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Borm KJ, Behzadi ST, Hörner-Rieber J, Krug D, Baumann R, Corradini S, Duma MN, Dunst J, Fastner G, Feyer P, Fietkau R, Haase W, Harms W, Hehr T, Matuschek C, Piroth MD, Schmeel LC, Souchon R, Strnad V, Budach W, Combs SE. DEGRO guideline for personalized radiotherapy of brain metastases and leptomeningeal carcinomatosis in patients with breast cancer. Strahlenther Onkol 2024; 200:259-275. [PMID: 38488902 DOI: 10.1007/s00066-024-02202-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 01/07/2024] [Indexed: 03/17/2024]
Abstract
PURPOSE The aim of this review was to evaluate the existing evidence for radiotherapy for brain metastases in breast cancer patients and provide recommendations for the use of radiotherapy for brain metastases and leptomeningeal carcinomatosis. MATERIALS AND METHODS For the current review, a PubMed search was conducted including articles from 01/1985 to 05/2023. The search was performed using the following terms: (brain metastases OR leptomeningeal carcinomatosis) AND (breast cancer OR breast) AND (radiotherapy OR ablative radiotherapy OR radiosurgery OR stereotactic OR radiation). CONCLUSION AND RECOMMENDATIONS Despite the fact that the biological subtype of breast cancer influences both the occurrence and relapse patterns of breast cancer brain metastases (BCBM), for most scenarios, no specific recommendations regarding radiotherapy can be made based on the existing evidence. For a limited number of BCBM (1-4), stereotactic radiosurgery (SRS) or fractionated stereotactic radiotherapy (SRT) is generally recommended irrespective of molecular subtype and concurrent/planned systemic therapy. In patients with 5-10 oligo-brain metastases, these techniques can also be conditionally recommended. For multiple, especially symptomatic BCBM, whole-brain radiotherapy (WBRT), if possible with hippocampal sparing, is recommended. In cases of multiple asymptomatic BCBM (≥ 5), if SRS/SRT is not feasible or in disseminated brain metastases (> 10), postponing WBRT with early reassessment and reevaluation of local treatment options (8-12 weeks) may be discussed if a HER2/Neu-targeting systemic therapy with significant response rates in the central nervous system (CNS) is being used. In symptomatic leptomeningeal carcinomatosis, local radiotherapy (WBRT or local spinal irradiation) should be performed in addition to systemic therapy. In patients with disseminated leptomeningeal carcinomatosis in good clinical condition and with only limited or stable extra-CNS disease, craniospinal irradiation (CSI) may be considered. Data regarding the toxicity of combining systemic therapies with cranial and spinal radiotherapy are sparse. Therefore, no clear recommendations can be given, and each case should be discussed individually in an interdisciplinary setting.
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Affiliation(s)
- Kai J Borm
- TUM School of Medicine, Department of Radiation Oncology, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Sophie T Behzadi
- TUM School of Medicine, Department of Radiation Oncology, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Rene Baumann
- Department of Radiation Oncology, St. Marien-Krankenhaus, Siegen, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Marciana Nona Duma
- Department of Radiation Oncology, Helios Clinics of Schwerin-University Campus of MSH Medical School Hamburg, Schwerin, Germany
- Department for Human Medicine, MSH Medical School Hamburg, Hamburg, Germany
| | - Jürgen Dunst
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Gerd Fastner
- Department of Radiotherapy and Radio-Oncology, University Hospital Salzburg, Landeskrankenhaus, Paracelsus Medical University, Salzburg, Austria
| | - Petra Feyer
- Formerly Department of Radiation Oncology, Vivantes Hospital Neukölln, Berlin, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Wulf Haase
- Formerly Department of Radiation Oncology, St.-Vincentius-Hospital Karlsruhe, Karlsruhe, Germany
| | - Wolfgang Harms
- Department of Radiation Oncology, St. Claraspital, Basel, Switzerland
| | - Thomas Hehr
- Department of Radiation Oncology, Marienhospital Stuttgart, Stuttgart, Germany
| | - Christiane Matuschek
- Department of Radiation Oncology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Marc D Piroth
- Department of Radiation Oncology, HELIOS University Hospital Wuppertal, Witten/Herdecke University, Wuppertal, Germany
| | | | - Rainer Souchon
- Formerly Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Vratislav Strnad
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Wilfried Budach
- Department of Radiation Oncology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Stephanie E Combs
- TUM School of Medicine, Department of Radiation Oncology, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany.
- Partner Site Munich, Deutsches Konsortium für Translationale Krebsforschung (DKTK), Munich, Germany.
- Department of Radiation Medicine (IRM), Helmholtz Zentrum München (HMGU), Neuherberg, Germany.
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Gkika E, Kostyszyn D, Fechter T, Moustakis C, Ernst F, Boda-Heggemann J, Sarria G, Dieckmann K, Dobiasch S, Duma MN, Eberle F, Kroeger K, Häussler B, Izaguirre V, Jazmati D, Lautenschläger S, Lohaus F, Mantel F, Menzel J, Pachmann S, Pavic M, Radlanski K, Riesterer O, Gerum S, Röder F, Willner J, Barczyk S, Imhoff D, Blanck O, Wittig A, Guckenberger M, Grosu AL, Brunner TB. Interobserver agreement on definition of the target volume in stereotactic radiotherapy for pancreatic adenocarcinoma using different imaging modalities. Strahlenther Onkol 2023; 199:973-981. [PMID: 37268767 PMCID: PMC10598103 DOI: 10.1007/s00066-023-02085-7] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 04/11/2023] [Indexed: 06/04/2023]
Abstract
PURPOSE The aim of this study was to evaluate interobserver agreement (IOA) on target volume definition for pancreatic cancer (PACA) within the Radiosurgery and Stereotactic Radiotherapy Working Group of the German Society of Radiation Oncology (DEGRO) and to identify the influence of imaging modalities on the definition of the target volumes. METHODS Two cases of locally advanced PACA and one local recurrence were selected from a large SBRT database. Delineation was based on either a planning 4D CT with or without (w/wo) IV contrast, w/wo PET/CT, and w/wo diagnostic MRI. Novel compared to other studies, a combination of four metrics was used to integrate several aspects of target volume segmentation: the Dice coefficient (DSC), the Hausdorff distance (HD), the probabilistic distance (PBD), and the volumetric similarity (VS). RESULTS For all three GTVs, the median DSC was 0.75 (range 0.17-0.95), the median HD 15 (range 3.22-67.11) mm, the median PBD 0.33 (range 0.06-4.86), and the median VS was 0.88 (range 0.31-1). For ITVs and PTVs the results were similar. When comparing the imaging modalities for delineation, the best agreement for the GTV was achieved using PET/CT, and for the ITV and PTV using 4D PET/CT, in treatment position with abdominal compression. CONCLUSION Overall, there was good GTV agreement (DSC). Combined metrics appeared to allow a more valid detection of interobserver variation. For SBRT, either 4D PET/CT or 3D PET/CT in treatment position with abdominal compression leads to better agreement and should be considered as a very useful imaging modality for the definition of treatment volumes in pancreatic SBRT. Contouring does not appear to be the weakest link in the treatment planning chain of SBRT for PACA.
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Affiliation(s)
- E Gkika
- Department of Radiation Oncology, University Medical Center Freiburg, Robert Koch Str 3, Freiburg, Germany.
| | - D Kostyszyn
- Department of Radiation Oncology, University Medical Center Freiburg, Robert Koch Str 3, Freiburg, Germany
| | - T Fechter
- Department of Radiation Oncology, University Medical Center Freiburg, Robert Koch Str 3, Freiburg, Germany
| | - C Moustakis
- Department of Radiation Oncology, University Medical Center Muenster, Muenster, Germany
| | - F Ernst
- Institute for Robotics and Cognitive Systems, University of Luebeck, Luebeck, Germany
| | - J Boda-Heggemann
- Department of Radiation Oncology, Faculty of Medicine Mannheim, Department of Radiation Oncology, University of Heidelberg, Mannheim, Germany
| | - G Sarria
- Department of Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | - K Dieckmann
- Department of Radiation Oncology, University Departments of the MedUni Vienna, Vienna General Hospital, Vienna, Austria
| | - S Dobiasch
- Department of Radiation Oncology, Klinikum Rechts der Isar, TU Munich, Munich, Germany
| | - M N Duma
- Department of Radiotherapy and Radiation Oncology, University Hospital Jena, Friedrich-Schiller University, Jena, Germany
| | - F Eberle
- Department of Radiation Oncology, University Hospital Marburg, Marburg, Germany
| | - K Kroeger
- Department of Radiation Oncology, University Medical Center Muenster, Muenster, Germany
| | - B Häussler
- Radiation Oncology Dr. Häussler/Dr. Schorer, Munich, Germany
| | - V Izaguirre
- Department of Radiation Oncology, University Hospital Halle, Halle, Germany
| | - D Jazmati
- Proton Therapy Centre, University Hospital Essen, Essen, Germany
| | - S Lautenschläger
- Department of Radiation Oncology, University Hospital, Marburg, Germany
| | - F Lohaus
- Department of Radiation Oncology, University Hospital Dresden, Dresden, Germany
| | - F Mantel
- Department of Radiation Oncology, University Hospital Würzburg, Würzburg, Germany
| | - J Menzel
- Department of Radiation Oncology, University Hospital Hannover, Hannover, Germany
| | - S Pachmann
- Department of Radiation Oncology, Weilheim Clinic, Weilheim, Germany
| | - M Pavic
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - K Radlanski
- Department of Radiation Oncology, Charite, University Hospital Berlin, Berlin, Germany
| | - O Riesterer
- Centre for Radiation Oncology KSA-KSB, Kantonsspital Aarau, Aarau, Switzerland
| | - S Gerum
- Department of Radiation Oncology, University Clinic, Paracelsus Medical University (PMU), Salzburg, Austria
| | - F Röder
- Department of Radiation Oncology, University Clinic, Paracelsus Medical University (PMU), Salzburg, Austria
| | - J Willner
- Department of Radiation Oncology, University Hospital Bayreuth, Bayreuth, Germany
| | - S Barczyk
- Center for Radiation Oncology, Belegklinik am St. Agnes-Hospital, Bocholt, Germany
| | - D Imhoff
- Department of Radiation Oncology, Saphir Radiosurgery, University Hospital Frankfurt, Frankfurt, Germany
| | - O Blanck
- Saphir Radiosurgery, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - A Wittig
- Department of Radiotherapy and Radiation Oncology, University Hospital Jena, Friedrich-Schiller University, Jena, Germany
| | - M Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Anca-L Grosu
- Department of Radiation Oncology, University Medical Center Freiburg, Robert Koch Str 3, Freiburg, Germany
| | - T B Brunner
- Department of Therapeutic Radiology and Oncology, Comprehensive Cancer Center, Medical University of Graz, Graz, Austria
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Völk F, Borm KJ, Düsberg M, Combs SE, Knippen S, Duma MN. Regional nodal irradiation in breast cancer patients: Effects of deep inspiration breath hold on the internal mammary chain location. Med Dosim 2023; 48:299-303. [PMID: 37648622 DOI: 10.1016/j.meddos.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 07/11/2023] [Accepted: 08/08/2023] [Indexed: 09/01/2023]
Abstract
The purpose of this study was to investigate the impact of deep inspiration breath hold (DIBH) on the positioning of thoracic structures and provide treatment planning recommendations for internal mammary chain (IMC) irradiation in breast cancer patients. Thirty-two breast cancer patients from our database underwent both DIBH and free breathing (FB) treatment planning. Contouring of the axillary lymph node clinical target volumes (CTVs: level I, II, III, IV, and IMC according to ESTRO), the internal mammary artery (IMA), the heart, and the left anterior descending artery (LAD) was performed. The following were then analyzed: the distance between the IMA and the heart, the craniocaudal distance in which IMC-CTV and heart coexist, the craniocaudal distance between the lower end of the of level III and IV and the upper end of the heart. Several significant geometric differences were observed between DIBH and FB that explain the efficacy of the DIBH for regional nodal irradiation. In >80% of patients the cranial origin of the LAD lies below the lower edge of the IMC-CTV in DIBH. In addition the slices in which the heart/LAD and IMC-CTV coexist decrease during DIBH. The IMA-heart distance is significantly larger in DIBH. Also the craniocaudal distance between the lower border of the CTV level III and IV and the upper border of the heart is larger in DIBH. The observed mechanisms during DIBH contribute significantly to the dose reduction in regional nodal irradiation. To further enhance the benefits of DIBH for the irradiation of the IMC-CTV, it is recommended to implement steep dose gradients in the caudal plane.
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Affiliation(s)
- Felix Völk
- Department of Radiation Oncology, Klinikum rechts der Isar, Medical School, Technical University of Munich (TUM), 81675 München, Germany
| | - Kai Joachim Borm
- Department of Radiation Oncology, Klinikum rechts der Isar, Medical School, Technical University of Munich (TUM), 81675 München, Germany
| | - Mathias Düsberg
- Department of Radiation Oncology, Klinikum rechts der Isar, Medical School, Technical University of Munich (TUM), 81675 München, Germany
| | - Stephanie Elisabeth Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Medical School, Technical University of Munich (TUM), 81675 München, Germany; Institute of Radiation Medicine, Helmholtz Zentrum München, Neuherberg, Germany; Deutsches Konsortium für Translationale Krebsforschung, DKTK Partner Site Munich, Munich, Germany
| | - Stefan Knippen
- Department for Human Medicine, MSH Medical School Hamburg, Hamburg, Germany; Department of Radiation Oncology, Helios Hospitals Schwerin, Schwerin, Germany
| | - Marciana Nona Duma
- Department of Radiation Oncology, Klinikum rechts der Isar, Medical School, Technical University of Munich (TUM), 81675 München, Germany; Department for Human Medicine, MSH Medical School Hamburg, Hamburg, Germany; Department of Radiation Oncology, Helios Hospitals Schwerin, Schwerin, Germany.
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4
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Piroth MD, Strnad V, Krug D, Fastner G, Baumann R, Combs SE, Duma MN, Dunst J, Feyer P, Fietkau R, Haase W, Harms W, Hehr T, Sedlmayer F, Souchon R, Budach W. Long-Term Results of the TARGIT-A Trial: More Questions than Answers. Breast Care (Basel) 2022; 17:81-84. [PMID: 35355706 PMCID: PMC8914270 DOI: 10.1159/000515386] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 02/20/2021] [Indexed: 02/03/2023] Open
Abstract
Background During the last decade, partial breast irradiation (PBI) has gained traction as a relevant treatment option for patients with early-stage low-risk breast cancer after breast-conserving surgery. The TARGIT-A prospective randomized trial compared a "risk-adapted" intraoperative radiotherapy (IORT) approach with 50-kv X-rays (INTRABEAM®) as the PBI followed by optional whole-breast irradiation (WBI) and conventional adjuvant WBI in terms of observed 5-year in-breast recurrence rates. Recently, long-term data were published. Since the first publication of the TARGIT-A trial, a broad debate has been emerged regarding several uncertainties and limitations associated with data analysis and interpretation. Our main objective was to summarize the data, with an emphasis on the updated report and the resulting implications. Summary From our point of view, the previously unresolved questions still remain and more have been added, especially with regard to the study design, a change in the primary outcome measure, the significant number of patients lost to follow-up, and the lack of a subgroup analysis according to risk factors and treatment specifications. Key Message Taking into account the abovementioned limitations of the recently published long-term results of the TARGIT-A trial, the German Society of Radiation Oncology (DEGRO) Breast Cancer Expert Panel adheres to its recently published recommendations on PBI: "the 50-kV system (INTRABEAM) cannot be recommended for routine adjuvant PBI treatment after breast-conserving surgery."
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Affiliation(s)
- Marc D. Piroth
- Department of Radiation Oncology, Helios University Hospital Wuppertal, Witten/Herdecke University, Wuppertal, Germany
| | - Vratislav Strnad
- Department of Radiation Oncology, University Hospital, Erlangen, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Gerd Fastner
- Department of Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
| | - René Baumann
- Department of Radiation Oncology, St. Marien-Krankenhaus, Siegen, Germany
| | - Stephanie E. Combs
- Department of Radiation Oncology, Technical University of Munich (TUM), München, Germany
| | - Marciana Nona Duma
- Department of Radiation Oncology, Friedrich-Schiller-University Hospital, Jena, Germany
| | - Jürgen Dunst
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Petra Feyer
- Department of Radiation Oncology, Vivantes Hospital Neukoelln, Berlin, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, University Hospital, Erlangen, Germany
| | - Wulf Haase
- Formerly St.-Vincentius-Hospital Karlsruhe, Karlsruhe, Germany
| | - Wolfgang Harms
- Department of Radiation Oncology, St. Claraspital, Basel, Switzerland
| | - Thomas Hehr
- Department of Radiation Oncology, Marienhospital, Stuttgart, Germany
| | - Felix Sedlmayer
- Department of Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
| | | | - Wilfried Budach
- Department of Radiation Oncology, Heinrich-Heine-University Hospital, Düsseldorf, Germany
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Kurrumeli D, Oechsner M, Weidenbächer B, Brambs C, Löffler M, Combs SE, Borm K, Duma MN. An easy way to determine bone mineral density and predict pelvic insufficiency fractures in patients treated with radiotherapy for cervical cancer. Strahlenther Onkol 2020; 197:487-493. [PMID: 33025097 PMCID: PMC8154790 DOI: 10.1007/s00066-020-01690-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 04/23/2020] [Accepted: 09/07/2020] [Indexed: 12/04/2022]
Abstract
Purpose The aim of this study was to investigate whether bone mineral density (BMD) as measured in planning computed tomographies (CTs) by a new method is a risk factor for pelvic insufficiency fractures (PIF) after radio(chemo)therapy (R(C)T) for cervical cancer. Methods 62 patients with cervical cancer who received definitive or adjuvant radio(chemo)therapy between 2013 and 2017 were reviewed. The PIF were detected on follow-up magntic resonance imaging (MRI). The MRI of the PIF patients was registered to the planning CT and the PIF contoured. On the contralateral side of the fracture, a mirrored structure of the fracture was generated (mPIF). For the whole sacral bone, three lumbar vertebrae, the first and second sacral vertebrae, and the PIF, we analyzed the BMD (mg/cm3), V50Gy, Dmean, and Dmax. Results Out of 62 patients, 6 (9.7%) had a fracture. Two out of the 6 patients had a bilateral fracture with only one of them being symptomatic. PIF patients showed a significantly lower BMD in the sacral and the lumbar vertebrae (p < 0.05). The BMD of the contoured PIF, however, when comparing to the mPIF, did not reach significance (p < 0.49). The difference of the V50Gy of the sacrum in the PIF group compared to the other (OTH) patients, i.e. those without PIF, did not reach significance. Conclusion The dose does not seem to have a relevant impact on the incidence of PIF in our patients. One of the predisposing factors for developing PIF after radiotherapy seems to be the low BMD. We presented an easy method to assess the BMD in planning CTs.
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Affiliation(s)
- Drilon Kurrumeli
- Department of Radiation Oncology, Klinikum rechts der Isar - Technical University of Munich (TUM), Munich, Germany
- School of Medicine, Klinikum rechts der Isar - Technical University of Munich (TUM), Munich, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Klinikum rechts der Isar - Technical University of Munich (TUM), Munich, Germany
| | - Bianca Weidenbächer
- Department of Radiation Oncology, Klinikum rechts der Isar - Technical University of Munich (TUM), Munich, Germany
| | - Christine Brambs
- Department of Gynaecology, Klinikum rechts der Isar - Technical University of Munich (TUM), Munich, Germany
| | - Maximilian Löffler
- Department of Neuroradiology, Klinikum rechts der Isar - Technical University of Munich (TUM), Munich, Germany
| | - Stephanie Elisabeth Combs
- Department of Radiation Oncology, Klinikum rechts der Isar - Technical University of Munich (TUM), Munich, Germany
- Institute of Radiation Medicine (IRM), Department of Radiation Sciences (DRS), Helmholtz Zentrum München (HMGU), Munich, Germany
- German Cancer Consortium (DKTK)-Partner Site Munich, Munich, Germany
| | - Kai Borm
- Department of Radiation Oncology, Klinikum rechts der Isar - Technical University of Munich (TUM), Munich, Germany
| | - Marciana Nona Duma
- School of Medicine, Klinikum rechts der Isar - Technical University of Munich (TUM), Munich, Germany.
- Department of Radiotherapy and Radiation Oncology, University Hospital Jena, Bachstr. 18, 07743, Jena, Germany.
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Mayinger M, Straube C, Habermehl D, Duma MN, Combs SE. Hypo- vs. normofractionated radiation therapy in breast cancer: A patterns of care analysis in German speaking countries. Rep Pract Oncol Radiother 2020; 25:775-779. [PMID: 32904392 DOI: 10.1016/j.rpor.2020.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 05/31/2020] [Accepted: 07/24/2020] [Indexed: 10/24/2022] Open
Abstract
Aim and background To assess the use of hypofractionated (HG-RT) versus normofractionated radiation therapy (NF-RT) in Breast Cancer in German speaking countries. Materials and methods Between July 2017 and August 2017, an email-based survey was sent to all 1408 physicians that are members of the German Society of Radiation Oncology (DEGRO). The survey was completed by 180 physicians including 10 private practice owners and 52 heads of departments. The majority (82.1%) of the participants had >15 years of experience in radiation therapy (RT). Results The majority (83.9%) of the heads of the departments agreed on using the normofractionated regimen of RT as standard treatment for breast cancer. Several physicians were skeptical about HF-RT with 6.5% of the heads refusing to use HF-RT. 40.3% of the departments had not seen the new German guidelines suggesting HF-RT as the standard treatment for all patients as positive or merely adopted a neutral position toward the guidelines (33.9%). The main points of criticism were increased side effects, an impaired toxicity profile and insufficient data. Most departments (46.8%) that perform HF-RT do so in an individual based manner. Conclusions HF-RT remains controversial in German speaking countries. Our data shows that NF-RT remains the predominant method of treatment. HF-RT is only used in a defined group of patients as most German physicians agree that particular patients, especially those at higher risk of RT late effects, may benefit from a less intense, extended fractionation schedule.
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Affiliation(s)
- M Mayinger
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany.,Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
| | - C Straube
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany.,Institute of Innovative Radiotherapy (iRT), Department of Radiation Sciences (DRS), Helmholtz Zentrum München, Munich, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partnerstandort München, Munich, Germany
| | - D Habermehl
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany.,Institute of Innovative Radiotherapy (iRT), Department of Radiation Sciences (DRS), Helmholtz Zentrum München, Munich, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partnerstandort München, Munich, Germany
| | - M N Duma
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany.,Institute of Innovative Radiotherapy (iRT), Department of Radiation Sciences (DRS), Helmholtz Zentrum München, Munich, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partnerstandort München, Munich, Germany
| | - S E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany.,Institute of Innovative Radiotherapy (iRT), Department of Radiation Sciences (DRS), Helmholtz Zentrum München, Munich, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partnerstandort München, Munich, Germany
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7
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Devecka M, Duma MN, Wilkens JJ, Kampfer S, Borm KJ, Münch S, Straube C, Combs SE. Craniospinal irradiation(CSI) in patients with leptomeningeal metastases: risk-benefit-profile and development of a prognostic score for decision making in the palliative setting. BMC Cancer 2020; 20:501. [PMID: 32487151 PMCID: PMC7268696 DOI: 10.1186/s12885-020-06984-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 05/20/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The aim of our study was to assess the feasibility and oncologic outcomes in patients treated with spinal (SI) or craniospinal irradiation (CSI) in patients with leptomeningeal metastases (LM) and to suggest a prognostic score as to which patients are most likely to benefit from this treatment. METHODS Nineteen patients treated with CSI at our institution were eligible for the study. Demographic data, primary tumor characteristics, outcome and toxicity were assessed retrospectively. The extent of extra-CNS disease was defined by staging CT-scans before the initiation of CSI. Based on outcome parameters a prognostic score was developed for stratification based on patient performance status and tumor staging. RESULTS Median follow-up and overall survival (OS) for the whole group was 3.4 months (range 0.5-61.5 months). The median overall survival (OS) for patients with LM from breast cancer was 4.7 months and from NSCLC 3.3 months. The median OS was 7.3 months, 3.3 months and 1.5 months for patients with 0, 1 and 2 risk factors according to the proposed prognostic score (KPS < 70 and the presence of extra-CNS disease) respectively. Nonhematologic toxicities were mild. CONCLUSION CSI demonstrated clinically meaningful survival that is comparable to the reported outcome of intrathecal chemotherapy. A simple scoring system could be used to better select patients for treatment with CSI in this palliative setting. In our opinion, the feasibility of performing CSI with modern radiotherapy techniques with better sparing of healthy tissue gives a further rationale for its use also in the palliative setting.
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Affiliation(s)
- Michal Devecka
- Klinikum rechts der Isar, Department of RadiationOncology, Technical University Munich, Ismaninger Strasse 22, 81675, München, Germany.
| | - Marciana Nona Duma
- Klinikum rechts der Isar, Department of RadiationOncology, Technical University Munich, Ismaninger Strasse 22, 81675, München, Germany.,Department of Radiotherapy and Radiation Oncology, University Hospital of the Friedrich Schiller University, Jena, Germany
| | - Jan J Wilkens
- Klinikum rechts der Isar, Department of RadiationOncology, Technical University Munich, Ismaninger Strasse 22, 81675, München, Germany
| | - Severin Kampfer
- Klinikum rechts der Isar, Department of RadiationOncology, Technical University Munich, Ismaninger Strasse 22, 81675, München, Germany
| | - Kai Joachim Borm
- Klinikum rechts der Isar, Department of RadiationOncology, Technical University Munich, Ismaninger Strasse 22, 81675, München, Germany
| | - Stefan Münch
- Klinikum rechts der Isar, Department of RadiationOncology, Technical University Munich, Ismaninger Strasse 22, 81675, München, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK)-Partner Site Munich, Munich, Germany
| | - Christoph Straube
- Klinikum rechts der Isar, Department of RadiationOncology, Technical University Munich, Ismaninger Strasse 22, 81675, München, Germany
| | - Stephanie E Combs
- Klinikum rechts der Isar, Department of RadiationOncology, Technical University Munich, Ismaninger Strasse 22, 81675, München, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK)-Partner Site Munich, Munich, Germany.,Institute of Innovative Radiotherapy, Helmholtzzentrum München, Munich, Germany
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8
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Schiller K, Stöhrer L, Düsberg M, Borm K, Devecka M, Vogel MME, Tauber R, Heck MM, Rauscher I, Eiber M, Gschwend JE, Duma MN, Combs SE. PSMA-PET/CT-based Lymph Node Atlas for Prostate Cancer Patients Recurring After Primary Treatment: Clinical Implications for Salvage Radiation Therapy. Eur Urol Oncol 2020; 4:73-83. [PMID: 32451312 DOI: 10.1016/j.euo.2020.04.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/06/2020] [Accepted: 04/17/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Many patients experience recurrence of prostate cancer after radical prostatectomy. OBJECTIVE The aim of this study was to visually analyze typical patterns of lymph node (LN) involvement for prostate cancer (PC) patients with biochemical recurrence after radical prostatectomy and lymphadenectomy by creating a color-coded heat map using gallium-68 prostate-specific membrane antigen positron emission tomography (68Ga-PSMA-PET) imaging. Further, we evaluated which LNs were covered by the Radiation Therapy Oncology Group (RTOG) clinical target volume (CTV) contouring guidelines. DESIGN, SETTING, AND PARTICIPANTS A total of 1653 68Ga-PSMA-PET/computed tomography (CT) datasets were screened retrospectively. After meeting the eligibility criteria, 233 patients with 799 LN metastases were included in our study. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We created a comprehensive three-dimensional color-coded LN atlas. Further, the coverage of LN metastases by RTOG CTV was assessed and stratification for risk factors was performed. RESULTS AND LIMITATIONS In the overall, mainly high risk, collective, complete coverage by the standard RTOG CTV was accomplished in 31.0% of all LN metastases. The vast majority of uncovered LNs are situated in the para-aortal, pararectal, paravesical, preacetabular, presacral, and inguinal regions. Concerning examined stratification factors, prostate-specific antigen (PSA) levels at the time of PET/CT imaging had the highest predictive value for extrapelvic metastatic LN spread. Every increase of 1 ng/mL in PSA raises the risk of metastases outside the CTV by a factor of 1.43. CONCLUSIONS We developed the first LN atlas for patients with recurrent PC using a heat map technique, in order to illustrate hot spots of LN recurrence. The vast majority of detected LNs are not covered by a standard CTV as recommended by the RTOG. Application of the standard RTOG CTV for pelvic irradiation in the salvage setting for high-risk PC patients seems to be inappropriate. PATIENT SUMMARY We visualized typical lymph node recurrence sites for patients after prostate cancer surgery.
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Affiliation(s)
- Kilian Schiller
- Department of Radiation Oncology, Technical University Munich (TUM), Munich, Germany.
| | - Lucia Stöhrer
- Department of Radiation Oncology, Technical University Munich (TUM), Munich, Germany
| | - Mathias Düsberg
- Department of Radiation Oncology, Technical University Munich (TUM), Munich, Germany
| | - Kai Borm
- Department of Radiation Oncology, Technical University Munich (TUM), Munich, Germany
| | - Michal Devecka
- Department of Radiation Oncology, Technical University Munich (TUM), Munich, Germany
| | - Marco M E Vogel
- Department of Radiation Oncology, Technical University Munich (TUM), Munich, Germany
| | - Robert Tauber
- Department of Urology, Technical University Munich (TUM), Munich, Germany
| | - Matthias M Heck
- Department of Urology, Technical University Munich (TUM), Munich, Germany
| | - Isabel Rauscher
- Department of Nuclear Medicine, Technical University Munich (TUM), Munich, Germany
| | - Matthias Eiber
- Department of Nuclear Medicine, Technical University Munich (TUM), Munich, Germany
| | - Jürgen E Gschwend
- Department of Urology, Technical University Munich (TUM), Munich, Germany
| | - Marciana Nona Duma
- Department of Radiation Oncology, Technical University Munich (TUM), Munich, Germany; Department of Radiation Oncology, Friedrich-Schiller University Jena, Jena, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University Munich (TUM), Munich, Germany; Department of Radiation Sciences (DRS), Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Munich, Germany; Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
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9
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Strnad V, Krug D, Sedlmayer F, Piroth MD, Budach W, Baumann R, Feyer P, Duma MN, Haase W, Harms W, Hehr T, Fietkau R, Dunst J, Sauer R. DEGRO practical guideline for partial-breast irradiation. Strahlenther Onkol 2020; 196:749-763. [PMID: 32350554 PMCID: PMC7449998 DOI: 10.1007/s00066-020-01613-z] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 03/19/2020] [Indexed: 12/24/2022]
Abstract
Purpose This consensus statement from the Breast Cancer Working Group of the German Society for Radiation Oncology (DEGRO) aims to define practical guidelines for accelerated partial-breast irradiation (APBI). Methods Recent recommendations for relevant aspects of APBI were summarized and a panel of experts reviewed all the relevant literature. Panel members of the DEGRO experts participated in a series of conferences, supplemented their clinical experience, performed a literature review, and formulated recommendations for implementing APBI in clinical routine, focusing on patient selection, target definition, and treatment technique. Results Appropriate patient selection, target definition for different APBI techniques, and basic rules for appropriate APBI techniques for clinical routine outside of clinical trials are described. Detailed recommendations for APBI in daily practice, including dose constraints, are given. Conclusion Guidelines are mandatory to assure optimal results of APBI using different techniques.
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Affiliation(s)
- V Strnad
- University Hospital Erlangen, Erlangen, Germany.
| | - D Krug
- University Hospital Schleswig-Holstein, Kiel, Germany
| | - F Sedlmayer
- Paracelsus Medical University Hospital Salzburg, Salzburg, Austria
| | - M D Piroth
- Helios University Hospital Wuppertal, Witten/Herdecke University, Wuppertal, Germany
| | - W Budach
- Heinrich-Heine-University Hospital Düsseldorf, Düsseldorf, Germany
| | - R Baumann
- St. Marien-Krankenhaus Siegen, Siegen, Germany
| | - P Feyer
- Vivantes Hospital Neukoelln, Berlin, Germany
| | - M N Duma
- University Hospital, Jena, Germany
| | - W Haase
- St.-Vincentius-Hospital Karlsruhe, Karlsruhe, Germany
| | - W Harms
- St. Claraspital Basel, Basel, Switzerland
| | - T Hehr
- Marienhospital Stuttgart, Stuttgart, Germany
| | - R Fietkau
- University Hospital Erlangen, Erlangen, Germany
| | - J Dunst
- University Hospital Schleswig-Holstein, Kiel, Germany
| | - R Sauer
- University Hospital Erlangen, Erlangen, Germany
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10
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Duma MN. An Update on Regional Nodal Irradiation: Indication, Target Volume Delineation, and Radiotherapy Techniques. Breast Care (Basel) 2020; 15:128-135. [PMID: 32398981 DOI: 10.1159/000507040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 03/09/2020] [Indexed: 12/15/2022] Open
Abstract
Background Tremendous changes have occurred in the treatment of breast cancer. This paper reviews and unifies the available data on modern axillary management of breast cancer patients with focus on the target volume delineation for regional nodal irradiation according to the most important contouring guidelines, the European Society for Radiotherapy and Oncology (ESTRO) and the Radiation Therapy and Oncology Group (RTOG). Summary The use of extensive radiotherapy target volumes (level I, II, III, IV) is probably not necessary for all patients to reproduce the clinical benefit shown in the available randomized trials (EORTC, MA.20, AMAROS, Z0011). Nevertheless, given the results in the MA.20 trial, where the patients received more modern systemic therapies and high irradiation doses in the medial paraclavicular region (level IV) and level II, it can be justified to include these regions completely in selected high-risk patients. Key Messages High-tangent irradiation results in a similar dose distribution in axillary levels I and II compared to the AMAROS treatment field design in some patients. This supports earlier assumptions that irradiation may have accounted for the good results after sentinel lymph node dissection alone in the Z0011 trial. The ESTRO and RTOG clinical target volume (CTV) definitions cover sufficiently the metastatic lymph node hotspots, with a better coverage for the ESTRO CTV. Further, contouring according to the ESTRO would spare a significantly larger part of the healthy lymphatic system, making it our preferred contouring atlas. Modern radiotherapy techniques, such as deep inspiration breath hold, should be cautiously employed in patients treated according to the inclusion criteria of the Z0011 as it will result in a lower dose to the axillary levels.
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Affiliation(s)
- Marciana Nona Duma
- Department of Radiotherapy and Radiation Oncology, University Hospital of the Friedrich Schiller University, Jena, Germany
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11
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Krug D, Baumann R, Budach W, Duma MN, Dunst J, Feyer P, Fietkau R, Haase W, Harms W, Hehr T, Piroth MD, Sedlmayer F, Souchon R, Wenz F, Sauer R. Commercially Available Gene Expression Assays as Predictive Tools for Adjuvant Radiotherapy? A Critical Review. Breast Care (Basel) 2020; 15:118-126. [PMID: 32398980 DOI: 10.1159/000505656] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 12/23/2019] [Indexed: 12/17/2022] Open
Abstract
Background Gene expression assays are increasingly used for decision-making regarding adjuvant chemotherapy in patients with hormone receptor-positive, HER2-negative breast cancer. There are some clinical situations in which there is also a need for better prognostic and predictive markers to better estimate the amount of benefit from adjuvant radiotherapy. The rising availability of gene expression analyses prompts the question whether their results can also be used to guide clinical decisions regarding adjuvant radiation. Summary Multiple studies suggest a correlation between results from gene expression assays and locoregional recurrence rates. Only few publications addressed the predictive value of results from gene expression analysis for the role of adjuvant radiotherapy in different settings. Key Messages To date, the available evidence on the possible predictive value of gene expression assays for radiotherapy does not support their inclusion into the decision-making process for adjuvant radiation. This is due to methodological weaknesses and limitations regarding patient selection, the nonrandomized design of all studies in terms of radiotherapy use, and limited availability of tissue from prospective trials. Thus, utilization of the present knowledge for clinical indication of radiotherapy should be very cautious.
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Affiliation(s)
- David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - René Baumann
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany.,Department of Radiation Oncology, St. Marien-Krankenhaus, Siegen, Germany
| | - Wilfried Budach
- Department of Radiation Oncology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Marciana Nona Duma
- Department of Radiation Oncology, University Hospital Jena, Jena, Germany
| | - Jürgen Dunst
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | | | | | - Wulf Haase
- St.-Vincentius-Hospital, Karlsruhe, Germany
| | | | - Thomas Hehr
- Department of Radiation Oncology, Marienhospital Stuttgart, Stuttgart, Germany
| | - Marc D Piroth
- HELIOS University Hospital Wuppertal, Witten/Herdecke University, Wuppertal, Germany
| | | | | | | | - Rolf Sauer
- University Hospital Erlangen, Erlangen, Germany
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12
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Mayinger M, Reibelt A, Borm KJ, Ettl J, Wilkens JJ, Combs SE, Oechsner M, Duma MN. MRI based neuroanatomical segmentation in breast cancer patients: leptomeningeal carcinomatosis vs. oligometastatic brain disease vs. multimetastastic brain disease. Radiat Oncol 2019; 14:170. [PMID: 31533742 PMCID: PMC6749713 DOI: 10.1186/s13014-019-1380-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 09/11/2019] [Indexed: 11/30/2022] Open
Abstract
Purpose Pathogenesis of brain metastases/meningeal cancer and the emotional and neurological outcomes are not yet well understood. The hypothesis of our study is that patients with leptomeningeal cancer show volumetric differences in brain substructures compared to patients with cerebral metastases. Methods Three groups consisting of female breast cancer patients prior to brain radiotherapy were compared. Leptomeningeal cancer patients (LMC Group), oligometastatic patients (1–3 brain metastases) prior to radiosurgery (OMRS Group) and patients prior to whole brain radiation (WB Group) were included. All patients had MRI imaging before treatment. T1 MRI sequences were segmented using automatic segmentation. For each patient, 14 bilateral and 11 central/median subcortical structures were tested. Overall 1127 structures were analyzed and compared between groups using age matched two-sided t-tests. Results The average age of patients in the OMRS group was 60.8 years (± 14.7), 65.3 (± 10.3) in the LMC group and 62.6 (± 10.2) in the WB group. LMC patients showed a significantly larger fourth ventricle compared to OMRS (p = 0.001) and WB (p = 0.003). The central corpus callosum appeared smaller in the LMC group (LMC vs OMRS p = 0.01; LMC vs WB p = 0.026). The right amygdala in the WB group appeared larger compared with the OMRS (p = 0.035). Conclusions Differences in the size of brain substructures of the three groups were found. The results appear promising and should be taken into account for further prospective studies also involving healthy controls. The volumetrically determined size of the fourth ventricle might be a helpful diagnostic marker in the future.
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Affiliation(s)
- Michael Mayinger
- Department of Radiation Oncology, Medical School, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Department of Radiation Oncology, University of Zurich, Zurich, Switzerland
| | - Antonia Reibelt
- Department of Radiation Oncology, Medical School, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Kai Joachim Borm
- Department of Radiation Oncology, Medical School, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Johannes Ettl
- Department of Obstetrics and Gynecology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Jan J Wilkens
- Department of Radiation Oncology, Medical School, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Stephanie Elisabeth Combs
- Department of Radiation Oncology, Medical School, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK)-Partner Site Munich, Munich, Germany.,Institute of Innovative Radiotherapy, Helmholtzzentrum München, Munich, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Medical School, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Marciana Nona Duma
- Department of Radiation Oncology, Medical School, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany. .,Department of Radiotherapy and Radiation Oncology, University Hospital of the Friedrich-Schiller-University, Bachstr. 18, 07745, Jena, Germany.
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13
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Borm KJ, Schönknecht C, Nestler A, Oechsner M, Waschulzik B, Combs SE, Münch S, Niemeyer M, Duma MN. Outcomes of immediate oncoplastic surgery and adjuvant radiotherapy in breast cancer patients. BMC Cancer 2019; 19:907. [PMID: 31510973 PMCID: PMC6739964 DOI: 10.1186/s12885-019-6104-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 08/29/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Oncoplastic surgery techniques lead to a rearrangement of the breast tissue and impede target definition during adjuvant radiotherapy (RT). The aim of this study was to assess local control rates after immediate oncoplastic surgery and adjuvant RT. METHODS This study comprises 965 patients who underwent breast-conserving therapy and adjuvant RT between 01/2000 and 12/2005. 288 patients received immediate oncoplastic surgery (ONC) and 677 patients breast-conserving surgery only (NONC). All patients were treated with adjuvant external tangential-beam RT (total dose: 50/50.4 Gy; fraction dose 1.8/2.0 Gy). An additional boost dose of 10-16 Gy to the primary tumor bed was given in 900 cases (93.3%). Local control rates (LCR), Progression free survival (PFS) and overall survival (OS) were assessed retrospectively after a median follow-up period of 67 (Q25-Q75: 51-84) months. RESULTS No significant difference was found between ONC and NONC in regard to LCR (5-yr: ONC 96.8% vs. NONC 95.3%; p = 0.25). This held also true for PFS (5-yr: ONC 92.1% vs. NONC 89.3%; p = 0.09) and OS (5-yr: ONC 96.0% vs. NONC 94.8%; p = 0.53). On univariate analyses G2-3 (p = 0.04), a younger age (p = 0.01), T-stage (p < 0.01) lymph node involvement (p < 0.01) as well as triple negative tumors (p < 0.01) were identified as risk factors for local recurrence. In a propensity score stratified Cox-regression model no significant impact of oncoplastic surgery on local control rate was found (HR: 2.05, 95% CI [0.93; 4.51], p = 0.08). CONCLUSION Immediate oncoplastic surgery seems not to affect the effectiveness of adjuvant whole breast RT on local control rates in breast cancer patients.
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Affiliation(s)
- Kai Joachim Borm
- Department of Radiation Oncology, Faculty of Medicine, Technical University Munich (TUM), Medical School, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Christine Schönknecht
- Department of Radiation Oncology, Faculty of Medicine, Technical University Munich (TUM), Medical School, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Andrea Nestler
- Department of Radiation Oncology, Faculty of Medicine, Technical University Munich (TUM), Medical School, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Faculty of Medicine, Technical University Munich (TUM), Medical School, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Birgit Waschulzik
- Institute of Medical Informatics, Statistics and Epidemiology, Technical University Munich (TUM), Ismaninger Strasse 22, 81675, Munich, Germany
| | - Stephanie Elisabeth Combs
- Department of Radiation Oncology, Faculty of Medicine, Technical University Munich (TUM), Medical School, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675, Munich, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK)-Partner Site Munich, Munich, Germany.,Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Ingolstädter Landstraße 1, Oberschleißheim, Germany
| | - Stefan Münch
- Department of Radiation Oncology, Faculty of Medicine, Technical University Munich (TUM), Medical School, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Markus Niemeyer
- Department of Obstetrics and Gynecology, Technical University Munich, Medical School, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Marciana Nona Duma
- Department of Radiation Oncology, Faculty of Medicine, Technical University Munich (TUM), Medical School, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675, Munich, Germany. .,Department of Radiation Oncology, University Hospital Jena, Bachstraße 18, 07743, Jena, Germany.
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14
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Schiller K, Geier M, Duma MN, Nieder C, Molls M, Combs SE, Geinitz H. Definitive, intensity modulated tomotherapy with a simultaneous integrated boost for prostate cancer patients - Long term data on toxicity and biochemical control. Rep Pract Oncol Radiother 2019; 24:315-321. [PMID: 31193851 DOI: 10.1016/j.rpor.2019.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 03/29/2019] [Accepted: 05/11/2019] [Indexed: 10/26/2022] Open
Abstract
Aim To report long-term data regarding biochemical control and late toxicity of simultaneous integrated boost intensity modulated radiotherapy (SIB-IMRT) with tomotherapy in patients with localized prostate cancer. Background Dose escalation improves cancer control after curative intended radiation therapy (RT) to patients with localized prostate cancer, without increasing toxicity, if IMRT is used. Materials and methods In this retrospective analysis, we evaluated long-term toxicity and biochemical control of the first 40 patients with intermediate risk prostate cancer receiving SIB-IMRT. Primary target volume (PTV) 1 including the prostate and proximal third of the seminal vesicles with safety margins was treated with 70 Gy in 35 fractions. PTV 2 containing the prostate with smaller safety margins was treated as SIB to a total dose of 76 Gy with 2.17 Gy per fraction. Toxicity was evaluated using an adapted CTCAE-Score (Version 3). Results Median follow-up of living patients was 66 (20-78) months. No late genitourinary toxicity higher than grade 2 has been reported. Grade 2 genitourinary toxicity rates decreased from 58% at the end of the treatment to 10% at 60 months. Late gastrointestinal (GI) toxicity was also moderate, though the prescribed PTV Dose of 76 Gy was accepted at the anterior rectal wall. 74% of patients reported any GI toxicity during follow up and no toxicity rates higher than grade 2 were observed. Grade 2 side effects were reported by 13% of the patients at 60 months. 5-year freedom from biochemical failure was 95% at our last follow up. Conclusion SIB-IMRT using daily MV-CT guidance showed excellent long-term biochemical control and low toxicity rates.
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Affiliation(s)
- Kilian Schiller
- Klinik und Poliklinik für Strahlentherapie und RadioOnkologie, Technische Universität München, München, Germany
| | - Michael Geier
- Klinik und Poliklinik für Strahlentherapie und RadioOnkologie, Technische Universität München, München, Germany.,Abteilung für Radioonkologie; Ordensklinikum Linz Barmherzige Schwestern, Linz, Austria
| | - Marciana Nona Duma
- Klinik und Poliklinik für Strahlentherapie und RadioOnkologie, Technische Universität München, München, Germany.,Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum, Friedrich-Schiller-Universität, Jena, Germany
| | - Carsten Nieder
- Department of Oncology and Palliative Care, Nordland Hospital, Nordland Hospital Trust, Bodø, Norway.,Institute of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
| | - Michael Molls
- Klinik und Poliklinik für Strahlentherapie und RadioOnkologie, Technische Universität München, München, Germany
| | - Stephanie E Combs
- Klinik und Poliklinik für Strahlentherapie und RadioOnkologie, Technische Universität München, München, Germany.,Institut für Innovative Radiotherapie (iRT), Department of Radiation Sciences (DRS), Helmholtz Zentrum München (HMGU), Oberschleißheim, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Germany
| | - Hans Geinitz
- Klinik und Poliklinik für Strahlentherapie und RadioOnkologie, Technische Universität München, München, Germany.,Abteilung für Radioonkologie; Ordensklinikum Linz Barmherzige Schwestern, Linz, Austria
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15
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Oechsner M, Düsberg M, Borm KJ, Combs SE, Wilkens JJ, Duma MN. Deep inspiration breath-hold for left-sided breast irradiation: Analysis of dose-mass histograms and the impact of lung expansion. Radiat Oncol 2019; 14:109. [PMID: 31215458 PMCID: PMC6582581 DOI: 10.1186/s13014-019-1293-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 05/08/2019] [Indexed: 11/22/2022] Open
Abstract
Background The aim of this study was to compare dose-volume histogram (DVH) with dose-mass histogram (DMH) parameters for treatment of left-sided breast cancer in deep inspiration breath-hold (DIBH) and free breathing (FB). Additionally, lung expansion and anatomical factors were analyzed and correlated to dose differences. Methods For 31 patients 3D conformal radiation therapy plans were retrospectively calculated on FB and DIBH CTs in the treatment planning system. The calculated doses, structures and CT data were transferred into MATLAB and DVHs and DMHs were calculated. Mean doses (Dmean), volumes and masses receiving certain doses (Vx, Mx) were determined for the left lung and the heart. Additionally, expansion of the left lung was evaluated using deformable image registration. Differences in DVH and DMH dose parameters between FB and DIBH were statistically analyzed and correlated to lung expansion and anatomical factors. Results DIBH reduced Dmean (DVH) and relative V20 (V20 [%]) of the left lung in all patients, on average by − 19 ± 9% (mean ± standard deviation) and − 24 ± 10%. Dmean (DMH) and M20 [%] were also significantly reduced (− 12 ± 11%, − 16 ± 13%), however 4 patients had higher DMH values in DIBH than in FB. Linear regression showed good correlations between DVH and DMH parameters, e.g. a dosimetric benefit smaller than 8.4% for Dmean (DVH) in DIBH indicated more irradiated lung mass in DIBH than in FB. The mean expansion of the left lung between FB and DIBH was 1.5 ± 2.4 mm (left), 16.0 ± 4.0 mm (anterior) and 12.2 ± 4.6 mm (caudal). No significant correlations were found between expansions and differences in Dmean for the left lung. The heart dose in DIBH was reduced in all patients by 53% (Dmean) and this dosimetric benefit correlated to lung expansion in anterior. Conclusions Treatment of left-sided breast cancer in DIBH reduced dose to the heart and in most cases the lung dose, relative irradiated lung volume and lung mass. A mass related dosimetric benefit in DIBH can be achieved as long as the volume related benefit is about ≥8–9%. The lung expansion (breathing pattern) showed no impact on lung dose, but on heart dose. A stronger chest breathing (anterior expansion) for DIBH seems to be more beneficial than abdominal breathing.
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Affiliation(s)
- Markus Oechsner
- Department of Radiation Oncology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, München, Germany.
| | - Mathias Düsberg
- Department of Radiation Oncology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, München, Germany
| | - Kai Joachim Borm
- Department of Radiation Oncology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, München, Germany
| | - Stephanie Elisabeth Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, München, Germany.,Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Oberschleißheim, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | - Jan Jakob Wilkens
- Department of Radiation Oncology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, München, Germany
| | - Marciana Nona Duma
- Department of Radiation Oncology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, München, Germany.,Department of Radiotherapy and Radiation Oncology, Universitätsklinikum Jena, Jena, Germany
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Duma MN, Wittig A. Universelle genetische Testungen gegen die Unterdiagnose von erblichem Brustkrebs. Strahlenther Onkol 2019; 195:573-575. [DOI: 10.1007/s00066-019-01448-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Duma MN. In Reply to Byun et al. Int J Radiat Oncol Biol Phys 2019; 103:779-780. [DOI: 10.1016/j.ijrobp.2018.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 10/09/2018] [Accepted: 10/15/2018] [Indexed: 11/16/2022]
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Brunner TB, Blanck O, Lewitzki V, Abbasi-Senger N, Momm F, Riesterer O, Duma MN, Wachter S, Baus W, Gerum S, Guckenberger M, Gkika E. Stereotactic body radiotherapy dose and its impact on local control and overall survival of patients for locally advanced intrahepatic and extrahepatic cholangiocarcinoma. Radiother Oncol 2019; 132:42-47. [DOI: 10.1016/j.radonc.2018.11.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 11/20/2018] [Accepted: 11/25/2018] [Indexed: 12/16/2022]
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Affiliation(s)
- Marciana Nona Duma
- Klinik und Poliklinik für RadioOnkologie und Strahlentherapie, Technische Universität München (TUM) Klinikum rechts der Isar, Ismaninger Straße 22, 81675, München, Deutschland.
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Duma MN, Oechsner M, Ertl C, Mozes P, Reitz S, Borm KJ, Combs SE. A prospective study on the need of gated (GAT) radiotherapy in left sided breast cancer patients treated at the Technical University Munich (TUM)
The GATTUM Trial: Study Protocol (Preprint). JMIR Res Protoc 2018. [DOI: 10.2196/11894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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21
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Borm KJ, Oechsner M, Wiegandt M, Hofmeister A, Combs SE, Duma MN. Moving targets in 4D-CTs versus MIP and AIP: comparison of patients data to phantom data. BMC Cancer 2018; 18:760. [PMID: 30041618 PMCID: PMC6056919 DOI: 10.1186/s12885-018-4647-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 06/28/2018] [Indexed: 11/23/2022] Open
Abstract
Purpose Maximum (MIP) and average intensity projection (AIP) CTs allow rapid definition of internal target volumes in a 4D-CT. The purpose of this study was to assess the accuracy of these techniques in a large patient cohort in combination with simulations on a lung phantom. Methods 4DCT data from a self-developed 3D lung phantom and from 50 patients with lung tumors were analyzed. ITVs were contoured in maximum (ITVMIP) and average intensity projection (ITVAIP) and subsequently compared to ITVs contoured in 10 phases of a 4D-CT (ITV10). In the phantom study additionally a theoretical target volume was calculated for each motion and compared to the contoured volumes. Results ITV10 overestimated the actual target volume by 9.5% whereas ITVMIP and ITVAIP lead to an underestimation of − 1.8% and − 11.4% in the phantom study. The ITVMIP (ITVAIP) was in average − 10.0% (− 18.7%) smaller compared to the ITV10. In the patient CTs deviations between ITV10 and MIP/AIP were significantly larger (MIP: – 20.2% AIP: -33.7%) compared to this. Tumors adjacent to the chestwall, the mediastinum or the diaphragm showed lower conformity between ITV10 and ITVMIP (ITVAIP) compared to tumors solely surrounded by lung tissue. Large tumor diameters (> 3.5 cm) and large motion amplitudes (> 1 cm) were associated with lower conformity between intensity projection CTs and ITV10−. Conclusion The application of MIP and AIP in the clinical practice should not be a standard procedure for every patient, since relevant underestimation of tumor volumes may occur. This is especially true if the tumor borders the mediastinum, the chest wall or the diaphragm and if tumors show a large motion amplitude.
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Affiliation(s)
- Kai Joachim Borm
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Moritz Wiegandt
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.,Medical School Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Andreas Hofmeister
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.,Medical School Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.,Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Oberschleißheim, Germany
| | - Marciana Nona Duma
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany. .,Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Oberschleißheim, Germany.
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Oechsner M, Chizzali B, Devecka M, Münch S, Combs SE, Wilkens JJ, Duma MN. Interobserver variability of patient positioning using four different CT datasets for image registration in lung stereotactic body radiotherapy. Strahlenther Onkol 2017; 193:831-839. [PMID: 28726056 DOI: 10.1007/s00066-017-1184-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 06/30/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE To assess the impact of different reference CT datasets on manual image registration with free-breathing three-dimensional (3D) cone beam CTs (FB-CBCT) for patient positioning by several observers. METHODS For 48 patients with lung lesions, manual image registration with FB-CBCTs was performed by four observers. A slow planning CT (PCT), average intensity projection (AIP), maximum intensity projection (MIP), and midventilation CT (MidV) were used as reference images. Couch shift differences between the four reference CT datasets for each observer as well as shift differences between the observers for the same reference CT dataset were determined. Statistical analyses were performed and correlations between the registration differences and the 3D tumor motion and the CBCT score were calculated. RESULTS The mean 3D shift difference between different reference CT datasets was the smallest for AIPvsMIP (range 1.1-2.2 mm) and the largest for MidVvsPCT (2.8-3.5 mm) with differences >10 mm. The 3D shifts showed partially significant correlations to 3D tumor motion and CBCT score. The interobserver comparison for the same reference CTs resulted in the smallest ∆3D mean differences and mean ∆3D standard deviation for ∆AIP (1.5 ± 0.7 mm, 0.7 ± 0.4 mm). The maximal 3D shift difference between observers was 10.4 mm (∆MidV). Both 3D tumor motion and mean CBCT score correlated with the shift differences (Rs = 0.336-0.740). CONCLUSION The applied reference CT dataset impacts image registration and causes interobserver variabilities. The 3D tumor motion and CBCT quality affect shift differences. The smallest differences were found for AIP which might be the most appropriate CT dataset for image registration with FB-CBCT.
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Affiliation(s)
- Markus Oechsner
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, München, Germany. .,Zentrum für Stereotaxie und personalisierte Hochpräzisionsstrahlentherapie (StereotakTUM), Technical University of Munich, Munich, Germany.
| | - Barbara Chizzali
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, München, Germany
| | - Michal Devecka
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, München, Germany
| | - Stefan Münch
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, München, Germany
| | - Stephanie Elisabeth Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, München, Germany.,Zentrum für Stereotaxie und personalisierte Hochpräzisionsstrahlentherapie (StereotakTUM), Technical University of Munich, Munich, Germany.,Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Munich, Germany
| | - Jan Jakob Wilkens
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, München, Germany.,Zentrum für Stereotaxie und personalisierte Hochpräzisionsstrahlentherapie (StereotakTUM), Technical University of Munich, Munich, Germany.,Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Munich, Germany
| | - Marciana Nona Duma
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, München, Germany.,Zentrum für Stereotaxie und personalisierte Hochpräzisionsstrahlentherapie (StereotakTUM), Technical University of Munich, Munich, Germany.,Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Munich, Germany
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Duma MN, Herr AC, Borm KJ, Trott KR, Molls M, Oechsner M, Combs SE. Tangential Field Radiotherapy for Breast Cancer-The Dose to the Heart and Heart Subvolumes: What Structures Must Be Contoured in Future Clinical Trials? Front Oncol 2017; 7:130. [PMID: 28674678 PMCID: PMC5474560 DOI: 10.3389/fonc.2017.00130] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 06/06/2017] [Indexed: 12/25/2022] Open
Abstract
Background and purpose The aim of the present study was to evaluate if it is feasible for experienced radiation oncologists to visually sort out patients with a large dose to the heart. This would facilitate large retrospective data evaluations. And in case of an insufficient visual assessment, to define which structures should be contoured and which structures can be skipped as their dose can be derived from other easily contoured structures for future clinical trials. Material and methods Planning CTs of left-sided breast cancer patients treated with 3D-conformal radiotherapy by tangential fields were visually divided into two groups: with an estimated high dose (HiD) and with an estimated low dose (LoD) to the heart. For 46 patients (22 HiD and 24 LoD), the heart, the left ventricle, the left anterior descending artery (LAD), the right coronary artery, and the ramus circumflexus were contoured. A helper structure (HS) around the LAD was generated in order to consider if contouring uncertainties of the LAD could be acceptable. We analyzed the mean dose (Dmean), the maximum dose, the V10, V20, V30, V40, and the length of the LAD that received 20 and 40 Gy. Results The two groups had a significant different Dmean of the heart (p < 0.001). The average Dmean to the heart was 4.0 ± 1.3 Gy (HiD) and 2.3 ± 0.8 Gy (LoD). The average Dmean to the LAD was 26.2 ± 7.4 Gy (HiD) and 13.0 ± 7.5Gy (LoD) with a very strong positive correlation between Dmean LAD and Dmean HS in both groups. The Dmean heart is not a good surrogate parameter for the dose to the LAD since it might underestimate clinically significant doses in 1/3 of the patients in LoD group. Conclusion A visual assessment of the dose to the heart could be reliable if performed by experienced radiation oncologists. However, the Dmean heart is not always a good surrogate parameter for the dose to the LAD or for the Dmean to the left ventricle. Thus, if specific late toxicities are evaluated, we strongly recommend contouring of the specific heart substructures as a heart Dmean is not highly specific.
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Affiliation(s)
- Marciana Nona Duma
- Department of Radiation Oncology, Technical University of Munich (TUM), Munich, Germany.,Center for Stereotactic and Highprecision Radiation Therapy (StereotakTUM), Technische Universität München (TUM), Munich, Germany.,Department of Radiation Sciences (DRS), Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Munich, Germany
| | - Anne-Claire Herr
- Department of Radiation Oncology, Technical University of Munich (TUM), Munich, Germany.,Medical School, Technische Universität München, Munich, Germany
| | - Kai Joachim Borm
- Department of Radiation Oncology, Technical University of Munich (TUM), Munich, Germany
| | - Klaus Rüdiger Trott
- Department of Radiation Oncology, Technical University of Munich (TUM), Munich, Germany.,Cancer Institute, University College of London, London, United Kingdom
| | - Michael Molls
- Department of Radiation Oncology, Technical University of Munich (TUM), Munich, Germany.,Technische Universität München, Munich, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Technical University of Munich (TUM), Munich, Germany.,Center for Stereotactic and Highprecision Radiation Therapy (StereotakTUM), Technische Universität München (TUM), Munich, Germany
| | - Stephanie Elisabeth Combs
- Department of Radiation Oncology, Technical University of Munich (TUM), Munich, Germany.,Center for Stereotactic and Highprecision Radiation Therapy (StereotakTUM), Technische Universität München (TUM), Munich, Germany.,Department of Radiation Sciences (DRS), Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Munich, Germany
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Habl G, Straube C, Schiller K, Duma MN, Oechsner M, Kessel KA, Eiber M, Schwaiger M, Kübler H, Gschwend JE, Combs SE. Oligometastases from prostate cancer: local treatment with stereotactic body radiotherapy (SBRT). BMC Cancer 2017; 17:361. [PMID: 28532400 PMCID: PMC5440986 DOI: 10.1186/s12885-017-3341-2] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 05/11/2017] [Indexed: 01/07/2023] Open
Abstract
Background The impact of local tumor ablative therapy in oligometastasized prostate cancer (PC) is still under debate. To gain data for this approach, we evaluated oligometastasized PC patients receiving stereotactic body radiotherapy (SBRT) to bone metastases. Methods In this retrospective study, 15 oligometastasized PC patients with a total of 20 bone metastases were evaluated regarding biochemical progression-free survival (PSA-PFS), time to initiation of ADT, and local control rate (LCR). Three patients received concomitant androgen deprivation therapy (ADT). Results The median follow-up after RT was 22.5 months (range 7.0–53.7 months). The median PSA-PFS was 6.9 months (range 1.1–28.4 months). All patients showing a decrease of PSA level after RT of at least factor 10 reveal a PSA-PFS of >12 months. Median PSA-PFS of this sub-group was 23.1 months (range 12.1–28.4 months). Local PFS (LPFS) after 2 years was 100%. One patient developed a local failure after 28.4 months. Median distant PFS (DPFS) was 7.36 months (range 1.74–54.34 months). The time to initiation of ADT in patients treated without ADT was 9.3 months (range 2.6–36.1 months). In all patients, the time to intensification of systemic therapy or the time to initiation of ADT increased from 9.3 to 12.3 months (range 2.6–36.1 months). Gleason-Score, ADT or the localization of metastasis had no impact on PFS or time to intensification of systemic therapy. No SBRT related acute or late toxicities were observed. Conclusion Our study shows that SBRT of bone metastases is a highly effective therapy with an excellent risk-benefit profile. However, PFS was limited due to a high distant failure rate implying the difficulty for patient selection for this oligometastatic concept. SBRT offers high local cancer control rates in bone oligometastases of PC and should be evaluated with the aim of curation or to delay modification of systemic treatment.
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Affiliation(s)
- Gregor Habl
- Department of Radiation Oncology, Technical University of Munich (TUM), Ismaninger Strasse 22, 81675, Munich, Germany. .,Zentrum für Stereotaxie und personalisierte Hochpräzisionsstrahlentherapie (StereotakTUM), Technische Universität München (TUM), Munich, Germany.
| | - Christoph Straube
- Department of Radiation Oncology, Technical University of Munich (TUM), Ismaninger Strasse 22, 81675, Munich, Germany.,Zentrum für Stereotaxie und personalisierte Hochpräzisionsstrahlentherapie (StereotakTUM), Technische Universität München (TUM), Munich, Germany
| | - Kilian Schiller
- Department of Radiation Oncology, Technical University of Munich (TUM), Ismaninger Strasse 22, 81675, Munich, Germany.,Zentrum für Stereotaxie und personalisierte Hochpräzisionsstrahlentherapie (StereotakTUM), Technische Universität München (TUM), Munich, Germany
| | - Marciana Nona Duma
- Department of Radiation Oncology, Technical University of Munich (TUM), Ismaninger Strasse 22, 81675, Munich, Germany.,Zentrum für Stereotaxie und personalisierte Hochpräzisionsstrahlentherapie (StereotakTUM), Technische Universität München (TUM), Munich, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Technical University of Munich (TUM), Ismaninger Strasse 22, 81675, Munich, Germany.,Zentrum für Stereotaxie und personalisierte Hochpräzisionsstrahlentherapie (StereotakTUM), Technische Universität München (TUM), Munich, Germany
| | - Kerstin A Kessel
- Department of Radiation Oncology, Technical University of Munich (TUM), Ismaninger Strasse 22, 81675, Munich, Germany.,Zentrum für Stereotaxie und personalisierte Hochpräzisionsstrahlentherapie (StereotakTUM), Technische Universität München (TUM), Munich, Germany.,Institute of Innovative Radiotherapy (iRT), Department of Radiation Sciences (DRS), Helmholtz Zentrum München, Neuherberg, Germany
| | - Matthias Eiber
- Department of Nuclear Medicine, Technical University Munich (TUM), Munich, Germany
| | - Markus Schwaiger
- Department of Nuclear Medicine, Technical University Munich (TUM), Munich, Germany
| | - Hubert Kübler
- Department of Urology, Technical University Munich (TUM), Munich, Germany.,Department of Urology, University of Würzburg, Würzburg, Germany
| | - Jürgen E Gschwend
- Department of Urology, Technical University Munich (TUM), Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich (TUM), Ismaninger Strasse 22, 81675, Munich, Germany.,Zentrum für Stereotaxie und personalisierte Hochpräzisionsstrahlentherapie (StereotakTUM), Technische Universität München (TUM), Munich, Germany.,Institute of Innovative Radiotherapy (iRT), Department of Radiation Sciences (DRS), Helmholtz Zentrum München, Neuherberg, Germany
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Duma MN, Heinrich C, Schönknecht C, Chizzali B, Mayinger M, Devecka M, Kampfer S, Combs SE. Helical TomoTherapy for locally advanced or recurrent breast cancer. Radiat Oncol 2017; 12:31. [PMID: 28129767 PMCID: PMC5273793 DOI: 10.1186/s13014-016-0736-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 12/01/2016] [Indexed: 12/25/2022] Open
Abstract
Purpose We report our experience of using helical tomotherapy (HT) to treat large and irregular shaped loco-regional advanced breast cancer target volumes embracing various organs at risk. Patients and methods We retrospectively analyzed 26 patients treated for very large, irregular shaped breast cancers. Patients were treated either with the intent to achieve local control in a primary setting (n = 14) or in a reirradiation setting (n = 12). The recurrence group was heavily pretreated with systemic therapy. Tumors were characterized by wide infiltration of the skin, encompassing mostly a complete hemithorax. The primary group underwent irradiation of supraclavicular, infraclavicular, axillary and parasternal lymphonodal region. Radiotherapy was combined with chemotherapy (n = 11). We assessed the PTV volume and its craniocaudal extension, the dose to the organs at risk, acute toxicity and survival. Results Median PTV was 2276 cm3 (1476–6837 cm3) with a median cranio-caudal extension of 28 cm (15–52 cm). The median dose to PTV was 40 Gy (32–60Gy). HT could be carried out in all patients without interruption. The acute toxicities were mild to moderate. The median LRFS and OS after radiotherapy was 21 and 57 months for the primary group versus 10 and 11 months for the recurrence group. Median PFS was 18 months (primary group) and 7 months (recurrence group). Conclusions HT is feasible for advanced thorax embracing target volumes with acceptable acute toxicity. Both curative and palliative indications can be considered good indications based on treatment volume and anatomical constellation.
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Affiliation(s)
- M N Duma
- Department of Radiation Oncology, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, München, Germany. .,Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, München, Germany.
| | - C Heinrich
- Department of Radiation Oncology, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, München, Germany.,Praxis für Strahlentherapie, Hausham, Germany
| | - C Schönknecht
- Department of Radiation Oncology, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - B Chizzali
- Department of Radiation Oncology, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - M Mayinger
- Department of Radiation Oncology, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - M Devecka
- Department of Radiation Oncology, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - S Kampfer
- Department of Radiation Oncology, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - S E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, München, Germany.,Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, München, Germany
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Duma MN, Berndt J, Rondak IC, Devecka M, Wilkens JJ, Geinitz H, Combs SE, Oechsner M. Implications of free breathing motion assessed by 4D-computed tomography on the delivered dose in radiotherapy for esophageal cancer. Med Dosim 2015; 40:378-82. [PMID: 26419857 DOI: 10.1016/j.meddos.2015.07.002] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Revised: 07/03/2015] [Accepted: 07/29/2015] [Indexed: 12/25/2022]
Abstract
The aim of this study was to assess the effect of breathing motion on the delivered dose in esophageal cancer 3-dimensional (3D)-conformal radiotherapy (3D-CRT), intensity-modulated radiotherapy (IMRT), and volumetric modulated arc therapy (VMAT). We assessed 16 patients with esophageal cancer. All patients underwent 4D-computed tomography (4D-CT) for treatment planning. For each of the analyzed patients, 1 3D-CRT, 1 IMRT, and 1 VMAT (RapidArc-RA) plan were calculated. Each of the 3 initial plans was recalculated on the 4D-CT (for the maximum free inspiration and maximum free expiration) to assess the effect of breathing motion. We assessed the minimum dose (Dmin) and mean dose (Dmean) to the esophagus within the planning target volume, the volume changes of the lungs, the Dmean and the total lung volume receiving at least 40Gy (V40), and the V30, V20, V10, and V5. For the heart we assessed the Dmean and the V25. Over all techniques and all patients the change in Dmean as compared with the planned Dmean (planning CT [PCT]) to the esophagus was 0.48% in maximum free inspiration (CT_insp) and 0.55% in maximum free expiration (CT_exp). The Dmin CT_insp change was 0.86% and CT_exp change was 0.89%. The Dmean change of the lungs (heart) was in CT_insp 1.95% (2.89%) and 3.88% (2.38%) in CT_exp. In all, 4 patients had a clinically relevant change of the dose (≥ 5% Dmean to the heart and the lungs) between inspiration and expiration. These patients had a very cranially or caudally situated tumor. There are no relevant differences in the delivered dose to the regions of interest among the 3 techniques. Breathing motion management could be considered to achieve a better sparing of the lungs or heart in patients with cranially or caudally situated tumors.
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Affiliation(s)
- Marciana Nona Duma
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München, München, Germany.
| | - Johannes Berndt
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Ina-Christine Rondak
- Institute of Medical Statistics and Epidemiology, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Michal Devecka
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Jan J Wilkens
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Hans Geinitz
- Department of Radiation Oncology, Krankenhaus Barmherzige Schwestern Linz, Austria
| | - Stephanie Elisabeth Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München, München, Germany
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Borm KJ, Oechsner M, Berndt J, Combs SE, Molls M, Duma MN. The importance of surrounding tissues and window settings for contouring of moving targets. Strahlenther Onkol 2015; 191:750-6. [PMID: 26087909 DOI: 10.1007/s00066-015-0862-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 05/25/2015] [Indexed: 11/29/2022]
Abstract
AIM The aim of the study was to assess the importance of surrounding tissues for the delineation of moving targets in tissue-specific phantoms and to find optimal settings for lung, soft tissue, and liver tumors. MATERIALS AND METHODS Tumor movement was simulated by a water-filled table tennis ball (target volume, TV). Three phantoms were created: corkboards to simulate lung tissue (lung phantom, LunPh), animal fat as fatty soft tissue (fatty tissue phantom, FatPh), and water enhanced with contrast medium as the liver tissue (liver phantom, LivPh). Slow planning three-dimensional compute tomography images (3D-CTs) were acquired with and without phantom movements. One-dimensional tumor movement (1D), three-dimensional tumor movement (3D), as well as a real patient's tumor trajectories were simulated. The TV was contoured using two lung window settings, two soft-tissue window settings, and one liver window setting. The volumes were compared to mathematical calculated values. RESULTS TVs were underestimated in all phantoms due to movement. The use of soft-tissue windows in the LivPh led to a significant underestimation of the TV (70.8% of calculated TV). When common window settings [LunPh + 200 HU/-1,000 HU (upper window/lower window threshold); FatPh: + 240 HU/-120 HU; LivPh: + 175 HU/+ 50 HU] were used, the contoured TVs were: LivPh, 84.0%; LunPh, 93.2%, and FatPh, 92.8%. The lower window threshold had a significant impact on the size of the delineated TV, whereas changes of the upper threshold led only to small differences. CONCLUSION The decisive factor for window settings is the lower window threshold (for adequate TV delineation in the lung and fatty-soft tissue it should be lower than density values of surrounding tissue). The use of a liver window should be considered.
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Müller BS, Duma MN, Kampfer S, Nill S, Oelfke U, Geinitz H, Wilkens JJ. Impact of interfractional changes in head and neck cancer patients on the delivered dose in intensity modulated radiotherapy with protons and photons. Phys Med 2015; 31:266-72. [PMID: 25724350 DOI: 10.1016/j.ejmp.2015.02.007] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 02/03/2015] [Accepted: 02/07/2015] [Indexed: 10/24/2022] Open
Abstract
PURPOSE To investigate the influence of interfractional changes on the delivered dose of intensity modulated proton (IMPT) and photon plans (IMXT). METHODS AND MATERIALS Five postoperative head and neck cancer patients, previously treated with tomotherapy at our institute, were analyzed. The planning study is based on megavoltage (MV) control images. For each patient one IMPT plan and one IMXT plan were generated on the first MV-CT and recalculated on weekly control MV-CTs in the actual treatment position. Dose criteria for evaluation were coverage and conformity of the planning target volume (PTV), as well as mean dose to parotids and maximum dose to spinal cord. RESULTS Considerable dosimetric changes were observed for IMPT and IMXT plans. Proton plans showed a more pronounced increase of maximum dose and decrease of minimum dose with local underdosage occurring even in the center of the PTV (worst IMPT vs. IMXT coverage: 66.7% vs. 85.0%). The doses to organs at risk (OARs) increased during the treatment period. However, the OAR doses of IMPT stayed below corresponding IMXT values at any time. For both modalities treatment plans did not necessarily worsen monotonically throughout the treatment. CONCLUSIONS Although absolute differences between planned and reconstructed doses were larger in IMPT plans, doses to OARs were higher in IMXT plans. Tumor coverage was more stable in IMXT plans; IMPT dose distributions indicated a high risk for local underdosage during the treatment course.
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Affiliation(s)
- Birgit Sabine Müller
- Department of Radiation Oncology, Technische Universität München, Klinikum rechts der Isar, Munich, Germany; Physik-Department, Technische Universität München, Munich, Germany.
| | - Marciana Nona Duma
- Department of Radiation Oncology, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
| | - Severin Kampfer
- Department of Radiation Oncology, Technische Universität München, Klinikum rechts der Isar, Munich, Germany; Physik-Department, Technische Universität München, Munich, Germany
| | - Simeon Nill
- Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Uwe Oelfke
- Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Hans Geinitz
- Department of Radiation Oncology, Krankenhaus der Barmherzigen Schwestern Linz, Linz, Austria; Medical Faculty, Johannes Kepler University, Linz, Austria
| | - Jan Jakob Wilkens
- Department of Radiation Oncology, Technische Universität München, Klinikum rechts der Isar, Munich, Germany; Physik-Department, Technische Universität München, Munich, Germany
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Schiller K, Petrucci A, Geinitz H, Schuster T, Specht H, Kampfer S, Duma MN. Impact of different setup approaches in image-guided radiotherapy as primary treatment for prostate cancer. Strahlenther Onkol 2014; 190:722-6. [DOI: 10.1007/s00066-014-0629-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 01/22/2014] [Indexed: 11/28/2022]
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Duma MN, Molls M, Trott KR. From heart to heart for breast cancer patients - cardiovascular toxicities in breast cancer radiotherapy. Strahlenther Onkol 2013; 190:5-7. [PMID: 24253182 DOI: 10.1007/s00066-013-0465-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Accepted: 09/11/2013] [Indexed: 12/25/2022]
Affiliation(s)
- M N Duma
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675 , München, Germany,
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Bundschuh RA, Andratschke N, Dinges J, Duma MN, Astner ST, Brügel M, Ziegler SI, Molls M, Schwaiger M, Essler M. Respiratory gated [18F]FDG PET/CT for target volume delineation in stereotactic radiation treatment of liver metastases. Strahlenther Onkol 2012; 188:592-8. [PMID: 22441441 DOI: 10.1007/s00066-012-0094-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Accepted: 02/02/2012] [Indexed: 11/28/2022]
Abstract
PURPOSE The use of 4D-[(18)F]fluorodeoxyglucose (FDG) PET/CT in combination with respiratory gated magnet resonance imaging (MRI) in target volume definition for stereotactic radiation of liver metastases was investigated. METHODS AND MATERIALS A total of 18 patients received respiration gated FDG-PET/CT and MRI. Data were fused using a rigid co-registration algorithm. The quality of the co-registration was rated on a scale from 1 (excellent) to 5 (poor) for co-registration of MRI with gated PET and ungated PET. Gross tumor volume (GTV) was delineated in CT (GTV (CT)), MRI (GTV(MRI)), and PET (GTV(PET)). MRI- and PET-based GTVs were defined by three observers each. Interobserver variability was calculated for all patients as well as for subgroups with and without previous treatment of liver metastases. All GTVs were compared for all patients and separately for patients with previous local therapy. In addition, a semiautomatic segmentation algorithm was applied on the PET images. RESULTS Co-registration between MR and PET images was rated with 3.3 in average when non-gated PET was used and improved significantly (p < 0.01) to 2.1 using gated PET. The average GTV(CT) was 51.5 ml, GTV(MRI) 51.8 ml, and the average GTV(PET) 48.1 ml. Volumes delineated in MRI were 9.9% larger compared to those delineated in CT. Volumes delineated in PET were 13.8% larger than in MRI. The differences between the GTVs were more pronounced in patients with previous treatment. The GTVs defined in MRI showed an interobserver variability of 47.9% (84.1% with previous treatment and 26.2% without previous treatment). The PET-defined GTVs showed an interobserver variability of 21% regardless of previous treatment. Semiautomatic segmentation did not provide satisfying results. CONCLUSION FDG-PET can distinguish vital tumor tissue and scar tissue, and therefore alters the GTV especially in patients with previous local treatment. In addition, it reduces the interobserver variability significantly compared to MRI. However, respiratory gated PET is necessary for good co-registration of PET and MRI.
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Affiliation(s)
- R A Bundschuh
- Nuklearmedizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany.
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Duma MN, Kampfer S, Schuster T, Aswathanarayana N, Fromm LS, Molls M, Andratschke N, Geinitz H. Do we need daily image-guided radiotherapy by megavoltage computed tomography in head and neck helical tomotherapy? The actual delivered dose to the spinal cord. Int J Radiat Oncol Biol Phys 2012; 84:283-8. [PMID: 22417803 DOI: 10.1016/j.ijrobp.2011.10.073] [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: 07/15/2011] [Revised: 10/27/2011] [Accepted: 10/28/2011] [Indexed: 11/19/2022]
Abstract
PURPOSE To quantify the actual delivered dose to the cervical spinal cord with different image-guided radiotherapy (IGRT) approaches during head and neck (HN) cancer helical tomotherapy. METHODS AND MATERIALS Twenty HN patients (HNpts) treated with bilateral nodal irradiation were analyzed. Daily megavoltage computed tomography MVCT) scans were performed for setup purposes. The maximum dose on the planning CT scan (plan-Dmax) and the magnitude and localization of the actual delivered Dmax (a-Dmax) were analyzed for four scenarios: daily image-guided radiotherapy (dIGRT), twice weekly IGRT (2×WkIGRT), once weekly IGRT (1×WkIGRT), and no IGRT at all (non-IGRT). The spinal cord was recontoured on 236 MVCTs for each scenario (total, 944 fractions), and the delivered dose was recalculated for each fraction (fx) separately. RESULTS Fifty-one percent of the analyzed fx for dIGRT, 56% of the analyzed fx for the 2×WkIGRT, 62% of the analyzed fx for the 1×WkIGRT, and 63% of the analyzed fx for the non-IGRT scenarios received a higher a-Dmax than the plan-Dmax. The median increase of dose in these fx was 3.3% more for dIGRT, 5.8% more for 2×WkIGRT, 10.0% more for 1×WkIGRT, and 9.5% more for non-IGRT than the plan-Dmax. The median spinal cord volumes receiving a higher dose than the plan-Dmax were 0.02 cm³ for dIGRT, 0.11 cm³ for 2×WkIGRT, 0.31 cm³ for 1×WkIGRT, and 0.22 cm³ for non-IGRT. Differences between the dIGRT and all other scenarios were statistically significant (p < 0.05). CONCLUSIONS Compared to the Dmax of the initial plan, daily IGRT had the smallest increase in dose. Furthermore, daily IGRT had the lowest proportion of fractions and the smallest volumes affected by a dose that was higher than the planned dose. For patients treated with doses close to the tolerance dose of the spinal cord, we recommend daily IGRT. For all other cases, twice weekly IGRT is sufficient.
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Affiliation(s)
- Marciana Nona Duma
- Department of Radiation Oncology, Technische Universität München, Klinikum rechts der Isar, München, Germany.
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Geier M, Astner ST, Duma MN, Jacob V, Nieder C, Putzhammer J, Winkler C, Molls M, Geinitz H. Dose-escalated simultaneous integrated-boost treatment of prostate cancer patients via helical tomotherapy. Strahlenther Onkol 2012; 188:410-6. [PMID: 22367410 DOI: 10.1007/s00066-012-0081-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Accepted: 01/20/2012] [Indexed: 11/28/2022]
Abstract
PURPOSE The goal of this work was to assess the feasibility of moderately hypofractionated simultaneous integrated-boost intensity-modulated radiotherapy (SIB-IMRT) with helical tomotherapy in patients with localized prostate cancer regarding acute side effects and dose-volume histogram data (DVH data). METHODS Acute side effects and DVH data were evaluated of the first 40 intermediate risk prostate cancer patients treated with a definitive daily image-guided SIB-IMRT protocol via helical tomotherapy in our department. The planning target volume including the prostate and the base of the seminal vesicles with safety margins was treated with 70 Gy in 35 fractions. The boost volume containing the prostate and 3 mm safety margins (5 mm craniocaudal) was treated as SIB to a total dose of 76 Gy (2.17 Gy per fraction). Planning constraints for the anterior rectal wall were set in order not to exceed the dose of 76 Gy prescribed to the boost volume. Acute toxicity was evaluated prospectively using a modified CTCAE (Common Terminology Criteria for Adverse Events) score. RESULTS SIB-IMRT allowed good rectal sparing, although the full boost dose was permitted to the anterior rectal wall. Median rectum dose was 38 Gy in all patients and the median volumes receiving at least 65 Gy (V65), 70 Gy (V70), and 75 Gy (V75) were 13.5%, 9%, and 3%, respectively. No grade 4 toxicity was observed. Acute grade 3 toxicity was observed in 20% of patients involving nocturia only. Grade 2 acute intestinal and urological side effects occurred in 25% and 57.5%, respectively. No correlation was found between acute toxicity and the DVH data. CONCLUSION This institutional SIB-IMRT protocol using daily image guidance as a precondition for smaller safety margins allows dose escalation to the prostate without increasing acute toxicity.
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Affiliation(s)
- M Geier
- Klinik und Poliklinik für Strahlentherapie und Radiologische Onkologie, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
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Sension MG, Quinn TC, Markowitz LE, Linnan MJ, Jones TS, Francis HL, Nzilambi N, Duma MN, Ryder RW. Measles in hospitalized African children with human immunodeficiency virus. Am J Dis Child 1988; 142:1271-2. [PMID: 3195521 DOI: 10.1001/archpedi.1988.02150120025021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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