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Henry M, Harvey R, Chen LM, Meaney M, Nguyen TTT, Kao HT, Rosberger Z, Frenkiel S, Hier M, Zeitouni A, Kost K, Mlynarek A, Richardson K, Greenwood CMT, Melnychuk D, Gold P, Chartier G, Black M, Mascarella M, MacDonald C, Sadeghi N, Sultanem K, Shenouda G, Cury F, O'Donnell KJ. Genetic predisposition to depression and inflammation impacts symptom burden and survival in patients with head and neck cancer: A longitudinal study. J Affect Disord 2023; 331:149-157. [PMID: 36948466 DOI: 10.1016/j.jad.2023.03.007] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 02/13/2023] [Accepted: 03/06/2023] [Indexed: 03/24/2023]
Abstract
OBJECTIVE The primary purpose of this study was to investigate the contribution of genetic predispositions to depression and inflammation, as measured through polygenic risk scores, on symptom burden (physical and psychological) in patients with head and neck cancer in the immediate post-treatment period (i.e., at three months post-diagnosis), as well as on 3-, 6-, 12-, 24- and 36-month survival. METHODS Prospective longitudinal study of 223 adults (72 % participation) newly diagnosed with a first occurrence of primary head and neck cancer, paired with genetic data (Illumina PsychArray), validated psychometric measures, Structured Clinical Interviews for DSM Disorders (SCID-I), and medical chart reviews. RESULTS Symptom burden at 3 months was predicted by (R2 adj. = 0.38, p < 0.001): a baseline SCID-I Anxiety Disorder (b = 1.69, B = 0.23, 95%CI = 0.43-2.94; p = 0.009), baseline levels of HADS anxiety (b = 0.20, B = 0.29, 95%CI = 0.07-0.34; p = 0.003), the polygenic risk score (PRS) for depression (b = 0.66, B = 0.18, 95%CI = 0.003-1.32; p = 0.049), and cumulated dose of radiotherapy (b = 0.002, B = 0.46, 95%CI = 0.001-0.003; p < 0.001). When controlling for factors known to be associated with cancer survival, patients with a higher PRS associated with depression and inflammation, respectively, presented higher risk of death within 36 months (b = 1.75, Exp(B) = 5.75, 95%CI = 1.55-21.27, p = 0.009 and b = 0.14, Exp(B) = 1.15, 95%CI = 1.01-1.30, p = 0.03). CONCLUSIONS Our results outline three potential pathways of symptom burden in patients with head and neck cancer: a genetic predisposition towards depression; an initial anxiety disorder upon being diagnosed with cancer or high levels of anxiety upon diagnosis; and a dose-related response to radiotherapy. One may want to investigate early interventions in these areas to alleviate symptom burden in patients faced with a life-threatening disease, as well as consider targeting genetic predisposition towards depression and inflammation implicated in survival. The high prevalence of distress in patients with head and neck cancer is an opportunity to study genetic predispositions, which could potentially be broadly generalized to other cancers and diseases.
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Affiliation(s)
- Melissa Henry
- McGill University, Canada; Jewish General Hospital, Canada; Lady-Davis Institute for Medical Research, Canada.
| | | | | | | | | | - Han-Tin Kao
- McGill University, Canada; Douglas Hospital, Canada
| | - Zeev Rosberger
- McGill University, Canada; Jewish General Hospital, Canada; Lady-Davis Institute for Medical Research, Canada
| | - Saul Frenkiel
- McGill University, Canada; Jewish General Hospital, Canada; Douglas Hospital, Canada
| | - Michael Hier
- McGill University, Canada; Jewish General Hospital, Canada; Lady-Davis Institute for Medical Research, Canada
| | - Anthony Zeitouni
- McGill University, Canada; McGill University Health Centre, Canada
| | - Karen Kost
- McGill University, Canada; McGill University Health Centre, Canada
| | - Alex Mlynarek
- McGill University, Canada; Jewish General Hospital, Canada; McGill University Health Centre, Canada
| | - Keith Richardson
- McGill University, Canada; McGill University Health Centre, Canada
| | - Celia M T Greenwood
- McGill University, Canada; Lady-Davis Institute for Medical Research, Canada
| | | | - Phil Gold
- McGill University, Canada; Jewish General Hospital, Canada
| | | | - Martin Black
- McGill University, Canada; Jewish General Hospital, Canada
| | - Marco Mascarella
- McGill University, Canada; McGill University Health Centre, Canada
| | | | - Nader Sadeghi
- McGill University, Canada; McGill University Health Centre, Canada
| | - Khalil Sultanem
- McGill University, Canada; McGill University Health Centre, Canada
| | - Georges Shenouda
- McGill University, Canada; McGill University Health Centre, Canada
| | - Fabio Cury
- McGill University, Canada; McGill University Health Centre, Canada
| | - Kieran John O'Donnell
- McGill University, Canada; Douglas Hospital, Canada; Yale Child Study Center, Yale School of Medicine, Yale University, United States of America; Department of Obstetrics Gynecology & Reproductive Sciences, Yale School of Medicine, Yale University, United States of America
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Shenouda G, Petrecca K, Abdulkarim B, Owen S, Panet-Raymond V, Diaz R, Guiot M, Carvalho T, Charbonneau M, Hall J, Souhami L. Comparison of Two Phase II Trials of Neoadjuvant Temozolomide Followed with Concomitant and Adjuvant Temozolomide and Hypofractionated Accelerated Radiotherapy with or without Metformin in Patients with Newly Diagnosed Glioblastoma. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.449] [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: 10/31/2022]
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Garden A, Harris J, Eisbruch A, Chao K, Morrison W, Harari P, Swanson T, Jones C, Yom S, Spencer S, Scrimger R, Shenouda G, Shukla M, Lau H, Mierzwa M, Torres-Saavedra P, Le Q. Final Report of NRG Oncology RTOG 0022: A Phase I/II Study of Conformal and Intensity Modulated Radiation for Oropharyngeal Cancer. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.322] [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: 10/20/2022]
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Lee N, Harris J, Pfister D, Kim J, Garden A, Mechalakos J, Chan A, Hu K, Yom S, Glisson B, Shenouda G, Ad VB, Waldron J, Harari P, Le Q. Long-Term Update of a Phase II Study of Concurrent Chemoradiotherapy Using Radiation + Bevacizumab (BV) For Locally or Regionally Advanced Nasopharyngeal Cancer (NPC): RTOG 0615. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2019.11.371] [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: 10/24/2022]
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Caudell J, Torres-Saavedra P, Rosenthal D, Axelrod R, Nguyen-Tan P, Sherman E, Weber R, Galvin J, El-Naggar A, Konski A, Trotti A, Dunlap N, Shenouda G, Singh A, Beitler J, Garsa A, Birrer M, Garden A, Herman T, Le Q. Long-Term Update of NRG Oncology RTOG 0522: A Randomized Phase III Trial of Concurrent Radiation and Cisplatin with or without Cetuximab in Locoregionally Advanced Head and Neck Cancer. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2019.11.393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Zhong H, Athamnah M, Huang M, Geng H, Cheng C, Men K, Rosen M, Rosenthal D, Thorstad W, Ad VB, Trotti A, Roach M, Gore E, Birrer M, Raben D, Shenouda G, Foote R, Fan Y, Xiao Y. Comparisons of Outcome Prediction Performance between Radiomics Features and Clinical Features Based on NRG Oncology/ RTOG-0522. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.06.548] [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: 10/26/2022]
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Awan M, Gittleman H, Barnholtz-Sloan J, Machtay M, Nguyen-Tan P, Rosenthal D, Takiar V, Garden A, Thorstad W, Wong S, Trotti A, Bonner J, Ridge J, Shenouda G, Suntharalingam M, Bahig H, Harris J, Le Q, Yao M. A Nomogram for Outcomes after Chemoradiation for Non-HPV-Related Squamous Cell Carcinomas of the Head and Neck – A Pooled Analysis of NRG Oncology RTOG 0129 and 0522. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.06.1619] [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: 11/28/2022]
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Daniel P, Meehan B, Sabri S, Chaddad A, Jean-Claude B, Shenouda G, Rak J, Abdulkarim B. Exploiting Molecular Subtype Cell Plasticity As Novel Strategy for Targeting Glioma Stem Cells Through Alternating Therapy. Int J Radiat Oncol Biol Phys 2018. [DOI: 10.1016/j.ijrobp.2018.07.743] [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: 10/28/2022]
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Shenouda G, Souhami L, Petrecca K, Owen S, Panet-Raymond V, Carvalho T, Guiot M, Abdulkarim B. A Phase 2 Trial of Neoadjuvant Temozolomide (TMZ) Followed By Accelerated Hypofractionated Radiation Therapy (AHRT) and TMZ Followed By Adjuvant TMZ in Patients with Newly Diagnosed Glioblastoma (GBM): Long Term Survival and Toxicity Analysis. Int J Radiat Oncol Biol Phys 2018. [DOI: 10.1016/j.ijrobp.2018.06.096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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10
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Shakir S, Souhami L, Petrecca K, Mansure J, Panet-Raymond V, Shenouda G, Singh K, Alodaini A, Abdulkarim B, Guiot M. PV-0502: Post-operative radiation therapy in atypical meningiomas: analysis of prognostic factors. Radiother Oncol 2017. [DOI: 10.1016/s0167-8140(17)30942-8] [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: 10/19/2022]
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Shakir S, Souhami L, Petrecca K, Mansure J, Khushdeep S, Panet-Raymond V, Shenouda G, Al Odaini A, Abdulkarim B, Guiot M. Analysis of Prognostic Factors for Local Recurrence in Atypical Meningiomas. Int J Radiat Oncol Biol Phys 2016. [DOI: 10.1016/j.ijrobp.2016.06.787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Neto OSB, Faria S, Cury F, David M, Duclos M, Shenouda G, Souhami L. Intermediate-Risk Prostate Cancer Treated With Hypofractionated External Beam Radiation Therapy Alone: Long-term Outcomes. Int J Radiat Oncol Biol Phys 2015. [DOI: 10.1016/j.ijrobp.2015.07.1107] [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: 11/25/2022]
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Konski A, Qiang Z, Ang K, Fu K, Trotti A, Spencer S, Gunn B, Shenouda G, Le Q. OC-016: Patient reported outcomes (PRO) of RTOG 9003. Radiother Oncol 2015. [DOI: 10.1016/s0167-8140(15)34776-9] [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: 11/25/2022]
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Sabit K, Panet-Raymond V, Souhami L, El Naqa I, Shenouda G, Zeitouni A, Sirhan D. Volumetric Growth Measurements of Pituitary Macroadenomas Following Surgical Resection and Indications for Early Adjuvant Radiation Therapy. Int J Radiat Oncol Biol Phys 2014. [DOI: 10.1016/j.ijrobp.2014.05.1007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Shenouda G, Souhami L, Panet-Raymond V, Abdulkarim B, Cury F, Owen S, Kavan P, Petrecca K, Guiot M. Results of a Phase 2 Clinical Trial of Neo-Adjuvant Temozolomide (TMZ), Followed by Concurrent TMZ and Hypofractionated Accelerated External Beam Radiation Therapy (Ac-EBRT) With Limited Margins, and Adjuvant TMZ for Patients With Glioblastoma Multiforme (GBM). Int J Radiat Oncol Biol Phys 2013. [DOI: 10.1016/j.ijrobp.2013.06.412] [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: 10/26/2022]
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Woods C, Zhang Q, Silverman C, Shenouda G, Harris J, Ang K, Machtay M. Comparison Between IMRT and 3D CRT in Laryngeal Cancer Patients Treated on RTOG 0522. Int J Radiat Oncol Biol Phys 2013. [DOI: 10.1016/j.ijrobp.2013.06.1189] [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: 10/26/2022]
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Bernad D, Collins L, Fiocco A, Ge M, Shenouda G, Panet-Raymond V, Giacomini P, del Carpio R, Souhami L. Analysis of Structural Changes in Hippocampal and Amygdala Volume After Systemic Therapy and Prophylactic Cranial Irradiation in Patients With Limited Stage-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2013. [DOI: 10.1016/j.ijrobp.2013.06.267] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Jeyaseelan K, Coates J, Ybarra N, David M, Faria S, Souhami L, Shenouda G, Cury F, Duclos M, ElNaqa I. Copy Number Variations as Predictors of Late Toxicities in Prostate Cancer. Int J Radiat Oncol Biol Phys 2013. [DOI: 10.1016/j.ijrobp.2013.06.1772] [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: 11/26/2022]
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Beitler J, Zhang Q, Fu K, Trotti A, Spencer S, Jones C, Garden A, Shenouda G, Harris J, Ang K. RTOG 90-03: Final Report. Int J Radiat Oncol Biol Phys 2012. [DOI: 10.1016/j.ijrobp.2012.07.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Bernad D, Fiocco A, Shenouda G, Panet-Raymond V, Giacomini P, del Carpio R, Souhami L. Prophylactic Cranial Irradiation in Patients With Limited Stage Small Cell Lung Cancer: A Pilot Study Investigating the Effects of Radiation Therapy on Neurocognitive Function. Int J Radiat Oncol Biol Phys 2012. [DOI: 10.1016/j.ijrobp.2012.07.783] [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: 11/25/2022]
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Hashem R, Parker W, Cury F, Sultanem K, Tong W, Shenouda G. The Utilization of IMRT Planning in Decreasing the Risk of Accelerated Demyelination in Multiple Sclerosis Patients Following External Beam Radiation Therapy. Int J Radiat Oncol Biol Phys 2012. [DOI: 10.1016/j.ijrobp.2012.07.2291] [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: 11/26/2022]
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Shakibnia L, Roberge D, Souhami L, Lambert C, Panet Raymond V, Shenouda G. Hypofractionated, Reduced Margin, Intensity Modulated Radiotherapy with Concurrent and Adjuvant Temozolomide for Patients with Glioblastoma Multiforme: A Pattern of Failure Analysis. Int J Radiat Oncol Biol Phys 2011. [DOI: 10.1016/j.ijrobp.2011.06.485] [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: 11/28/2022]
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Pocinho R, Popovic M, Poon E, Shenouda G, Cury F. 2046 POSTER Volumetric Modulated Arc Therapy Vs. IMRT: a Treatment Planning Comparison for Larynx, Oro- and Hypopharynx Carcinomas. Eur J Cancer 2011. [DOI: 10.1016/s0959-8049(11)71004-8] [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: 12/01/2022]
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Cury FL, Duclos M, Aprikian AG, Patrocinio H, Kassouf W, Shenouda G, Faria S, David M, Souhami L. Single fraction high-dose-rate brachytherapy and hypofractionated external beam radiation therapy in the treatment of intermediate-risk prostate cancer: Long-term results. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.7_suppl.83] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
83 Background: We present the long-term results of a cohort of patients with intermediate-risk prostate cancer (PC) treated with single fraction high-dose-rate brachytherapy (HDRB) combined with hypofractionated external beam radiation therapy (HRT). Methods: Patients with intermediate-risk PC were treated exclusively with HDRB and HRT. HDRB delivered a dose of 10 Gy to the prostate gland and HRT consisted of 50 Gy delivered in 20 daily fractions. The planning target volume was the prostate gland with a 1 cm margin all around. The first 121 consecutive patients with a minimum of 2 years post-treatment follow-up were assessed for acute and chronic toxicity and disease control. Results: The median follow-up was 62.8 months. No acute grade III or higher toxicities were seen. Grade II late GI toxicity was seen in 9 patients (7.4%) and grade III in 2 (1.6%). Grade 3 GU toxicity was seen in 2 patients (1.6%), both with urinary obstructive symptoms requiring catheterization. A repeat biopsy was offered to the first 58 consecutively treated patients, and 44 patients agreed with the procedure. A negative biopsy was found in 40 patients (91%). The biochemical relapse-free survival rate at 5 and 8 years were 90.7% and 81.4%, with 13 patients presenting biochemical failure. Among them, nine were diagnosed with distant metastasis. Prostate cancer-specific and overall survival rates at 8 years were 100% and 95.5%, respectively. Conclusions: Our program of HDRB and HRT is well tolerated, with acceptable toxicity rates. Furthermore, results from re-biopsies revealed an elevated rate of local control. These results are encouraging and confirm that the use of conformal RT techniques, adapted to specific biological features, have the potential to improve the therapeutic ratio in intermediate risk PC patients. No significant financial relationships to disclose.
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Affiliation(s)
- F. L. Cury
- McGill University Health Centre, Montreal, QC, Canada; McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - M. Duclos
- McGill University Health Centre, Montreal, QC, Canada; McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - A. G. Aprikian
- McGill University Health Centre, Montreal, QC, Canada; McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - H. Patrocinio
- McGill University Health Centre, Montreal, QC, Canada; McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - W. Kassouf
- McGill University Health Centre, Montreal, QC, Canada; McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - G. Shenouda
- McGill University Health Centre, Montreal, QC, Canada; McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - S. Faria
- McGill University Health Centre, Montreal, QC, Canada; McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - M. David
- McGill University Health Centre, Montreal, QC, Canada; McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - L. Souhami
- McGill University Health Centre, Montreal, QC, Canada; McGill University Health Centre, McGill University, Montreal, QC, Canada
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Dal Pra A, Faria S, Cury FL, David M, Duclos M, Shenouda G, Souhami L. Treating intermediate-risk prostate cancer with hypofractionated external beam radiotherapy alone. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.7_suppl.93] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
93 Background: A wide range of therapeutic alternatives is available for the treatment of intermediate-risk prostate cancer (IRPC). The use of hypofractionated external beam radiotherapy (HypoRT) in this group of patients appears to be an attractive option. Non-randomized institutional results have provided similar outcomes to conventional fractionation. For health-systems such as we have in Canada, where many patients live far, it significantly shortens treatment duration and impacts favorably in health costs. We report our results using HypoRT alone in IRPC. Methods: Between October/2002 and July/2009, 82 men with IRPC (T2b-T2c, or PSA 10–20 ng/dL, or GS=7) were treated with HypoRT, without any androgen deprivation. Ultrasound image guidance was used daily to confirm setup. The dose was 66 Gy in 22 daily fractions of 3 Gy (BED=79.4Gy/44) prescribed at the isocenter. PTV was the prostate (+/− 1cm seminal vesicles) with 7-mm margin in all directions. GI and GU toxicity were prospectively assessed every 4–6 months using the CTCAE v3 scoring system. Biochemical failure was defined as nadir PSA + 2 ng/dL. Results: 60% of patients had Gleason score 7; 43% had stage T2; median initial PSA=9 ng/ml; median age 71 years. With a median follow-up of 43 months (range: 7–89), only three patients (4%) have developed biochemical failure. All three showed metastatic disease few months after biochemical failure. Actuarial biochemical recurrence free survival (bNED) is 95.4%. There was no death related to prostate cancer. Three patients died from other causes without biochemical failure. The 5-year overall survival was 93%. At the last follow up visit, grade ≥ 2 late GI and GU toxicity rates were 2% and 7%, respectively. No grade 4 or 5 has occurred. Conclusions: Men with IRPC treated with 66Gy/22 fractions and without androgen deprivation have experienced excellent 5-year biochemical control rate with acceptable late toxicity. This regimen is very convenient because the duration of the treatment is half of the time used with conventional fractionation. Whether the addition of short-term androgen deprivation would further improve outcome remains unclear. No significant financial relationships to disclose.
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Affiliation(s)
- A. Dal Pra
- McGill University Health Centre, Montreal, QC, Canada
| | - S. Faria
- McGill University Health Centre, Montreal, QC, Canada
| | - F. L. Cury
- McGill University Health Centre, Montreal, QC, Canada
| | - M. David
- McGill University Health Centre, Montreal, QC, Canada
| | - M. Duclos
- McGill University Health Centre, Montreal, QC, Canada
| | - G. Shenouda
- McGill University Health Centre, Montreal, QC, Canada
| | - L. Souhami
- McGill University Health Centre, Montreal, QC, Canada
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Abstract
Canadian law, and the physician's code of ethics, requires that informed consent be obtained before any medical act is performed. However, there are no rules about how consent is to be obtained and by whom, and how that consent is to be documented.In April 2008, we asked the heads of all Canadian radiation oncology departments to tell us whether their centre uses a written consent form for external-beam radiotherapy and, if it did, to send us a copy of the form or forms used. Responses were received from 29 of the 38 centres contacted (76%). In 12 centres, all of them in British Columbia or Quebec, no written consent is obtained. Of the 17 centres (59%) that do seek written consent, 9 use a generic hospital or cancer centre form. Only 5 use a form specific to radiotherapy that mentions multiple visits, photographs in the treatment position, use of tattoos, and so on, and only 2 use a form that is specific to the tumour type or site irradiated and that explains the risks associated with treatment. The final centre of the 17 did not provide a form for review.While current practice at the McGill University Health Centre is not out of line with that at other Canadian centres, the results of our survey suggest a need for dialogue on the subject of consent for external-beam radiotherapy.
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Affiliation(s)
- C Freeman
- Department of Radiation Oncology, McGill University Health Centre, Montreal, QC
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Al Wassia R, Dal Pra A, Shun K, Shaban A, Corriveau C, Edelstein C, Ruo R, Patrocinio H, Shenouda G. Juxtapapillary Choroidal Melanoma Treated with Fractionated Stereotactic Radiotherapy: Local Control and Toxicity Outcomes. Int J Radiat Oncol Biol Phys 2010. [DOI: 10.1016/j.ijrobp.2010.07.1012] [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: 11/26/2022]
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Berlach D, Nguyen N, Cury F, Al Halabi H, Shenouda G. Comparison of Prophylactic and Emergent Percutaneous Endoscopic Gastrostomy Tube Placement in Patients Treated with Chemotherapy and Radiation for Head and Neck Cancer. Int J Radiat Oncol Biol Phys 2010. [DOI: 10.1016/j.ijrobp.2010.07.1028] [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: 10/19/2022]
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Elhateer H, Muanza T, Roberge D, Ruo R, Eldebawy E, Lambert C, Patrocinio H, Shenouda G, Souhami L. Fractionated stereotactic radiotherapy in the treatment of pituitary macroadenomas. ACTA ACUST UNITED AC 2010; 15:286-92. [PMID: 19079630 PMCID: PMC2601024 DOI: 10.3747/co.v15i6.293] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background The use of fractionated stereotactic radiotherapy (fsrt) has evolved with technical advances in noninvasive immobilization, radiation delivery, and image guidance. The application of fsrt to pituitary tumours is aimed at reducing toxicity through improved dose conformality and reduced treatment margins. The aim of the present paper is to report our own experience and to review the published data on fsrt for pituitary macroadenomas. Methods Between September 2000 and October 2005, 13 patients with pituitary macroadenoma underwent fsrt at our institution. In 12 patients, radiotherapy treatment followed surgical resection (transsphenoidal resection in 8, frontal craniotomy in 3, and multiple transsphenoidal resections followed by craniotomy in 1). In 4 patients, the tumours were functional (2 adrenocorticotropic hormone–secreting, 1 prolactinoma, and 1 growth hormone–secreting); the tumours in the remaining patients were clinically non-secretory. Before radiation, 3 patients had panhypopituitarism, and 6 patients had visual field defects. All patients were treated with fsrt using non-coplanar micro–multileaf collimation portals. A median dose of 50.4 Gy (range: 45–60 Gy) was prescribed to the 76.9%–95.2% isodose surface and delivered in 1.8-Gy fractions. The median planning target volume (gross tumour plus 3 mm) was 33.5 cm3 (range: 3.2–75 cm3). Results After a median follow-up of 24 months (range: 6–60 months), local control was 100%. One patient achieved clinical complete response. Treatment was well tolerated acutely for all patients. Neither radiation-induced optic neuropathy nor any radiation-related endocrine dysfunction was observed in our patients. Conclusions In accordance with published series, we found fsrt to be safe and effective in the management of large pituitary macroadenomas.
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Affiliation(s)
- H Elhateer
- Department of Radiation Oncology, McGill University Health Center, Montreal, QC
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Duclos M, Al-Hamad A, Al-Halabi H, Alsuhaibani A, Kost K, Zeitouni A, Hier M, Shenouda G, Black M. Organ Preservation using HDR Brachytherapy for Locally Advanced Head and Neck Cancers: A Single Center Experience. Int J Radiat Oncol Biol Phys 2009. [DOI: 10.1016/j.ijrobp.2009.07.993] [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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Rene N, Parker W, Souhami L, Shenouda G, Duclos M, Faria S, David M, Cury F. 181 ULTRASOUND IMAGE GUIDED RADIOTHERAPY (RT): POSTERIOR DISPLACEMENT OF THE PROSTATE (PST) INDUCED BY THE ULTRASOUND (US) PROBE IN PATIENTS WITH A DISTENDED RECTUM. Radiother Oncol 2009. [DOI: 10.1016/s0167-8140(12)72568-9] [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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Rene N, Faria S, Souhami L, Cury F, David M, Shenouda G, Duclos M. 32 HYPOFRACTIONATED RADIATION THERAPY (RT) FOR LOCALIZED PROSTATE CANCER (PC). Radiother Oncol 2009. [DOI: 10.1016/s0167-8140(12)72419-2] [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: 11/17/2022]
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Quinlan-Davidson S, Evans M, Edelstein C, Shenouda G. Visual Acuity and Complications after Ruthenium-106 Plaque Brachytherapy for Medium Size Choroidal Melanoma. Int J Radiat Oncol Biol Phys 2008. [DOI: 10.1016/j.ijrobp.2008.06.1332] [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: 10/21/2022]
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Al Hamad A, Black M, Shenouda G, Zeitouni A, Kost K, Hier M, Bahoric B, Duclos M. Does HDR Brachytherapy for Primary or Recurrent Head and Neck Cancers have Lower Local Control than the External Beam Radiotherapy? Int J Radiat Oncol Biol Phys 2008. [DOI: 10.1016/j.ijrobp.2008.06.1298] [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: 11/16/2022]
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36
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Hauerstock D, Shenouda G, Sultanem K. Hypofractionated Radiation Therapy for Early Stage Glottic Cancer. Int J Radiat Oncol Biol Phys 2008. [DOI: 10.1016/j.ijrobp.2008.06.1256] [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: 10/21/2022]
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Chen Y, Fraser D, Cury F, Heon J, Parker W, Shenouda G, Duclos M, Souhami L, Falco T, Verhaegen F. SU-GG-J-23: Accurate Dose Assessment for Prostate Cancer Patients Using 3D Ultrasound and Monte Carlo Dose Calculation. Med Phys 2008. [DOI: 10.1118/1.2961580] [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: 11/07/2022] Open
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AlHamad AN, Black M, Shenouda G, Zeitouni A, Kost K, Hier M, Duclos M. HDR brachytherapy for primary or recurrent head and neck cancers: A retrospective analysis of the McGill experience. Brachytherapy 2008. [DOI: 10.1016/j.brachy.2008.02.433] [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: 10/22/2022]
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Cury F, Duclos M, Aprikian A, Shenouda G, Faria S, David M, Patrocinio H, Evans M, Souhami L. Improving the Therapeutic Ratio in the Treatment of Intermediate Risk Prostate Cancer With Single Fraction High Dose Rate Brachytherapy and Hypofractionated External Beam Radiation Therapy. Int J Radiat Oncol Biol Phys 2007. [DOI: 10.1016/j.ijrobp.2007.07.1392] [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: 11/26/2022]
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40
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Panet-Raymond V, Roberge D, Souhami L, Shakibnia L, Kavan P, Muanza T, Lambert C, Guiot M, Shenouda G. Accelerated Hypofractionated Intensity Modulated Radiotherapy With Concurrent and Adjuvant Temozolomide for Patients With Glioblastoma Multiforme: A Safety and Efficacy Analysis. Int J Radiat Oncol Biol Phys 2007. [DOI: 10.1016/j.ijrobp.2007.07.1245] [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: 10/22/2022]
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Joshua B, Souhami L, Jeyaganth S, Faria S, Shenouda G, David M, Cury F, Duclos M. 4021 POSTER Testosterone recovery following prolonged adjuvant androgen blockade in localized prostate cancer: is there an effect on outcome? EJC Suppl 2007. [DOI: 10.1016/s1359-6349(07)71089-3] [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: 10/22/2022] Open
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Joshua BB, Faria S, Patrocinio H, DeBlois F, Duclos M, David M, Shenouda G, Souhami L. The impact of varying rectal contours on rectal dose in prostate cancer patients treated with hypofractionated radiation. J Clin Oncol 2007. [DOI: 10.1200/jco.2007.25.18_suppl.15598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
15598 Background: In curative radiation treatment of prostate cancer,the advent of 3DCRT has made a reduction in the incidence of normal tissue toxicities while optimizing tumor control. To optimize 3DCRT, the ICRU has published standard definitions of target volumes and organs at risk such that the tumor can receive the optimal dose with as little as possible dose to the organs at risk. However, the definition of the rectum as an organ at risk in radiation treatment of the prostate varies widely among institutions and so does the report of toxicities. We studied the effect of varying rectal contouring on rectal dose obtained from DVHs in a homogenous group of prostate cancer patients treated with hypo fractionationed radiation. Methods: 71 patients with favorable risk prostate cancer treated with a total of 66Gy in 3Gy/day fractionation.18 MV photons in a 5-field technique was used. None of the patients received hormonal therapy. Their treatment plans were archived and the rectum was re-contoured by a single investigator. 4 different contours were drawn to compare the rectal dose: i) the whole rectum from the anal verge to the recto sigmoid junction (WR); ii) the rectum from 1cm below the PTV to 1cm above (RPTV); iii) the rectal wall (i.e. the inner and outer rectal wall) from the anal verge to the recto sigmoid junction (RW); iv) the rectal wall from 1cm below the PTV to 1cm above (RWPTV) Results: There were significant differences in the median volume, minimum, mean rectal doses and dose to 50% of the volume, (p=0.0001). The whole rectum (WR) is having the lowest and the rectal wall with 1cm above and below the PTV (RWPTV) having the highest in all the parameters. The only parameter not significantly different among the 4 contours is the maximum rectal dose. Conclusion: the varied rectal contouring across different institutions is a possible reason for the broadly different reports of rectal toxicity after prostate irradiation. Our results suggest significant differences in rectal doses with varied contouring. Contouring the rectal wall only and limiting the volume to 1cm above and below the PTV confers the highest mean rectal dose. Comparison of rectal toxicity between institutions can only be meaningful if a consensual volume definition of the organ at risk is agreed upon. No significant financial relationships to disclose.
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Affiliation(s)
- B. B. Joshua
- McGill University Health Center, Montreal, PQ, Canada
| | - S. Faria
- McGill University Health Center, Montreal, PQ, Canada
| | - H. Patrocinio
- McGill University Health Center, Montreal, PQ, Canada
| | - F. DeBlois
- McGill University Health Center, Montreal, PQ, Canada
| | - M. Duclos
- McGill University Health Center, Montreal, PQ, Canada
| | - M. David
- McGill University Health Center, Montreal, PQ, Canada
| | - G. Shenouda
- McGill University Health Center, Montreal, PQ, Canada
| | - L. Souhami
- McGill University Health Center, Montreal, PQ, Canada
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Faria S, Souhami L, Patrocinio H, Joshua B, Deblois F, Duclos M, David M, Shenouda G. 36 Late rectal toxicity after hypofractionated radiation therapy (RT) for prostate cancer: Lack of correlation with recognized dose-volume guidelines. Radiother Oncol 2006. [DOI: 10.1016/s0167-8140(06)80777-2] [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: 10/23/2022]
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Shenouda G, Roberge D, Kavan P, Muanza T, Lambert C, Leblanc R, Del Maestro R, Guiot MC, Souhami L. 42 A novel approach using accelerated hypo-fractionation-IMRT (AH-IMRT) and temozolomide (TMZ) in patients with glioblastoma multiforme (GBM). Radiother Oncol 2006. [DOI: 10.1016/s0167-8140(06)80783-8] [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: 11/27/2022]
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Huang F, Chauvin P, Mehio A, Muanza T, Shenouda G. 77 Erythropoietin receptor expression in human squamous cell carcinoma of the tongue: Molecular considerations for radiation oncologists. Radiother Oncol 2006. [DOI: 10.1016/s0167-8140(06)80818-2] [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: 11/27/2022]
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Ballivy O, Parker W, Vuong T, Shenouda G, Patrocinio H. Impact of geometric uncertainties on dose distribution during intensity modulated radiotherapy of head-and-neck cancer: the need for a planning target volume and a planning organ-at-risk volume. Curr Oncol 2006; 13:108-15. [PMID: 17576450 PMCID: PMC1891177] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
We assessed the effect of geometric uncertainties on target coverage and on dose to the organs at risk (OARS) during intensity-modulated radiotherapy (IMRT) for head-and-neck cancer, and we estimated the required margins for the planning target volume (PTV) and the planning organ-at-risk volume (PRV). For eight head-and-neck cancer patients, we generated IMRT plans with localization uncertainty margins of 0 mm, 2.5 mm, and 5.0 mm. The beam intensities were then applied on repeat computed tomography (CT) scans obtained weekly during treatment, and dose distributions were recalculated.The dose-volume histogram analysis for the repeat ct scans showed that target coverage was adequate (V(100) >/= 95%) for only 12.5% of the gross tumour volumes, 54.3% of the upper-neck clinical target volumes (CTVS), and 27.4% of the lower-neck CTVS when no margins were added for PTV. The use of 2.5-mm and 5.0-mm margins significantly improved target coverage, but the mean dose to the contralateral parotid increased from 25.9 Gy to 29.2 Gy. Maximum dose to the spinal cord was above limit in 57.7%, 34.6%, and 15.4% of cases when 0-mm, 2.5-mm, and 5.0-mm margins (respectively) were used for prv.Significant deviations from the prescribed dose can occur during IMRT treatment delivery for head-and-neck cancer. The use of 2.5-mm to 5.0-mm margins for PTV and PRV greatly reduces the risk of underdosing targets and of overdosing the spinal cord.
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Affiliation(s)
- O. Ballivy
- Division of Radiation Oncology, Department of Oncology, McGill University, Montreal, Quebec
| | - W. Parker
- Division of Radiation Oncology, Department of Oncology, McGill University, Montreal, Quebec
- Medical Physics Unit, Department of Oncology, McGill University, Montreal, Quebec
- Correspondence to: William Parker, McGill University, 1650 avenue des Cèdres, Montreal General Hospital, L5-112, Montreal, Quebec H3G 1A4. E-mail:
| | - T. Vuong
- Division of Radiation Oncology, Department of Oncology, McGill University, Montreal, Quebec
| | - G. Shenouda
- Division of Radiation Oncology, Department of Oncology, McGill University, Montreal, Quebec
| | - H. Patrocinio
- Division of Radiation Oncology, Department of Oncology, McGill University, Montreal, Quebec
- Medical Physics Unit, Department of Oncology, McGill University, Montreal, Quebec
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Shenouda G, Mehio A, Souhami L, Duclos M, Portelance L, Belenkov A, Chow T. Erythropoietin receptor expression in biopsy specimens from patients with uterine cervix squamous cell carcinoma. Int J Gynecol Cancer 2006; 16:752-6. [PMID: 16681756 DOI: 10.1111/j.1525-1438.2006.00357.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [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: 11/29/2022] Open
Abstract
Hypoxia, an important mechanism of radioresistance, is a strong stimulus for erythropoietin (EPO) production. The stimulatory effects of EPO are mediated through the activation of its receptors, EPO receptors (EPORs). The objective of this study is to determine whether EPORs are expressed in biopsy specimens of patients with squamous cell carcinoma of the cervix. Eighteen biopsy specimens were studied after obtaining Institutional Review Board-approved consent. Standard immunohistochemistry techniques were utilized. Expression of EPORs was present in 16 out of 18 (88.9%) specimens. The intensity (qualitative) and the frequency (semiquantitative) of EPORs expression showed a statistically significant correlation (P= 0.00379). Statistical analysis was performed to determine whether EPORs expression is related to other parameters such as age, FIGO stage, histologic grade, and hemoglobin levels. Only age showed a statistically significant correlation with EPORs frequency of expression (P= 0.00878). Currently, work is in progress in our laboratory to study the radiobiologic effects of EPO on the radiation response of cultured cancer cell lines in vitro.
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Affiliation(s)
- G Shenouda
- Department of Radiation Oncology, The Montreal General Hospital, McGill University, Montreal, Quebec, Canada.
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Niazi TM, Sultanern K, Shenouda G, Hier M, Corns R, Lavole I, Skelly J, Black M. 183 Differential dose allocation to variable sub-volumes of head and neck (H/N) squamous cell carcinoma (SCCa), using intensity-modulated radiotherapy (IMRT): A phase II dose escalation study. Radiother Oncol 2005. [DOI: 10.1016/s0167-8140(05)80344-5] [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: 10/23/2022]
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Alyahya K, Schwartz M, Patrocinio H, Parker W, Shenouda G, Verhaegen F, Freeman C, Seuntjens J. 52 Monte Carlo-Based Inverse Planning of Modulated Electron Beam Therapy using a Few-Leaf Electron Collimator Provides Highly Conformal Treatment and Decreases Whole Body Dose. Radiother Oncol 2005. [DOI: 10.1016/s0167-8140(05)80213-0] [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: 11/24/2022]
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50
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Al-Yahya K, Schwartz M, Shenouda G, Verhaegen F, Freeman C, Seuntjens J. MO-E-T-617-02: Dosimetric Evaluation of Inverse Monte Carlo-Based Modulated Electron Beam Treatment Planning and Delivery Using a Few Leaf Electron Collimator. Med Phys 2005. [DOI: 10.1118/1.1998306] [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: 11/07/2022] Open
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