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Staplin N, Haynes R, Judge PK, Wanner C, Green JB, Emberson J, Preiss D, Mayne KJ, Ng SYA, Sammons E, Zhu D, Hill M, Stevens W, Wallendszus K, Brenner S, Cheung AK, Liu ZH, Li J, Hooi LS, Liu WJ, Kadowaki T, Nangaku M, Levin A, Cherney D, Maggioni AP, Pontremoli R, Deo R, Goto S, Rossello X, Tuttle KR, Steubl D, Petrini M, Seidi S, Landray MJ, Baigent C, Herrington WG, Abat S, Abd Rahman R, Abdul Cader R, Abdul Hafidz MI, Abdul Wahab MZ, Abdullah NK, Abdul-Samad T, Abe M, Abraham N, Acheampong S, Achiri P, Acosta JA, Adeleke A, Adell V, Adewuyi-Dalton R, Adnan N, Africano A, Agharazii M, Aguilar F, Aguilera A, Ahmad M, Ahmad MK, Ahmad NA, Ahmad NH, Ahmad NI, Ahmad Miswan N, Ahmad Rosdi H, Ahmed I, Ahmed S, Ahmed S, Aiello J, Aitken A, AitSadi R, Aker S, Akimoto S, Akinfolarin A, Akram S, Alberici F, Albert C, Aldrich L, Alegata M, Alexander L, Alfaress S, Alhadj Ali M, Ali A, Ali A, Alicic R, Aliu A, Almaraz R, Almasarwah R, Almeida J, Aloisi A, Al-Rabadi L, Alscher D, Alvarez P, Al-Zeer B, Amat M, Ambrose C, Ammar H, An Y, Andriaccio L, Ansu K, Apostolidi A, Arai N, Araki H, Araki S, Arbi A, Arechiga O, Armstrong S, Arnold T, Aronoff S, Arriaga W, Arroyo J, Arteaga D, Asahara S, Asai A, Asai N, Asano S, Asawa M, Asmee MF, Aucella F, Augustin M, Avery A, Awad A, Awang IY, Awazawa M, Axler A, Ayub W, Azhari Z, Baccaro R, Badin C, Bagwell B, Bahlmann-Kroll E, Bahtar AZ, Baigent C, Bains D, Bajaj H, Baker R, Baldini E, Banas B, Banerjee D, Banno S, Bansal S, Barberi S, Barnes S, Barnini C, Barot C, Barrett K, Barrios R, Bartolomei Mecatti B, Barton I, Barton J, Basily W, Bavanandan S, Baxter A, Becker L, Beddhu S, Beige J, Beigh S, Bell S, Benck U, Beneat A, Bennett A, Bennett D, Benyon S, Berdeprado J, Bergler T, Bergner A, Berry M, Bevilacqua M, Bhairoo J, Bhandari S, Bhandary N, Bhatt A, Bhattarai M, Bhavsar M, Bian W, Bianchini F, Bianco S, Bilous R, Bilton J, Bilucaglia D, Bird C, Birudaraju D, Biscoveanu M, Blake C, Bleakley N, Bocchicchia K, Bodine S, Bodington R, Boedecker S, Bolduc M, Bolton S, Bond C, Boreky F, Boren K, Bouchi R, Bough L, Bovan D, Bowler C, Bowman L, Brar N, Braun C, Breach A, Breitenfeldt M, Brenner S, Brettschneider B, Brewer A, Brewer G, Brindle V, Brioni E, Brown C, Brown H, Brown L, Brown R, Brown S, Browne D, Bruce K, Brueckmann M, Brunskill N, Bryant M, Brzoska M, Bu Y, Buckman C, Budoff M, Bullen M, Burke A, Burnette S, Burston C, Busch M, Bushnell J, Butler S, Büttner C, Byrne C, Caamano A, Cadorna J, Cafiero C, Cagle M, Cai J, Calabrese K, Calvi C, Camilleri B, Camp S, Campbell D, Campbell R, Cao H, Capelli I, Caple M, Caplin B, Cardone A, Carle J, Carnall V, Caroppo M, Carr S, Carraro G, Carson M, Casares P, Castillo C, Castro C, Caudill B, Cejka V, Ceseri M, Cham L, Chamberlain A, Chambers J, Chan CBT, Chan JYM, Chan YC, Chang E, Chang E, Chant T, Chavagnon T, Chellamuthu P, Chen F, Chen J, Chen P, Chen TM, Chen Y, Chen Y, Cheng C, Cheng H, Cheng MC, Cherney D, Cheung AK, Ching CH, Chitalia N, Choksi R, Chukwu C, Chung K, Cianciolo G, Cipressa L, Clark S, Clarke H, Clarke R, Clarke S, Cleveland B, Cole E, Coles H, Condurache L, Connor A, Convery K, Cooper A, Cooper N, Cooper Z, Cooperman L, Cosgrove L, Coutts P, Cowley A, Craik R, Cui G, Cummins T, Dahl N, Dai H, Dajani L, D'Amelio A, Damian E, Damianik K, Danel L, Daniels C, Daniels T, Darbeau S, Darius H, Dasgupta T, Davies J, Davies L, Davis A, Davis J, Davis L, Dayanandan R, Dayi S, Dayrell R, De Nicola L, Debnath S, Deeb W, Degenhardt S, DeGoursey K, Delaney M, Deo R, DeRaad R, Derebail V, Dev D, Devaux M, Dhall P, Dhillon G, Dienes J, Dobre M, Doctolero E, Dodds V, Domingo D, Donaldson D, Donaldson P, Donhauser C, Donley V, Dorestin S, Dorey S, Doulton T, Draganova D, Draxlbauer K, Driver F, Du H, Dube F, Duck T, Dugal T, Dugas J, Dukka H, Dumann H, Durham W, Dursch M, Dykas R, Easow R, Eckrich E, Eden G, Edmerson E, Edwards H, Ee LW, Eguchi J, Ehrl Y, Eichstadt K, Eid W, Eilerman B, Ejima Y, Eldon H, Ellam T, Elliott L, Ellison R, Emberson J, Epp R, Er A, Espino-Obrero M, Estcourt S, Estienne L, Evans G, Evans J, Evans S, Fabbri G, Fajardo-Moser M, Falcone C, Fani F, Faria-Shayler P, Farnia F, Farrugia D, Fechter M, Fellowes D, Feng F, Fernandez J, Ferraro P, Field A, Fikry S, Finch J, Finn H, Fioretto P, Fish R, Fleischer A, Fleming-Brown D, Fletcher L, Flora R, Foellinger C, Foligno N, Forest S, Forghani Z, Forsyth K, Fottrell-Gould D, Fox P, Frankel A, Fraser D, Frazier R, Frederick K, Freking N, French H, Froment A, Fuchs B, Fuessl L, Fujii H, Fujimoto A, Fujita A, Fujita K, Fujita Y, Fukagawa M, Fukao Y, Fukasawa A, Fuller T, Funayama T, Fung E, Furukawa M, Furukawa Y, Furusho M, Gabel S, Gaidu J, Gaiser S, Gallo K, Galloway C, Gambaro G, Gan CC, Gangemi C, Gao M, Garcia K, Garcia M, Garofalo C, Garrity M, Garza A, Gasko S, Gavrila M, Gebeyehu B, Geddes A, Gentile G, George A, George J, Gesualdo L, Ghalli F, Ghanem A, Ghate T, Ghavampour S, Ghazi A, Gherman A, Giebeln-Hudnell U, Gill B, Gillham S, Girakossyan I, Girndt M, Giuffrida A, Glenwright M, Glider T, Gloria R, Glowski D, Goh BL, Goh CB, Gohda T, Goldenberg R, Goldfaden R, Goldsmith C, Golson B, Gonce V, Gong Q, Goodenough B, Goodwin N, Goonasekera M, Gordon A, Gordon J, Gore A, Goto H, Goto S, Goto S, Gowen D, Grace A, Graham J, Grandaliano G, Gray M, Green JB, Greene T, Greenwood G, Grewal B, Grifa R, Griffin D, Griffin S, Grimmer P, Grobovaite E, Grotjahn S, Guerini A, Guest C, Gunda S, Guo B, Guo Q, Haack S, Haase M, Haaser K, Habuki K, Hadley A, Hagan S, Hagge S, Haller H, Ham S, Hamal S, Hamamoto Y, Hamano N, Hamm M, Hanburry A, Haneda M, Hanf C, Hanif W, Hansen J, Hanson L, Hantel S, Haraguchi T, Harding E, Harding T, Hardy C, Hartner C, Harun Z, Harvill L, Hasan A, Hase H, Hasegawa F, Hasegawa T, Hashimoto A, Hashimoto C, Hashimoto M, Hashimoto S, Haskett S, Hauske SJ, Hawfield A, Hayami T, Hayashi M, Hayashi S, Haynes R, Hazara A, Healy C, Hecktman J, Heine G, Henderson H, Henschel R, Hepditch A, Herfurth K, Hernandez G, Hernandez Pena A, Hernandez-Cassis C, Herrington WG, Herzog C, Hewins S, Hewitt D, Hichkad L, Higashi S, Higuchi C, Hill C, Hill L, Hill M, Himeno T, Hing A, Hirakawa Y, Hirata K, Hirota Y, Hisatake T, Hitchcock S, Hodakowski A, Hodge W, Hogan R, Hohenstatt U, Hohenstein B, Hooi L, Hope S, Hopley M, Horikawa S, Hosein D, Hosooka T, Hou L, Hou W, Howie L, Howson A, Hozak M, Htet Z, Hu X, Hu Y, Huang J, Huda N, Hudig L, Hudson A, Hugo C, Hull R, Hume L, Hundei W, Hunt N, Hunter A, Hurley S, Hurst A, Hutchinson C, Hyo T, Ibrahim FH, Ibrahim S, Ihana N, Ikeda T, Imai A, Imamine R, Inamori A, Inazawa H, Ingell J, Inomata K, Inukai Y, Ioka M, Irtiza-Ali A, Isakova T, Isari W, Iselt M, Ishiguro A, Ishihara K, Ishikawa T, Ishimoto T, Ishizuka K, Ismail R, Itano S, Ito H, Ito K, Ito M, Ito Y, Iwagaitsu S, Iwaita Y, Iwakura T, Iwamoto M, Iwasa M, Iwasaki H, Iwasaki S, Izumi K, Izumi K, Izumi T, Jaafar SM, Jackson C, Jackson Y, Jafari G, Jahangiriesmaili M, Jain N, Jansson K, Jasim H, Jeffers L, Jenkins A, Jesky M, Jesus-Silva J, Jeyarajah D, Jiang Y, Jiao X, Jimenez G, Jin B, Jin Q, Jochims J, Johns B, Johnson C, Johnson T, Jolly S, Jones L, Jones L, Jones S, Jones T, Jones V, Joseph M, Joshi S, Judge P, Junejo N, Junus S, Kachele M, Kadowaki T, Kadoya H, Kaga H, Kai H, Kajio H, Kaluza-Schilling W, Kamaruzaman L, Kamarzarian A, Kamimura Y, Kamiya H, Kamundi C, Kan T, Kanaguchi Y, Kanazawa A, Kanda E, Kanegae S, Kaneko K, Kaneko K, Kang HY, Kano T, Karim M, Karounos D, Karsan W, Kasagi R, Kashihara N, Katagiri H, Katanosaka A, Katayama A, Katayama M, Katiman E, Kato K, Kato M, Kato N, Kato S, Kato T, Kato Y, Katsuda Y, Katsuno T, Kaufeld J, Kavak Y, Kawai I, Kawai M, Kawai M, Kawase A, Kawashima S, Kazory A, Kearney J, Keith B, Kellett J, Kelley S, Kershaw M, Ketteler M, Khai Q, Khairullah Q, Khandwala H, Khoo KKL, Khwaja A, Kidokoro K, Kielstein J, Kihara M, Kimber C, Kimura S, Kinashi H, Kingston H, Kinomura M, Kinsella-Perks E, Kitagawa M, Kitajima M, Kitamura S, Kiyosue A, Kiyota M, Klauser F, Klausmann G, Kmietschak W, Knapp K, Knight C, Knoppe A, Knott C, Kobayashi M, Kobayashi R, Kobayashi T, Koch M, Kodama S, Kodani N, Kogure E, Koizumi M, Kojima H, Kojo T, Kolhe N, Komaba H, Komiya T, Komori H, Kon SP, Kondo M, Kondo M, Kong W, Konishi M, Kono K, Koshino M, Kosugi T, Kothapalli B, Kozlowski T, Kraemer B, Kraemer-Guth A, Krappe J, Kraus D, Kriatselis C, Krieger C, Krish P, Kruger B, Ku Md Razi KR, Kuan Y, Kubota S, Kuhn S, Kumar P, Kume S, Kummer I, Kumuji R, Küpper A, Kuramae T, Kurian L, Kuribayashi C, Kurien R, Kuroda E, Kurose T, Kutschat A, Kuwabara N, Kuwata H, La Manna G, Lacey M, Lafferty K, LaFleur P, Lai V, Laity E, Lambert A, Landray MJ, Langlois M, Latif F, Latore E, Laundy E, Laurienti D, Lawson A, Lay M, Leal I, Leal I, Lee AK, Lee J, Lee KQ, Lee R, Lee SA, Lee YY, Lee-Barkey Y, Leonard N, Leoncini G, Leong CM, Lerario S, Leslie A, Levin A, Lewington A, Li J, Li N, Li X, Li Y, Liberti L, Liberti ME, Liew A, Liew YF, Lilavivat U, Lim SK, Lim YS, Limon E, Lin H, Lioudaki E, Liu H, Liu J, Liu L, Liu Q, Liu WJ, Liu X, Liu Z, Loader D, Lochhead H, Loh CL, Lorimer A, Loudermilk L, Loutan J, Low CK, Low CL, Low YM, Lozon Z, Lu Y, Lucci D, Ludwig U, Luker N, Lund D, Lustig R, Lyle S, Macdonald C, MacDougall I, Machicado R, MacLean D, Macleod P, Madera A, Madore F, Maeda K, Maegawa H, Maeno S, Mafham M, Magee J, Maggioni AP, Mah DY, Mahabadi V, Maiguma M, Makita Y, Makos G, Manco L, Mangiacapra R, Manley J, Mann P, Mano S, Marcotte G, Maris J, Mark P, Markau S, Markovic M, Marshall C, Martin M, Martinez C, Martinez S, Martins G, Maruyama K, Maruyama S, Marx K, Maselli A, Masengu A, Maskill A, Masumoto S, Masutani K, Matsumoto M, Matsunaga T, Matsuoka N, Matsushita M, Matthews M, Matthias S, Matvienko E, Maurer M, Maxwell P, Mayne KJ, Mazlan N, Mazlan SA, Mbuyisa A, McCafferty K, McCarroll F, McCarthy T, McClary-Wright C, McCray K, McDermott P, McDonald C, McDougall R, McHaffie E, McIntosh K, McKinley T, McLaughlin S, McLean N, McNeil L, Measor A, Meek J, Mehta A, Mehta R, Melandri M, Mené P, Meng T, Menne J, Merritt K, Merscher S, Meshykhi C, Messa P, Messinger L, Miftari N, Miller R, Miller Y, Miller-Hodges E, Minatoguchi M, Miners M, Minutolo R, Mita T, Miura Y, Miyaji M, Miyamoto S, Miyatsuka T, Miyazaki M, Miyazawa I, Mizumachi R, Mizuno M, Moffat S, Mohamad Nor FS, Mohamad Zaini SN, Mohamed Affandi FA, Mohandas C, Mohd R, Mohd Fauzi NA, Mohd Sharif NH, Mohd Yusoff Y, Moist L, Moncada A, Montasser M, Moon A, Moran C, Morgan N, Moriarty J, Morig G, Morinaga H, Morino K, Morisaki T, Morishita Y, Morlok S, Morris A, Morris F, Mostafa S, Mostefai Y, Motegi M, Motherwell N, Motta D, Mottl A, Moys R, Mozaffari S, Muir J, Mulhern J, Mulligan S, Munakata Y, Murakami C, Murakoshi M, Murawska A, Murphy K, Murphy L, Murray S, Murtagh H, Musa MA, Mushahar L, Mustafa R, Mustafar R, Muto M, Nadar E, Nagano R, Nagasawa T, Nagashima E, Nagasu H, Nagelberg S, Nair H, Nakagawa Y, Nakahara M, Nakamura J, Nakamura R, Nakamura T, Nakaoka M, Nakashima E, Nakata J, Nakata M, Nakatani S, Nakatsuka A, Nakayama Y, Nakhoul G, Nangaku M, Naverrete G, Navivala A, Nazeer I, Negrea L, Nethaji C, Newman E, Ng SYA, Ng TJ, Ngu LLS, Nimbkar T, Nishi H, Nishi M, Nishi S, Nishida Y, Nishiyama A, Niu J, Niu P, Nobili G, Nohara N, Nojima I, Nolan J, Nosseir H, Nozawa M, Nunn M, Nunokawa S, Oda M, Oe M, Oe Y, Ogane K, Ogawa W, Ogihara T, Oguchi G, Ohsugi M, Oishi K, Okada Y, Okajyo J, Okamoto S, Okamura K, Olufuwa O, Oluyombo R, Omata A, Omori Y, Ong LM, Ong YC, Onyema J, Oomatia A, Oommen A, Oremus R, Orimo Y, Ortalda V, Osaki Y, Osawa Y, Osmond Foster J, O'Sullivan A, Otani T, Othman N, Otomo S, O'Toole J, Owen L, Ozawa T, Padiyar A, Page N, Pajak S, Paliege A, Pandey A, Pandey R, Pariani H, Park J, Parrigon M, Passauer J, Patecki M, Patel M, Patel R, Patel T, Patel Z, Paul R, Paul R, Paulsen L, Pavone L, Peixoto A, Peji J, Peng BC, Peng K, Pennino L, Pereira E, Perez E, Pergola P, Pesce F, Pessolano G, Petchey W, Petr EJ, Pfab T, Phelan P, Phillips R, Phillips T, Phipps M, Piccinni G, Pickett T, Pickworth S, Piemontese M, Pinto D, Piper J, Plummer-Morgan J, Poehler D, Polese L, Poma V, Pontremoli R, Postal A, Pötz C, Power A, Pradhan N, Pradhan R, Preiss D, Preiss E, Preston K, Prib N, Price L, Provenzano C, Pugay C, Pulido R, Putz F, Qiao Y, Quartagno R, Quashie-Akponeware M, Rabara R, Rabasa-Lhoret R, Radhakrishnan D, Radley M, Raff R, Raguwaran S, Rahbari-Oskoui F, Rahman M, Rahmat K, Ramadoss S, Ramanaidu S, Ramasamy S, Ramli R, Ramli S, Ramsey T, Rankin A, Rashidi A, Raymond L, Razali WAFA, Read K, Reiner H, Reisler A, Reith C, Renner J, Rettenmaier B, Richmond L, Rijos D, Rivera R, Rivers V, Robinson H, Rocco M, Rodriguez-Bachiller I, Rodriquez R, Roesch C, Roesch J, Rogers J, Rohnstock M, Rolfsmeier S, Roman M, Romo A, Rosati A, Rosenberg S, Ross T, Rossello X, Roura M, Roussel M, Rovner S, Roy S, Rucker S, Rump L, Ruocco M, Ruse S, Russo F, Russo M, Ryder M, Sabarai A, Saccà C, Sachson R, Sadler E, Safiee NS, Sahani M, Saillant A, Saini J, Saito C, Saito S, Sakaguchi K, Sakai M, Salim H, Salviani C, Sammons E, Sampson A, Samson F, Sandercock P, Sanguila S, Santorelli G, Santoro D, Sarabu N, Saram T, Sardell R, Sasajima H, Sasaki T, Satko S, Sato A, Sato D, Sato H, Sato H, Sato J, Sato T, Sato Y, Satoh M, Sawada K, Schanz M, Scheidemantel F, Schemmelmann M, Schettler E, Schettler V, Schlieper GR, Schmidt C, Schmidt G, Schmidt U, Schmidt-Gurtler H, Schmude M, Schneider A, Schneider I, Schneider-Danwitz C, Schomig M, Schramm T, Schreiber A, Schricker S, Schroppel B, Schulte-Kemna L, Schulz E, Schumacher B, Schuster A, Schwab A, Scolari F, Scott A, Seeger W, Seeger W, Segal M, Seifert L, Seifert M, Sekiya M, Sellars R, Seman MR, Shah S, Shah S, Shainberg L, Shanmuganathan M, Shao F, Sharma K, Sharpe C, Sheikh-Ali M, Sheldon J, Shenton C, Shepherd A, Shepperd M, Sheridan R, Sheriff Z, Shibata Y, Shigehara T, Shikata K, Shimamura K, Shimano H, Shimizu Y, Shimoda H, Shin K, Shivashankar G, Shojima N, Silva R, Sim CSB, Simmons K, Sinha S, Sitter T, Sivanandam S, Skipper M, Sloan K, Sloan L, Smith R, Smyth J, Sobande T, Sobata M, Somalanka S, Song X, Sonntag F, Sood B, Sor SY, Soufer J, Sparks H, Spatoliatore G, Spinola T, Squyres S, Srivastava A, Stanfield J, Staplin N, Staylor K, Steele A, Steen O, Steffl D, Stegbauer J, Stellbrink C, Stellbrink E, Stevens W, Stevenson A, Stewart-Ray V, Stickley J, Stoffler D, Stratmann B, Streitenberger S, Strutz F, Stubbs J, Stumpf J, Suazo N, Suchinda P, Suckling R, Sudin A, Sugamori K, Sugawara H, Sugawara K, Sugimoto D, Sugiyama H, Sugiyama H, Sugiyama T, Sullivan M, Sumi M, Suresh N, Sutton D, Suzuki H, Suzuki R, Suzuki Y, Suzuki Y, Suzuki Y, Swanson E, Swift P, Syed S, Szerlip H, Taal M, Taddeo M, Tailor C, Tajima K, Takagi M, Takahashi K, Takahashi K, Takahashi M, Takahashi T, Takahira E, Takai T, Takaoka M, Takeoka J, Takesada A, Takezawa M, Talbot M, Taliercio J, Talsania T, Tamori Y, Tamura R, Tamura Y, Tan CHH, Tan EZZ, Tanabe A, Tanabe K, Tanaka A, Tanaka A, Tanaka N, Tang S, Tang Z, Tanigaki K, Tarlac M, Tatsuzawa A, Tay JF, Tay LL, Taylor J, Taylor K, Taylor K, Te A, Tenbusch L, Teng KS, Terakawa A, Terry J, Tham ZD, Tholl S, Thomas G, Thong KM, Tietjen D, Timadjer A, Tindall H, Tipper S, Tobin K, Toda N, Tokuyama A, Tolibas M, Tomita A, Tomita T, Tomlinson J, Tonks L, Topf J, Topping S, Torp A, Torres A, Totaro F, Toth P, Toyonaga Y, Tripodi F, Trivedi K, Tropman E, Tschope D, Tse J, Tsuji K, Tsunekawa S, Tsunoda R, Tucky B, Tufail S, Tuffaha A, Turan E, Turner H, Turner J, Turner M, Tuttle KR, Tye YL, Tyler A, Tyler J, Uchi H, Uchida H, Uchida T, Uchida T, Udagawa T, Ueda S, Ueda Y, Ueki K, Ugni S, Ugwu E, Umeno R, Unekawa C, Uozumi K, Urquia K, Valleteau A, Valletta C, van Erp R, Vanhoy C, Varad V, Varma R, Varughese A, Vasquez P, Vasseur A, Veelken R, Velagapudi C, Verdel K, Vettoretti S, Vezzoli G, Vielhauer V, Viera R, Vilar E, Villaruel S, Vinall L, Vinathan J, Visnjic M, Voigt E, von-Eynatten M, Vourvou M, Wada J, Wada J, Wada T, Wada Y, Wakayama K, Wakita Y, Wallendszus K, Walters T, Wan Mohamad WH, Wang L, Wang W, Wang X, Wang X, Wang Y, Wanner C, Wanninayake S, Watada H, Watanabe K, Watanabe K, Watanabe M, Waterfall H, Watkins D, Watson S, Weaving L, Weber B, Webley Y, Webster A, Webster M, Weetman M, Wei W, Weihprecht H, Weiland L, Weinmann-Menke J, Weinreich T, Wendt R, Weng Y, Whalen M, Whalley G, Wheatley R, Wheeler A, Wheeler J, Whelton P, White K, Whitmore B, Whittaker S, Wiebel J, Wiley J, Wilkinson L, Willett M, Williams A, Williams E, Williams K, Williams T, Wilson A, Wilson P, Wincott L, Wines E, Winkelmann B, Winkler M, Winter-Goodwin B, Witczak J, Wittes J, Wittmann M, Wolf G, Wolf L, Wolfling R, Wong C, Wong E, Wong HS, Wong LW, Wong YH, Wonnacott A, Wood A, Wood L, Woodhouse H, Wooding N, Woodman A, Wren K, Wu J, Wu P, Xia S, Xiao H, Xiao X, Xie Y, Xu C, Xu Y, Xue H, Yahaya H, Yalamanchili H, Yamada A, Yamada N, Yamagata K, Yamaguchi M, Yamaji Y, Yamamoto A, Yamamoto S, Yamamoto S, Yamamoto T, Yamanaka A, Yamano T, Yamanouchi Y, Yamasaki N, Yamasaki Y, Yamasaki Y, Yamashita C, Yamauchi T, Yan Q, Yanagisawa E, Yang F, Yang L, Yano S, Yao S, Yao Y, Yarlagadda S, Yasuda Y, Yiu V, Yokoyama T, Yoshida S, Yoshidome E, Yoshikawa H, Young A, Young T, Yousif V, Yu H, Yu Y, Yuasa K, Yusof N, Zalunardo N, Zander B, Zani R, Zappulo F, Zayed M, Zemann B, Zettergren P, Zhang H, Zhang L, Zhang L, Zhang N, Zhang X, Zhao J, Zhao L, Zhao S, Zhao Z, Zhong H, Zhou N, Zhou S, Zhu D, Zhu L, Zhu S, Zietz M, Zippo M, Zirino F, Zulkipli FH. Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial. Lancet Diabetes Endocrinol 2024; 12:39-50. [PMID: 38061371 PMCID: PMC7615591 DOI: 10.1016/s2213-8587(23)00321-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial. METHODS EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110. FINDINGS Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001). INTERPRETATION Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor. FUNDING Boehringer Ingelheim and Eli Lilly.
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Judge PK, Staplin N, Mayne KJ, Wanner C, Green JB, Hauske SJ, Emberson JR, Preiss D, Ng SYA, Roddick AJ, Sammons E, Zhu D, Hill M, Stevens W, Wallendszus K, Brenner S, Cheung AK, Liu ZH, Li J, Hooi LS, Liu WJ, Kadowaki T, Nangaku M, Levin A, Cherney D, Maggioni AP, Pontremoli R, Deo R, Goto S, Rossello X, Tuttle KR, Steubl D, Massey D, Landray MJ, Baigent C, Haynes R, Herrington WG, Abat S, Abd Rahman R, Abdul Cader R, Abdul Hafidz MI, Abdul Wahab MZ, Abdullah NK, Abdul-Samad T, Abe M, Abraham N, Acheampong S, Achiri P, Acosta JA, Adeleke A, Adell V, Adewuyi-Dalton R, Adnan N, Africano A, Agharazii M, Aguilar F, Aguilera A, Ahmad M, Ahmad MK, Ahmad NA, Ahmad NH, Ahmad NI, Ahmad Miswan N, Ahmad Rosdi H, Ahmed I, Ahmed S, Ahmed S, Aiello J, Aitken A, AitSadi R, Aker S, Akimoto S, Akinfolarin A, Akram S, Alberici F, Albert C, Aldrich L, Alegata M, Alexander L, Alfaress S, Alhadj Ali M, Ali A, Ali A, Alicic R, Aliu A, Almaraz R, Almasarwah R, Almeida J, Aloisi A, Al-Rabadi L, Alscher D, Alvarez P, Al-Zeer B, Amat M, Ambrose C, Ammar H, An Y, Andriaccio L, Ansu K, Apostolidi A, Arai N, Araki H, Araki S, Arbi A, Arechiga O, Armstrong S, Arnold T, Aronoff S, Arriaga W, Arroyo J, Arteaga D, Asahara S, Asai A, Asai N, Asano S, Asawa M, Asmee MF, Aucella F, Augustin M, Avery A, Awad A, Awang IY, Awazawa M, Axler A, Ayub W, Azhari Z, Baccaro R, Badin C, Bagwell B, Bahlmann-Kroll E, Bahtar AZ, Baigent C, Bains D, Bajaj H, Baker R, Baldini E, Banas B, Banerjee D, Banno S, Bansal S, Barberi S, Barnes S, Barnini C, Barot C, Barrett K, Barrios R, Bartolomei Mecatti B, Barton I, Barton J, Basily W, Bavanandan S, Baxter A, Becker L, Beddhu S, Beige J, Beigh S, Bell S, Benck U, Beneat A, Bennett A, Bennett D, Benyon S, Berdeprado J, Bergler T, Bergner A, Berry M, Bevilacqua M, Bhairoo J, Bhandari S, Bhandary N, Bhatt A, Bhattarai M, Bhavsar M, Bian W, Bianchini F, Bianco S, Bilous R, Bilton J, Bilucaglia D, Bird C, Birudaraju D, Biscoveanu M, Blake C, Bleakley N, Bocchicchia K, Bodine S, Bodington R, Boedecker S, Bolduc M, Bolton S, Bond C, Boreky F, Boren K, Bouchi R, Bough L, Bovan D, Bowler C, Bowman L, Brar N, Braun C, Breach A, Breitenfeldt M, Brenner S, Brettschneider B, Brewer A, Brewer G, Brindle V, Brioni E, Brown C, Brown H, Brown L, Brown R, Brown S, Browne D, Bruce K, Brueckmann M, Brunskill N, Bryant M, Brzoska M, Bu Y, Buckman C, Budoff M, Bullen M, Burke A, Burnette S, Burston C, Busch M, Bushnell J, Butler S, Büttner C, Byrne C, Caamano A, Cadorna J, Cafiero C, Cagle M, Cai J, Calabrese K, Calvi C, Camilleri B, Camp S, Campbell D, Campbell R, Cao H, Capelli I, Caple M, Caplin B, Cardone A, Carle J, Carnall V, Caroppo M, Carr S, Carraro G, Carson M, Casares P, Castillo C, Castro C, Caudill B, Cejka V, Ceseri M, Cham L, Chamberlain A, Chambers J, Chan CBT, Chan JYM, Chan YC, Chang E, Chang E, Chant T, Chavagnon T, Chellamuthu P, Chen F, Chen J, Chen P, Chen TM, Chen Y, Chen Y, Cheng C, Cheng H, Cheng MC, Cherney D, Cheung AK, Ching CH, Chitalia N, Choksi R, Chukwu C, Chung K, Cianciolo G, Cipressa L, Clark S, Clarke H, Clarke R, Clarke S, Cleveland B, Cole E, Coles H, Condurache L, Connor A, Convery K, Cooper A, Cooper N, Cooper Z, Cooperman L, Cosgrove L, Coutts P, Cowley A, Craik R, Cui G, Cummins T, Dahl N, Dai H, Dajani L, D'Amelio A, Damian E, Damianik K, Danel L, Daniels C, Daniels T, Darbeau S, Darius H, Dasgupta T, Davies J, Davies L, Davis A, Davis J, Davis L, Dayanandan R, Dayi S, Dayrell R, De Nicola L, Debnath S, Deeb W, Degenhardt S, DeGoursey K, Delaney M, Deo R, DeRaad R, Derebail V, Dev D, Devaux M, Dhall P, Dhillon G, Dienes J, Dobre M, Doctolero E, Dodds V, Domingo D, Donaldson D, Donaldson P, Donhauser C, Donley V, Dorestin S, Dorey S, Doulton T, Draganova D, Draxlbauer K, Driver F, Du H, Dube F, Duck T, Dugal T, Dugas J, Dukka H, Dumann H, Durham W, Dursch M, Dykas R, Easow R, Eckrich E, Eden G, Edmerson E, Edwards H, Ee LW, Eguchi J, Ehrl Y, Eichstadt K, Eid W, Eilerman B, Ejima Y, Eldon H, Ellam T, Elliott L, Ellison R, Emberson J, Epp R, Er A, Espino-Obrero M, Estcourt S, Estienne L, Evans G, Evans J, Evans S, Fabbri G, Fajardo-Moser M, Falcone C, Fani F, Faria-Shayler P, Farnia F, Farrugia D, Fechter M, Fellowes D, Feng F, Fernandez J, Ferraro P, Field A, Fikry S, Finch J, Finn H, Fioretto P, Fish R, Fleischer A, Fleming-Brown D, Fletcher L, Flora R, Foellinger C, Foligno N, Forest S, Forghani Z, Forsyth K, Fottrell-Gould D, Fox P, Frankel A, Fraser D, Frazier R, Frederick K, Freking N, French H, Froment A, Fuchs B, Fuessl L, Fujii H, Fujimoto A, Fujita A, Fujita K, Fujita Y, Fukagawa M, Fukao Y, Fukasawa A, Fuller T, Funayama T, Fung E, Furukawa M, Furukawa Y, Furusho M, Gabel S, Gaidu J, Gaiser S, Gallo K, Galloway C, Gambaro G, Gan CC, Gangemi C, Gao M, Garcia K, Garcia M, Garofalo C, Garrity M, Garza A, Gasko S, Gavrila M, Gebeyehu B, Geddes A, Gentile G, George A, George J, Gesualdo L, Ghalli F, Ghanem A, Ghate T, Ghavampour S, Ghazi A, Gherman A, Giebeln-Hudnell U, Gill B, Gillham S, Girakossyan I, Girndt M, Giuffrida A, Glenwright M, Glider T, Gloria R, Glowski D, Goh BL, Goh CB, Gohda T, Goldenberg R, Goldfaden R, Goldsmith C, Golson B, Gonce V, Gong Q, Goodenough B, Goodwin N, Goonasekera M, Gordon A, Gordon J, Gore A, Goto H, Goto S, Goto S, Gowen D, Grace A, Graham J, Grandaliano G, Gray M, Green JB, Greene T, Greenwood G, Grewal B, Grifa R, Griffin D, Griffin S, Grimmer P, Grobovaite E, Grotjahn S, Guerini A, Guest C, Gunda S, Guo B, Guo Q, Haack S, Haase M, Haaser K, Habuki K, Hadley A, Hagan S, Hagge S, Haller H, Ham S, Hamal S, Hamamoto Y, Hamano N, Hamm M, Hanburry A, Haneda M, Hanf C, Hanif W, Hansen J, Hanson L, Hantel S, Haraguchi T, Harding E, Harding T, Hardy C, Hartner C, Harun Z, Harvill L, Hasan A, Hase H, Hasegawa F, Hasegawa T, Hashimoto A, Hashimoto C, Hashimoto M, Hashimoto S, Haskett S, Hauske SJ, Hawfield A, Hayami T, Hayashi M, Hayashi S, Haynes R, Hazara A, Healy C, Hecktman J, Heine G, Henderson H, Henschel R, Hepditch A, Herfurth K, Hernandez G, Hernandez Pena A, Hernandez-Cassis C, Herrington WG, Herzog C, Hewins S, Hewitt D, Hichkad L, Higashi S, Higuchi C, Hill C, Hill L, Hill M, Himeno T, Hing A, Hirakawa Y, Hirata K, Hirota Y, Hisatake T, Hitchcock S, Hodakowski A, Hodge W, Hogan R, Hohenstatt U, Hohenstein B, Hooi L, Hope S, Hopley M, Horikawa S, Hosein D, Hosooka T, Hou L, Hou W, Howie L, Howson A, Hozak M, Htet Z, Hu X, Hu Y, Huang J, Huda N, Hudig L, Hudson A, Hugo C, Hull R, Hume L, Hundei W, Hunt N, Hunter A, Hurley S, Hurst A, Hutchinson C, Hyo T, Ibrahim FH, Ibrahim S, Ihana N, Ikeda T, Imai A, Imamine R, Inamori A, Inazawa H, Ingell J, Inomata K, Inukai Y, Ioka M, Irtiza-Ali A, Isakova T, Isari W, Iselt M, Ishiguro A, Ishihara K, Ishikawa T, Ishimoto T, Ishizuka K, Ismail R, Itano S, Ito H, Ito K, Ito M, Ito Y, Iwagaitsu S, Iwaita Y, Iwakura T, Iwamoto M, Iwasa M, Iwasaki H, Iwasaki S, Izumi K, Izumi K, Izumi T, Jaafar SM, Jackson C, Jackson Y, Jafari G, Jahangiriesmaili M, Jain N, Jansson K, Jasim H, Jeffers L, Jenkins A, Jesky M, Jesus-Silva J, Jeyarajah D, Jiang Y, Jiao X, Jimenez G, Jin B, Jin Q, Jochims J, Johns B, Johnson C, Johnson T, Jolly S, Jones L, Jones L, Jones S, Jones T, Jones V, Joseph M, Joshi S, Judge P, Junejo N, Junus S, Kachele M, Kadowaki T, Kadoya H, Kaga H, Kai H, Kajio H, Kaluza-Schilling W, Kamaruzaman L, Kamarzarian A, Kamimura Y, Kamiya H, Kamundi C, Kan T, Kanaguchi Y, Kanazawa A, Kanda E, Kanegae S, Kaneko K, Kaneko K, Kang HY, Kano T, Karim M, Karounos D, Karsan W, Kasagi R, Kashihara N, Katagiri H, Katanosaka A, Katayama A, Katayama M, Katiman E, Kato K, Kato M, Kato N, Kato S, Kato T, Kato Y, Katsuda Y, Katsuno T, Kaufeld J, Kavak Y, Kawai I, Kawai M, Kawai M, Kawase A, Kawashima S, Kazory A, Kearney J, Keith B, Kellett J, Kelley S, Kershaw M, Ketteler M, Khai Q, Khairullah Q, Khandwala H, Khoo KKL, Khwaja A, Kidokoro K, Kielstein J, Kihara M, Kimber C, Kimura S, Kinashi H, Kingston H, Kinomura M, Kinsella-Perks E, Kitagawa M, Kitajima M, Kitamura S, Kiyosue A, Kiyota M, Klauser F, Klausmann G, Kmietschak W, Knapp K, Knight C, Knoppe A, Knott C, Kobayashi M, Kobayashi R, Kobayashi T, Koch M, Kodama S, Kodani N, Kogure E, Koizumi M, Kojima H, Kojo T, Kolhe N, Komaba H, Komiya T, Komori H, Kon SP, Kondo M, Kondo M, Kong W, Konishi M, Kono K, Koshino M, Kosugi T, Kothapalli B, Kozlowski T, Kraemer B, Kraemer-Guth A, Krappe J, Kraus D, Kriatselis C, Krieger C, Krish P, Kruger B, Ku Md Razi KR, Kuan Y, Kubota S, Kuhn S, Kumar P, Kume S, Kummer I, Kumuji R, Küpper A, Kuramae T, Kurian L, Kuribayashi C, Kurien R, Kuroda E, Kurose T, Kutschat A, Kuwabara N, Kuwata H, La Manna G, Lacey M, Lafferty K, LaFleur P, Lai V, Laity E, Lambert A, Landray MJ, Langlois M, Latif F, Latore E, Laundy E, Laurienti D, Lawson A, Lay M, Leal I, Leal I, Lee AK, Lee J, Lee KQ, Lee R, Lee SA, Lee YY, Lee-Barkey Y, Leonard N, Leoncini G, Leong CM, Lerario S, Leslie A, Levin A, Lewington A, Li J, Li N, Li X, Li Y, Liberti L, Liberti ME, Liew A, Liew YF, Lilavivat U, Lim SK, Lim YS, Limon E, Lin H, Lioudaki E, Liu H, Liu J, Liu L, Liu Q, Liu WJ, Liu X, Liu Z, Loader D, Lochhead H, Loh CL, Lorimer A, Loudermilk L, Loutan J, Low CK, Low CL, Low YM, Lozon Z, Lu Y, Lucci D, Ludwig U, Luker N, Lund D, Lustig R, Lyle S, Macdonald C, MacDougall I, Machicado R, MacLean D, Macleod P, Madera A, Madore F, Maeda K, Maegawa H, Maeno S, Mafham M, Magee J, Maggioni AP, Mah DY, Mahabadi V, Maiguma M, Makita Y, Makos G, Manco L, Mangiacapra R, Manley J, Mann P, Mano S, Marcotte G, Maris J, Mark P, Markau S, Markovic M, Marshall C, Martin M, Martinez C, Martinez S, Martins G, Maruyama K, Maruyama S, Marx K, Maselli A, Masengu A, Maskill A, Masumoto S, Masutani K, Matsumoto M, Matsunaga T, Matsuoka N, Matsushita M, Matthews M, Matthias S, Matvienko E, Maurer M, Maxwell P, Mayne KJ, Mazlan N, Mazlan SA, Mbuyisa A, McCafferty K, McCarroll F, McCarthy T, McClary-Wright C, McCray K, McDermott P, McDonald C, McDougall R, McHaffie E, McIntosh K, McKinley T, McLaughlin S, McLean N, McNeil L, Measor A, Meek J, Mehta A, Mehta R, Melandri M, Mené P, Meng T, Menne J, Merritt K, Merscher S, Meshykhi C, Messa P, Messinger L, Miftari N, Miller R, Miller Y, Miller-Hodges E, Minatoguchi M, Miners M, Minutolo R, Mita T, Miura Y, Miyaji M, Miyamoto S, Miyatsuka T, Miyazaki M, Miyazawa I, Mizumachi R, Mizuno M, Moffat S, Mohamad Nor FS, Mohamad Zaini SN, Mohamed Affandi FA, Mohandas C, Mohd R, Mohd Fauzi NA, Mohd Sharif NH, Mohd Yusoff Y, Moist L, Moncada A, Montasser M, Moon A, Moran C, Morgan N, Moriarty J, Morig G, Morinaga H, Morino K, Morisaki T, Morishita Y, Morlok S, Morris A, Morris F, Mostafa S, Mostefai Y, Motegi M, Motherwell N, Motta D, Mottl A, Moys R, Mozaffari S, Muir J, Mulhern J, Mulligan S, Munakata Y, Murakami C, Murakoshi M, Murawska A, Murphy K, Murphy L, Murray S, Murtagh H, Musa MA, Mushahar L, Mustafa R, Mustafar R, Muto M, Nadar E, Nagano R, Nagasawa T, Nagashima E, Nagasu H, Nagelberg S, Nair H, Nakagawa Y, Nakahara M, Nakamura J, Nakamura R, Nakamura T, Nakaoka M, Nakashima E, Nakata J, Nakata M, Nakatani S, Nakatsuka A, Nakayama Y, Nakhoul G, Nangaku M, Naverrete G, Navivala A, Nazeer I, Negrea L, Nethaji C, Newman E, Ng SYA, Ng TJ, Ngu LLS, Nimbkar T, Nishi H, Nishi M, Nishi S, Nishida Y, Nishiyama A, Niu J, Niu P, Nobili G, Nohara N, Nojima I, Nolan J, Nosseir H, Nozawa M, Nunn M, Nunokawa S, Oda M, Oe M, Oe Y, Ogane K, Ogawa W, Ogihara T, Oguchi G, Ohsugi M, Oishi K, Okada Y, Okajyo J, Okamoto S, Okamura K, Olufuwa O, Oluyombo R, Omata A, Omori Y, Ong LM, Ong YC, Onyema J, Oomatia A, Oommen A, Oremus R, Orimo Y, Ortalda V, Osaki Y, Osawa Y, Osmond Foster J, O'Sullivan A, Otani T, Othman N, Otomo S, O'Toole J, Owen L, Ozawa T, Padiyar A, Page N, Pajak S, Paliege A, Pandey A, Pandey R, Pariani H, Park J, Parrigon M, Passauer J, Patecki M, Patel M, Patel R, Patel T, Patel Z, Paul R, Paul R, Paulsen L, Pavone L, Peixoto A, Peji J, Peng BC, Peng K, Pennino L, Pereira E, Perez E, Pergola P, Pesce F, Pessolano G, Petchey W, Petr EJ, Pfab T, Phelan P, Phillips R, Phillips T, Phipps M, Piccinni G, Pickett T, Pickworth S, Piemontese M, Pinto D, Piper J, Plummer-Morgan J, Poehler D, Polese L, Poma V, Pontremoli R, Postal A, Pötz C, Power A, Pradhan N, Pradhan R, Preiss D, Preiss E, Preston K, Prib N, Price L, Provenzano C, Pugay C, Pulido R, Putz F, Qiao Y, Quartagno R, Quashie-Akponeware M, Rabara R, Rabasa-Lhoret R, Radhakrishnan D, Radley M, Raff R, Raguwaran S, Rahbari-Oskoui F, Rahman M, Rahmat K, Ramadoss S, Ramanaidu S, Ramasamy S, Ramli R, Ramli S, Ramsey T, Rankin A, Rashidi A, Raymond L, Razali WAFA, Read K, Reiner H, Reisler A, Reith C, Renner J, Rettenmaier B, Richmond L, Rijos D, Rivera R, Rivers V, Robinson H, Rocco M, Rodriguez-Bachiller I, Rodriquez R, Roesch C, Roesch J, Rogers J, Rohnstock M, Rolfsmeier S, Roman M, Romo A, Rosati A, Rosenberg S, Ross T, Rossello X, Roura M, Roussel M, Rovner S, Roy S, Rucker S, Rump L, Ruocco M, Ruse S, Russo F, Russo M, Ryder M, Sabarai A, Saccà C, Sachson R, Sadler E, Safiee NS, Sahani M, Saillant A, Saini J, Saito C, Saito S, Sakaguchi K, Sakai M, Salim H, Salviani C, Sammons E, Sampson A, Samson F, Sandercock P, Sanguila S, Santorelli G, Santoro D, Sarabu N, Saram T, Sardell R, Sasajima H, Sasaki T, Satko S, Sato A, Sato D, Sato H, Sato H, Sato J, Sato T, Sato Y, Satoh M, Sawada K, Schanz M, Scheidemantel F, Schemmelmann M, Schettler E, Schettler V, Schlieper GR, Schmidt C, Schmidt G, Schmidt U, Schmidt-Gurtler H, Schmude M, Schneider A, Schneider I, Schneider-Danwitz C, Schomig M, Schramm T, Schreiber A, Schricker S, Schroppel B, Schulte-Kemna L, Schulz E, Schumacher B, Schuster A, Schwab A, Scolari F, Scott A, Seeger W, Seeger W, Segal M, Seifert L, Seifert M, Sekiya M, Sellars R, Seman MR, Shah S, Shah S, Shainberg L, Shanmuganathan M, Shao F, Sharma K, Sharpe C, Sheikh-Ali M, Sheldon J, Shenton C, Shepherd A, Shepperd M, Sheridan R, Sheriff Z, Shibata Y, Shigehara T, Shikata K, Shimamura K, Shimano H, Shimizu Y, Shimoda H, Shin K, Shivashankar G, Shojima N, Silva R, Sim CSB, Simmons K, Sinha S, Sitter T, Sivanandam S, Skipper M, Sloan K, Sloan L, Smith R, Smyth J, Sobande T, Sobata M, Somalanka S, Song X, Sonntag F, Sood B, Sor SY, Soufer J, Sparks H, Spatoliatore G, Spinola T, Squyres S, Srivastava A, Stanfield J, Staplin N, Staylor K, Steele A, Steen O, Steffl D, Stegbauer J, Stellbrink C, Stellbrink E, Stevens W, Stevenson A, Stewart-Ray V, Stickley J, Stoffler D, Stratmann B, Streitenberger S, Strutz F, Stubbs J, Stumpf J, Suazo N, Suchinda P, Suckling R, Sudin A, Sugamori K, Sugawara H, Sugawara K, Sugimoto D, Sugiyama H, Sugiyama H, Sugiyama T, Sullivan M, Sumi M, Suresh N, Sutton D, Suzuki H, Suzuki R, Suzuki Y, Suzuki Y, Suzuki Y, Swanson E, Swift P, Syed S, Szerlip H, Taal M, Taddeo M, Tailor C, Tajima K, Takagi M, Takahashi K, Takahashi K, Takahashi M, Takahashi T, Takahira E, Takai T, Takaoka M, Takeoka J, Takesada A, Takezawa M, Talbot M, Taliercio J, Talsania T, Tamori Y, Tamura R, Tamura Y, Tan CHH, Tan EZZ, Tanabe A, Tanabe K, Tanaka A, Tanaka A, Tanaka N, Tang S, Tang Z, Tanigaki K, Tarlac M, Tatsuzawa A, Tay JF, Tay LL, Taylor J, Taylor K, Taylor K, Te A, Tenbusch L, Teng KS, Terakawa A, Terry J, Tham ZD, Tholl S, Thomas G, Thong KM, Tietjen D, Timadjer A, Tindall H, Tipper S, Tobin K, Toda N, Tokuyama A, Tolibas M, Tomita A, Tomita T, Tomlinson J, Tonks L, Topf J, Topping S, Torp A, Torres A, Totaro F, Toth P, Toyonaga Y, Tripodi F, Trivedi K, Tropman E, Tschope D, Tse J, Tsuji K, Tsunekawa S, Tsunoda R, Tucky B, Tufail S, Tuffaha A, Turan E, Turner H, Turner J, Turner M, Tuttle KR, Tye YL, Tyler A, Tyler J, Uchi H, Uchida H, Uchida T, Uchida T, Udagawa T, Ueda S, Ueda Y, Ueki K, Ugni S, Ugwu E, Umeno R, Unekawa C, Uozumi K, Urquia K, Valleteau A, Valletta C, van Erp R, Vanhoy C, Varad V, Varma R, Varughese A, Vasquez P, Vasseur A, Veelken R, Velagapudi C, Verdel K, Vettoretti S, Vezzoli G, Vielhauer V, Viera R, Vilar E, Villaruel S, Vinall L, Vinathan J, Visnjic M, Voigt E, von-Eynatten M, Vourvou M, Wada J, Wada J, Wada T, Wada Y, Wakayama K, Wakita Y, Wallendszus K, Walters T, Wan Mohamad WH, Wang L, Wang W, Wang X, Wang X, Wang Y, Wanner C, Wanninayake S, Watada H, Watanabe K, Watanabe K, Watanabe M, Waterfall H, Watkins D, Watson S, Weaving L, Weber B, Webley Y, Webster A, Webster M, Weetman M, Wei W, Weihprecht H, Weiland L, Weinmann-Menke J, Weinreich T, Wendt R, Weng Y, Whalen M, Whalley G, Wheatley R, Wheeler A, Wheeler J, Whelton P, White K, Whitmore B, Whittaker S, Wiebel J, Wiley J, Wilkinson L, Willett M, Williams A, Williams E, Williams K, Williams T, Wilson A, Wilson P, Wincott L, Wines E, Winkelmann B, Winkler M, Winter-Goodwin B, Witczak J, Wittes J, Wittmann M, Wolf G, Wolf L, Wolfling R, Wong C, Wong E, Wong HS, Wong LW, Wong YH, Wonnacott A, Wood A, Wood L, Woodhouse H, Wooding N, Woodman A, Wren K, Wu J, Wu P, Xia S, Xiao H, Xiao X, Xie Y, Xu C, Xu Y, Xue H, Yahaya H, Yalamanchili H, Yamada A, Yamada N, Yamagata K, Yamaguchi M, Yamaji Y, Yamamoto A, Yamamoto S, Yamamoto S, Yamamoto T, Yamanaka A, Yamano T, Yamanouchi Y, Yamasaki N, Yamasaki Y, Yamasaki Y, Yamashita C, Yamauchi T, Yan Q, Yanagisawa E, Yang F, Yang L, Yano S, Yao S, Yao Y, Yarlagadda S, Yasuda Y, Yiu V, Yokoyama T, Yoshida S, Yoshidome E, Yoshikawa H, Young A, Young T, Yousif V, Yu H, Yu Y, Yuasa K, Yusof N, Zalunardo N, Zander B, Zani R, Zappulo F, Zayed M, Zemann B, Zettergren P, Zhang H, Zhang L, Zhang L, Zhang N, Zhang X, Zhao J, Zhao L, Zhao S, Zhao Z, Zhong H, Zhou N, Zhou S, Zhu D, Zhu L, Zhu S, Zietz M, Zippo M, Zirino F, Zulkipli FH. Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial. Lancet Diabetes Endocrinol 2024; 12:51-60. [PMID: 38061372 DOI: 10.1016/s2213-8587(23)00322-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population. METHODS EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110. FINDINGS Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1). INTERPRETATION In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease. FUNDING Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.
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Weissmann T, Rückert M, Putz F, Donaubauer AJ, Hecht M, Schnellhardt S, Schubert P, Roesch J, Höfler D, Ott OJ, Haderlein M, Lettmaier S, Fietkau R, Frey B, Gaipl US, Deloch L. Low-dose radiotherapy of osteoarthritis: from biological findings to clinical effects-challenges for future studies. Strahlenther Onkol 2023; 199:1164-1172. [PMID: 36602569 PMCID: PMC10674008 DOI: 10.1007/s00066-022-02038-6] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 11/25/2022] [Indexed: 01/06/2023]
Abstract
Osteoarthritis (OA) is one of the most common and socioeconomically relevant diseases, with rising incidence and prevalence especially with regard to an ageing population in the Western world. Over the decades, the scientific perception of OA has shifted from a simple degeneration of cartilage and bone to a multifactorial disease involving various cell types and immunomodulatory factors. Despite a wide range of conventional treatment modalities available, a significant proportion of patients remain treatment refractory. Low-dose radiotherapy (LDRT) has been used for decades in the treatment of patients with inflammatory and/or degenerative diseases and has proven a viable option even in cohorts of patients with a rather poor prognosis. While its justification mainly derives from a vast body of empirical evidence, prospective randomized trials have until now failed to prove the effectiveness of LDRT. Nevertheless, over the decades, adaptions of LDRT treatment modalities have evolved using lower dosages with establishment of different treatment schedules for which definitive clinical proof is still pending. Preclinical research has revealed that the immune system is modulated by LDRT and very recently osteoimmunological mechanisms have been described. Future studies and investigations further elucidating the underlying mechanisms are an essential key to clarify the optimal patient stratification and treatment procedure, considering the patients' inflammatory status, age, and sex. The present review aims not only to present clinical and preclinical knowledge about the mechanistic and beneficial effects of LDRT, but also to emphasize topics that will need to be addressed in future studies. Further, a concise overview of the current status of the underlying radiobiological knowledge of LDRT for clinicians is given, while seeking to stimulate further translational research.
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Affiliation(s)
- Thomas Weissmann
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Michael Rückert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Translational Radiobiology, Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Florian Putz
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Anna-Jasmina Donaubauer
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Translational Radiobiology, Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Markus Hecht
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Sören Schnellhardt
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Philipp Schubert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Johannes Roesch
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Daniel Höfler
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Oliver J Ott
- Translational Radiobiology, Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Marlen Haderlein
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Sebastian Lettmaier
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Benjamin Frey
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Translational Radiobiology, Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Udo S Gaipl
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Translational Radiobiology, Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Lisa Deloch
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.
- Translational Radiobiology, Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.
- Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany.
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Roesch J, Rühle A, Nicolay NH, Hecht M. Reply to the comment on "Dose-escalated re-irradiation improves outcome in locally recurrent head and neck cancer - Results of a large multicenter analysis'' by Kahvecioglu et al. Radiother Oncol 2023; 188:109866. [PMID: 37619658 DOI: 10.1016/j.radonc.2023.109866] [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] [Received: 08/04/2023] [Accepted: 08/17/2023] [Indexed: 08/26/2023]
Affiliation(s)
- Johannes Roesch
- Department of Radiation Oncology, die Strahlentherapeuten, Coburg, Germany.
| | - Alexander Rühle
- Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Department of Radiation Oncology, University of Leipzig, Leipzig, Germany
| | - Nils H Nicolay
- Department of Radiation Oncology, University of Leipzig, Leipzig, Germany
| | - Markus Hecht
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Center, Homburg, Germany
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Ruhle A, Roesch J, Oertel M, Fabian A, Wegen S, Trommer M, Hering D, Maeurer M, Dobiasch S, von der Grün J, Medenwald D, Süß C, Hoeck M, Fleischmann DF, Löser A, Heß S, Tamaskovic B, Vinsensia M, Hecht M, Nicolay NH. MRI, FDG-PET/CT and Image-Guidance for Re-Irradiation of Locoregionally Recurrent or Second Primary Head-and-Neck Squamous Cell Carcinoma Patients - Results of a Multicenter Cohort Study. Int J Radiat Oncol Biol Phys 2023; 117:e619-e620. [PMID: 37785856 DOI: 10.1016/j.ijrobp.2023.06.2002] [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) To investigate patterns of care and prognostic benefits of MRI, FDG-PET/CT and image-guidance in re-irradiation of locoregionally recurrent or second primary head-and-neck squamous cell carcinomas (r/s HNSCCs) within a multicenter cohort study. MATERIALS/METHODS Patients receiving re-irradiation for r/s HNSCC between 2009 and 2020 at 16 tertiary cancer centers in Germany were retrospectively analyzed in terms of MRI and FDG-PET/CT usage for treatment planning and regarding image-guidance frequency during re-irradiation. Patterns of use of these modalities over time were analyzed by binary logistic regression analysis, and the association between the usage of these modalities and best locoregional treatment response was analyzed with chi-square tests. Cumulative incidence analyses of locoregional failures with death as competing event were performed. RESULTS In the total cohort of 297 patients, 226 (76%) were male, median age was 62 years (IQR, 56-70), and median ECOG was 1 (IQR, 1-2). There were 260 locoregionally recurrent HNSCCs, and 37 second primary HNSCCs; 44 patients (15%) had distant metastases at the time of re-irradiation. MRI and FDG-PET/CT was used for re-irradiation planning in 117 (39%) and 71 patients (24%), respectively. In median, image guidance (IGRT) was performed twice weekly (IQR, 1-5), usually with cone beam CTs or megavolt-CTs, and 85 patients (29%) received daily IGRT during re-irradiation. Usage of MRI (OR = 0.967; 95% CI, 0.892-1.048; p = .416), FDG-PET/CT (OR = 1.053; 95% CI, 0.960-1.156; p = .274), or daily IGRT (OR = 1.057; 95% CI, 0.968-1.115; p = .218) did not increase in frequency over time within the analyzed time span but was significantly dependent on the treatment center (χ2(15), P<.001 for all modalities). Daily IGRT was associated with a higher rate of at least stable disease after re-irradiation as assessed by RECIST criteria (χ2(1) = 4.011, p<.05). There was a trend towards better RECIST-assessed treatment response for MRI (χ2(1) = 3.223, p = .073) and FDG-PET/CT (χ2(1) = 2.792, p = .095) as part of the re-irradiation planning process. Incidence of locoregional failures was not dependent on MRI (SHR = 0.94; 95% CI, 0.67-1.33; p = 0.741, Fine-Gray), FDG-PET/CT (SHR = 0.88; 95% CI, 0.59-1.33; p = 0.552) or daily IGRT (SHR = 0.76; 95% CI, 0.51-1.14, p = 0.182), There was a trend towards lower acute grade 3/4-toxicities in patients receiving daily IGRT (χ2(1) = 3.354, p = 0.067). CONCLUSION Our data suggest that daily IGRT may increase disease control and should be regularly applied for re-irradiation of r/s HNSCCs. MRI and FDG-PET/CT usage were not associated with the incidence of locoregional failures after re-irradiation. However, prospective trials with multiparametric MRI and/or FDG-PET/CT for optimal re-irradiation planning are warranted.
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Affiliation(s)
- A Ruhle
- Department of Radiation Oncology, University of Leipzig, Leipzig, Germany; Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - J Roesch
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - M Oertel
- Department of Radiation Oncology, University Hospital Muenster, Muenster, Germany
| | - A Fabian
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - S Wegen
- Department of Radiation Oncology, CyberKnife and Radiotherapy, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - M Trommer
- Department of Radiation Oncology, CyberKnife and Radiotherapy, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - D Hering
- Department of Radiation Oncology, University Hospital Muenster, Muenster, Germany
| | - M Maeurer
- Department of Radiation Oncology, University Hospital Jena, Jena, Germany
| | - S Dobiasch
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - J von der Grün
- Department of Radiotherapy and Oncology, Goethe-University Frankfurt am Main, Frankfurt, Germany
| | - D Medenwald
- Department of Radiation Oncology, University Hospital Halle, Halle, Germany
| | - C Süß
- Department of Radiation Oncology, University Hospital Regensburg, Regensburg, Germany
| | - M Hoeck
- Department of Radiation Oncology, University Hospital Augsburg, Augsburg, Germany
| | - D F Fleischmann
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - A Löser
- Department of Radiotherapy and Radiation Oncology, University Medical Center Hamburg-Eppendorf, Outpatient Center of the UKE GmbH, Hamburg, Germany; Department of Radiation Oncology, University Medical Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - S Heß
- Department of Radiation Oncology, University Hospital Würzburg, Julius-Maximilians-University, Würzburg, Germany
| | - B Tamaskovic
- Department of Radiation Oncology, Düsseldorf University Hospital, Heinrich Heine University, Düsseldorf, Germany
| | - M Vinsensia
- Department of Radiation Oncology, University Hospital Mannheim, Mannheim, Germany
| | - M Hecht
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany; Department of Radiotherapy and Radiation Oncology, Saarland University Medical Center, Homburg, Germany
| | - N H Nicolay
- Department of Radiation Oncology, University of Leipzig, Leipzig, Germany; Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
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Roesch J, Oertel M, Wegen S, Trommer M, Schleifenbaum J, Hering D, Mäurer M, Knippen S, Dobiasch S, Waltenberger M, von der Grün J, Medenwald D, Süß C, Hoeck M, Käsmann L, Fleischmann DF, Rühle A, Nicolay NH, Fabian A, Löser A, Heß S, Tamaskovics B, Vinsensia M, Hecht M. Dose-escalated re-irradiation improves outcome in locally recurrent head and neck cancer - Results of a large multicenter analysis. Radiother Oncol 2023; 181:109380. [PMID: 36273736 DOI: 10.1016/j.radonc.2022.10.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [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: 03/21/2022] [Revised: 09/21/2022] [Accepted: 10/11/2022] [Indexed: 11/07/2022]
Abstract
To determine efficacy and prognostic parameters of definitive re-irradiation of locoregionally recurrent squamous cell carcinoma of the head and neck (HNSCC). MATERIALS AND METHODS Patients with locoregionally recurrent or second primary HNSCC undergoing re-irradiation with modern radiotherapy technique were eligible for this multicentric retrospective analysis. Main endpoints were overall survival (OS), progression-free survival (PFS) and locoregional control (LC). Univariate analyses were performed using the Kaplan Meier Method (log-rank). For multivariable analysis, Cox regression was used. RESULTS A total of 253 patients treated between 2009 and 2020 at 16 university hospitals in Germany were included. The median follow up was 27.4 months (range 0.5-130). The median OS and PFS were 13.2 (CI: 10.7 - 15.7) months and 7.9 (CI: 6.7 - 9.1) months, respectively, corresponding to two-year OS and PFS rates of 29 % and 19 %. Rates of locoregional progression and "in-field-failure" were 62 % and 51 % after two years. Multivariable Cox regression analysis identified good ECOG performance status and high radiation dose as independent prognostic parameters for OS. Doses above 50 Gy (EQD2) achieved longer median OS of 17.8 months (vs 11.7 months, p < 0.01) and longer PFS of 9.6 months (vs 6.8 months, p < 0.01). In addition, there was a trend for worse survival in patients with tracheostomy (multivariable, p = 0.061). Concomitant systemic therapy did not significantly impact PFS or OS. CONCLUSION Re-irradiation of locally recurrent or second primary HNSCC is efficient, especially if doses above 50 Gy (EQD2) are delivered. ECOG performance score was the strongest prognostic parameter for OS and PFS.
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Affiliation(s)
- Johannes Roesch
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany; Deutsches Zentrum Immuntherapie, Erlangen, Germany.
| | - Michael Oertel
- Department of Radiation Oncology, University Hospital Münster, Münster, Germany
| | - Simone Wegen
- Department of Radiation Oncology, Cyberknife and Radiotherapy, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Maike Trommer
- Department of Radiation Oncology, Cyberknife and Radiotherapy, Faculty of Medicine and University Hospital Cologne, Cologne, Germany; Center for Molecular Medicine Cologne, University of Cologne, Cologne, Germany
| | - Julia Schleifenbaum
- Department of Radiation Oncology, Cyberknife and Radiotherapy, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Dominik Hering
- Department of Radiation Oncology, University Hospital Münster, Münster, Germany
| | - Matthias Mäurer
- Department of Radiation Oncology, University Hospital Jena, Jena, Germany
| | - Stefan Knippen
- Department of Radiation Oncology, University Hospital Jena, Jena, Germany
| | - Sophie Dobiasch
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Maria Waltenberger
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Jens von der Grün
- Department of Radiation Oncology, University Hospital Frankfurt, Frankfurt, Germany
| | - Daniel Medenwald
- Department of Radiation Oncology, University Hospital Halle, Halle, Germany
| | - Christoph Süß
- Department of Radiation Oncology, University Hospital Regensburg, Regensburg, Germany
| | - Michael Hoeck
- Department of Radiation Oncology, University Hospital Augsburg, Augsburg, Germany
| | - Lukas Käsmann
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Daniel F Fleischmann
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany; German Cancer Consortium (DKTK), partner site Munich, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Alexander Rühle
- Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Nils H Nicolay
- Department of Radiation Oncology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Alexander Fabian
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Anastassia Löser
- Outpatient Center of the University Medical Hospital Hamburg-Eppendorf, Department of Radiotherapy and Radiation Oncology) and Department of Oncology, Haematology and Bone Marrow Transplantation with the Section Pneumology (Centre for Oncology), University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Sebastian Heß
- Department of Radiation Oncology, University Hospital Würzburg, Julius-Maximilians-University, Würzburg, Germany
| | - Bálint Tamaskovics
- Department of Radiation Oncology, Düsseldorf University Hospital, Heinrich Heine University, Düsseldorf, Germany
| | - Maria Vinsensia
- Department of Radiation Oncology, University Hospital Mannheim, Mannheim, Germany
| | - Markus Hecht
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Center, Homburg/Saar, Germany
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Weissmann T, Huang Y, Fischer S, Roesch J, Mansoorian S, Ayala Gaona H, Gostian AO, Hecht M, Lettmaier S, Deloch L, Frey B, Gaipl US, Distel LV, Maier A, Iro H, Semrau S, Bert C, Fietkau R, Putz F. Deep learning for automatic head and neck lymph node level delineation provides expert-level accuracy. Front Oncol 2023; 13:1115258. [PMID: 36874135 PMCID: PMC9978473 DOI: 10.3389/fonc.2023.1115258] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [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: 12/03/2022] [Accepted: 01/30/2023] [Indexed: 02/18/2023] Open
Abstract
Background Deep learning-based head and neck lymph node level (HN_LNL) autodelineation is of high relevance to radiotherapy research and clinical treatment planning but still underinvestigated in academic literature. In particular, there is no publicly available open-source solution for large-scale autosegmentation of HN_LNL in the research setting. Methods An expert-delineated cohort of 35 planning CTs was used for training of an nnU-net 3D-fullres/2D-ensemble model for autosegmentation of 20 different HN_LNL. A second cohort acquired at the same institution later in time served as the test set (n = 20). In a completely blinded evaluation, 3 clinical experts rated the quality of deep learning autosegmentations in a head-to-head comparison with expert-created contours. For a subgroup of 10 cases, intraobserver variability was compared to the average deep learning autosegmentation accuracy on the original and recontoured set of expert segmentations. A postprocessing step to adjust craniocaudal boundaries of level autosegmentations to the CT slice plane was introduced and the effect of autocontour consistency with CT slice plane orientation on geometric accuracy and expert rating was investigated. Results Blinded expert ratings for deep learning segmentations and expert-created contours were not significantly different. Deep learning segmentations with slice plane adjustment were rated numerically higher (mean, 81.0 vs. 79.6, p = 0.185) and deep learning segmentations without slice plane adjustment were rated numerically lower (77.2 vs. 79.6, p = 0.167) than manually drawn contours. In a head-to-head comparison, deep learning segmentations with CT slice plane adjustment were rated significantly better than deep learning contours without slice plane adjustment (81.0 vs. 77.2, p = 0.004). Geometric accuracy of deep learning segmentations was not different from intraobserver variability (mean Dice per level, 0.76 vs. 0.77, p = 0.307). Clinical significance of contour consistency with CT slice plane orientation was not represented by geometric accuracy metrics (volumetric Dice, 0.78 vs. 0.78, p = 0.703). Conclusions We show that a nnU-net 3D-fullres/2D-ensemble model can be used for highly accurate autodelineation of HN_LNL using only a limited training dataset that is ideally suited for large-scale standardized autodelineation of HN_LNL in the research setting. Geometric accuracy metrics are only an imperfect surrogate for blinded expert rating.
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Affiliation(s)
- Thomas Weissmann
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Yixing Huang
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Stefan Fischer
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Johannes Roesch
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Sina Mansoorian
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Horacio Ayala Gaona
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Antoniu-Oreste Gostian
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany.,Department of Otolaryngology, Head and Neck Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Markus Hecht
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Sebastian Lettmaier
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Lisa Deloch
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany.,Translational Radiobiology, Department of Radiation Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Benjamin Frey
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany.,Translational Radiobiology, Department of Radiation Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Udo S Gaipl
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany.,Translational Radiobiology, Department of Radiation Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Luitpold Valentin Distel
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Andreas Maier
- Pattern Recognition Lab, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Heinrich Iro
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany.,Department of Otolaryngology, Head and Neck Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Sabine Semrau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Florian Putz
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
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8
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Roesch J, Oertel M, Fabian A, Höck M, von der Grün J, Löser A, Süss C, Vinsensia M, Tamaskovics B, Heß S, Waltenberger M, Wegen S, Trommer M, Mäurer M, Medenwald D, Rühle A, Käsmann L, Fleischmann D, Dobiasch S, Hecht M. PH-0054 Re-Irradiation in head & neck cancer - a pooled analysis of 253 individual cases. Radiother Oncol 2021. [DOI: 10.1016/s0167-8140(21)07236-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Oft D, Schmidt MA, Weissmann T, Roesch J, Mengling V, Masitho S, Bert C, Lettmaier S, Frey B, Distel LV, Fietkau R, Putz F. Volumetric Regression in Brain Metastases After Stereotactic Radiotherapy: Time Course, Predictors, and Significance. Front Oncol 2021; 10:590980. [PMID: 33489888 PMCID: PMC7820888 DOI: 10.3389/fonc.2020.590980] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 08/03/2020] [Accepted: 11/26/2020] [Indexed: 11/13/2022] Open
Abstract
Background There is insufficient understanding of the natural course of volumetric regression in brain metastases after stereotactic radiotherapy (SRT) and optimal volumetric criteria for the assessment of response and progression in radiotherapy clinical trials for brain metastases are currently unknown. Methods Volumetric analysis via whole-tumor segmentation in contrast-enhanced 1 mm³-isotropic T1-Mprage sequences before SRT and during follow-up. A total of 3,145 MRI studies of 419 brain metastases from 189 patients were segmented. Progression was defined using a volumetric extension of the RANO-BM criteria. A subset of 205 metastases without progression/radionecrosis during their entire follow-up of at least 3 months was used to study the natural course of volumetric regression after SRT. Predictors for volumetric regression were investigated. A second subset of 179 metastases was used to investigate the prognostic significance of volumetric response at 3 months (defined as ≥20% and ≥65% volume reduction, respectively) for subsequent local control. Results Median relative metastasis volume post-SRT was 66.9% at 6 weeks, 38.6% at 3 months, 17.7% at 6 months, 2.7% at 12 months and 0.0% at 24 months. Radioresistant histology and FSRT vs. SRS were associated with reduced tumor regression for all time points. In multivariate linear regression, radiosensitive histology (p=0.006) was the only significant predictor for metastasis regression at 3 months. Volumetric regression ≥20% at 3 months post-SRT was the only significant prognostic factor for subsequent control in multivariate analysis (HR 0.63, p=0.023), whereas regression ≥65% was no significant predictor. Conclusions Volumetric regression post-SRT does not occur at a constant rate but is most pronounced in the first 6 weeks to 3 months. Despite decreasing over time, volumetric regression continues beyond 6 months post-radiotherapy and may lead to complete resolution of controlled lesions by 24 months. Radioresistant histology is associated with slower regression. We found that a cutoff of ≥20% regression for the volumetric definition of response at 3 months post-SRT was predictive for subsequent control whereas the currently proposed definition of ≥65% was not. These results have implications for standardized volumetric criteria in future radiotherapy trials for brain metastases.
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Affiliation(s)
- Dominik Oft
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Manuel Alexander Schmidt
- Department of Neuroradiology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Thomas Weissmann
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Johannes Roesch
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Veit Mengling
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Siti Masitho
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Sebastian Lettmaier
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Benjamin Frey
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Luitpold Valentin Distel
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Florian Putz
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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10
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Putz F, Oft D, Perrin R, Mengling V, Weissmann T, Roesch J, Mansoorian S, Distel L, Bert C, Fietkau R. PD-0170: Volumetric regression in brain metastases after stereotactic RT: Time course and significance. Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(21)00194-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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11
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Putz F, Weissmann T, Oft D, Schmidt MA, Roesch J, Siavooshhaghighi H, Filimonova I, Schmitter C, Mengling V, Bert C, Frey B, Lettmaier S, Distel LV, Semrau S, Fietkau R. FSRT vs. SRS in Brain Metastases-Differences in Local Control and Radiation Necrosis-A Volumetric Study. Front Oncol 2020; 10:559193. [PMID: 33102223 PMCID: PMC7554610 DOI: 10.3389/fonc.2020.559193] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [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: 05/05/2020] [Accepted: 08/12/2020] [Indexed: 12/13/2022] Open
Abstract
Background: While the role of stereotactic radiotherapy for brain metastases is increasing, evidence on the comparative efficacy and safety of fractionated stereotactic radiotherapy (FSRT) and single-session radiosurgery (SRS) is scarce. Methods: Longitudinal volumetric analysis was performed in a consecutive cohort of 120 patients and 190 brain metastases (>0.065 cm3 in volume / > ~5 mm in diameter) treated exclusively with FSRT (n = 98) and SRS (n = 92), respectively. A total of 972 tumor segmentations was used, averaging 5.1 time points per metastasis. Progression was defined using a volumetric extension of the RANO-BM criteria. Local control and radionecrosis were compared for lesions treated with FSRT and SRS, respectively. Results: Metastases treated with FSRT were significantly larger at baseline (mean, 4.66 vs. 0.40 cm3, p < 0.001). Biologically effective dose (BED) for metastases (α/β = 12, linear-quadratic-cubic model) was significantly associated with local control, whereas BED for normal brain (α/β = 2, linear-quadratic model) was significantly associated with radionecrosis. Median time to local progression was 22.9 months in the FSRT group compared to 14.5 months in the SRS group (p = 0.022). Overall radionecrosis rate at 12 months was 3.4% for FSRT and 14.8% for SRS (p = 0.010). Radionecrosis °IV requiring resection with histologic proof of radiation necrosis also was significantly reduced in the FSRT group (FSRT 0.0% vs. SRS 3.9%, p = 0.041). In multivariate analysis, FSRT was associated with reduced risk of progression (HR 0.47, p = 0.015) and reduced risk of radionecrosis (HR 0.18, p = 0.045). Conclusions: This volumetric study provides initial evidence that the improvements in therapeutic ratio expected for FSRT in larger brain metastases, might equally extend into the domain of smaller metastases, traditionally less considered for fractionated treatment. FSRT might constitute an important tool to further increase local control and reduce radionecrosis risk in stereotactic radiotherapy for brain metastases, that should be assessed in randomized intervention trials.
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Affiliation(s)
- Florian Putz
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Thomas Weissmann
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Dominik Oft
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Manuel Alexander Schmidt
- Department of Neuroradiology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Johannes Roesch
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Hadi Siavooshhaghighi
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Irina Filimonova
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Charlotte Schmitter
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Veit Mengling
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Benjamin Frey
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Sebastian Lettmaier
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Luitpold Valentin Distel
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Sabine Semrau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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12
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Pavic M, Bogowicz M, Würms X, Glatz S, Finazzi T, Riesterer O, Roesch J, Rudofsky L, Friess M, Veit-Haibach P, Huellner M, Opitz I, Weder W, Frauenfelder T, Guckenberger M, Tanadini-Lang S. Influence of inter-observer delineation variability on radiomics stability in different tumor sites. Acta Oncol 2018. [PMID: 29513054 DOI: 10.1080/0284186x.2018.1445283] [Citation(s) in RCA: 126] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Radiomics is a promising methodology for quantitative analysis and description of radiological images using advanced mathematics and statistics. Tumor delineation, which is still often done manually, is an essential step in radiomics, however, inter-observer variability is a well-known uncertainty in radiation oncology. This study investigated the impact of inter-observer variability (IOV) in manual tumor delineation on the reliability of radiomic features (RF). METHODS Three different tumor types (head and neck squamous cell carcinoma (HNSCC), malignant pleural mesothelioma (MPM) and non-small cell lung cancer (NSCLC)) were included. For each site, eleven individual tumors were contoured on CT scans by three experienced radiation oncologists. Dice coefficients (DC) were calculated for quantification of delineation variability. RF were calculated with an in-house developed software implementation, which comprises 1404 features: shape (n = 18), histogram (n = 17), texture (n = 137) and wavelet (n = 1232). The IOV of RF was studied using the intraclass correlation coefficient (ICC). An ICC >0.8 indicates a good reproducibility. For the stable RF, an average linkage hierarchical clustering was performed to identify classes of uncorrelated features. RESULTS Median DC was high for NSCLC (0.86, range 0.57-0.90) and HNSCC (0.72, 0.21-0.89), whereas it was low for MPM (0.26, 0-0.9) indicating substantial IOV. Stability rate of RF correlated with DC and depended on tumor site, showing a high stability in NSCLC (90% of total parameters), acceptable stability in HNSCC (59% of total parameters) and low stability in MPM (36% of total parameters). Shape features showed the weakest stability across all tumor types. Hierarchical clustering revealed 14 groups of correlated and stable features for NSCLC and 6 groups for both HNSCC and MPM. CONCLUSION Inter-observer delineation variability has a relevant influence on radiomics analysis and is strongly influenced by tumor type. This leads to a reduced number of suitable imaging features.
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Affiliation(s)
- Matea Pavic
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Marta Bogowicz
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Xaver Würms
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Stefan Glatz
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Tobias Finazzi
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Oliver Riesterer
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Johannes Roesch
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Leonie Rudofsky
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Martina Friess
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Patrick Veit-Haibach
- Department of Nuclear Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Martin Huellner
- Department of Nuclear Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Walter Weder
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Frauenfelder
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
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13
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Karava K, Ehrbar S, Riesterer O, Roesch J, Glatz S, Klöck S, Guckenberger M, Tanadini-Lang S. Potential dosimetric benefits of adaptive tumor tracking over the internal target volume concept for stereotactic body radiation therapy of pancreatic cancer. Radiat Oncol 2017; 12:175. [PMID: 29121945 PMCID: PMC5680781 DOI: 10.1186/s13014-017-0906-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 10/30/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Radiotherapy for pancreatic cancer has two major challenges: (I) the tumor is adjacent to several critical organs and, (II) the mobility of both, the tumor and its surrounding organs at risk (OARs). A treatment planning study simulating stereotactic body radiation therapy (SBRT) for pancreatic tumors with both the internal target volume (ITV) concept and the tumor tracking approach was performed. The two respiratory motion-management techniques were compared in terms of doses to the target volume and organs at risk. METHODS AND MATERIALS Two volumetric-modulated arc therapy (VMAT) treatment plans (5 × 5 Gy) were created for each of the 12 previously treated pancreatic cancer patients, one using the ITV concept and one the tumor tracking approach. To better evaluate the overall dose delivered to the moving tumor volume, 4D dose calculations were performed on four-dimensional computed tomography (4DCT) scans. The resulting planning target volume (PTV) size for each technique was analyzed. Target and OAR dose parameters were reported and analyzed for both 3D and 4D dose calculation. RESULTS Tumor motion ranged from 1.3 to 11.2 mm. Tracking led to a reduction of PTV size (max. 39.2%) accompanied with significant better tumor coverage (p<0.05, paired Wilcoxon signed rank test) both in 3D and 4D dose calculations and improved organ at risk sparing. Especially for duodenum, stomach and liver, the mean dose was significantly reduced (p<0.05) with tracking for 3D and 4D dose calculations. CONCLUSIONS By using an adaptive tumor tracking approach for respiratory-induced pancreatic motion management, a significant reduction in PTV size can be achieved, which subsequently facilitates treatment planning, and improves organ dose sparing. The dosimetric benefit of tumor tracking is organ and patient-specific.
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Affiliation(s)
- Konstantina Karava
- Department of Radiation Oncology, University Hospital Zurich (USZ), Rämistrasse 100, Zurich, 8091, Switzerland. .,University of Zurich, Rämistrasse 71, Zurich, 8006, Switzerland.
| | - Stefanie Ehrbar
- Department of Radiation Oncology, University Hospital Zurich (USZ), Rämistrasse 100, Zurich, 8091, Switzerland.,University of Zurich, Rämistrasse 71, Zurich, 8006, Switzerland
| | - Oliver Riesterer
- Department of Radiation Oncology, University Hospital Zurich (USZ), Rämistrasse 100, Zurich, 8091, Switzerland.,University of Zurich, Rämistrasse 71, Zurich, 8006, Switzerland
| | - Johannes Roesch
- Department of Radiation Oncology, University Hospital Zurich (USZ), Rämistrasse 100, Zurich, 8091, Switzerland.,University of Zurich, Rämistrasse 71, Zurich, 8006, Switzerland
| | - Stefan Glatz
- Department of Radiation Oncology, University Hospital Zurich (USZ), Rämistrasse 100, Zurich, 8091, Switzerland.,University of Zurich, Rämistrasse 71, Zurich, 8006, Switzerland
| | - Stephan Klöck
- Department of Radiation Oncology, University Hospital Zurich (USZ), Rämistrasse 100, Zurich, 8091, Switzerland.,University of Zurich, Rämistrasse 71, Zurich, 8006, Switzerland
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich (USZ), Rämistrasse 100, Zurich, 8091, Switzerland.,University of Zurich, Rämistrasse 71, Zurich, 8006, Switzerland
| | - Stephanie Tanadini-Lang
- Department of Radiation Oncology, University Hospital Zurich (USZ), Rämistrasse 100, Zurich, 8091, Switzerland.,University of Zurich, Rämistrasse 71, Zurich, 8006, Switzerland
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14
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Roesch J, Cho JB, Fahim DK, Gerszten PC, Flickinger JC, Grills IS, Jawad M, Kersh R, Letourneau D, Mantel F, Sahgal A, Shin JH, Winey B, Guckenberger M. Risk for surgical complications after previous stereotactic body radiotherapy of the spine. Radiat Oncol 2017; 12:153. [PMID: 28893299 PMCID: PMC5594477 DOI: 10.1186/s13014-017-0887-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 09/05/2017] [Indexed: 11/10/2022] Open
Abstract
OBJECT Stereotactic body radiotherapy (SBRT) for vertebral metastases has emerged as a promising technique, offering high rates of symptom relief and local control combined with low risk of toxicity. Nonetheless, local failure or vertebral instability may occur after spine SBRT, generating the need for subsequent surgery in the irradiated region. This study evaluated whether there is an increased incidence of surgical complications in patients previously treated with SBRT at the index level. METHODS Based upon a retrospective international database of 704 cases treated with SBRT for vertebral metastases, 30 patients treated at 6 different institutions were identified who underwent surgery in a region previously treated with SBRT. RESULTS Thirty patients, median age 59 years (range 27-84 years) underwent SBRT for 32 vertebral metastases followed by surgery at the same vertebra. Median follow-up time from SBRT was 17 months. In 17 cases, conventional radiotherapy had been delivered prior to SBRT at a median dose of 30 Gy in median 10 fractions. SBRT was administered with a median prescription dose of 19.3 Gy (range 15-65 Gy) delivered in median 1 fraction (range 1-17) (median EQD2/10 = 44 Gy). The median time interval between SBRT and surgical salvage therapy was 6 months (range 1-39 months). Reasons for subsequent surgery were pain (n = 28), neurological deterioration (n = 15) or fracture of the vertebral body (n = 13). Open surgical decompression (n = 24) and/or stabilization (n = 18) were most frequently performed; Five patients (6 vertebrae) were treated without complications with vertebroplasty only. Increased fibrosis complicating the surgical procedure was explicitly stated in one surgical report. Two durotomies occurred which were closed during the operation, associated with a neurological deficit in one patient. Median blood loss was 500 ml, but five patients had a blood loss of more than 1 l during the procedure. Delayed wound healing was reported in two cases. One patient died within 30 days of the operation. CONCLUSION In this series of surgical interventions following spine SBRT, the overall complication rate was 19%, which appears comparable to primary surgery without previous SBRT. Prior spine SBRT does not appear to significantly increase the risk of intra- and post-surgical complications.
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Affiliation(s)
- Johannes Roesch
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - John B.C. Cho
- Princess Margaret Cancer Centre, Radiation Medicine Program, Toronto, Canada
| | - Daniel K. Fahim
- Department of Neurosurgery, William Beaumont Hospital, Royal Oak, Michigan USA
| | - Peter C. Gerszten
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania USA
| | - John C. Flickinger
- Department of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania USA
| | - Inga S. Grills
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan USA
| | - Maha Jawad
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan USA
| | - Ronald Kersh
- Department of Radiation Oncology, Riverside Medical Center, Newport News, Virginia USA
| | - Daniel Letourneau
- Princess Margaret Cancer Centre, Radiation Medicine Program, Toronto, Canada
| | - Frederick Mantel
- Department of Radiation Oncology, University Hospital Würzburg, Würzburg, Germany
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - John H. Shin
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts USA
| | - Brian Winey
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts USA
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Roesch J, Cho J, Fahim D, Flickinger J, Gerszten P, Grills I, Jawad M, Kersh R, Letourneau D, Mantel F, Sahgal A, Shin J, Winey B, Guckenberger M. PO-0653: Surgical interventions after previous SBRT of the spine - increased risk for complications? Radiother Oncol 2016. [DOI: 10.1016/s0167-8140(16)31903-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Roesch J, Andratschke N, Guckenberger M. SBRT in operable early stage lung cancer patients. Transl Lung Cancer Res 2015; 3:212-24. [PMID: 25806303 DOI: 10.3978/j.issn.2218-6751.2014.08.06] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 08/12/2014] [Indexed: 12/25/2022]
Abstract
Since decades the gold standard for treatment of early stage non-small cell lung cancer (NSCLC) is surgical lobectomy plus mediastinal lymph node dissection. Patients in worse health status are treated with sublobar resection or radiation treatment. With development of stereotactic-body-radiotherapy (SBRT), outcome of patients treated with radiation was substantially improved. Comparison of SBRT and surgical techniques is difficult due to the lack of randomized trials. However, all available evidence in form of case control studies of population based studies show equivalence between sublobar resection and SBRT indicating that SBRT-when performed by a trained and experienced team-should be offered to all high-risk surgical patients. For patients not willing to take the risk of lobectomy and therefore refusing surgery, SBRT is an excellent treatment option.
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Affiliation(s)
- Johannes Roesch
- Department of Radiation Oncology, University Hospital Zurich, Zürich, Switzerland
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich, Zürich, Switzerland
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Strecker T, Agaimy A, Roesch J, Weyand M. Pathological Findings in Cardiac Apex Removed during Implantation of Left Ventricular Assist Devices (LVAD) are Non-Specific. A 13-Year-Experience at a German Heart Center. Thorac Cardiovasc Surg 2015. [DOI: 10.1055/s-0035-1544327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Lang S, Struffert T, Kloska S, Engelhorn T, Gölitz P, Roesch J, Dörfler A. Flow-Diverter im Langzeit-Follow up: FD-CTA vs. DSA. ROFO-FORTSCHR RONTG 2014. [DOI: 10.1055/s-0034-1373336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Lang S, Struffert T, Gölitz P, Roesch J, Dörfler A. Visualisierung spinaler Gefäßmalformationen mit der 3D-DSA. ROFO-FORTSCHR RONTG 2014. [DOI: 10.1055/s-0034-1373353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Guckenberger M, Roesch J, Baier K, Sweeney R, Flentje M. OC-0045 GEOMETRIC AND DOSIMETRIC ACCURACY OF FRAME-LESS IMAGE-GUIDED RADIOSURGERY IN CLINICAL PRACTICE. Radiother Oncol 2012. [DOI: 10.1016/s0167-8140(12)70384-5] [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: 11/30/2022]
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Guckenberger M, Roesch J, Baier K, Sweeney RA, Flentje M. Dosimetric consequences of translational and rotational errors in frame-less image-guided radiosurgery. Radiat Oncol 2012; 7:63. [PMID: 22531060 PMCID: PMC3441228 DOI: 10.1186/1748-717x-7-63] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [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: 03/27/2012] [Accepted: 04/24/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To investigate geometric and dosimetric accuracy of frame-less image-guided radiosurgery (IG-RS) for brain metastases. METHODS AND MATERIALS Single fraction IG-RS was practiced in 72 patients with 98 brain metastases. Patient positioning and immobilization used either double- (n = 71) or single-layer (n = 27) thermoplastic masks. Pre-treatment set-up errors (n = 98) were evaluated with cone-beam CT (CBCT) based image-guidance (IG) and were corrected in six degrees of freedom without an action level. CBCT imaging after treatment measured intra-fractional errors (n = 64). Pre- and post-treatment errors were simulated in the treatment planning system and target coverage and dose conformity were evaluated. Three scenarios of 0 mm, 1 mm and 2 mm GTV-to-PTV (gross tumor volume, planning target volume) safety margins (SM) were simulated. RESULTS Errors prior to IG were 3.9 mm ± 1.7 mm (3D vector) and the maximum rotational error was 1.7° ± 0.8° on average. The post-treatment 3D error was 0.9 mm ± 0.6 mm. No differences between double- and single-layer masks were observed. Intra-fractional errors were significantly correlated with the total treatment time with 0.7 mm ± 0.5 mm and 1.2 mm ± 0.7 mm for treatment times ≤23 minutes and >23 minutes (p<0.01), respectively. Simulation of RS without image-guidance reduced target coverage and conformity to 75% ± 19% and 60% ± 25% of planned values. Each 3D set-up error of 1 mm decreased target coverage and dose conformity by 6% and 10% on average, respectively, with a large inter-patient variability. Pre-treatment correction of translations only but not rotations did not affect target coverage and conformity. Post-treatment errors reduced target coverage by >5% in 14% of the patients. A 1 mm safety margin fully compensated intra-fractional patient motion. CONCLUSIONS IG-RS with online correction of translational errors achieves high geometric and dosimetric accuracy. Intra-fractional errors decrease target coverage and conformity unless compensated with appropriate safety margins.
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Vater P, Laue C, Jacobs I, Heise S, Jiang H, Brandt R, Roesch J, Haag J. New achievements in industrial applications of nuclear track microfilters. ACTA ACUST UNITED AC 1993. [DOI: 10.1016/0969-8078(93)90211-l] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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