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Suvaal I, Kirchheiner K, Nout RA, Sturdza AE, Van Limbergen E, Lindegaard JC, Putter H, Jürgenliemk-Schulz IM, Chargari C, Tanderup K, Pötter R, Creutzberg CL, Ter Kuile MM. Vaginal changes, sexual functioning and distress of women with locally advanced cervical cancer treated in the EMBRACE vaginal morbidity substudy. Gynecol Oncol 2023; 170:123-132. [PMID: 36682090 DOI: 10.1016/j.ygyno.2023.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/05/2023] [Accepted: 01/05/2023] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The EMBRACE-vaginal morbidity substudy prospectively evaluated physician-assessed vaginal changes and patient-reported-outcomes (PRO) on vaginal and sexual functioning problems and distress in the first 2-years after image-guided radio(chemo)therapy and brachytherapy for locally advanced cervical cancer. METHODS Eligible patients had stage IB1-IIIB cervical cancer with ≤5 mm vaginal involvement. Assessment of vaginal changes was graded using CTCAE. PRO were assessed using validated Quality-of-Life and sexual questionnaires. Statistical analysis included Generalized-Linear-Mixed-Models and Spearman's rho-correlation coefficients. RESULTS 113 eligible patients were included. Mostly mild (grade 1) vaginal changes were reported over time in about 20% (range 11-37%). At 2-years, 47% was not sexually active. Approximately 50% of the sexually active women reported any vaginal and sexual functioning problems and distress over time; more substantial vaginal and sexual problems and distress were reported by up to 14%, 20% and 8%, respectively. Physician-assessed vaginal changes and PRO sexual satisfaction differed significantly (p ≤ .05) between baseline and first follow-up, without further significant changes over time. No or only small associations between physician-assessed vaginal changes and PRO vaginal functioning problems and sexual distress were found. CONCLUSIONS Mild vaginal changes were reported after image-guided radio(chemo)therapy and brachytherapy, potentially due to the combination of tumors with limited vaginal involvement, EMBRACE-specific treatment optimization and rehabilitation recommendations. Although vaginal and sexual functioning problems and sexual distress were frequently reported, the rate of substantial problems and distress was low. The lack of association between vaginal changes, vaginal functioning problems and sexual distress shows that sexual functioning is more complex than vaginal morbidity alone.
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Affiliation(s)
- I Suvaal
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Zone K6-T, PO Box 9600, 2300 RC Leiden, the Netherlands
| | - K Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - R A Nout
- Department of Radiotherapy, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - A E Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - E Van Limbergen
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - J C Lindegaard
- Department of Radiation Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - H Putter
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, the Netherlands
| | - I M Jürgenliemk-Schulz
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - C Chargari
- Department of Radiation Oncology, Institute Gustave-Roussy, Paris, France
| | - K Tanderup
- Department of Radiation Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - R Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - C L Creutzberg
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - M M Ter Kuile
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Zone K6-T, PO Box 9600, 2300 RC Leiden, the Netherlands.
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2
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Oaknin A, Bosse TJ, Creutzberg CL, Giornelli G, Harter P, Joly F, Lorusso D, Marth C, Makker V, Mirza MR, Ledermann JA, Colombo N. Endometrial cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Ann Oncol 2022; 33:860-877. [PMID: 35690222 DOI: 10.1016/j.annonc.2022.05.009] [Citation(s) in RCA: 123] [Impact Index Per Article: 61.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/27/2022] [Accepted: 05/19/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- A Oaknin
- Gynaecologic Cancer Programme, Vall d'Hebron Institute of Oncology (VHIO), Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - T J Bosse
- Departments of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - C L Creutzberg
- Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - G Giornelli
- Department of Oncology, Instituto Alexander Fleming, Buenos Aires, Argentina
| | - P Harter
- Department of Gynecology & Gynecologic Oncology, Ev. Kliniken Essen-Mitte, Essen, Germany
| | - F Joly
- ANTICIPE, Cancer and Cognition Platform, Normandie University, Caen, France; Medical Oncology Department, Centre François Baclesse, Caen, France
| | - D Lorusso
- Department of Life Science and Public Health, Catholic University of Sacred Heart, Largo Agostino Gemelli, Rome, Italy; Department of Women and Child Health, Division of Gynaecologic Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - C Marth
- Department of Obstetrics and Gynecology, Medical University Innsbruck, Innsbruck, Austria
| | - V Makker
- Gynecologic Medical Oncology Service, Memorial Sloan Kettering Cancer Center, New York, USA; Department of Medicine, Weill Cornell Medical College, New York, USA
| | - M R Mirza
- Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - J A Ledermann
- Cancer Institute, University College London (UCL), London, UK; Department of Oncology, UCL Hospitals, London, UK
| | - N Colombo
- Department of Gynecologic Oncology, Istituto Europeo di Oncologia IRCCS, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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van den Heerik ASVM, Aiyer KTS, Stelloo E, Jürgenliemk-Schulz IM, Lutgens LCHW, Jobsen JJ, Mens JWM, van der Steen-Banasik EM, Creutzberg CL, Smit VTHBM, Horeweg N, Bosse T. Microcystic elongated and fragmented (MELF) pattern of invasion: Molecular features and prognostic significance in the PORTEC-1 and -2 trials. Gynecol Oncol 2022; 166:530-537. [PMID: 35840357 DOI: 10.1016/j.ygyno.2022.06.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/24/2022] [Accepted: 06/26/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Microcystic, elongated fragmented (MELF) pattern of myometrial invasion is a distinct histologic feature occasionally seen in low-grade endometrial carcinomas (EC). The prognostic relevance of MELF invasion was uncertain due to conflicting data, and it had not yet appropriately been studied in the context of the molecular EC classification. We aimed to determine the relation of MELF invasion with clinicopathological and molecular characteristics, and define its prognostic relevance in early-stage low/intermediate risk EC. METHODS Single whole tumor slides of 979 (85.8%) out of 1141 (high)intermediate-risk EC of women who participated in the PORTEC-1/-2 trials were available for review. Clinicopathological and molecular features were compared between MELF invasion positive and negative cases. Time-to-event analyses were done by Kaplan-Meier method, log-rank tests and Cox' proportional hazards models. RESULTS MELF invasion was found in 128 (13.1%) cases, and associated with grade 1-2 histology, deep myometrial invasion and substantial lymph-vascular space invasion (LVSI). 85.6% of MELF invasion positive tumors were no-specific-molecular-profile (NSMP) EC. NSMP EC with MELF invasion were CTNNB1 wild type in 92.2% and KRAS mutated in 24.4% of cases. Risk of recurrence was lower for MELF invasion positive as compared to MELF invasion negative cases (4.9% vs. 12.7%, p = 0.026). However, MELF invasion had no independent impact on risk of recurrence (HR 0.65, p = 0.30) after correction for clinicopathological and molecular factors. CONCLUSIONS MELF invasion has no independent impact on risk of recurrence in early-stage EC, and is frequently observed in low-grade NSMP tumors. Routine assessment of MELF invasion has no clinical implications and is not recommended.
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Affiliation(s)
- A S V M van den Heerik
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - K T S Aiyer
- Department of Pathology, Leiden University Medical Center, Leiden, the Netherlands
| | - E Stelloo
- Department of Pathology, Leiden University Medical Center, Leiden, the Netherlands
| | - I M Jürgenliemk-Schulz
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - L C H W Lutgens
- Department of Radiation Oncology, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - J J Jobsen
- Department of Radiation Oncology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - J W M Mens
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | - C L Creutzberg
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - V T H B M Smit
- Department of Pathology, Leiden University Medical Center, Leiden, the Netherlands
| | - N Horeweg
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - T Bosse
- Department of Pathology, Leiden University Medical Center, Leiden, the Netherlands.
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Khaw P, Do V, Lim K, Cunninghame J, Dixon J, Vassie J, Bailey M, Johnson C, Kahl K, Gordon C, Cook O, Foo K, Fyles A, Powell M, Haie-Meder C, D'Amico R, Bessette P, Mileshkin L, Creutzberg CL, Moore A. Radiotherapy Quality Assurance in the PORTEC-3 (TROG 08.04) Trial. Clin Oncol (R Coll Radiol) 2021; 34:198-204. [PMID: 34903431 DOI: 10.1016/j.clon.2021.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/09/2021] [Accepted: 11/18/2021] [Indexed: 11/03/2022]
Abstract
AIMS Quality assurance in radiotherapy (QART) is essential to ensure the scientific integrity of a clinical trial. This paper reports the findings of the retrospective QART assessment for all centres that participated in PORTEC-3; a randomised controlled trial that compared pelvic radiotherapy with concurrent chemoradiotherapy to the pelvis followed by adjuvant chemotherapy. The trial showed an overall survival benefit for the addition of the chemotherapy in the management of women with high-risk endometrial cancer. MATERIALS AND METHODS Clinicians were invited to upload a randomly selected case/s treated at each of the participating sites. Panel reviewers analysed the contours to certify that the target volumes and organ at risk structures were contoured according to guidelines. The results were categorised into acceptable, minor variation, major variation or unevaluable. The radiotherapy plans were dosimetrically evaluated using the well-established Trans-Tasman Radiation Oncology Group (TROG) protocol. RESULTS Between August 2010 and January 2018, data from 146 patients of 686 consecutively treated patients were retrospectively reviewed. All 16 Australia and New Zealand and 71 of 77 international centres uploaded data for evaluation. In total, 3514 dosimetric and contour variables were reviewed. Of these, 3136 variables were deemed acceptable (89.2%), with 335 minor (9.6%) and 43 major variations (1.2%). Major contour variations included the clinical target volume vaginal vault, clinical target volume parametria and differential planning target volume vault expansion. CONCLUSION The results of the QART assessment confirmed high uniformity and low rates of both minor and major deviations in contouring and dosimetry in all sites. This supports the safe introduction of the PORTEC-3 treatment protocol into routine clinical practice.
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Affiliation(s)
- P Khaw
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia.
| | - V Do
- Liverpool Cancer Therapy Centre, Liverpool, New South Wales, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - K Lim
- Liverpool Cancer Therapy Centre, Liverpool, New South Wales, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - J Cunninghame
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - J Dixon
- Illawarra Cancer Care Centre, Wollongong, New South Wales, Australia
| | - J Vassie
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - M Bailey
- Illawarra Cancer Care Centre, Wollongong, New South Wales, Australia
| | - C Johnson
- Blood & Cancer Centre, Wellington Hospital, Wellington, New Zealand
| | - K Kahl
- Shoalhaven Cancer Care Centre, Nowra, New South Wales, Australia
| | - C Gordon
- Illawarra Cancer Care Centre, Wollongong, New South Wales, Australia
| | - O Cook
- Trans-Tasman Radiation Oncology Group (TROG), Waratah, New South Wales, Australia
| | - K Foo
- Institute of Medical Physics, School of Physics, University of Sydney, Sydney, New South Wales, Australia
| | - A Fyles
- Canadian Cancer Trials Group, Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - M Powell
- Department of Clinical Oncology, Barts Health NHS Trust, London, UK
| | - C Haie-Meder
- Department of Radiotherapy, Institut Gustave Roussy, Villejuif, France
| | - R D'Amico
- Division of Radiation Oncology, ASST-Lecco, Ospedale A. Manzoni, Lecco, Italy
| | - P Bessette
- Gynaecologic Oncology, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - L Mileshkin
- Division of Cancer Medicine, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - C L Creutzberg
- Department of Radiation Oncology, Leiden University Medical Centre, Leiden, the Netherlands
| | - A Moore
- Trans-Tasman Radiation Oncology Group (TROG), Waratah, New South Wales, Australia
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5
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Wortman BG, Astreinidou E, Laman MS, van der Steen-Banasik EM, Lutgens LCHW, Westerveld H, Koppe F, Slot A, van den Berg HA, Nowee ME, Bijmolt S, Stam TC, Zwanenburg AG, Mens JWM, Jürgenliemk-Schulz IM, Snyers A, Gillham CM, Weidner N, Kommoss S, Vandecasteele K, Tomancova V, Creutzberg CL, Nout RA. Brachytherapy quality assurance in the PORTEC-4a trial for molecular-integrated risk profile guided adjuvant treatment of endometrial cancer. Radiother Oncol 2020; 155:160-166. [PMID: 33159971 DOI: 10.1016/j.radonc.2020.10.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/26/2020] [Accepted: 10/26/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The PORTEC-4a trial investigates molecular-integrated risk profile guided adjuvant treatment for endometrial cancer. The quality assurance programme included a dummy run for vaginal brachytherapy prior to site activation, and annual quality assurance to verify protocol adherence. Aims of this study were to evaluate vaginal brachytherapy quality and protocol adherence. METHODS For the dummy run, institutes were invited to create a brachytherapy plan on a provided CT-scan with the applicator in situ. For annual quality assurance, institutes provided data of one randomly selected brachytherapy case. A brachytherapy panel reviewed and scored the brachytherapy plans according to a checklist. RESULTS At the dummy run, 15 out of 21 (71.4%) institutes needed adjustments of delineation or planning. After adjustments, the mean dose at the vaginal apex (protocol: 100%; 7 Gy) decreased from 100.7% to 99.9% and range and standard deviation (SD) narrowed from 83.6-135.1 to 96.4-101.4 and 8.8 to 1.1, respectively. At annual quality assurance, 22 out of 27 (81.5%) cases had no or minor and 5 out of 27 (18.5%) major deviations. Most deviations were related to delineation, mean dose at the vaginal apex (98.0%, 74.7-114.2, SD 7.6) or reference volume length. CONCLUSIONS Most feedback during the brachytherapy quality assurance procedure of the PORTEC-4a trial was related to delineation, dose at the vaginal apex and the reference volume length. Annual quality assurance is essential to promote protocol compliance, ensuring high quality vaginal brachytherapy in all participating institutes.
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Affiliation(s)
- B G Wortman
- Department of Radiation Oncology, Leiden University Medical Centre, The Netherlands.
| | - E Astreinidou
- Department of Radiation Oncology, Leiden University Medical Centre, The Netherlands
| | - M S Laman
- Department of Radiation Oncology, Leiden University Medical Centre, The Netherlands
| | | | | | - H Westerveld
- Department of Radiation Oncology, Amsterdam University Medical Centres, University of Amsterdam, The Netherlands
| | - F Koppe
- Department of Radiation Oncology, Institute Verbeeten, Tilburg, The Netherlands
| | - A Slot
- Radiotherapy Institute Friesland, Leeuwarden, The Netherlands
| | - H A van den Berg
- Department of Radiation Oncology, Catharina Hospital Eindhoven, The Netherlands
| | - M E Nowee
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - S Bijmolt
- Department of Radiation Oncology, University Medical Centre Groningen, The Netherlands
| | - T C Stam
- Department of Radiation Oncology, Haaglanden Medical Centre, Leidschendam, The Netherlands
| | - A G Zwanenburg
- Department of Radiation Oncology, Zwolle, The Netherlands
| | - J W M Mens
- Department of Radiation Oncology, Erasmus MC-Cancer Institute, Rotterdam, The Netherlands
| | | | - A Snyers
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - C M Gillham
- Department of Radiation Oncology, St Luke's Radiation Oncology Network, Dublin 6, Ireland
| | - N Weidner
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University, Germany
| | - S Kommoss
- Department of Women's Health, Tübingen University Hospital, Germany
| | - K Vandecasteele
- Department of Radiation Oncology, Ghent University Hospital, Belgium
| | - V Tomancova
- Department of Clinical Oncology, General Teaching Hospital, First Medical School, Charles University, Prague, Czech Republic
| | - C L Creutzberg
- Department of Radiation Oncology, Leiden University Medical Centre, The Netherlands
| | - R A Nout
- Department of Radiation Oncology, Leiden University Medical Centre, The Netherlands
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6
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de Boer SM, Wortman BG, Bosse T, Powell ME, Singh N, Hollema H, Wilson G, Chowdhury MN, Mileshkin L, Pyman J, Katsaros D, Carinelli S, Fyles A, McLachlin CM, Haie-Meder C, Duvillard P, Nout RA, Verhoeven-Adema KW, Putter H, Creutzberg CL, Smit VTHBM. Clinical consequences of upfront pathology review in the randomised PORTEC-3 trial for high-risk endometrial cancer. Ann Oncol 2019; 29:424-430. [PMID: 29190319 PMCID: PMC5834053 DOI: 10.1093/annonc/mdx753] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background In the PORTEC-3 trial, women with high-risk endometrial cancer (HR-EC) were randomised to receive pelvic radiotherapy (RT) with or without concurrent and adjuvant chemotherapy (two cycles of cisplatin 50 mg/m2 in weeks 1 and 4 of RT, followed by four cycles of carboplatin AUC5 and paclitaxel 175 mg/m2). Pathology review was required before patient enrolment. The aim of this analysis was to evaluate the role of central pathology review before randomisation. Patients and methods A total of 1295 cases underwent pathology review to confirm HR-EC in the Netherlands (n = 395) and the UK (n = 900), and for 1226/1295 (95%) matching review and original reports were available. In total, 329 of these patients were enrolled in the PORTEC-3 trial: 145 in the Netherlands and 184 in the UK, comprising 48% of the total PORTEC-3 cohort of 686 participants. Areas of discrepancies were evaluated, and inter-observer agreement between original and review opinion was evaluated by calculating the kappa value (κ). Results In the 1226 pathology reviews, 6356 selected items were evaluable for both original and review pathology. In 43% of cases at least one pathology item changed after review. For 102 patients (8%), this discrepancy led to ineligibility for the PORTEC-3 trial, most frequently due to differences in the assessment of histological type (34%), endocervical stromal involvement (27%) and histological grade (19%). Lowest inter-observer agreement was found for histological type (κ = 0.72), lymph-vascular space invasion (κ = 0.72) and histological grade (κ = 0.70). Conclusion Central pathology review by expert gynaeco-pathologists changed histological type, grade or other items in 43% of women with HR-EC, leading to ineligibility for the PORTEC-3 trial in 8%. Upfront pathology review is essential to ensure enrolment of the target trial-population, and to avoid over- or undertreatment, especially when treatment modalities with substantial toxicity are involved. This study is registered with ISRCTN (ISRCTN14387080, www.controlled-trials.com) and with ClinicalTrials.gov (NCT00411138).
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Affiliation(s)
- S M de Boer
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands.
| | - B G Wortman
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands; Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - T Bosse
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - M E Powell
- Department of Clinical Oncology, Barts Health NHS Trust, St Bartholomew's Hospital, London
| | - N Singh
- Department of Cellular Pathology, Barts Health NHS Trust, Royal London Hospital, London, UK
| | - H Hollema
- Department of Pathology, University Medical Center Groningen, Groningen, The Netherlands
| | - G Wilson
- Department of Pathology, Central Manchester Hospitals NHS Foundation Trust, Manchester Royal Infirmary, Manchester, UK
| | - M N Chowdhury
- Department of Cellular Pathology, Barts Health NHS Trust, Royal London Hospital, London, UK
| | - L Mileshkin
- Division of Cancer Medicine, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - J Pyman
- Department of Anatomical Pathology, Royal Women's Hospital, Parkville, Australia
| | - D Katsaros
- Department of Surgical Sciences, Az O-Universitaria Città della Salute di Torino, Torino, Italy
| | - S Carinelli
- Division of Pathology and Laboratory Medicine, European Institute of Pathology, Milan, Italy
| | - A Fyles
- CCTG, Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - C M McLachlin
- Department of Pathology and Laboratory Medicine, Western University, London, Canada
| | - C Haie-Meder
- Department of Radiation Oncology, Institut Gustave Roussy, Villejuif, France
| | - P Duvillard
- Department of Pathology, Institut Gustave Roussy, Villejuif, France
| | - R A Nout
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - K W Verhoeven-Adema
- Central Trials Office, Comprehensive Cancer Center The Netherlands, Leiden, The Netherlands
| | - H Putter
- Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - C L Creutzberg
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - V T H B M Smit
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
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7
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Wortman BG, Creutzberg CL, Putter H, Jürgenliemk-Schulz IM, Jobsen JJ, Lutgens LCHW, van der Steen-Banasik EM, Mens JWM, Slot A, Kroese MCS, van Triest B, Nijman HW, Stelloo E, Bosse T, de Boer SM, van Putten WLJ, Smit VTHBM, Nout RA. Ten-year results of the PORTEC-2 trial for high-intermediate risk endometrial carcinoma: improving patient selection for adjuvant therapy. Br J Cancer 2018; 119:1067-1074. [PMID: 30356126 PMCID: PMC6219495 DOI: 10.1038/s41416-018-0310-8] [Citation(s) in RCA: 153] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 09/26/2018] [Accepted: 09/28/2018] [Indexed: 01/16/2023] Open
Abstract
Background PORTEC-2 was a randomised trial for women with high-intermediate risk (HIR) endometrial cancer, comparing pelvic external beam radiotherapy (EBRT) with vaginal brachytherapy (VBT). We evaluated long-term outcomes combined with the results of pathology review and molecular analysis. Methods 427 women with HIR endometrial cancer were randomised between 2002–2006 to VBT or EBRT. Primary endpoint was vaginal recurrence (VR). Pathology review was done in 97.4%, combined with molecular analysis. Results Median follow-up was 116 months; 10-year VR was 3.4% versus 2.4% for VBT vs. EBRT (p = 0.55). Ten-year pelvic recurrence (PR) was more frequent in the VBT group (6.3% vs. 0.9%, p = 0.004), mostly combined with distant metastases (DM). Ten-year isolated PR was 2.5% vs. 0.5%, p = 0.10, and DM 10.4 vs. 8.9% (p = 0.45). Overall survival for VBT vs. EBRT was 69.5% vs. 67.6% at 10 years (p = 0.72). L1CAM and p53-mutant expression and substantial lymph-vascular space invasion were risk factors for PR and DM. EBRT reduced PR in cases with these risk factors. Conclusion Long-term results of the PORTEC-2 trial confirm VBT as standard adjuvant treatment for HIR endometrial cancer. Molecular risk assessment has the potential to guide adjuvant therapy. EBRT provided better pelvic control in patients with unfavourable risk factors.
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Affiliation(s)
- B G Wortman
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - C L Creutzberg
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - H Putter
- Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - I M Jürgenliemk-Schulz
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J J Jobsen
- Department of Radiotherapy, Medisch Spectrum Twente, Enschede, The Netherlands
| | - L C H W Lutgens
- Maastricht Radiation Oncology Clinic, Maastricht, The Netherlands
| | | | - J W M Mens
- Department of Radiation Oncology, Erasmus MC- Cancer Institute, Rotterdam, The Netherlands
| | - A Slot
- Radiotherapy Institute Friesland, Leeuwarden, The Netherlands
| | | | - B van Triest
- Department of Radiotherapy, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - H W Nijman
- Department of Gynaecologic Oncology, University Medical Center Groningen, Groningen, The Netherlands
| | - E Stelloo
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - T Bosse
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - S M de Boer
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - W L J van Putten
- Department of Biostatistics, ErasmusMC Cancer Institute, Rotterdam, The Netherlands
| | - V T H B M Smit
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - R A Nout
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands.
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Wortman BG, Bosse T, Nout RA, Lutgens LCHW, van der Steen-Banasik EM, Westerveld H, van den Berg H, Slot A, De Winter KAJ, Verhoeven-Adema KW, Smit VTHBM, Creutzberg CL. Molecular-integrated risk profile to determine adjuvant radiotherapy in endometrial cancer: Evaluation of the pilot phase of the PORTEC-4a trial. Gynecol Oncol 2018; 151:69-75. [PMID: 30078506 DOI: 10.1016/j.ygyno.2018.07.020] [Citation(s) in RCA: 116] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 07/24/2018] [Accepted: 07/27/2018] [Indexed: 01/09/2023]
Abstract
OBJECTIVE The Post-Operative Radiation Therapy in Endometrial Carcinoma (PORTEC)-4a trial is a randomized trial for women with high-intermediate risk endometrial cancer (EC), comparing individualized adjuvant treatment based on a molecular-integrated risk profile to standard adjuvant treatment; vaginal brachytherapy. To evaluate patient acceptability and pathology logistics of determining the risk profile, a pilot phase was included in the study. METHODS PORTEC-4a is ongoing and the first 50 patients enrolled were included in the pilot phase. Primary endpoints of the pilot phase were patient acceptance, evaluated by analyzing the screening logs of the participating centers, and logistical feasibility of determination of the risk profile within 2 weeks, evaluated by analyzing the pathology database. RESULTS In the first year, 145 eligible women were informed about the trial at 13 centers, of whom 50 (35%) provided informed consent. Patient accrual ranged from 0 to 57% per center. Most common reasons for not participating were: not willing to participate in any trial (43.2%) and not willing to risk receiving no adjuvant treatment (32.6%). Analysis of the pathology database showed an average time between randomization and determination of the molecular-integrated risk profile of 10.2 days (1-23 days). In 5 of the 32 patients (15.6%), pathology review took >2 weeks. CONCLUSIONS The PORTEC-4a trial design was proven feasible with a satisfactory patient acceptance rate and an optimized workflow of the determination of the molecular-integrated risk profile. PORTEC-4a is the first randomized trial to investigate use of a molecular-integrated risk profile to determine adjuvant treatment in EC.
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Affiliation(s)
- B G Wortman
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands.
| | - T Bosse
- Department of Pathology, Leiden University Medical Center, Leiden, the Netherlands
| | - R A Nout
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - L C H W Lutgens
- Maastricht Radiation Oncology Clinic, Maastricht, the Netherlands
| | | | - H Westerveld
- Department of Radiation Oncology, Academic Medical Center, Amsterdam, the Netherlands
| | - H van den Berg
- Department of Radiotherapy, Catharina Hospital Eindhoven, the Netherlands
| | - A Slot
- Radiotherapy Institute Friesland, Leeuwarden, the Netherlands
| | - K A J De Winter
- Department of Radiation Oncology, Institute Verbeeten, Tilburg, the Netherlands
| | | | - V T H B M Smit
- Department of Pathology, Leiden University Medical Center, Leiden, the Netherlands
| | - C L Creutzberg
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
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Affiliation(s)
- C L Creutzberg
- Departments of Radiation Oncology Medical Centre, Leiden, The Netherlands.
| | - T Bosse
- Pathology, Leiden University Medical Centre, Leiden, The Netherlands
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Eggink FA, Mom CH, Bouwman K, Boll D, Becker JH, Creutzberg CL, Niemeijer GC, van Driel WJ, Reyners AK, van der Zee AG, Bremer GL, Ezendam NP, Kruitwagen RF, Pijnenborg JM, Hollema H, Nijman HW, van der Aa MA. Corrigendum to "Less-favourable prognosis for low-risk endometrial cancer patients with a discordant pre- versus post-operative risk stratification" [Eur J Cancer 78 (2017) 82-90]. Eur J Cancer 2017; 84:370. [PMID: 28844347 DOI: 10.1016/j.ejca.2017.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- F A Eggink
- University of Groningen, University Medical Center Groningen, Department of Obstetrics and Gynecology, Groningen, The Netherlands
| | - C H Mom
- VU University Medical Center, Center for Gynecologic Oncology Amsterdam, Amsterdam, The Netherlands
| | - K Bouwman
- University of Groningen, University Medical Center Groningen, Department of Obstetrics and Gynecology, Groningen, The Netherlands
| | - D Boll
- Catharina Hospital, Department of Obstetrics and Gynecology, Eindhoven, The Netherlands
| | - J H Becker
- St. Antonius Hospital, Department of Obstetrics and Gynecology, Nieuwegein, The Netherlands
| | - C L Creutzberg
- Leiden University Medical Center, Department of Radiation Oncology, Leiden, The Netherlands
| | - G C Niemeijer
- University Medical Center Groningen, Department of UMC Staff, Groningen, The Netherlands
| | - W J van Driel
- Antoni van Leeuwenhoek Hospital, Center for Gynecologic Oncology Amsterdam, Amsterdam, The Netherlands
| | - A K Reyners
- University of Groningen, University Medical Center Groningen, Department of Medical Oncology, Groningen, The Netherlands
| | - A G van der Zee
- University of Groningen, University Medical Center Groningen, Department of Obstetrics and Gynecology, Groningen, The Netherlands
| | - G L Bremer
- Zuyderland Medical Center, Department of Obstetrics and Gynecology, Heerlen/Sittard, The Netherlands
| | - N P Ezendam
- Netherlands Comprehensive Cancer Organization, Department of Research, Utrecht, The Netherlands
| | - R F Kruitwagen
- Maastricht University Medical Center, Department of Obstetrics and Gynecology, Maastricht, The Netherlands; GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - J M Pijnenborg
- Radboud University Medical Center Nijmegen, Department of Obstetrics and Gynecology, Nijmegen, The Netherlands
| | - H Hollema
- University of Groningen, University Medical Center Groningen, Department of Pathology, Groningen, The Netherlands
| | - H W Nijman
- University of Groningen, University Medical Center Groningen, Department of Obstetrics and Gynecology, Groningen, The Netherlands.
| | - M A van der Aa
- Netherlands Comprehensive Cancer Organization, Department of Research, Utrecht, The Netherlands
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11
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Nooij LS, van der Slot MA, Dekkers OM, Stijnen T, Gaarenstroom KN, Creutzberg CL, Smit VTHBM, Bosse T, van Poelgeest MIE. Tumour-free margins in vulvar squamous cell carcinoma: Does distance really matter? Eur J Cancer 2016. [PMID: 27497345 DOI: 10.1016/j.ejca.2016.0o'donnell7.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
BACKGROUND There is no consensus on the width of tumour-free margins after surgery for vulvar squamous cell carcinoma (VSCC). Most current guidelines recommend tumour-free margins of ≥8 mm. The aim of this study was to investigate whether a margin of <8 mm is associated with an increased risk of local recurrence in VSCC. METHODS A meta-analysis of the available literature and a cohort study of 148 VSCC patients seen at a referral centre from 2000 to 2012 was performed. The primary end-point of the cohort study was a histologically confirmed ipsilateral local recurrence within 2 years after primary treatment in relation to the margin distance. RESULTS Based on 10 studies, the meta-analysis showed that a tumour-free margin of <8 mm is associated with a higher risk of local recurrence compared to a tumour-free margin of ≥8 mm (pooled risk ratio, 1.99 [95% confidence interval {CI}: 1.13-3.51], p = 0.02). In the cohort study, we found no clear difference in the risk of local recurrence in the <8 versus ≥8 mm group; however, 40% of the patients in the <8 mm group received additional treatment. Tumour-positive margin was the only independent risk factor for local recurrence in the multivariable analysis (hazard ratio, 0.21 [95% CI: 0.08-0.55]). CONCLUSIONS This work provides important data to question the commonly used 8-mm margin as a prognosticator for local recurrence. More research is needed to address the question of whether additional treatment improves the prognosis in patients with a tumour-free margin of <8 mm.
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Affiliation(s)
- L S Nooij
- Department of Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands; Department of Pathology, Leiden University Medical Centre, Leiden, The Netherlands
| | - M A van der Slot
- Department of Pathology, Leiden University Medical Centre, Leiden, The Netherlands
| | - O M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - T Stijnen
- Department of Medical Statistics, Leiden University Medical Centre, Leiden, The Netherlands
| | - K N Gaarenstroom
- Department of Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - C L Creutzberg
- Department of Radiotherapy, Leiden University Medical Centre, Leiden, The Netherlands
| | - V T H B M Smit
- Department of Pathology, Leiden University Medical Centre, Leiden, The Netherlands
| | - T Bosse
- Department of Pathology, Leiden University Medical Centre, Leiden, The Netherlands
| | - M I E van Poelgeest
- Department of Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands.
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12
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Nooij LS, van der Slot MA, Dekkers OM, Stijnen T, Gaarenstroom KN, Creutzberg CL, Smit VTHBM, Bosse T, van Poelgeest MIE. Tumour-free margins in vulvar squamous cell carcinoma: Does distance really matter? Eur J Cancer 2016; 65:139-49. [PMID: 27497345 DOI: 10.1016/j.ejca.2016.07.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 06/29/2016] [Accepted: 07/04/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is no consensus on the width of tumour-free margins after surgery for vulvar squamous cell carcinoma (VSCC). Most current guidelines recommend tumour-free margins of ≥8 mm. The aim of this study was to investigate whether a margin of <8 mm is associated with an increased risk of local recurrence in VSCC. METHODS A meta-analysis of the available literature and a cohort study of 148 VSCC patients seen at a referral centre from 2000 to 2012 was performed. The primary end-point of the cohort study was a histologically confirmed ipsilateral local recurrence within 2 years after primary treatment in relation to the margin distance. RESULTS Based on 10 studies, the meta-analysis showed that a tumour-free margin of <8 mm is associated with a higher risk of local recurrence compared to a tumour-free margin of ≥8 mm (pooled risk ratio, 1.99 [95% confidence interval {CI}: 1.13-3.51], p = 0.02). In the cohort study, we found no clear difference in the risk of local recurrence in the <8 versus ≥8 mm group; however, 40% of the patients in the <8 mm group received additional treatment. Tumour-positive margin was the only independent risk factor for local recurrence in the multivariable analysis (hazard ratio, 0.21 [95% CI: 0.08-0.55]). CONCLUSIONS This work provides important data to question the commonly used 8-mm margin as a prognosticator for local recurrence. More research is needed to address the question of whether additional treatment improves the prognosis in patients with a tumour-free margin of <8 mm.
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Affiliation(s)
- L S Nooij
- Department of Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands; Department of Pathology, Leiden University Medical Centre, Leiden, The Netherlands
| | - M A van der Slot
- Department of Pathology, Leiden University Medical Centre, Leiden, The Netherlands
| | - O M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - T Stijnen
- Department of Medical Statistics, Leiden University Medical Centre, Leiden, The Netherlands
| | - K N Gaarenstroom
- Department of Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - C L Creutzberg
- Department of Radiotherapy, Leiden University Medical Centre, Leiden, The Netherlands
| | - V T H B M Smit
- Department of Pathology, Leiden University Medical Centre, Leiden, The Netherlands
| | - T Bosse
- Department of Pathology, Leiden University Medical Centre, Leiden, The Netherlands
| | - M I E van Poelgeest
- Department of Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands.
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13
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Nooij LS, Brand FAM, Gaarenstroom KN, Creutzberg CL, de Hullu JA, van Poelgeest MIE. Risk factors and treatment for recurrent vulvar squamous cell carcinoma. Crit Rev Oncol Hematol 2016; 106:1-13. [PMID: 27637349 DOI: 10.1016/j.critrevonc.2016.07.007] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 06/02/2016] [Accepted: 07/13/2016] [Indexed: 11/30/2022] Open
Abstract
Recurrent disease occurs in 12-37% of patients with vulvar squamous cell carcinoma (VSCC). Decisions about treatment of recurrent VSCC mainly depend on the location of the recurrence and previous treatment, resulting in individualized and consensus-based approaches. Most recurrences (40-80%) occur within 2 years after initial treatment. Currently, wide local excision is the treatment of choice for local recurrences. Isolated local recurrence of VSCC has a good prognosis, with reported 5-year survival rates of up to 60%. Groin recurrences and distant recurrences are less common and have an extremely poor prognosis. For groin recurrences, surgery with or without (chemo) radiotherapy is a treatment option, depending on prior treatment. For distant recurrences, there are only palliative treatment options. In this review, we give an overview of the available literature and discuss epidemiology, risk factors, and prognostic factors for the different types of recurrent VSCC and we describe treatment options and clinical outcome.
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Affiliation(s)
- L S Nooij
- Department of Gynecology, LUMC, Netherlands
| | | | | | | | - J A de Hullu
- Department of Gynecology, Radboud UMC, Netherlands
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14
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Versluis MA, de Jong RA, Plat A, Bosse T, Smit VT, Mackay H, Powell M, Leary A, Mileshkin L, Kitchener HC, Crosbie EJ, Edmondson RJ, Creutzberg CL, Hollema H, Daemen T, de Bock GH, Nijman HW. Prediction model for regional or distant recurrence in endometrial cancer based on classical pathological and immunological parameters. Br J Cancer 2015. [PMID: 26217922 PMCID: PMC4559831 DOI: 10.1038/bjc.2015.268] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Background: Adjuvant therapy increases disease-free survival in endometrial cancer (EC), but has no impact on overall survival and negatively influences the quality of life. We investigated the discriminatory power of classical and immunological predictors of recurrence in a cohort of EC patients and confirmed the findings in an independent validation cohort. Methods: We reanalysed the data from 355 EC patients and tested our findings in an independent validation cohort of 72 patients with EC. Predictors were selected and Harrell's C-index for concordance was used to determine discriminatory power for disease-free survival in the total group and stratified for histological subtype. Results: Predictors for recurrence were FIGO stage, lymphovascular space invasion and numbers of cytotoxic and memory T-cells. For high risk cancer, cytotoxic or memory T-cells predicted recurrence as well as a combination of FIGO stage and lymphovascular space invasion (C-index 0.67 and 0.71 vs 0.70). Recurrence was best predicted when FIGO stage, lymphovascular space invasion and numbers of cytotoxic cells were used in combination (C-index 0.82). Findings were confirmed in the validation cohort. Conclusions: In high-risk EC, clinicopathological or immunological variables can predict regional or distant recurrence with equal accuracy, but the use of these variables in combination is more powerful.
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Affiliation(s)
- M A Versluis
- Department of Gynecology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - R A de Jong
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - A Plat
- Department of Gynecology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - T Bosse
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - V T Smit
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - H Mackay
- Division of Medical Oncology and Hematology, Department of Medicine, University of Toronto, Toronto, Canada
| | - M Powell
- Department of Clinical Oncology, Barts Health NHS trust, London, UK
| | - A Leary
- Department of Medicine, Gynecology Unit, Gustave Roussy, Villejuif, France
| | - L Mileshkin
- Division of Medical Oncology, Peter MacCallum Cancer Center, Victoria, Australia
| | - H C Kitchener
- Department of Gynecology, St Marys Hospital, Manchester, UK
| | - E J Crosbie
- Department of Gynecology, St Marys Hospital, Manchester, UK
| | - R J Edmondson
- Department of Gynecology, St Marys Hospital, Manchester, UK
| | - C L Creutzberg
- Department of Clinical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - H Hollema
- Department of Pathology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - T Daemen
- Department of Medical Microbiology, Molecular Virology Section, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - G H de Bock
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - H W Nijman
- Department of Gynecology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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15
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Daniëls LA, Krol ADG, de Graaf MA, Scholte AJHA, Van't Veer MB, Putter H, de Roos A, Schalij MJ, Creutzberg CL. Screening for coronary artery disease after mediastinal irradiation in Hodgkin lymphoma survivors: phase II study of indication and acceptance†. Ann Oncol 2014; 25:1198-203. [PMID: 24692582 DOI: 10.1093/annonc/mdu130] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Cardiovascular diseases are the most common nonmalignant cause of death in Hodgkin lymphoma (HL) survivors, especially after mediastinal irradiation. We investigated the role of computed tomographic coronary angiography (CTA) as a screening tool for coronary artery disease (CAD) in asymptomatic HL survivors, and related CTA findings to exercise testing and subsequent interventions. PATIENTS AND METHODS Patients were eligible for this phase II study if at least 10 years disease-free and treated with mediastinal radiotherapy. Screening consisted of electrocardiogram, exercise testing and CTA. Primary end point was significant CAD (stenosis >50%) on CTA. CTA screening was considered to be indicated for testing in a larger population if ≥6 of 50 CTA scanned patients (12%) would need revascularization. Screening was evaluated with a questionnaire before and after screening. RESULTS Fifty-two patients were included, and 48 patients underwent CTA. Median age was 47 years, time since HL diagnosis 21 years. There were 45 evaluable scans. Significant CAD on CTA was found in 20% (N = 9), significantly increased compared with the 7% expected abnormalities (P = 0.01, 95% confidence interval 8.3% to 31.7%). In 11% (N = 5), significant stenosis was confirmed at coronary angiography, and revascularization was carried out. Additionally, two patients were treated with optimal medical therapy. Ninety percent of patients were content with screening, regardless whether the CTA showed abnormalities. CONCLUSIONS Prevalence of significant CAD among HL survivors is high, while asymptomatic even in the presence of life-threatening CAD. This might justify screening by CTA in asymptomatic HL survivors who had mediastinal radiotherapy, but needs to be evaluated in a larger cohort. The trial protocol was approved by the Ethics Committee of the LUMC and registered with ClinicalTrials.gov, NCT01271127.
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Affiliation(s)
| | | | - M A de Graaf
- Department of Cardiology The Interuniversity Cardiology Institute of The Netherlands, Utrecht, The Netherlands
| | | | | | - H Putter
- Department of Medical Statistics and Bio-informatics
| | - A de Roos
- Radiology, Leiden University Medical Center, Leiden
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Daniëls LA, Oerlemans S, Krol ADG, Creutzberg CL, van de Poll-Franse LV. Chronic fatigue in Hodgkin lymphoma survivors and associations with anxiety, depression and comorbidity. Br J Cancer 2014; 110:868-74. [PMID: 24434433 PMCID: PMC3929869 DOI: 10.1038/bjc.2013.779] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 11/06/2013] [Accepted: 11/18/2013] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Fatigue is a frequent and persistent problem among Hodgkin lymphoma (HL) survivors. We investigated the prevalence of clinically relevant fatigue in HL survivors and the relation between fatigue and anxiety and depression. METHODS Fatigue was measured through the generic European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (QLQ-C30) and Fatigue Assessment Scale (FAS). Anxiety and depression were measured with the Hospital Anxiety and Depression Scale. Questionnaires were mailed to 267 HL survivors. Results were compared with a Dutch age-matched normative population. RESULTS Response rate was 68% (median age 46 years, mean time since diagnosis 4.6 years). Prevalence of fatigue was significantly higher among HL survivors than in the norm population (FAS 41% vs 23%, QLQ-C30 43% vs 28%), as were fatigue levels. There was a significant association between fatigue, anxiety and depression. Of the HL survivors with high symptom levels of depression, 97% also reported fatigue. In multivariate analysis, depression was strongly associated with high levels of fatigue and, to a lesser extent, anxiety and comorbidity. CONCLUSIONS Prevalence rates of fatigue are significantly higher in HL survivors than in the general population and differences are clinically relevant. Depression and anxiety were strongly associated with high levels of fatigue. Reducing fatigue levels by treatment of depression and anxiety should be further explored.
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Affiliation(s)
- L A Daniëls
- Department of Clinical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - S Oerlemans
- 1] Comprehensive Cancer Centre South, Eindhoven, The Netherlands [2] Center of Research on Psychology in Somatic Diseases (CoRPS), Tilburg University, Tilburg, The Netherlands
| | - A D G Krol
- Department of Clinical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - C L Creutzberg
- Department of Clinical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - L V van de Poll-Franse
- 1] Comprehensive Cancer Centre South, Eindhoven, The Netherlands [2] Center of Research on Psychology in Somatic Diseases (CoRPS), Tilburg University, Tilburg, The Netherlands
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17
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Trimbos JBMZ, Fleuren GJ, van der Zee AGJ, Creutzberg CL. Tumoren van de vrouwelijke geslachtsorganen. ONCOLOGIE 2011. [DOI: 10.1007/978-90-313-8476-1_25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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18
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Nout RA, Smit VTHBM, Putter H, Jürgenliemk-Schulz IM, Jobsen JJ, Lutgens LCHW, van der Steen-Banasik EM, Mens JWM, Slot A, Kroese MCS, van Bunningen BNFM, Ansink AC, van Putten WLJ, Creutzberg CL. Vaginal brachytherapy versus pelvic external beam radiotherapy for patients with endometrial cancer of high-intermediate risk (PORTEC-2): an open-label, non-inferiority, randomised trial. Lancet 2010; 375:816-23. [PMID: 20206777 DOI: 10.1016/s0140-6736(09)62163-2] [Citation(s) in RCA: 774] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND After surgery for intermediate-risk endometrial carcinoma, the vagina is the most frequent site of recurrence. This study established whether vaginal brachytherapy (VBT) is as effective as pelvic external beam radiotherapy (EBRT) in prevention of vaginal recurrence, with fewer adverse effects and improved quality of life. METHODS In this open-label, non-inferiority, randomised trial undertaken in 19 Dutch radiation oncology centres, 427 patients with stage I or IIA endometrial carcinoma with features of high-intermediate risk were randomly assigned by a computer-generated, biased coin minimisation procedure to pelvic EBRT (46 Gy in 23 fractions; n=214) or VBT (21 Gy high-dose rate in three fractions, or 30 Gy low-dose rate; n=213). All investigators were masked to the assignment of treatment group. The primary endpoint was vaginal recurrence. The predefined non-inferiority margin was an absolute difference of 6% in vaginal recurrence. Analysis was by intention to treat, with competing risk methods. The study is registered, number ISRCTN16228756. FINDINGS At median follow-up of 45 months (range 18-78), three vaginal recurrences had been diagnosed after VBT and four after EBRT. Estimated 5-year rates of vaginal recurrence were 1.8% (95% CI 0.6-5.9) for VBT and 1.6% (0.5-4.9) for EBRT (hazard ratio [HR] 0.78, 95% CI 0.17-3.49; p=0.74). 5-year rates of locoregional relapse (vaginal or pelvic recurrence, or both) were 5.1% (2.8-9.6) for VBT and 2.1% (0.8-5.8) for EBRT (HR 2.08, 0.71-6.09; p=0.17). 1.5% (0.5-4.5) versus 0.5% (0.1-3.4) of patients presented with isolated pelvic recurrence (HR 3.10, 0.32-29.9; p=0.30), and rates of distant metastases were similar (8.3% [5.1-13.4] vs 5.7% [3.3-9.9]; HR 1.32, 0.63-2.74; p=0.46). We recorded no differences in overall (84.8% [95% CI 79.3-90.3] vs 79.6% [71.2-88.0]; HR 1.17, 0.69-1.98; p=0.57) or disease-free survival (82.7% [76.9-88.6] vs 78.1% [69.7-86.5]; HR 1.09, 0.66-1.78; p=0.74). Rates of acute grade 1-2 gastrointestinal toxicity were significantly lower in the VBT group than in the EBRT group at completion of radiotherapy (12.6% [27/215] vs 53.8% [112/208]). INTERPRETATION VBT is effective in ensuring vaginal control, with fewer gastrointestinal toxic effects than with EBRT. VBT should be the adjuvant treatment of choice for patients with endometrial carcinoma of high-intermediate risk. FUNDING Dutch Cancer Society.
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Affiliation(s)
- R A Nout
- Department of Clinical Oncology, Leiden University Medical Center, Leiden, Netherlands.
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Nout RA, Putter H, Jürgenliemk-Schulz IM, Jobsen JJ, Lutgens LC, van der Steen-Banasik EM, Mens JW, Slot A, Smit VT, Creutzberg CL. Vaginal brachytherapy versus external beam pelvic radiotherapy for high-intermediate risk endometrial cancer: Results of the randomized PORTEC-2 trial. J Clin Oncol 2008. [DOI: 10.1200/jco.2008.26.15_suppl.lba5503] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Kleijn WC, Ogoshi K, Yamaoka K, Shigehisa T, Takeda Y, Creutzberg CL, Nortier JWR, Kaptein AA. Conceptual equivalence and health-related quality of life: an exploratory study in Japanese and Dutch cancer patients. Qual Life Res 2006; 15:1091-101. [PMID: 16900289 DOI: 10.1007/s11136-006-0049-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2006] [Indexed: 11/25/2022]
Abstract
Research into the equivalence of Western and Japanese conceptualizations of health-related quality of life (HR-QOL) is scarce. We used the Western (European Organization for Research and Treatment of Cancer, EORTC-QLQ-C30) and the Japanese (HRQoL-20) questionnaire in order to analyze the conceptual similarity of HR-QOL factors, and the associations between specific symptom items with overall HR-QOL in Japanese (n=265) and Dutch (n=174) patients with various types of cancer. Both populations completed both instruments. In both patient groups, the overall health scale of the EORTC-QLQ-C30 correlated highly (r=0.59; p<0.001) with the HRQOL-20 composite average score, indicating substantial conceptual comparability. Relationships between all EORTC-QLQ-C30 symptom items with HR-QOL were examined by ranking their correlations with the two overall measures of HR-QOL. Comparable patterns in the Japanese and Dutch samples were observed. The results suggest a considerable conceptual equivalence of HR-QOL in Japanese and Dutch cancer patients, and indicate a satisfactory structural and cross-cultural equivalence for the EORTC-QLQ-C30 with regard to items measuring functioning and specific symptoms. Longitudinal studies are needed to examine the impact of specific symptoms on general quality of life.
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Affiliation(s)
- W Chr Kleijn
- Medical Psychology, Leiden University Medical Center, P. O. Box 9555, 2300 RB, Leiden, The Netherlands.
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21
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Pieterse QD, Trimbos JBMZ, Dijkman A, Creutzberg CL, Gaarenstroom KN, Peters AAW, Kenter GG. Postoperative radiation therapy improves prognosis in patients with adverse risk factors in localized, early-stage cervical cancer: a retrospective comparative study. Int J Gynecol Cancer 2006; 16:1112-8. [PMID: 16803494 DOI: 10.1111/j.1525-1438.2006.00600.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The objective of this study was to assess the role of postoperative radiotherapy (RT) in early-stage cervical carcinoma with risk factors other than positive nodes, parametrial invasion, or positive margins and to compare outcomes using the Leiden University Medical Center (LUMC) modification of the Gynecologic Oncology Group (GOG) system with the GOG prognostic scoring system itself. Between January 1984 and April 2005, 402 patients with early-stage cervical cancer underwent radical hysterectomy. A total of 51 patients (13%) had two of the three risk factors and had pathologic tumor size (> or =40 mm), invasion (> or =15 mm), and capillary lymphatic space involvement, and were identified as the so-called high-risk (HR). We compared 34 patients who received RT based on the LUMC risk profile (67%) with 17 who did not (33%). The GOG score was calculated as well. We compared the GOG scores within the LUMC risk groups: HR+ (two out of three risk factors) and HR- (less than two out of three risk factors). Differences in 5-year cancer-specific survival (CSS) and 5-year disease-free survival (DFS) between the HR group treated with RT (86%, 85%) and without RT (57%; 43%) were statistically significant. The LUMC criteria did not significantly differ from the GOG risk profile, concerning recurrence, CSS, and DFS. HR patients benefit from adjuvant RT. The LUMC modification of the GOG system seems to be simpler and has a slightly higher threshold for the indication for RT but without a difference in outcome.
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Affiliation(s)
- Q D Pieterse
- Department of Gynaecology, Leiden University Medical Center, 2300 RC Leiden, The Netherlands.
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22
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Scholten AN, Aliredjo R, Creutzberg CL, Smit VTHBM. Combined E-cadherin, alpha-catenin, and beta-catenin expression is a favorable prognostic factor in endometrial carcinoma. Int J Gynecol Cancer 2006; 16:1379-85. [PMID: 16803534 DOI: 10.1111/j.1525-1438.2006.00406.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Cell adhesion molecules, such as epithelial cadherin (E-cadherin), might be involved in the processes of tumor invasion and differentiation. The aim of this study was to investigate the expression of E-cadherin, alpha-catenin, and beta-catenin in endometrial carcinoma and to determine the prognostic value of these factors. We have investigated the expression of E-cadherin, alpha-catenin, and beta-catenin by immunohistochemistry in 225 endometrial carcinomas. The correlation between the E-cadherin and the catenins and their correlation with several histologic and clinical parameters were analyzed. Negative E-cadherin, alpha-catenin, and beta-catenin expression was observed in 44%, 47%, and 33% of endometrial carcinomas, respectively, and was correlated with histologic FIGO grade 3 (P < 0.001). Negative E-cadherin expression was more often observed in nonendometrioid endometrial carcinomas (NEECs) than in endometrioid carcinomas (75% versus 43%; P= 0.04). Combined positive E-cadherin, alpha-catenin, and beta-catenin expression was an independent positive prognostic factor for survival in patients with grade 1-2 carcinomas (P= 0.02). Negative E-cadherin expression was found to be associated with histologic grade 3 and with NEEC. Combined positive E-cadherin, alpha-catenin, and beta-catenin expression was a significant prognostic factor.
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Affiliation(s)
- A N Scholten
- Department of Clinical Oncology, Leiden University Medical Center, 2300 RC Leiden, The Netherlands.
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23
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Pieterse QD, Trimbos JB, Dijkman A, Creutzberg CL, Gaarenstroom KN, Peters AA, Kenter GG. Postoperative radiation therapy improves prognosis in patients with adverse risk factors in localized, early-stage cervical cancer: a retrospective comparative study. Int J Gynecol Cancer 2006. [DOI: 10.1136/ijgc-00009577-200605000-00026] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The objective of this study was to assess the role of postoperative radiotherapy (RT) in early-stage cervical carcinoma with risk factors other than positive nodes, parametrial invasion, or positive margins and to compare outcomes using the Leiden University Medical Center (LUMC) modification of the Gynecologic Oncology Group (GOG) system with the GOG prognostic scoring system itself. Between January 1984 and April 2005, 402 patients with early-stage cervical cancer underwent radical hysterectomy. A total of 51 patients (13%) had two of the three risk factors and had pathologic tumor size (≥40 mm), invasion (≥15 mm), and capillary lymphatic space involvement, and were identified as the so-called high-risk (HR). We compared 34 patients who received RT based on the LUMC risk profile (67%) with 17 who did not (33%). The GOG score was calculated as well. We compared the GOG scores within the LUMC risk groups: HR+ (two out of three risk factors) and HR− (less than two out of three risk factors). Differences in 5-year cancer-specific survival (CSS) and 5-year disease-free survival (DFS) between the HR group treated with RT (86%, 85%) and without RT (57%; 43%) were statistically significant. The LUMC criteria did not significantly differ from the GOG risk profile, concerning recurrence, CSS, and DFS. HR patients benefit from adjuvant RT. The LUMC modification of the GOG system seems to be simpler and has a slightly higher threshold for the indication for RT but without a difference in outcome.
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24
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Seynaeve C, Verhoog LC, van de Bosch LMC, van Geel AN, Menke-Pluymers M, Meijers-Heijboer EJ, van den Ouweland AMW, Wagner A, Creutzberg CL, Niermeijer MF, Klijn JGM, Brekelmans CTM. Ipsilateral breast tumour recurrence in hereditary breast cancer following breast-conserving therapy. Eur J Cancer 2004; 40:1150-8. [PMID: 15110878 DOI: 10.1016/j.ejca.2004.01.017] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2003] [Revised: 12/03/2003] [Accepted: 01/07/2004] [Indexed: 11/30/2022]
Abstract
The overall rate of an ipsilateral breast tumour recurrence (IBTR) after breast-conserving therapy (BCT) ranges from 1% to 2% per year. Risk factors include young age but data on the impact of BRCA1/2 mutations or a definite positive family history for breast cancer are scarce. We investigated IBTR after BCT in patients with hereditary breast cancer (HBC). Through our family cancer clinic we identified 87 HBC patients, including 26 BRCA1/2 carriers, who underwent BCT between 1980 and 1995 (cases). They were compared to 174 patients with sporadic breast cancer (controls) also treated with BCT, matched for age and year of diagnosis. Median follow up was 6.1 years for the cases and 6.0 years for controls. Patient and tumour characteristics were similar in both groups. An IBTR was observed in 19 (21.8%) hereditary and 21 (12.1%) sporadic patients. In the hereditary patients more recurrences occurred elsewhere in the breast (21% versus 9.5%), suggestive of new primaries. Overall, the actuarial IBTR rate was similar at 2 years, but higher in hereditary as compared to sporadic patients at 5 years (14% versus 7%) and at 10 years (30% versus 16%) (P=0.05). Post-relapse and overall survival was not different between hereditary and sporadic cases. Hereditary breast cancer was therefore associated with a higher frequency of early (2-5 years) and late (>5 years) local recurrences following BCT. These data suggest an indication for long-term follow up in HBC and should be taken into account when additional 'risk-reducing' surgery after primary BCT is eventually considered.
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Affiliation(s)
- C Seynaeve
- Family Cancer Clinic, Department of Medical Oncology, Erasmus University Medical Centre-Daniel den Hoed Cancer Centre, Groene Hilledijk, 301, 3075 EA Rotterdam, The Netherlands.
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25
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Scholten AN, Creutzberg CL, van den Broek LJCM, Noordijk EM, Smit VTHBM. Nuclear ?-catenin is a molecular feature of type I endometrial carcinoma. J Pathol 2003; 201:460-5. [PMID: 14595758 DOI: 10.1002/path.1402] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Two types of endometrial carcinoma can be distinguished: type I tumours, which are oestrogen-related and are typically low-grade endometrioid carcinomas; and type II tumours, which are unrelated to oestrogen stimulation and are often non-endometrioid carcinomas. The molecular abnormalities involved in carcinogenesis appear to be different for these tumour types. The aim of this study was to test the hypothesis that an abnormality in the Wnt/beta-catenin signalling pathway is a molecular feature of type I endometrial carcinoma. This study investigated nuclear beta-catenin by immunohistochemistry in 233 endometrial carcinomas and analysed its correlation with several immunohistochemical, histological, and clinical parameters, such as proliferation rate (Ki-67), expression of oestrogen and progesterone receptors, and survival. Nuclear beta-catenin expression was observed in 39 cases (16%). All tumours expressing nuclear beta-catenin were endometrioid adenocarcinomas, were significantly better differentiated, and were more often hormone receptor-positive than tumours without nuclear beta-catenin. No correlation with proliferation rate was found. It was found that several features of type I endometrial carcinoma occur significantly more often in tumours expressing nuclear beta-catenin, suggesting that an abnormality in the Wnt/beta-catenin signalling pathway, resulting in nuclear beta-catenin immunopositivity, is a molecular feature of a subset of type I endometrial carcinomas.
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Affiliation(s)
- A N Scholten
- Department of Clinical Oncology, Leiden University Medical Center, Leiden, The Netherlands.
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26
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Noordijk EM, Creutzberg CL. [Is there an indication for additional local irradiation in conserving treatment of breast cancer patients aged 60 and over?]. Ned Tijdschr Geneeskd 2002; 146:395-8. [PMID: 11901938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
Recent results from the European Organisation for Research and Treatment of Cancer (EORTC) trial of additional irradiation in patients with breast cancer, show that after breast-conserving surgery and radiotherapy (50 Gy) of the whole breast, an additional dose of 16 Gy on the tumour bed significantly reduces the local recurrence rate from 7.3% to 4.3%. A relative reduction was seen in all age groups but was most significant in patients aged 40 years and below (19.5% versus 10.2%). In women aged 60 years and over, the local recurrence rate after radiotherapy of 50 Gy (without the additional radiation dose) is already very low (4.0%). Therefore it is questionable whether an additional dose of 16 Gy (reducing the recurrence rate to 2.5%) is still justified as a standard treatment in this age group.
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Affiliation(s)
- E M Noordijk
- Leids Universitair Medisch Centrum, afd. Klinische Oncologie, Postbus 9600, 2300 RC Leiden.
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27
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de Boer HC, van Sörnsen de Koste JR, Creutzberg CL, Visser AG, Levendag PC, Heijmen BJ. Electronic portal image assisted reduction of systematic set-up errors in head and neck irradiation. Radiother Oncol 2001; 61:299-308. [PMID: 11731000 DOI: 10.1016/s0167-8140(01)00437-6] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE To quantify systematic and random patient set-up errors in head and neck irradiation and to investigate the impact of an off-line correction protocol on the systematic errors. MATERIAL AND METHODS Electronic portal images were obtained for 31 patients treated for primary supra-glottic larynx carcinoma who were immobilised using a polyvinyl chloride cast. The observed patient set-up errors were input to the shrinking action level (SAL) off-line decision protocol and appropriate set-up corrections were applied. To assess the impact of the protocol, the positioning accuracy without application of set-up corrections was reconstructed. RESULTS The set-up errors obtained without set-up corrections (1 standard deviation (SD)=1.5-2mm for random and systematic errors) were comparable to those reported in other studies on similar fixation devices. On an average, six fractions per patient were imaged and the set-up of half the patients was changed due to the decision protocol. Most changes were detected during weekly check measurements, not during the first days of treatment. The application of the SAL protocol reduced the width of the distribution of systematic errors to 1mm (1 SD), as expected from simulations. A retrospective analysis showed that this accuracy should be attainable with only two measurements per patient using a different off-line correction protocol, which does not apply action levels. CONCLUSIONS Off-line verification protocols can be particularly effective in head and neck patients due to the smallness of the random set-up errors. The excellent set-up reproducibility that can be achieved with such protocols enables accurate dose delivery in conformal treatments.
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Affiliation(s)
- H C de Boer
- Department of Radiation Oncology, Division of Clinical Physics, Daniel den Hoed Cancer Center/University Hospital Rotterdam, Groene Hilledijk 301, P.O. Box 5201, 3008 Rotterdam, The Netherlands
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28
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Creutzberg CL, van Putten WL, Koper PC, Lybeert ML, Jobsen JJ, Wárlám-Rodenhuis CC, De Winter KA, Lutgens LC, van den Bergh AC, van der Steen-Banasik E, Beerman H, van Lent M. The morbidity of treatment for patients with Stage I endometrial cancer: results from a randomized trial. Int J Radiat Oncol Biol Phys 2001; 51:1246-55. [PMID: 11728684 DOI: 10.1016/s0360-3016(01)01765-5] [Citation(s) in RCA: 138] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To compare the treatment complications for patients with Stage I endometrial cancer treated with surgery and pelvic radiotherapy (RT) or surgery alone in a multicenter randomized trial. METHODS AND MATERIALS The Postoperative Radiation Therapy in Endometrial Carcinoma (PORTEC) trial included patients with endometrial cancer confined to the uterine corpus, either Grade 1 or 2 with more than 50% myometrial invasion, or Grade 2 or 3 with less than 50% myometrial invasion. Surgery consisted of an abdominal hysterectomy and oophorectomy, without lymphadenectomy. After surgery, patients were randomized to receive pelvic RT (46 Gy), or no further treatment. A total of 715 patients were randomized. Treatment complications were graded using the French-Italian glossary. RESULTS The analysis was done at a median follow-up duration of 60 months. 691 patients were evaluable. Five-year actuarial rates of late complications (Grades 1-4) were 26% in the RT group and 4% in the control group (p < 0.0001). Most were Grade 1 complications, with 5-year rates of 17% in the RT group and 4% in the control group. All severe (Grade 3-4) complications were observed in the RT group (3%). Most complications were of the gastrointestinal tract. The symptoms resolved after some years in 50% of the patients. Grade 1-2 genitourinary complications occurred in 8% of the RT patients, and 4% of the controls. Bone complications occurred in 4 RT patients (1%). Seven patients (2%) discontinued their RT due to acute RT-related symptoms. Patients with acute morbidity had an increased risk of late RT complications (p = 0.001). The 4-field box technique was associated with a lower risk of late complications (p = 0.06). CONCLUSION Pelvic RT increases the morbidity of treatment in Stage I endometrial cancer. In the PORTEC trial, severe complications occurred in 3% of treated patients, and over 20% experienced mild (mostly Grade 1) symptoms. Patients with acute RT-related morbidity had an increased risk of late complications. As pelvic RT in Stage I endometrial carcinoma was shown to significantly reduce the rate of locoregional recurrence, but without a survival benefit, its use in the adjuvant setting requires careful patient selection (treating those at increased risk of relapse), and the use of treatment schemes with the lowest risk of morbidity.
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Affiliation(s)
- C L Creutzberg
- Department of Radiation Oncology, University Hospital Rotterdam-Daniel den Hoed Cancer Center, Rotterdam, The Netherlands.
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Abstract
PURPOSE To improve the treatment technique for chest wall irradiation, using the multileaf collimator (MLC) of the MM50 Racetrack Microtron to shape both photon and electron beams, and to check the dose delivery in the match-line region of these fields for the routine and improved technique. METHODS AND MATERIALS Using diode and film phantom measurements, the optimal number of photon beam segments and their positions relative to the electron beam were determined. On phantoms, and during actual patient treatment using in vivo dosimetry, the dose homogeneity in the match-line region was determined for both the routine and improved techniques. RESULTS Three photon beam segments (9-mm gap, perfect match, and 9-mm overlap) were used to match the electron beam, resulting in minimum-maximum dose values in the match-line region of 88-109%, compared to 80-115% for the routine technique (2 photon beam segments). During patient treatment, the average minimum and maximum dose values were 95% and 115%, respectively, compared to 78% and 127%, respectively, for the routine technique. The interfraction variation in dose delivery was reduced from 11.0% (1 SD) to 4.6% (1 SD). The actual treatment time was reduced from 10 to 4.5 min. CONCLUSION Using the MLC of the MM50 to shape both photon and electron beams, an improved treatment technique for chest wall irradiation was developed, which is less labor intensive, faster, and yields a more homogeneous, and better reproducible dose delivery.
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Affiliation(s)
- M Essers
- Division of Clinical Physics, University Hospital Rotterdam-Daniel den Hoed Cancer Center, Rotterdam, The Netherlands.
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30
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Creutzberg CL, van Putten WL, Koper PC, Lybeert ML, Jobsen JJ, Wárlám-Rodenhuis CC, De Winter KA, Lutgens LC, van den Bergh AC, van de Steen-Banasik E, Beerman H, van Lent M. Surgery and postoperative radiotherapy versus surgery alone for patients with stage-1 endometrial carcinoma: multicentre randomised trial. PORTEC Study Group. Post Operative Radiation Therapy in Endometrial Carcinoma. Lancet 2000; 355:1404-11. [PMID: 10791524 DOI: 10.1016/s0140-6736(00)02139-5] [Citation(s) in RCA: 1249] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Postoperative radiotherapy for International Federation of Gynaecology and Obstetrics (FIGO) stage-1 endometrial carcinoma is a subject of controversy due to the low relapse rate and the lack of data from randomised trials. We did a multicentre prospective randomised trial to find whether postoperative pelvic radiotherapy improves locoregional control and survival for patients with stage-1 endometrial carcinoma. METHODS Patients with stage-1 endometrial carcinoma (grade 1 with deep [> or =50%] myometrial invasion, grade 2 with any invasion, or grade 3 with superficial [<50%] invasion) were enrolled. After total abdominal hysterectomy and bilateral salpingo-oophorectomy, without lymphadenectomy, 715 patients from 19 radiation oncology centres were randomised to pelvic radiotherapy (46 Gy) or no further treatment. The primary study endpoints were locoregional recurrence and death, with treatment-related morbidity and survival after relapse as secondary endpoints. FINDINGS Analysis was done according to the intention-to-treat principle. Of the 715 patients, 714 could be evaluated. The median duration of follow-up was 52 months. 5-year actuarial locoregional recurrence rates were 4% in the radiotherapy group and 14% in the control group (p<0.001). Actuarial 5-year overall survival rates were similar in the two groups: 81% (radiotherapy) and 85% (controls), p=0.31. Endometrial-cancer-related death rates were 9% in the radiotherapy group and 6% in the control group (p=0.37). Treatment-related complications occurred in 25% of radiotherapy patients, and in 6% of the controls (p<0.0001). Two-thirds of the complications were grade 1. Grade 3-4 complications were seen in eight patients, of which seven were in the radiotherapy group (2%). 2-year survival after vaginal recurrence was 79%, in contrast to 21% after pelvic recurrence or distant metastases. Survival after relapse was significantly (p=0.02) better for patients in the control group. Multivariate analysis showed that for locoregional recurrence, radiotherapy and age below 60 years were significant favourable prognostic factors. INTERPRETATION Postoperative radiotherapy in stage-1 endometrial carcinoma reduces locoregional recurrence but has no impact on overall survival. Radiotherapy increases treatment-related morbidity. Postoperative radiotherapy is not indicated in patients with stage-1 endometrial carcinoma below 60 years and patients with grade-2 tumours with superficial invasion.
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Affiliation(s)
- C L Creutzberg
- Department of Radiation Oncology, University Hospital Rotterdam-Daniel den Hoed Cancer Center, The Netherlands.
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Stroom JC, Olofsen-van Acht MJ, Quint S, Seven M, de Hoog M, Creutzberg CL, de Boer HC, Visser AG. On-line set-up corrections during radiotherapy of patients with gynecologic tumors. Int J Radiat Oncol Biol Phys 2000; 46:499-506. [PMID: 10661359 DOI: 10.1016/s0360-3016(99)00386-7] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE Positioning of patients with gynecologic tumors for radiotherapy has proven to be relatively inaccurate. To improve the accuracy and reduce the margins from clinical target volume (CTV) to planning target volume (PTV), on-line set-up corrections were investigated. METHODS AND MATERIALS Anterior-posterior portal images of 14 patients were acquired using the first six monitor units (MU) of each irradiation fraction. The set-up deviation was established by matching three user-defined landmarks in portal and simulator image. If the two-dimensional deviation exceeded 4 mm, the table position was corrected. A second portal image was acquired using 30 MU of the remaining dose. This image was analyzed off-line using a semiautomatic contour match to obtain the final set-up accuracy. To verify the landmark match accuracy, the contour match was retrospectively performed on the six MU images as well. RESULTS The standard deviation (SD) of the distribution of systematic set-up deviations after correction was < 1 mm in left-right and cranio-caudal directions. The average random deviation was < 2 mm in these directions (1 SD). Before correction, all standard deviations were 2 to 3 mm. The landmark match procedure was sufficiently accurate and added on average 3 min to the treatment time. The application of on-line corrections justifies a CTV-to-PTV margin reduction to about 5 mm. CONCLUSIONS On-line set-up corrections significantly improve the positioning accuracy. The procedure increases treatment time but might be used effectively in combination with off-line corrections.
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Affiliation(s)
- J C Stroom
- Division of Clinical Physics and Instrumentation, University Hospital Rotterdam, Daniel den Hoed Cancer Center, The Netherlands.
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Bel A, Vos PH, Rodrigus PT, Creutzberg CL, Visser AG, Stroom JC, Lebesque JV. High-precision prostate cancer irradiation by clinical application of an offline patient setup verification procedure, using portal imaging. Int J Radiat Oncol Biol Phys 1996; 35:321-32. [PMID: 8635940 DOI: 10.1016/0360-3016(95)02395-x] [Citation(s) in RCA: 179] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE To investigate in three institutions, The Netherlands Cancer Institute (Antoni van Leeuwenhoek Huis [AvL]), Dr. Daniel den Hoed Cancer Center (DDHC), and Dr, Bernard Verbeeten Institute (BVI), how much the patient setup accuracy for irradiation of prostate cancer can be improved by an offline setup verification and correction procedure, using portal imaging. METHODS AND MATERIALS The verification procedure consisted of two stages. During the first stage, setup deviations were measured during a number (Nmax) of consecutive initial treatment sessions. The length of the average three dimensional (3D) setup deviation vector was compared with an action level for corrections, which shrunk with the number of setup measurements. After a correction was applied, Nmax measurements had to be performed again. Each institution chose different values for the initial action level (6, 9, and 10 mm) and Nmax (2 and 4). The choice of these parameters was based on a simulation of the procedure, using as input preestimated values of random and systematic deviations in each institution. During the second stage of the procedure, with weekly setup measurements, the AvL used a different criterion ("outlier detection") for corrective actions than the DDHC and the BVI ("sliding average"). After each correction the first stage of the procedure was restarted. The procedure was tested for 151 patients (62 in AvL, 47 in DDHC, and 42 in BVI) treated for prostate carcinoma. Treatment techniques and portal image acquisition and analysis were different in each institution. RESULTS The actual distributions of random and systematic deviations without corrections were estimated by eliminating the effect of the corrections. The percentage of mean (systematic) 3D deviations larger than 5 mm was 26% for the AvL and the DDHC, and 36% for the BVI. The setup accuracy after application of the procedure was considerably improved (percentage of mean 3D deviations larger than 5 mm was 1.6% in the AvL and 0% in the DDHC and BVI), in agreement with the results of the simulation. The number of corrections (about 0.7 on the average per patient) was not larger than predicted. CONCLUSION The verification procedure appeared to be feasible in the three institutions and enabled a significant reduction of mean 3D setup deviations. The computer simulation of the procedure proved to be a useful tool, because it enabled an accurate prediction of the setup accuracy and the required number of corrections.
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Affiliation(s)
- A Bel
- Radiotherapy Department, The Netherlands Cancer Institute (Antoni van Leeuwenhoek Huis), Amsterdam
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Creutzberg CL, Althof VG, de Hoog MD, Visser AG, Huizenga H, Wijnmaalen A, Levendag PC. A quality control study of the accuracy of patient positioning in irradiation of pelvic fields. Int J Radiat Oncol Biol Phys 1996; 34:697-708. [PMID: 8621295 DOI: 10.1016/0360-3016(95)02034-9] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE Determining and improving the accuracy of patient positioning in pelvic fields. METHODS AND MATERIALS Small pelvic fields were studied in 16 patients treated for urological cancers using a three-field isocentric technique. Large pelvic fields were studied in 17 gynecological cancer patients treated with anterior and posterior (AP-PA) parallel opposed fields. Quantitative analysis of 645 megavolt images and comparison to 82 simulation images were carried out. RESULTS Small pelvic fields: for the position of the patient in the field, standard deviations of the difference between simulation (SIM) and treatment (MV) images were 3.4 mm in the lateral direction, 5.3 mm in the cranio-caudal direction, and 4.8 mm in the ventro-dorsal direction. Alterations in the positioning technique were made and tested. Large pelvic fields: differences between simulation and treatment images for the position of the patient in the field were 4 mm [1 standard deviation (SD)] in the lateral direction and 6.5 mm in the cranio-caudal direction. A systematic shift of the treatment field in the cranial direction had occurred in the majority of patients. A positioning technique using laser lines and marking of the caudal field border was shown to be more accurate. CONCLUSIONS Studies of positioning accuracy in routine irradiation techniques are needed to obtain data for definition of the margins for each treatment site at each institution. Random variations should be kept at a minimum by monitoring and improving positioning techniques. Treatment verification by megavolt imaging or film should be used to detect and correct systematic variations early in the treatment series.
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Affiliation(s)
- C L Creutzberg
- Department of Radiation Oncology, Dr. Daniel den Hoed Cancer Center, Rotterdam, The Netherlands
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Creutzberg CL, Althof VG, Huizenga H, Visser AG, Levendag PC. Quality assurance using portal imaging: the accuracy of patient positioning in irradiation of breast cancer. Int J Radiat Oncol Biol Phys 1993; 25:529-39. [PMID: 8436532 DOI: 10.1016/0360-3016(93)90077-9] [Citation(s) in RCA: 81] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE To study the accuracy of patient positioning in irradiation of breast cancer. METHODS AND MATERIALS Megavolt portal images were obtained using a fast electronic megavoltage radiotherapy imaging system in 17 breast cancer patients immobilized with plastic fixation masks on a flat board with arm support and in 14 patients positioned without a mask on either a flat or a wedge-shaped board. Quantitative analysis of 510 megavolt portal images and comparison to 66 digitized simulation films was performed. Differences between the positioning techniques were evaluated. RESULTS For the position of the patient in the field, standard deviations of the difference between simulation and treatment images were 3.2 mm and 4.6 mm for irradiation with and without masks, respectively. Larger standard deviations were found for the field width and length (5-7 mm), for collimator rotation (1.5-2 degrees), and for the position of the lung shielding block for patients positioned on the flat board (10-16 mm). The changes in field size and collimator rotation appeared to be largely due to the inclination of the technologists to slightly adapt fields in order to obtain a seemingly better congruity of the field with the skin or mask markings. Comparison of the accuracy of patient positioning with and without masks yielded similar error rates; standard deviations and extremes tended to be somewhat larger in positioning without a mask. The wedge-shaped board was preferred because of the ease of patient set-up and because the use of a lung block is avoided. The transition from simulation to treatment set-up yielded larger deviations than repeated treatment set-ups. CONCLUSION These results emphasize again the continuous need for focusing attention on the accuracy of patient positioning in order to achieve maximal precision in radiotherapy. The electronic portal imaging system is very suitable for both quick on-line treatment verification and off-line analyses.
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Affiliation(s)
- C L Creutzberg
- Dr. Daniel den Hoed Cancer Center, Groene Hilledijk, Rotterdam, The Netherlands
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Abstract
A prospective study of the accuracy of patient positioning in mantle field irradiation was carried out in 13 lymphoma patients treated with curative radiotherapy. Patients were treated in the supine and prone position for anterior and posterior fields, respectively. Individually shaped divergent shielding blocks were placed in a fixed position in a template which was positioned on a tray above the patient. A total number of 94 megavoltage portal films (MV) was analysed and compared to 26 simulation films (SIM). MV-SIM differences were larger for posterior fields than for anterior fields. Regarding the position of the lung shielding blocks, mean MV-SIM differences ranged from 1.3 to 4.4 mm and errors exceeding 1 cm were found in 7.2% of cases. Most discrepancies appeared to be randomly distributed. A 4-5 mm systematic cranial shift of patients in the posterior treatment position was noted. Discrepancies in the position of the laryngeal block, spinal cord shielding block and humerus blocks were small with mean MV-SIM differences ranging from 0.3 to 2.7 mm. Differences between simulation set-up and treatment set-up were modest as compared to error rates reported in the literature. Shielding of tumour-bearing areas did not occur. It was concluded that the present standardised technique of patient positioning and the design of treatment fields results in acceptable error rates. Attention should be directed towards increasing the stability of patients in the prone treatment position in order to further reduce both systematic and random error rates.
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Affiliation(s)
- C L Creutzberg
- Department of Radiation Oncology, Dr. Daniel den Hoed Cancer Center, Rotterdam, The Netherlands
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Creutzberg CL, Jansen PP, Merkelbach JW. [Visit to the emergency department: primary or secondary character?]. Ned Tijdschr Geneeskd 1989; 133:73-6. [PMID: 2915730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
In a prospective study, 961 patients who came to the Emergency Department were registered and their cases were analysed on the basis of criteria drawn up in consultation with a group of general practitioners. Of this number 74% had presented themselves on their own initiative; 40% had been suffering from the complaint for some time. 66% of the patients who had not been referred and 60% of the total number could have been treated by their GP, at less expense for the National Health Service. It is worth considering for GPs on duty to make use of the facilities provided by the Emergency Departments of hospitals. This would increase patients' understanding of the function and the accessibility of Emergency Departments, enable GPs to work more efficiently and be cost effective.
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Schelfhout LJ, Creutzberg CL, Hamming JF, Fleuren GJ, Smeenk D, Hermans J, van de Velde CJ, Goslings BM. Multivariate analysis of survival in differentiated thyroid cancer: the prognostic significance of the age factor. Eur J Cancer Clin Oncol 1988; 24:331-7. [PMID: 3356216 DOI: 10.1016/0277-5379(88)90276-3] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
A retrospective analysis of tumour and patient characteristics was performed in 202 patients with papillary (n = 132) or follicular (n = 70) thyroid carcinoma, in order to identify prognostic factors related to survival. The following facts were found to be unfavourably related to survival: follicular histology, extrathyroidal growth of the primary tumour (stage pT4), regional lymph node involvement (stages pN1-3), presence of distant metastases at diagnosis (stage pM1), male sex (in papillary cancer) and old age (only death due to thyroid tumour was evaluated). For 190 patients sufficient material was available to permit extensive histopathological investigation. In patients with papillary cancer the presence of small anaplastic foci and/or greater than 25% solid structures (n = 18) was correlated with a reduced survival rate. Our study underlines the importance of distinguishing, histologically, between papillary and follicular cancer and in addition demonstrates the prognostic value of histological grade in papillary (but not follicular) carcinoma. We applied Cox's proportional hazard model to the survival data of these 190 patients and, after stage grouping, found that tumour stage (locoregional vs. advanced disease) was the most important prognostic factor. The second most important factor was the histological (sub)type (well differentiated papillary carcinoma vs. moderately differentiated papillary carcinoma and follicular carcinoma). Age at diagnosis and sex appeared to be of lesser importance. Therefore our study does not recommend the use of age as a guide for therapeutical decisions in differentiated thyroid cancer.
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Affiliation(s)
- L J Schelfhout
- Department of Endocrinology, University Hospital, Leiden, The Netherlands
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