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Dei D, Lambri N, Crespi L, Brioso RC, Loiacono D, Clerici E, Bellu L, De Philippis C, Navarria P, Bramanti S, Carlo-Stella C, Rusconi R, Reggiori G, Tomatis S, Scorsetti M, Mancosu P. Deep learning and atlas-based models to streamline the segmentation workflow of total marrow and lymphoid irradiation. Radiol Med 2024; 129:515-523. [PMID: 38308062 DOI: 10.1007/s11547-024-01760-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 01/03/2024] [Indexed: 02/04/2024]
Abstract
PURPOSE To improve the workflow of total marrow and lymphoid irradiation (TMLI) by enhancing the delineation of organs at risk (OARs) and clinical target volume (CTV) using deep learning (DL) and atlas-based (AB) segmentation models. MATERIALS AND METHODS Ninety-five TMLI plans optimized in our institute were analyzed. Two commercial DL software were tested for segmenting 18 OARs. An AB model for lymph node CTV (CTV_LN) delineation was built using 20 TMLI patients. The AB model was evaluated on 20 independent patients, and a semiautomatic approach was tested by correcting the automatic contours. The generated OARs and CTV_LN contours were compared to manual contours in terms of topological agreement, dose statistics, and time workload. A clinical decision tree was developed to define a specific contouring strategy for each OAR. RESULTS The two DL models achieved a median [interquartile range] dice similarity coefficient (DSC) of 0.84 [0.71;0.93] and 0.85 [0.70;0.93] across the OARs. The absolute median Dmean difference between manual and the two DL models was 2.0 [0.7;6.6]% and 2.4 [0.9;7.1]%. The AB model achieved a median DSC of 0.70 [0.66;0.74] for CTV_LN delineation, increasing to 0.94 [0.94;0.95] after manual revision, with minimal Dmean differences. Since September 2022, our institution has implemented DL and AB models for all TMLI patients, reducing from 5 to 2 h the time required to complete the entire segmentation process. CONCLUSION DL models can streamline the TMLI contouring process of OARs. Manual revision is still necessary for lymph node delineation using AB models.
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Affiliation(s)
- Damiano Dei
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Nicola Lambri
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy.
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
| | - Leonardo Crespi
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
- Health Data Science Centre, Human Technopole, Milan, Italy
| | - Ricardo Coimbra Brioso
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Daniele Loiacono
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Elena Clerici
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Luisa Bellu
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Chiara De Philippis
- Department of Oncology and Hematology, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Pierina Navarria
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Stefania Bramanti
- Department of Oncology and Hematology, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Carmelo Carlo-Stella
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
- Department of Oncology and Hematology, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Roberto Rusconi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Giacomo Reggiori
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Stefano Tomatis
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Marta Scorsetti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Pietro Mancosu
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
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Jiang D, Deng D, Xiong Y, Wang D, Gong J, Zhao H, Bao Z, Wei Y, Xie C, Jia L, Liao C, Liu S, Liu H, Wang X. Total marrow lymphoid irradiation IMRT treatment using a novel CT-linac. Eur J Med Res 2023; 28:463. [PMID: 37884978 PMCID: PMC10605975 DOI: 10.1186/s40001-023-01380-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 09/18/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND A novel CT-linac (kilovolt fan-beam CT-linac) has been introduced into total marrow and lymphoid irradiation (TMLI) treatment. Its integrated kilovolt fan-beam CT (kV FBCT) can be used not only for image guidance (IGRT) but also to re-calculate the dose. PURPOSE This study reported our clinical routine on performing TMIL treatment on the CT-linac, as well as dose distribution comparison between planned and re-calculated based on IGRT FBCT image sets. METHODS 11 sets of data from 5 male and 6 female patients who had underwent the TMLI treatment with uRT-linac 506c were selected for this study. The planning target volumes consist of all skeletal bones exclusion of the mandible and lymphatic sanctuary sites. A planned dose of 10 Gy was prescribed to all skeletal bones exclusion of the mandible in two fractions and 12 Gy in two fractions was prescribed to lymphatic sanctuary sites. Each TMLI plan contained two sub-plans, one dynamic IMRT for the upper body and the other VMAT for the lower extremity. Two attempts were made to obtain homogeneous dose in the overlapping region, i.e., applying two plans with different isocenters for the treatment of two fractions, and using a dose gradient matching scheme. The CT scans, including planning CT and IGRT FBCT, were stitched to a whole body CT scan for dose distribution evaluation. RESULTS The average beam-on time of Planupper is 30.6 min, ranging from 24.9 to 37.5 min, and the average beam-on time of Planlower is 6.3 min, ranging from 5.7 to 8.2 min. For the planned dose distribution, the 94.79% of the PTVbone is covered by the prescription dose of 10 Gy (V10), and the 94.68% of the PTVlymph is covered by the prescription dose of 12 Gy (V12). For the re-calculated dose distribution, the 92.17% of the PTVbone is covered by the prescription dose of 10 Gy (V10), and the 90.07% of the PTVlymph is covered by the prescription dose of 12 Gy (V12). The results showed that there is a significant difference (p < 0.05) between planning V10, V12 and delivery V10, V12. There is no significant difference (p > 0.05) between planned dose and re-calculated dose on selected organs, except for right lens (p < 0.05, Dmax). The actual delivered maximum dose of right lens is apparently larger than the planned dose of it. CONCLUSION TMLI treatment can be performed on the CT-linac with clinical acceptable quality and high efficiency. Evaluation of the recalculated dose on IGRT FBCT suggests the treatment was delivered with adequate target coverage.
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Affiliation(s)
- Dazhen Jiang
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Di Deng
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Yu Xiong
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Dajiang Wang
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Jian Gong
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Hongli Zhao
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Zhirong Bao
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Yongchang Wei
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Conghua Xie
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Lecheng Jia
- United Imaging Research Institute of Innovative Medical Equipment, Shenzhen, 518045, China
| | - Can Liao
- Shanghai United Imaging Healthcare Co., Ltd, Shanghai, 201807, China
| | - Shuo Liu
- Shanghai United Imaging Healthcare Co., Ltd, Shanghai, 201807, China
| | - Hui Liu
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China.
| | - Xiaoyong Wang
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China.
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Godson HF, Raj JS, Sebastian P, Ponmalar RY, Babu ES, Paul I, Krishna R, Backianathan S, George B, Ravindran PB, Balakrishnan R. Feasibility study of total marrow lymphoid irradiation with volumetric modulated arc therapy: clinical implementation in a tertiary care center. Strahlenther Onkol 2023; 199:922-935. [PMID: 37278833 DOI: 10.1007/s00066-023-02100-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 05/07/2023] [Indexed: 06/07/2023]
Abstract
PURPOSE Total marrow lymphoid irradiation (TMLI) with volumetric modulated arc therapy (VMAT) is challenging due to large treatment fields with multiple isocenters, field matching at junctions, and targets being surrounded by many organs at risk. This study aimed to describe our methodology for safe dose escalation and accurate dose delivery of TMLI treatment with the VMAT technique based on early experience at our center. MATERIALS AND METHODS Computed tomography (CT) scans were acquired in head-first supine and feet-first supine orientations for each patient with an overlap at mid-thigh. VMAT plans were generated for 20 patients on the head-first CT images with either three or four isocenters in the Eclipse treatment planning system (Varian Medical Systems Inc., Palo Alto, CA) and the treatment was delivered in a Clinac 2100 C/D linear accelerator (Varian Medical Systems Inc., Palo Alto, CA). RESULTS Five patients were treated with a prescription dose of 13.5 Gy in 9 fractions and 15 patients were treated with an escalated dose of 15 Gy in 10 fractions. The mean doses to 95% of the clinical target volume (CTV) and planning target volume (PTV) were 14.3 ± 0.3 Gy and 13.6 ± 0.7 Gy for the prescription doses of 15 Gy, and 13 ± 0.2 Gy and 12.3 ± 0.3 Gy for the prescription doses of 13.5 Gy, respectively. Mean dose to the lung in both schedules was 8.7 ± 0.6 Gy. The overall time taken to execute the treatment plans was approximately 2 h for the first fraction and 1.5 h for subsequent fractions. The average in-room time of 15.5 h per patient over 5 days leads to potential changes in the regular treatment schedules for other patients. CONCLUSION This feasibility study highlights the methodology adopted for safe implementation of TMLI with the VMAT technique at our institution. Escalation of dose to the target with adequate coverage and sparing of critical structures was achieved with the adopted treatment technique. Clinical implementation of this methodology at our center could serve as a practical guide to start the VMAT-based TMLI program safely by others who are keen to start this service.
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Affiliation(s)
- Henry Finlay Godson
- Department of Radiation Oncology, Christian Medical College, 632 004, Vellore, Tamil Nadu, India
| | - Jose Solomon Raj
- Department of Radiation Oncology, Christian Medical College, 632 004, Vellore, Tamil Nadu, India
| | - Patricia Sebastian
- Department of Radiation Oncology, Christian Medical College, 632 004, Vellore, Tamil Nadu, India
| | - Retna Y Ponmalar
- Department of Radiation Oncology, Christian Medical College, 632 004, Vellore, Tamil Nadu, India
| | - Ebenezer Suman Babu
- Department of Radiation Oncology, Christian Medical College, 632 004, Vellore, Tamil Nadu, India
| | - Ivin Paul
- Department of Radiation Oncology, Christian Medical College, 632 004, Vellore, Tamil Nadu, India
| | - Raj Krishna
- Department of Radiation Oncology, Amala Institute of Medical Sciences, Trissur, Kerala, India
| | - Selvamani Backianathan
- Department of Radiation Oncology, Christian Medical College, 632 004, Vellore, Tamil Nadu, India
| | - Biju George
- Department of Haematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Paul B Ravindran
- Department of Radiation Oncology, Christian Institute of Health Sciences and Research, Dimapur, Nagaland, India
| | - Rajesh Balakrishnan
- Department of Radiation Oncology, Christian Medical College, 632 004, Vellore, Tamil Nadu, India.
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George B, Balakrishnan R, S P, Lionel S, Selvarajan S, Devasia AJ, Korula A, Lakshmi KM, Aboobacker FN, Kulkarni U, Godson HF, Raj JS, Abraham A, Backianathan S, Mathews V. Total marrow lymphoid irradiation and cyclophosphamide is associated with low toxicity and good outcomes in patients undergoing hematopoietic stem cell transplantation for acute lymphoblastic leukemia and chronic myeloid leukemia in lymphoid blast crises - A phase I study. Clin Transplant 2023; 37:e15010. [PMID: 37144852 DOI: 10.1111/ctr.15010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 04/22/2023] [Accepted: 04/25/2023] [Indexed: 05/06/2023]
Abstract
INTRODUCTION Total marrow lymphoid irradiation (TMLI) can deliver higher doses of irradiation without increasing toxicity compared to Total body irradiation (TBI). METHODS Twenty adult patients undergoing hematopoietic stem cell transplantation (HSCT) for acute lymphoblastic leukemia (ALL) and chronic myeloid leukemia with lymphoid blast crises (CML-LBC) received TMLI and cyclophosphamide for conditioning. Ten patients each received 13.5 or 15 Gy of TMLI. The graft source was peripheral blood stem cells in all, and donors included matched related (n = 15), haplo-identical (n = 3) or matched unrelated donors (n = 2). RESULTS The median cell dose infused was 9 × 106 CD34/kg (range 4.8-12.4). Engraftment occurred in all (100%) at a median of 15 days (range: 14-17). Toxicity was low with hemorrhagic cystitis seen in two but no sinusoidal obstruction syndrome. Acute GVHD occurred in 40% while chronic GVHD was seen in 70.5%. Viral infections were seen in 55% while blood stream bacterial infections occurred in 20% and invasive fungal disease (IFD) in 10%. The Day 100 non-relapse mortality (NRM) was 10%. At a median follow up of 25 months (range 2-48), two patients have relapsed. Overall survival at 2 years is 80% while the disease-free survival is 75%. CONCLUSIONS The combination of TMLI and cyclophosphamide for myeloablative conditioning is associated with low toxicity and favorable early outcomes in patients undergoing HSCT for ALL and CML-LBC.
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Affiliation(s)
- Biju George
- Department of Haematology, Christian Medical College, Vellore, India
| | | | - Patricia S
- Department of Radiation Therapy, Christian Medical College, Vellore, India
| | - Sharon Lionel
- Department of Haematology, Christian Medical College, Vellore, India
| | - Sushil Selvarajan
- Department of Haematology, Christian Medical College, Vellore, India
| | - Anup J Devasia
- Department of Haematology, Christian Medical College, Vellore, India
| | - Anu Korula
- Department of Haematology, Christian Medical College, Vellore, India
| | - Kavitha M Lakshmi
- Department of Haematology, Christian Medical College, Vellore, India
| | | | - Uday Kulkarni
- Department of Haematology, Christian Medical College, Vellore, India
| | | | - Jose Solomon Raj
- Department of Radiation Therapy, Christian Medical College, Vellore, India
| | - Aby Abraham
- Department of Haematology, Christian Medical College, Vellore, India
| | | | - Vikram Mathews
- Department of Haematology, Christian Medical College, Vellore, India
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Kaufman DB, Forrest LJ, Fechner J, Post J, Coonen J, Haynes LD, Haynes WJ, Christensen N, Zhong W, Little CJ, D’Alessandro A, Fernandez L, Brunner K, Jensen K, Burlingham WJ, Hematti P, Strober S. Helical TomoTherapy Total Lymphoid Irradiation and Hematopoietic Cell Transplantation for Kidney Transplant Tolerance in Rhesus Macaques. Transpl Int 2023; 36:11279. [PMID: 37426429 PMCID: PMC10324513 DOI: 10.3389/ti.2023.11279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 06/07/2023] [Indexed: 07/11/2023]
Abstract
Development of a post-transplant kidney transplant tolerance induction protocol involving a novel total lymphoid irradiation (TLI) conditioning method in a rhesus macaque model is described. We examined the feasibility of acheiving tolerance to MHC 1-haplotype matched kidney transplants by establishing a mixed chimeric state with infusion of donor hematopoietic cells (HC) using TomoTherapy TLI. The chimeric state was hypothesized to permit the elimination of all immunosuppressive (IS) medications while preserving allograft function long-term without development of graft-versus-host-disease (GVHD) or rejection. An experimental group of 11 renal transplant recipients received the tolerance induction protocol and outcomes were compared to a control group (n = 7) that received the same conditioning but without donor HC infusion. Development of mixed chimerism and operational tolerance was accomplished in two recipients in the experimental group. Both recipients were withdrawn from all IS and continued to maintain normal renal allograft function for 4 years without rejection or GVHD. None of the animals in the control group achieved tolerance when IS was eliminated. This novel experimental model demonstrated the feasibility for inducing of long-term operational tolerance when mixed chimerism is achieved using a TLI post-transplant conditioning protocol in 1-haplotype matched non-human primate recipients of combined kidney and HC transplantation.
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Affiliation(s)
- Dixon B. Kaufman
- Department of Surgery, University of Wisconsin, Madison, WI, United States
| | - Lisa J. Forrest
- School of Veternary Medicine, University of Wisconsin, Madison, WI, United States
| | - John Fechner
- Department of Surgery, University of Wisconsin, Madison, WI, United States
| | - Jennifer Post
- Department of Surgery, University of Wisconsin, Madison, WI, United States
| | - Jennifer Coonen
- Wisconsin National Primate Research Center, University of Wisconsin, Madison, WI, United States
| | - Lynn D. Haynes
- Department of Surgery, University of Wisconsin, Madison, WI, United States
| | - W. John Haynes
- Department of Surgery, University of Wisconsin, Madison, WI, United States
| | - Neil Christensen
- School of Veternary Medicine, University of Wisconsin, Madison, WI, United States
| | - Weixiong Zhong
- Department of Pathology, University of Wisconsin, Madison, WI, United States
| | | | | | - Luis Fernandez
- Department of Surgery, University of Wisconsin, Madison, WI, United States
| | - Kevin Brunner
- Wisconsin National Primate Research Center, University of Wisconsin, Madison, WI, United States
| | - Kent Jensen
- Department of Medicine, Stanford University, Palo Alto, CA, United States
| | | | - Peiman Hematti
- Department of Medicine, University of Wisconsin, Madison, WI, United States
| | - Samuel Strober
- Department of Medicine, Stanford University, Palo Alto, CA, United States
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Brand DH, Tree AC. Fractionation Choice for Elective Lymph Node Radiation Therapy in Prostate Cancer: Slightly More to CHIRP About. Int J Radiat Oncol Biol Phys 2022; 114:108-110. [PMID: 35843786 DOI: 10.1016/j.ijrobp.2022.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 05/24/2022] [Indexed: 10/17/2022]
Affiliation(s)
- Douglas H Brand
- Department of Medical Physics and Bioengineering, University College London, London, United Kingdom; Department of Clinical Oncology, University College London Hospitals, London, United Kingdom; Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom
| | - Alison C Tree
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom; Urology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom.
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Shi J, Wang Z, Kan H, Zhao M, Xue X, Yan B, An H, Shen J, Bartlett J, Lu W, Duan J. Automatic Segmentation of Target Structures for Total Marrow and Lymphoid Irradiation in Bone Marrow Transplantation. Annu Int Conf IEEE Eng Med Biol Soc 2022; 2022:5025-5029. [PMID: 36086265 DOI: 10.1109/embc48229.2022.9871824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The use of total marrow and lymphoid irradiation (TMLI) as part of conditioning regimens for bone marrow transplantation is trending due to its advantages in disease control and low toxicity. Accurate contouring of target structures such as bone and lymph nodes plays an important role in irradiation planning. However, this process is often time-consuming and prone to inter-observer variation. Recently, deep learning methods such as convolutional neural networks (CNNs) and vision transformers have achieved tremendous success in medical image segmentation, therefore enabling fast semiautomatic radiotherapy planning. In this paper, we propose a dual-encoder U-shaped model named DE-Net, to automatically segment the target structures for TMLI. To enhance the learned features, the encoder of DE-Net is composed of parallel CNNs and vision transformers, which can model both local and global contexts. The multi-level features from the two branches are progressively fused by intermediate modules, therefore effectively preserving low-level details. Our experiments demonstrate that the proposed method achieves state-of-the-art results and a significant improvement in lymph node segmentation compared with existing methods.
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Abstract
We present the update of the recommendations of the French society of oncological radiotherapy on radiotherapy for hypopharynx. Intensity-modulated radiotherapy is the gold standard treatment for hypopharynx cancers. Early T1 and T2 tumors could be treated by exclusive radiotherapy or surgery followed by postoperative radiotherapy in case of high recurrence risk. For locally advanced tumours requiring total pharyngolaryngectomy (T2 or T3) or with significant lymph nodes involvement, induction chemotherapy followed by exclusive radiotherapy or concurrent chemoradiotherapy were possible. For T4 tumour, surgery must be proposed. The treatment of lymph nodes is based on initial primary tumour treatment. In non-surgical procedure, for 35 fractions, curative dose is 70Gy (2Gy per fraction) and prophylactic dose are 50 to 56Gy (2Gy per fraction in case of sequential radiotherapy or 1.6Gy in case of integrated simultaneous boost) radiotherapy; for 33 fractions, curative dose is 69.96Gy (2.12Gy per fraction) and prophylactic dose is 52.8Gy (1.6Gy per fraction in integrated simultaneous boost radiotherapy or 54Gy in 1.64Gy per fraction); for 30 fractions, curative dose is 66Gy (2.2Gy per fraction) and prophylactic dose is 54Gy (1.8Gy per fraction in integrated simultaneous boost radiotherapy). Doses over 2Gy per fraction could be done when chemotherapy is not used regarding potential larynx toxicity. Postoperatively, radiotherapy is used in locally advanced cancer with dose levels based on pathologic criteria, 60 to 66Gy for R1 resection and 54 to 60Gy for complete resection in bed tumour; 50 to 66Gy in lymph nodes areas regarding extracapsular spread. Volume delineation were based on guidelines cited in this article.
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Affiliation(s)
- Y Pointreau
- Institut interrégional de cancérologie (ILC), centre Jean-Bernard, 9, rue Beauverger, 72000 Le Mans, France; Service de radiothérapie, centre régional universitaire de cancérologie Henry-S.-Kaplan, hôpital Bretonneau, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours, France.
| | - J Biau
- Département de radiothérapie, centre Jean-Perrin, 58, rue Montalembert, BP 5026, 63011 Clermont-Ferrand cedex 1, France
| | - N Delaby
- Unité de physique médicale, centre Eugène-Marquis, rue de la Bataille-Flandres-Dunkerque, CS 44229, 35042 Rennes cedex, France
| | - J Thariat
- Département de radiothérapie, centre François-Baclesse, 14000 Caen, France
| | - M Lapeyre
- Département de radiothérapie, centre Jean-Perrin, 58, rue Montalembert, BP 5026, 63011 Clermont-Ferrand cedex 1, France
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Ferrer C, Huertas C, Plaza R, de la Monja P, Ocanto A, Escribano A, Pérez A, Sáez M. Simple template-based optimization for pediatric total lymphoid irradiation (TLI) radiotherapy treatments. Med Dosim 2021; 46:201-207. [PMID: 33309515 DOI: 10.1016/j.meddos.2020.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 08/13/2020] [Revised: 10/27/2020] [Accepted: 11/18/2020] [Indexed: 10/22/2022]
Abstract
Total lymphoid irradiation (TLI) is used in the management of pediatric allogeneic hematopoietic stem cell transplantation (HSCT. This work aims to simplify the treatment planning process for TLI via a proposed template using the volumetric modulated arc therapy (VMAT) technique. Fifteen pediatric patients were planned, prescribed to 8 Gy in 4 fractions. Cost functions included in the template were the ones for the planning target volume (PTV), and conformality cost function (CCF) for the rest of the patient's volume. Conformity index (CI), homogeneity index (HI), conformation number (CN), gradient index (GI), integral dose, and doses to the organs at risk achieved with the template were reported. Cost function influence over various indexes was studied by Wilcoxon signed ranks test. Same 15 patients were planned with 3-dimensional conventional radiotherapy (3D-CRT) technique for comparison. Mean CI and HI were 1.33 and 0.13, respectively, which indicates good dose conformation and homogeneity. Mean CN and GI values were 0.69 and 4.51, respectively. Mean PTV coverage was reached (V100% > 95%). No correlation between the CCF and indexes values was found (p > 0.05). Doses to organs at risk (OARs) were as low as possible without losing PTV coverage. VMAT plan showed higher levels of conformation and similar homogeneity as 3D-CRT plans. Doses to OARs were inferior with VMAT except for the right kidney. The proposed template simplifies the planning of TLI treatments, and it is able to create acceptable plans with little modification in order to reduce doses to certain organs like the kidneys or the heart. VMAT technique showed higher conformation and lower doses to OAR compared to 3D-CRT.
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Affiliation(s)
- C Ferrer
- Department of Medical Physics and Radiation Protection, Hospital Universitario La Paz, Madrid, Spain.
| | - C Huertas
- Department of Medical Physics and Radiation Protection, Hospital Universitario La Paz, Madrid, Spain
| | - R Plaza
- Department of Medical Physics and Radiation Protection, Hospital Universitario La Paz, Madrid, Spain
| | - P de la Monja
- Department of Medical Physics and Radiation Protection, Hospital Universitario La Paz, Madrid, Spain
| | - A Ocanto
- Radiation Oncology Department, Hospital Universitario La Paz, Madrid, Spain
| | - A Escribano
- Radiation Oncology Department, Hospital Universitario La Paz, Madrid, Spain
| | - A Pérez
- Pediatric Hematology-Oncology Department, Hospital Universitario La Paz, Madrid, Spain
| | - M Sáez
- Department of Medical Physics and Radiation Protection, Hospital Universitario La Paz, Madrid, Spain
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10
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Zhao XR, Fang H, Tang Y, Hu ZH, Jing H, Liang L, Yan XN, Song YW, Jin J, Liu YP, Chen B, Tang Y, Qi SN, Li N, Lu NN, Men K, Hu C, Zhang YH, Li YX, Wang SL. POstmastectomy radioThErapy in Node-posiTive breast cancer with or without Internal mAmmary nodaL irradiation (POTENTIAL): a study protocol for a multicenter prospective phase III randomized controlled trial. BMC Cancer 2021; 21:1185. [PMID: 34742270 PMCID: PMC8571887 DOI: 10.1186/s12885-021-08852-y] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 10/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Various randomized trials have demonstrated that postmastectomy radiotherapy (RT) to the chest wall and comprehensive regional nodal areas improves survival in patients with axillary node-positive breast cancer. Controversy exists as to whether the internal mammary node (IMN) region is an essential component of regional nodal irradiation. Available data on the survival benefit of IMN irradiation (IMNI) are conflicting. The patient populations enrolled in previous studies were heterogeneous and most studies were conducted before modern systemic treatment and three-dimensional (3D) radiotherapy (RT) techniques were introduced. This study aims to assess the efficacy and safety of IMNI in the context of modern systemic treatment and computed tomography (CT)-based RT planning techniques. METHODS POTENTIAL is a prospective, multicenter, open-label, parallel, phase III, randomized controlled trial investigating whether IMNI improves disease-free survival (DFS) in high-risk breast cancer with positive axillary nodes (pN+) after mastectomy. A total of 1800 patients will be randomly assigned in a 1:1 ratio to receive IMNI or not. All patients are required to receive ≥ six cycles of anthracycline and/or taxane-based chemotherapy. Randomization will be stratified by institution, tumor location (medial/central vs. other quadrants), the number of positive axillary nodes (1-3 vs. 4-9 vs. ≥10), and neoadjuvant chemotherapy (yes vs. no). Treatment will be delivered with CT-based 3D RT techniques, including 3D conformal RT, intensity-modulated RT, or volumetric modulated arc therapy. The prescribed dose is 50 Gy in 25 fractions or 43.5 Gy in 15 fractions. Tiered RT quality assurance is required. After RT, patients will be followed up at regular intervals. Oncological and toxilogical outcomes, especially cardiac toxicities, will be assessed. DISCUSSION This trial design is intended to overcome the limitations of previous prospective studies by recruiting patients with pN+ breast cancer, using DFS as the primary endpoint, and prospectively assessing cardiac toxicities and requiring RT quality assurance. The results of this study will provide high-level evidence for elective IMNI in patients with breast cancer after mastectomy. TRIAL REGISTRATION ClinicalTrails.gov , NCT04320979 . Registered 25 Match 2020, https://clinicaltrials.gov/ct2/show/NCT04320979.
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Affiliation(s)
- Xu-Ran Zhao
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Hui Fang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Yu Tang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Zhi-Hui Hu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Hao Jing
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Lin Liang
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Xue-Na Yan
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Yong-Wen Song
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Jing Jin
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Yue-Ping Liu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Bo Chen
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Yuan Tang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Shu-Nan Qi
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Ning Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Ning-Ning Lu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Kuo Men
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
| | - Chen Hu
- Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, 21205-2013, USA.
| | - Yu-Hui Zhang
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China.
| | - Ye-Xiong Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
| | - Shu-Lian Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
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11
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Burkoň P, Oberreiterová S, Kazda T, Slávik M, Bobek L, Komínek L, Procházka T, Vrzal M, Šlampa P. Stereotactic Body Radiotherapy of Lymph Node Oligometastases. Klin Onkol 2021; 33:114-122. [PMID: 32303132 DOI: 10.14735/amko2020114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The aim of this retrospective study is to evaluate the efficacy and toxicity of extracranial stereotactic radiotherapy for the treatment of oligometastatic lymph node involvement in the mediastinum, retroperitoneum, and pelvis in a consecutive group of patients from real clinical practice. MATERIAL AND METHODS Of a total of 50 patients treated between 2011 and 2017, 29 were men and 21 were women, and the mean age was 62 years (median 66 years, range 25-81 years). Patients were most often irradiated in five fractions; the dose was selected according to dose-volume histograms of organs-at-risk in proximity to the planning target volume. The primary objectives were local control (LC), progression-free survival (PFS), time to multiple dissemination not allowing the use of local treatment methods (freedom from widepread dissemination - FFWD), and overall survival (OS). Acute and delayed toxicity were evaluated as well. RESULTS The median dose equivalent at α/β = 10 (BED10) was 54 Gy (range 48-80 Gy). The median follow-up period was 40.4 months. LC after irradiation was 90% in 1 year and 75% in 3 years. Median time to local progression was not achieved. Patients irradiated with a high dose had significantly better LC than patients irradiated with a low dose; the cut-off was the median of the applied dose (ie BED10 = 54 Gy). Pathological node localization had no significant effect on LC. The median PFS was 8.2 months (95% CI 7.4-11.6 months). PFS in 1 year was 38.5% and 17% in 3 years. The median OS was 37.3 months (95% CI 23.2-51.4 months). One-year OS was 83% and 3-year OS was 51%. The median FFWD was 13.6 months (range 8.7-18.5 months). The one-year FFWD was 55% and the 3-year FFWD was 24%. None of these parameters (PFS, OS, FFWD) was dose or localization dependent. No grade III or IV toxicity was reported. CONCLUSION Our study shows that targeted stereotactic radiotherapy is a very effective low toxic treatment for oligometastatic lymph node involvement. It can delay cytotoxic chemotherapy and thus improve/maintain the quality of life of patients. Approximately one fifth of patients treated with extracranial stereotactic radiotherapy for oligometastatic lymph node involvement survived without signs of disease for prolonged periods. Future studies should aim at identifying patients who would benefit most from this treatment, adjusting the timing of extracranial stereotactic radiotherapy depending on the treatment strategy, and optimizing the dose prescription. This work was supported by grant of the Ministry of Health of the Czech Republic AZV 19-00354 and by grant of the Ministry of Health of the Czech Republic - Conceptual development of a research organization (MMCI 00209805). The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.
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12
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Nimalasena S, Gothard L, Anbalagan S, Allen S, Sinnett V, Mohammed K, Kothari G, Musallam A, Lucy C, Yu S, Nayamundanda G, Kirby A, Ross G, Sawyer E, Castell F, Cleator S, Locke I, Tait D, Westbury C, Wolstenholme V, Box C, Robinson SP, Yarnold J, Somaiah N. Intratumoral Hydrogen Peroxide With Radiation Therapy in Locally Advanced Breast Cancer: Results From a Phase 1 Clinical Trial. Int J Radiat Oncol Biol Phys 2020; 108:1019-1029. [PMID: 32585332 DOI: 10.1016/j.ijrobp.2020.06.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/09/2020] [Accepted: 06/12/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE Hydrogen peroxide (H2O2) plays a vital role in normal cellular processes but at supraphysiological concentrations causes oxidative stress and cytotoxicity, a property that is potentially exploitable for the treatment of cancer in combination with radiation therapy (RT). We report the first phase 1 trial testing the safety and tolerability of intratumoral H2O2 + external beam RT as a novel combination in patients with breast cancer and exploratory plasma marker analyses investigating possible mechanisms of action. METHODS AND MATERIALS Twelve patients with breast tumors ≥3 cm (surgically or medically inoperable) received intratumoral H2O2 with either 36 Gy in 6 twice-weekly fractions (n = 6) or 49.5 Gy in 18 daily fractions (n = 6) to the whole breast ± locoregional lymph nodes in a single-center, nonrandomized study. H2O2 was mixed in 1% sodium hyaluronate gel (final H2O2 concentration 0.5%) before administration to slow drug release and minimize local discomfort. The mixture was injected intratumorally under ultrasound guidance twice weekly 1 hour before RT. The primary endpoint was patient-reported maximum intratumoral pain intensity before and 24 hours postinjection. Secondary endpoints included grade ≥3 skin toxicity and tumor response by ultrasound. Blood samples were collected before, during, and at the end of treatment for cell-death and immune marker analysis. RESULTS Compliance with H2O2 and RT was 100%. Five of 12 patients reported moderate pain after injection (grade 2 Common Terminology Criteria for Adverse Events v4.02) with median duration 60 minutes (interquartile range, 20-120 minutes). Skin toxicity was comparable to RT alone, with maintained partial/complete tumor response relative to baseline in 11 of 12 patients at last follow-up (median 12 months). Blood marker analysis highlighted significant associations of TRAIL, IL-1β, IL-4, and MIP-1α with tumor response. CONCLUSIONS Intratumoral H2O2 with RT is well tolerated with no additional toxicity compared with RT alone. If efficacy is confirmed in a randomized phase 2 trial, the approach has potential as a cost-effective radiation response enhancer in multiple cancer types in which locoregional control after RT alone remains poor.
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MESH Headings
- Aged
- Aged, 80 and over
- Biomarkers, Tumor/blood
- Breast Neoplasms/blood
- Breast Neoplasms/diagnostic imaging
- Breast Neoplasms/pathology
- Breast Neoplasms/therapy
- Breast Neoplasms, Male/blood
- Breast Neoplasms, Male/pathology
- Breast Neoplasms, Male/therapy
- Chemokine CCL3/blood
- Chemoradiotherapy/methods
- Dose Fractionation, Radiation
- Female
- Humans
- Hyaluronic Acid/administration & dosage
- Hydrogen Peroxide/administration & dosage
- Hydrogen Peroxide/adverse effects
- Injections, Intralesional/adverse effects
- Injections, Intralesional/methods
- Interleukin-1beta/blood
- Interleukin-4/blood
- Lymphatic Irradiation
- Male
- Middle Aged
- Oxidants/administration & dosage
- Oxidants/adverse effects
- Pain Measurement
- Pain, Procedural/chemically induced
- Radiodermatitis/pathology
- Skin/drug effects
- TNF-Related Apoptosis-Inducing Ligand/blood
- Ultrasonography, Interventional
- Viscosupplements/administration & dosage
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Affiliation(s)
- Samantha Nimalasena
- Division of Radiotherapy and Imaging, the Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK
| | - Lone Gothard
- Division of Radiotherapy and Imaging, the Institute of Cancer Research, London, UK
| | - Selvakumar Anbalagan
- Division of Radiotherapy and Imaging, the Institute of Cancer Research, London, UK
| | - Steven Allen
- The Royal Marsden NHS Foundation Trust, London, UK
| | | | | | | | | | - Claire Lucy
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Sheng Yu
- Division of Radiotherapy and Imaging, the Institute of Cancer Research, London, UK
| | - Gift Nayamundanda
- Division of Radiotherapy and Imaging, the Institute of Cancer Research, London, UK
| | - Anna Kirby
- Division of Radiotherapy and Imaging, the Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK
| | - Gill Ross
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Elinor Sawyer
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Fiona Castell
- King's College Hospital NHS Foundation Trust, London, UK
| | | | - Imogen Locke
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Diana Tait
- The Royal Marsden NHS Foundation Trust, London, UK
| | | | | | - Carol Box
- Division of Radiotherapy and Imaging, the Institute of Cancer Research, London, UK
| | - Simon P Robinson
- Division of Radiotherapy and Imaging, the Institute of Cancer Research, London, UK
| | - John Yarnold
- Division of Radiotherapy and Imaging, the Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK
| | - Navita Somaiah
- Division of Radiotherapy and Imaging, the Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK.
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13
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Kustić D, Klarica Gembić T, Grebić D, Petretić Majnarić S, Nekić J. The role of different lymph node staging systems in predicting prognosis and determining indications for postmastectomy radiotherapy in patients with T1-T2pN1 breast carcinoma. Strahlenther Onkol 2020; 196:1044-1054. [PMID: 32710122 DOI: 10.1007/s00066-020-01669-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 07/06/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Based on the risk of locoregional recurrence (LRR), postmastectomy radiotherapy (PMRT) is recommended in T1-T2pN1 breast carcinoma (BC). We aimed to elucidate our institutional strategies underlying selection of these patients for PMRT. In the no-PMRT subset, we compared various lymph node (LN) staging systems' abilities to predict 5‑year overall and locoregional-free survival (OS/LRFS). METHODS We retrospectively enrolled 548 women with T1-T2pN1 BC undergoing mastectomy and axillary LN dissection. Depending on PMRT delivery, the participants were divided into the PMRT and no-PMRT groups. Predictors of OS/LRFS were calculated for the no-PMRT group only. Based on Cox regression modelling, the number of positive LNs (PLN), negative LNs (NLN), LN ratio (LNR), log odds of PLN (LODDS), and modified LNR (mLNR) were modelled, each respectively, with OS model covariates (age, grade III, lymphovascular invasion [LVI], tumor size, hormone receptor [HR] status) and LRFS model covariates (age, grade III, LVI). The C‑statistic, Akaike information criterion, and likelihood ratio χ2 of the models were compared. RESULTS Median follow-up was 60.5 (18-82), 61 (28-82), and 60 (18-80) months for the entire cohort, PMRT, and no-PMRT group, respectively. The PMRT and no-PMRT groups had comparable OS (p = 0.235). LRFS was better (p = 0.030) in the PMRT group comprising 105 subjects (19.16%) who were younger, more likely to have a higher-grade, HR-, HER2+ tumors, more PLNs, fewer NLNs, Ki-67 ≥ 20%, LVI, and extranodal extension (p ≤ 0.001). In the no-PMRT group, LNR-based OS/LRFS models exhibited superior prognostic performance. CONCLUSION In early-stage BC patients undergoing mastectomies, LN dissections and no PMRT, we propose LNR-based multivariable models to predict OS/LRFS with superior accuracy.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Antineoplastic Agents, Hormonal/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Breast Neoplasms/drug therapy
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/drug therapy
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/secondary
- Chemotherapy, Adjuvant
- Combined Modality Therapy
- Female
- Follow-Up Studies
- Humans
- Lymph Node Excision
- Lymphatic Irradiation
- Lymphatic Metastasis/radiotherapy
- Mastectomy
- Middle Aged
- Neoplasm Recurrence, Local/drug therapy
- Neoplasm Recurrence, Local/radiotherapy
- Neoplasm Staging/methods
- Neoplasms, Hormone-Dependent/therapy
- Prognosis
- Proportional Hazards Models
- Radiotherapy, Adjuvant/methods
- Retrospective Studies
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Affiliation(s)
- Domagoj Kustić
- Department of Nuclear Medicine, Clinical Hospital Center Rijeka, Rijeka, Croatia.
| | | | - Damir Grebić
- Clinic for Surgery, Clinical Hospital Center Rijeka, Rijeka, Croatia
| | | | - Jasna Nekić
- Department of Nuclear Medicine, Clinical Hospital Center Rijeka, Rijeka, Croatia
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14
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Ocanto A, Escribano A, Glaría L, Rodríguez I, Ferrer C, Huertas C, Pérez A, Morera R. TLI in pediatric patients. Clin Transl Oncol 2019; 22:884-891. [PMID: 31542864 DOI: 10.1007/s12094-019-02205-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 08/09/2019] [Accepted: 08/31/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE Hematopoietic progenitor cell transplantation (HSCT) is a procedure used in different hematological diseases as part of the curative treatment, so the investigators propose a system of conditioning of reduced intensity based on total lymphoid irradiation (TLI) as an alternative to the classic total body irradiation (TBI) followed by haploidentical transplantation in patients compatible with a single HLA haplotype, as an alternative to patients who do not have an HLA compatible donor. MATERIALS AND METHODS A cohort of 25 patients with hematological disease underwent haploidentical HSCT from February 2015 to May 2018, conditioned with TLI from day - 10 (2-4 days of treatment) followed by thiotepa (5 mg/kg/12 h) and melphalan (70 mg/m2/day) prior to HSCT and prophylaxis with ciclosporin (1.5 mg/kg/12 h). 2 Gy/fraction was administered to complete 8 Gy with IMRT and VMAT technique. RESULTS 12% rejection of the transplant was obtained with acute GVHD < II (48%) and chronic GVHD 12%. No acute toxicity was recorded in irradiated patients and 56% survival of patients at the end of follow-up. CONCLUSION Conditioning the haploidentical transplant with TLI, IMRT, and VMAT techniques compared with TBI and RT3D-C techniques is a feasible technique that helps inducing the necessary immunosuppression in patients with a high risk of graft rejection, minimal adverse effects, low incidence of GVHD, and high survival rate.
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Affiliation(s)
- A Ocanto
- Radiation Oncology Department, Hospital Universitario La Paz, Pº de La Castellana, 261, Madrid, 28046, Spain.
| | - A Escribano
- Radiation Oncology Department, Hospital Universitario La Paz, Pº de La Castellana, 261, Madrid, 28046, Spain
| | - L Glaría
- Radiation Oncology Department, Hospital Universitario La Paz, Pº de La Castellana, 261, Madrid, 28046, Spain
| | - I Rodríguez
- Radiation Oncology Department, Hospital Universitario La Paz, Pº de La Castellana, 261, Madrid, 28046, Spain
| | - C Ferrer
- Radiophysics and Radioprotection Department, Hospital Universitario La Paz, Pº de La Castellana, 261, Madrid, 28046, Spain
| | - C Huertas
- Radiophysics and Radioprotection Department, Hospital Universitario La Paz, Pº de La Castellana, 261, Madrid, 28046, Spain
| | - A Pérez
- Pediatric Hematology-Oncology Department, Hospital Universitario La Paz, Pº de La Castellana, 261, 28046, Madrid, Spain
| | - R Morera
- Radiation Oncology Department, Hospital Universitario La Paz, Pº de La Castellana, 261, Madrid, 28046, Spain
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15
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Haffty BG, McCall LM, Ballman KV, Buchholz TA, Hunt KK, Boughey JC. Impact of Radiation on Locoregional Control in Women with Node-Positive Breast Cancer Treated with Neoadjuvant Chemotherapy and Axillary Lymph Node Dissection: Results from ACOSOG Z1071 Clinical Trial. Int J Radiat Oncol Biol Phys 2019; 105:174-182. [PMID: 31085287 PMCID: PMC6699883 DOI: 10.1016/j.ijrobp.2019.04.038] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 04/27/2019] [Accepted: 04/30/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Use of adjuvant radiation therapy (RT) after neoadjuvant chemotherapy (NAC) in node-positive breast cancer (BC) is highly variable. In ACOSOG Z1071, RT after NAC was used at the discretion of treating physicians. Herein, we report the impact of RT and pathologic response on locoregional recurrence (LRR) after NAC. METHODS AND MATERIALS ACOSOG Z1071 enrolled women with cT0-4N1-2 BC treated with NAC from 2009 to 2011. Patients underwent sentinel node surgery and completion axillary lymph node dissection. The RT was at the discretion of the treating physicians. Patient outcomes were analyzed as a function of clinical-pathologic factors and use of RT. RESULTS Of 701 eligible patients, mastectomy was performed in 423 (59.6%) and breast-conserving surgery in 277 (40.4%). After NAC, residual disease was observed in 506 (72.2%), and 195 (27.8%) had a pathologic complete response. Of the patients, 591 (85.3%) received adjuvant RT and 102 (14.7%) did not. Median follow-up was 5.9 years. Forty-three patients (6.1%) experienced LRR, 145 (20.7%) experienced distant metastasis, and 142 (20.4%) died. Patients with pathologic complete response had the best LRR-relapse-free survival (hazard ratio [HR], 0.32; 95% confidence interval, 0.12-0.81; P = .016), distant metastasis-free survival (HR, 0.31; 95% CI, 0.19-0.52; P < .0001), BC-specific survival (HR, 0.34; 95% CI, 0.19-0.59; P = .0001) and overall survival (HR, 0.39; 95% CI, 0.240-0.63; P = .001) compared to patients with residual disease after NAC. Patients with triple-negative BC had a higher LRR rate compared to those with hormone receptor-positive BC (HR, 5.91; 95% CI, 2.80-12.49). There was a trend toward lower LRR with the use of postmastectomy and regional nodal RT, but there was no impact on overall, disease-free, or BC-specific survival. CONCLUSION In the ACOSOG Z1071 trial, in which the use of RT after NAC was at the discretion of the treating physicians, RT was associated with a trend toward decreased LRR. There was no association of RT with overall survival, BC-specific survival, or Disease Specific Survival. Triple-negative BC was associated with higher locoregional relapse rates.
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Affiliation(s)
- Bruce G Haffty
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey.
| | - Linda M McCall
- Alliance Statistics and Data Center, Duke University, Durham, North Carolina
| | - Karla V Ballman
- Weill Medical College of Cornell University, New York, New York
| | | | - Kelly K Hunt
- University of Texas, MD Anderson Cancer Center, Houston, Texas
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Marcenaro M, Foppiano F, Durzu S, Barra S, Corvò R. Kidney-Sparing Radiotherapy by Multiple-Field Three-Dimensional Technique in the Postoperative Management of Patients with Gastric Cancer: Comparison with Standard Two-Field Conformal Technique. Tumori 2018; 92:34-40. [PMID: 16683382 DOI: 10.1177/030089160609200107] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIMS AND BACKGROUND The opposed two-field technique is the standard approach for delivering adjuvant radiotherapy to patients with resected gastric cancer. Since a considerable radiation dose may reach both kidneys with this beam arrangement, with a potential risk of late effects, we investigated whether the CT-based multiple-field (M-F) approach was superior in terms of sparing critical organs at risk. METHODS From March 2001 to March 2004, 19 patients with radically resected gastric cancer entered the study. They were treated with adjuvant chemoradiotherapy according to the INT 0116 protocol. For each patient dose-volume histograms were calculated and the volume values of both kidneys and liver receiving 25 Gy (V25), 30 Gy (V30) and 40 Gy (V40) individually estimated with the M-F and two-field techniques were compared in detail. RESULTS Right kidney median V25, V30 and V40 values for the two-field and M-F techniques were 1.50%, 0%, 0% and 0%, 0% and 0%, respectively (P < 0.005, P < 0.01, P < 0.05). Left kidney median V25, V30 and V40 values for the M-F and two-field technique were 16%, 9.80%, 0.90% and 33.20%, 30.20%, 21.40% (P < 0.001, P < 0.0005, P < 0.0005). Liver median V25, V30 and V40 values for the M-F and two-field techniques were 51.30%, 22.30%, 8.90% and 13.30%, 11.60%, 8.10%, respectively (P < 0.0001, P < 0.0005 and P = 0.18). CONCLUSIONS Our comparison revealed that with the multiple-field technique the right kidney may be largely spared from irradiation; with respect to the two-field technique, the left kidney may receive a significantly reduced dose; however, the liver receives an increased dose that warrants careful long-term monitoring of hepatic function.
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Affiliation(s)
- Michela Marcenaro
- Radiation Oncology Department, National Cancer Research Institute, Genoa, Italy.
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Caudell JJ, Ward MC, Riaz N, Zakem SJ, Awan MJ, Dunlap NE, Isrow D, Hassanzadeh C, Vargo JA, Heron DE, Marcrom S, Boggs DH, Reddy CA, Dault J, Bonner JA, Higgins KA, Beitler JJ, Koyfman SA, Machtay M, Yao M, Trotti AM, Siddiqui F, Lee NY. Volume, Dose, and Fractionation Considerations for IMRT-based Reirradiation in Head and Neck Cancer: A Multi-institution Analysis. Int J Radiat Oncol Biol Phys 2018; 100:606-617. [PMID: 29413274 PMCID: PMC7269162 DOI: 10.1016/j.ijrobp.2017.11.036] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 11/12/2017] [Accepted: 11/24/2017] [Indexed: 01/04/2023]
Abstract
PURPOSE Limited data exist to guide the treatment technique for reirradiation of recurrent or second primary squamous carcinoma of the head and neck. We performed a multi-institution retrospective cohort study to investigate the effect of the elective treatment volume, dose, and fractionation on outcomes and toxicity. METHODS AND MATERIALS Patients with recurrent or second primary squamous carcinoma originating in a previously irradiated field (≥40 Gy) who had undergone reirradiation with intensity modulated radiation therapy (IMRT); (≥40 Gy re-IMRT) were included. The effect of elective nodal treatment, dose, and fractionation on overall survival (OS), locoregional control, and acute and late toxicity were assessed. The Kaplan-Meier and Gray's competing risks methods were used for actuarial endpoints. RESULTS From 8 institutions, 505 patients were included in the present updated analysis. The elective neck was not treated in 56.4% of patients. The median dose of re-IMRT was 60 Gy (range 39.6-79.2). Hyperfractionation was used in 20.2%. Systemic therapy was integrated for 77.4% of patients. Elective nodal radiation therapy did not appear to decrease the risk of locoregional failure (LRF) or improve the OS rate. Doses of ≥66 Gy were associated with improvements in both LRF and OS in the definitive re-IMRT setting. However, dose did not obviously affect LRF or OS in the postoperative re-IMRT setting. Hyperfractionation was not associated with improved LRF or OS. The rate of acute grade ≥3 toxicity was 22.1% overall. On multivariable logistic regression, elective neck irradiation was associated with increased acute toxicity in the postoperative setting. The rate of overall late grade ≥3 toxicity was 16.7%, with patients treated postoperatively with hyperfractionation experiencing the highest rates. CONCLUSIONS Doses of ≥66 Gy might be associated with improved outcomes in high-performance patients undergoing definitive re-IMRT. Postoperatively, doses of 50 to 66 Gy appear adequate after removal of gross disease. Hyperfractionation and elective neck irradiation were not associated with an obvious benefit and might increase toxicity.
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MESH Headings
- Carcinoma, Squamous Cell/mortality
- Carcinoma, Squamous Cell/radiotherapy
- Carcinoma, Squamous Cell/virology
- Dose Fractionation, Radiation
- Female
- Head and Neck Neoplasms/mortality
- Head and Neck Neoplasms/radiotherapy
- Head and Neck Neoplasms/virology
- Humans
- Kaplan-Meier Estimate
- Logistic Models
- Lymphatic Irradiation
- Male
- Neoplasm Recurrence, Local/mortality
- Neoplasm Recurrence, Local/radiotherapy
- Neoplasm Recurrence, Local/virology
- Neoplasms, Second Primary/mortality
- Neoplasms, Second Primary/radiotherapy
- Neoplasms, Second Primary/virology
- Radiation Dose Hypofractionation
- Radiation Injuries/etiology
- Radiotherapy, Intensity-Modulated/adverse effects
- Radiotherapy, Intensity-Modulated/methods
- Re-Irradiation/adverse effects
- Re-Irradiation/methods
- Retrospective Studies
- Treatment Outcome
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Affiliation(s)
- Jimmy J Caudell
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida.
| | - Matthew C Ward
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nadeem Riaz
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sara J Zakem
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, Cleveland, Ohio
| | - Musaddiq J Awan
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, Cleveland, Ohio
| | - Neal E Dunlap
- Department of Radiation Oncology, University of Louisville, Louisville, Kentucky
| | - Derek Isrow
- Department of Radiation Oncology, Henry Ford Health System, Detroit, Michigan
| | | | - John A Vargo
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Dwight E Heron
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania; Division of Head and Neck Surgery, Department of Otolaryngology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Samuel Marcrom
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama
| | - Drexell H Boggs
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama
| | - Chandana A Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joshua Dault
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - James A Bonner
- Department of Radiation Oncology, University of Alabama, Birmingham, Alabama
| | - Kristin A Higgins
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Jonathan J Beitler
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Shlomo A Koyfman
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Mitchell Machtay
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, Cleveland, Ohio
| | - Min Yao
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, Cleveland, Ohio
| | - Andy M Trotti
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Farzan Siddiqui
- Department of Radiation Oncology, Henry Ford Health System, Detroit, Michigan
| | - Nancy Y Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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Scandling JD, Busque S, Lowsky R, Shizuru J, Shori A, Engleman E, Jensen K, Strober S. Macrochimerism and clinical transplant tolerance. Hum Immunol 2018; 79:266-271. [PMID: 29330112 DOI: 10.1016/j.humimm.2018.01.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [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: 08/29/2017] [Revised: 12/15/2017] [Accepted: 01/04/2018] [Indexed: 11/18/2022]
Abstract
Current theory holds that macrochimerism is essential to the development of transplant tolerance. Hematopoietic cell transplantation from the solid organ donor is necessary to achieve macrochimerism. Over the last 10-20 years, trials of tolerance induction with combined kidney and hematopoietic cell transplantation have moved from the preclinical to the clinical arena. The achievement of macrochimerism in the clinical setting is challenging, and potentially toxic due to the conditioning regimen necessary to hematopoietic cell transplantation and due to the risk of graft-versus-host disease. There are differences in chimerism goals and methods of the three major clinical stage tolerance induction strategies in both HLA-matched and HLA-mismatched living donor kidney transplantation, with consequent differences in efficacy and safety. The Stanford protocol has proven efficacious in the induction of tolerance in HLA-matched kidney transplantation, allowing cessation of immunosuppressive drug therapy in 80% of study participants, with the safety profile of conventional transplantation. In HLA-mismatched transplantation, multi-lineage macrochimerism of over a year's duration can now be consistently achieved with the Stanford protocol, with complete withdrawal of immunosuppressive drug therapy during the second post-transplant year as the next experimental step and test of tolerance.
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Affiliation(s)
- John D Scandling
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA.
| | - Stephan Busque
- Divsion of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Robert Lowsky
- Divsion of Blood and Marrow Transplantation, Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Judith Shizuru
- Divsion of Blood and Marrow Transplantation, Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Asha Shori
- Divsion of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Edgar Engleman
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA; Department of Pathology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Kent Jensen
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Samuel Strober
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
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Affiliation(s)
- Michael Pinkawa
- Department of Radiation Oncology, MediClin Robert Janker Klinik, Bonn, Germany
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Abstract
RATIONALE Nasopharyngeal carcinoma (NPC) has a high propensity of metastasis. The most commonly described sites of distant metastasis are the bones, lungs, and liver, whereas axillary metastasis is seldom reported. PATIENT CONCERNS We hereby present the case of a 66-year-old man with NPC, cT2N2M0, at diagnosis. He had completed chemoradiotherapy and been disease-free for 7 years. DIAGNOSES After that period, late recurrence in the form of a solitary axillary lymph node metastasis was detected and confirmed by core-needle biopsy. INTERVENTIONS The lesion was chemoresistant but responded to salvage radiotherapy at a dose of 65 Gy in 21 fractions. OUTCOMES Post-radiotherapy positron emission tomography scan showed no evidence of disease. LESSONS We suggested that long-term follow-up of NPC patients is important because a late relapse may occur at an unusual site. Aggressive management of solitary metastasis may achieve good outcome.
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Affiliation(s)
| | | | - Shan-Ying Wang
- Division of Nuclear Medicine, Far Eastern Memorial Hospital, New Taipei City
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei
| | - Pei-Ying Hsieh
- Division of Medical Oncology, Far Eastern Memorial Hospital, New Taipei City
| | - Pei-Wei Shueng
- Division of Radiation Oncology
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei
- Department of Radiation Oncology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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21
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Affiliation(s)
- Christopher A Barker
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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22
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Affiliation(s)
- Penny Fang
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
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23
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McDowell LJ, Huang SH, Xu W, Che J, Wong RKS, Brierley J, Kim J, Cummings B, Waldron J, Bayley A, Hansen A, Witterick I, Ringash J. Effect of Intensity Modulated Radiation Therapy With Concurrent Chemotherapy on Survival for Patients With Cervical Esophageal Carcinoma. Int J Radiat Oncol Biol Phys 2017; 98:186-195. [PMID: 28258892 DOI: 10.1016/j.ijrobp.2017.01.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 12/17/2016] [Accepted: 01/01/2017] [Indexed: 11/19/2022]
Abstract
PURPOSE We evaluated the effect of consecutive protocols on overall survival (OS) for cervical esophageal carcinoma (CEC). METHODS AND MATERIALS All CEC cases that received definitive radiation therapy (RT) with or without chemotherapy from 1997 to 2013 in 3 consecutive protocols were reviewed. Protocol 1 (P1) consisted of 2-dimensional RT of 54 Gy in 20 fractions with 5-fluorouracil plus either mitomycin C or cisplatin. Protocol 2 (P2) consisted of 3-dimensional conformal RT (3DRT) of ≥60 Gy in 30 fractions plus elective nodal irradiation plus cisplatin. Protocol 3 (P3) consisted of intensity modulated RT (IMRT) of ≥60 Gy in 30 fractions plus elective nodal irradiation plus cisplatin. Multivariable analyses were used to assess the effect of the treatment protocol, RT technique, and RT dose on OS, separately. RESULTS Of 81 cases (P1, 21; P2, 23; and P3, 37), 34 local (P1, 11 [52%]; P2, 12 [52%]; and P3, 11 [30%]), 16 regional (P1, 6 [29%]); P2, 3 [13%]; and P3, 7 [19%]), and 34 distant (P1, 10 [48%]; P2, 9 [39%]; and P3, 15 [41%]) failures were identified. After adjusting for age (P=.49) and chemotherapy (any vs none; hazard ratio [HR] 0.5, 95% confidence interval [CI] 0.3-0.9; P=.023), multivariable analysis showed P3 had improved OS compared with P1 (HR 0.4, 95% CI 0.2-0.8; P=.005), with a trend shown for benefit compared with P2 (HR 0.6, 95% CI 0.3-1.0; P=.061). OS between P1 and P2 did not differ (P=.29). Analyzed as a continuous variable, higher RT doses were associated with a borderline improved OS (HR 0.97, 95% CI 0.95-1.0; P=.075). IMRT showed improved OS compared with non-IMRT (HR 0.57, 95% CI 0.3-0.8; P=.008). CONCLUSIONS The present retrospective consecutive cohort study showed improved OS with our current protocol (P3; high-dose IMRT with concurrent high-dose cisplatin) compared with historical protocols. The outcomes for patients with CEC remain poor, and novel approaches to improve the therapeutic ratio are warranted.
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Affiliation(s)
- Lachlan J McDowell
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Shao Hui Huang
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Wei Xu
- Department of Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jiahua Che
- Department of Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Rebecca K S Wong
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - James Brierley
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - John Kim
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Bernard Cummings
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - John Waldron
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Bayley
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Aaron Hansen
- Division of Medical Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ian Witterick
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jolie Ringash
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada.
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24
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Abstract
The nasal cavity and parasinusal cancer are rare (10% of tumors of the head and neck) and are mainly represented by squamous cell carcinoma of the nasal cavity or the maxillary sinus and adenocarcinoma of the ethmoid sinus (occupational disease, wood dust). The most common clinical sign is nasal obstruction, but tumors can also manifest as rhinorrhea and/or epistaxis (usually unilateral signs). A magnetic resonance imaging of the facial structure is systematic for staging before treatment. The treatment consists of a first surgery if the patient is operable with a resectable tumor. If it is not the case, the treatment consists of radiotherapy (RT) associated with chemotherapy (CT) according to the initial data (T3/T4 or N+). After first surgery, RT is indicated (except T1N0 with complete resection) associated with a CT based on postoperative data (capsular effraction or incomplete resection). Lymph node irradiation is considered case by case, but is indicated in any nodal involvement. RT must be an intensity modulated RT (IMRT), static or dynamic, and must be imagery guided (IGRT). According to ICRU 83, doses to organs at risk and target volumes must be carried. Finally, after a post-treatment baseline imaging between 2 and 4 months, monitoring will be alternated with the ENT surgeon every 2 or 3 months for 2 years, then every 4 to 6 months for 5 years.
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MESH Headings
- Adenocarcinoma/diagnosis
- Adenocarcinoma/diagnostic imaging
- Adenocarcinoma/radiotherapy
- Adenocarcinoma/therapy
- Aftercare
- Carcinoma, Squamous Cell/diagnosis
- Carcinoma, Squamous Cell/diagnostic imaging
- Carcinoma, Squamous Cell/radiotherapy
- Carcinoma, Squamous Cell/therapy
- Combined Modality Therapy
- Dose Fractionation, Radiation
- Humans
- Lymphatic Irradiation
- Maxillary Sinus Neoplasms/radiotherapy
- Nasal Cavity
- Nose Neoplasms/diagnosis
- Nose Neoplasms/diagnostic imaging
- Nose Neoplasms/radiotherapy
- Nose Neoplasms/therapy
- Organs at Risk
- Paranasal Sinus Neoplasms/diagnosis
- Paranasal Sinus Neoplasms/diagnostic imaging
- Paranasal Sinus Neoplasms/radiotherapy
- Paranasal Sinus Neoplasms/therapy
- Radiation Injuries/etiology
- Radiation Injuries/prevention & control
- Radiotherapy Dosage
- Radiotherapy Planning, Computer-Assisted
- Radiotherapy, Adjuvant/methods
- Radiotherapy, Adjuvant/standards
- Radiotherapy, Image-Guided
- Radiotherapy, Intensity-Modulated/adverse effects
- Radiotherapy, Intensity-Modulated/methods
- Radiotherapy, Intensity-Modulated/standards
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Affiliation(s)
- G Peyraga
- Département de radiothérapie, institut cancérologique de l'Ouest (ICO), site Paul-Papin, 15, rue André-Boquel, 49055 Angers cedex 02, France.
| | - C Lafond
- Département de radiothérapie, institut cancérologique de l'Ouest (ICO), site Paul-Papin, 15, rue André-Boquel, 49055 Angers cedex 02, France
| | - Y Pointreau
- Département de radiothérapie, institut cancérologique de l'Ouest (ICO), site Paul-Papin, 15, rue André-Boquel, 49055 Angers cedex 02, France
| | - P Giraud
- Service de radiothérapie, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France
| | - P Maingon
- Département de radiothérapie, centre Georges-François-Leclerc, 1, rue du Pr-Marion, 21000 Dijon, France
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25
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Studer G, Huber GF, Holz E, Glanzmann C. Less may be more: nodal treatment in neck positive head neck cancer patients. Eur Arch Otorhinolaryngol 2016; 273:1549-56. [PMID: 25920604 PMCID: PMC4858567 DOI: 10.1007/s00405-015-3634-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 04/17/2015] [Indexed: 11/09/2022]
Abstract
Ongoing debates about the need and extent of planned neck dissection (PND), and required nodal radiation doses volumes lead to this evaluation. Aim was to assess nodal control after definitive intensity modulated radiation therapy (IMRT ± systemic therapy) followed by PND in our head neck cancer cohort with advanced nodal disease. Between 01/2005 and 12/2013, 99 squamous cell cancer HNC patients with pre-therapeutic nodal metastasis ≥3 cm were treated with definitive IMRT followed by PND. In addition, outcome in 103 patients with nodal relapse after IMRT and observation only (no-PND cohort) were analyzed. Prior to PND, PET-CT, fine needle aspirations, ultrasound and palpation were assessed regarding its predictive value. Patterns of nodal relapse were assessed in patients with isolated neck failure after definitive IMRT alone. 70/99 (70 %) PND specimens showed histopathological complete response (hCR), which translated into statistically significantly superior survival compared with partial response (hPR) with 4-year overall survival, disease specific survival and nodal control rates of 90/83/96 vs 67/60/78 % (p = 0.002/0.001/0.003). 1/99 patient developed isolated subsequent nodal disease. 64/2147 removed nodes contained viable tumor (3 %). Predictive information of the performed diagnostic investigations was not reliable. 17/70 hCR patients showed true negative findings in available three to four investigations (0/29 hPR). 27/103 no-PND patients developed isolated neck disease (26 %) with successful salvage in 21/24 [88 %, or 21/27 (78 %)]. Nearly all failures occurred in the prior nodal gross tumor volume area. A more restrictive approach regarding PND and/or nodal IMRT dose-volumes may be justified.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Carcinoma, Squamous Cell/drug therapy
- Carcinoma, Squamous Cell/mortality
- Carcinoma, Squamous Cell/radiotherapy
- Carcinoma, Squamous Cell/surgery
- Combined Modality Therapy/methods
- Female
- Head and Neck Neoplasms/drug therapy
- Head and Neck Neoplasms/mortality
- Head and Neck Neoplasms/radiotherapy
- Head and Neck Neoplasms/surgery
- Humans
- Lymphatic Irradiation
- Lymphatic Metastasis
- Male
- Middle Aged
- Neck Dissection
- Neoplasm Recurrence, Local/drug therapy
- Neoplasm Recurrence, Local/mortality
- Neoplasm Recurrence, Local/radiotherapy
- Neoplasm Recurrence, Local/surgery
- Radiotherapy, Intensity-Modulated
- Salvage Therapy
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Affiliation(s)
- Gabriela Studer
- />Department of Radiation Oncology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Gerhard F. Huber
- />Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Edna Holz
- />Department of Radiation Oncology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Christoph Glanzmann
- />Department of Radiation Oncology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
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26
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Boekel NB, Schaapveld M, Gietema JA, Russell NS, Poortmans P, Theuws JCM, Schinagl DAX, Rietveld DHF, Versteegh MIM, Visser O, Rutgers EJT, Aleman BMP, van Leeuwen FE. Cardiovascular Disease Risk in a Large, Population-Based Cohort of Breast Cancer Survivors. Int J Radiat Oncol Biol Phys 2015; 94:1061-72. [PMID: 27026313 DOI: 10.1016/j.ijrobp.2015.11.040] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 11/03/2015] [Accepted: 11/29/2015] [Indexed: 11/17/2022]
Abstract
PURPOSE To conduct a large, population-based study on cardiovascular disease (CVD) in breast cancer (BC) survivors treated in 1989 or later. METHODS AND MATERIALS A large, population-based cohort comprising 70,230 surgically treated stage I to III BC patients diagnosed before age 75 years between 1989 and 2005 was linked with population-based registries for CVD. Cardiovascular disease risks were compared with the general population, and within the cohort using competing risk analyses. RESULTS Compared with the general Dutch population, BC patients had a slightly lower CVD mortality risk (standardized mortality ratio 0.92, 95% confidence interval [CI] 0.88-0.97). Only death due to valvular heart disease was more frequent (standardized mortality ratio 1.28, 95% CI 1.08-1.52). Left-sided radiation therapy after mastectomy increased the risk of any cardiovascular event compared with both surgery alone (subdistribution hazard ratio (sHR) 1.23, 95% CI 1.11-1.36) and right-sided radiation therapy (sHR 1.19, 95% CI 1.04-1.36). Radiation-associated risks were found for not only ischemic heart disease, but also for valvular heart disease and congestive heart failure (CHF). Risks were more pronounced in patients aged <50 years at BC diagnosis (sHR 1.48, 95% CI 1.07-2.04 for left- vs right-sided radiation therapy after mastectomy). Left- versus right-sided radiation therapy after wide local excision did not increase the risk of all CVD combined, yet an increased ischemic heart disease risk was found (sHR 1.14, 95% CI 1.01-1.28). Analyses including detailed radiation therapy information showed an increased CVD risk for left-sided chest wall irradiation alone, left-sided breast irradiation alone, and internal mammary chain field irradiation, all compared with right-sided breast irradiation alone. Compared with patients not treated with chemotherapy, chemotherapy used ≥1997 (ie, anthracyline-based chemotherapy) increased the risk of CHF (sHR 1.35, 95% CI 1.00-1.83). CONCLUSION Radiation therapy regimens used in BC treatment between 1989 and 2005 increased the risk of CVD, and anthracycline-based chemotherapy regimens increased the risk of CHF.
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Affiliation(s)
- Naomi B Boekel
- Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Jourik A Gietema
- Medical Oncology, University Medical Center Groningen, Groningen, The Netherlands
| | - Nicola S Russell
- Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Philip Poortmans
- Radiation Oncology, Institute Verbeeten, Tilburg, The Netherlands; Radiation Oncology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | | | - Dominic A X Schinagl
- Radiation Oncology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Derek H F Rietveld
- Radiation Oncology, VU University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Michel I M Versteegh
- Steering Committee Cardiac Interventions Netherlands, Leiden University Medical Center, Leiden, The Netherlands
| | - Otto Visser
- Registration and Research, Comprehensive Cancer Center The Netherlands, Utrecht, The Netherlands
| | | | - Berthe M P Aleman
- Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
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van den Bosch S, Dijkema T, Verhoef LCG, Zwijnenburg EM, Janssens GO, Kaanders JHAM. Patterns of Recurrence in Electively Irradiated Lymph Node Regions After Definitive Accelerated Intensity Modulated Radiation Therapy for Head and Neck Squamous Cell Carcinoma. Int J Radiat Oncol Biol Phys 2015; 94:766-74. [PMID: 26972649 DOI: 10.1016/j.ijrobp.2015.12.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 11/25/2015] [Accepted: 12/04/2015] [Indexed: 11/17/2022]
Abstract
PURPOSE To provide a comprehensive risk assessment on the patterns of recurrence in electively irradiated lymph node regions after definitive radiation therapy for head and neck cancer. METHODS AND MATERIALS Two hundred sixty-four patients with stage cT2-4N0-2M0 squamous cell carcinoma of the oropharynx, larynx, or hypopharynx treated with accelerated intensity modulated radiation therapy between 2008 and 2012 were included. On the radiation therapy planning computed tomography (CT) scans from all patients, 1166 lymph nodes (short-axis diameter ≥5 mm) localized in the elective volume were identified and delineated. The exact sites of regional recurrences were reconstructed and projected on the initial radiation therapy planning CT scan by performing coregistration with diagnostic imaging of the recurrence. RESULTS The actuarial rate of recurrence in electively irradiated lymph node regions at 2 years was 5.1% (95% confidence interval 2.4%-7.8%). Volumetric analysis showed an increased risk of recurrence with increasing nodal volume. Receiver operating characteristic analysis demonstrated that the summed long- and short-axis diameter is a good alternative for laborious volume calculations, using ≥17 mm as cut-off (hazard ratio 17.8; 95% confidence interval 5.7-55.1; P<.001). CONCLUSIONS An important risk factor was identified that can help clinicians in the pretreatment risk assessment of borderline-sized lymph nodes. Not overtly pathologic nodes with a summed diameter ≥17 mm may require a higher than elective radiation therapy dose. For low-risk elective regions (all nodes <17 mm), the safety of dose de-escalation below the traditional 45 to 50 Gy should be investigated.
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Affiliation(s)
- Sven van den Bosch
- Department of Radiation Oncology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands.
| | - Tim Dijkema
- Department of Radiation Oncology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Lia C G Verhoef
- Department of Radiation Oncology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Ellen M Zwijnenburg
- Department of Radiation Oncology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Geert O Janssens
- Department of Radiation Oncology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Johannes H A M Kaanders
- Department of Radiation Oncology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
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Harris VA, Staffurth J, Naismith O, Esmail A, Gulliford S, Khoo V, Lewis R, Littler J, McNair H, Sadoyze A, Scrase C, Sohaib A, Syndikus I, Zarkar A, Hall E, Dearnaley D. Consensus Guidelines and Contouring Atlas for Pelvic Node Delineation in Prostate and Pelvic Node Intensity Modulated Radiation Therapy. Int J Radiat Oncol Biol Phys 2015; 92:874-83. [PMID: 26104940 DOI: 10.1016/j.ijrobp.2015.03.021] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 03/19/2015] [Accepted: 03/20/2015] [Indexed: 12/29/2022]
Abstract
PURPOSE The purpose of this study was to establish reproducible guidelines for delineating the clinical target volume (CTV) of the pelvic lymph nodes (LN) by combining the freehand Royal Marsden Hospital (RMH) and Radiation Therapy Oncology Group (RTOG) vascular expansion techniques. METHODS AND MATERIALS Seven patients with prostate cancer underwent standard planning computed tomography scanning. Four different CTVs (RMH, RTOG, modified RTOG, and Prostate and pelvIs Versus prOsTate Alone treatment for Locally advanced prostate cancer [PIVOTAL] trial) were created for each patient, and 6 different bowel expansion margins (BEM) were created to assess bowel avoidance by the CTV. The resulting CTVs were compared visually and by using Jaccard conformity indices. The volume of overlap between bowel and planning target volume (PTV) was measured to aid selection of an appropriate BEM to enable maximal LN yet minimal normal tissue coverage. RESULTS In total, 84 nodal contours were evaluated. LN coverage was similar in all groups, with all of the vascular-expansion techniques (RTOG, modified RTOG, and PIVOTAL), resulting in larger CTVs than that of the RMH technique (mean volumes: 287.3 cm(3), 326.7 cm(3), 310.3 cm(3), and 256.7 cm(3), respectively). Mean volumes of bowel within the modified RTOG PTV were 19.5 cm(3) (with 0 mm BEM), 17.4 cm(3) (1-mm BEM), 10.8 cm(3) (2-mm BEM), 6.9 cm(3) (3-mm BEM), 5.0 cm(3) (4-mm BEM), and 1.4 cm(3) (5-mm BEM) in comparison with an overlap of 9.2 cm(3) seen using the RMH technique. Evaluation of conformity between LN-CTVs from each technique revealed similar volumes and coverage. CONCLUSIONS Vascular expansion techniques result in larger LN-CTVs than the freehand RMH technique. Because the RMH technique is supported by phase 1 and 2 trial safety data, we proposed modifications to the RTOG technique, including the addition of a 3-mm BEM, which resulted in LN-CTV coverage similar to that of the RMH technique, with reduction in bowel and planning target volume overlap. On the basis of these findings, recommended guidelines including a detailed pelvic LN contouring atlas have been produced and implemented in the PIVOTAL trial.
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Affiliation(s)
- Victoria A Harris
- Academic Urology Unit, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - John Staffurth
- Institute of Cancer and Genetics, School of Medicine, Cardiff University, Cardiff, Wales, United Kingdom
| | - Olivia Naismith
- Joint Department of Physics, Institute of Cancer Research, and Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Alikhan Esmail
- Ipswich Hospital NHS Foundation Trust, Ipswich, United Kingdom
| | - Sarah Gulliford
- Joint Department of Physics, Institute of Cancer Research, and Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Vincent Khoo
- Academic Urology Unit, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Rebecca Lewis
- Clinical Trials and Statistics Unit, Institute of Cancer Research, London, United Kingdom
| | - John Littler
- Clatterbridge Cancer Centre, Liverpool, United Kingdom
| | - Helen McNair
- Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Azmat Sadoyze
- Beatson West of Scotland Cancer Centre, Scotland, Glasgow, United Kingdom
| | | | - Aslam Sohaib
- Department of Radiology, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | | | - Anjali Zarkar
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Emma Hall
- Clinical Trials and Statistics Unit, Institute of Cancer Research, London, United Kingdom
| | - David Dearnaley
- Academic Urology Unit, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom.
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Horii T, Yoshinaga K, Kobayashi N, Seto K, Orikawa Y, Okamoto M, Eta R, Ohira Y, Katsunuma K, Hori Y, Tanaka T, Takei M. Z-100, an immunomodulatory extract of Mycobacterium tuberculosis strain Aoyama B, prevents spontaneous lymphatic metastasis of B16-BL6 melanoma. Biol Pharm Bull 2015; 37:642-7. [PMID: 24818259 DOI: 10.1248/bpb.b13-00927] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Lymphatic metastasis is common in advanced-stage carcinoma and is associated with a poor prognosis. However, few effective treatments to inhibit it are available. Z-100 is an immunomodulatory extract of Mycobacterium tuberculosis strain Aoyama B that contains polysaccharides such as arabinomannan and mannan. Here, we investigated the inhibitory effect of Z-100 on spontaneous lymphatic metastasis. C57BL/6N mice injected subcutaneously with B16-BL6 melanoma cells in the right hind footpad were administered Z-100 subcutaneously in the right inguinal region on a daily basis. On day twenty-one after the injection, the right inguinal lymph nodes were excised, and the extent of metastasis, the number of immune cells, and the amount of granzyme B protein in the lymph nodes were examined. We also investigated the combined effect of Z-100 and irradiation in this model. Results showed that Z-100 reduced number of animals with metastasis, with respective metastasis rates of 85.7%, 42.9%, 7.1% and 0.0% in saline, 0.1 mg/kg Z-100, 1 mg/kg Z-100 and 10 mg/kg Z-100 group. Further, mice that had been given Z-100 were found to have more immune cells and granzyme B protein in the lymph nodes than control mice. The combination of low dose Z-100 and irradiation also inhibited spontaneous lymph node metastases. These findings suggest that Z-100 may be beneficial in preventing lymphatic metastasis by enhancing the immune response.
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Colvin MM, Cook JL, Chang P, Francis G, Hsu DT, Kiernan MS, Kobashigawa JA, Lindenfeld J, Masri SC, Miller D, O'Connell J, Rodriguez ER, Rosengard B, Self S, White-Williams C, Zeevi A. Antibody-mediated rejection in cardiac transplantation: emerging knowledge in diagnosis and management: a scientific statement from the American Heart Association. Circulation 2015; 131:1608-39. [PMID: 25838326 DOI: 10.1161/cir.0000000000000093] [Citation(s) in RCA: 205] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Gronnier C, Mariette C. [Lymph node involvement in œsophageal cancer: surgical approach]. Cancer Radiother 2014; 18:559-64. [PMID: 25195112 DOI: 10.1016/j.canrad.2014.06.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 06/07/2014] [Revised: 06/18/2014] [Accepted: 06/21/2014] [Indexed: 11/16/2022]
Abstract
Lymph node invasion is an early event in the oesophageal carcinogenesis and represents the main prognostic factor in the curative setting. Even though the primacy of surgical resection has been challenged by the definitive radiochemotherapy for locally advanced squamous cell carcinomas of the oesophagus, surgery is now again a gold standard, in combination with (radio)chemotherapy, to improve locoregional disease control and long term survival. Surgery, especially lymphadenectomy, has consequently to be standardized through quality criteria. Lymph node stations invaded in œsophageal and junctional cancers, lymphadenectomy, and its impact on outcomes are discussed in this review based on the highest level of evidence published data.
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Affiliation(s)
- C Gronnier
- Service de chirurgie digestive et générale, hôpital Claude-Huriez, CHRU de Lille, place de Verdun, 59037 Lille cedex, France
| | - C Mariette
- Service de chirurgie digestive et générale, hôpital Claude-Huriez, CHRU de Lille, place de Verdun, 59037 Lille cedex, France.
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Lin Y, Chen J, Li J, Liu J, Zhu K, Pan C, Chen M, Pan J. [Value of postoperative radiochemotherapy for thoracic esophageal squamous cell carcinoma with lymph node metastasis]. Zhonghua Zhong Liu Za Zhi 2014; 36:151-154. [PMID: 24796467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To retrospectively compare the efficacy of postoperative radiotherapy (RT) alone with that of postoperative radiotherapy with concurrent chemotherapy (CRT) for thoracic esophageal squamous cell carcinoma (EPC) with positive lymph nodes, and to evaluate the clinical value of RT + CRT. METHODS 304 EPC patients underwent esophagectomy with three-field lymph node dissection had pathological lymph node metastases, but no hematogenous distant metastasis. Among them, 140 cases underwent postoperative RT alone, and 164 cases underwent postoperative CRT. The dose of irradiation was 50 Gy, and the chemotherapy regimen was taxol and cis-platinum, and a cycle was 21 days. RESULTS The 1-, 3- and 5-year total survival rates of the whole group were 90.1%, 56.6% and 43.3%, respectively, with a median survival time of 49.7 months. The 5-year overall survival rates of the CRT and RT groups were 47.4% and 38.6%, respectively (P = 0.030), with a median survival time of 53.5 and 41.7 months, respectively (P = 0.030). The overall survival rates of the patients who underwent 1, 2, 3, 4 cycles of chemotherapy were 24.4%, 53.0%, 58.1% and 43.3%, respectively (P = 0.007). Among them, the 5-year total survival rate of patients with 2-4 cycles of chemotherapy was significantly better than that of patients who underwent one cycle of chemotherapy (P = 0.001). Univariate analysis showed that number of metastatic lymph nodes, pT stage, therapeutic regimen and number of chemotherapy cycles were significantly correlated with the prognosis of the patients (P < 0.05 for all). Multivariate analysis showed that number of metastatic lymph nodes, pT stage, and number of chemotherapy cycles were independent prognostic factors of the patients (P < 0.05 for all). Early toxic effects including neutropenia, radiation esophagitis, and gastrointestinal effects were significantly more severe in the CRT group than that in the RT group (P < 0.05), however, there were no significant differences of late toxic effects between the two groups (P > 0.05). CONCLUSION Postoperative CRT for thoracic EPC with positive lymph nodes can improve the survival rate, with tolerable adverse effects.
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Affiliation(s)
- Yu Lin
- Fujian Provincial Tumor Hospital, Fuzhou 350014, China
| | - Junqiang Chen
- Fujian Provincial Tumor Hospital, Fuzhou 350014, China
| | - Jiancheng Li
- Fujian Provincial Tumor Hospital, Fuzhou 350014, China
| | - Jian Liu
- Fujian Provincial Tumor Hospital, Fuzhou 350014, China
| | - Kunshou Zhu
- Fujian Provincial Tumor Hospital, Fuzhou 350014, China
| | - Caizhu Pan
- Fujian Provincial Tumor Hospital, Fuzhou 350014, China
| | | | - Jianji Pan
- Fujian Provincial Tumor Hospital, Fuzhou 350014, China
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Zhu D, Qi G, Tang Q, Li L, Yang C, Lin M, Wu B, Xu M, Cai J, Zhu T, Rong R. Combination of Total Lymphoid Irradiation, Low-Dose IVIG and ATG as Rescue Therapy for Highly Sensitized and Antibody-Mediated Rejection Renal Transplant Recipients. Clin Transpl 2014:215-221. [PMID: 26281148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
UNLABELLED Background: It is now clear that antibody- mediated rejection (AMR) is a major cause of graft failure. To avoid AMR, transplantation is preferably performed in non- or low-sensitized patients. For patients with pre-existing HLA antibodies due to pre-transplant sensitization or those with de novo HLA antibodies due to transplantation, elimination or reduction of HLA antibodies becomes critical to prevent AMR. Materials and Methods: In this clinical trial, we test the efficacy of a combination therapy of total lymphoid irradiation (TLI), low- dose intravenous immunoglobulin (IVIG), and anti-thymocyte globulin (ATG) with or without plasmapheresis (PP) in treating patients with HLA antibodies. Thirteen HLA antibody positive patients receiving renal transplants during 2009-2011 were enrolled in this study. Two cases with pre-existing HLA antibodies received combined therapy of TLI, PP, low-dose IVIG, and ATG induction. Eleven cases with de novo HLA antibodies and biopsy-proven AMR received TLI, low-dose IVIG, and ATG with or without PP. RESULTS Two sensitized patients with pre-existing HLA antibodies were successfully desensitized and able to accept renal transplantation without an observable AMR episode in 12 months of post-transplant follow-up. In 11 AMR cases with de novo HLA antibodies, only one patient failed to respond to the therapy and lost the allograft. In the other ten cases, the follow-up biopsies at one year post transplant showed no evidence of rejection and the patients had stable renal function. B cell proliferation was persistently inhibited in both desensitization and AMR patients. CONCLUSIONS Combined therapy of TLI, PP, low-dose IVIG, and ATG is an effective therapeutic measure to reduce the level of HLA antibodies and therefore to desensitize recipients pre-transplant and to reverse AMR post transplant. The potential mechanism of the therapy involves inhibition of B cell proliferation.
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Thorsen LBJ, Thomsen MS, Overgaard M, Overgaard J, Offersen BV. Quality assurance of conventional non-CT-based internal mammary lymph node irradiation in a prospective Danish Breast Cancer Cooperative Group trial: the DBCG-IMN study. Acta Oncol 2013; 52:1526-34. [PMID: 23957621 DOI: 10.3109/0284186x.2013.813643] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
UNLABELLED In 2003, the Danish Breast Cancer Cooperative Group (DBCG) initiated DBCG-IMN, a prospective study on the effect of adjuvant internal mammary lymph node radiotherapy (IMN-RT) in patients with early lymph node positive breast cancer (BC). In the study, standard DBCG IMN-RT was provided only to patients with right-sided BC. We provide estimates of doses to IMNs and organs at risk (OARs) in patients treated with the non-CT-based RT techniques used during the DBCG-IMN study. MATERIAL AND METHODS Five DBCG RT regimens were simulated on planning CT scans from 50 consecutively scanned BC patients, 10 in each group. Intended target volumes were chest wall or breast and regional lymph nodes ± IMNs. Field planning was conducted in the Eclipse(TM) RT treatment planning system. Subsequently, IMN clinical target volumes (CTVs) and OARs were delineated. Estimates on doses to the IMN-CTV and OARs were made. RESULTS IMN dose coverage estimates were consistently higher in right-sided techniques where IMN treatment was intended (p < 0.0001). Estimated doses to cardiac structures were low regardless of whether IMNs were treated or not. Post-lumpectomy patients had the highest estimated lung doses. CONCLUSION Overall, simulator-based treatment using the DBCG RT techniques resulted in satisfactory coverage of IMNs and acceptable levels of OAR irradiation.
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Affiliation(s)
- Lise B J Thorsen
- Department of Experimental Clinical Oncology, Aarhus University Hospital , Aarhus , Denmark
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Chen JZ, Le QT, Han F, Lu LX, Huang SM, Lin CG, Deng XW, Cui NJ, Zhao C. Results of a phase 2 study examining the effects of omitting elective neck irradiation to nodal levels IV and Vb in patients with N(0-1) nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys 2013; 85:929-34. [PMID: 22975606 DOI: 10.1016/j.ijrobp.2012.07.2356] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Revised: 07/11/2012] [Accepted: 07/17/2012] [Indexed: 02/05/2023]
Abstract
PURPOSE To evaluate the patterns of nodal failure and toxicity in clinically negative necks of N0-1 nasopharyngeal carcinoma (NPC) patients who were treated with intensity modulated radiation therapy (IMRT) but did not receive elective neck irradiation (ENI) to level IV and Vb nodes. METHODS AND MATERIALS We conducted a phase 2 prospective study in N0-1 NPC patients treated with IMRT. ENI included the retropharyngeal nodes and levels II to Va but omitted levels IV and Vb in clinically negative necks. Patterns of nodal failure, regional control (RC), and late toxicity were evaluated. RESULTS Between 2001 and 2008, a total of 212 patients (128 N0 and 84 N1) were enrolled in the study. Seven patients (4 in-field and 3 out-of-field) developed nodal failure. One patient (0.5%) developed nodal failure at level Vb, but no patients developed nodal failure at level IV. The 5-year RC rates of the entire group, N0 patients and N1 patients were 95.6%, 98.2%, and 91.3%, respectively. Fifteen patients (7.1%) developed distant metastases. The 5-year distant failure-free survival (DFFS) and overall survival (OS) rates were 91.4% and 89.8%, respectively. The rates of grade 2 or greater skin dystrophy, subcutaneous fibrosis and xerostomia were 6.2%, 16.6%, and 17.9%, respectively. CONCLUSIONS The rate of out-of-field nodal failure when omitting ENI to levels IV and Vb in clinically negative necks of patients with N0-1 NPC was extremely low; therefore, a further phase 3 study is warranted.
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Affiliation(s)
- Jian-zhou Chen
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, China
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Clerc J, Sunyach MP, Duruisseaux M, Mignotte H, Bajard A, Tredan O, Arnaud A. [Regional recurrence of triple-negative breast cancer: interest of systematic adjuvant lymph node irradiation?]. Gynecol Obstet Fertil 2013; 41:90-95. [PMID: 22771170 DOI: 10.1016/j.gyobfe.2012.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Accepted: 04/03/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To evaluate the percentage of regional recurrence (RR) in patients with triple-negative (TN) N0 breast cancer in order to consider the interests of a systematic adjuvant nodal irradiation. PATIENTS AND METHODS Between February 1996 and June 2009, 249 patients were treated for TN breast cancer in Léon-Bérard center (Lyon, France). All patients received first surgical treatment followed or not by chemotherapy or radiotherapy. We excluded patients with metastasis at diagnosis, patients who were initially irradiated regional lymph node, patients which ER, PR and/or HER2 status was not known and patients who didn't have standard treatment. Ultimately, 100 patients were included. RESULTS Two patients (2%) developed regional recurrence (1 sub and supraclavicular recurrence and 1 supraclavicular recurrence). The median follow-up was 34 months (95% CI: 29,2 to 37,4). The survival rate at 3 years was 98% (95% CI: 90-99). Our study showed no differences in terms of RR between TN cancers and not TN cancers for a median followed up of 34 months. CONCLUSION The results of our study do not suggest that patients with TN breast cancer should receive systematic nodal adjuvant radiotherapy.
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Affiliation(s)
- J Clerc
- Département de radiothérapie et d'oncologie, centre régional Léon-Bérard, 28, rue Laennec, 69008 Lyon, France.
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Ji K, Zhao L, Yang C, Meng M, Wang P. Three-dimensional conformal radiation for esophageal squamous cell carcinoma with involved-field irradiation may deliver considerable doses of incidental nodal irradiation. Radiat Oncol 2012; 7:200. [PMID: 23186308 PMCID: PMC3585467 DOI: 10.1186/1748-717x-7-200] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Accepted: 11/22/2012] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND To quantify the incidental irradiation dose to esophageal lymph node stations when irradiating T1-4N0M0 thoracic esophageal squamous cell carcinoma (ESCC) patients with a dose of 60 Gy/30f. METHODS Thirty-nine patients with medically inoperable T1-4N0M0 thoracic ESCC were treated with three-dimensional conformal radiation (3DCRT) with involved-field radiation (IFI). The conformal clinical target volume (CTV) was re-created using a 3-cm margin in the proximal and distal direction beyond the barium esophagogram, endoscopic examination and CT scan defined the gross tumor volume (GTV) and a 0.5-cm margin in the lateral and anteroposterior directions of the CT scan-defined GTV. The PTV encompassed 1-cm proximal and distal margins and 0.5-cm radial margin based on the CTV. Nodal regions were delineated using the Japanese Society for Esophageal Diseases (JSED) guidelines and an EORTC-ROG expert opinion. The equivalent uniform dose (EUD) and other dosimetric parameters were calculated for each nodal station. Nodal regions with a metastasis rate greater than 5% were considered a high-risk lymph node subgroup. RESULTS Under a 60 Gy dosage, the median D mean and EUD was greater than 40 Gy in most high-risk nodal regions except for regions of 104, 106tb-R in upper-thoracic ESCC and 101, 104-R, 105, 106rec-L, 2, 3&7 in middle-thoracic ESCC and 107, 3&7 in lower-thoracic ESCC. In the regions with an EUD less than 40 Gy, most incidental irradiation doses were significantly associated with esophageal tumor length and location. CONCLUSIONS Lymph node stations near ESCC receive considerable incidental irradiation doses with involved-field irradiation that may contribute to the elimination of subclinical lesions.
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Affiliation(s)
- Kai Ji
- Department of Radiotherapy, Tianjin Medical University Cancer Institute and Hospital, and Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin, PR China
| | - Lujun Zhao
- Department of Radiotherapy, Tianjin Medical University Cancer Institute and Hospital, and Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin, PR China
| | - Chengwen Yang
- Department of Radiotherapy, Tianjin Medical University Cancer Institute and Hospital, and Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin, PR China
| | - Maobin Meng
- Department of Radiotherapy, Tianjin Medical University Cancer Institute and Hospital, and Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin, PR China
| | - Ping Wang
- Department of Radiotherapy, Tianjin Medical University Cancer Institute and Hospital, and Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin, PR China
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Jacob J, Pierga JY, Fourchotte V, Kirova YM, Bollet MA. [A case of cutaneous mammary re-irradiation]. Cancer Radiother 2012; 16:638-40. [PMID: 23092807 DOI: 10.1016/j.canrad.2012.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Revised: 07/07/2012] [Accepted: 08/09/2012] [Indexed: 11/19/2022]
Abstract
In early-stage breast cancer, radiotherapy delivered after conservative surgery leads to a reduction in the risk of local recurrences by approximately two thirds. However, some local recurrences can occur in a previously irradiated region and be relevant for a second radiotherapy, exposing to an increased risk of adverse effects. We describe here the observation of a 66-year-old woman treated for a triple negative ductal infiltrative carcinoma of the left breast, who presented an early locoregional recurrence, notably as skin nodules, developed within the irradiated volume and progressing on chemotherapy. The patient was treated by re-irradiation performed concomitantly to oral chemotherapy by capecitabine.
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Affiliation(s)
- J Jacob
- Département de radiothérapie, institut Curie, Paris, France.
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Noushi F, Spillane AJ, Uren RF. In regard to Hindie et al. Int J Radiat Oncol Biol Phys 2012; 84:302. [PMID: 22935386 DOI: 10.1016/j.ijrobp.2012.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 02/02/2012] [Accepted: 02/05/2012] [Indexed: 11/17/2022]
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Voordeckers M, Farrag A, Everaert H, Tournel K, Storme G, Verellen D, De Ridder M. Parotid gland sparing with helical tomotherapy in head-and-neck cancer. Int J Radiat Oncol Biol Phys 2012; 84:443-8. [PMID: 22836056 DOI: 10.1016/j.ijrobp.2011.11.070] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Indexed: 11/19/2022]
Abstract
PURPOSE This study evaluated the ability of helical tomotherapy to spare the function of the parotid glands in patients with head-and-neck cancer by analyzing dose-volume histograms, salivary gland scintigraphy, and quality of life assessment. METHODS AND MATERIALS Data from 76 consecutive patients treated with helical tomotherapy (Hi-Art Tomotherapy) at the University Hospital Brussel were analyzed. During planning, priority was given to planning target volume (PTV) coverage: ≥ 95% of the dose must be delivered to ≥ 95% of the PTV. Elective nodal regions received 54 Gy (1.8 Gy/fraction). A dose of 70.5 Gy (2.35 Gy/fraction) was prescribed to the primary tumor and pathologic lymph nodes (simultaneous integrated boost scheme). Objective scoring of salivary excretion was performed by salivary gland scintigraphy. Subjective scoring of salivary gland function was evaluated by the European Organization for Research and Treatment of Cancer quality of life questionnaires Quality of Life Questionnaire-C30 (QLQ-C30) and Quality of Life Questionnaire-Head and Neck 35 (H&N35). RESULTS Analysis of dose-volume histograms (DVHs) showed excellent coverage of the PTV. The volume of PTV receiving 95% of the prescribed dose (V95%) was 99.4 (range, 96.3-99.9). DVH analysis of parotid gland showed a median value of the mean parotid dose of 32.1 Gy (range, 17.5-70.3 Gy). The median parotid volume receiving a dose <26 Gy was 51.2%. Quality of life evaluation demonstrated an initial deterioration of almost all scales and items in QLQ-C30 and QLQ-H&N35. Most items improved in time, and some reached baseline values 18 months after treatment. CONCLUSION DVH analysis, scintigraphic evaluation of parotid function, and quality of life assessment of our patient group showed that helical tomotherapy makes it possible to preserve parotid gland function without compromising disease control. We recommend mean parotid doses of <34 Gy and doses <26 Gy to a maximum 47% of the parotid volume as planning goals. Intensity-modulated radiotherapy should be considered as standard treatment in patients with head-and-neck cancer.
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Affiliation(s)
- Mia Voordeckers
- Department of Radiation Oncology, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium.
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Wenz F, Abo-Madyan Y, Welzel G, Giordano FA. ABVD vs. radiotherapy in early stage Hodgkin's lymphoma: A critical look at the NCIC HD.6 trial. Strahlenther Onkol 2012; 188:649-52. [PMID: 22729282 DOI: 10.1007/s00066-012-0151-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Fields RC, Busam KJ, Chou JF, Panageas KS, Pulitzer MP, Allen PJ, Kraus DH, Brady MS, Coit DG. Recurrence after complete resection and selective use of adjuvant therapy for stage I through III Merkel cell carcinoma. Cancer 2011; 118:3311-20. [PMID: 22072529 DOI: 10.1002/cncr.26626] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2011] [Revised: 08/29/2011] [Accepted: 08/29/2011] [Indexed: 11/12/2022]
Abstract
BACKGROUND Merkel cell carcinoma (MCC) is a rare cutaneous neuroendocrine neoplasm whose natural history is poorly understood. Here, the authors describe their experience with a large cohort of patients who were treated at a single institution to describe patterns of recurrence after curative therapy. METHODS Review of a prospective database was performed. Patient-related, tumor-related, and treatment-related variables were recorded, and the site and timing of initial recurrence were recorded. Factors associated with receipt of adjuvant therapy and recurrence were determined. RESULTS In total, 364 patients with stage I through III MCC who underwent complete resection were identified. Adjuvant local radiation therapy (RT), lymph node RT, and chemotherapy were received selectively by 23%, 23%, and 15% of patients, respectively. Factors associated with the receipt of adjuvant therapy included younger age, primary tumor features (larger size, lymphovascular invasion [LVI], positive margin excision), and increasing pathologic stage. With median follow-up of 3.6 years, 108 patients (30%) developed a recurrence, including 11 local recurrences (3%), 12 in-transit recurrences (3%), 43 lymph node recurrences (12%), and 42 distant recurrences (12%). Clinically involved lymph nodes, primary tumor LVI, and a history of leukemia/lymphoma were predictive of recurrence. The majority of recurrences (80%) occurred in patients who had clinically involved lymph nodes or patients who did not undergo pathologic lymph node evaluation. CONCLUSIONS A low recurrence rate in patients with clinically lymph node-negative MCC was achieved with adequate surgery (including sentinel lymph node biopsy) and the selective use of adjuvant RT for high-risk tumors. In contrast, patients with clinically lymph node-positive MCC had significantly higher rates of recurrence, especially distant recurrence. The authors concluded that contemporary natural history studies are critical in designing treatment pathways and clinical trials for MCC.
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Affiliation(s)
- Ryan C Fields
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10065, USA
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Fiengo L, Ekci B, Tellan G, Marandola M, Redler A. Chemoradiation for anal squamous cell carcinoma: case report. G Chir 2011; 32:365-367. [PMID: 22018257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
INTRODUCTION Anal squamous cell carcinoma is rare and seems to be associated with chronic inflammatory conditions, infections and immunosuppression. Their incidence has been arising since the last 25 years. Compared to adenocarcinoma of the rectum and squamous cell cancer of the anal canal, squamous cell carcinoma is a distinct entity with a different etiology, pathogenesis, prognosis and requires a different therapeutic approach. Even if surgery remains the main therapeutic option, recent advances have made chemoradiation a valuable therapeutic addition. This case discuss the efficacy of chemoradiation wich can prevent complications and can improve the quality of life. CASE REPORT A 63-year-old woman presented with history of bloody stool for the last past month. The colonoscopy showed a 2 cm circular lesion on the posterior wall of the anal canal. Biopsy was positive for squamous cell carcinoma and afterwards the patient underwent chemoradiation. At 1 year of follow-up the patient is disease free, with a good sphincter control and had no late complications. CONCLUSION Since the first studies in 1974, chemoradiation seems to be a good option for most patients with squamous cell carcinoma avoiding surgery.
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Affiliation(s)
- L Fiengo
- Department of Surgery Sciences, Sapienza, University, Rome, Italy
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Abstract
BACKGROUND Extrahepatic biliary duct cancers (EBDC) are uncommon malignancies characterized by a poor prognosis with high rate of loco-regional recurrence. The purpose of the present study is to assess the feasibility and the potential impact of adjuvant radiotherapy (RT) in a series of patients treated in one institution. METHODS Twenty three patients with non-metastatic bile duct cancer treated surgically with curative intent (4 gallbladder, 7 ampullary and 12 cholangiocarcinoma) received 3D conformal external beam RT to a median total dose of 50.4 Gy. Concurrent chemotherapy based on 5-FU was delivered to 21 patients (91%). Surgical margins were negative in 11 patients (48%), narrow in 2 (9%), and microscopically involved in 8 (35%). Eleven patients (55%) had metastatic nodal involvement. The average follow-up time for all patients was 30 months (ranging from 3-98). RESULTS Acute gastrointestinal grade 2 toxicity (RTOG scale) was recorded in 2 patients (9%). Nausea or vomiting grade 1 and 2 was observed in 8 (35%) and 2 patients (9%) respectively. Only one patient developed a major late radiation-induced toxicity. The main pattern of recurrence was both loco-regional and distant (liver, peritoneum and/or lung). No difference was observed in loco-regional control according to the tumor location. The 5-year actuarial loco-regional control rate was 48.3% (67% and 30% for patients operated on with negative and positive/narrow/unknown margins respectively, p=0.04). The 5-year actuarial overall survival was of 35.9% for the entire group (61.4% in case of negative margins and 16.7% in case of positive/narrow/unknown margins, p=0.07). CONCLUSIONS Postoperative RT with 50-60 Gy is feasible with acceptable acute and late toxicities. The potential benefit observed in our series may support the use of adjuvant RT in patients with locally advanced disease. Prospective randomized trials are warranted to confirm definitively the role of RT in this tumor location.
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Affiliation(s)
- Marta Bonet Beltrán
- Servei d'Oncologia Radioteràpica, Consorci Sanitari de Terrassa, Institut Oncològic del Vallès (CST-HGC-CSPT), Ctra. Torrebonica s/n. 08227 Terrassa - Barcelona, Spain
- Radiation-Oncology, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1211 Genève 14, Switzerland
| | - Arnaud D Roth
- Onco-Surgery and Surgery, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4 1211 Genève 14, Switzerland
| | - Gilles Mentha
- Onco-Surgery and Surgery, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4 1211 Genève 14, Switzerland
| | - Abdelkarim S Allal
- Radiation-Oncology, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1211 Genève 14, Switzerland
- Radiation-Oncology, HFR-Fribourg, Chemin des Pensionnats 2-6, 1752 Villars-sur-Glâne, Switzerland
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Hu X, Bao Y, Zhang L, Guo Y, Chen YY, Li KX, Wang WH, Liu Y, He H, Chen M. Omitting elective nodal irradiation and irradiating postinduction versus preinduction chemotherapy tumor extent for limited-stage small cell lung cancer: interim analysis of a prospective randomized noninferiority trial. Cancer 2011; 118:278-87. [PMID: 21598237 DOI: 10.1002/cncr.26119] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Revised: 02/15/2011] [Accepted: 02/15/2011] [Indexed: 12/27/2022]
Abstract
BACKGROUND Controversies exist with regard to thoracic radiotherapy volumes for limited-stage small cell lung cancer (SCLC). This study compared locoregional progression and overall survival between limited-stage SCLC patients who received thoracic radiotherapy to different target volumes after induction chemotherapy. METHODS Chemotherapy consisted of 6 cycles of etoposide and cisplatin. After 2 cycles of etoposide and cisplatin, patients were randomly assigned to receive thoracic radiotherapy to either the postchemotherapy or prechemotherapy tumor extent as study arm or control. Elective nodal irradiation was omitted for both arms. Forty-five Gy/30Fx/19 days thoracic radiotherapy was administered concurrently with cycle 3 chemotherapy. Prophylactic cranial irradiation was administered to patients who achieved complete remission. An interim analysis was planned when the first 80 patients had been followed for at least 6 months, for consideration of potential inferiority in the study arm. RESULTS Forty-two and 43 patients were randomly assigned to a study arm and a control, respectively. The local recurrence rates were 31.6% (12 of 38) and 28.6% (12 of 42), respectively (P = .81). The isolated nodal failure rates were 2.6% (1 of 38) and 2.4% (1 of 42), respectively (P = 1.00). All isolated nodal failure sites were in the ipsilateral supraclavicular fossa. Mediastinal N3 was the only factor to predict isolated nodal failure (P = .004; odds ratio [OR], 29.33; 95% CI, 2.94-292.38). One-year and 3-year overall survival rates were 80.6%, 36.2%, and 78.9%, 36.4%, respectively (P = .54). CONCLUSIONS Preliminary results indicated that irradiated postchemotherapy tumor extent and omitted elective nodal irradiation did not decrease locoregional control in the study arm, and the overall survival difference was not statistically significant between the 2 arms. Further investigation is warranted.
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Affiliation(s)
- Xiao Hu
- Department of Radiation Oncology, Cancer Center, Sun Yat Sen University, Guangzhou, People's Republic of China
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Yamashita H, Okuma K, Wakui R, Kobayashi-Shibata S, Ohtomo K, Nakagawa K. Details of recurrence sites after elective nodal irradiation (ENI) using 3D-conformal radiotherapy (3D-CRT) combined with chemotherapy for thoracic esophageal squamous cell carcinoma--a retrospective analysis. Radiother Oncol 2011; 98:255-60. [PMID: 21074880 DOI: 10.1016/j.radonc.2010.10.021] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Revised: 10/17/2010] [Accepted: 10/19/2010] [Indexed: 12/11/2022]
Abstract
PURPOSE To describe patterns of recurrence of elective nodal irradiation (ENI) in definitive chemoradiotherapy (CRT) for thoracic esophageal squamous cell carcinoma (SqCC) using 3D-conformal radiotherapy. METHODS AND MATERIALS One hundred and twenty-six consecutive patients with stages I-IVB thoracic esophageal SqCC newly diagnosed between June 2000 and July 2009 and treated with 3D-CRT in our institution were recruited from our database. Definitive CRT consisted of two cycles of nedaplatin/5FU repeated every 4 weeks, with concurrent radiation therapy of 50-50.4 Gy in 25-28 fractions. Until completion, radiotherapy was delivered to the N1 and M1a lymph nodes as ENI in addition to gross tumor volume. RESULTS All 126 patients were included in this analysis, and their tumors were staged as follows: T1/T2/T3/T4, 28/18/54/26; N0/N1, 50/76; M0/M1a/M1b, 91/5/30. The mean follow-up period for the 63 surviving patients was 28.3 (±22.8) months. Eighty-seven patients (69%) achieved complete response (CR) without any residual tumor at least once after completion of CRT. After achieving CR, each of 40 patients experienced failures (local=20 and distant=20) and no patient experienced elective nodal failure without having any other site of recurrence. The upper thoracic esophageal carcinoma showed significantly more (34%) relapses at the local site than the middle (9%) or lower thoracic (11%) carcinomas. The 2-year and 3-year overall survival was 56% and 43%, respectively. The 1-year, 2-year and 3-year disease-free survival was 46%, 38% and 33%, respectively. CONCLUSIONS In CRT for esophageal SqCC, ENI was effective for preventing regional nodal failure. The upper thoracic esophageal carcinomas had significantly more local recurrences than the middle or lower thoracic sites.
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Affiliation(s)
- Hideomi Yamashita
- Department of Radiology, University of Tokyo Hospital, Hongo, Bunkyo-ku, Tokyo, Japan
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Abstract
CONCLUSION In our experience, the prognosis for parotid gland acinic cell carcinoma (AciCC) is good. Surgery alone would be sufficient in early-stage tumor. Postoperative adjuvant treatment in advanced-stage patients or those with positive resection margins usually gives satisfactory control of the disease. OBJECTIVES AciCC is a rare tumor in parotid gland malignancy. The aim of this study was to retrospectively analyze the experience in our hospital in treating this malignancy. METHODS Twenty-five patients with AciCC diagnosed from 1983 to 2007 at the Chang Gung Memorial Hospital were retrospectively reviewed. RESULTS Thirteen male and 12 female patients ranged in age from 16 to 84 years (mean 37.5 years) at the time of diagnosis. Most patients (92%) presented with symptoms of infra-auricular mass. The tumor stage distributions of the patients were 24%, 44%, 28%, and 4% for stages I, II, III, and IV, respectively. Thirteen patients underwent superficial parotidectomy and 12 patients underwent total parotidectomy. Four patients had positive resection margins. Ten patients had surgery and postoperative radiotherapy; one received surgery and postoperative chemo/radiotherapy. The 10-year disease-free and overall actuarial survivals were both 84% in a mean follow-up of 75.8 months.
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Affiliation(s)
- Wan-Ni Lin
- Department of Otolaryngology, Head and Neck Surgery, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan
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Nakayama H, Satoh H, Kurishima K, Ishikawa H, Tokuuye K. High-dose conformal radiotherapy for patients with stage III non-small-cell lung carcinoma. Int J Radiat Oncol Biol Phys 2010; 78:645-50. [PMID: 20869582 DOI: 10.1016/j.ijrobp.2009.08.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2009] [Revised: 08/18/2009] [Accepted: 08/19/2009] [Indexed: 11/17/2022]
Abstract
PURPOSE To determine the effectiveness of high-dose conformal radiotherapy to the involved field for patients with Stage III non-small-cell lung cancer (NSCLC). METHODS AND MATERIALS Between May 1999 and April 2006, a total of 100 consecutive patients with inoperable Stage IIIA or IIIB NSCLC with a performance score of 0 to 2 and treatment by radical radiotherapy combined with chemotherapy were included. Up to August 2002, 33 patients underwent conventional radiotherapy of 56 Gy to 66 Gy using anteroposterior opposite ports to the primary tumor and elective lymph nodes (conventional group). After September 2002, the remaining 67 patients underwent high-dose radiotherapy of 66 Gy to 84 Gy to the involved volume with three-dimensional (3-D) conformal radiotherapy (conformal group). RESULTS The median survival was 13.2 months (95% confidence interval [CI], 7.5-18.5 months) in the conventional group and 17.3 months (95% CI, 10.7- 24.0 months) in the conformal group. The overall survival at 3 years were 9.1% (95% CI, -0.7-18.9%) in the conventional group and 31.0% (95% CI, 18.9-43.1%) in the conformal group; the conformal group had a significantly better overall survival (p < 0.05). The radiotherapy method (hazard ratio = 0.55, p < 0.05) and performance status (hazard ratio = 1.48, p < 0.05) were shown to be statistically significant independent prognostic factors. CONCLUSIONS Based on the practical experience reported here, 3-D conformal radiotherapy allowed dose escalation without excessive toxicity, and may improve overall survival rates for patients with Stage III NSCLC.
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Affiliation(s)
- Hidetsugu Nakayama
- Department of Radiation Oncology, Tsukuba Medical Center, Ibaraki, Japan.
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Nakamae H, Terada Y, Nakane T, Koh H, Nakamae M, Aimoto R, Hirose A, Hayashi Y, Nishimoto M, Inoue E, Yoshimura T, Inoue A, Koh KR, Yamane T, Hino M. [A modified myeloablative conditioning regimen for allogeneic hematopoietic stem cell transplantation, consisting of intravenous busulfan, cyclophosphamide and total lymphoid irradiation, in advanced leukemia]. Gan To Kagaku Ryoho 2010; 37:1691-1695. [PMID: 20841930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
In nine patients with advanced acute or chronic leukemia, we performed allogeneic hematopoietic stem cell transplantation (HSCT) following a modified myeloablative conditioning regimen intended to optimize the intensity of conditioning. This regimen consisted of intravenous busulfan 8mg/kg, cyclophosphamide 120mg/kg and total lymphoid irradiation 7.5 Gy. The median age of the patients was 30 years (range 18-59). Stem cell sources were related bone marrow in two, related peripheral blood in one, and unrelated bone marrow in six patients. Prophylaxis against acute graft-versus-host disease (GVHD) was cyclosporine and short-term methotrexate. Acute GVHD appeared in six patients (67%), grade II in all. Extensive chronic GVHD occurred in three of seven evaluable patients. The median follow-up period after HSCT was 813 days (248- 1,702). Of nine patients, five relapsed or progressed after HSCT. However, no patient relapsed or progressed within 100 days after HSCT. During the full follow-up period, transplant-related mortality (TRM) was not observed. The two-year overall survival and event-free survival were 88.9% and 50.0%, respectively. Our results suggested that we might reduce the incidence of TRM and simultaneously control disease by using an optimized conditioning regimen for HSCT.
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Affiliation(s)
- Hirohisa Nakamae
- Dept. of Hematology, Graduate School of Medicine, Osaka City University, Japan
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Roth SL, Audretsch W, Bojar H, Lang I, Willers R, Budach W. Retrospective study of neoadjuvant versus adjuvant radiochemotherapy in locally advanced noninflammatory breast cancer : survival advantage in cT2 category by neoadjuvant radiochemotherapy. Strahlenther Onkol 2010; 186:299-306. [PMID: 20495968 DOI: 10.1007/s00066-010-2143-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Accepted: 03/19/2010] [Indexed: 11/25/2022]
Abstract
PURPOSE This retrospective study compares patients treated between 1991 and 1998 with neoadjuvant radiotherapy +/- chemotherapy (RCT) or adjuvant RCT for locally advanced noninflammatory breast cancers (LABC) in terms of pathologic complete response (pCR), 10-year relapse-free (RFS), and overall survival (OS). PATIENTS AND METHODS Preoperative RCT in 315 and adjuvant RCT in 329 cases consisted in 50 Gy (5 x 2 Gy/week) to the breast and the supra-/infraclavicular lymph nodes. 101 neoadjuvant patients received - in case of breast conservation - a 10-Gy interstitial boost with (192)Ir afterloading before and 214 neoadjuvant patients a preoperative electron boost after external-beam radiotherapy. In the neoadjuvant RCT group, chemotherapy was applied prior to radiotherapy in 192 patients, and simultaneously in 113; ten had no chemotherapy. In the adjuvant RCT group, chemotherapy was applied to 44 patients before surgery and to 166 after surgery; 119 had no chemotherapy. RESULTS Breast conservation became possible in 50.8% after neoadjuvant RCT for LABC with a pCR rate at surgery of 29.2%. A complete nodal remission (pN0) after RCT was observed in 56% (89/159) of the cN+ (clinically node-positive) neoadjuvant patients. There were trends in favor of preoperative RCT for RFS and OS (hazard ratio [HR] = 0.85; p = 0.09 for RFS; HR = 0.8130; p = 0.1037 for OS). For patients with cT2 tumors the RFS and OS were statistically significantly better (HR = 0.5090; p = 0.0130 for RFS; HR = 0.4390; p = 0.0026 for OS) after neoadjuvant compared to adjuvant RCT. CONCLUSION Neoadjuvant RCT achieved a pCR rate of 29.2% and a statistically significantly better RFS and OS in patients with cT2-category breast cancer.
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MESH Headings
- Brachytherapy
- Breast Neoplasms/drug therapy
- Breast Neoplasms/mortality
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/drug therapy
- Carcinoma, Ductal, Breast/mortality
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Chemotherapy, Adjuvant
- Cobalt Radioisotopes/therapeutic use
- Combined Modality Therapy
- Disease-Free Survival
- Female
- Humans
- Iridium Radioisotopes/therapeutic use
- Lymphatic Irradiation
- Mastectomy, Segmental
- Middle Aged
- Neoadjuvant Therapy
- Neoplasm Staging
- Radioisotope Teletherapy
- Radiotherapy Dosage
- Radiotherapy, Adjuvant
- Retrospective Studies
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Affiliation(s)
- Stephan Ludwig Roth
- Department of Radiotherapy, Heinrich Heine University of Düsseldorf, Düsseldorf, Germany.
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