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Laughlin BS, Bhangoo RS, Niska JR, Thorpe CS, Girardo ME, Anderson JD, Kosiorek HE, McGee LA, Hartsell WF, Chang JH, Rossi CJ, Tsai HK, Choi IJ, Vargas CE. Proton therapy for isolated local regional recurrence of breast cancer after mastectomy alone. Front Oncol 2022; 12:925078. [DOI: 10.3389/fonc.2022.925078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 11/10/2022] [Indexed: 11/29/2022] Open
Abstract
Purpose/ObjectivesTo assess adverse events (AEs) and disease-specific outcomes after proton therapy for isolated local-regional recurrence (LRR) of breast cancer after mastectomy without prior radiotherapy (RT).Materials/MethodsPatients were identified from a multi-institutional prospective registry and included if diagnosed with invasive breast cancer, initially underwent mastectomy without adjuvant RT, experienced an LRR, and subsequently underwent salvage treatment, including proton therapy. Follow-up and cancer outcomes were measured from the date of RT completion.ResultsNineteen patients were included. Seventeen patients were treated with proton therapy to the chest wall and comprehensive regional lymphatics (17/19, 90%). Maximum grade AE was grade 2 in 13 (69%) patients and grade 3 in 4 (21%) patients. All patients with grade 3 AE received > 60 GyE (p=0.04, Spearman correlation coefficient=0.5). At the last follow-up, 90% of patients were alive with no LRR or distant recurrence.ConclusionsFor breast cancer patients with isolated LRR after initial mastectomy without adjuvant RT, proton therapy is well-tolerated in the salvage setting with excellent loco-regional control. All grade 3 AEs occurred in patients receiving > 60 GyE.
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2
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Laughlin BS, Bhangoo RS, Thorpe CS, Golafshar MA, DeWees TA, Anderson JD, Vern-Gross TZ, McGee LA, Wong WW, Halyard MY, Keole SR, Vargas CE. Patient-reported outcomes for patients with breast cancer undergoing radiotherapy: A single-center registry experience. Front Oncol 2022; 12:920739. [PMID: 36091145 PMCID: PMC9458857 DOI: 10.3389/fonc.2022.920739] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 08/08/2022] [Indexed: 11/29/2022] Open
Abstract
Background We present Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) for patients undergoing adjuvant radiotherapy for breast cancer with curative intent. We describe the frequency and severity of PRO-CTCAE and analyze them with respect to dose fractionation. Methods Patients were included in this study if they were treated with curative intent for breast cancer and enrolled on a prospective registry. Patients must have completed at least one baseline and one post-radiation survey that addressed PRO-CTCAE. For univariate and multivariate analysis, categorical variables were analyzed by Fisher’s exact test and continuous variables by Wilcoxon rank sum test. PRO-CTCAE items graded ≥2 and ≥3 were analyzed between patients who received hypofractionation (HF) versus standard conventional fractionation (CF) therapy by the Chi-square test. Results Three hundred thirty-one patients met inclusion criteria. Pathologic tumor stage was T1–T2 in 309 (94%) patients. Eighty-seven (29%) patients were node positive. Two hundred forty-seven patients (75%) experienced any PRO-CTCAE grade ≥2, and 92 (28%) patients experienced any PRO-CTCAE grade ≥3. CF was found to be associated with an increased risk of grade ≥3 skin toxicity, swallowing, and nausea (all p < 0.01). HF (OR 0.48, p < 0.01) was significant in the multivariate model for decreased risk of any occurrence of PRO-CTCAE ≥3. Conclusions Our study reports one of the first clinical experiences utilizing multiple PRO-CTCAE items for patients with breast cancer undergoing radiation therapy with curative intent. Compared with CF, HF was associated with a significant decrease in any PRO-CTCAE ≥3 after multivariate analysis.
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Affiliation(s)
- Brady S. Laughlin
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | - Ronik S. Bhangoo
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | - Cameron S. Thorpe
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | - Michael A. Golafshar
- Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ, United States
| | - Todd A. DeWees
- Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ, United States
| | - Justin D. Anderson
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | | | - Lisa A. McGee
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | - William W. Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | - Michele Y. Halyard
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | - Sameer R. Keole
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | - Carlos E. Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
- *Correspondence: Carlos E. Vargas,
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Bhangoo RS, Cheng TW, Petersen MM, Thorpe CS, DeWees TA, Anderson JD, Vargas CE, Patel SH, Halyard MY, Schild SE, Wong WW. Radiation recall dermatitis: A review of the literature. Semin Oncol 2022; 49:152-159. [DOI: 10.1053/j.seminoncol.2022.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/20/2021] [Accepted: 04/01/2022] [Indexed: 12/28/2022]
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4
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Thorpe CS, DeWees TA, Golafshar MA, Bhangoo RS, Vern-Gross TZ, McGee LA, Wong WW, Halyard MY, Keole SR, Vargas CE. Patient-reported outcomes version of the common terminology criteria for adverse events and quality-of-life linear analogue self-assessment in breast cancer patients receiving radiation therapy: single-institution prospective registry. J Patient Rep Outcomes 2022; 6:3. [PMID: 35006393 PMCID: PMC8748600 DOI: 10.1186/s41687-021-00408-9] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 12/23/2021] [Indexed: 11/26/2022] Open
Abstract
Purpose/objectives We sought to investigate the impact of patient-reported outcomes version of the common terminology criteria for adverse events (PRO-CTCAE) on overall quality-of-life (QOL) employing linear analogue self-assessment (LASA) in breast cancer (BC) patients undergoing radiation therapy (RT). Materials/methods All patients treated with RT for BC with curative intent from 2015 to 2019 at our institution were included. Breast specific PRO-CTCAE and overall QOL LASA questionnaires were administered at baseline, end-of-treatment, 3, 6, 12 months, and then annually. Minimal clinically important difference in overall QOL was a 10-point change in LASA. Hypofractionation was any treatment > 2 Gy per fraction. Mixed models for repeated measures were used to determine the association of PRO-CTCAE and overall QOL LASA. Results Three hundred thirty-one (331) patients with a median follow-up of 3.1 years (range 0.4–4.9) were included. Average overall QOL LASA scores were 78.5 at baseline, 79.8 at end-of-treatment, 79.8 at 3 months, 77.1 at 6 months, 79.4 at 12 months, and 79.7 at 24 months. On univariate analysis, patients reporting a grade ≥ 3 PRO-CTCAE had, on average, a 10.4-point reduction in overall LASA QOL (p < 0.0001). On multivariate analysis, not being treated with hypofractionation and higher BMI were predictive for worse overall LASA QOL with a 10-point reduction in LASA for patients reporting a grade ≥ 3 PRO-CTCAE (p < 0.0001). Conclusions Patients reporting a grade ≥ 3 PRO-CTCAE experienced statistically significant and clinically meaningful deterioration in overall QOL LASA. Hypofractionation improved QOL while higher BMI predicted for worse QOL. PRO-CTCAE should be integrated into future clinical trials.
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Affiliation(s)
- C S Thorpe
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, USA
| | - T A DeWees
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, USA.,Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ, USA
| | - M A Golafshar
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, USA
| | - R S Bhangoo
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, USA
| | - T Z Vern-Gross
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, USA
| | - L A McGee
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, USA
| | - W W Wong
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, USA
| | - M Y Halyard
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, USA
| | - S R Keole
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, USA
| | - C E Vargas
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, USA.
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5
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Bulman GF, Bhangoo RS, DeWees TA, Petersen MM, Thorpe CS, Wong WW, Rwigema JCM, Daniels TB, Keole SR, Schild SE, Vargas CE. Dose-volume histogram parameters and patient-reported EPIC-Bowel domain in prostate cancer proton therapy. Radiat Oncol J 2021; 39:122-128. [PMID: 34619829 PMCID: PMC8497859 DOI: 10.3857/roj.2021.00388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 05/14/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose To analyze rectal dose and changes in quality of life (QOL) measured with the Expanded Prostate and Cancer Index Composite (EPIC) bowel domain in patients being treated for prostate cancer with curative-intent proton beam therapy (PBT) within a large single-institution prospective registry. Materials and Methods Data was collected from 243 patients with localized prostate cancer treated with PBT from 2016 to 2018. The EPIC survey was administered at baseline, end-of-treatment, 3, 6, and 12 months, then annually. Dose-volume histogram (DVH) parameters for the rectum were computed, and rectal dose was analyzed using BED (α/β = 3), EQD2Gy, and total dose. Repeated measures mixed models were implemented to determine the effect of patient, clinical, and treatment factors (including DVH) on patient-reported bowel symptom burden (EPIC-Bowel). Results Treatment overall resulted in changes in EPIC-Bowel scores (baseline score = 93.7), most notably at end-of-treatment (90.6) and 12 months (89.7). However, they returned to baseline at 36 months (92.9). On multivariate modeling, rectal BED D25 (Gy) ≥23% was significantly associated with decline in QOL scores measuring bother (p < 0.01; 4.06 points different). Conclusion Rectal doses, specifically BED D25 (Gy) ≥23%, are significantly associated with decline in bowel bother-related QOL in patients undergoing definitive radiotherapy for localized prostate cancer. This study demonstrates BED as an independent predictor of bowel QOL across dose fractionations of PBT.
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Affiliation(s)
| | - Ronik S Bhangoo
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Todd A DeWees
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA.,Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ, USA
| | - Molly M Petersen
- Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ, USA
| | | | - William W Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | | | | | - Sameer R Keole
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Carlos E Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
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6
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Bhangoo RS, Petersen MM, Bulman GF, Vargas CE, Thorpe CS, Shen J, Wong WW, Rwigema JCM, Daniels TB, Keole SR, Schild SE, Rong Y, DeWees TA. Biologically Effective Dose and Rectal Bleeding in Definitive Proton Therapy for Prostate Cancer. Int J Part Ther 2021; 8:37-46. [PMID: 35530190 PMCID: PMC9009455 DOI: 10.14338/ijpt-21-00007.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 07/27/2021] [Indexed: 12/03/2022] Open
Abstract
Purpose and Objectives With increasing use of hypofractionation and extreme hypofractionation for prostate cancer, rectal dose-volume histogram (DVH) parameters that apply across dose fractionations may be helpful for treatment planning in clinical practice. We present an exploratory analysis of biologically effective rectal dose (BED) and equivalent rectal dose in 2 Gy fractions (EQD2) for rectal bleeding in patients treated with proton therapy across dose fractionations. Materials and Methods From 2016 to 2018, 243 patients with prostate cancer were treated with definitive proton therapy. Rectal DVH parameters were obtained from treatment plans, and rectal bleeding events were recorded. The BED and EQD2 transformations were applied to each rectal DVH parameter. Univariate analysis using logistic regression was used to determine DVH parameters that were significant predictors of grade ≥ 2 rectal bleeding. Youden index was used to determine optimum cutoffs for clinically meaningful DVH constraints. Stepwise model-selection criteria were then applied to fit a “best” multivariate logistic model for predicting Common Terminology Criteria for Adverse Events grade ≥ 2 rectal bleeding. Results Conventional fractionation, hypofractionation, and extreme hypofractionation were prescribed to 117 (48%), 84 (34%), and 42 (17.3%) patients, respectively. With a median follow-up of 20 (2.5-40) months, 10 (4.1%) patients experienced rectal bleeding. On univariate analysis, multiple rectal DVH parameters were significantly associated with rectal bleeding across BED, EQD2, and nominal doses. The BED volume receiving 55 Gy > 13.91% was found to be statistically and clinically significant. The BED volume receiving 55 Gy remained statistically significant for an association with rectal bleeding in the multivariate model (odds ratio, 9.81; 95% confidence interval, 2.4-40.5; P = .002). Conclusion In patients undergoing definitive proton therapy for prostate cancer, dose to the rectum and volume of the rectum receiving the dose were significantly associated with rectal bleeding across conventional fractionation, hypofractionation, and extreme hypofractionation when using BED and EQD2 transformations.
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Affiliation(s)
| | - Molly M. Petersen
- Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ, USA
| | | | | | | | - Jason Shen
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - William W. Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | | | | | - Sameer R. Keole
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | | | - Yi Rong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Todd A. DeWees
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
- Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ, USA
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7
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Bhangoo RS, Mullikin TC, Ashman JB, Cheng TW, Golafshar MA, DeWees TA, Johnson JE, Shiraishi S, Liu W, Hu Y, Merrell KW, Haddock MG, Krishnan S, Rule WG, Sio TT, Hallemeier CL. Intensity Modulated Proton Therapy for Hepatocellular Carcinoma: Initial Clinical Experience. Adv Radiat Oncol 2021; 6:100675. [PMID: 34409199 PMCID: PMC8361033 DOI: 10.1016/j.adro.2021.100675] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/14/2021] [Accepted: 02/10/2021] [Indexed: 02/08/2023] Open
Abstract
Purpose Our purpose was to assess the safety and efficacy of intensity modulated proton therapy (IMPT) for the treatment of hepatocellular carcinoma (HCC). Methods and Materials A retrospective review was conducted on all patients who were treated with IMPT for HCC with curative intent from June 2015 to December 2018. All patients had fiducials placed before treatment. Inverse treatment planning used robust optimization with 2 to 3 beams. The majority of patients were treated in 15 fractions (n = 30, 81%, 52.5-67.5 Gy, relative biological effectiveness), whereas the remainder were treated in 5 fractions (n = 7, 19%, 37.5-50 Gy, relative biological effectiveness). Daily image guidance consisted of orthogonal kilovoltage x-rays and use of a 6° of freedom robotic couch. Outcomes (local control, progression free survival, and overall survival) were determined using Kaplan-Meier methods. Results Thirty-seven patients were included. The median follow-up for living patients was 21 months (Q1-Q3, 17-30 months). Pretreatment Child-Pugh score was A5-6 in 70% of patients and B7-9 in 30% of patients. Nineteen patients had prior liver directed therapy for HCC before IMPT. Eight patients (22%) required a replan during treatment, most commonly due to inadequate clinical target volume coverage. One patient (3%) experienced a grade 3 acute toxicity (pain) with no recorded grade 4 or 5 toxicities. An increase in Child-Pugh score by ≥ 2 within 3 months of treatment was observed in 6 patients (16%). At 1 year, local control was 94%, intrahepatic control was 54%, progression free survival was 35%, and overall survival was 78%. Conclusions IMPT is safe and feasible for treatment of HCC.
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Affiliation(s)
- Ronik S Bhangoo
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Trey C Mullikin
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Tiffany W Cheng
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | | | - Todd A DeWees
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona.,Department of Health Sciences Research, Mayo Clinic, Scottsdale, Arizona
| | | | - Satomi Shiraishi
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Yanle Hu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | | | | | - Sunil Krishnan
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - William G Rule
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
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8
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Yang Y, Vargas CE, Bhangoo RS, Wong WW, Schild SE, Daniels TB, Keole SR, Rwigema JCM, Glass JL, Shen J, DeWees TA, Liu T, Bues M, Fatyga M, Liu W. Exploratory Investigation of Dose-Linear Energy Transfer (LET) Volume Histogram (DLVH) for Adverse Events Study in Intensity Modulated Proton Therapy (IMPT). Int J Radiat Oncol Biol Phys 2021; 110:1189-1199. [PMID: 33621660 DOI: 10.1016/j.ijrobp.2021.02.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 01/25/2021] [Accepted: 02/11/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE We proposed a novel tool-a dose linear energy transfer (LET)-volume histogram (DLVH)-and performed an exploratory study to investigate rectal bleeding in prostate cancer treated with intensity modulated proton therapy. METHODS AND MATERIALS The DLVH was constructed with dose and LET as 2 axes, and the normalized volume of the structure was contoured in the dose-LET plane as isovolume lines. We defined the DLVH index, DLv%(d,l) (ie, v% of the structure) to have a dose of ≥d Gy and an LET of ≥l keV/μm, similar to the dose-volume histogram index Dv%. Nine patients with prostate cancer with rectal bleeding (Common Terminology Criteria for Adverse Events grade ≥2) were included as the adverse event group, and 48 patients with no complications were considered the control group. A P value map was constructed by comparison of the DLVH indices of all patients between the 2 groups using the Mann-Whitney U test. Dose-LET volume constraints (DLVCs) were derived based on the P value map with a manual selection procedure facilitated by Spearman's correlation tests. The obtained DLVCs were further cross-validated using a multivariate support vector machine (SVM)-based normal tissue complication probability (NTCP) model with an independent testing data set composed of 8 adverse event and 13 control patients. RESULTS We extracted 2 DLVC constraints. One DLVC was obtained, Vdose/LETboundary:2.5keVμmat 75 Gy to 3.2keVμmat8.65Gy <1.27% (DLVC1), revealing a high LET volume effect. The second DLVC, V(72.2Gy,0keVμm) < 2.23% (DVLC2), revealed a high dose volume effect. The SVM-based NTCP model with 2 DLVCs provided slightly superior performance than using dose only, with an area under the curve of 0.798 versus 0.779 for the testing data set. CONCLUSIONS Our results demonstrated the importance of rectal "hot spots" in both high LET (DLVC1) and high dose (DLVC2) in inducing rectal bleeding. The SVM-based NTCP model confirmed the derived DLVCs as good predictors for rectal bleeding when intensity modulated proton therapy is used to treat prostate cancer.
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Affiliation(s)
- Yunze Yang
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Carlos E Vargas
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Ronik S Bhangoo
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona
| | - William W Wong
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Thomas B Daniels
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Sameer R Keole
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona
| | | | - Jennifer L Glass
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Jiajian Shen
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Todd A DeWees
- Division of Biostatics, Mayo Clinic Arizona, Phoenix, Arizona
| | - Tianming Liu
- Department of Computer Science, the University of Georgia, Athens, Georgia
| | - Martin Bues
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Mirek Fatyga
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona.
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9
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Feng H, Shan J, Ashman JB, Rule WG, Bhangoo RS, Yu NY, Chiang J, Fatyga M, Wong WW, Schild SE, Sio TT, Liu W. Technical Note: 4D robust optimization in small spot intensity-modulated proton therapy (IMPT) for distal esophageal carcinoma. Med Phys 2021; 48:4636-4647. [PMID: 34058026 DOI: 10.1002/mp.15003] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To compare the dosimetric performances of small-spot three-dimensional (3D) and four-dimensional (4D) robustly optimized intensity-modulated proton (IMPT) plans in the presence of uncertainties and interplay effect simultaneously for distal esophageal carcinoma. METHOD AND MATERIALS Thirteen (13) patients were selected and re-planned with small-spot ( σ ~ 2-6 mm) 3D and 4D robust optimization in IMPT, respectively. The internal clinical target volumes (CTVhigh3d , CTVlow3d ) were used in 3D robust optimization. Different CTVs (CTVhigh4d , CTVlow4d ) were generated by subtracting an inner margin of the motion amplitudes in three cardinal directions from the internal CTVs and used in 4D robust optimization. All patients were prescribed the same dose to CTVs (50 Gy[RBE] for CTVhigh3d /CTVhigh4d and 45 Gy[RBE] for CTVlow3d /CTVlow4d ). Dose-volume histogram (DVH) indices were calculated to assess plan quality. Comprehensive plan robustness evaluations that consisted of 300 perturbed scenarios (10 different motion patterns to consider irregular motion (sampled from a Gaussian distribution) and 30 different uncertainties scenarios (sampled from a 4D uniform distribution) combined), were performed to quantify robustness to uncertainties and interplay effect simultaneously. Wilcoxon signed-rank test was used for statistical analysis. RESULTS Compared to 3D robustly optimized plans, 4D robustly optimized plans had statistically improved target coverage and better sparing of lungs and heart (heart Dmean , P = 0.001; heart V30Gy[RBE] , P = 0.001) in the nominal scenario. 4D robustly optimized plans had better robustness in target dose coverage (CTVhigh4d V100% , P = 0.002) and the protection of lungs and heart (heart Dmean , P = 0.001; heart V30Gy[RBE] , P = 0.001) when uncertainties and interplay effect were considered simultaneously. CONCLUSIONS Even with small spots in IMPT, 4D robust optimization outperformed 3D robust optimization in terms of normal tissue protection and robustness to uncertainties and interplay effect simultaneously. Our findings support the use of 4D robust optimization to treat distal esophageal carcinoma with small spots in IMPT.
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Affiliation(s)
- Hongying Feng
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Jie Shan
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Jonathan B Ashman
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - William G Rule
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Ronik S Bhangoo
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Nathan Y Yu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Jennifer Chiang
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Mirek Fatyga
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - William W Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, 85054, USA
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10
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Anderson JD, Hammond JB, Kosiorek HE, Thorpe CS, Bhangoo RS, Pockaj BA, Gray RJ, Cronin PA, Rebecca AM, Casey WJ, Wong WW, Keole SR, Vern-Gross TZ, McGee LA, Halyard MY, DeWees TA, Vargas CE. Unplanned implant removal in locally advanced breast cancer. Breast J 2021; 27:466-471. [PMID: 33715231 DOI: 10.1111/tbj.14224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/25/2021] [Accepted: 02/25/2021] [Indexed: 11/28/2022]
Abstract
Study conducted to determine frequency and timing of unplanned breast implant removal after mastectomy, reconstruction, and postmastectomy radiation (PMRT). From 2010-2017, 52 patients underwent mastectomy, reconstruction, and PMRT. With median follow-up of 3.1 years, 23 patients (44%) experienced implant removal. Implant removal occurred in 9 (17%) patients before starting PMRT and 14 (27%) patients after starting PMRT. Implant removal rates were similar for hypofractionated PMRT compared with standard fractionation and for proton compared with photon PMRT. Implant removal is common for women undergoing mastectomy and reconstruction followed by PMRT. The risk is clinically significant even before starting radiation.
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Affiliation(s)
| | - Jacob B Hammond
- Department of General Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Heidi E Kosiorek
- Department of Health Sciences Research, Division of Biostatistics, Mayo Clinic, Scottsdale, AZ, USA
| | | | - Ronik S Bhangoo
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | | | - Richard J Gray
- Department of General Surgery, Mayo Clinic, Phoenix, AZ, USA
| | | | | | - William J Casey
- Department of Plastic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - William W Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Sameer R Keole
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | | | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | | | - Todd A DeWees
- Department of Health Sciences Research, Division of Biostatistics, Mayo Clinic, Scottsdale, AZ, USA
| | - Carlos E Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
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11
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Feng H, Sio TT, Rule WG, Bhangoo RS, Lara P, Patrick CL, Korte S, Fatyga M, Wong WW, Schild SE, Ashman JB, Liu W. Beam angle comparison for distal esophageal carcinoma patients treated with intensity-modulated proton therapy. J Appl Clin Med Phys 2020; 21:141-152. [PMID: 33058523 PMCID: PMC7700921 DOI: 10.1002/acm2.13049] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 07/28/2020] [Revised: 09/03/2020] [Accepted: 09/10/2020] [Indexed: 12/24/2022] Open
Abstract
Purpose To compare the dosimetric performances of intensity‐modulated proton therapy (IMPT) plans generated with two different beam angle configurations (the Right–Left oblique posterior beams and the Superior–Inferior oblique posterior beams) for the treatment of distal esophageal carcinoma in the presence of uncertainties and interplay effect. Methods and Materials Twenty patients’ IMPT plans were retrospectively selected, with 10 patients treated with the R‐L oblique posterior beams (Group R‐L) and the other 10 patients treated with the S‐I oblique posterior beams (Group S‐I). Patients in both groups were matched by their clinical target volumes (CTVs—high and low dose levels) and respiratory motion amplitudes. Dose‐volume‐histogram (DVH) indices were used to assess plan quality. DVH bandwidth was calculated to evaluate plan robustness. Interplay effect was quantified using four‐dimensional (4D) dynamic dose calculation with random respiratory starting phase of each fraction. Normal tissue complication probability (NTCP) for heart, liver, and lung was calculated, respectively, to estimate the clinical outcomes. Wilcoxon signed‐rank test was used for statistical comparison between the two groups. Results Compared with plans in Group R‐L, plans in Group S‐I resulted in significantly lower liver Dmean and lung V30Gy[RBE] with slightly higher but clinically acceptable spinal cord Dmax. Similar plan robustness was observed between the two groups. When interplay effect was considered, plans in Group S‐I performed statistically better for heart Dmean and V30Gy[RBE], lung Dmean and V5Gy[RBE], and liver Dmean, with slightly increased but clinically acceptable spinal cord Dmax. NTCP for liver was significantly better in Group S‐I. Conclusions IMPT plans in Group S‐I have better sparing of liver, heart, and lungs at the slight cost of spinal cord maximum dose protection, and are more interplay‐effect resilient compared to IMPT plans in Group R‐L. Our study supports the routine use of the S‐I oblique posterior beams for the treatments of distal esophageal carcinoma.
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Affiliation(s)
- Hongying Feng
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - William G Rule
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Ronik S Bhangoo
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Pedro Lara
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | | | - Shawn Korte
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Mirek Fatyga
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - William W Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | | | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
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12
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Liu C, Yu NY, Shan J, Bhangoo RS, Daniels TB, Chiang JS, Ding X, Lara P, Patrick CL, Archuleta JP, DeWees T, Hu Y, Schild SE, Bues M, Sio TT, Liu W. Technical Note: Treatment planning system (TPS) approximations matter - comparing intensity-modulated proton therapy (IMPT) plan quality and robustness between a commercial and an in-house developed TPS for nonsmall cell lung cancer (NSCLC). Med Phys 2019; 46:4755-4762. [PMID: 31498885 DOI: 10.1002/mp.13809] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/29/2019] [Accepted: 08/29/2019] [Indexed: 11/07/2022] Open
Abstract
PURPOSE Approximate dose calculation methods were used in the nominal dose distribution and the perturbed dose distributions due to uncertainties in a commercial treatment planning system (CTPS) for robust optimization in intensity-modulated proton therapy (IMPT). We aimed to investigate whether the approximations influence plan quality, robustness, and interplay effect of the resulting IMPT plans for the treatment of locally advanced lung cancer patients. MATERIALS AND METHODS Ten consecutively treated locally advanced nonsmall cell lung cancer (NSCLC) patients were selected. Two IMPT plans were created for each patient using our in-house developed TPS, named "Solo," and also the CTPS, EclipseTM (Varian Medical Systems, Palo Alto, CA, USA), respectively. The plans were designed to deliver prescription doses to internal target volumes (ITV) drawn by a physician on averaged four-dimensional computed tomography (4D-CT). Solo plans were imported back to CTPS, and recalculated in CTPS for fair comparison. Both plans were further verified for each patient by recalculating doses in the inhalation and exhalation phases to ensure that all plans met clinical requirements. Plan robustness was quantified on all phases using dose-volume-histograms (DVH) indices in the worst-case scenario. The interplay effect was evaluated for every plan using an in-house developed software, which randomized starting phases of each field per fraction and accumulated dose in the exhalation phase based on the patient's breathing motion pattern and the proton spot delivery in a time-dependent fashion. DVH indices were compared using Wilcoxon rank-sum test. RESULTS Compared to the plans generated using CTPS on the averaged CT, Solo plans had significantly better target dose coverage and homogeneity (normalized by the prescription dose) in the worst-case scenario [ITV D95% : 98.04% vs 96.28%, Solo vs CTPS, P = 0.020; ITV D5% -D95% : 7.20% vs 9.03%, P = 0.049] while all DVH indices were comparable in the nominal scenario. On the inhalation phase, Solo plans had better target dose coverage and cord Dmax in the nominal scenario [ITV D95% : 99.36% vs 98.45%, Solo vs CTPS, P = 0.014; cord Dmax : 20.07 vs 23.71 Gy(RBE), P = 0.027] with better target coverage and cord Dmax in the worst-case scenario [ITV D95% : 97.89% vs 96.47%, Solo vs CTPS, P = 0.037; cord Dmax : 24.57 vs 28.14 Gy(RBE), P = 0.037]. On the exhalation phase, similar phenomena were observed in the nominal scenario [ITV D95% : 99.63% vs 98.87%, Solo vs CTPS, P = 0.037; cord Dmax : 19.67 vs 23.66 Gy(RBE), P = 0.039] and in the worst-case scenario [ITV D95% : 98.20% vs 96.74%, Solo vs CTPS, P = 0.027; cord Dmax : 23.47 vs 27.93 Gy(RBE), P = 0.027]. In terms of interplay effect, plans generated by Solo had significantly better target dose coverage and homogeneity, less hot spots, and lower esophageal Dmean , and cord Dmax [ITV D95% : 101.81% vs 98.68%, Solo vs CTPS, P = 0.002; ITV D5% -D95% : 2.94% vs 7.51%, P = 0.002; cord Dmax : 18.87 vs 22.29 Gy(RBE), P = 0.014]. CONCLUSIONS Solo-generated IMPT plans provide improved cord sparing, better target robustness in all considered phases, and reduced interplay effect compared with CTPS. Consequently, the approximation methods currently used in commercial TPS programs may have space for improvement in generating optimal IMPT plans for patient cases with locally advanced lung cancer.
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Affiliation(s)
- Chenbin Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Nathan Y Yu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Jie Shan
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Ronik S Bhangoo
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Thomas B Daniels
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Jennifer S Chiang
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Xiaoning Ding
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Pedro Lara
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, 85054, USA
| | | | - James P Archuleta
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Todd DeWees
- Division of Biostatistics, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Yanle Hu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Martin Bues
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, 85054, USA
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13
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Liu C, Bhangoo RS, Sio TT, Yu NY, Shan J, Chiang JS, Ding JX, Rule WG, Korte S, Lara P, Ding X, Bues M, Hu Y, DeWees T, Ashman JB, Liu W. Dosimetric comparison of distal esophageal carcinoma plans for patients treated with small-spot intensity-modulated proton versus volumetric-modulated arc therapies. J Appl Clin Med Phys 2019; 20:15-27. [PMID: 31112371 PMCID: PMC6612702 DOI: 10.1002/acm2.12623] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [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: 02/17/2019] [Revised: 04/24/2019] [Accepted: 05/02/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Esophageal carcinoma is the eighth most common cancer in the world. Volumetric-modulated arc therapy (VMAT) is widely used to treat distal esophageal carcinoma due to high conformality to the target and good sparing of organs at risk (OAR). It is not clear if small-spot intensity-modulated proton therapy (IMPT) demonstrates a dosimetric advantage over VMAT. In this study, we compared dosimetric performance of VMAT and small-spot IMPT for distal esophageal carcinoma in terms of plan quality, plan robustness, and interplay effects. METHODS 35 distal esophageal carcinoma patients were retrospectively reviewed; 19 patients received small-spot IMPT and the remaining 16 of them received VMAT. Both plans were generated by delivering prescription doses to clinical target volumes (CTVs) on phase-averaged 4D-CT's. The dose-volume-histogram (DVH) band method was used to quantify plan robustness. Software was developed to evaluate interplay effects with randomized starting phases for each field per fraction. DVH indices were compared using Wilcoxon rank-sum test. For fair comparison, all the treatment plans were normalized to have the same CTVhigh D95% in the nominal scenario relative to the prescription dose. RESULTS In the nominal scenario, small-spot IMPT delivered statistically significantly lower liver Dmean and V30Gy[RBE] , lung Dmean , heart Dmean compared with VMAT. CTVhigh dose homogeneity and protection of other OARs were comparable between the two treatments. In terms of plan robustness, the IMPT and VMAT plans were comparable for kidney V18Gy[RBE] , liver V30Gy[RBE] , stomach V45Gy[RBE] , lung Dmean , V5Gy[RBE] , and V20Gy[RBE] , cord Dmax and D 0.03 c m 3 , liver Dmean , heart V20Gy[RBE] , and V30Gy[RBE] , but IMPT was significantly worse for CTVhigh D95% , D 2 c m 3 , and D5% -D95% , CTVlow D95% , heart Dmean , and V40Gy[RBE] , requiring careful and experienced adjustments during the planning process and robustness considerations. The small-spot IMPT plans still met the standard clinical requirements after interplay effects were considered. CONCLUSIONS Small-spot IMPT decreases doses to heart, liver, and total lung compared to VMAT as well as achieves clinically acceptable plan robustness. Our study supports the use of small-spot IMPT for the treatment of distal esophageal carcinoma.
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Affiliation(s)
- Chenbin Liu
- Department of Radiation OncologyMayo ClinicPhoenixAZ85054USA
| | | | - Terence T. Sio
- Department of Radiation OncologyMayo ClinicPhoenixAZ85054USA
| | - Nathan Y. Yu
- Department of Radiation OncologyMayo ClinicPhoenixAZ85054USA
| | - Jie Shan
- Department of Radiation OncologyMayo ClinicPhoenixAZ85054USA
| | | | - Julia X. Ding
- Department of Radiation OncologyMayo ClinicPhoenixAZ85054USA
| | - William G. Rule
- Department of Radiation OncologyMayo ClinicPhoenixAZ85054USA
| | - Shawn Korte
- Department of Radiation OncologyMayo ClinicPhoenixAZ85054USA
| | - Pedro Lara
- Department of Radiation OncologyMayo ClinicPhoenixAZ85054USA
| | - Xiaoning Ding
- Department of Radiation OncologyMayo ClinicPhoenixAZ85054USA
| | - Martin Bues
- Department of Radiation OncologyMayo ClinicPhoenixAZ85054USA
| | - Yanle Hu
- Department of Radiation OncologyMayo ClinicPhoenixAZ85054USA
| | - Todd DeWees
- Division of BiostatisticsMayo ClinicPhoenixAZ85054USA
| | | | - Wei Liu
- Department of Radiation OncologyMayo ClinicPhoenixAZ85054USA
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Bhangoo RS, Bhangoo MS, Mangold AR, Wong WW. Radiation Recall Dermatitis After the Use of Pralatrexate for Peripheral T-cell Lymphoma. Adv Radiat Oncol 2019; 4:31-34. [PMID: 30706007 PMCID: PMC6349631 DOI: 10.1016/j.adro.2018.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 08/31/2018] [Accepted: 10/01/2018] [Indexed: 12/13/2022] Open
Affiliation(s)
| | - Munveer S Bhangoo
- Department of Hematology Oncology, Scripps Clinic, La Jolla, California
| | | | - William W Wong
- Department of Dermatology, Mayo Clinic, Phoenix, Arizona
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15
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Khan UA, Giamouriadis A, Bhangoo RS. Delayed presentation of iatrogenic ventriculoperitoneal shunt transection following laparoscopic weight loss surgery in a patient with idiopathic intracranial hypertension. Ann R Coll Surg Engl 2018; 101:e5-e7. [PMID: 30286641 DOI: 10.1308/rcsann.2018.0147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Idiopathic intracranial hypertension is strongly associated with central obesity and consequential raised intra-abdominal pressure. If left untreated it poses significant risk to vision and can eventually cause blindness. Owing to its pathophysiology, this condition is managed by both medical and surgical specialities. When medical management fails neurosurgeons commonly treat idiopathic intracranial hypertension by permanent cerebrospinal fluid peritoneal shunting. Weight reduction surgery provides patients who are obese with a multitude of benefits and it is not uncommon for the general surgeon to be presented with a patient with idiopathic intracranial hypertension and a cerebrospinal fluid peritoneal shunt in place. This provides a potential challenging situation in weight-loss surgical procedures. We describe an interesting case where laparoscopic bariatric surgery resulted in transection of the abdominal catheter with a delayed presentation of recurrent symptoms and an abdominal cerebrospinal fluid collection in a patient with idiopathic intracranial hypertension. We discuss how this could be avoided and its management.
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Affiliation(s)
- U A Khan
- King's College Hospital, Department of Neurosurgery , London , UK
| | - A Giamouriadis
- King's College Hospital, Department of Neurosurgery , London , UK
| | - R S Bhangoo
- King's College Hospital, Department of Neurosurgery , London , UK
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16
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Liu C, Sio TTW, Bhangoo RS, Rule WG, Ross HJ, Paripati H, Jaroszewski DE, Beamer S, Fleischer D, Ramirez F, Ding X, Bues M, Ashman JB, Liu W. Dosimetric analysis of distal esophageal adenocarcinoma patients treated by intensity-modulated proton therapy with small spot size. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.4_suppl.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
159 Background: Intensity-modulated proton therapy (IMPT) with small spot size has the potential to reduce dose to normal tissues but also introduces new confounding factors such as setup uncertainty, range uncertainty, and interplay effects due to breathing motion. We investigated plan quality and robustness of IMPT with small spot size for distal esophageal adenocarcinoma (DEA). Methods: 19 patients with DEA treated by IMPT were retrospectively evaluated. Spot sizes ranged from 2 to 6mm, with spot spacing of 5mm. All plans were generated using a commercial treatment planning system. In-house-developed dose-evaluation software modeled time-dependent spot delivery to incorporate interplay effects. Dose-volume-histogram (DVH) indices were used to evaluate plan quality and robustness was evaluated using the DVH band method. Results: For plan quality, median values of clinical target volume D95% and D5%-D95% (normalized to the prescribed doses), total lung mean dose, heart mean dose, and cord Dmax were 1.014, 0.035, 3.82Gy[RBE], 7.73Gy[RBE], 39.16Gy[RBE], respectively. For plan robustness, median band widths of the aforementioned DVH indices were 0.018, 0.048, 0.60Gy[RBE], 4.17Gy[RBE], and 2.36Gy[RBE], respectively. For interplay effects, median values of the aforementioned DVH indices were 0.99, 0.061, 4.07Gy[RBE], 7.87Gy[RBE], and 39.66Gy[RBE], respectively. Seven patients underwent esophagectomy after neoadjuvant chemoradiation, and five, three, and one of them achieved downstaging, near complete response, and pathologic complete response, respectively; R0 resection was achieved in all cases. For all patients, acute side effects were mostly limited to grades 1-2 only. The only grade 3 adverse events were related to feeding tube placement (8 patients); there were no RT-induced pneumonitis or other lung-related toxicities. Conclusions: IMPT plans with small spot size for DEA have good target dose coverage, homogeneity and normal tissue protection. Treatment plans are also robust to uncertainties and interplay effects. Early clinical results demonstrate low acute toxicity and encouraging clinical and pathologic response.
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17
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Parikh CR, Hall IE, Bhangoo RS, Ficek J, Abt PL, Thiessen-Philbrook H, Lin H, Bimali M, Murray PT, Rao V, Schröppel B, Doshi MD, Weng FL, Reese PP. Associations of Perfusate Biomarkers and Pump Parameters With Delayed Graft Function and Deceased Donor Kidney Allograft Function. Am J Transplant 2016; 16:1526-39. [PMID: 26695524 PMCID: PMC4844819 DOI: 10.1111/ajt.13655] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Revised: 11/24/2015] [Accepted: 11/25/2015] [Indexed: 01/25/2023]
Abstract
Hypothermic machine perfusion (HMP) is increasingly used in deceased donor kidney transplantation, but controversy exists regarding the value of perfusion biomarkers and pump parameters for assessing organ quality. We prospectively determined associations between perfusate biomarkers (neutrophil gelatinase-associated lipocalin [NGAL], kidney injury molecule 1, IL-18 and liver-type fatty acid-binding protein [L-FABP]) and pump parameters (resistance and flow) with outcomes of delayed graft function (DGF) and 6-mo estimated GFR (eGFR). DGF occurred in 230 of 671 (34%) recipients. Only 1-h flow was inversely associated with DGF. Higher NGAL or L-FABP concentrations and increased resistance were inversely associated with 6-mo eGFR, whereas higher flow was associated with higher adjusted 6-mo eGFR. Discarded kidneys had consistently higher median resistance and lower median flow than transplanted kidneys, but median perfusate biomarker concentrations were either lower or not significantly different in discarded compared with transplanted kidneys. Notably, most recipients of transplanted kidneys with isolated "undesirable" biomarker levels or HMP parameters experienced acceptable 6-mo allograft function, suggesting these characteristics should not be used in isolation for discard decisions. Additional studies must confirm the utility of combining HMP measurements with other characteristics to assess kidney quality.
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Affiliation(s)
- Chirag R. Parikh
- Program of Applied Translational Research, Department of Medicine, Yale University School of Medicine, New Haven, CT,Section of Nephrology, Yale University School of Medicine, New Haven, CT,Veterans Affairs Connecticut Healthcare System, West Haven, CT
| | - Isaac E. Hall
- Program of Applied Translational Research, Department of Medicine, Yale University School of Medicine, New Haven, CT,Section of Nephrology, Yale University School of Medicine, New Haven, CT
| | | | - Joseph Ficek
- Program of Applied Translational Research, Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Peter L. Abt
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Heather Thiessen-Philbrook
- Program of Applied Translational Research, Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Haiqun Lin
- Program of Applied Translational Research, Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Milan Bimali
- Program of Applied Translational Research, Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Patrick T. Murray
- Department of Medicine, School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - Veena Rao
- Program of Applied Translational Research, Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Bernd Schröppel
- Mount Sinai School of Medicine, New York, NY,University Hospital, Ulm, Germany
| | | | | | - Peter P. Reese
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA,Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA,Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA
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18
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Hall IE, Bhangoo RS, Reese PP, Doshi MD, Weng FL, Hong K, Lin H, Han G, Hasz RD, Goldstein MJ, Schröppel B, Parikh CR. Glutathione S-transferase iso-enzymes in perfusate from pumped kidneys are associated with delayed graft function. Am J Transplant 2014; 14:886-96. [PMID: 24612768 PMCID: PMC4051136 DOI: 10.1111/ajt.12635] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 11/14/2013] [Accepted: 12/09/2013] [Indexed: 01/25/2023]
Abstract
Accurate and reliable assessment tools are needed in transplantation. The objective of this prospective, multi-center study was to determine the associations of the alpha and pi iso-enzymes of glutathione S-transferase (GST), measured from perfusate solution at the start and end (base and post) of kidney allograft machine perfusion, with subsequent delayed graft function (DGF). We also compared GST iso-enzyme perfusate levels from discarded versus transplanted kidneys. A total of 428 kidneys were linked to outcomes as recorded by the United Network of Organ Sharing. DGF, defined as any dialysis in the first week of transplant, occurred in 141 recipients (32%). Alpha- and pi-GST levels significantly increased during machine perfusion. The adjusted relative risks (95% confidence interval) of DGF with each log-unit increase in base and post pi-GST were 1.14 (1.0-1.3) and 1.36 (1.1-1.8), respectively. Alpha-GST was not independently associated with DGF. There were no significant differences in GST values between discarded and transplanted kidneys, though renal resistance was significantly higher in discarded kidneys. We found pi-GST at the end of machine perfusion to be independently associated with DGF. Further studies should elucidate the utility of GST for identifying injured kidneys with regard to organ allocation, discard and recipient management decisions.
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Affiliation(s)
- Isaac E. Hall
- Program of Applied Translational Research, Department of Medicine, Yale University School of Medicine, New Haven, CT
,Section of Nephrology, Yale University School of Medicine, New Haven, CT
| | | | - Peter P. Reese
- Renal Division, University of Pennsylvania, Philadelphia, PA
,Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA
| | | | | | - Kwangik Hong
- Program of Applied Translational Research, Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Haiqun Lin
- Program of Applied Translational Research, Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Gang Han
- Program of Applied Translational Research, Department of Medicine, Yale University School of Medicine, New Haven, CT
| | | | | | - Bernd Schröppel
- Mount Sinai School of Medicine, New York, NY
,University Hospital, Ulm, Germany
| | - Chirag R. Parikh
- Program of Applied Translational Research, Department of Medicine, Yale University School of Medicine, New Haven, CT
,Section of Nephrology, Yale University School of Medicine, New Haven, CT
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19
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Bhangoo RS, Hall IE, Reese PP, Parikh CR. Deceased-donor kidney perfusate and urine biomarkers for kidney allograft outcomes: a systematic review. Nephrol Dial Transplant 2012; 27:3305-14. [PMID: 22498916 DOI: 10.1093/ndt/gfr806] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Accurate and reliable assessment of kidney quality before transplantation is needed to predict recipient outcomes and to optimize management and allocation of the allograft. The aim of this study was to systematically review the published literature on biomarkers in two mediums (the perfusate from deceased-donor kidneys receiving machine perfusion and deceased-donor urine) that were evaluated for their possible association with outcomes after kidney transplantation. METHODS We searched the Ovid Medline and Scopus databases using broad keywords related to deceased-donor biomarkers in kidney transplantation (limited to humans and the English language). Studies were included if they involved deceased-donor kidneys, measured perfusate or urine biomarkers and studied a possible relationship between biomarker concentrations and kidney allograft outcomes. Each included article was assessed for methodological quality. RESULTS Of 1430 abstracts screened, 29 studies met the inclusion criteria. Of these, 23 were studies of perfusate (16 biomarkers examined) and 6 were studies of urine (18 biomarkers examined). Only 3 studies (two perfusate) met the criteria of 'good' quality and only 12 were published since 2000. Perfusate lactate dehydrogenase, glutathione-S-transferase (GST) and aspartate transaminase were all found to be significantly associated with delayed graft function in a majority of their respective studies (6/9, 4/6 and 2/2 studies, respectively). Urine neutrophil gelatinase-associated lipocalin, GST, Trolox-equivalent antioxidant capacity and kidney injury molecule-1 were found to be significantly associated with allograft outcomes in single studies that examined diverse end points. CONCLUSION Higher quality studies are needed to investigate modern kidney injury biomarkers, to validate novel biomarkers in larger donor populations and to determine the incremental predictive value of biomarkers over traditional clinical variables.
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Affiliation(s)
- Ronik S Bhangoo
- Section of Nephrology, Department of Medicine, Yale School of Medicine, New Haven, CT, USA
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20
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Joshi MPHA, Bhangoo RS, Kumar K. Quality of nutrition related information on the internet for osteoporosis patients: a critical review. Technol Health Care 2012; 19:391-400. [PMID: 22129940 DOI: 10.3233/thc-2011-0643] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Internet has provided patients with a new source of variable medical information. Osteoporosis is a major public health concern and providing patients with accurate information regarding diseases and treatment is an essential component of medical care. The primary objective of this study was to assess the quality of Internet based nutrition information for osteoporosis patients. The search items "osteoporosis", "diet", "nutrition", and "bone loss" were entered into the five most consulted search engines: Google, Yahoo, Bing, AOL and Lycos. The first 20 website matches generated by each search engine were 400 and grouped together by URL (uniform resource locators) suffix. 326 websites were excluded from the study as they had insufficient information, nonfunctioning links, websites not in English and duplicate websites. Of the remaining 74 sites, 64% were .Com sites followed by 18% .Org sites. .Org websites received the highest interface and content scores. Raters with healthcare and technical background rated the website interface and quality of content on the internet differently and this could be largely due to different training of the two raters and the manner in which they perceived the content. Health information websites should take into account the users' diverse backgrounds when presenting content to consumers.
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Affiliation(s)
- M P H Ashish Joshi
- Center for Global Health and Development and Department of Health Services Research and Administration, College of Public Health, University of Nebraska Medical Center, Omaha, NE 68198, USA.
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Abstract
Severe basilar impression leads to an upward translocation of the upper cervical spine and clivus into the foramen magnum and is a diagnosis best made with computed tomography or magnetic resonance imaging scans. Basilar impression may be a primary condition or secondary to bone softening disorders. Symptoms relating to direct neuraxial compression, obstruction to cerebral spinal fluid outflow, and vascular compromise all have been described. Management depends on the exact nature of the abnormality seen, but it is now firmly accepted that those with anterior neuraxial compression should have an anterior decompression. The severe basilar impression and craniofacial abnormalities seen in osteogenesis imperfecta together with the progressive nature of the condition have led to the development of a specific surgical response, the open door maxillotomy combined with a contoured loop fixation of the cervical spine. Little is known of the long term outcome of severe basilar impression, and long term studies undertaken by centers familiar with the condition and its management are required if definitive care is to be delivered to these patients.
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Affiliation(s)
- R S Bhangoo
- Department of Surgical Neurology, National Hospital for Neurology and Neurosurgery, London, United Kingdom
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22
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Affiliation(s)
- R S Bhangoo
- Department of Surgical Neurology, National Hospital for Neurology and Neurosurgery, London, U.K
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