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Chan AW, Simone Ii CB, van der Velden JM, van der Linden Y, Hoskin P, Detsky J, Choi JI, Lee SF, Wong HCY, Martin EJ, Raman S, Rades D, Willmann J, Rembielak A, Kazmierska J, Keit ER, Marta GN, Vassiliou V, Alcorn S, Bonomo P, Oldenburger E. A phase II trial on radiotherapy for high-risk asymptomatic bone metastases-creating more questions than answers? Ann Palliat Med 2024; 0:apm-23-595. [PMID: 38644554 DOI: 10.21037/apm-23-595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Affiliation(s)
- Adrian Wai Chan
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Charles B Simone Ii
- Department of Radiation Oncology, New York Proton Center, New York, NY, USA; Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Yvette van der Linden
- Department of Radiotherapy, Leiden University Medical Centre, Leiden, Netherlands; Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, Netherlands
| | - Peter Hoskin
- Mount Vernon Cancer Centre, Northwood, UK; Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - J Isabelle Choi
- Department of Radiation Oncology, New York Proton Center, New York, NY, USA; Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Shing Fung Lee
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore, Singapore; Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong, China
| | - Henry C Y Wong
- Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong, China
| | - Emily J Martin
- Department of Medicine, University of California, Los Angeles, CA, USA
| | - Srinivas Raman
- Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada
| | - Dirk Rades
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany
| | - Jonas Willmann
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Agata Rembielak
- Division of Cancer Sciences, University of Manchester, Manchester, UK; Department of Clinical Oncology, Christie NHS Foundation Trust, Manchester, UK
| | - Joanna Kazmierska
- Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland; Electroradiology Department, University of Medical Sciences, Poznan, Poland
| | - Emily R Keit
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Gustavo Nader Marta
- Department of Radiation Oncology, Hospital Sírio-Libanês, São Paulo, Brazil; Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil
| | - Vassilios Vassiliou
- Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus
| | - Sara Alcorn
- Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Pierluigi Bonomo
- Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Eva Oldenburger
- Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
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Chan AW, Simone CB, van der Linden Y, Hoskin P, Detsky J, Choi JI, Lee SF, Wong HC, Martin EJ, Raman S, Rades D, Rembielak A, Kazmierska J, Vassiliou V, Alcorn S, Bonomo P, Oldenburger E. Prophylactic Radiation Therapy for High-Risk Asymptomatic Bone Metastases: A New Standard of Care or Need for More Data? J Clin Oncol 2024; 42:1326-1327. [PMID: 38320224 DOI: 10.1200/jco.23.02391] [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: 11/03/2023] [Accepted: 12/06/2023] [Indexed: 02/08/2024] Open
Affiliation(s)
- Adrian Wai Chan
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Charles B Simone
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Yvette van der Linden
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Peter Hoskin
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Jay Detsky
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - J Isabelle Choi
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - S F Lee
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Henry Cy Wong
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Emily J Martin
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Srinivas Raman
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Dirk Rades
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Agata Rembielak
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Joanna Kazmierska
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Vassilios Vassiliou
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Sara Alcorn
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Pierluigi Bonomo
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Eva Oldenburger
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
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3
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Shor D, Louie AV, Zeng KL, Menjak IB, Atenafu EG, Chia-Lin Tseng, Detsky J, Larouche J, Zhang B, Soliman H, Myrehaug S, Maralani P, Hwang DM, Sahgal A, Chen H. Utility of molecular markers in predicting local control specific to lung cancer spine metastases treated with stereotactic body radiotherapy. J Neurooncol 2024; 167:275-283. [PMID: 38526757 DOI: 10.1007/s11060-024-04603-8] [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: 01/06/2024] [Accepted: 02/07/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND AND PURPOSE We report outcomes following spine stereotactic body radiotherapy (SBRT) in metastatic non-small cell lung cancer (NSCLC) and the significance of programmed death-ligand 1 (PD-L1) status, epidermal growth factor receptor (EGFR) mutation and timing of immune check point inhibitors (ICI) on local failure (LF). MATERIALS AND METHODS 165 patients and 389 spinal segments were retrospectively reviewed from 2009 to 2021. Baseline patient characteristics, treatment and outcomes were abstracted. Primary endpoint was LF and secondary, overall survival (OS) and vertebral compression fracture (VCF). Multivariable analysis (MVA) evaluated factors predictive of LF and VCF. RESULTS The median follow-up and OS were: 13.0 months (range, 0.5-95.3 months) and 18.4 months (95% CI 11.4-24.6). 52.1% were male and 76.4% had adenocarcinoma. Of the 389 segments, 30.3% harboured an EGFR mutation and 17.0% were PD-L1 ≥ 50%. The 24 months LF rate in PD-L1 ≥ 50% vs PD-L1 < 50% was 10.7% vs. 38.0%, and in EGFR-positive vs. negative was 18.1% vs. 30.0%. On MVA, PD-L1 status of ≥ 50% (HR 0.32, 95% CI 0.15-0.69, p = 0.004) significantly predicted for lower LF compared to PD-L1 < 50%. Lower LF trend was seen with ICI administration peri and post SBRT (HR 0.41, 95% CI 0.16-1.05, p = 0.062). On MVA, polymetastatic disease (HR 3.28, 95% CI 1.84-5.85, p < 0.0001) and ECOG ≥ 2 (HR 1.87, 95% CI 1.16-3.02, p = 0.011) significantly predicted for worse OS and absence of baseline VCF predicted for lower VCF rate (HR 0.20, 95% CI 0.10-0.39, p < 0.0001). CONCLUSION We report a significant association of PD-L1 ≥ 50% status on improved LC rates from spine SBRT in NSCLC patients.
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Affiliation(s)
- Dana Shor
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Alexander V Louie
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Kang Liang Zeng
- Department of Radiation Oncology, Simcoe Muskoka Regional Cancer Centre, Barrie, ON, Canada
| | - Ines B Menjak
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Jeremie Larouche
- Division of Orthopedic Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Beibei Zhang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Pejman Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - David M Hwang
- Department of Laboratory Medicine & Molecular Diagnostics, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.
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4
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Ong WL, Stewart J, Sahgal A, Soliman H, Tseng CL, Detsky J, Chen H, Ho L, Das S, Maralani P, Lipsman N, Stanisz G, Perry J, Lim-Fat MJ, Atenafu EG, Lau A, Ruschin M, Myrehaug S. Predictors of tumour dynamics over a 6-week course of concurrent chemoradiotherapy for glioblastoma and the impact on survival. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00453-X. [PMID: 38561051 DOI: 10.1016/j.ijrobp.2024.03.036] [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: 08/29/2023] [Revised: 02/09/2024] [Accepted: 03/20/2024] [Indexed: 04/04/2024]
Abstract
PURPOSE We present the final analyses of tumour dynamics and their prognostic significance during a 6-week course of concurrent chemoradiotherapy (chemoRT) for glioblastoma (GBM) in the GLIO study. METHODS AND MATERIALS This is a prospective serial MR imaging study in 129 patients with GBM who had MRIs obtained at RT planning (F0), fraction-10 (F10), fraction-20 (F20), and 1-month post-RT. Tumour dynamics assessed included gross tumour volume (GTV) relative to F0 (Vrel), and tumour migration distance (dmigration). Covariables evaluated included: corpus callosum involvement, extent of surgery, MGMT methylation and IDH mutation status. RESULTS The median Vrel were 0.85 (range: 0.25-2.29) at F10, 0.79 (range: 0.09-2.22) at F20 and 0.78 (range: 0.13-4.27) at P1M. The median dmigration were 4.7mm (range: 1.1-20.4mm) at F10, 4.7mm (range: 0.8-20.7mm) at F20 and 6.1mm (range: 0.0-45.5mm) at P1M. Compared to patients who had corpus callosum involvement (n=26), those without corpus callosum involvement (n=103) had significant Vrel reduction at F20 (P=0.03) and smaller dmigration at F20 (P=0.007). Compared to patients who had biopsy alone (n=19) and subtotal resection (n=71), those who had gross total resection (n=38) had significant Vrel reduction at F10 (P=0.001) and F20 (P=0.001) and a smaller dmigration at F10 (P=0.03) and F20 (P=0.002). MGMT methylation and IDH mutation status were not significantly associated with tumour dynamics. The median progression free survival and overall survival (OS) were 8.5 months (95%CI=6.9-9.9) and 20.4 months (95%CI=17.6-25.2). In multivariable analyses, patients with Vrel≥1.33 at F10 had worse OS (HR=4.6; 95%CI=1.8-11.4; P=0.001), while patients with dmigration≥5mm at 1-month post-RT had worse PFS (HR=1.76; 95%CI=1.08-2.87) and OS (HR=2.2; 95%CI=1.2-4.0; P=0.007). CONCLUSION Corpus callosum involvement and extent of surgery are independent predictors of tumour dynamics during RT and can enable patient selection for adaptive RT strategies. Significant tumour enlargement at F10 and tumour migration 1-month post-RT were associated with poorer OS.
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Affiliation(s)
- Wee Loon Ong
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada; Alfred Health Radiation Oncology, Central Clinical School, Monash University, Melbourne, Australia
| | - James Stewart
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Ling Ho
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Sunit Das
- Division of Neurosurgery, University of Toronto, Toronto, Canada; Division of Neurosurgery and Centre for Ethics, St Michael's Hospital, Toronto, Canada; The Arthur and Sonia Labatt Brain Tumour Research Centre, SickKids Hospital, Toronto, Canada
| | - Pejman Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Nir Lipsman
- Division of Neurosurgery, University of Toronto, Toronto, Canada; Department of Physical Sciences, Sunnybrook Research Institute, Toronto, Canada; Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto Canada
| | - Greg Stanisz
- Department of Physical Sciences, Sunnybrook Research Institute, Toronto, Canada; Department of Medical Biophysics, University of Toronto, Toronto, Canada; Department of Neurosurgery and Paediatric Neurosurgery, Medical University Lublin, Poland
| | - James Perry
- Division of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Mary Jane Lim-Fat
- Division of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, University of Toronto, Toronto, Canada.
| | - Angus Lau
- Department of Physical Sciences, Sunnybrook Research Institute, Toronto, Canada; Department of Medical Biophysics, University of Toronto, Toronto, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, University of Toronto, Toronto, Canada; Department of Medical Physics, Sunnybrook Odette Cancer Centre, Toronto, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada.
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5
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Tseng CL, Zeng KL, Mellon EA, Soltys SG, Ruschin M, Lau AZ, Lutsik NS, Chan RW, Detsky J, Stewart J, Maralani PJ, Sahgal A. Evolving concepts in margin strategies and adaptive radiotherapy for glioblastoma: A new future is on the horizon. Neuro Oncol 2024; 26:S3-S16. [PMID: 38437669 PMCID: PMC10911794 DOI: 10.1093/neuonc/noad258] [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] [Indexed: 03/06/2024] Open
Abstract
Chemoradiotherapy is the standard treatment after maximal safe resection for glioblastoma (GBM). Despite advances in molecular profiling, surgical techniques, and neuro-imaging, there have been no major breakthroughs in radiotherapy (RT) volumes in decades. Although the majority of recurrences occur within the original gross tumor volume (GTV), treatment of a clinical target volume (CTV) ranging from 1.5 to 3.0 cm beyond the GTV remains the standard of care. Over the past 15 years, the incorporation of standard and functional MRI sequences into the treatment workflow has become a routine practice with increasing adoption of MR simulators, and new integrated MR-Linac technologies allowing for daily pre-, intra- and post-treatment MR imaging. There is now unprecedented ability to understand the tumor dynamics and biology of GBM during RT, and safe CTV margin reduction is being investigated with the goal of improving the therapeutic ratio. The purpose of this review is to discuss margin strategies and the potential for adaptive RT for GBM, with a focus on the challenges and opportunities associated with both online and offline adaptive workflows. Lastly, opportunities to biologically guide adaptive RT using non-invasive imaging biomarkers and the potential to define appropriate volumes for dose modification will be discussed.
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Affiliation(s)
- Chia-Lin Tseng
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - K Liang Zeng
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Department of Radiation Oncology, Simcoe Muskoka Regional Cancer Program, Royal Victoria Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | - Eric A Mellon
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University, Stanford, California, USA
| | - Mark Ruschin
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Angus Z Lau
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Natalia S Lutsik
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Rachel W Chan
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - James Stewart
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Pejman J Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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6
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Zeng KL, Soliman H, Myrehaug S, Tseng CL, Detsky J, Chen H, Lim-Fat MJ, Ruschin M, Atenafu EG, Keith J, Lipsman N, Heyn C, Maralani P, Das S, Pirouzmand F, Sahgal A. Dose-Escalated Radiation Therapy Is Associated With Improved Outcomes for High-Grade Meningioma. Int J Radiat Oncol Biol Phys 2024; 118:662-671. [PMID: 37793575 DOI: 10.1016/j.ijrobp.2023.09.026] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 09/12/2023] [Accepted: 09/16/2023] [Indexed: 10/06/2023]
Abstract
PURPOSE The optimal modern radiation therapy (RT) approach after surgery for atypical and malignant meningioma is unclear. We present results of dose escalation in a single-institution cohort spanning 2000 to 2021. METHODS AND MATERIALS Consecutive patients with histopathologic grade 2 or 3 meningioma treated with RT were reviewed. A dose-escalation cohort (≥66 Gy equivalent dose in 2-Gy fractions using an α/β = 10) was compared with a standard-dose cohort (<66 Gy). Outcomes were progression-free survival (PFS), cause-specific survival, overall survival (OS), local failure (LF), and radiation necrosis. RESULTS One hundred eighteen patients (111 grade 2, 94.1%) were identified; 54 (45.8%) received dose escalation and 64 (54.2%) standard dose. Median follow-up was 45.4 months (IQR, 24.0-80.0 months) and median OS was 9.7 years (Q1: 4.6 years, Q3: not reached). All dose-escalated patients had residual disease versus 65.6% in the standard-dose cohort (P < .001). PFS at 3, 4, and 5 years in the dose-escalated versus standard-dose cohort was 78.9%, 72.2%, and 64.6% versus 57.2%, 49.1%, and 40.8%, respectively, (P = .030). On multivariable analysis, dose escalation (hazard ratio [HR], 0.544; P = .042) was associated with improved PFS, whereas ≥2 surgeries (HR, 1.989; P = .035) and older age (HR, 1.035; P < .001) were associated with worse PFS. The cumulative risk of LF was reduced with dose escalation (P = .016). Multivariable analysis confirmed that dose escalation was protective for LF (HR, 0.483; P = .019), whereas ≥2 surgeries before RT predicted for LF (HR, 2.145; P = .008). A trend was observed for improved cause-specific survival and OS in the dose-escalation cohort (P < .1). Seven patients (5.9%) developed symptomatic radiation necrosis with no significant difference between the 2 cohorts. CONCLUSIONS Dose-escalated RT with ≥66 Gy for high-grade meningioma is associated with improved local control and PFS with an acceptable risk of radiation necrosis.
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Affiliation(s)
- K Liang Zeng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Mary-Jane Lim-Fat
- Division of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, Toronto, Ontario, Canada
| | - Julia Keith
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Nir Lipsman
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Chris Heyn
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Pejman Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sunit Das
- Division of Neurosurgery, Unity Health Toronto, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Farhad Pirouzmand
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
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7
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Ong WL, Allan Hupman M, Davidson M, Ruschin M, Detsky J, Liu S, Vesprini D, Loblaw A. Urethra contouring on computed tomography urethrogram versus magnetic resonance imaging for stereotactic body radiotherapy in prostate cancer. Clin Transl Radiat Oncol 2024; 45:100722. [PMID: 38234697 PMCID: PMC10792737 DOI: 10.1016/j.ctro.2023.100722] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/24/2023] [Accepted: 12/30/2023] [Indexed: 01/19/2024] Open
Abstract
Accurate urethra contouring is critical in prostate SBRT. We compared urethra contouring on CT-urethrogram and T2-weighted MRI. The dice similarity coefficient, Jaccard index, Hausdorff distance and mean distance to agreement were evaluated. All four metrics indicate better agreement and less variability in urethra contouring on CT-urethrogram, compared to T2-weighted MRI.
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Affiliation(s)
- Wee Loon Ong
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Canada
- Alfred Health Radiation Oncology, Monash University, Melbourne, Australia
| | - M. Allan Hupman
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Canada
| | - Melanie Davidson
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Canada
| | - Mark Ruschin
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Canada
| | - Jay Detsky
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Canada
| | - Stanley Liu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Canada
| | - Danny Vesprini
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Canada
| | - Andrew Loblaw
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Canada
- Department of Health Policy, Measurement and Evaluation, University of Toronto, Canada
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8
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Moore-Palhares D, Zeng KL, Tseng CL, Chen H, Myrehaug S, Soliman H, Maralani P, Larouche J, Shakil H, Jerzak K, Ruschin M, Zhang B, Atenafu EG, Sahgal A, Detsky J. Stereotactic Body Radiation Therapy for Sacral Metastases: Deviation From Recommended Target Volume Delineation Increases the Risk of Local Failure. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00282-7. [PMID: 38395085 DOI: 10.1016/j.ijrobp.2024.01.213] [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] [Received: 07/25/2023] [Revised: 01/03/2024] [Accepted: 01/26/2024] [Indexed: 02/25/2024]
Abstract
PURPOSE Although spine stereotactic body radiation therapy (SBRT) is considered a standard of care in the mobile spine, mature evidence reporting outcomes specific to sacral metastases is lacking. Furthermore, there is a need to validate the existing sacral SBRT international consensus contouring guidelines to define the optimal contouring approach. We report mature rates of local failure (LF), adverse events, and the effect of contouring deviations in the largest experience to date specific to sacrum SBRT. METHODS AND MATERIALS Consecutive patients who underwent sacral SBRT from 2010 to 2021 were retrospectively reviewed. The primary endpoint was magnetic resonance imaging-based LF with a focus on adherence to target volume contouring recommendations. Secondary endpoints included vertebral compression fracture and neural toxicity. RESULTS Of the 215 sacrum segments treated in 112 patients, most received 30 Gy/4 fractions (51%), 24 Gy/2 fractions (31%), or 30 Gy/5 fractions (10%). Sixteen percent of segments were nonadherent to the consensus guideline with a more restricted target volume (undercontoured). The median follow-up was 21.4 months (range, 1.5-116.9 months). The cumulative incidence of LF at 1 and 2 years was 18.4% and 23.1%, respectively. In those with guideline adherent versus nonadherent contours, the LF rate at 1 year was 15.1% versus 31.4% and at 2 years 18.8% versus 40.0% (hazard ratio [HR], 2.5; 95% CI, 1.4-4.6; P = .003), respectively. On multivariable analysis, guideline nonadherence (HR, 2.4; 95% CI, 1.3-4.7; P = .008), radioresistant histology (HR, 2.4; 95% CI, 1.4-4.1; P < .001), and extraosseous extension (HR, 2.5; 95% CI, 1.3-4.7; P = .005) predicted for an increased risk of LF. The cumulative incidence of vertebral compression fracture was 7.1% at 1 year and 12.3% at 2 years. Seven patients (6.3%) developed peripheral nerve toxicity, of whom 4 had been previously radiated. CONCLUSIONS Sacral SBRT is associated with high efficacy rates and an acceptable toxicity profile. Adhering to consensus guidelines for target volume delineation is recommended to reduce the risk of LF.
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Affiliation(s)
- Daniel Moore-Palhares
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - K Liang Zeng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Pejman Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jeremie Larouche
- Division of Orthopedic Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Husain Shakil
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Katarzyna Jerzak
- Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Beibei Zhang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
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9
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Chen H, Atenafu EG, Zeng KL, Chan A, Detsky J, Myrehaug S, Soliman H, Tseng CL, Sahgal A, Maralani PJ. Magnetic Resonance Imaging Frequency After Stereotactic Body Radiation Therapy for Spine Metastases. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00319-5. [PMID: 38373656 DOI: 10.1016/j.ijrobp.2024.02.010] [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] [Received: 09/07/2023] [Revised: 01/03/2024] [Accepted: 02/08/2024] [Indexed: 02/21/2024]
Abstract
PURPOSE Stereotactic body radiation therapy (SBRT) is increasingly being used to treat spine metastases. Current post-SBRT imaging surveillance strategies in this patient population may benefit from a more data-driven and personalized approach. The objective of this study was to develop risk-stratified post-SBRT magnetic resonance imaging (MRI) surveillance strategies using quantitative methods. METHODS AND MATERIALS Adult patients with bony spine metastases treated with SBRT between 2008 and 2021 and who had at least 2 follow-up spine MRIs were reviewed retrospectively. A recursive partitioning analysis model was developed to separate patients into different risk categories for post-SBRT progression anywhere within the spine. Imaging intervals were derived for each risk category using parametric survival regression based on multiple expected spine progression rates per scan. RESULTS A total of 446 patients and 1039 vertebral segments were included. Cumulative incidence of spine progression was 19.2% at 1 year, 26.7% at 2 years, and 35.3% at 4 years. The internally validated risk stratification model was able to divide patients into 3 risk categories based on epidural disease, paraspinal disease, and Spinal Instability Neoplastic Score category. The 4-year risk of spine progression was 23.4%, 39.0%, and 51.8%, respectively, for the low-, intermediate-, and high-risk groups. Using an expected per-scan spine progression rate of 3.75%, the low-risk group would require follow-up scans every 6.0 months (95% CI, 4.9-7.6) and the intermediate-risk group would require surveillance every 3.1 months (95% CI, 2.6-3.7). At an expected spine progression rate of 5%, the high-risk group would require surveillance every 1.3 months (95% CI, 1.1-1.6) during the first 13.2 months after SBRT and every 5.9 months thereafter (95% CI, 2.8-12.3). CONCLUSIONS Data-driven follow-up MRI surveillance intervals at a range of expected spine progression rates have been determined for patients at different risks of spine progression based on an internally validated, single-institution risk stratification model.
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Affiliation(s)
- Hanbo Chen
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada.
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, University of Toronto, Toronto, Ontario Canada
| | - K Liang Zeng
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
| | - Aimee Chan
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
| | - Pejman J Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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10
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Ong WL, Cheung P, Chung H, Chu W, Detsky J, Liu S, Morton G, Szumacher E, Tseng CL, Vesprini D, Davidson M, Ravi A, McGuffin M, Zhang L, Mamedov A, Deabreu A, Kulasingham-Poon M, Loblaw A. To Boost or Not to Boost: Pooled Analyses From 2-Fraction SABR Trials for Localized Prostate Cancer. Int J Radiat Oncol Biol Phys 2023; 117:1153-1162. [PMID: 37419394 DOI: 10.1016/j.ijrobp.2023.06.250] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 06/07/2023] [Accepted: 06/23/2023] [Indexed: 07/09/2023]
Abstract
PURPOSE Focal boost to dominant intraprostatic lesion (DIL) is an approach for dose escalation in prostate radiation therapy. In this study, we aimed to report the outcomes of 2-fraction SABR ± DIL boost. METHODS AND MATERIALS We included 60 patients with low- to intermediate-risk prostate cancer enrolled in 2 phase 2 trials (30 patients in each trial). In the 2STAR trial (NCT02031328), 26 Gy (equivalent dose in 2-Gy fractions = 105.4 Gy) was delivered to the prostate. In the 2SMART trial (NCT03588819), 26 Gy was delivered to the prostate, with up to 32 Gy boost to magnetic resonance imaging-defined DIL (equivalent dose in 2-Gy fractions = 156.4 Gy). The reported outcomes included prostate-specific antigen (PSA) response (ie, <0.4 ng/mL) at 4 years (4yrPSARR), biochemical failure (BF), acute and late toxicities, and quality of life (QOL). RESULTS In 2SMART, median DIL D99% of 32.3 Gy was delivered. Median follow-up was 72.7 months (range, 69.1-75.) in 2STAR and 43.6 months (range, 38.7-49.5) in 2SMART. The 4yrPSARR was 57% (17/30) in 2STAR and 63% (15/24) in 2SMART (P = 0.7). The 4-year cumulative BF was 0% in 2STAR and 8.3% in 2SMART (P = 0.1). The 6-year BF in 2STAR was 3.5%. For genitourinary toxicities, there were differences in grade ≥1 urinary urgency in the acute (0% vs 47%; P < .001) and late settings (10% vs 67%; P < .001) favoring 2STAR. For urinary QOL, no difference was observed in the acute setting, but lower proportion in 2STAR had minimal clinically important changes in urinary QOL score in the late setting (21% vs 50%; P = .03). There were no significant differences in gastrointestinal and sexual toxicities and QOL in both acute and late settings between the 2 trials. CONCLUSIONS This study presents the first prospective data comparing 2-fraction prostate SABR ± DIL boost. The addition of DIL boost resulted in similar medium-term efficacy (in 4yrPSARR and BF), with impact on late urinary QOL outcomes.
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Affiliation(s)
- Wee Loon Ong
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Alfred Health Radiation Oncology, Monash University, Melbourne, Victoria, Australia
| | - Patrick Cheung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Hans Chung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - William Chu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Jay Detsky
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Stanley Liu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Gerard Morton
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Ewa Szumacher
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Chia-Lin Tseng
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Danny Vesprini
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Melanie Davidson
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Ananth Ravi
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; MOLLI Surgical, Toronto, Ontario, Canada
| | - Merrylee McGuffin
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Liying Zhang
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Alexandre Mamedov
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Andrea Deabreu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Andrew Loblaw
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Department of Health Policy, Measurement and Evaluation, University of Toronto, Toronto, Ontario, Canada.
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11
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Ong WL, Davidson M, Cheung P, Chung H, Chu W, Detsky J, Liu S, Morton G, Szumacher E, Tseng CL, Vesprini D, Ravi A, McGuffin M, Zhang L, Mamedov A, Deabreu A, Kulasingham-Poon M, Loblaw A. Dosimetric correlates of toxicities and quality of life following two-fraction stereotactic ablative radiotherapy (SABR) for prostate cancer. Radiother Oncol 2023; 188:109864. [PMID: 37619656 DOI: 10.1016/j.radonc.2023.109864] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 05/03/2023] [Revised: 08/15/2023] [Accepted: 08/17/2023] [Indexed: 08/26/2023]
Abstract
PURPOSE There is no evidence-based data to guide dose constraints in two-fraction prostate stereotactic ablative radiotherapy (SABR). Using individual patient-data from two prospective trials, we aimed to correlate dosimetric parameters with toxicities and quality of life (QoL) outcomes. MATERIALS AND METHODS We included 60 patients who had two-fraction prostate SABR in the 2STAR (NCT02031328) and 2SMART (NCT03588819) trials. The prescribed dose was 26 Gy to the prostate+/-32 Gy boost to the dominant intraprostatic lesions. Toxicities and QoL data were prospectively collected using CTCAEv4 and EPIC-26 questionnaire. The outcomes evaluated were acute and late grade ≥ 2 toxicities, and late minimal clinical important changes (MCIC) in QoL domains. Dosimetric parameters for bladder, urethra, rectum, and penile bulb were evaluated. RESULTS The median follow-up was 56 months (range: 39-78 months). The cumulative incidence of grade ≥ 2 genitourinary (GU), gastrointestinal (GI), and sexual toxicities were 62%, 3%, and 17% respectively in the acute setting (<3 months), and 57%, 15%, and 52% respectively in late setting (>6 months). There were 36%, 28%, and 29% patients who had late MCIC in urinary, bowel and sexual QoL outcomes respectively. Bladder 0.5 cc was significant predictor for late grade ≥ 2 GU toxicities, with optimal cut-off of 25.5 Gy. Penile bulb D5cc was associated of late grade ≥ 2 sexual toxicities (no optimal cut-off was identified). No dosimetric parameters were identified to be associated with other outcomes. CONCLUSION Using real-life patient data from prospective trials with medium-term follow-up, we identified additional dose constraints that may mitigate the risk of late treatment-related toxicities for two-fraction prostate SABR.
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Affiliation(s)
- Wee Loon Ong
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada; Alfred Health Radiation Oncology, Monash University, Melbourne, Australia
| | - Melanie Davidson
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Patrick Cheung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Hans Chung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - William Chu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Jay Detsky
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Stanley Liu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Gerard Morton
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Ewa Szumacher
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Chia-Lin Tseng
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Danny Vesprini
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Ananth Ravi
- Department of Radiation Oncology, University of Toronto, Canada; Molli Surgical, Toronto, Canada
| | - Merrylee McGuffin
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Liying Zhang
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Alexandre Mamedov
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Andrea Deabreu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | | | - Andrew Loblaw
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada; Department of Health Policy, Measurement and Evaluation, University of Toronto, Canada.
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12
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Lawrence LSP, Chan RW, Chen H, Stewart J, Ruschin M, Theriault A, Myrehaug S, Detsky J, Maralani PJ, Tseng CL, Soliman H, Jane Lim-Fat M, Das S, Stanisz GJ, Sahgal A, Lau AZ. Diffusion-weighted imaging on an MRI-linear accelerator to identify adversely prognostic tumour regions in glioblastoma during chemoradiation. Radiother Oncol 2023; 188:109873. [PMID: 37640160 DOI: 10.1016/j.radonc.2023.109873] [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: 04/21/2023] [Revised: 07/12/2023] [Accepted: 08/20/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND AND PURPOSE Survival in glioblastoma might be extended by escalating the radiotherapy dose to treatment-resistant tumour and adapting to tumour changes. Diffusion-weighted imaging (DWI) on MRI-linear accelerators (MR-Linacs) could be used to identify a dose escalation target, but its prognostic value must be demonstrated. The purpose of this study was to determine whether MR-Linac DWI can assess treatment response in glioblastoma and whether changes in DWI show greater prognostic value than changes in the contrast-enhancing gross tumour volume (GTV). MATERIALS AND METHODS Seventy-five patients with glioblastoma were treated with chemoradiotherapy, of which 32 were treated on a 1.5 T MRI-linear accelerator (MR-Linac). Patients were imaged with simulation MRI scanners (MR-sim) at treatment planning and weeks 2, 4, and 10 after treatment start. Twenty-eight patients had additional MR-Linac DWI sequences. Cox modelling was used to evaluate the correlation of overall and progression-free survival (OS and PFS) with clinical variables and volumetric changes in the GTV and low-ADC regions (ADC < 1.25 µm2/ms within GTV). RESULTS In total, 479 MR-Linac DWI and 289 MR-sim DWI datasets were analyzed. MR-Linac low-ADC changes between weeks 2 and 5 inclusive were prognostic for OS (hazard ratio lower limits ≥ 1.2, p-values ≤ 0.02). MR-sim low-ADC changes showed greater correlation with OS and PFS than GTV changes (e.g., OS hazard ratio at week 2 was 3.4 (p <0.001) for low-ADC versus 2.0 (p = 0.022) for GTV). CONCLUSION MR-Linac DWI can measure low-ADC tumour volumes that correlate with OS and PFS better than contrast-enhancing GTV. Low-ADC regions could serve as dose escalation targets.
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Affiliation(s)
| | - Rachel W Chan
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - James Stewart
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Aimee Theriault
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Pejman J Maralani
- Medical Imaging, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Mary Jane Lim-Fat
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sunit Das
- Keenan Chair in Surgery, St. Michael's Hospital, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Greg J Stanisz
- Medical Biophysics, University of Toronto, Toronto, Ontario, Canada; Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada; Department of Neurosurgery and Paediatric Neurosurgery, Medical University, Lublin, Poland
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Angus Z Lau
- Medical Biophysics, University of Toronto, Toronto, Ontario, Canada; Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.
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13
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Moore-Palhares D, Sahgal A, Zeng KL, Myrehaug S, Tseng CL, Detsky J, Chen H, Ruschin M, Atenafu EG, Wilson J, Larouche J, da Costa L, Maralani PJ, Soliman H. 30 Gy in 4 Stereotactic Body Radiotherapy Fractions for Complex Spinal Metastases: Mature Outcomes Supporting This Novel Regimen. Neurosurgery 2023; 93:813-823. [PMID: 37074052 DOI: 10.1227/neu.0000000000002498] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 02/23/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND AND OBJECTIVES We designed a 30 Gy in 4 fractions stereotactic body radiotherapy protocol, as an alternative option to our standard 2-fraction approach, for primarily large volume, multilevel, or previously radiated spinal metastases. We report imaging-based outcomes of this novel fractionation scheme. METHODS The institutional database was reviewed to identify all patients who underwent 30 Gy/4 fractions from 2010 to 2021. Primary outcomes were magnetic resonance-based vertebral compression fracture (VCF) and local failure per treated vertebral segment. RESULTS We reviewed 245 treated segments in 116 patients. The median age was 64 years (range, 24-90). The median number of consecutive segments within the treatment volume was 2 (range, 1-6), and the clinical target volume (CTV) was 126.2 cc (range, 10.4-863.5). Fifty-four percent had received at least 1 previous course of radiotherapy, and 31% had previous spine surgery at the treated segment. The baseline Spinal Instability Neoplastic Score was stable, potentially unstable, and unstable for 41.6%, 51.8%, and 6.5% of segments, respectively. The cumulative incidence of local failure was 10.7% (95% CI 7.1-15.2) at 1 year and 16% (95% CI 11.5-21.2) at 2 years. The cumulative incidence of VCF was 7.3% (95% CI 4.4-11.2) at 1 year and 11.2% (95% CI 7.5-15.8) at 2 years. On multivariate analysis, age ≥68 years ( P = .038), CTV volume ≥72 cc ( P = .021), and no previous surgery ( P = .021) predicted an increased risk of VCF. The risk of VCF for CTV volumes <72 cc/≥72 cc was 1.8%/14.6% at 2 years. No case of radiation-induced myelopathy was observed. Five percent of patients developed plexopathy. CONCLUSION 30 Gy in 4 fractions was safe and efficacious despite the population being at increased risk of toxicity. The lower risk of VCF in previously stabilized segments highlights the potential for a multimodal treatment approach for complex metastases, especially for those with a CTV volume of ≥72 cc.
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Affiliation(s)
- Daniel Moore-Palhares
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Ontario , Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Ontario , Canada
| | - K Liang Zeng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Ontario , Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Ontario , Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Ontario , Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Ontario , Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Ontario , Canada
| | - Mark Ruschin
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Ontario , Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, University of Toronto, Toronto , Ontario , Canada
| | - Jeff Wilson
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto , Ontario , Canada
| | - Jeremie Larouche
- Division of Orthopedic Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Ontario , Canada
| | - Leodante da Costa
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Ontario , Canada
| | - Pejman Jabehdar Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Ontario , Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Ontario , Canada
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14
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Thomsen B, Vesprini D, Zeng L, Myrehaug SD, Tseng CL, Detsky J, Chen H, Zhang B, Jerzak K, Atenafu E, Maralani P, Soliman H, Sahgal A. Stereotactic Body Radiotherapy (SBRT) for Breast Cancer Spinal Metastases is Associated with Low Rates of Long-Term Local Failure (LF) and Vertebral Compression Fracture (VCF) Independent of Molecular Status. Int J Radiat Oncol Biol Phys 2023; 117:e153. [PMID: 37784740 DOI: 10.1016/j.ijrobp.2023.06.976] [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: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) There is limited outcome data specific to breast cancer spinal metastases following spine SBRT. This study aims to report outcomes specific to breast cancer spinal metastases receiving spine SBRT and determine the implication of biomarker status. MATERIALS/METHODS We have been maintaining a prospective database since the inception of the spine SBRT program. A retrospective review identified 168 breast cancer patients with 409 spinal segments treated with spine SBRT between January 2008 and January 2023. Molecular subtypes were grouped based on luminal A, luminal B, basal, and HER2 enriched. Patients were followed with q3-monthly full-spine MRI and a clinical assessment. The primary endpoint was MRI-based local failure (LF), and secondary endpoints were overall survival (OS) and vertebral compression fracture (VCF). RESULTS The median follow-up was 33 months (range, 3.3-123 months). Amongst the 168 patients, the majority were ECOG 0 or 1 (95%), neurologically intact (94%), polymetastatic (74%), and either luminal A (71%) or luminal B (8%). A total of 17% of patients were HER2+ve versus 83% HER2-ve. Of 409 treated segments the majority (76%) had no prior radiation or surgery (de novo), were SINS stable (60%), had either no or low-grade epidural disease (86%) and treated with 24-28 Gy in 2 fractions (73%). The LF and OS rates at 1, 3, and 5 years were 5%, 11%, and 14%, respectively, and 91%, 65%, and 45%, respectively, independent of molecular subtype on univariate analyses. The cumulative risk of VCF at 2 and 5 years was 7% and 10%, respectively. CONCLUSION We observe, in the largest breast cancer spine cohort to date, excellent long-term local control rates independent of molecular sub-group, and acceptable VCF rates.
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Affiliation(s)
- B Thomsen
- University of Toronto, Toronto, ON, Canada
| | - D Vesprini
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - L Zeng
- Royal Victoria Regional Health Centre, Barrie, ON, Canada
| | - S D Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - C L Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - J Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - H Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - B Zhang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - K Jerzak
- Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - E Atenafu
- Department of Biostatistics, University Health Network, University of Toronto, Toronto, ON, Canada
| | - P Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - H Soliman
- University of Toronto, Department of Radiation Oncology, Toronto, ON, Canada
| | - A Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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15
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Ong WL, Zeng L, Soliman H, Myrehaug SD, Detsky J, Chen H, Ruschin ME, Atenafu E, Larouche J, Maralani P, Sahgal A, Tseng CL. Outcomes Specific to Spinal Metastases with Paraspinal Disease Extension Following Spine Stereotactic Body Radiotherapy. Int J Radiat Oncol Biol Phys 2023; 117:e142-e143. [PMID: 37784717 DOI: 10.1016/j.ijrobp.2023.06.954] [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: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Spinal metastases with paraspinal disease (PD) extension are known to have worse outcomes following stereotactic body radiotherapy (SBRT). Characteristics of the PD itself have not been investigated to determine the impact on outcomes such as local control, which is the purpose of this study. MATERIALS/METHODS We retrospectively reviewed those patients who had SBRT for spinal metastases with PD disease, identified from a prospectively maintained database. Spinal metastases previously irradiated or surgical resected were excluded. The extent of PD was classified as involving the rib, neuroforamina, and muscle invasion. The gross tumor volume of PD (GTV_PD) and the clinical target volume of PD (CTV_PD) were segregated from the bony compartments based on the treatment plan contours. The outcomes of interest included the cumulative risk of local failure (LF), re-irradiation rates (ReRT), and overall survival (OS). LF and ReRT were estimated for each treated sites using the competing risk model (death as the competing risk), while OS was evaluated per patient using the Kaplan Meier method. RESULTS A total of 86 patients with 96 spinal metastases sites with PD were included. Of the 96 treated sites, 65% (62/96), 29% (28/96) and 6% (6/96) of PD spanned 1, 2, and 3 vertebral levels respectively. The median follow-up was 12.4months (range: 0.6-100months). The 6- and 12-month OS for the cohort was 81% and 51%, respectively. 33/86 (38%) patients had radioresistant cancer (gastrointestinal, renal cell carcinoma, thyroid, sarcoma, or melanoma). Involvement of rib, neuroforamina and muscle invasion were observed in 39% (37/96), 65% (62/96) and 21% (20/96) of the treated sites, respectively. Epidural disease was present in 57% (55/96) of treated sites. The median GTV_PD volume was 7cc (range: 0.3-114cc), and the median CTV_PD volume was 24cc (range: 0.4-248cc). The prescribed doses were 24 Gy/2 fractions (fx) (80%), 28 Gy/2 fx (10%) and 30 Gy/4 fx (10%). There were 84 treated sites with at least one post-treatment MRI available for LF assessment. The crude LF risk was 32% (27/84), and the 6- and 12-month cumulative LF rates were 12% and 28%, respectively. There was a trend towards an increased risk of LF when PD involved the rib (35% vs 24% at 1 year respectively, P = 0.07) and muscle (67% vs 20% at 1 year respectively; P = 0.06), but no difference in LF for neuroforamina involvement (26% vs 34% at 1 year respectively, P = 0.5). There were no differences in LF based on cancer radioresistance (P = 0.6), GTV_PD volume (P = 0.3) or CTV_PD volume (P = 0.4). Of the 96 treated sites, 14% (14/96) were re-irradiated (9 with repeat SBRT and 5 with conventional EBRT) at a median of 15 months (range: 4.7-59 months) post initial SBRT. The cumulative incidence of ReRT at 6- and 12-months were 1.2% and 7.3%, respectively. CONCLUSION PD involving adjacent rib and muscle may be associated with worse LF following SBRT. Further expansion of the cohort and dosimetric analyses are ongoing.
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Affiliation(s)
- W L Ong
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada; Alfred Health Radiation Oncology, Monash University Central Clinical School, Melbourne, Australia
| | - L Zeng
- Royal Victoria Regional Health Centre, Barrie, ON, Canada
| | - H Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - S D Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - J Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - H Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - M E Ruschin
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - E Atenafu
- Department of Biostatistics, University Health Network, University of Toronto, Toronto, ON, Canada
| | - J Larouche
- Division of Orthopedic Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - P Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - A Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - C L Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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16
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Burgess L, Zeng L, Myrehaug SD, Soliman H, Tseng CL, Detsky J, Chen H, Palhares DM, Witiw CD, Zhang B, Maralani P, Sahgal A. Stereotactic Body Radiotherapy for Posterior Element Only Spinal Metastases: Outcomes and Validation of Recommended Clinical Target Volume Delineation Practice. Int J Radiat Oncol Biol Phys 2023; 117:e91. [PMID: 37786212 DOI: 10.1016/j.ijrobp.2023.06.849] [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: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Spine stereotactic body radiotherapy (SBRT) results in improved local control and pain response compared to conventional external beam radiotherapy. Consensus stipulates MRI-based delineation of the clinical target volume (CTV) is critical and is based on spine segment sector involvement. The applicability of these contouring guidelines to metastases confined to the posterior elements is unknown. The purpose of this study was to determine the patterns of failure, as well as the safety of treating posterior element metastases when the vertebral body was intentionally excluded from the CTV. MATERIALS/METHODS A retrospective review of a prospectively maintained database of 605 patients and 1412 spine segments treated with spine SBRT was performed. Only treated segments involving the posterior elements alone were included for the analyses. The primary outcome was local failure, as per SPINO recommendations, and secondary outcomes included patterns of failure, toxicities. Clinical and tumor factors were reported with descriptive statistics. The cumulative risk of local failure was estimated using the Fine-Gray method, accounting for death before local failure as a competing risk. RESULTS A total of 24/605 patients and 31/1412 segments within the database were treated to the posterior elements only. Local failure occurred in 11/31 segments. The cumulative rate of local recurrence was 9.7% at 12 months and 30.8% at 24 months. Amongst local failures, the most common histologies were renal cell carcinoma (36.4%) and non-small cell lung cancer (36.4%). At baseline, 4/11 (36.4%) segments with local failure (36.4%) had epidural disease and 8/11 (72.7%) had paraspinal disease. Most local failures were treated in the de novo setting (8/11, 72.7%). 6/11 (54.5%) failed exclusively within treated CTV sectors and 5/11 (45.5%) with both treated and adjacent untreated sectors. Of these five, four had disease progression within the untreated vertebral body. No failures occurred exclusively within the untreated vertebral body. One patient (4.2%) experienced a grade 4 skin toxicity and one patient (4.2%) developed an iatrogenic Grade 1 vertebral compression fracture. CONCLUSION Posterior element alone metastases are rare. Our analyses support SBRT consensus contouring guidelines such that the vertebral body can be excluded from CTV in spinal metastases confined to the posterior elements.
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Affiliation(s)
- L Burgess
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - L Zeng
- Royal Victoria Regional Health Centre, Barrie, ON, Canada
| | - S D Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - H Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - C L Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - J Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - H Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - D M Palhares
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - C D Witiw
- St. Michaels Hospital, Toronto, ON, Canada
| | - B Zhang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - P Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - A Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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17
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Zeng KL, Soliman H, Myrehaug SD, Tseng CL, Detsky J, Chen H, Lim-Fat MJ, Ruschin ME, Atenafu E, Keith J, Lipsman N, Heyn C, Maralani P, Das S, Pirouzmand F, Sahgal A. Outcomes Following Dose Escalated Radiotherapy for High Grade Meningioma. Int J Radiat Oncol Biol Phys 2023; 117:e161. [PMID: 37784757 DOI: 10.1016/j.ijrobp.2023.06.991] [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: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Conventionally fractionated radiotherapy (RT) is a defined treatment following surgery for atypical and malignant meningioma. However, the optimal radiotherapeutic approach is not well defined. We present the results of our dose-escalation strategy. MATERIALS/METHODS Consecutive patients with a histopathologic grade 2 or 3 meningioma treated with RT were retrospectively reviewed. The primary outcome was progression-free survival (PFS), and secondary outcomes included cause-specific survival (CSS), overall survival (OS), local failure and incidence of radiation necrosis. We specifically compared the dose-escalation cohort, defined as those treated with ≥66 Gy EQD2 (equivalent dose in 2 Gy fractions, a/b = 10), to the standard dose cohort receiving <66 Gy EQD2. We defined adjuvant as RT delivered within 6 months of surgery otherwise the treatment was salvage. RESULTS A total of 118 patients with Grade 2 (111/118) or 3 (7/118) meningioma were identified. 54/118 (45.8%) received dose-escalation and 64/118 (54.2%) standard dosing. 34/54 (63.0%) dose-escalated and 45/64 (70.3%) standardly dosed were treated adjuvantly. The median follow-up was 45.4 months (IQR: 24.0-80.0 months) and median OS was 9.7 years. Post-operative residual disease was present in all dose-escalated patients, as compared to 65.6% in the standard dose cohort. PFS at 3-, 4- and 5-years in the dose-escalated vs. standard dose cohort were 78.9%, 72.2% and 64.6% vs. 57.2%, 49.1% and 40.8%, respectively, (p = 0.030). On multivariable (MVA) analysis, dose-escalation (HR: 0.544, 95% CI: 0.303-0.977, p = 0.042) was associated with improved PFS, whereas ≥2 surgeries (HR: 1.989, 95% CI: 1.049-3.773, p = 0.035) and older age (HR: 1.035, 95% CI:1.015-1.056, p<0.001) associated with worse PFS. The cumulative risk of local failure at 3-, 4- and 5-years in the dose-escalated vs. standard dose cohort were 16.9%, 23.8% and 31.8% vs. 39.6%, 45.6% and 53.9%, respectively, favoring dose-escalation (p = 0.016). MVA confirmed dose-escalation as predictive of a lower risk of LF (HR: 0.483, 95% CI: 0.263-0.887, p = 0.019), while ≥2 surgeries prior to RT predicted for greater LF rates (HR:2.145, 95% CI:1.220-3.771, p = 0.008). A trend was observed for prolonged CSS and OS in the dose escalation cohort (p = <0.1). Seven patients (5.9%) developed symptomatic radiation necrosis (RN) with no significant difference between the two cohorts. CONCLUSION Dose-escalated radiotherapy for high grade meningioma to at least 66 Gy is associated with significantly improved rates of local control and PFS with an acceptable risk of RN.
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Affiliation(s)
- K L Zeng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - H Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - S D Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - C L Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - J Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - H Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - M J Lim-Fat
- Sunnybrook Odette Cancer Centre, Toronto, ON, Canada
| | - M E Ruschin
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - E Atenafu
- Department of Biostatistics, University Health Network, University of Toronto, Toronto, ON, Canada
| | - J Keith
- Department of Neuropathology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - N Lipsman
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada
| | - C Heyn
- Department of Neuroradiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - P Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - S Das
- Division of Neurosurgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, ON, Canada
| | - F Pirouzmand
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - A Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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18
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Shor D, Zeng L, Holden L, Chen H, Maralani P, Heyn C, Zhang B, Myrehaug SD, Tseng CL, Detsky J, Soliman H, Sahgal A. Staged Stereotactic Radiosurgery as a Novel Adaptive Approach to Salvage Previously Irradiated Brain Metastases. Int J Radiat Oncol Biol Phys 2023; 117:e150. [PMID: 37784734 DOI: 10.1016/j.ijrobp.2023.06.969] [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: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) We report outcomes specific to a novel 3 fraction (frx) staged stereotactic radiosurgery (St-SRS) regimen designed to salvage metastases previously irradiated and considered to be at high risk of radiation necrosis (RN). MATERIALS/METHODS A total of 24 patients with 55 metastases treated with our 3 frx St-SRS approach were reviewed. Prior to each frx, patients were re-simulated and planned with a new MRI to allow for treatment adaption. The primary endpoint was the cumulative incidence of local failure (LF) and secondary endpoints included tumor dynamics and RN rates. RESULTS The median follow up was 9.0 months (range: 2.7-40.1 months) and median age was 59-years (range: 32-84). Primary cancers were of breast (44%), lung (33%), melanoma (22%), and gastro-intestinal (1%) origin. Individual metastases treated with St-SRS had initially failed surgery and post-op cavity hypofractionated SRS (HSRS) for 2/55 (4%), SRS alone for 19/55 (34%), whole brain radiation (WBRT) alone for 6/55 (11%), HSRS for 2/55 (4%), and prior SRS and WBRT exposure for 28/55 (51%). 46/55 (84%) were prescribed 8 Gy, 8 Gy, 4 Gy; 8/55 (14%) had 6 Gy, 6 Gy, 4 Gy and 1/55 (2%) had 8 Gy, 8 Gy, 6 Gy. The median number of weeks between frx was 2.6 (range: 1.0-6.8). The median of the mean and maximum target doses were 9.7 Gy (range: 5.4-11.7 Gy) and 12.4 Gy (range, 7.5-16.0 Gy) respectively. The median prescription isodose line was 62% (range: 50-85%). The mean lesion volume and diameter was 3.8cc (range: 0.05-24.8cc) and 1.6cm (range: 0.2-4.4cm), respectively. The mean percent target volume coverage, Paddick Conformality Index and Gradient Index were 100% (range: 97-100%), 0.7 (range: 0.1-0.9), and 3.2 (range: 2.5-6.7), respectively. The mean volume change between staged frxs was -4.2% (range: -69.3 to +63.1%), and based on the first and last St-SRS MRI was -10.8% (range: -86.6% to +68.7%). The crude LF rate was 27%. The median time to LF was 3.4 months (range: 1.2-7.4 months). Amongst those with a LF, 7/15 (46%) were melanoma, 6/15 (40%) HER2 positive breast cancer, 1/15 (7%) gastrointestinal and 1/15 (7%) non-small cell lung carcinoma. 8/15 (53%) had prior WBRT and SRS exposure, 1/16 (7%) surgery and cavity HSRS, 5/15 (33%) SRS alone and 1/15 (7%) WBRT alone. Only asymptomatic RN events were observed in 4/55 (7%). CONCLUSION St-SRS is a promising approach to salvage previously irradiated brain metastases, including prior SRS, with a favorable rate of RN. Tumor volume dynamics between stages can be significant warranting adaptive replanning.
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Affiliation(s)
- D Shor
- Sunnybrook Odette Cancer Centre, Toronto, ON, Canada
| | - L Zeng
- Royal Victoria Regional Health Centre, Barrie, ON, Canada
| | - L Holden
- Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - H Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - P Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - C Heyn
- Department of Neuroradiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - B Zhang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - S D Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - C L Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - J Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - H Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - A Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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Shor D, Zeng KL, Chen H, Louie AV, Menjak I, Atenafu E, Tseng CL, Detsky J, Larouche J, Zhang B, Soliman H, Maralani P, Myrehaug SD, Sahgal A. Molecular Status Predicts for Local Control in Patients with Non-Small Cell Lung Cancer Spinal Metastases Following Spine Stereotactic Body Radiotherapy. Int J Radiat Oncol Biol Phys 2023; 117:e57-e58. [PMID: 37785740 DOI: 10.1016/j.ijrobp.2023.06.773] [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: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) We report outcomes after spine stereotactic body radiotherapy (SBRT) in patients with metastatic non-small cell lung cancer (NSCLC), to determine the significance of programmed death-ligand 1 (PD-L1) status and epidermal growth factor (EGFR) mutation on local failure (LF) rate. MATERIALS/METHODS A total of 165 patients and 389 spinal segments were retrospectively reviewed from 2009 to 2021. Baseline patient characteristics, treatment and outcomes were abstracted. Primary endpoint was LF and secondary outcomes included overall survival (OS) and vertebral compression fracture (VCF) rates. OS was estimated using the Kaplan-Meier method. Cumulative LF and VCF rates were calculated using competing risk analysis method. Multivariable analysis (MVA) evaluated factors predictive of LF and VCF. RESULTS Median follow-up was 13 months (range, 0.5-95 months). Median OS was 18.4 months (95% CI 11.4-24.6). Median age was 67 years (range, 28.2-89.9). 52% were female, 76% had an adenocarcinoma histology and 61% had a smoking history. 49/165 (29%) had an EGFR mutation. PD-L1 status was analyzed in 109/165 (66%) patients with 16% PD-L1 ≥ 50%, 20% PD-L1 1-49% and 35% PD-L1 <1%. Of 389 segments, 79% were de novo and 21% were previously radiated. At baseline, 35% had a VCF, 27% had epidural disease, 27% had paraspinal extension, and 49% were Spinal Instability in Neoplasia Score (SINS) stable. 239/389 (61%) were treated with either 24 or 28 Gy in 2 SBRT fractions. Within 1 month of SBRT, 39/165 (24%) had a tyrosine kinase inhibitor, 27/165 (16%) immunotherapy (IO) with or without chemotherapy, and 31/165 (19%) chemotherapy alone. LF cumulative incidence at 1- and 2-years was 16.3% (95% CI 12.8-20.3%) and 25.4% (95% CI 20.9%-30%), respectively. EGFR positivity (p<0.0001), PD-L1≥50% (p = 0.013) and treatment with IO within 1 month of SBRT (p = 0.004) predicted for improved local control on MVA. The 1- and 2-year LF rate in EGFR-positive vs. negative patients were 12.9% vs. 16.6% and 17.7% vs. 28.8%, respectively, and in those PD-L1 ≥50% vs PD-L1<50% were 7.8% vs. 19.6% and 7.8% vs. 38.1% respectively. Cumulative incidence of VCF at 1- and 2-years were 6.6% (95% CI 4.4-9.4%) and 8.8% (95% CI 6.1-12.0%). MVA identified prior SBRT to the same treated segment (P<0.0001) and a baseline VCF (p<0.0001) as significant predictors. 18/389 (4.6%) had radiation-induced radiculopathy and no radiation myelopathy events detected. CONCLUSION We identify the predictive utility of EGFR mutation and PD-L1 ≥50% status on local control in NSCLC patients with spinal metastases treated with spine SBRT, and a therapeutic benefit with peri-SBRT IO.
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Affiliation(s)
- D Shor
- Sunnybrook Odette Cancer Centre, Toronto, ON, Canada
| | - K L Zeng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - H Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - A V Louie
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - I Menjak
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - E Atenafu
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - C L Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - J Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - J Larouche
- Division of Orthopedic Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - B Zhang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - H Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - P Maralani
- Department of Neuroradiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - S D Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - A Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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Ong WL, Stewart J, Sahgal A, Soliman H, Tseng CL, Detsky J, Ho L, Das S, Maralani P, Lipsman N, Stanisz G, Perry J, Chen H, Atenafu E, Lau A, Ruschin ME, Myrehaug SD. Predictors of Tumor Dynamics during a 6-Week Course of Chemoradiotherapy for Glioblastoma. Int J Radiat Oncol Biol Phys 2023; 117:e142. [PMID: 37784716 DOI: 10.1016/j.ijrobp.2023.06.953] [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: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Our prior imaging studies have shown geometrically meaningful inter-fraction tumor dynamics specific to glioblastoma (GBM). We aim to identify predictors associated with tumor dynamics during a 6-week course of concurrent chemoradiotherapy (CRT) for GBM. MATERIALS/METHODS Patients enrolled in a prospective serial magnetic resonance imaging (MRI) study were reviewed. All patients were treated with 54-60 Gy in 30 fractions. The gross tumor volume (GTV) included the surgical cavity and T1c enhanced residual tumor; clinical tumor volume (CTV) included GTV with a 15mm isotropic expansion, respecting anatomical boundaries; planning target volume (PTV) was 4mm expansion. MRIs were obtained at RT planning (F0), fraction 10 (F10), and fraction 20 (F20). Tumor dynamic metrics (relative to F0) assessed included the GTV volume (Vrel), Hausdorff distance (dH) and migration distance (dM). dH is the average distance between two datasets in metric space. dM is the maximum linear displacement of the GTV in any direction. Factors to be determined associated with tumor dynamics included: age, sex, corpus callosum (CC) involvement, extent of surgery (gross total resection (GTR), subtotal resection (STR) or biopsy alone (Bx)), MGMT methylation and IDH mutation status. RESULTS A total of 129 patients were reviewed. Median GTV was 20.9cc at F0, 17.6cc at F10 (Vrel 0.85), and 16.1cc at F20 (Vrel 0.78). Patients without CC involvement had more marked GTV volume reduction: Vrel 0.82 vs 1.02 with CC involvement at F10 (P = 0.05), and Vrel 0.77 vs 0.88 with CC involvement at F20 (P = 0.03). Patients with GTR (vs STR vs Bx) had more marked GTV volume reduction across all time points: Vrel 0.78, 0.85 and 1.07 respectively at F10 (P = 0.001), and Vrel 0.69, 0.80, 1.04 respectively at F20 (P = 0.001). The median dH was 8.1mm at F10 and 9.2mm at F20. Patients with CC involvement (vs without CC involvement) had a larger dH: 54% vs 25% had dH>10mm respectively at F10 (P = 0.03), and 73% vs 28% had dH>10mm respectively at F20 (P<0.005). Patients with a GTR had smaller dH at both F10 (P = 0.02) and F20 (P = 0.006). At F20, 20%, 47% and 37% of patients with GTR, STR and Bx had dH>10mm (P = 0.04). The median dM were 4.7mm at F10 and 4.7mm at F20. Patients with CC involvement (vs without CC involvement) had larger dM: 41% vs 12% had dM >10mm respectively at F10 (P = 0.01), and 45% vs 9% had dM >10mm respectively at F20 (P<0.001). Patients with GTR had smaller dM at F10 (P = 0.03) and F20 (P0.002). At F20, 0%, 25% and 19% of patients with GTR, STR and Bx had dM>10mm (P = 0.002). Age, sex, MGMT methylation and IDH mutation status were not associated with Vrel, dH and dM at F10 and F20. CONCLUSION We identified CC involvement and extent of surgery to be associated with tumor dynamics at F10 and F20 over the course of CRT for GBM. This offers opportunities to better select patients who may benefit from earlier/ more frequent RT replan/ adaptation to ensure adequate tumor coverage, or to reduce RT toxicities.
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Affiliation(s)
- W L Ong
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada; Alfred Health Radiation Oncology, Monash University Central Clinical School, Melbourne, Australia
| | - J Stewart
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - A Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - H Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - C L Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - J Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - L Ho
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - S Das
- Division of Neurosurgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, ON, Canada
| | - P Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - N Lipsman
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada
| | - G Stanisz
- Department of Physical Sciences, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada; Department of Neurosurgery and Pediatric Neurosurgery, Medical University, Lublin, Poland
| | - J Perry
- Department of Neurooncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - H Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - E Atenafu
- Department of Biostatistics, University Health Network, University of Toronto, Toronto, ON, Canada
| | - A Lau
- Department of Physical Sciences, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada
| | - M E Ruschin
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - S D Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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21
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Palhares DM, Zeng KL, Myrehaug SD, Tseng CL, Soliman H, Chen H, Maralani P, Larouche J, Wilson J, Ruschin ME, Zhang B, Atenafu E, Sahgal A, Detsky J. Stereotactic Body Radiotherapy (SBRT) for Sacral Metastases: Deviation from Recommended Target Volume Delineation Predicts Higher Risk of Local Failure. Int J Radiat Oncol Biol Phys 2023; 117:e143-e144. [PMID: 37784719 DOI: 10.1016/j.ijrobp.2023.06.956] [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: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) A international consensus recommendation was published to guide target volume delineation specific to sacral stereotactic body radiotherapy (SBRT). We report outcomes after sacrum SBRT, focusing on the impact of contouring deviation on local failure (LF) risk, with an aim to validate this guideline. MATERIALS/METHODS All patients who underwent SBRT to any level between S1 and S5 from 2010 to 2021 were identified from a prospectively maintained institutional database. The primary outcome was magnetic resonance-based LF. Secondary outcomes included vertebral compression fracture (VCF) and overall survival (OS). Cumulative LF and VCF rates were calculated per segment using the competing risk analysis method. Kaplan Meier analysis was used to estimate OS per patient. Cox proportional hazards model was used to assess predictive factors of LF, VCF, and OS. RESULTS A total of 215 treated sacral segments in 112 patients were retrospectively reviewed. The median follow-up was 13 months (range, 0.4-116.9). The median age was 64 years (range, 18-86), and 56% were male. Most patients (52%) had treatment to a single segment. The median clinical target volume (CTV) was 129.2 cc (range, 5.8-753.5). Most segments were treated with 30 Gy/4 fractions (51%), 24 Gy/2 fractions (31%), or 30 Gy/5 fractions (10%). Thirty-one percent of segments were of radioresistant histology (gastrointestinal, kidney, melanoma, sarcoma, or thyroid primary), and 51% had extraosseous disease. Sixteen percent of segments were under-contoured per consensus guidelines, with incomplete coverage of the involved sector (71%), omission of the adjacent uninvolved sector (17%), or both (11%) as the causes for deviation. The cumulative incidence of LF was 18.4% (95% CI 13.5-24.0) at 12-months and 23.1% (95% CI 17.6-29.0) at 24-months. On multivariate analysis (MVA), under-contouring (HR 2.4, 95% CI 1.3-4.7, p = 0.008), radioresistant histology (HR 2.4, 95% CI 1,4-4.1, p = 0.001), and extraosseous extension (HR 2.5, 95% CI 1.3-4.7, p = 0.005) were predictors of increased risk of LF. The LF rates at 12/24-months were 15.1%/18.8% for segments contoured per guideline versus 31.4%/40.0% for those under-contoured. The cumulative incidence of VCF was 7.1% (95% CI 4.1-11.1) at 12-months and 12.3% (95% CI 8.2-17.2) at 24-months. On MVA, female gender was the only risk factor for VCF (HR 2.3, 95% CI 1.1-5.2, p = 0.04). The median OS was 29.5 months (95% CI 17.5-59.2). On MVA, primary kidney (HR 4.7, 95% CI 1.7-12.5, p = 0.002) or lung histology (HR 3.4, 95% CI 1.3-8.5, p = 0.010), the presence of liver (HR 2.8, 95% CI 1.2-6.4, p = 0.016) or lung (HR 2.5, 95% CI 1.3-5.1, p = 0.008) metastases, ECOG performance status 2 or 3 (HR 3.3, 95% CI 1.2-8.2, p = 0.013), and the presence of sensory or motor deficit (HR 2.6, 95% CI 1.2-5.4, p = 0.012) were prognostic for worse OS. CONCLUSION Sacral SBRT is associated with high rates of efficacy and an acceptable VCF risk. Adherence to target volume delineation consensus guidelines reduces the risk of LF.
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Affiliation(s)
- D M Palhares
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - K L Zeng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - S D Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - C L Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - H Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - H Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - P Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - J Larouche
- Division of Orthopedic Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - J Wilson
- St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada, Toronto, ON, Canada
| | - M E Ruschin
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - B Zhang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - E Atenafu
- Department of Biostatistics, University Health Network, University of Toronto, Toronto, ON, Canada
| | - A Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - J Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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22
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Ruschin ME, Stewart J, Hudson JM, Myrehaug SD, Tseng CL, Soliman H, Chen H, Maralani P, Sahgal A, Detsky J. Dosimetric Implications of Weekly On-Line MR-Guided Adaptive Radiotherapy (RT) for Glioblastomas (GBM) Growing during RT. Int J Radiat Oncol Biol Phys 2023; 117:e713-e714. [PMID: 37786085 DOI: 10.1016/j.ijrobp.2023.06.2214] [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: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) The UNITED trial (NCT04726397) involves once-weekly on-line adaptive RT for patients with GBM on a 1.5T MRI-Linac (MRL). For tumors that continue to enlarge during the course of RT, we hypothesize that the adaptive strategy improves the dosimetric coverage of the target relative to a non-adaptive strategy. MATERIALS/METHODS As per the trial protocol, T1+contrast (T1c) and FLAIR MRI sequences were acquired once per week during RT to re-define and adapt the gross tumor volume (GTV) as the contrast enhanced volume, the clinical target volume (CTV) as a 5mm expansion around the GTV plus adjacent FLAIR hyperintense regions considered at-risk by the radiation oncologist, and a 3 mm PTV around the CTV. Nine UNITED patients with tumors that grew throughout RT (GTV and/or CTV) were identified. 5/9 patients were treated with 60 Gy in 30 fractions (6 weekly adaptions) and 4/9 with 40 Gy in 15 fractions (3 weekly adaptions). For the final week's GTV and CTV (GTVfinal and CTVfinal), the dosimetric outcomes of the delivered and adaptive summative plans (Dsum) were compared to dose of the baseline plan (Dbaseline) generated on Fraction 1 of treatment, the latter being indicative of the theoretical situation where no further adaption was taken. We measured the dose to 99% of the GTVfinal and CTVfinal: Dsum99 and Dbaseline99. RESULTS For each adaptive fraction, the plan was optimized to achieve an objective of D99 greater than 95% of the prescription (D99>95%) for both the GTV and CTV. The relative increase in GTVfinal and CTVfinal from baseline was on average 119% (range: 98% to 144.7%) and 128% (range: 109% to 176%), respectively. The proportion of CTVfinal that was outside the baseline plan's PTV was on average 11.5% (range: 0% to 32%). The GTVfinal did not extend beyond the baseline PTV for any of the 9 cases. GTVfinal Dsum99 was >95% for all cases while CTVfinal Dsum99 was < 95% in 2 of 9 cases (74%, and 87%). By contrast, the baseline plan, if given for all fractions with no further adaptation, yielded a D99 for CTVfinal of <95% in 5 of 9 cases (28%, 52%, 75%, 84%, and 87%). In general, coverage of the CTVfinal decreased with increasing levels of CTVfinal outside of the baseline PTV. For all 5 cases where CTVfinal D99<95% on the baseline plan, more than 10% of CTVfinal was outside of the baseline PTV. Small margin, weekly adaptive RT on an MRL for GBM maintains coverage of the GTV in the presence of tumor growth while minimizing the degree of normal brain tissue irradiated. Dosimetric impact on non-GTV/CTV brain is outside the scope of the present study. CONCLUSION Preliminary results indicate that a once weekly adaptive approach for small margin MR-guided RT improves tumor coverage for progressive tumors compared to a static (baseline) plan without adaptation.
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Affiliation(s)
- M E Ruschin
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - J Stewart
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - J M Hudson
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - S D Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - C L Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - H Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - H Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - P Maralani
- Department of Neuroradiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - A Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - J Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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23
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Heyn C, Moody AR, Tseng CL, Wong E, Kang T, Kapadia A, Howard P, Maralani P, Symons S, Goubran M, Martel A, Chen H, Myrehaug S, Detsky J, Sahgal A, Soliman H. Segmentation of Brain Metastases Using Background Layer Statistics (BLAST). AJNR Am J Neuroradiol 2023; 44:1135-1143. [PMID: 37735088 PMCID: PMC10549939 DOI: 10.3174/ajnr.a7998] [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] [Received: 05/24/2023] [Accepted: 08/16/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND AND PURPOSE Accurate segmentation of brain metastases is important for treatment planning and evaluating response. The aim of this study was to assess the performance of a semiautomated algorithm for brain metastases segmentation using Background Layer Statistics (BLAST). MATERIALS AND METHODS Nineteen patients with 48 parenchymal and dural brain metastases were included. Segmentation was performed by 4 neuroradiologists and 1 radiation oncologist. K-means clustering was used to identify normal gray and white matter (background layer) in a 2D parameter space of signal intensities from postcontrast T2 FLAIR and T1 MPRAGE sequences. The background layer was subtracted and operator-defined thresholds were applied in parameter space to segment brain metastases. The remaining voxels were back-projected to visualize segmentations in image space and evaluated by the operators. Segmentation performance was measured by calculating the Dice-Sørensen coefficient and Hausdorff distance using ground truth segmentations made by the investigators. Contours derived from the segmentations were evaluated for clinical acceptance using a 5-point Likert scale. RESULTS The median Dice-Sørensen coefficient was 0.82 for all brain metastases and 0.9 for brain metastases of ≥10 mm. The median Hausdorff distance was 1.4 mm. Excellent interreader agreement for brain metastases volumes was found with an intraclass correlation coefficient = 0.9978. The median segmentation time was 2.8 minutes/metastasis. Forty-five contours (94%) had a Likert score of 4 or 5, indicating that the contours were acceptable for treatment, requiring no changes or minor edits. CONCLUSIONS We show accurate and reproducible segmentation of brain metastases using BLAST and demonstrate its potential as a tool for radiation planning and evaluating treatment response.
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Affiliation(s)
- Chris Heyn
- From the Department of Medical Imaging (C.H., A.R.M., E.W., T.K., A.K., P.H., P.M., S.S.), Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
- Sunnybrook Research Institute (C.H., A.R.M., M.G., A.M.), Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Alan R Moody
- From the Department of Medical Imaging (C.H., A.R.M., E.W., T.K., A.K., P.H., P.M., S.S.), Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
- Sunnybrook Research Institute (C.H., A.R.M., M.G., A.M.), Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology (C.-L.T., H.C., S.M., J.D., A.S., H.S.), Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Erin Wong
- From the Department of Medical Imaging (C.H., A.R.M., E.W., T.K., A.K., P.H., P.M., S.S.), Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Tony Kang
- From the Department of Medical Imaging (C.H., A.R.M., E.W., T.K., A.K., P.H., P.M., S.S.), Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Anish Kapadia
- From the Department of Medical Imaging (C.H., A.R.M., E.W., T.K., A.K., P.H., P.M., S.S.), Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Peter Howard
- From the Department of Medical Imaging (C.H., A.R.M., E.W., T.K., A.K., P.H., P.M., S.S.), Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Pejman Maralani
- From the Department of Medical Imaging (C.H., A.R.M., E.W., T.K., A.K., P.H., P.M., S.S.), Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Sean Symons
- From the Department of Medical Imaging (C.H., A.R.M., E.W., T.K., A.K., P.H., P.M., S.S.), Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Maged Goubran
- Sunnybrook Research Institute (C.H., A.R.M., M.G., A.M.), Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
- Department of Medical Biophysics (M.G., A.M.), University of Toronto, Toronto, Ontario, Canada
| | - Anne Martel
- Sunnybrook Research Institute (C.H., A.R.M., M.G., A.M.), Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
- Department of Medical Biophysics (M.G., A.M.), University of Toronto, Toronto, Ontario, Canada
| | - Hanbo Chen
- Department of Radiation Oncology (C.-L.T., H.C., S.M., J.D., A.S., H.S.), Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology (C.-L.T., H.C., S.M., J.D., A.S., H.S.), Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Jay Detsky
- Department of Radiation Oncology (C.-L.T., H.C., S.M., J.D., A.S., H.S.), Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology (C.-L.T., H.C., S.M., J.D., A.S., H.S.), Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Hany Soliman
- Department of Radiation Oncology (C.-L.T., H.C., S.M., J.D., A.S., H.S.), Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
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Ong WL, Davidson MTM, Cheung P, Chung HT, Chu W, Detsky J, Liu SK, Morton G, Szumacher E, Tseng CL, Vesprini D, Ravi A, McGuffin M, Zhang L, Mamedov A, Deabreu A, Kulasingham-Poon M, Loblaw DA. Dosimetric Predictors of Toxicities and Quality of Life Following Two-Fraction Stereotactic Body Radiotherapy for Prostate Cancer. Int J Radiat Oncol Biol Phys 2023; 117:e425-e426. [PMID: 37785394 DOI: 10.1016/j.ijrobp.2023.06.1585] [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: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) There is emerging interest in two-fraction stereotactic body radiotherapy (2#SBRT) for localized prostate cancer. However, there is limited data to guide organs at risk (OAR) dose constraints in 2#SBRT. We aim to identify dosimetric predictors of toxicities and quality of life (QoL) using real life patient data from two prospective 2#SBRT trials. MATERIALS/METHODS We included 60 patients who had 2#SBRT in the 2STAR (NCT02031328) and 2SMART (NCT03588819) phase 2 trials. The prescribed dose was 26Gy to the prostate +/- focal boost of 32Gy to the dominant intraprostatic lesions. Toxicities and QoL data were prospectively collected using CTCAEv4 and EPIC26 questionnaires. For QoL, we reported the minimal clinical important changes (MCIC), defined as changes in QoL score of >0.5 standard deviation from baseline QoL score. We evaluated the bladder, urethra, rectum, and penile bulb dosimetry (urethra dosimetry only available in 30 patients in 2SMART trial). Some of the dosimetric parameters were log-transformed to normalize the distribution. Cox regression was used to identify dosimetric predictors for acute and late grade ≥2 GU toxicities. Logistic regression was used to identify dosimetric predictors for late MCIC in urinary, bowel and sexual QoL domains. Backward stepwise selection was used to identify significant dosimetric parameters. For GU toxicities and urinary QoL, three additional clinical factors (age, prostate volume and IPSS) were included in the final model as confounding factors. Receiver operating characteristics curve was used to identify cut-off for significant dosimetric parameters. RESULTS The median follow-up for the cohort was 56 months (range: 39-78 months). The cumulative acute and late grade ³2 GU toxicities were 62% (37/60) and 57% (34/60) respectively. No bladder or urethra dosimetric parameter was associated with acute grade ≥2 GU toxicities. Bladder D0.5cc was significant predictor of late grade ≥2 GU toxicities in univariate model (P = 0.05), but not in multivariate model. Baseline IPSS score was the single strongest predictor for late grade ≥2 GU toxicities (HR = 1.9; 95% CI = 1.1-3.4; P = 0.03). For late QoL outcomes, there were 36% (21/58), 28% (16/58), and 29% (17/58) of patients with MCIC in urinary, bowel and sexual QoL domains respectively. Bladder V10Gy was associated with late urinary MCIC in multivariate model after adjusting for clinical confounders (HR = 2.6, 95% CI = 1.1-6.6; P = 0.04). 48% (14/29) and 24% (7/29) of patients with bladder V10Gy>13.9% and V10Gy≤13.9% respectively had late urinary MCIC. No rectum and penile bulb dosimetry parameters was identified to be associated with late bowel or sexual QoL. CONCLUSION Using real life patient data from prospective clinical trials with medium term follow-up, we identified statistically significant bladder dosimetry parameter predictive of late urinary QoL. This finding could be useful to guide OAR dose constraints in prostate 2#SBRT trials.
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Affiliation(s)
- W L Ong
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada; Alfred Health Radiation Oncology, Monash University Central Clinical School, Melbourne, Australia
| | - M T M Davidson
- Department of Medical Physics, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - P Cheung
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - H T Chung
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - W Chu
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - J Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - S K Liu
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - G Morton
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - E Szumacher
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - C L Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - D Vesprini
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - A Ravi
- Molli Surgical, Toronto, ON, Canada
| | - M McGuffin
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - L Zhang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - A Mamedov
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - A Deabreu
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - M Kulasingham-Poon
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - D A Loblaw
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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25
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Id Said B, Soliman H, Moravan V, Myrehaug S, Tseng CL, Detsky J, Sahgal A, Warner E, Jerzak KJ. Patterns of treatment and outcomes of patients with brain-only metastatic breast cancer. J Neurooncol 2023; 164:437-445. [PMID: 37634217 DOI: 10.1007/s11060-023-04421-4] [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: 07/05/2023] [Accepted: 08/09/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND We characterized the risk factors and survival of metastatic breast cancer (MBC) patients with brain metastases (BrM) as the first and only site of disease in a large, retrospective cohort. METHODS MBC patients treated for BrM with radiation at a quaternary institution between 2005 and 2019 were identified. MBC patients with BrM but without concurrent extracranial metastases (ECM) or leptomeningeal disease (LMD) were classified as brain-only. Factors associated with brain-only MBC, brain-specific progression free survival (bsPFS) and overall survival (OS) were investigated. RESULTS A total of 691 patients with MBC and BrM were analyzed. Among them, 67 patients (9.7%, n = 67/691) presented with brain-only MBC without concurrent ECM/LMD. Within this subgroup, 40 patients (5.8%, n = 40/691) remained free of any ECM or LMD, while 17 patients (2.5%) developed LMD, and 10 patients (1.4%%) developed ECM with a median follow-up of 8 months (IQR 2-35). Patients with brain-only MBC were more likely to have a single BrM [OR 3.41 (1.62-7.19), p = 0.001] and either HER2+ [OR 3.3 (1.13-9.65), p = 0.03] or TNBC [OR 4.09 (1.42-11.74), p = 0.009] subtypes. Patients who presented with brain-only MBC also had significantly longer OS [HR 0.45, (0.22-0.86), p = 0.008] and a trend toward longer bsPFS [HR 0.67 (0.44-1.03), p = 0.05] compared to those with concurrent ECM/LMD. CONCLUSION Patients with brain-only MBC had a longer bsPFS and OS than those with ECM. Patients with HER2+ and TNBC were more likely to have brain-only disease compared to those with HR+/HER2- MBC.
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Affiliation(s)
- Badr Id Said
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, Toronto, ON, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, Toronto, ON, Canada
| | | | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, Toronto, ON, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, Toronto, ON, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, Toronto, ON, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, Toronto, ON, Canada
| | - Ellen Warner
- Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada
| | - Katarzyna J Jerzak
- Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada.
- Department of Medicine, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada.
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Jabehdar Maralani P, Stewart J, Hiremath S, Lawrence L, Chan R, Lau A, Chen H, Chan A, Zeng LK, Tseng CL, Myrehaug S, Soliman H, Detsky J, Heyn C, Lim Fat M, Lipsman N, Sahgal A. Relationship between apparent diffusion coefficient and survival as a function of distance from gross tumor volume on radiation planning MRI in newly diagnosed glioblastoma. J Neurooncol 2023; 164:597-605. [PMID: 37707752 DOI: 10.1007/s11060-023-04440-1] [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: 07/12/2023] [Accepted: 08/26/2023] [Indexed: 09/15/2023]
Abstract
PURPOSE To investigate the changes in apparent diffusion coefficient (ADC) within incrementally-increased margins beyond the gross tumor volume (GTV) on post-operative radiation planning MRI and their prognostic utility in glioblastoma. METHODS Radiation planning MRIs of adult patients with newly diagnosed glioblastoma from 2017 to 2020 were assessed. The ADC values were normalized to contralateral normal white matter (nADC). Using 1 mm isotropic incremental margin increases from the GTV, the nADC values were calculated at each increment. Age, ECOG performance status, extent of resection and MGMT promoter methylation status were obtained from medical records. Using univariate and multivariable Cox regression analysis, association of nADC to progression-free and overall survival (PFS, OS) was assessed at each increment. RESULTS Seventy consecutive patients with mean age of 53.6 ± 10.3 years, were evaluated. The MGMT promoter was methylated in 31 (44.3%), unmethylated in 36 (51.6%) and unknown in 3 (4.3%) patients. 11 (16%) underwent biopsy, 41 (44%) subtotal resection and 18 (26%) gross total resection. For each 1 mm increase in distance from GTV, the nADC decreased by 0.16% (p < 0.0001). At 1-5 mm increment, the nADC was associated with OS (p < 0.01). From 6 to 11 mm increment the nADC was associated with OS with the p-value gradually increasing from 0.018 to 0.046. nADC was not associated with PFS. CONCLUSION The nADC values at 1-11 mm increments from the GTV margin were associated with OS. Future prospective multicenter studies are needed to validate the findings and to pave the way for the utilization of ADC for margin reduction in radiation planning.
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Affiliation(s)
- Pejman Jabehdar Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada.
| | - James Stewart
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Shivaprakash Hiremath
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Liam Lawrence
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Rachel Chan
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Angus Lau
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Aimee Chan
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Liang K Zeng
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Chinthaka Heyn
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - MaryJane Lim Fat
- Division of Neurology, Department of Medicine, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Nir Lipsman
- Division of Neurosurgery, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
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Viani GA, Gouveia AG, Pavoni JF, Louie AV, Detsky J, Spratt DE, Moraes FY. A Meta-analysis of the Efficacy and Safety of Stereotactic Arrhythmia Radioablation (STAR) in Patients with Refractory Ventricular Tachycardia. Clin Oncol (R Coll Radiol) 2023; 35:611-620. [PMID: 37365062 DOI: 10.1016/j.clon.2023.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 12/06/2022] [Revised: 03/24/2023] [Accepted: 04/19/2023] [Indexed: 06/28/2023]
Abstract
AIMS Reports of stereotactic arrhythmia radioablation (STAR) in patients with refractory ventricular tachycardia after catheter ablation are limited to small series. Here, we carried out a systematic review and meta-analysis of studies to better determine the efficacy and toxicity of STAR for ventricular tachycardia. MATERIALS AND METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) and the Meta-analyses Of Observational Studies in Epidemiology (MOOSE) guidelines, eligible studies were identified on Medline, Embase, Cochrane Library and the proceedings of annual meetings to 10 February 2023. Efficacy was defined as a ventricular tachycardia burden reduction >70% at 6 months; safety was defined as <10% of any grade ≥3 toxicity. RESULTS Seven observational studies with a total of 61 patients treated were included. At 6 months, the ventricular tachycardia burden reduction was 92% (95% confidence interval 85-100%) and use of fewer than two anti-arrhythmic drugs was seen in 85% (95% confidence interval 50-100). Six months after STAR, an 86% reduction (95% confidence interval 80-93) in the number of implantable cardioverter-defibrillator shocks was observed. The rates for improved, unchanged and decreased cardiac ejection fraction were 10%, 84% and 6%, respectively. Overall survival at 6 and 12 months was 89% (95% confidence interval 81-97) and 82% (95% confidence interval 65-98). The cardiac-specific survival at 6 months was 87%. Late grade 3 toxicity occurred in 2% (95% confidence interval 0-5%) with no grade 4-5 toxicity. CONCLUSION STAR demonstrated both satisfactory efficacy and safety for the management of refractory ventricular tachycardia and was also associated with a significant decline in anti-arrhythmic drugs consumption. These findings support the continued development of STAR as a treatment option.
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Affiliation(s)
- G A Viani
- Ribeirão Preto Medical School, Department of Medical Imaging, Hematology and Oncology of University of São Paulo (FMRP-USP), Ribeirão Preto, Brazil; Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil.
| | - A G Gouveia
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Radiation Oncology Department - Americas Oncologia, Rio de Janeiro, Brazil
| | - J F Pavoni
- Faculdade de Filosofia, Letras e Ciências Naturais, Universidade de São Paulo, Ribeirão Preto, Brazil
| | - A V Louie
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - J Detsky
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - D E Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, Cleveland, Ohio, USA
| | - F Y Moraes
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Department of Oncology - Division of Radiation Oncology, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
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28
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Moore-Palhares D, Chen H, Keith J, Wang M, Myrehaug S, Tseng CL, Detsky J, Perry J, Lim-Fat MJ, Heyn C, Maralani P, Lipsman N, Das S, Sahgal A, Soliman H. Correction to: Re-irradiation for recurrent high-grade glioma: an analysis of prognostic factors for survival and predictors of radiation necrosis. J Neurooncol 2023; 163:553. [PMID: 37378836 DOI: 10.1007/s11060-023-04364-w] [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: 06/29/2023]
Affiliation(s)
- Daniel Moore-Palhares
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Julia Keith
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Michael Wang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - James Perry
- Division of Neurology, Department of Medicine Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Mary Jane Lim-Fat
- Division of Neurology, Department of Medicine Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Chris Heyn
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Pejman Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Nir Lipsman
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Sunit Das
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.
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29
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Moore-Palhares D, Chen H, Keith J, Wang M, Myrehaug S, Tseng CL, Detsky J, Perry J, Lim-Fat MJ, Heyn C, Maralani P, Lipsman N, Das S, Sahgal A, Soliman H. Re-irradiation for recurrent high-grade glioma: an analysis of prognostic factors for survival and predictors of radiation necrosis. J Neurooncol 2023; 163:541-551. [PMID: 37256526 DOI: 10.1007/s11060-023-04340-4] [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: 04/02/2023] [Accepted: 05/11/2023] [Indexed: 06/01/2023]
Abstract
PURPOSE Recurrent high-grade glioma (rHGG) is a heterogeneous population, and the ideal patient selection for re-irradiation (re-RT) has yet to be established. This study aims to identify prognostic factors for rHGG patients treated with re-RT. METHODS We retrospectively reviewed consecutive adults with rHGG who underwent re-RT from 2009 to 2020 from our institutional database. The primary objective was overall survival (OS). Secondary endpoints included prognostic factors for early death (< 6 months after re-RT) and predictors of radiation necrosis (RN). RESULTS For the 79 patients identified, the median OS after re-RT was 9.9 months (95% CI 8.3-11.6). On multivariate analyses, re-resection at progression (HR 0.56, p = 0.027), interval from primary treatment to first progression ≥ 16.3 months (HR 0.61, p = 0.034), interval from primary treatment to re-RT ≥ 23.9 months (HR 0.35, p < 0.001), and re-RT PTV volume < 112 cc (HR 0.27, p < 0.001) were prognostic for improved OS. Patients who had unmethylated-MGMT tumours (OR 12.4, p = 0.034), ≥ 3 prior systemic treatment lines (OR 29.1, p = 0.022), interval to re-RT < 23.9 months (OR 9.0, p = 0.039), and re-RT PTV volume ≥ 112 cc (OR 17.8, p = 0.003) were more likely to die within 6 months of re-RT. The cumulative incidence of RN was 11.4% (95% CI 4.3-18.5) at 12 months. Concurrent bevacizumab use (HR < 0.001, p < 0.001) and cumulative equivalent dose in 2 Gy fractions (EQD2, α/β = 2) < 99 Gy2 (HR < 0.001, p < 0.001) were independent protective factors against RN. Re-RT allowed for less corticosteroid dependency. Sixty-six percent of failures after re-RT were in-field. CONCLUSION We observe favorable OS rates following re-RT and identified prognostic factors, including methylation status, that can assist in patient selection and clinical trial design. Concurrent use of bevacizumab mitigated the risk of RN.
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Affiliation(s)
- Daniel Moore-Palhares
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Julia Keith
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Michael Wang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - James Perry
- Division of Neurology, Department of Medicine Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Mary Jane Lim-Fat
- Division of Neurology, Department of Medicine Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Chris Heyn
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Pejman Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Nir Lipsman
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Sunit Das
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.
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Nguyen EK, Ruschin M, Zhang B, Soliman H, Myrehaug S, Detsky J, Chen H, Sahgal A, Tseng CL. Stereotactic body radiotherapy for spine metastases: a review of 24 Gy in 2 daily fractions. J Neurooncol 2023; 163:15-27. [PMID: 37155133 DOI: 10.1007/s11060-023-04327-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 03/29/2023] [Accepted: 04/24/2023] [Indexed: 05/10/2023]
Abstract
PURPOSE Stereotactic body radiotherapy (SBRT) has proven to be a highly effective treatment for selected patients with spinal metastases. Randomized evidence shows improvements in complete pain response rates and local control with lower retreatment rates favoring SBRT, compared to conventional external beam radiotherapy (cEBRT). While there are several reported dose-fractionation schemes for spine SBRT, 24 Gy in 2 fractions has emerged with Level 1 evidence providing an excellent balance between minimizing treatment toxicity while respecting patient convenience and financial strain. METHODS We provide an overview of the 24 Gy in 2 SBRT fraction regimen for spine metastases, which was developed at the University of Toronto and tested in an international Phase 2/3 randomized controlled trial. RESULTS The literature summarizing global experience with 24 Gy in 2 SBRT fractions suggests 1-year local control rates ranging from 83-93.9%, and 1-year rates of vertebral compression fracture ranging from 5.4-22%. Reirradiation of spine metastases that failed prior cEBRT is also feasible with 24 Gy in 2 fractions, and 1-year local control rates range from 72-86%. Post-operative spine SBRT data are limited but do support the use of 24 Gy in 2 fractions with reported 1-year local control rates ranging from 70-84%. Typically, the rates of plexopathy, radiculopathy and myositis are under 5% in those series reporting mature follow up, with no cases of radiation myelopathy (RM) reported in the de novo setting when the spinal cord avoidance structure is limited to 17 Gy in 2 fractions. However, re-irradiation RM has been observed following 2 fraction SBRT. More recently, 2-fraction dose escalation with 28 Gy, with a higher dose constraint to the critical neural tissues, has been reported suggesting improved rates of local control. This regimen may be important in those patients with radioresistant histologies, high grade epidural disease, and/or paraspinal disease. CONCLUSION The dose-fractionation of 24 Gy in 2 fractions is well-supported by published literature and is an ideal starting point for centers looking to establish a spine SBRT program.
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Affiliation(s)
- Eric K Nguyen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Beibei Zhang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
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Yan M, Lee M, Myrehaug S, Tseng CL, Detsky J, Chen H, Das S, Yeboah C, Lipsman N, Costa LD, Holden L, Heyn C, Maralani P, Ruschin M, Sahgal A, Soliman H. Hypofractionated stereotactic radiosurgery (HSRS) as a salvage treatment for brain metastases failing prior stereotactic radiosurgery (SRS). J Neurooncol 2023; 162:119-128. [PMID: 36914878 DOI: 10.1007/s11060-023-04265-y] [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: 01/20/2023] [Accepted: 02/09/2023] [Indexed: 03/14/2023]
Abstract
INTRODUCTION Various treatment options exist to salvage stereotactic radiosurgery (SRS) failures for brain metastases, including repeat SRS and hypofractionated SRS (HSRS). Our objective was to report outcomes specific to salvage HSRS for brain metastases that failed prior HSRS/SRS. METHODS Patients treated with HSRS to salvage local failures (LF) following initial HSRS/SRS, between July 2010 and April 2020, were retrospectively reviewed. The primary outcomes were the rates of LF, radiation necrosis (RN), and symptomatic radiation necrosis (SRN). Univariable (UVA) and multivariable (MVA) analyses using competing risk regression were performed to identify predictive factors for each endpoint. RESULTS 120 Metastases in 91 patients were identified. The median clinical follow up was 13.4 months (range 1.1-111.1), and the median interval between SRS courses was 13.1 months (range 3.0-56.5). 115 metastases were salvaged with 20-35 Gy in 5 fractions and the remaining five with a total dose ranging from 20 to 24 Gy in 3-fractions. 67 targets (56%) were postoperative cavities. The median re-treatment target volume and biological effective dose (BED10) was 9.5 cc and 37.5 Gy, respectively. The 6- and 12- month LF rates were 18.9% and 27.7%, for RN 13% and 15.6%, and for SRN were 6.1% and 7.0%, respectively. MVA identified larger re-irradiation volume (hazard ratio [HR] 1.02, p = 0.04) and shorter interval between radiosurgery courses (HR 0.93, p < 0.001) as predictors of LF. Treatment of an intact target was associated with a higher risk of RN (HR 2.29, p = 0.04). CONCLUSION Salvage HSRS results in high local control rates and toxicity rates that compare favorably to those single fraction SRS re-irradiation experiences reported in the literature.
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Affiliation(s)
- Michael Yan
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Minha Lee
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Sunit Das
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Collins Yeboah
- Department of Medical Physics, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Nir Lipsman
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Leodante Da Costa
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Lori Holden
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Chinthaka Heyn
- Division of Radiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Pejman Maralani
- Division of Radiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Mark Ruschin
- Department of Medical Physics, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada.
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Burgess L, Zeng KL, Myrehaug S, Soliman H, Tseng CL, Detsky J, Chen H, Moore-Palhares D, Witiw CD, Zhang B, Maralani P, Sahgal A. Stereotactic Body Radiotherapy for Posterior Element Only Spinal Metastases: A First Report on Outcomes and Validation of Recommended Clinical Target Volume Delineation Practice. Pract Radiat Oncol 2023:S1879-8500(23)00063-2. [PMID: 36997023 DOI: 10.1016/j.prro.2023.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/27/2023] [Accepted: 03/04/2023] [Indexed: 03/30/2023]
Abstract
PURPOSE Spine stereotactic body radiotherapy (SBRT) results in improved local control and pain response compared to conventional external beam radiotherapy. Consensus exists stipulating that MRI-based delineation of the clinical target volume (CTV) is critical and based on spine segment sector involvement. The applicability of contouring guidelines to metastases involving the posterior elements alone remains to be validated, and the purpose of this report was to determine the patterns of failure and safety of treating posterior element metastases when the vertebral body (VB) was intentionally excluded from the CTV. METHODS AND MATERIALS A retrospective review of a prospectively maintained database of 605 patients and 1412 spine segments treated with spine SBRT was performed. Only treated segments involving the posterior elements alone were included for the analyses. The primary outcome was local failure, as per SPINO recommendations, and secondary outcomes included patterns of failure, toxicities. RESULTS 24/605 patients and 31/1412 segments were treated to the posterior elements only. Local failure occurred in 11/31 segments. The cumulative rate of local recurrence was 9.7% at 12 months and 30.8% at 24 months. Amongst local failures, the most common histologies were renal cell carcinoma (36.4%) and non-small cell lung cancer (36.4%) and 73% had baseline paraspinal disease extension. 6/11 (54.5%) failed exclusively within treated CTV sectors and 5/11 (45.5%) with both treated and adjacent untreated sectors. Four of these 5 cases had recurrent disease extending into the VB, but no failure was observed exclusively within the VB. CONCLUSIONS Posterior element alone metastases are rare. Our analyses support SBRT consensus contouring guidelines such that the VB can be excluded from CTV in spinal metastases confined to the posterior elements.
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Yan M, Holden L, Detsky J, Tseng CL, Soliman H, Myrehaug S, Husain Z, Das S, Yeboah C, Lipsman N, Ruschin M, Sahgal A. Conventionally fully fractionated Gamma Knife Icon re-irradiation of primary recurrent intracranial tumors: the first report indicating feasibility and safety. J Neurosurg 2023; 138:674-682. [PMID: 35986735 DOI: 10.3171/2022.6.jns22998] [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: 05/07/2022] [Accepted: 06/17/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE With the incorporation of real-time image guidance on the Gamma Knife system allowing for mask-based immobilization (Gamma Knife Icon [GKI]), conventionally fully fractionated (1.8-3.0 Gy/day) GKI radiation can now be delivered to take advantage of an inherently minimal margin for delivery uncertainty, sharp dose falloff, and inhomogeneous dose distribution. This case series details the authors' preliminary experience in re-irradiating 7 complex primary intracranial tumors, which were considered to have been previously maximally radiated and situated adjacent to critical organs at risk. METHODS The authors retrospectively reviewed all patients who received fractionated re-irradiation using GKI at the Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada, between 2016 and 2021. Patients with brain metastases, and those who received radiotherapy courses in 5 or fewer fractions, were excluded. All radiotherapy doses were converted to the equivalent total dose in 2-Gy fractions (EQD2), with the assumption of an α/β ratio of 2 for late normal tissue toxicity and 10 for the tumor. RESULTS A total of 7 patients were included in this case series. Three patients had recurrent meningiomas, as well as 1 patient each with ependymoma, intracranial sarcoma, pituitary macroadenoma, and papillary pineal tumor. Six patients had undergone prior linear accelerator-based conventional fractionated radiotherapy and 1 patient had undergone prior proton therapy. Patients were re-irradiated with a median (range) total dose of 50.4 (30-63.4) Gy delivered in a median (range) of 28 (10-38) fractions with GKI. The median (range) target volume was 6.58 (0.2-46.3) cm3. The median (range) cumulative mean EQD2 administered to the tumor was 121.1 (107.9-181.3) Gy, and the median (range) maximum point EQD2 administered to the brainstem, optic nerves, and optic chiasm were 91.6 (74.0-111.5) Gy, 58.9 (6.3-102.9) Gy, and 59.9 (36.7-127.3) Gy, respectively. At a median (range) follow-up of 15 (6-42) months, 6 of 7 patients were alive with 4 having locally controlled disease. Only 3 patients experienced treatment-related toxicities, which were self-limited. CONCLUSIONS Fractionated radiotherapy using GKI may be a safe and effective method for the re-irradiation of complex progressive primary intracranial tumors, where the aim is to minimize the potential for serious late effects.
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Affiliation(s)
- Michael Yan
- 1Department of Radiation Oncology, Sunnybrook Health Sciences Centre
| | - Lori Holden
- 1Department of Radiation Oncology, Sunnybrook Health Sciences Centre
| | - Jay Detsky
- 1Department of Radiation Oncology, Sunnybrook Health Sciences Centre
| | - Chia-Lin Tseng
- 1Department of Radiation Oncology, Sunnybrook Health Sciences Centre
| | - Hany Soliman
- 1Department of Radiation Oncology, Sunnybrook Health Sciences Centre
| | - Sten Myrehaug
- 1Department of Radiation Oncology, Sunnybrook Health Sciences Centre
| | - Zain Husain
- 1Department of Radiation Oncology, Sunnybrook Health Sciences Centre
| | - Sunit Das
- 2Division of Neurosurgery, St. Michael's Hospital
| | - Collins Yeboah
- 3Department of Medical Physics, Sunnybrook Health Sciences Centre; and
| | - Nir Lipsman
- 4Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Mark Ruschin
- 3Department of Medical Physics, Sunnybrook Health Sciences Centre; and
| | - Arjun Sahgal
- 1Department of Radiation Oncology, Sunnybrook Health Sciences Centre
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Zeng KL, Abugarib A, Soliman H, Myrehaug S, Husain ZA, Detsky J, Ruschin M, Karotki A, Atenafu EG, Larouche J, Campbell M, Maralani P, Sahgal A, Tseng CL. Dose-Escalated 2-Fraction Spine Stereotactic Body Radiation Therapy: 28 Gy Versus 24 Gy in 2 Daily Fractions. Int J Radiat Oncol Biol Phys 2023; 115:686-695. [PMID: 36309076 DOI: 10.1016/j.ijrobp.2022.09.076] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 09/18/2022] [Accepted: 09/21/2022] [Indexed: 01/19/2023]
Abstract
PURPOSE Stereotactic body radiation therapy (SBRT) for spine metastases improves pain response rates compared with conventional external beam radiation therapy; however, the optimal fractionation schedule is unclear. We report local control and toxicity outcomes after dose-escalated 2-fraction spine SBRT. METHODS AND MATERIALS A prospectively maintained institutional database of over 600 patients and 1400 vertebral segments treated with spine SBRT was reviewed to identify those prescribed 28 or 24 Gy in 2 daily fractions. The primary endpoint was magnetic resonance imaging based local failure (LF), and secondary endpoints included overall survival and vertebral compression fracture (VCF). RESULTS A total of 947 treated vertebral segments in 482 patients were identified, of which 301 segments in 159 patients received 28 Gy, and 646 segments in 323 patients received 24 Gy in 2 fractions. Median follow-up per patient was 23.5 months, and median overall survival was 49.1 months. In the 28 Gy cohort, the 6-, 12-, and 24-month cumulative incidences of LF were 3.5%, 5.4%, and 11.1%, respectively, versus 6.0%, 12.5%, and 17.6% in the 24 Gy cohort, respectively (P = .008). On multivariable analysis, 24 Gy (hazard ratio [HR], 1.525; 95% confidence interval, 1.039-2.238; P = .031), paraspinal disease extension (HR, 1.422; 95% confidence interval, 1.010-2.002; P = .044), and epidural extension in either radioresistant or radiosensitive histologies (HR, 2.117 and 1.227, respectively; P = .003) were prognostic for higher rates of LF. Risk of VCF was 5.5%, 7.6%, and 10.7% at 6, 12, and 24 months, respectively, and was similar between cohorts (P = .573). Spinal malalignment (P < .001), baseline VCF (P = .003), junctional spine location (P = .030), and greater minimum dose to 90% of planning target volume were prognostic for higher rates of VCF. CONCLUSIONS Dose escalation to 28 Gy in 2 daily fractions was associated with improved local control without increasing the risk of VCF. The 2-year local control rates are consistent with those predicted by the Hypofractionated Treatment Effects in the Clinic spine tumor control probability model, and these data will inform a proposed dose escalation randomized trial.
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Affiliation(s)
- K Liang Zeng
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ahmed Abugarib
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Clinical Oncology Department, Sohag University Hospital, Sohag, Egypt
| | - Hany Soliman
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sten Myrehaug
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Zain A Husain
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jay Detsky
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Mark Ruschin
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Aliaksandr Karotki
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, Toronto, Ontario, Canada
| | - Jeremie Larouche
- Division of Orthopedic Surgery and Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Mikki Campbell
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Pejman Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Chia-Lin Tseng
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
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Ong WL, Cheung P, Chung HT, Chu W, Detsky J, Liu SK, Morton G, Szumacher E, Tseng CL, Vesprini D, Davidson M, Ravi A, McGuffin M, Zhang L, Mamedov A, Deabreu A, Poon M, Loblaw A. Two-fraction stereotactic MRI-guided ablative radiotherapy with simultaneous boost to dominant intraprostatic lesion: Results from the 2SMART phase 2 trial. J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.6_suppl.349] [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: 03/16/2023] Open
Abstract
349 Background: Prostate stereotactic ablative radiotherapy (SABR) for localised prostate cancer is commonly delivered over 5 fractions. Focal boost to the dominant intraprostatic lesion (DIL) seen on multiparametric magnetic resonance imaging (mpMRI) is an approach for dose-escalation in prostate SABR. This is the first report of the outcomes of the 2SMART trial, a phase 2 single-arm study using 2-fraction prostate SABR with DIL boost. Methods: Men with low to intermediate risk prostate cancer were enrolled in the study. Three gold fiducial markers were inserted for image guidance. The clinical target volume (CTV) included the prostate gland, and the planning target volume (PTV) was a 2mm expansion antero-posterior and laterally, and 2.5mm supero-inferiorly. The DIL was contoured on fused mpMRI. The prescribed dose was 26Gy in 2 fractions (EQD2 110Gy, α/β of 1.4) to the CTV, and up to 32Gy in 2 fractions (EQD2 164Gy) to the DIL as long as the dose constraints for the organs at risks were not exceeded. Each fraction was delivered 1 week apart. Daily image guidance with cone-beam computed tomography was used pre- and post-treatment. The primary endpoint was acute (≤3 months) changes in quality of life (QOL), assessed using the EPIC questionnaire. Minimal clinically important change (MCIC) in QOL was defined as an EPIC score decrease of >0.5 standard deviation of the baseline EPIC score for each domain. Secondary endpoints were acute and late toxicities (assessed using CTCAEv4), and biochemical failure (based on Phoenix criteria). Results: 30 men were enrolled in the study, of which 2 (7%) had low risk and 28 (93%) had intermediate risk prostate cancer. The median follow-up was 44 months (range: 39-49 months). The median PSA nadir was 0.2ng/mL, with median time to nadir of 37 months. One patient (3%) had biochemical failure at 44 months post-treatment. 1 (3%) and 17 (57%) had acute Grade 2 GU and GI toxicities, while 3 (10%) and 15 (50%) had late (>6 months) Grade 2 GU and GI toxicities. No acute or late Grade ≥3 GU or GI was reported. 10 (33%), 6 (20%), and 3 (10%) men had acute MCIC in urinary, bowel and sexual domains respectively. 15 (50%), 9 (30%) and 13 (43%) had late MCIC in urinary, bowel and sexual domain respectively. Conclusions: Two-fraction prostate SABR with DIL boost is a safe approach for dose-escalation for localised prostate cancer, with minimal impact on acute QOL, and no grade 3-4 toxicities. Clinical trial information: NCT03588819 .
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Affiliation(s)
- Wee Loon Ong
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Patrick Cheung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Hans T. Chung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - William Chu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jay Detsky
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Stanley K. Liu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Gerard Morton
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Ewa Szumacher
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Chia-Lin Tseng
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Danny Vesprini
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Melanie Davidson
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Merrylee McGuffin
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Liying Zhang
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Alexandre Mamedov
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Andrea Deabreu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Meghan Poon
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Andrew Loblaw
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Stewart J, Sahgal A, Zadeh MM, Moazen B, Jabehdar Maralani P, Breen S, Lau A, Binda S, Keller B, Husain Z, Myrehaug S, Detsky J, Soliman H, Tseng CL, Ruschin M. Empirical planning target volume modeling for high precision MRI guided intracranial radiotherapy. Clin Transl Radiat Oncol 2023; 39:100582. [PMID: 36699195 PMCID: PMC9869418 DOI: 10.1016/j.ctro.2023.100582] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
Purpose Magnetic resonance image-guided radiotherapy for intracranial indications is a promising advance; however, uncertainties remain for both target localization after translation-only MR setup and intrafraction motion. This investigation quantified these uncertainties and developed a population-based planning target volume (PTV) model to explore target and organ-at-risk (OAR) volumetric coverage tradeoffs. Methods Sixty-six patients, 49 with a primary brain tumor and 17 with a post-surgical resection cavity, treated on a 1.5T-based MR-linac across 1329 fractions were included. At each fraction, patients were setup by translation-only fusion of the online T1 MRI to the planning image. Each fusion was independently repeated offline accounting for rotations. The six degree-of-freedom difference between fusions was applied to transform the planning CTV at each fraction (CTVfx). A PTV model parameterized by volumetric CTVfx coverage, proportion of fractions, and proportion of patients was developed. Intrafraction motion was quantified in a 412 fraction subset as the fusion difference between post- and pre-irradiation T1 MRIs. Results For the left-right/anterior-posterior/superior-inferior axes, mean ± SD of the rotational fusion differences were 0.1 ± 0.8/0.1 ± 0.8/-0.2 ± 0.9°. Covering 98 % of the CTVfx in 95 % of fractions in 95 % of patients required a 3 mm PTV margin. Margin reduction decreased PTV-OAR overlap; for example, the proportion of optic chiasm overlapped by the PTV was reduced up to 23.5 % by margin reduction from 4 mm to 3 mm. Conclusions An evidence-based PTV model was developed for brain cancer patients treated on the MR-linac. Informed by this model, we have clinically adopted a 3 mm PTV margin for conventionally fractionated intracranial patients.
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Affiliation(s)
- James Stewart
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Mahtab M. Zadeh
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Bahareh Moazen
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Pejman Jabehdar Maralani
- Department of Medical Imaging, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Stephen Breen
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
- Department of Medical Physics, Sunnybrook Odette Cancer Centre, Toronto, Canada
| | - Angus Lau
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Shawn Binda
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
| | - Brian Keller
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
- Department of Medical Physics, Sunnybrook Odette Cancer Centre, Toronto, Canada
| | - Zain Husain
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
- Department of Medical Physics, Sunnybrook Odette Cancer Centre, Toronto, Canada
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Corresponding author at: Department of Medical Physics, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada.
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Singnurkar A, Poon R, Detsky J. 18F-FET-PET imaging in high-grade gliomas and brain metastases: a systematic review and meta-analysis. J Neurooncol 2023; 161:1-12. [PMID: 36502457 DOI: 10.1007/s11060-022-04201-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 10/17/2022] [Accepted: 11/16/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE To provide a summary of the diagnostic performance of 18F-FET-PET in the management of patients with high-grade brain gliomas or metastases from extracranial primary malignancies. METHODS MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews databases were searched for studies that reported on diagnostic test parameters in radiotherapy planning, response assessment, and tumour recurrence/treatment-related changes differentiation. Radiomic studies were excluded. Quality assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool and the GRADE approach. A bivariate, random-effects model was used to produce summary estimates of sensitivity and specificity. RESULTS Twenty-six studies with a total of 1206 patients/lesions were included in the analysis. For radiotherapy planning of glioma, the pooled proportion of patients from 3 studies with 18F-FET uptake extending beyond the 20 mm margin from the gadolinium enhancement on standard MRI was 39% (95% CI, 10-73%). In 3 studies, 18F-FET-PET was also shown to be predictive of early responders to treatment, whereas MRI failed to show any prognostic value. For the differentiation of glioma recurrence from treatment-related changes, the pooled sensitivity and specificity of TBRmax 1.9-2.3 from 6 studies were 91% (95% CI, 74-97%) and 84% (95% CI, 69-93%), respectively. The respective values for brain metastases from 4 studies were 82% (95% CI, 74-88%) and 82% (95% CI, 74-88%) using TBRmax 2.15-3.11. CONCLUSION While 18F-FET shows promise as a complementary modality to standard-of-care MRI for the management of primary and metastatic brain malignancies, further validation with standardized image interpretation methods in well-designed prospective studies are warranted.
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Affiliation(s)
- Amit Singnurkar
- Department of Medical Imaging, University of Toronto Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Raymond Poon
- Program in Evidence-Based Care, Ontario Health (Cancer Care Ontario), Department of Oncology, McMaster University McMaster University, Hamilton, ON, Canada. .,Program in Evidence-Based Care, Ontario Health (Cancer Care Ontario), Juravinski Hospital and Cancer Centre, G Wing, 2nd Floor, 711 Concession Street, Hamilton, ON, L8V 1C3, Canada.
| | - Jay Detsky
- Department of Radiation Oncology, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Canada
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Tseng CL, Chen H, Stewart J, Lau AZ, Chan RW, Lawrence LSP, Myrehaug S, Soliman H, Detsky J, Lim-Fat MJ, Lipsman N, Das S, Heyn C, Maralani PJ, Binda S, Perry J, Keller B, Stanisz GJ, Ruschin M, Sahgal A. High grade glioma radiation therapy on a high field 1.5 Tesla MR-Linac - workflow and initial experience with daily adapt-to-position (ATP) MR guidance: A first report. Front Oncol 2022; 12:1060098. [PMID: 36518316 PMCID: PMC9742425 DOI: 10.3389/fonc.2022.1060098] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [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: 10/02/2022] [Accepted: 11/10/2022] [Indexed: 07/30/2023] Open
Abstract
PURPOSE This study reports the workflow and initial clinical experience of high grade glioma (HGG) radiotherapy on the 1.5 T MR-Linac (MRL), with a focus on the temporal variations of the tumor and feasibility of multi-parametric image (mpMRI) acquisition during routine treatment workflow. MATERIALS AND METHODS Ten HGG patients treated with radiation within the first year of the MRL's clinical operation, between October 2019 and August 2020, were identified from a prospective database. Workflow timings were recorded and online adaptive plans were generated using the Adapt-To-Position (ATP) workflow. Temporal variation within the FLAIR hyperintense region (FHR) was assessed by the relative FHR volumes (n = 281 contours) and migration distances (maximum linear displacement of the volume). Research mpMRIs were acquired on the MRL during radiation and changes in selected functional parameters were investigated within the FHR. RESULTS All patients completed radiotherapy to a median dose of 60 Gy (range, 54-60 Gy) in 30 fractions (range, 30-33), receiving a total of 287 fractions on the MRL. The mean in-room time per fraction with or without post-beam research imaging was 42.9 minutes (range, 25.0-69.0 minutes) and 37.3 minutes (range, 24.0-51.0 minutes), respectively. Three patients (30%) required re-planning between fractions 9 to 12 due to progression of tumor and/or edema identified on daily MRL imaging. At the 10, 20, and 30-day post-first fraction time points 3, 3, and 4 patients, respectively, had a FHR volume that changed by at least 20% relative to the first fraction. Research mpMRIs were successfully acquired on the MRL. The median apparent diffusion coefficient (ADC) within the FHR and the volumes of FLAIR were significantly correlated when data from all patients and time points were pooled (R=0.68, p<.001). CONCLUSION We report the first clinical series of HGG patients treated with radiotherapy on the MRL. The ATP workflow and treatment times were clinically acceptable, and daily online MRL imaging triggered adaptive re-planning for selected patients. Acquisition of mpMRIs was feasible on the MRL during routine treatment workflow. Prospective clinical outcomes data is anticipated from the ongoing UNITED phase 2 trial to further refine the role of MR-guided adaptive radiotherapy.
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Affiliation(s)
- Chia-Lin Tseng
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - James Stewart
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Angus Z. Lau
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, ON, Canada
- Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Rachel W. Chan
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, ON, Canada
| | | | - Sten Myrehaug
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Mary Jane Lim-Fat
- Department of Medicine, Division of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Nir Lipsman
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Sunit Das
- Division of Neurosurgery, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
| | - Chinthaka Heyn
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Pejman J. Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Shawn Binda
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - James Perry
- Department of Medicine, Division of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Brian Keller
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Greg J. Stanisz
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, ON, Canada
- Medical Biophysics, University of Toronto, Toronto, ON, Canada
- Department of Neurosurgery and Paediatric Neurosurgery, Medical University, Lublin, Poland
| | - Mark Ruschin
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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Bennett J, Nobre L, Sheth J, Ryall S, Fang K, Johnson M, Negm L, Chung J, Komosa M, Nunes N, Lim-Fat MJ, Perry J, Sahgal A, Detsky J, Bouffet E, Hazrati LN, Dirks P, Ertl-Wagner B, Kongkham P, Zadeh G, Mason W, Cusimano M, Das S, Gao A, Tsang D, Nguyen L, Laperriere N, Keith J, Munoz D, Tabori U, Hawkins C. EPID-25. THE CLINICAL AND MOLECULAR LANDSCAPE OF GLIOMAS IN ADOLESCENTS AND YOUNG ADULTS. Neuro Oncol 2022. [DOI: 10.1093/neuonc/noac209.435] [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: 11/16/2022] Open
Abstract
Abstract
OBJECTIVE
Gliomas in adolescents and young adults (AYA) are commonly treated with a standard chemo-radiation approach. Molecular alterations have not been comprehensively described to date.
METHODS
We compiled a multi-institutional cohort of patients diagnosed with glioma between 15-39.9 years over 20 years. Molecular analysis, therapeutic data and outcome was collected. For specific alterations, analysis included patients aged 0-39.9 years.
RESULTS
A total of 1900 patients with 876 AYA gliomas were included. Ongoing analysis reveals genetic alterations in 95% of available tumours. IDH p.R132H was found in 49% of tumours, while non-canonical IDH mutations were found in 7%. Paediatric-type mutations were found in 33% of AYA tumours with IDH-WT GBM accounting for the remaining 11%. The most common paediatric alterations in AYAs included BRAF p.V600E (11%) and FGFR alterations (7%) while BRAF fusions, H3 p.K27M and H3.3 p.G34R were rarely observed (4%, 4% and 1% respectively). BRAF fused tumours with non-canonical binding partners were enriched in AYAs. Analysis of BRAF-V600E gliomas between ages 0-40 revealed increased tendency for malignant tumours in patients > 20 years suggesting malignant transformation possibly due to higher rate of secondary hits. This resulted in worse overall-survival for AYA patients with BRAF-V600E glioma when compared to children under 20 years (p=0.0032). Ten-year OS of 100%, 90% and 95% was seen for BRAF fused, BRAF-V600E and FGFR-altered AYA low grade glioma respectively, compared to 14% and 25% for BRAF-V600E and FGFR-altered high grade glioma. In contrast, continuous decline was observed in the IDH-mutant gliomas with 10-year OS of 50% which declined to 29% at 15 years.
CONCLUSIONS
Gliomas in AYA often have non-canonical alterations that may evade standard molecular analysis. They are enriched for paediatric-type alterations with distinct molecularly-based outcomes. These tumours may respond to targeted inhibitors and would benefit from comprehensive diagnostic and therapeutic approaches.
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Affiliation(s)
- Julie Bennett
- Hospital for Sick Children, Toronto , Ontario , Canada
| | - Liana Nobre
- Hospital for Sick Children, Toronto , Ontario , Canada
| | - Javal Sheth
- Hospital for Sick Children, University of Toronto , Toronto , Canada
| | - Scott Ryall
- Hospital for Sick Children , Toronto , Canada
| | - Karen Fang
- The Hospital for Sick Children , Toronto , USA
| | | | - Logine Negm
- Hospital for Sick Children, Toronto , Ontario , Canada
| | - Jiil Chung
- Hospital for Sick Children, Toronto , Ontario , Canada
| | | | - Nuno Nunes
- The Hospital for Sick Children , Toronto , Canada
| | - Mary Jane Lim-Fat
- Sunnybrook Health Sciences Centre, University of Toronto , Toronto , Canada
| | | | - Arjun Sahgal
- Sunnybrook Health Sciences Centre , Toronto , Canada
| | - Jay Detsky
- Sunnybrook Health Sciences Centre , Toronto , Canada
| | - Eric Bouffet
- Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada , Toronto , Canada
| | | | - Peter Dirks
- Department of Developmental and Stem Cell Biology, Hospital for Sick Children, Toronto, ON, Canada, Toronto , Ontario , Canada
| | | | | | - Gelareh Zadeh
- Princess Margaret Cancer Center and MacFeeters-Hamilton Center for Neuro-Oncology Research, University Health Network, Wilkins Family Chair in Brain Tumor Research , Toronto , Canada
| | - Warren Mason
- The Princess Margaret Cancer Center , Toronto , Canada
| | | | - Sunit Das
- Unity Health Toronto, Toronto , Ontario , Canada
| | | | - Derek Tsang
- Department of Radiation Oncology, University of Toronto, Toronto , Ontario , Canada
| | - Lananh Nguyen
- Department of Lab Medicine and Pathology, Unity Health Toronto, Toronto , Ontario , Canada
| | | | - Julia Keith
- Department of Anatomical Pathology, Sunnybrook Health Sciences Centre, Toronto , Ontario , Canada
| | | | - Uri Tabori
- Hospital for Sick Children , Toronto , Canada
| | - Cynthia Hawkins
- Hospital for Sick Children, University of Toronto , Toronto , USA
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Palhares D, Chen H, Wang M, Myrehaug S, Detsky J, Tseng C, Husain Z, Perry J, Lim-Fat M, Lipsman N, Das S, Keith J, Sahgal A, Soliman H. Predictive Factors for Survival and Radiation Necrosis in Patients with Recurrent High-Grade Glioma Treated with Re-Irradiation. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.843] [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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41
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Oglesby RT, Lam WW, Ruschin M, Holden L, Sarfehnia A, Yeboah C, Sahgal A, Soliman H, Detsky J, Tseng CL, Myrehaug S, Husain Z, Lau AZ, Stanisz GJ, Chugh BP. Skull phantom-based methodology to validate MRI co-registration accuracy for Gamma Knife radiosurgery. Med Phys 2022; 49:7071-7084. [PMID: 35842918 DOI: 10.1002/mp.15851] [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: 03/21/2022] [Revised: 05/09/2022] [Accepted: 06/28/2022] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Target localization, for stereotactic radiosurgery (SRS) treatment with Gamma Knife, has become increasingly reliant on the co-registration between the planning MRI and the stereotactic cone-beam computed tomography (CBCT). Validating image registration between modalities would be particularly beneficial when considering the emergence of novel functional and metabolic MRI pulse sequences for target delineation. This study aimed to develop a phantom-based methodology to quantitatively compare the co-registration accuracy of the standard clinical imaging protocol to a representative MRI sequence that was likely to fail co-registration. The comparative methodology presented in this study may serve as a useful tool to evaluate the clinical translatability of novel MRI sequences. METHODS A realistic human skull phantom with fiducial marker columns was designed and manufactured to fit into a typical MRI head coil and the Gamma Knife patient positioning system. A series of "optimized" 3D MRI sequences-T1 -weighted Dixon, T1 -weighted fast field echo (FFE), and T2 -weighted fluid-attenuated inversion recovery (FLAIR)-were acquired and co-registered to the CBCT. The same sequences were "compromised" by reconstructing without geometric distortion correction and re-collecting with lower signal-to-noise-ratio (SNR) to simulate a novel MRI sequence with poor co-registration accuracy. Image similarity metrics-structural similarity (SSIM) index, mean squared error (MSE), and peak SNR (PSNR)-were used to quantitatively compare the co-registration of the optimized and compromised MR images. RESULTS The ground truth fiducial positions were compared to positions measured from each optimized image volume revealing a maximum median geometric uncertainty of 0.39 mm (LR), 0.92 mm (AP), and 0.13 mm (SI) between the CT and CBCT, 0.60 mm (LR), 0.36 mm (AP), and 0.07 mm (SI) between the CT and T1 -weighted Dixon, 0.42 mm (LR), 0.23 mm (AP), and 0.08 mm (SI) between the CT and T1 -weighted FFE, and 0.45 mm (LR), 0.19 mm (AP), and 1.04 mm (SI) between the CT and T2 -weighted FLAIR. Qualitatively, pairs of optimized and compromised image slices were compared using a fusion image where separable colors were used to differentiate between images. Quantitatively, MSE was the most predictive and SSIM the second most predictive metric for evaluating co-registration similarity. A clinically relevant threshold of MSE, SSIM, and/or PSNR may be defined beyond which point an MRI sequence should be rejected for target delineation based on its dissimilarity to an optimized sequence co-registration. All dissimilarity thresholds calculated using correlation coefficients with in-plane geometric uncertainty would need to be defined on a sequence-by-sequence basis and validated with patient data. CONCLUSION This study utilized a realistic skull phantom and image similarity metrics to develop a methodology capable of quantitatively assessing whether a modern research-based MRI sequence can be co-registered to the Gamma Knife CBCT with equal or less than equal accuracy when compared to a clinically accepted protocol.
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Affiliation(s)
- Ryan T Oglesby
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Wilfred W Lam
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Mark Ruschin
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Lori Holden
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Arman Sarfehnia
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Department of Physics, Ryerson University, Toronto, Ontario, Canada
| | - Collins Yeboah
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Hany Soliman
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Jay Detsky
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Chia-Lin Tseng
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Sten Myrehaug
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Zain Husain
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Angus Z Lau
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Greg J Stanisz
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Neurosurgery and Paediatric Neurosurgery, Medical University of Lublin, Lublin, Poland.,Department of Physics, Ryerson University, Toronto, Ontario, Canada
| | - Brige P Chugh
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Department of Physics, Ryerson University, Toronto, Ontario, Canada
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Zeng K, Abugarib A, Soliman H, Myrehaug S, Husain Z, Detsky J, Ruschin M, Karotki A, Atenafu E, Maralani P, Sahgal A, Tseng C. Dose-Escalated Two-Fraction Spine Stereotactic Body Radiotherapy: 28 Gy vs. 24 Gy in 2 Daily Fractions. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.663] [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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43
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Hudson J, Stewart J, Zeng K, Chen H, Ruschin M, Soliman H, Tseng C, Myrehaug S, Husain Z, Sahgal A, Detsky J. Impact of MGMT Promoter Methylation Status on Tumor Dynamics during Weekly Adaptive Radiotherapy for Glioblastoma. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.448] [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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Zeng K, Myrehaug S, Soliman H, Husain Z, Tseng C, Detsky J, Ruschin M, Atenafu E, Witiw C, Larouche J, da Costa L, Maralani P, Parulekar W, Sahgal A. Mature Local Control and Reirradiation Rates Comparing Spine Stereotactic Body Radiotherapy to Conventional Palliative External Beam Radiotherapy. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.345] [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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Mehrabian H, Chan RW, Sahgal A, Chen H, Theriault A, Lam WW, Myrehaug S, Tseng CL, Husain Z, Detsky J, Soliman H, Stanisz GJ. Chemical Exchange Saturation Transfer MRI for Differentiating Radiation Necrosis From Tumor Progression in Brain Metastasis-Application in a Clinical Setting. J Magn Reson Imaging 2022; 57:1713-1725. [PMID: 36219521 DOI: 10.1002/jmri.28440] [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: 07/15/2022] [Revised: 09/07/2022] [Accepted: 09/08/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND High radiation doses of stereotactic radiosurgery (SRS) for brain metastases (BM) can increase the likelihood of radiation necrosis (RN). Advanced MRI sequences can improve the differentiation between RN and tumor progression (TP). PURPOSE To use saturation transfer MRI methods including chemical exchange saturation transfer (CEST) and magnetization transfer (MT) to distinguish RN from TP. STUDY TYPE Prospective cohort study. SUBJECTS Seventy patients (median age 60; 73% females) with BM (75 lesions) post-SRS. FIELD STRENGTH/SEQUENCE 3-T, CEST imaging using low/high-power (saturation B1 = 0.52 and 2.0 μT), quantitative MT imaging using B1 = 1.5, 3.0, and 5.0 μT, WAter Saturation Shift Referencing (WASSR), WAter Shift And B1 (WASABI), T1 , and T2 mapping. All used gradient echoes except T2 mapping (gradient and spin echo). ASSESSMENT Voxel-wise metrics included: magnetization transfer ratio (MTR); apparent exchange-dependent relaxation (AREX); MTR asymmetry; normalized MT exchange rate and pool size product; direct water saturation peak width; and the observed T1 and T2 . Regions of interests (ROIs) were manually contoured on the post-Gd T1 w. The mean (of median ROI values) was compared between groups. Clinical outcomes were determined by clinical and radiologic follow-up or histopathology. STATISTICAL TESTS t-Test, univariable and multivariable logistic regression, receiver operating characteristic, and area under the curve (AUC) with sensitivity/specificity values with the optimal cut point using the Youden index, Akaike information criterion (AIC), Cohen's d. P < 0.05 with Bonferroni correction was considered significant. RESULTS Seven metrics showed significant differences between RN and TP. The high-power MTR showed the highest AUC of 0.88, followed by low-power MTR (AUC = 0.87). The combination of low-power CEST scans improved the separation compared to individual parameters (with an AIC of 70.3 for low-power MTR/AREX). Cohen's d effect size showed that the MTR provided the largest effect sizes among all metrics. DATA CONCLUSION Significant differences between RN and TP were observed based on saturation transfer MRI. EVIDENCE LEVEL 3 Technical Efficacy: Stage 2.
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Affiliation(s)
- Hatef Mehrabian
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Rachel W Chan
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Aimee Theriault
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Wilfred W Lam
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Zain Husain
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Greg J Stanisz
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, Lublin, Poland
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Jabehdar Maralani P, Chen H, Moazen B, Mojtahed Zadeh M, Salehi F, Chan A, Zeng LK, Abugharib A, Tseng CL, Husain Z, Myrehaug S, Soliman H, Detsky J, Heyn C, Ruschin M, Larouche J, Sahgal A. Proposing a quantitative MRI-based linear measurement framework for response assessment following stereotactic body radiation therapy in patients with spinal metastasis. J Neurooncol 2022; 160:265-272. [PMID: 36203028 DOI: 10.1007/s11060-022-04152-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 08/13/2022] [Accepted: 09/28/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE To provide evidence towards a quantitative response assessment framework incorporating MRI-based linear measurements for spinal metastasis that predicts outcome following stereotactic body radiation therapy (SBRT). METHODS Adult patients with de novo spinal metastases treated with SBRT between 2008 and 2018 were retrospectively assessed. The metastatic lesions involving the pedicles, articular processes, lamina, transverse process, spinous process and vertebral body at leach level were measured separately using linear measurements on pre- and all post-SBRT MRIs. The outcome was segment-specific progression (SSP) using SPINO guidelines which was dated to the first clinical documentation of progression, or the date of the associated MRI if imaging was the reason for progression. Random forest analysis for variable selection and recursive partitioning analysis for SSP probability prediction were used. RESULTS Five Hundred Ninety-three spinal levels (323 patients) from 4081 MRIs were evaluated. The appearance of new T1 hypointensity and increase in Bilsky grade had an odds ratio (OR) of 33.5 and 15.5 for SSP, respectively. Compared to baseline, an increase of > 3 mm in any lesion dimension, combined with a 1.67-fold increase in area, had an OR of 4.6 for SSP. The sensitivity, specificity, positive predictive value, negative predictive value, balanced accuracy and area under the curve of the training model were 96.7%, 89.6%, 28.6%, 99.8%, 93.2% and 0.905 and of the test model were 91.3%, 89.3%, 27.1% 99.6%, 90.3% and 0.933, respectively. CONCLUSION With further refinement and validation in prospective multicentre studies, MRI-based linear measurements can help predict response assessment in SBRT-treated spinal metastases.
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Affiliation(s)
- Pejman Jabehdar Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, AG270c, Toronto, ON, M4N 3M5, Canada.
| | - Hanbo Chen
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Bahareh Moazen
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, AG270c, Toronto, ON, M4N 3M5, Canada
| | - Mahtab Mojtahed Zadeh
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, AG270c, Toronto, ON, M4N 3M5, Canada
| | - Fateme Salehi
- Department of Radiology, McMaster University, Hamilton, Canada
| | - Aimee Chan
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, AG270c, Toronto, ON, M4N 3M5, Canada
| | - Liang K Zeng
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Ahmed Abugharib
- Department of Clinical Oncology, Sohag University Hospital, Sohag, Egypt
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Zain Husain
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Chinthaka Heyn
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, AG270c, Toronto, ON, M4N 3M5, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Jeremie Larouche
- Division of Orthopedic Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
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47
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Abstract
Glioblastoma is the most aggressive primary brain tumor with a poor prognosis. The 2021 WHO CNS5 classification has further stressed the importance of molecular signatures in diagnosis although therapeutic breakthroughs are still lacking. In this review article, updates on the current and novel therapies in IDH-wildtype GBM will be discussed.
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Affiliation(s)
- Jawad M Melhem
- Division of Neurology, Department of Medicine, Faculty of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Mary Jane Lim-Fat
- Division of Neurology, Department of Medicine, Faculty of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - James R Perry
- Division of Neurology, Department of Medicine, Faculty of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada.
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48
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Lim-Fat MJ, Macdonald M, Lapointe S, Climans SA, Cacciotti C, Chahal M, Perreault S, Tsang DS, Gao A, Yip S, Keith J, Bennett J, Ramaswamy V, Detsky J, Tabori U, Das S, Hawkins C. Molecular testing for adolescent and young adult central nervous system tumors: A Canadian guideline. Front Oncol 2022; 12:960509. [PMID: 36249063 PMCID: PMC9559579 DOI: 10.3389/fonc.2022.960509] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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] [Received: 06/03/2022] [Accepted: 08/19/2022] [Indexed: 11/25/2022] Open
Abstract
The 2021 World Health Organization (WHO) classification of CNS tumors incorporates molecular signatures with histology and has highlighted differences across pediatric vs adult-type CNS tumors. However, adolescent and young adults (AYA; aged 15–39), can suffer from tumors across this spectrum and is a recognized orphan population that requires multidisciplinary, specialized care, and often through a transition phase. To advocate for a uniform testing strategy in AYAs, pediatric and adult specialists from neuro-oncology, radiation oncology, neuropathology, and neurosurgery helped develop this review and testing framework through the Canadian AYA Neuro-Oncology Consortium. We propose a comprehensive approach to molecular testing in this unique population, based on the recent tumor classification and within the clinical framework of the provincial health care systems in Canada.
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Affiliation(s)
- Mary Jane Lim-Fat
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- *Correspondence: Mary Jane Lim-Fat,
| | - Maria Macdonald
- Department of Oncology, London Health Sciences Centre, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Sarah Lapointe
- Division of Neurology, Department of Medicine, Centre Hospitalier de l'Universite de Montreal, Montreal, QC, Canada
| | - Seth Andrew Climans
- Department of Oncology, London Health Sciences Centre, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Chantel Cacciotti
- Department of Paediatrics, Division of Pediatric Hematology/Oncology, London Health Sciences Centre, London, ON, Canada
| | - Manik Chahal
- Department of Medical Oncology, BC Cancer Vancouver Centre, Vancouver, BC, Canada
| | - Sebastien Perreault
- Department of Pediatrics, Division of Child Neurology, CHU Sainte-Justine, Montreal, QC, Canada
| | - Derek S. Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Andrew Gao
- Department of Laboratory Medicine and Pathobiology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Stephen Yip
- Department of Pathology & Laboratory Medicine, Faculty of Medicine, University of British Columbia, BC, Canada
| | - Julia Keith
- Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada
| | - Julie Bennett
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto ON, Canada
| | - Vijay Ramaswamy
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto ON, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada
| | - Uri Tabori
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto ON, Canada
| | - Sunit Das
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Cynthia Hawkins
- Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto ON, Canada
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49
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Palhares D, Chen H, Wang M, Myrehaug S, Detsky J, Tseng CLE, Husain Z, Lim-fat MJ, Lipsman N, Das S, Keith J, Sahgal A, Soliman H. 43: Predictive Factors for Survival and Radiation Necrosis in Patients with Recurrent High-Grade Glioma Treated with Re-Irradiation. Radiother Oncol 2022. [DOI: 10.1016/s0167-8140(22)04322-5] [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: 11/15/2022]
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50
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Hudson JM, Stewart J, Zeng KL, Chen H, Ruschin M, Soliman H, Myrehaug S, Husain Z, Sahgal A, Detsky J. 2: Impact of MGMT Promoter Methylation Status on Tumour Dynamics During Weekly Adaptive Radiotherapy for Glioblastoma. Radiother Oncol 2022. [DOI: 10.1016/s0167-8140(22)04281-5] [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: 11/25/2022]
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