopathy after Spine Stereotactic Body Radiotherapy - Should the Lumbosacral Plexi be Contoured? Clin Oncol (R Coll Radiol) 2020; 32:884-886. [PMID: 33082091 DOI: 10.1016/j.clon.2020.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 10/01/2020] [Indexed: 11/19/2022]
Affiliation(s)
- M C Tjong
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - F Y Moraes
- Department of Radiation Oncology, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Y Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - S Brar
- Division of Surgical Oncology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - G Y Cederquist
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - E Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - A M Schmitt
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - D B Shultz
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.
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10
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Vargas E, Susko MS, Mummaneni PV, Braunstein SE, Chou D. Vertebral body fracture rates after stereotactic body radiation therapy compared with external-beam radiation therapy for metastatic spine tumors. J Neurosurg Spine 2020; 33:870-876. [PMID: 32796141 DOI: 10.3171/2020.5.spine191383] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 05/11/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Stereotactic body radiation therapy (SBRT) is utilized to deliver highly conformal, dose-escalated radiation to a target while sparing surrounding normal structures. Spinal SBRT can allow for durable local control and palliation of disease while minimizing the risk of damage to the spinal cord; however, spinal SBRT has been associated with an increased risk of vertebral body fractures. This study sought to compare the fracture rates between SBRT and conventionally fractionated external-beam radiation therapy (EBRT) in patients with metastatic spine tumors. METHODS Records from patients treated at the University of California, San Francisco, with radiation therapy for metastatic spine tumors were retrospectively reviewed. Vertebral body fracture and local control rates were compared between SBRT and EBRT. Ninety-six and 213 patients were identified in the SBRT and EBRT groups, respectively. Multivariate analysis identified the need to control for primary tumor histology (p = 0.003 for prostate cancer, p = 0.0496 for renal cell carcinoma). The patient-matched EBRT comparison group was created by matching SBRT cases using propensity scores for potential confounders, including the Spinal Instability Neoplastic Score (SINS), the number and location of spine levels treated, sex, age at treatment, duration of follow-up (in months) after treatment, and primary tumor histology. Covariate balance following group matching was confirmed using the Student t-test for unequal variance. Statistical analysis, including propensity score matching and multivariate analysis, was performed using R software and related packages. RESULTS A total of 90 patients met inclusion criteria, with 45 SBRT and 45 EBRT matched cases. Balance of the covariates, SINS, age, follow-up time, and primary tumor histology after the matching process was confirmed between groups (p = 0.062, p = 0.174, and 0.991, respectively, along with matched tumor histology). The SBRT group had a higher 5-year rate of vertebral body fracture at 22.22% (n = 10) compared with 6.67% (n = 3) in the EBRT group (p = 0.044). Survival analysis was used to adjust for uneven follow-up time and showed a significant difference in fracture rates between the two groups (p = 0.044). SBRT also was associated with a higher rate of local control (86.67% vs 77.78%). CONCLUSIONS Patients with metastatic cancer undergoing SBRT had higher rates of vertebral body fractures compared with patients undergoing EBRT, and this difference held up after survival analysis. SBRT also had higher rates of initial local control than EBRT but this difference did not hold up after survival analysis, most likely because of a high percentage of radiosensitive tumors in the EBRT cohort.
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Affiliation(s)
- Enrique Vargas
- Departments of1Neurosurgery and
- 3School of Medicine, University of California, San Francisco, California
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11
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Roggen T, Bobic M, Givehchi N, Scheib SG. Deep Learning model for markerless tracking in spinal SBRT. Phys Med 2020; 74:66-73. [PMID: 32422577 DOI: 10.1016/j.ejmp.2020.04.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 04/26/2020] [Accepted: 04/28/2020] [Indexed: 12/31/2022] Open
Abstract
Stereotactic Body Radiation Therapy (SBRT), alternatively termed Stereotactic ABlative Radiotherapy (SABR) or Stereotactic RadioSurgery (SRS), delivers high dose with a sub-millimeter accuracy. It requires meticulous precautions on positioning, as sharp dose gradients near critical neighboring structures (e.g. the spinal cord for spinal tumor treatment) are an important clinical objective to avoid complications such as radiation myelopathy, compression fractures, or radiculopathy. To allow for dose escalation within the target without compromising the dose to critical structures, proper immobilization needs to be combined with (internal) motion monitoring. Metallic fiducials, as applied in prostate, liver or pancreas treatments, are not suitable in clinical practice for spine SBRT. However, the latest advances in Deep Learning (DL) allow for fast localization of the vertebrae as landmarks. Acquiring projection images during treatment delivery allows for instant 2D position verification as well as sequential (delayed) 3D position verification when incorporated in a Digital TomoSynthesis (DTS) or Cone Beam Computed Tomography (CBCT). Upgrading to an instant 3D position verification system could be envisioned with a stereoscopic kilovoltage (kV) imaging setup. This paper describes a fast DL landmark detection model for vertebra (trained in-house) and evaluates its accuracy to detect 2D motion of the vertebrae with the help of projection images acquired during treatment. The introduced motion consists of both translational and rotational variations, which are detected by the DL model with a sub-millimeter accuracy.
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Affiliation(s)
- Toon Roggen
- Varian Medical Systems Imaging Laboratory, Taefernstrasse 7, 5405 Daettwil AG, Switzerland.
| | - Mislav Bobic
- Varian Medical Systems Imaging Laboratory, Taefernstrasse 7, 5405 Daettwil AG, Switzerland
| | - Nasim Givehchi
- Varian Medical Systems Imaging Laboratory, Taefernstrasse 7, 5405 Daettwil AG, Switzerland
| | - Stefan G Scheib
- Varian Medical Systems Imaging Laboratory, Taefernstrasse 7, 5405 Daettwil AG, Switzerland
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12
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Gu H, Sun L, Dou Z, Kong C, Zu J, Xiao J, Jiang T, Li N. Analysis of lung adenocarcinoma with bone metastasis: a case report. Transl Lung Cancer Res 2020; 9:389-392. [PMID: 32420080 PMCID: PMC7225164 DOI: 10.21037/tlcr.2020.03.11] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Lung adenocarcinoma is one of the most common types of lung cancer, and patients with epidermal growth factor receptor (EGFR) mutation-positive can be intervened with EGFR-TKI therapy to achieve longer survival. AURA3 study showed that patients resistant with the first generation of EGFR-TKI and with T790M mutation still received longer progression-free survival (PFS) after treatment with the third generation of EGFR-TKI osimertinib, and osimertinib also had a good effect on brain metastasis. Moreover, the FLAURA study published by the European Society of Medical Oncology (ESMO) in 2019 showed that the first line use of osimertinib could achieve a PFS of 18.9 months. In recent years, researches on lung cancer seem like blooming flowers. The new treatment mode for lung cancer treatment such as anti-angiogenic drugs, immunotherapy programs has satisfactory efficacy either alone or in combination. Notably, patients with lung adenocarcinoma often have single or multiple bone metastasis, which brings great suffering to patients, especially when metastases occurred in the weight-bearing bone. However, there is no solid evidence to prove that chemotherapy, targeted therapy, anti-angiogenic drugs, or immunotherapy have long-term efficacy in bone metastasis of lung adenocarcinoma. The present strategies for bone metastasis of lung cancer include of: palliative care, analgesia, improvement of bone metabolism, local radiotherapy, and radionuclide therapy. However, by far, no medical treatment has a significant advantage in inhibiting the course of bone metastasis in lung cancer at the source. In this case, patient with advanced lung adenocarcinoma and EGFR mutation was resistant with the first generation of EGFR-TKI treatment, and after detection of T790M mutation, we switched to osimertinib for primary disease control, bone metastasis was still obvious, and there was still no obvious effect after pain relief, bone metabolism improvement and local radiotherapy. This case is reported to suggest that further efforts in anti-tumor and palliative treatment in bone metastasis of lung adenocarcinoma are urgently needed.
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Affiliation(s)
- Haibo Gu
- Department of Respiratory, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu 310009, China
| | - Li Sun
- Department of Respiratory, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu 310009, China
| | - Zhengwei Dou
- Department of Respiratory, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu 310009, China
| | - Chengying Kong
- Department of Respiratory, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu 310009, China
| | - Jun Zu
- Department of Respiratory, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu 310009, China
| | - Jian Xiao
- Department of Respiratory, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu 310009, China
| | - Tao Jiang
- Department of Respiratory, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu 310009, China
| | - Ning Li
- Department of Respiratory, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu 310009, China
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13
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Kim WB, Jeon MJ, Kim WG, Kim TY, Shong YK. Unmet Clinical Needs in the Treatment of Patients with Thyroid Cancer. Endocrinol Metab (Seoul) 2020; 35:14-25. [PMID: 32207260 PMCID: PMC7090306 DOI: 10.3803/enm.2020.35.1.14] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 02/17/2020] [Accepted: 02/24/2020] [Indexed: 12/13/2022] Open
Abstract
The increased incidence of thyroid cancer is a worldwide phenomenon; however, the issue of overdiagnosis has been most prominent in South Korea. The age-standardized mortality rate of thyroid cancer in Korea steeply increased from 1985 to 2004 (from 0.17 per 100,000 to 0.85 per 100,000), and then decreased until 2015 to 0.42 per 100,000, suggesting that early detection reduced mortality. However, early detection of thyroid cancer may be cost-ineffective, considering its very high prevalence and indolent course. Therefore, risk stratification and tailored management are vitally important, but many prognostic markers can only be evaluated postoperatively. Discovery of preoperative marker(s), especially for small cancers, is the most important unmet clinical need for thyroid cancer. Herein, we discuss some such factors that we recently discovered. Another unmet clinical need is better treatment of radioiodine-refractory (RAIR) differentiated thyroid cancer (DTC) and undifferentiated cancers. Although sorafenib and lenvatinib are available, better drugs are needed. We found that phosphoglycerate dehydrogenase, a critical enzyme for serine biosynthesis, could be a novel therapeutic target, and that the lymphocyte-to-monocyte ratio is a prognostic marker of survival in patients with anaplastic thyroid carcinoma or RAIR DTC. Deeper insights are needed into tumor-host interactions in thyroid cancer to improve treatment.
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Affiliation(s)
- Won Bae Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Min Ji Jeon
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won Gu Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Yong Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Kee Shong
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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14
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Fugazzola L, Elisei R, Fuhrer D, Jarzab B, Leboulleux S, Newbold K, Smit J. 2019 European Thyroid Association Guidelines for the Treatment and Follow-Up of Advanced Radioiodine-Refractory Thyroid Cancer. Eur Thyroid J 2019; 8:227-245. [PMID: 31768334 PMCID: PMC6873012 DOI: 10.1159/000502229] [Citation(s) in RCA: 154] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 07/19/2019] [Indexed: 01/03/2023] Open
Abstract
The vast majority of thyroid cancers of follicular origin (TC) have a very favourable outcome, but 5-10% of cases will develop metastatic disease. Around 60-70% of this subset, hence less than 5% of all patients with TC, will become radioiodine refractory (RAI-R), with a significant negative impact on prognosis and a mean life expectancy of 3-5 years. Since no European expert consensus or guidance for this challenging condition is currently available, a task force of TC experts was nominated by the European Thyroid Association (ETA) to prepare this document based on the principles of clinical evidence. The task force started to work in September 2018 and after several revision rounds, prepared a list of recommendations to support the treatment and follow-up of patients with advanced TC. Criteria for advanced RAI-R TC were proposed, and the most appropriate diagnostic tools and the local, systemic and palliative treatments are described. Systemic therapy with multikinase inhibitors is fully discussed, including recommendations on how to start it and at which dosage, on the duration of treatment, and on the management of side effects. The appropriate relationship between the specialist and the patient/family as well as ethical issues are covered. Based on the available studies and on personal experience, the experts provided 39 recommendations aimed to improve the management of advanced RAI-R TCs. Above all of them is the indication to treat and follow these patients in a specialized setting which allows the interaction between several specialists in a multidisciplinary team.
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Affiliation(s)
- Laura Fugazzola
- Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Rossella Elisei
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Dagmar Fuhrer
- Department of Endocrinology, Diabetes and Metabolism, Endocrine Tumour Center at West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Duisburg, Germany
| | - Barbara Jarzab
- Department of Nuclear Medicine and Endocrine Oncology, Maria Sklodowska-Curie Institute, Oncology Center, Gliwice Branch, Gliwice, Poland
| | - Sophie Leboulleux
- Department of Nuclear Medicine and Endocrine Oncology, Gustave Roussy and Université Paris Saclay, Villejuif, France
| | - Kate Newbold
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, United Kingdom
| | - Jan Smit
- Division of Endocrinology, Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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15
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What Neuroradiologists Need to Know About Radiation Treatment for Neural Tumors. Top Magn Reson Imaging 2019; 28:37-47. [PMID: 31022047 DOI: 10.1097/rmr.0000000000000196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Radiation oncologists and radiologists have a unique and mutually dependent relationship. Radiation oncologists rely on diagnostic imaging to locate the tumor and define the treatment target volume, evaluation of response to therapy, and follow-up. Accurate interpretation of post-treatment imaging requires diagnostic radiologists to have a basic understanding of radiation treatment planning and delivery. There are various radiation treatment modalities such as 3D conformal radiation therapy, intensity modulated radiation therapy and stereotactic radiosurgery as well as different radiation modalities such as photons and protons that can be used for treatment. All of these have subtle differences in how the treatment is planned and how the imaging findings might be affected. This paper provides an overview of the basic principles of radiation oncology, different radiation treatment modalities, how radiation therapy is planned and delivered, how knowledge of this process can help interpretation of images, and how the radiologist can contribute to this process.
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16
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Mohindra P, Sawant A, Griffin RJ, Lamichhane N, Vlashi E, Xu‐Welliver M, Dominello M, Joiner MC, Burmeister J. Three discipline collaborative radiation therapy (3DCRT) special debate: I would treat all early-stage NSCLC patients with SBRT. J Appl Clin Med Phys 2019; 20:7-13. [PMID: 30793828 PMCID: PMC6414141 DOI: 10.1002/acm2.12545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 01/24/2019] [Accepted: 01/24/2019] [Indexed: 11/27/2022] Open
Affiliation(s)
- Pranshu Mohindra
- Department of Radiation OncologyUniversity of Maryland School of MedicineBaltimoreMDUSA
| | - Amit Sawant
- Department of Radiation OncologyUniversity of Maryland School of MedicineBaltimoreMDUSA
| | - Robert J. Griffin
- Department of Radiation OncologyUniversity of Arkansas for Medical SciencesLittle RockARUSA
| | - Narottam Lamichhane
- Department of Radiation OncologyUniversity of Maryland School of MedicineBaltimoreMDUSA
| | - Erina Vlashi
- Department of Radiation OncologyUniversity of California‐Los AngelesLos AngelesCAUSA
| | - Meng Xu‐Welliver
- Department of Radiation OncologyThe James Cancer CenterOhio State UniversityColumbusOHUSA
| | - Michael Dominello
- Department of OncologyWayne State University School of MedicineDetroitMIUSA
| | - Michael C. Joiner
- Department of OncologyWayne State University School of MedicineDetroitMIUSA
| | - Jay Burmeister
- Department of OncologyWayne State University School of MedicineDetroitMIUSA
- Gershenson Radiation Oncology CenterBarbara Ann Karmanos Cancer InstituteDetroitMIUSA
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