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Nielsen CP, Lorenzen EL, Jensen K, Eriksen JG, Johansen J, Gyldenkerne N, Zukauskaite R, Kjellgren M, Maare C, Lønkvist CK, Nowicka-Matus K, Szejniuk WM, Farhadi M, Ujmajuridze Z, Marienhagen K, Johansen TS, Friborg J, Overgaard J, Hansen CR. Interobserver variation in organs at risk contouring in head and neck cancer according to the DAHANCA guidelines. Radiother Oncol 2024; 197:110337. [PMID: 38772479 DOI: 10.1016/j.radonc.2024.110337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 04/24/2024] [Accepted: 05/14/2024] [Indexed: 05/23/2024]
Affiliation(s)
- Camilla Panduro Nielsen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Ebbe L Lorenzen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Kenneth Jensen
- Danish Centre for Particle Therapy, Aarhus University Hospital, Denmark
| | - Jesper Grau Eriksen
- Department of Oncology, Aarhus University Hospital, Denmark; Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
| | - Jørgen Johansen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Danish Centre for Particle Therapy, Aarhus University Hospital, Denmark; Department of Oncology, Odense University Hospital, Denmark
| | | | - Ruta Zukauskaite
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Department of Oncology, Odense University Hospital, Denmark
| | - Martin Kjellgren
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
| | - Christian Maare
- Department of Oncology, Copenhagen University Hospital Herlev, Denmark
| | | | - Kinga Nowicka-Matus
- Department of Oncology & Clinical Cancer Research Center, Aalborg University Hospital, Denmark
| | - Weronika Maria Szejniuk
- Danish Centre for Particle Therapy, Aarhus University Hospital, Denmark; Department of Oncology & Clinical Cancer Research Center, Aalborg University Hospital, Denmark; Department of Clinical Medicine, Aalborg University, Denmark
| | - Mohammad Farhadi
- Department of Oncology, Zealand University Hospital Næstved, Denmark
| | - Zaza Ujmajuridze
- Department of Oncology, Zealand University Hospital Næstved, Denmark
| | | | - Tanja Stagaard Johansen
- Danish Centre for Particle Therapy, Aarhus University Hospital, Denmark; Department of Oncology, Rigshospitalet, Denmark
| | | | - Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
| | - Christian Rønn Hansen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Danish Centre for Particle Therapy, Aarhus University Hospital, Denmark
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Hansen CR, Jensen K, Smulders B, Holm AIS, Samsøe E, Nielsen MS, Sibolt P, Skyt P, Elstrøm UV, Nielsen CP, Johansen J, Zukauskaite R, Eriksen JG, Farhadi M, Andersen M, Andersen E, Overgaard J, Grau C, Friborg J. Evaluation of decentralised model-based selection of head and neck cancer patients for a proton treatment study. DAHANCA 35. Radiother Oncol 2024; 190:109812. [PMID: 37479061 DOI: 10.1016/j.radonc.2023.109812] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 06/22/2023] [Accepted: 07/12/2023] [Indexed: 07/23/2023]
Abstract
INTRODUCTION Proton treatment can potentially spare patients with H&N cancer for substantial treatment-related toxicities. The current study investigated the reproducibility of a decentralised model-based selection of patients for a proton treatment study when the selection plans were compared to the clinical treatment plans performed at the proton centre. METHODS Sixty-three patients were selected for proton treatment in the six Danish Head and Neck Cancer (DAHANCA) centres. The patients were selected based on normal tissue complication probability (NTCP) estimated from local photon and proton treatment plans, which showed a ΔNTCP greater than 5%-point for either grade 2 + dysphagia or grade 2 + xerostomia at six months. The selection plans were compared to the clinical treatment plans performed at the proton centre. RESULTS Of the 63 patients, 49 and 25 were selected based on an estimated benefit in risk of dysphagia and xerostomia, respectively. Eleven patients had a potential gain in both toxicities. The mean ΔNTCP changed from the local selection plan comparison to the clinical comparison from 6.9 to 5.3 %-points (p = 0.01) and 7.3 to 4.9 %-points (p = 0.03) for dysphagia and xerostomia, respectively. Volume differences in both CTV and OAR could add to the loss in ΔNTCP. 61 of the 63 clinical plans had a positive ΔNTCP, and 38 had a ΔNTCP of 5%-points for at least one of the two endpoints. CONCLUSION A local treatment plan comparison can be used to select candidates for proton treatment. The local comparative proton plan overestimates the potential benefit of the clinical proton plan. Continuous quality assurance of the delineation procedures and planning is crucial in the subsequent randomised clinical trial setting.
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Affiliation(s)
- Christian Rønn Hansen
- Laboratory of Radiation Physics, Odense University Hospital, Denmark; Institute of Clinical Research, University of Southern Denmark, Denmark; Danish Center of Particle Therapy, Aarhus University Hospital, Denmark.
| | - Kenneth Jensen
- Danish Center of Particle Therapy, Aarhus University Hospital, Denmark
| | - Bob Smulders
- Danish Center of Particle Therapy, Aarhus University Hospital, Denmark; Department of Oncology, Rigshospitalet, Denmark
| | | | - Eva Samsøe
- Danish Center of Particle Therapy, Aarhus University Hospital, Denmark; Department of Oncology, Zealand University Hospital, Naestved, Denmark
| | | | - Patrik Sibolt
- Department of Oncology, Copenhagen University Hospital - Herlev & Gentofte, Herlev, Denmark
| | - Peter Skyt
- Danish Center of Particle Therapy, Aarhus University Hospital, Denmark
| | | | - Camilla Panduro Nielsen
- Laboratory of Radiation Physics, Odense University Hospital, Denmark; Institute of Clinical Research, University of Southern Denmark, Denmark
| | | | - Ruta Zukauskaite
- Institute of Clinical Research, University of Southern Denmark, Denmark; Department of Oncology, Odense University Hospital, Denmark
| | - Jesper Grau Eriksen
- Department of Oncology, Aarhus University Hospital, Denmark; Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
| | - Mohamma Farhadi
- Department of Oncology, Zealand University Hospital, Naestved, Denmark
| | - Maria Andersen
- Department of Oncology, Aalborg University Hospital, Denmark
| | - Elo Andersen
- Department of Oncology, Copenhagen University Hospital - Herlev & Gentofte, Herlev, Denmark
| | - Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
| | - Cai Grau
- Danish Center of Particle Therapy, Aarhus University Hospital, Denmark; Department of Oncology, Aarhus University Hospital, Denmark
| | - Jeppe Friborg
- Danish Center of Particle Therapy, Aarhus University Hospital, Denmark; Department of Oncology, Rigshospitalet, Denmark
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Nielsen CP, Lorenzen EL, Jensen K, Sarup N, Brink C, Smulders B, Holm AIS, Samsøe E, Nielsen MS, Sibolt P, Skyt PS, Elstrøm UV, Johansen J, Zukauskaite R, Eriksen JG, Farhadi M, Andersen M, Maare C, Overgaard J, Grau C, Friborg J, Hansen CR. Consistency in contouring of organs at risk by artificial intelligence vs oncologists in head and neck cancer patients. Acta Oncol 2023; 62:1418-1425. [PMID: 37703300 DOI: 10.1080/0284186x.2023.2256958] [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: 05/21/2023] [Accepted: 09/04/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND In the Danish Head and Neck Cancer Group (DAHANCA) 35 trial, patients are selected for proton treatment based on simulated reductions of Normal Tissue Complication Probability (NTCP) for proton compared to photon treatment at the referring departments. After inclusion in the trial, immobilization, scanning, contouring and planning are repeated at the national proton centre. The new contours could result in reduced expected NTCP gain of the proton plan, resulting in a loss of validity in the selection process. The present study evaluates if contour consistency can be improved by having access to AI (Artificial Intelligence) based contours. MATERIALS AND METHODS The 63 patients in the DAHANCA 35 pilot trial had a CT from the local DAHANCA centre and one from the proton centre. A nationally validated convolutional neural network, based on nnU-Net, was used to contour OARs on both scans for each patient. Using deformable image registration, local AI and oncologist contours were transferred to the proton centre scans for comparison. Consistency was calculated with the Dice Similarity Coefficient (DSC) and Mean Surface Distance (MSD), comparing contours from AI to AI and oncologist to oncologist, respectively. Two NTCP models were applied to calculate NTCP for xerostomia and dysphagia. RESULTS The AI contours showed significantly better consistency than the contours by oncologists. The median and interquartile range of DSC was 0.85 [0.78 - 0.90] and 0.68 [0.51 - 0.80] for AI and oncologist contours, respectively. The median and interquartile range of MSD was 0.9 mm [0.7 - 1.1] mm and 1.9 mm [1.5 - 2.6] mm for AI and oncologist contours, respectively. There was no significant difference in Δ NTCP. CONCLUSIONS The study showed that OAR contours made by the AI algorithm were more consistent than those made by oncologists. No significant impact on the Δ NTCP calculations could be discerned.
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Affiliation(s)
- Camilla Panduro Nielsen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ebbe Laugaard Lorenzen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Kenneth Jensen
- Danish Centre of Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Nis Sarup
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
| | - Carsten Brink
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Bob Smulders
- Danish Centre of Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | | | - Eva Samsøe
- Danish Centre of Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Zealand University Hospital, Naestved, Denmark
| | | | - Patrik Sibolt
- Department of Oncology, University Hospital Herlev, Herlev, Denmark
| | | | | | - Jørgen Johansen
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Ruta Zukauskaite
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Jesper Grau Eriksen
- Department of Oncology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Oncology, Aalborg University Hospital, Aalborg, Denmark
| | - Mohammad Farhadi
- Department of Oncology, Zealand University Hospital, Naestved, Denmark
| | - Maria Andersen
- Department of Oncology, Aalborg University Hospital, Aalborg, Denmark
| | - Christian Maare
- Department of Oncology, University Hospital Herlev, Herlev, Denmark
| | - Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
| | - Cai Grau
- Danish Centre of Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Jeppe Friborg
- Danish Centre of Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Christian Rønn Hansen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- Danish Centre of Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
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Co-registration of radiotherapy planning and recurrence scans with different imaging modalities in head and neck cancer. Phys Imaging Radiat Oncol 2022; 23:80-84. [PMID: 35844257 PMCID: PMC9284447 DOI: 10.1016/j.phro.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 06/24/2022] [Accepted: 06/27/2022] [Indexed: 11/30/2022] Open
Abstract
Head and neck magnetic resonance imaging and computed tomography co-registration. Validation of planning and recurrence scan co-registration separated in time. Mean distances to agreement for regions of interest/normal tissue were tolerable.
MRI (magnetic resonance imaging) scans are frequently used in follow-up after radiotherapy for head and neck cancer. With the overall aim of enabling MRI-based pattern of failure analysis, this study evaluated the accuracy of recurrence MRI (rMRI) deformable co-registration with planning CT (computed tomography)-scans (pCT). Uncertainty of anatomical changes between pCT and rMRI was assessed by similarity metric analyses of co-registered image structures from 19 patients. Average mean distance to agreement and Dice similarity coefficient performed adequately. Our findings provide proof of concept for reliable co-registration of pCT and rMRI months to years apart for MRI-based pattern of failure analysis.
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Sharma MB, Jensen K, Friborg J, Smulders B, Andersen E, Samsøe E, Johansen J, Hansen CR, Andersen M, Nielsen MS, Filtenborg MV, Ren J, Korreman SS, Overgaard J, Grau C. Target coverage and local recurrences after radiotherapy for sinonasal cancer in Denmark 2008-2015. A DAHANCA study. Acta Oncol 2022; 61:120-126. [PMID: 34979878 DOI: 10.1080/0284186x.2021.2022199] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
PURPOSE The study aimed to investigate the pattern of failure and describe compromises in the definition and coverage of the target for patients treated with curatively intended radiotherapy (RT) for sinonasal cancer (SNC). METHODS AND MATERIAL Patients treated with curatively intended RT in 2008-2015 in Denmark for SNC were eligible for the retrospective cohort study. Information regarding diagnosis and treatment was retrieved from the national database of the Danish Head and Neck Cancer Group (DAHANCA). Imaging from the diagnosis of recurrences was collected, and the point of origin (PO) of the recurrent tumour was estimated. All treatment plans were collected and reviewed with the focus on target coverage, manual modifications of target volumes, and dose to organs at risk (OARs) above defined constraints. RESULTS A total of 184 patients were included in the analysis, and 76 (41%) relapsed. The majority of recurrences involved T-site (76%). Recurrence imaging of 39 patients was evaluated, and PO was established. Twenty-nine POs (74%) were located within the CTV, and the minimum dose to the PO was median 64.1 Gy (3.1-70.7). The criteria for target coverage (V95%) was not met in 89/184 (48%) of the CTV and 131/184 (71%) of the PTV. A total of 24% of CTVs had been manually modified to spare OARs of high-dose irradiation. No difference in target volume modifications was observed between patients who suffered recurrence and patients with lasting remission. CONCLUSION The majority of relapses after radical treatment of SNC were located in the T-site (the primary tumour site). Multiple compromises with regards to target coverage and tolerance levels for OARs in the sinonasal region, as defined from RT guidelines, were taken. No common practice in this respect could be derived from the study.
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Affiliation(s)
- Maja B. Sharma
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Kenneth Jensen
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Jeppe Friborg
- Department of Oncology, Rigshospitalet, Copenhagen, Denmark
| | - Bob Smulders
- Department of Oncology, Rigshospitalet, Copenhagen, Denmark
| | - Elo Andersen
- Department of Oncology, Herlev Hospital, Copenhagen, Denmark
| | - Eva Samsøe
- Department of Oncology, Herlev Hospital, Copenhagen, Denmark
- Department of Oncology, Zealand University Hospital, Naestved, Denmark
| | - Jørgen Johansen
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Christian R. Hansen
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Maria Andersen
- Department of Oncology, Aalborg University Hospital, Aalborg, Denmark
| | - Martin S. Nielsen
- Department of Oncology, Aalborg University Hospital, Aalborg, Denmark
| | - Mads V. Filtenborg
- Department of Otorhinolaryngology, Head and Neck Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Jintao Ren
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Stine S. Korreman
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Jens Overgaard
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Cai Grau
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
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Jensen K, Friborg J, Hansen CR, Samsøe E, Johansen J, Andersen M, Smulders B, Andersen E, Nielsen MS, Eriksen JG, Petersen JBB, Elstrøm UV, Holm AI, Farhadi M, Morthorst MH, Skyt PS, Overgaard J, Grau C. The Danish Head and Neck Cancer Group (DAHANCA) 2020 radiotherapy guidelines. Radiother Oncol 2020; 151:149-151. [DOI: 10.1016/j.radonc.2020.07.037] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 07/21/2020] [Accepted: 07/21/2020] [Indexed: 10/23/2022]
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Saksø M, Mortensen LS, Primdahl H, Johansen J, Kallehauge J, Hansen CR, Overgaard J. Influence of FAZA PET hypoxia and HPV-status for the outcome of head and neck squamous cell carcinoma (HNSCC) treated with radiotherapy: Long-term results from the DAHANCA 24 trial (NCT01017224). Radiother Oncol 2020; 151:126-133. [PMID: 32805273 DOI: 10.1016/j.radonc.2020.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/30/2020] [Accepted: 08/11/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Hypoxic tumor volumes can be visualized with 18F-FAZA PET/CT. In head and neck squamous cell carcinoma (HNSCC), hypoxia is important for the clinical outcome after primary radiotherapy (RT). The outcome is furthermore heavily influenced by the HPV/p16-positivity of oropharyngeal tumors (OPCp16+ tumors). The study purposes were (1) to report on locoregional failures within five years after primary RT in a prospective cohort stratified by both HPV/p16-status and PET hypoxia and (2) to characterize the failure site and the spatial association to PET hypoxia. MATERIAL AND METHODS From 2009 to 2011, 38 patients with non-metastatic SCC of the larynx, oro-, hypo- and nasopharynx completing primary RT were included in the prospective DAHANCA 24 trial (NCT01017224). Fifteen patients had OPCp16+ tumors. All were imaged with a static FAZA PET/CT prior to treatment. The hypoxia threshold was determined by a tumor-to-muscle ratio (TMR) of 1.6. Recurrences were documented histologically. Imaging of the recurrence was deformable fused with the pre-treatment FAZA PET/CT. The spatial information of recurrence- and hypoxic volumes were compared visually. RESULTS Sixteen patients had more hypoxic tumors (high tracer uptake, TMR ≥1.6) before treatment (42%). With a median follow-up of 7.8 years, nine locoregional recurrences were observed, of which seven were in patients with high-uptake tumors (44% and 9%, respectively, HR 5.8 [1.2-28.2]). The risk of locoregional recurrence was highest among patients with more hypoxic, non-OPCp16+ tumors (57% [21-94%]), with a risk difference of 45% [4-86%], when comparing to less hypoxic, non-OPCp16+ tumors. Eight patients had sufficient imaging of the recurrence for co-registration with the FAZA PET/CT. Six had hypoxic primary tumors, and in two, the recurrence was overlapping the baseline hypoxic subvolume. CONCLUSION HNSCC demonstrating a TMR ≥1.6 at baseline is significantly associated with treatment failure after primary RT. In addition to HPV/p16-status, FAZA PET/CT has potential for the selection of tumors requiring treatment intensification.
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Affiliation(s)
- Mette Saksø
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark.
| | | | - Hanne Primdahl
- Department of Oncology, Aarhus University Hospital, Denmark
| | | | | | | | - Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
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Li XA, Moughan J, White JR, Freedman GM, Arthur DW, Galvin J, Xiao Y, McNulty S, Lyons JA, Kavadi VS, Fields MT, Mitchell MP, Anderson BM, Lock MI, Kokeny KE, Bazan JG, Currey AD, Hijal T, Cheston SB, Vicini FA. Patterns of Failure Observed in the 2-Step Institution Credentialing Process for NRG Oncology/Radiation Therapy Oncology Group 1005 (NCT01349322) and Lessons Learned. Pract Radiat Oncol 2020; 10:265-273. [DOI: 10.1016/j.prro.2019.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 11/04/2019] [Accepted: 11/13/2019] [Indexed: 10/25/2022]
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Hansen CR, Bertelsen A, Zukauskaite R, Johnsen L, Bernchou U, Thwaites DI, Eriksen JG, Johansen J, Brink C. Prediction of radiation-induced mucositis of H&N cancer patients based on a large patient cohort. Radiother Oncol 2020; 147:15-21. [PMID: 32224314 DOI: 10.1016/j.radonc.2020.03.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 02/25/2020] [Accepted: 03/09/2020] [Indexed: 01/08/2023]
Abstract
PURPOSE/OBJECTIVE Radiation-induced mucositis is a severe acute side effect, which can jeopardize treatment compliance and cause weight loss during treatment. The study aimed to develop robust models to predict the risk of severe mucositis. MATERIALS/METHODS Mucosal toxicity scores were prospectively recorded for 802 consecutive Head and Neck (H&N) cancer patients and dichotomised into non-severe event (grade 0-2) and severe event (grade 3+) groups. Two different model approaches were utilised to evaluate the robustness of the models. These used LASSO and Best Subset selection combined with 10-fold cross-validation performed on two-thirds of the patient cohort using principal component analysis of DVHs. The remaining one-third of the patients were used for validation. Model performance was tested through calibration plot and model performance metrics. RESULTS The main predicted risk factors were treatment acceleration and the first two principal dose components, which reflect the mean dose and the balance between high and low doses to the oral cavity. For the LASSO model, gender and current smoker status were also included in the model. The AUC values of the two models on the validation cohort were 0.797 (95%CI: 0.741-0.857) and 0.808 (95%CI: 0.749-0.859), respectively. The two models predicted very similar risk values with an internal Pearson coefficient of 0.954, indicating their robustness. CONCLUSIONS Robust prediction models of the risk of severe mucositis have been developed based on information from the entire dose distribution for a large cohort of patients consisting of all patients treated H&N for within our institution over a five year period.
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Affiliation(s)
- C R Hansen
- Laboratory of Radiation Physics, Odense University Hospital, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark; Institute of Medical Physics, School of Physics, University of Sydney, Australia; Danish Centre for Particle Therapy, Aarhus University Hospital, Denmark.
| | - A Bertelsen
- Laboratory of Radiation Physics, Odense University Hospital, Denmark
| | - R Zukauskaite
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark; Department of Oncology, Odense University Hospital, Denmark
| | - L Johnsen
- Laboratory of Radiation Physics, Odense University Hospital, Denmark
| | - U Bernchou
- Laboratory of Radiation Physics, Odense University Hospital, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - D I Thwaites
- Institute of Medical Physics, School of Physics, University of Sydney, Australia
| | - J G Eriksen
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark; Department of Oncology, Odense University Hospital, Denmark; Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
| | - J Johansen
- Department of Oncology, Odense University Hospital, Denmark
| | - C Brink
- Laboratory of Radiation Physics, Odense University Hospital, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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10
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Saksø M, Primdahl H, Johansen J, Nowicka-Matus K, Overgaard J. DAHANCA 33: functional image-guided dose-escalated radiotherapy to patients with hypoxic squamous cell carcinoma of the head and neck (NCT02976051). Acta Oncol 2020; 59:208-211. [PMID: 31805799 DOI: 10.1080/0284186x.2019.1695065] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- M. Saksø
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - H. Primdahl
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - J. Johansen
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - K. Nowicka-Matus
- Department of Oncology, Aalborg University Hospital, Aalborg, Denmark
| | - J. Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
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11
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Hansen CR, Friborg J, Jensen K, Samsøe E, Johnsen L, Zukauskaite R, Grau C, Maare C, Johansen J, Primdahl H, Bratland Å, Kristensen CA, Andersen M, Eriksen JG, Overgaard J. NTCP model validation method for DAHANCA patient selection of protons versus photons in head and neck cancer radiotherapy. Acta Oncol 2019; 58:1410-1415. [PMID: 31432744 DOI: 10.1080/0284186x.2019.1654129] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Introduction: Prediction models using logistic regression may perform poorly in external patient cohorts. However, there is a need to standardize and validate models for clinical use. The purpose of this project was to describe a method for validation of external NTCP models used for patient selection in the randomized trial of protons versus photons in head and neck cancer radiotherapy, DAHANCA 35. Material and methods: Organs at risk of 588 patients treated primarily with IMRT in the randomized controlled DAHANCA19 trial were retrospectively contoured according to recent international recommendations. Dose metrics were extracted using MatLab and all clinical parameters were retrieved from the DAHANCA database. The model proposed by Christianen et al. to predict physician-rated dysphagia was validated through the closed testing, where change of the model intercept, slope and individual beta's were tested for significant prediction improvements. Results: Six months prevalence of dysphagia in the validation cohort was 33%. The closed testing procedure for physician-rated dysphagia showed that the Christianen et al. model needed an intercept refitting for the best match for the Danish patients. The intercept update increased the risk of dysphagia for the validation cohort by 7.9 ± 2.5% point. For the raw model performance, the Brier score (mean squared residual) was 0.467, which improved significantly with a new intercept to 0.415. Conclusions: The previously published Dutch dysphagia model needed an intercept update to match the Danish patient cohort. The implementation of a closed testing procedure on the current validation cohort allows quick and efficient validation of external NTCP models for patient selection in the future.
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Affiliation(s)
- C. R. Hansen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Institute of Medical Physics, School of Physics, The University of Sydney, Sydney, Australia
| | - J. Friborg
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Rigshospitalet, Copenhagen, Denmark
| | - K. Jensen
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - E. Samsøe
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Copenhagen University Hospital Herlev, Copenhagen, Denmark
| | - L. Johnsen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
| | - R. Zukauskaite
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - C. Grau
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - C. Maare
- Department of Oncology, Copenhagen University Hospital Herlev, Copenhagen, Denmark
| | - J. Johansen
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - H. Primdahl
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Å. Bratland
- The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | | | - M Andersen
- Department of Oncology, Aalborg University Hospital, Aalborg, Denmark
| | - J. G. Eriksen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - J. Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
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12
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Evensen JF, Sand Hansen H, Overgaard M, Johansen J, Andersen LJ, Overgaard J. DAHANCA 9 - a randomized multicenter study to compare accelerated normo-fractionated radiotherapy with accelerated hyperfractionated radiotherapy in patients with primary squamous cell carcinoma of the head and neck (HNSCC). Acta Oncol 2019; 58:1502-1505. [PMID: 31282236 DOI: 10.1080/0284186x.2019.1629012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
| | - Hanne Sand Hansen
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Marie Overgaard
- Department of Oncology, Aarhus University Hospital, Aarhus N, Denmark
| | - Jørgen Johansen
- Department of Oncology, Odense University Hospital, Odense C, Denmark
| | | | - Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
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Aarup-Kristensen S, Hansen CR, Forner L, Brink C, Eriksen JG, Johansen J. Osteoradionecrosis of the mandible after radiotherapy for head and neck cancer: risk factors and dose-volume correlations. Acta Oncol 2019; 58:1373-1377. [PMID: 31364903 DOI: 10.1080/0284186x.2019.1643037] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background: The project aimed at determining the incidence of mandibular osteoradionecrosis (ORN) after radiotherapy, possible risk factors, and mandibular dose-volume effects in a large cohort of head and neck cancer patients (HNC). Methods: The cohort consisted of 1224 HNC patients treated with 66-68 Gy in 2007-2015 predominantly with IMRT. ORN cases were defined from clinical observations at follow-up and through hospital code diagnostics after oral-maxillofacial surgery and cross-checked with the national Danish Head and Neck Cancer database. In a nested case-control study, patients with ORN cases were matched with two controls (1:2) and pre-RT dental procedures including surgery to the mandible were documented. Multivariable Cox regression analysis was applied using demographic and treatment variables including dental procedures, smoking and tumor characteristics, and combined with dosimetric data. Mean mandibular dose (Dmean) was pre-selected for the multivariable model. Results: ORN was recorded in 56 cases (4.6%) with a median time to event of 10.9 months (range 1.8-89.7) after RT, 90% occurred within 37.4 months. Median follow-up time was 22 months (0.3-95). Average Dmean was significantly higher in the ORN event cohort and significant dose-volume differences were observed for population mean DVH doses between 30 Gy and 60 Gy. In univariable analysis, smoking (HR = 1.69; CI 1.14-2.5), pre-RT surgery/tooth extraction (HR = 2.76; 1.48-5.14), and several dosimetric parameters including Dmean (HR = 1.05, 1.02-1.08) were all significantly associated with ORN. Dmean and surgery/tooth extraction remained significant predictors of ORN in multivariable analysis, HR = 1.04 (CI 1.01-1.07) and HR = 2.09 (CI 1.1-3.98), respectively, while smoking only retained its significance in an interaction analysis with pre-RT dental procedures. Conclusion: The onset of ORN of the mandible was early (median 10.8 months) and the incidence low (4.6%) after IMRT in HNC cancer patients. Surgery to the mandible and pre-RT tooth extraction, tobacco smoking, and treatment dose were associated with the development of ORN.
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Affiliation(s)
- S. Aarup-Kristensen
- Department of Oncology, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - C. R. Hansen
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
| | - L. Forner
- Department of Oral and Maxillofacial Surgery, Centre for Head and Orthopedics, Copenhagen University Hospital, Copenhagen, Denmark
| | - C. Brink
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
| | - J. G. Eriksen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - J. Johansen
- Department of Oncology, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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14
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Saksø M, Andersen E, Bentzen J, Andersen M, Johansen J, Primdahl H, Overgaard J, Eriksen JG. A prospective, multicenter DAHANCA study of hyperfractionated, accelerated radiotherapy for head and neck squamous cell carcinoma. Acta Oncol 2019; 58:1495-1501. [PMID: 31519130 DOI: 10.1080/0284186x.2019.1658897] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: The study aimed to evaluate Hyperfractionated, Accelerated Radiotherapy (HART) with nimorazole for patients with head and neck squamous cell carcinoma (HNSCC) using loco-regional failure (LRF), overall survival (OS), early and late morbidity as endpoints. Material and methods: From February 2007 to January 2018, 295 patients with unresected HNSCC, T1-T4, N0-N3, M0, were treated with HART prescribed as 76 Gy in 56 fractions (fx), 10 fx weekly. IMRT was used in >90% of patients. No chemotherapy was given. Patients were prospectively registered in the DAHANCA database. Results: The median age was 64 years, 75% of patients were males. Primary sites were larynx (25%), pharynx (64%) and oral cavity (11%). In total, 59% were stage III-IV (UICC 2002). Of the 150 oropharyngeal cancer (OPC) patients, 42% were p16+. The proportion of patients receiving HART as planned was 97%. The median follow-up time was 66 months. Three-year actuarial LRF was 19% and OS was 66%. LRF was significantly higher for stage III-IV patients compared to stage I-II (25% vs. 11%, HR 2.12 [1.21-3.74]). The site-specific LRF rates were: for larynx 22% [12-32], hypopharynx 30% [16-45], non-p16+ oropharynx 15% [8-23], p16+ oropharynx 7% [1-13] and oral cavity 35% [18-53]. During therapy, 51% reported severe dysphagia and 60% required feeding tubes. The peak incidence of late, severe dysphagia and xerostomia was 21% and 9%, respectively. A comparison to historical data from previous DAHANCA trials showed that tumor control and morbidity are comparable to treatment with acceleration and/or chemo-radiation. Conclusions: HART represents an attractive approach for patients with HNSCC where treatment intensification is indicated.
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Affiliation(s)
- Mette Saksø
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Elo Andersen
- Department of Oncology, Herlev Hospital, Herlev, Denmark
| | - Jens Bentzen
- Department of Oncology, Herlev Hospital, Herlev, Denmark
| | - Maria Andersen
- Department of Oncology, Aalborg University Hospital, Aalborg, Denmark
| | - Jørgen Johansen
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Hanne Primdahl
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Jesper Grau Eriksen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
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15
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Christiansen RL, Gornitzka J, Andersen P, Nielsen M, Johnsen L, Bertelsen AS, Zukauskaite R, Johansen J, Hansen CR. Awareness and surveillance of radiation treatment schedules reduces head and neck overall treatment time. Tech Innov Patient Support Radiat Oncol 2019; 9:26-30. [PMID: 32095592 PMCID: PMC7033770 DOI: 10.1016/j.tipsro.2019.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 12/21/2018] [Accepted: 01/15/2019] [Indexed: 11/03/2022] Open
Abstract
Overall treatment time for HNC treatment was reduced according to DAHANCA guidelines. Sufficient accelerator capacity alone did not sufficiently minimize treatment time. Surveillance of treatment calendars reduced breaches to 3% (6fx/wk) and 13% (5 fx/wk). Radiobiological efficacy was increased by 1.3 Gy (6 fx/wk) and 2.0 Gy (5 fx/wk). Surveillance of treatment calendars presented minimal financial costs.
Background and purpose Overall treatment time (OTT) is essential for local tumour control and survival in radiotherapy of head and neck cancer (HNC). National radiotherapy guidelines of the Danish Head and Neck Cancer Group (DAHANCA) recommend a maximum OTT of 41 days for moderately accelerated radiation treatment (6 fractions/week) and 48 days for conventional treatment (5 fractions/week). The purpose of this study was to evaluate the effect of surveillance of the radiotherapy course length and treatment gaps in HNC patients to reduce OTT. Methods The study included 2011 patients with HNC undergoing radical radiation treatment with 66–68 Gy in 33–34 fractions in 2003–2017 at Odense University Hospital. In February 2016, a systematic weekly review by two radiation therapists of all planned treatment courses was introduced to check OTT of individual patients to portend likely breaks or treatment prolongations. Schedules that violated the OTT guidelines were conferred with the responsible radiation oncologist, and treatment rescheduled by treating twice daily to catch up with a delay. Results The mean length of accelerated treatment courses was reduced from a maximum of 40.9 days in 2007 to 38.3 days in 2017 and from 50.3 days to 45.9 days for conventional courses. The percentage of individual treatment courses that violated the recommended OTT was reduced to 3% of the accelerated treatments and 13% for the conventional treatments. Conclusion Continuous surveillance of treatment schedules of HNC patients by a brief weekly survey reduced treatment course duration to an extent that was radiobiologically and clinically meaningful.
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Affiliation(s)
- Rasmus Lübeck Christiansen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Janne Gornitzka
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Pia Andersen
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Morten Nielsen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
| | - Lars Johnsen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
| | | | - Ruta Zukauskaite
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Jørgen Johansen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Christian Rønn Hansen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Cardenas CE, Anderson BM, Aristophanous M, Yang J, Rhee DJ, McCarroll RE, Mohamed ASR, Kamal M, Elgohari BA, Elhalawani HM, Fuller CD, Rao A, Garden AS, Court LE. Auto-delineation of oropharyngeal clinical target volumes using 3D convolutional neural networks. ACTA ACUST UNITED AC 2018; 63:215026. [DOI: 10.1088/1361-6560/aae8a9] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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17
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DAHANCA 10 - Effect of darbepoetin alfa and radiotherapy in the treatment of squamous cell carcinoma of the head and neck. A multicenter, open-label, randomized, phase 3 trial by the Danish head and neck cancer group. Radiother Oncol 2018. [PMID: 29523409 DOI: 10.1016/j.radonc.2018.02.018] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE To evaluate if correction of low hemoglobin (Hb) levels by means of darbepoetin alfa improves the outcomes of radiotherapy in patients with squamous cell carcinoma of the head and neck (HNSCC). PATIENTS AND METHODS Patients eligible for primary radiotherapy and who had Hb values below 14.0 g/dl were randomized to receive accelerated fractionated radiotherapy with or without darbepoetin alfa. Patients also received the hypoxic radiosensitizer nimorazole. Darbepoetin alfa was given weekly during radiotherapy or until the Hb value exceeded 15.5 g/dl. RESULTS Following a planned interim analysis which showed inferiority of the experimental treatment the trial was stopped after inclusion of 522 patients (of a planned intake of 600). Of these, 513 were eligible for analysis (254 patients treated with darbepoetin alfa and 259 patients in the control group). Overall, the patients were distributed according to the stratification parameters (gender, T and N staging, tumor site). Treatment with darbepoetin alfa increased the Hb level to the planned value in 81% of the patients. The compliance was good without excess serious adverse events. The results showed a poorer outcome with a 5-year cumulative loco-regional failure rate of 47% vs. 34%, Hazard Ratio (HR): 1.53 [1.16-2.02], for the darbepoetin alfa vs. control arm, respectively. This was also seen for the endpoints of event-free survival (HR: 1.36 [1.09-1.69]), disease-specific death (HR: 1.43 [1.08-1.90]), and overall survival (HR: 1.30 [1.02-1.64]). There was no enhanced risk of cardio-vascular events observed in the experimental arm or any significant differences in acute or late radiation related morbidity. All univariate analyses were confirmed in a multivariate setting. CONCLUSION Correction of the Hb level with darbepoetin alfa during radiotherapy of patients with HNSCC resulted in a significantly poorer tumor control and survival.
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Local recurrences after curative IMRT for HNSCC: Effect of different GTV to high-dose CTV margins. Radiother Oncol 2018; 126:48-55. [DOI: 10.1016/j.radonc.2017.11.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 11/27/2017] [Accepted: 11/27/2017] [Indexed: 01/29/2023]
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19
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Grau C, Høyer M, Poulsen PR, Muren LP, Korreman SS, Tanderup K, Lindegaard JC, Alsner J, Overgaard J. Rethink radiotherapy - BIGART 2017. Acta Oncol 2017; 56:1341-1352. [PMID: 29148908 DOI: 10.1080/0284186x.2017.1371326] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Cai Grau
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Morten Høyer
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Ludvig Paul Muren
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | | | - Kari Tanderup
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | | | - Jan Alsner
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
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20
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Zukauskaite R, Hansen CR, Brink C, Johansen J, Asmussen JT, Grau C, Overgaard J, Eriksen JG. Analysis of CT-verified loco-regional recurrences after definitive IMRT for HNSCC using site of origin estimation methods. Acta Oncol 2017; 56:1554-1561. [PMID: 28826293 DOI: 10.1080/0284186x.2017.1346384] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION A significant part of patients with head and neck squamous cell carcinoma (HNSCC) develop recurrent disease after curative radiotherapy. We aimed to analyze loco-regional recurrence pattern by identifying possible points of recurrence origin by three different methods in relation to treatment volumes. MATERIAL AND METHODS A total of 455 patients completed IMRT-based treatment for HNSCC from 2006 to 2012. A total of 159 patients had remaining cancer after IMRT, developed loco-regional recurrence or distant disease during follow-up. Among those, 69 patients with loco-regional recurrences had affirmative CT or PET/CT scan. Possible points of origin (POs) of the recurrences were identified on scans by two independent observers, estimated as center of mass and as maximum surface distance. The recurrence position was analyzed in relation to high-dose treatment volume (CTV1) and 95% of prescription dose. RESULTS In total, 104 loco-regional recurrences (54 in T-site and 50 in N-site) were identified in 69 patients. Median time to recurrence for the 69 patients was 10 months. No clinically relevant difference was found between the four POs, with standard deviation between POs in x, y and z axes of 3, 3 and 6 mm. For recurrences inside CTV1, 0-5 mm and 5-10 mm outside CTV1 the standard deviation of dose differences between the POs were 1, 1.4 and 1 Gy, respectively. 56% and 25% of T-site and N-site recurrences were inside CTV1, respectively. Coverage by 95% prescription dose to high-dose treatment volume was achieved in 78% of T-site and 39% of N-site recurrences. CONCLUSIONS For recurrences identified by possible points of recurrence origin, no significant difference between observer-based or mathematically estimated methods was found. More than half of T-site recurrences were inside high-dose treatment volume, whereas N-site recurrences were mainly outside.
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Affiliation(s)
- Ruta Zukauskaite
- Department of Oncology, Odense University Hospital, Denmark
- Institute of Clinical Research, University of Southern Denmark, Denmark
| | - Christian R. Hansen
- Institute of Clinical Research, University of Southern Denmark, Denmark
- Laboratory of Radiation Physics, Odense University Hospital, Denmark
| | - Carsten Brink
- Institute of Clinical Research, University of Southern Denmark, Denmark
- Laboratory of Radiation Physics, Odense University Hospital, Denmark
| | | | - Jon T. Asmussen
- Department of Radiology, Odense University Hospital, Denmark
| | - Cai Grau
- Department of Oncology, Aarhus University Hospital, Denmark
| | - Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
| | - Jesper G. Eriksen
- Department of Oncology, Odense University Hospital, Denmark
- Institute of Clinical Research, University of Southern Denmark, Denmark
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21
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Hansen CR, Johansen J, Samsøe E, Andersen E, Petersen JBB, Jensen K, Andersen LJ, Sand HMB, Bertelsen AS, Grau C. Consequences of introducing geometric GTV to CTV margin expansion in DAHANCA contouring guidelines for head and neck radiotherapy. Radiother Oncol 2017; 126:43-47. [PMID: 28987748 DOI: 10.1016/j.radonc.2017.09.019] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 09/18/2017] [Accepted: 09/18/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND PURPOSE Defining margins around the Gross Tumour Volume (GTV) to create a Clinical Target Volume (CTV) for head and neck cancer radiotherapy has traditionally been based on presumed knowledge of anatomical routes of spread. However, using a concentric geometric expansion around the GTV may be more reproducible. The purpose of this study was to analyse the inter-observer consistency of geometric CTV delineation with adaptation for anatomical boundaries versus anatomically defined CTVs. MATERIAL AND METHODS Radiation oncologists at four Danish cancer centres delineated high, intermediate and elective dose CTVs (CTV1, CTV2 and CTV3, respectively) in a patient-case template (stage IV squamous cell carcinoma of the oropharynx), first using mainly anatomical margins (original standard) and then using concentric geometric expansion (new standard). Each centre made a dummy-run radiotherapy plan based on the delineated CTVs. The difference between the CTV contours and the radiotherapy plans was evaluated across the centres. RESULTS Anatomy-based contours were significantly more heterogenous and showed larger volume differences between centres than geometric margins. Dice similarity coefficient increased by 0.29 and mean surface distance decreased by 4mm for CTV1. Use of consistent CTV volumes resulted in more consistent irradiated volumes between centres. CONCLUSION Introduction of geometric margins resulted in more uniform CTV1 and CTV2 delineation. Geometric CTV expansion was easier, left less room for misinterpretation, and resulted in more uniform treatment plans with similar irradiated high and intermediate dose volumes across all centres.
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Affiliation(s)
- Christian Rønn Hansen
- Laboratory of Radiation Physics, Odense University Hospital, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | | | - Eva Samsøe
- Department of Oncology, Radiotherapy Research Unit, Herlev Hospital, University of Copenhagen, Denmark
| | - Elo Andersen
- Department of Oncology, Herlev Hospital, University of Copenhagen, Denmark
| | | | - Kenneth Jensen
- Department of Oncology, Aarhus University Hospital, Denmark
| | | | - Hella M B Sand
- Department of Oncology, Aalborg University Hospital, Denmark
| | | | - Cai Grau
- Department of Oncology, Aarhus University Hospital, Denmark
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22
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Hansen CR, Christiansen RL, Lorenzen EL, Bertelsen AS, Asmussen JT, Gyldenkerne N, Eriksen JG, Johansen J, Brink C. Contouring and dose calculation in head and neck cancer radiotherapy after reduction of metal artifacts in CT images. Acta Oncol 2017; 56:874-878. [PMID: 28464749 DOI: 10.1080/0284186x.2017.1287427] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Delineation accuracy of the gross tumor volume (GTV) in radiotherapy planning for head and neck (H&N) cancer is affected by computed tomography (CT) artifacts from metal implants which obscure identification of tumor as well as organs at risk (OAR). This study investigates the impact of metal artifact reduction (MAR) in H&N patients in terms of delineation consistency and dose calculation precision in radiation treatment planning. MATERIAL AND METHODS Tumor and OAR delineations were evaluated in planning CT scans of eleven oropharynx patients with streaking artifacts in the tumor region preceding curative radiotherapy (RT). The GTV-tumor (GTV-T), GTV-node and parotid glands were contoured by four independent observers on standard CT images and MAR images. Dose calculation was evaluated on thirty H&N patients with dental implants near the treated volume. For each patient, the dose derived from the clinical treatment plan using the standard image set was compared with the recalculated dose on the MAR image dataset. RESULTS Reduction of metal artifacts resulted in larger volumes of all delineated structures compared to standard reconstruction. The GTV-T and the parotids were on average 22% (p < 0.06) and 7% larger (p = 0.005), respectively, in the MAR image plan compared to the standard image plan. Dice index showed reduced inter-observer variations after reduction of metal artifacts for all structures. The average surface distance between contours of different observers improved using the MAR images for GTV and parotids (p = 0.04 and p = 0.01). The median volume receiving a dose difference larger than ±3% was 2.3 cm3 (range 0-32 cm3). CONCLUSIONS Delineation of structures in the head and neck were affected by metal artifacts and volumes were generally larger and more consistent after reduction of metal artifacts, however, only small changes were observed in the dose calculations.
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Affiliation(s)
- Christian Rønn Hansen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | | | | | - Jon Thor Asmussen
- Department of Radiology, Odense University Hospital, Odense, Denmark
| | | | - Jesper Grau Eriksen
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Jørgen Johansen
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Carsten Brink
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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The effect of low hemoglobin levels on outcomes of radiotherapy following microscopically complete resection of locally advanced SCCHN: Implications for the future. J Craniomaxillofac Surg 2016; 44:1441-4. [DOI: 10.1016/j.jcms.2016.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Revised: 05/27/2016] [Accepted: 07/01/2016] [Indexed: 12/27/2022] Open
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Hazell I, Bzdusek K, Kumar P, Hansen CR, Bertelsen A, Eriksen JG, Johansen J, Brink C. Automatic planning of head and neck treatment plans. J Appl Clin Med Phys 2016; 17:272-282. [PMID: 26894364 PMCID: PMC5690191 DOI: 10.1120/jacmp.v17i1.5901] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 09/15/2015] [Accepted: 09/11/2015] [Indexed: 12/13/2022] Open
Abstract
Treatment planning is time‐consuming and the outcome depends on the person performing the optimization. A system that automates treatment planning could potentially reduce the manual time required for optimization and could also provide a method to reduce the variation between persons performing radiation dose planning (dosimetrist) and potentially improve the overall plan quality. This study evaluates the performance of the Auto‐Planning module that has recently become clinically available in the Pinnacle3 radiation therapy treatment planning system. Twenty‐six clinically delivered head and neck treatment plans were reoptimized with the Auto‐Planning module. Comparison of the two types of treatment plans were performed using DVH metrics and a blinded clinical evaluation by two senior radiation oncologists using a scale from one to six. Both evaluations investigated dose coverage of target and dose to healthy tissues. Auto‐Planning was able to produce clinically acceptable treatment plans in all 26 cases. Target coverages in the two types of plans were similar, but automatically generated plans had less irradiation of healthy tissue. In 94% of the evaluations, the autoplans scored at least as high as the previously delivered clinical plans. For all patients, the Auto‐Planning tool produced clinically acceptable head and neck treatment plans without any manual intervention, except for the initial target and OAR delineations. The main benefit of the method is the likely improvement in the overall treatment quality since consistent, high‐quality plans are generated which even can be further optimized, if necessary. This makes it possible for the dosimetrist to focus more time on difficult dose planning goals and to spend less time on the more tedious parts of the planning process. PACS number: 87.55.de
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