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Håkansson K, Josipovic M, Ottosson W, Behrens CP, Vogelius IR, Persson G. Evaluating the dosimetric effect of intra-fractional variations in deep inspiration breath-hold radiotherapy - a proof-of-concept study. Acta Oncol 2023; 62:1246-1250. [PMID: 37738385 DOI: 10.1080/0284186x.2023.2259084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 09/10/2023] [Indexed: 09/24/2023]
Affiliation(s)
- K Håkansson
- Department of Oncology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - M Josipovic
- Department of Oncology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health Science, University of Copenhagen, Copenhagen, Denmark
| | - W Ottosson
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - C P Behrens
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
- Department of Health Technology, Technical University of Denmark, Roskilde, Denmark
| | - I R Vogelius
- Department of Oncology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health Science, University of Copenhagen, Copenhagen, Denmark
| | - G Persson
- Department of Clinical Medicine, Faculty of Health Science, University of Copenhagen, Copenhagen, Denmark
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
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Klavsen MF, Ankjærgaard C, Boye K, Behrens CP, Vogelius IR, Ehrbar S, Baumgartl M, Rippke C, Buchele C, Renkamp CK, Santurio GV, Andersen CE. Accumulated dose implications from systematic dose-rate transients in gated treatments with Viewray MRIdian accelerators. Biomed Phys Eng Express 2023; 9:065001. [PMID: 37591227 DOI: 10.1088/2057-1976/acf138] [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: 02/17/2023] [Accepted: 08/17/2023] [Indexed: 08/19/2023]
Abstract
The combination of magnetic resonance (MR) imaging and linear accelerators (linacs) into MR-Linacs enables continuous MR imaging and advanced gated treatments of patients. Previously, a dose-rate transient (∼8% reduced dose rate during the initial 0.5 s of each beam) was identified for a Viewray MRIdian MR-Linac (Klavsenet al2022Radiation Measurement106759). Here, the dose-rate transient is studied in more detail at four linacs of the same type at different hospitals. The implications of dose-rate transients were examined for gated treatments. The dose-rate transients were investigated using dose-per pulse measurements with organic plastic scintillators in three experiments: (i) A gated treatment with the scintillator placed in a moving target in a dynamic phantom, (ii) a gated treatment with the same dynamic conditions but with the scintillator placed in a stationary target, and (iii) measurements in a water-equivalent material to examine beam quality deviations at a dose-per-pulse basis. Gated treatments (i) compared with non-gated treatments with a static target in the same setup showed a broadening of accumulated dose profiles due to motion (dose smearing). The linac with the largest dose-rate transient had a reduced accumulated dose of up to (3.1 ± 0.65) % in the center of the PTV due to the combined dose smearing and dose-rate transient effect. Dose-rate transients were found to vary between different machines. Two MR-Linacs showed initial dose-rate transients that could not be identified from conventional linearity tests. The source of the transients includes an initial change in photon fluence rate and an initial change in x-ray beam quality. For gated treatments, this caused a reduction of more than 1% dose delivered at the central part of the beam for the studied, cyclic-motion treatment plan. Quality assurance of this effect should be considered when gated treatment with the Viewray MRIdian is implemented clinically.
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Affiliation(s)
- M F Klavsen
- DTU Health Tech, Technical University of Denmark, Roskilde, Denmark
| | - C Ankjærgaard
- DTU Health Tech, Technical University of Denmark, Roskilde, Denmark
| | - K Boye
- Dept. of Oncology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - C P Behrens
- DTU Health Tech, Technical University of Denmark, Roskilde, Denmark
- Dept. of Oncology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - I R Vogelius
- Dept. of Oncology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen- Copenhagen, Denmark
| | - S Ehrbar
- Dept. of Radiation Oncology, University Hospital Zürich and University of Zürich, Zürich, Switzerland
| | - M Baumgartl
- Dept. of Radiation Oncology, University Hospital Zürich and University of Zürich, Zürich, Switzerland
| | - C Rippke
- Dept. of Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - C Buchele
- Dept. of Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - C K Renkamp
- Dept. of Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - G V Santurio
- Dept. of Oncology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - C E Andersen
- DTU Health Tech, Technical University of Denmark, Roskilde, Denmark
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Terrones-Campos C, Ledergerber B, Forbes N, Smith AG, Petersen J, Helleberg M, Lundgren J, Specht L, Vogelius IR. Prediction of Radiation-induced Lymphopenia following Exposure of the Thoracic Region and Associated Risk of Infections and Mortality. Clin Oncol (R Coll Radiol) 2023; 35:e434-e444. [PMID: 37149425 DOI: 10.1016/j.clon.2023.04.003] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 02/08/2023] [Accepted: 04/11/2023] [Indexed: 05/08/2023]
Abstract
AIMS Large blood volumes are irradiated when the heart is exposed to radiation. The mean heart dose (MHD) may be a good surrogate for circulating lymphocytes exposure. We investigated the association between MHD and radiation-induced lymphopenia and explored the impact of the end-of-radiation-therapy (EoRT) lymphocyte count on clinical outcomes. MATERIALS AND METHODS In total, 915 patients were analysed: 303 patients with breast cancer and 612 with intrathoracic tumours: oesophageal cancer (291), non-small cell lung cancer (265) and small cell lung cancer (56). Heart contours were generated using an interactive deep learning delineation process and an individual dose volume histogram for each heart was obtained. A dose volume histogram for the body was extracted from the clinical systems. We compared different models analysing the effect of heart dosimetry on the EoRT lymphocyte count using multivariable linear regression and assessed goodness of fit. We published interactive nomograms for the best models. The association of the degree of EoRT lymphopenia with clinical outcomes (overall survival, cancer treatment failure and infection) was investigated. RESULTS An increasing low dose bath to the body and MHD were associated with a low EoRT lymphocyte count. The best models for intrathoracic tumours included dosimetric parameters, age, gender, number of fractions, concomitant chemotherapy and pre-treatment lymphocyte count. Models for patients with breast cancer showed no improvement when adding dosimetric variables to the clinical predictors. EoRT lymphopenia grade ≥3 was associated with decreased survival and increased risk of infections among patients with intrathoracic tumours. CONCLUSION Among patients with intrathoracic tumours, radiation exposure to the heart contributes to lymphopenia and low levels of peripheral lymphocytes after radiotherapy are associated with worse clinical outcomes.
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Affiliation(s)
- C Terrones-Campos
- Centre of Excellence for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - B Ledergerber
- Centre of Excellence for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - N Forbes
- Centre of Excellence for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - A G Smith
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Department of Computer Science, University of Copenhagen, Copenhagen, Denmark
| | - J Petersen
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Department of Computer Science, University of Copenhagen, Copenhagen, Denmark
| | - M Helleberg
- Centre of Excellence for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - J Lundgren
- Centre of Excellence for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - L Specht
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - I R Vogelius
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Rasmussen JH, Grønhøj C, Håkansson K, Friborg J, Andersen E, Lelkaitis G, Klussmann JP, Wittekindt C, Wagner S, Vogelius IR, von Buchwald C. Risk profiling based on p16 and HPV DNA more accurately predicts location of disease relapse in patients with oropharyngeal squamous cell carcinoma. Ann Oncol 2019; 30:629-636. [PMID: 30657857 DOI: 10.1093/annonc/mdz010] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [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] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND In the era of precision medicine and HPV-related oropharyngeal squamous cell carcinoma (OPSCC), it is relevant to assess the risk of not only survival, but also the risk of local, regional, or distant treatment failure. The UICC 8th edition uses the surrogate marker p16 to stratify for HPV association but discordance between p16 status and HPV association has been shown. The purpose of this study was to develop a prognostic model to predict the risk of local, regional, and distant metastases and non-cancer-related death for patients with OPSCC, test the prognostic relevance of adding HPV DNA and p16 status, and validate the findings in an independent external dataset. PATIENTS AND METHODS Consecutive patients diagnosed with OPSCC and treated with curative radiotherapy with or without cisplatin in eastern Denmark from 2000 to 2014 were included. Characteristics included age, gender, TNM stage, smoking habits, performance status, and HPV status assessed with p16 and HPV DNA. The information was used to develop a prognostic model for first site of failure with four competing events: recurrence in T-, N-, and M-site, and death with no evidence of disease. RESULTS Overall 1243 patients were eligible for the analysis. A prognostic model with the four events was developed and externally validated in an independent dataset with a heterogeneously treated patient population from another institution. The individual prognostication from the competing risk analysis is displayed in a user friendly online tool (https://rasmussen.shinyapps.io/OPSCCmodelHPV_p16/). Replacing p16 status with the combined variable HPV/p16 status influenced the HR and patients with HPV-/p16+ had significantly higher HR of M-site recurrence than HPV+/p16+ with a HR = 2.56; CI [1.30; 5.02]; P = 0.006 (P = 0.013 in the validation cohort). CONCLUSION Patients with HPV-/p16+ have significantly higher risk of M-site recurrence and could potentially be relevant candidates for clinical trials testing systemic treatments in combination with conventional treatments.
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Affiliation(s)
- J H Rasmussen
- Departments of Otorhinolaryngology, Head and Neck Surgery and Audiology.
| | - C Grønhøj
- Departments of Otorhinolaryngology, Head and Neck Surgery and Audiology
| | - K Håkansson
- Oncology, Section of Radiotherapy, Rigshospitalet, University of Copenhagen, Copenhagen
| | - J Friborg
- Oncology, Section of Radiotherapy, Rigshospitalet, University of Copenhagen, Copenhagen
| | - E Andersen
- Department of Oncology, Herlev Hospital, University of Copenhagen, Copenhagen
| | - G Lelkaitis
- Department of Pathology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - J P Klussmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty, University of Cologne, Cologne
| | - C Wittekindt
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Giessen, Giessen, Germany
| | - S Wagner
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Giessen, Giessen, Germany
| | - I R Vogelius
- Oncology, Section of Radiotherapy, Rigshospitalet, University of Copenhagen, Copenhagen
| | - C von Buchwald
- Departments of Otorhinolaryngology, Head and Neck Surgery and Audiology
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Bandak M, Jørgensen N, Juul A, Vogelius IR, Lauritsen J, Kier MG, Mortensen MS, Glovinski P, Daugaard G. Testosterone deficiency in testicular cancer survivors - a systematic review and meta-analysis. Andrology 2016; 4:382-8. [DOI: 10.1111/andr.12177] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 12/21/2015] [Accepted: 02/01/2016] [Indexed: 11/27/2022]
Affiliation(s)
- M. Bandak
- Department of Oncology; Copenhagen University Hospital Rigshospitalet; Copenhagen Denmark
| | - N. Jørgensen
- Department of Growth and Reproduction; Copenhagen University Hospital Rigshospitalet; Copenhagen Denmark
| | - A. Juul
- Department of Growth and Reproduction; Copenhagen University Hospital Rigshospitalet; Copenhagen Denmark
| | - I. R. Vogelius
- Department of Oncology; Copenhagen University Hospital Rigshospitalet; Copenhagen Denmark
| | - J. Lauritsen
- Department of Oncology; Copenhagen University Hospital Rigshospitalet; Copenhagen Denmark
| | - M. G. Kier
- Department of Oncology; Copenhagen University Hospital Rigshospitalet; Copenhagen Denmark
- Department of Survivorship; Danish Cancer Society; Copenhagen Denmark
| | - M. S. Mortensen
- Department of Oncology; Copenhagen University Hospital Rigshospitalet; Copenhagen Denmark
| | - P. Glovinski
- Department of Breast Surgery and Reconstructive Surgery; Copenhagen University Hospital Rigshospitalet; Copenhagen Denmark
| | - G. Daugaard
- Department of Oncology; Copenhagen University Hospital Rigshospitalet; Copenhagen Denmark
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Rasmussen JH, Fischer BM, Aznar MC, Hansen AE, Vogelius IR, Löfgren J, Andersen FL, Loft A, Kjaer A, Højgaard L, Specht L. Reproducibility of (18)F-FDG PET uptake measurements in head and neck squamous cell carcinoma on both PET/CT and PET/MR. Br J Radiol 2015; 88:20140655. [PMID: 25634069 DOI: 10.1259/bjr.20140655] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE To investigate reproducibility of fluorine-18 fludeoxyglucose ((18)F-FDG) uptake on (18)F-FDG positron emission tomography (PET)/CT and (18)F-FDG PET/MR scans in patients with head and neck squamous cell carcinoma (HNSCC). METHODS 30 patients with HNSCC were included in this prospective study. The patients were scanned twice before radiotherapy treatment with both PET/CT and PET/MR. Patients were scanned on the same scanners, 3 days apart and according to the same protocol. Metabolic tumour activity was measured by the maximum and peak standardized uptake value (SUVmax and SUVpeak, respectively), and total lesion glycolysis from the metabolic tumour volume defined from ≥50% SUVmax. Bland-Altman analysis with limits of agreement, coefficient of variation (CV) from the two modalities were performed in order to test the reproducibility. Furthermore, CVs from SUVmax and SUVpeak were compared. The area under the curve from cumulative SUV-volume histograms were measured and tested for reproducibility of the distribution of (18)F-FDG uptake. RESULTS 24 patients had two pre-treatment PET/CT scans and 21 patients had two pre-treatment PET/MR scans available for further analyses. Mean difference for SUVmax, peak and mean was approximately 4% for PET/CT and 3% for PET/MR, with 95% limits of agreement less than ±20%. CV was small (5-7%) for both modalities. There was no significant difference in CVs between PET/CT and PET/MR (p = 0.31). SUVmax was not more reproducible than SUVpeak (p = 0.09). CONCLUSION (18)F-FDG uptake in PET/CT and PET/MR is highly reproducible and we found no difference in reproducibility between PET/CT and PET/MR. ADVANCES IN KNOWLEDGE This is the first report to test reproducibility of PET/CT and PET/MR.
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Affiliation(s)
- J H Rasmussen
- 1 Department of Oncology, Section of Radiotherapy, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Maraldo MV, Brodin NP, Aznar MC, Vogelius IR, Munck af Rosenschöld P, Petersen PM, Specht L. Estimated risk of cardiovascular disease and secondary cancers with modern highly conformal radiotherapy for early-stage mediastinal Hodgkin lymphoma. Ann Oncol 2013; 24:2113-8. [PMID: 23619032 DOI: 10.1093/annonc/mdt156] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [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: 12/25/2022] Open
Abstract
BACKGROUND Hodgkin lymphoma (HL) survivors have an increased morbidity and mortality from secondary cancers and cardiovascular disease (CD). We evaluate doses with involved node radiotherapy (INRT) delivered as 3D conformal radiotherapy (3D CRT), volumetric modulated arc therapy (VMAT), or proton therapy (PT), compared with the extensive Mantle Field (MF). PATIENTS AND METHODS For 27 patients with early-stage, mediastinal HL, treated with chemotherapy and INRT delivered as 3D CRT (30 Gy), we simulated an MF (36 Gy), INRT-VMAT and INRT-PT (30 Gy). Dose to the heart, lungs, and breasts, estimated risks of CD, lung (LC) and breast cancer (BC), and corresponding life years lost (LYL) were compared. RESULTS 3D CRT, VMAT or PT significantly lower the dose to the heart, lungs and breasts and provide lower risk estimates compared with MF, but with substantial patient variability. The risk of CD is not significantly different for 3D CRT versus VMAT. The risk of LC and BC is highest with VMAT. For LYL, PT is the superior modern technique. CONCLUSIONS In early-stage, mediastinal HL modern radiotherapy provides superior results compared with MF. However, there is no single best radiotherapy technique for HL-the decision should be made at the individual patient level.
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Affiliation(s)
- M V Maraldo
- Department of Radiation Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
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