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Brooks ED, Deladisma AM, Morris CG, Mobley EM, Neumayer LA, Bradley JA, Mailhot Vega RB. Axillary Surgery for Chemoresidual (ypN-Positive) Nodal Disease. JAMA Oncol 2024:2818764. [PMID: 38753348 PMCID: PMC11099839 DOI: 10.1001/jamaoncol.2024.1136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/05/2024] [Indexed: 05/19/2024]
Abstract
This cohort study using pooled data from 2 randomized clinical trials examines whether removing more lymph nodes with axillary lymph node dissection improved outcomes over sentinel lymph node biopsy when most patients received adjuvant radiation therapy or regional nodal irradiation.
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Affiliation(s)
- Eric D. Brooks
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville
| | - Adeline M. Deladisma
- Department of Surgery, University of Florida College of Medicine Jacksonville, Jacksonville
| | - Christopher G. Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville
| | - Erin M. Mobley
- Department of Surgery, University of Florida College of Medicine Jacksonville, Jacksonville
| | - Leigh A. Neumayer
- Department of Surgery, University of Florida College of Medicine Jacksonville, Jacksonville
| | - Julie A. Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville
| | - Raymond B. Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville
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Siva Kumar S, Bradley JA, Mendenhall NP, Mailhot Vega RB, Brooks ED, Okunieff PG, Giap F, Burchianti T, Daily K, Heldermon CD, Galochkina Z, Lee JH, Swarts S, O’Dell WG. Effects on Lung Tissue After Breast Cancer Radiation: Comparing Photon and Proton Therapies. Int J Part Ther 2024; 11:100006. [PMID: 38757081 PMCID: PMC11095095 DOI: 10.1016/j.ijpt.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 11/27/2023] [Accepted: 02/15/2024] [Indexed: 05/18/2024] Open
Abstract
Purpose In breast cancer, improved treatment approaches that reduce injury to lung tissue and early diagnosis and intervention for lung toxicity are increasingly important in survivorship. The aims of this study are to (1) compare lung tissue radiographic changes in women treated with conventional photon radiation therapy and those treated with proton therapy (PT), (2) assess the volume of lung irradiated to 5 Gy (V5) and 20 Gy (V20) by treatment modality, and (3) quantify the effects of V5, V20, time, and smoking history on the severity of tissue radiographic changes. Patients and Methods A prospective observational study of female breast cancer patients was conducted to monitor postradiation subclinical lung tissue radiographic changes. Repeated follow-up x-ray computed tomography scans were acquired through 2 years after treatment. In-house software was used to quantify an internally normalized measure of pulmonary tissue density change over time from the computed tomography scans, emphasizing the 6- and 12-month time points. Results Compared with photon therapy, PT was associated with significantly lower lung V5 and V20. Lung V20 (but not V5) correlated significantly with increased subclinical lung tissue radiographic changes 6 months after treatment, and neither correlated with lung effects at 12 months. Significant lung tissue density changes were present in photon therapy patients at 6 and 12 months but not in PT patients. Significant lung tissue density change persisted at 12 months in ever-smokers but not in never-smokers. Conclusion Patients treated with PT had significantly lower radiation exposure to the lungs and less statistically significant tissue density change, suggesting decreased injury and/or improved recovery compared to photon therapy. These findings motivate additional studies in larger, randomized, and more diverse cohorts to further investigate the contributions of treatment modality and smoking regarding the short- and long-term radiographic effects of radiation on lung tissue.
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Affiliation(s)
| | - Julie A. Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Nancy P. Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Raymond B. Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Eric D. Brooks
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Paul G. Okunieff
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Fantine Giap
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Teena Burchianti
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Karen Daily
- Division of Hematology & Oncology, Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Coy D. Heldermon
- Division of Hematology & Oncology, Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Zhanna Galochkina
- Division of Quantitative Sciences, University of Florida Health Cancer Center, Gainesville, FL, USA
| | - Ji-Hyun Lee
- Department of Biostatistics, University of Florida College of Health Profession & Public Health and College of Medicine, Gainesville, FL, USA
| | - Steven Swarts
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Walter G. O’Dell
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
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Bush A, Eslin DE, Joyce MJ, Hess D, Leon D, Ermoian RP, Mailhot Vega RB. Consolidative Proton Radiotherapy for Pediatric Extramedullary Ocular Acute Myeloid Leukemia. Int J Part Ther 2024; 11:100002. [PMID: 38757078 PMCID: PMC11095097 DOI: 10.1016/j.ijpt.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 05/18/2024] Open
Abstract
Purpose Pediatric acute myeloid leukemia (AML) often involves extramedullary sites, which can be resistant to standard induction chemotherapy. Consolidative radiation therapy can be used in select cases to improve local control rates and help bridge patients to curative stem cell transplants. However, there is no previously published data to support the use of proton radiotherapy (PT) in this setting. We present radiographic findings and pathologic outcomes of the first reported patient with extramedullary ocular AML to be treated with PT. Patients and Methods Details regarding diagnostic evaluation and treatment were obtained from the electronic medical records at the University of Florida Proton Therapy Institute, Nemours Children's Health, and St. Joseph's Children's Hospital. Results This 7-month-old patient presented with biopsy-proven relapsed AML in the bilateral anterior chambers of the eyes, which did not resolve with induction chemotherapy. The patient then received PT to a dose of 24 cobalt gray equivalent to both eyes and was found to have no evidence of disease following treatment. Conclusion This case provides further evidence that consolidative radiotherapy may be considered for select patients with extramedullary AML who have limited response to induction chemotherapy. Given the increased prevalence of extramedullary AML in pediatric patients, it is worth considering the utilization of PT to mitigate damage to nearby organs and the risk of secondary malignancies.
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Affiliation(s)
- Aaron Bush
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Don E. Eslin
- Department of Pediatric Hematology/Oncology, St. Joseph’s Hospital, Tampa, FL, USA
| | - Michael J. Joyce
- Department of Hematology/Oncology, Nemours Children’s Health, Jacksonville, FL, USA
| | - Derek Hess
- Hess Pediatric Ophthalmology, Saint Petersburg, FL, USA
| | - Diana Leon
- Department of Pediatric Hematology/Oncology, St. Joseph’s Hospital, Tampa, FL, USA
| | - Ralph P. Ermoian
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Raymond B. Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
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O'Dell WG, Siva Kumar S, Klassen CL, Rutenberg MS, Mailhot Vega RB, Mendenhall NP, Okunieff PG, Bradley JA. Measuring early changes in heart function due to radiation treatment in breast cancer patients. Am Heart J Plus 2024; 38:100349. [PMID: 38510742 PMCID: PMC10946026 DOI: 10.1016/j.ahjo.2023.100349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/21/2023] [Accepted: 11/21/2023] [Indexed: 03/22/2024]
Affiliation(s)
- Walter G. O'Dell
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | | | - Christopher L. Klassen
- Department of Radiology, University of Florida Health Shands Hospital, Jacksonville, FL, USA
| | | | | | - Nancy P. Mendenhall
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Paul G. Okunieff
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Julie A. Bradley
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
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Drescher NR, Indelicato DJ, Dagan R, Bradley JA, Holtzman AL, Mailhot Vega RB, Aldana PR, Sandler ES, Morris CG, Mendenhall WM. Outcomes following proton therapy for pediatric esthesioneuroblastoma. Pediatr Blood Cancer 2024; 71:e30793. [PMID: 38018357 DOI: 10.1002/pbc.30793] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/31/2023] [Accepted: 11/18/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Pediatric esthesioneuroblastoma (EN) can infiltrate skull base anatomy, presenting challenges due to high radiation doses and pediatric tissue sensitivity. This study reports outcomes of pediatric EN treated with proton radiotherapy (PT). PROCEDURE Using an IRB-approved prospective outcomes registry, we evaluated patient, tumor, and treatment-related variables impacting disease control and toxicity in pediatric nonmetastatic EN treated with modern multimodality therapy, including PT. RESULTS Fifteen consecutive patients (median age 16) comprising Kadish stage B (n = 2), C (n = 9), and D (n = 4) tumors were assessed, including six with intracranial involvement, four with cranial nerve deficits, and four with cervical lymphadenopathy. Before radiation, two had subtotal and 13 had gross total resections (endoscopic or craniofacial). Two underwent neck dissection. Eleven received chemotherapy before radiation (n = 5), concurrent with radiation (n = 4), or both (n = 2). Median total radiation dose (primary site) was 66 Gy/CGE for gross disease and 54 Gy/CGE (cobalt Gray equivalent) for microscopic disease. Median follow-up was 4.8 years. No patients were lost to follow-up. Five-year disease-free and overall survival rates were 86% (no local or regional recurrences). Two patients developed vertebral metastases and died. Two required a temporary feeding tube for oral mucositis/dysphagia. Late toxicities included symptomatic retinopathy, major reconstructive surgery, cataracts, chronic otitis media, chronic keratoconjunctivitis, hypothyroidism, and in-field basal cell skin cancer. CONCLUSIONS A multimodality approach for pediatric EN results in excellent local control. Despite the moderate-dose PT, serious radiation toxicity was observed; further dose and target volume reductions may benefit select patients. Longer follow-up and comparative data from modern photon series are necessary to fully characterize any relative PT advantage.
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Affiliation(s)
- Nicolette R Drescher
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Roi Dagan
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Adam L Holtzman
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Philipp R Aldana
- Department of Neurosurgery, University of Florida College of Medicine Jacksonville, Jacksonville, Florida, USA
| | - Eric S Sandler
- Department of Pediatrics, Nemours Children's Specialty Clinic, Jacksonville, Florida, USA
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - William M Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
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Bradley JA, Gracie J, Mailhot Vega RB, Brooks ED, Burchianti T, Oladeru OT, Liang X, Mendenhall NP. Proton Therapy in the Treatment of Men with Breast Cancer. Int J Part Ther 2023; 10:94-104. [PMID: 38075485 PMCID: PMC10698632 DOI: 10.14338/ijpt-23-00007.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 07/20/2023] [Indexed: 02/12/2024] Open
Abstract
Purpose Male breast cancer treatment involves multimodality therapy, including radiation therapy; nevertheless, few men have received proton therapy (PT) for it. Further, heart disease is an established leading cause of death in men, and radiation therapy heart dose correlates with cardiac toxicity, highlighting the need for cardiac-sparing radiation techniques. Thus, we provide a descriptive analysis of PT in a male breast cancer cohort. Patients and Methods Men who received PT for localized breast cancer between 2012 and 2022 were identified from a prospective database. Toxicities were prospectively recorded by using the Common Terminology Criteria for Adverse Events (CTCAE), version 4.0. Results Five male patients were identified. All had estrogen receptor (ER)-positive, Her2neu-negative disease and received adjuvant endocrine therapy. One had genetic testing positive for BRCA2, one had a variant of unknown significance (VUS) in the APC gene, and one had a VUS in MSH2. Median age was 73 years (range, 41-80). Baseline comorbidities included obesity (n = 1), diabetes (n = 1), hypertension (n = 4), history of deep vein thrombosis (n = 1), personal history of myocardial infarction (n = 3; 1 with a pacemaker), and a history of lung cancer (n = 1). All received PT to the left chest wall and comprehensive regional lymphatics. One received passive-scattering PT, and 4 received pencil beam scanning. One patient received a boost to the mastectomy incision via electrons. Median heart dose was 1 GyRBE (range, 0-1.0), median 0.1-cm3 dose to the left anterior descending artery was 7.5 GyRBE (range, 0-14.2), and median follow-up was 2 years (range, 0.75-6.5); no patient experienced a new cardiac event, and all remain free from breast cancer recurrence and progression. Conclusion In a small case series for a rare diagnosis, PT to the chest wall and regional lymphatics, including internal mammary nodes, resulted in low cardiac exposure, high local regional disease control rates, and minimal toxicity. Proton therapy should be considered for treating men with breast cancer to achieve cardiac sparing.
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Affiliation(s)
- Julie A. Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Jayden Gracie
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Raymond B. Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Eric D. Brooks
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Tenna Burchianti
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | | | - Xiaoying Liang
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Nancy P. Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
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Mailhot Vega RB, Harker-Murray PD, Forlenza CJ, Cole P, Kelly KM, Milgrom SA, Parikh RR, Hodgson DC, Castellino SM, Kahn J, Roberts KB, Constine LS, Hoppe BS. Radiation Therapy Use in Refractory and Relapsed Adolescent and Young Adult Hodgkin Lymphoma: A Report from the Children's Oncology Group. Int J Radiat Oncol Biol Phys 2023; 117:400-403. [PMID: 37116589 PMCID: PMC10655744 DOI: 10.1016/j.ijrobp.2023.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/31/2023] [Accepted: 04/18/2023] [Indexed: 04/30/2023]
Affiliation(s)
- Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida.
| | - Paul D Harker-Murray
- Department of Pediatric Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Christopher J Forlenza
- Department of Pediatric Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Peter Cole
- Department of Pediatrics, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Kara M Kelly
- Department of Pediatric Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Sarah A Milgrom
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Rahul R Parikh
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - David C Hodgson
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | | | - Justine Kahn
- Department of Pediatrics Hematology-Oncology, Columbia University Herbert Irving Comprehensive Cancer Center, New York, New York
| | - Kenneth B Roberts
- Department of Therapeutic Radiology; Yale School of Medicine, New Haven, Connecticut
| | - Louis S Constine
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
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Giap F, Ma SJ, Oladeru OT, Hong YR, Yu B, Mailhot Vega RB, Brooks ED, Singh AK, Okunieff PG, Mendenhall NP, Bradley JA. Palliative care utilization and racial and ethnic disparities among women with de novo metastatic breast cancer in the United States. Breast Cancer Res Treat 2023; 200:347-354. [PMID: 37269438 PMCID: PMC10653207 DOI: 10.1007/s10549-023-06963-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 04/27/2023] [Indexed: 06/05/2023]
Abstract
PURPOSE The potential disparities in palliative care delivery for underrepresented minorities with breast cancer are not well known. We sought to determine whether race and ethnicity impact the receipt of palliative care for patients with metastatic breast cancer (MBC). METHODS We retrospectively reviewed the National Cancer Database for female patients diagnosed with stage IV breast cancer between 2010 and 2017 who received palliative care following diagnosis of MBC to assess the proportion of patients who received palliative care, including non-curative-intent local-regional or systemic therapy. Multivariable logistic regression analysis was performed to identify variables associated with receiving palliative care. RESULTS 60,685 patients were diagnosed with de novo MBC. Of these, only 21.4% (n = 12,963) received a palliative care service. Overall, there was a positive trend in palliative care receipt from 18.2% in 2010 to 23.0% in 2017 (P < 0.001), which persisted when stratified by race and ethnicity. Relative to non-Hispanic White women, Asian/Pacific Islander women (aOR 0.80, 95% CI 0.71-0.90, P < 0.001), Hispanic women (adjusted odds ratio [aOR] 0.69, 95% CI 0.63-0.76, P < 0.001), and non-Hispanic Black women (aOR 0.94, 95% CI 0.88-0.99, P = 0.03) were less likely to receive palliative care. CONCLUSIONS Fewer than 25% of women with MBC received palliative care between 2010 and 2017. While palliative care has significantly increased for all racial/ethnic groups, Hispanic White, Black, and Asian/Pacific Islander women with MBC still receive significantly less palliative care than non-Hispanic White women. Further research is needed to identify the socioeconomic and cultural barriers to palliative care utilization.
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Affiliation(s)
- Fantine Giap
- Department of Radiation Oncology, University of Florida College of Medicine, 2015 North Jefferson Street, Jacksonville, FL, 32206, USA
| | - Sung Jun Ma
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | | | - Young-Rock Hong
- Department of Health Services Research, Management and Policy, University of Florida, Gainesville, FL, USA
| | - Brian Yu
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, 2015 North Jefferson Street, Jacksonville, FL, 32206, USA
| | - Eric D Brooks
- Department of Radiation Oncology, University of Florida College of Medicine, 2015 North Jefferson Street, Jacksonville, FL, 32206, USA
| | - Anurag K Singh
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Paul G Okunieff
- Department of Radiation Oncology, University of Florida College of Medicine, 2015 North Jefferson Street, Jacksonville, FL, 32206, USA
| | - Nancy P Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, 2015 North Jefferson Street, Jacksonville, FL, 32206, USA
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, 2015 North Jefferson Street, Jacksonville, FL, 32206, USA.
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Mailhot Vega RB, Garcia Robles BE, Morris CG, Buss K, Mejia U, Poitevin A, Chilaca Rosas MF, Perez Villanueva H, Felix Leyva JA, Indelicato DJ, De la Mata D. Analysis of the Pediatric Radiotherapy Landscape in Mexico and a Subsequent Educational e-Contouring Intervention. JCO Glob Oncol 2023; 9:e2200372. [PMID: 37384858 PMCID: PMC10497300 DOI: 10.1200/go.22.00372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 04/26/2023] [Accepted: 05/30/2023] [Indexed: 07/01/2023] Open
Abstract
PURPOSE Mexico and Central America have the highest childhood cancer incidence in the West. Pediatric-specific oncology knowledge contributes to the disparity. We sought to (1) determine the self-identified treatment patterns and needs of Mexican pediatric radiation oncologists and (2) pilot a workshop to improve contouring accuracy. MATERIALS AND METHODS Partnering with local experts and the Sociedad Mexicana de Radioterapeutas (SOMERA), a 35-question survey was designed to ascertain pediatric radiotherapy capacity and distributed through the SOMERA listserv. The most challenging malignancies were selected for workshop. Participants received precontouring and postcontouring homework to assess improvement per the Dice metric. The Wilcoxon sign-rank test was used for comparative statistics. RESULTS Ninety-four radiation oncologists attempted and 79 completed the survey. Forty-four (76%) felt comfortable treating a pediatric patient, and 36 (62%) were familiar with national protocols for pediatric treatment. Most had access to nutrition, rehabilitation, endocrinology, and anesthesia; 14% had access to fertility services and 27% to neurocognitive support; 11% noted no support, and only one respondent had child-life support. The postsurvey contouring workshop was conducted for high-grade glioma, medulloblastoma, and Hodgkin lymphoma. Significant improvements were seen in all target volumes. CONCLUSION We present the first national survey of Mexico's pediatric radiotherapy capacity and Latin American e-contouring educational intervention with preworkshop and postworkshop Dice metrics, noting statistically significant improvement in all target volumes. Participation improved compared with prior experience through SOMERA partnership and Continuing Medical Education incentivization.
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Affiliation(s)
- Raymond B. Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | | | - Christopher G. Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | - Kara Buss
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | - Ulises Mejia
- Instituto Nacional de Cancerología, Hospital Infantil de México, Ciudad de México, México
| | | | | | | | | | - Daniel J. Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
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Fakhry JS, Pena MJ, Pomputius A, Giap F, Vega RBM. Racial and Ethnic Demographic Reporting in Phase 2 Proton Therapy Clinical Trials: A Review. Int J Part Ther 2023; 10:51-58. [PMID: 37823018 PMCID: PMC10563665 DOI: 10.14338/ijpt-22-00042.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 03/27/2023] [Indexed: 10/13/2023] Open
Abstract
Purpose Equitable inclusion of racial and ethnic participation in clinical trials is crucial to improving disparities in health care, especially for historically marginalized populations. Our study aims to describe the racial and ethnic demographics of patients enrolled in published phase 2 clinical trials involving proton therapy in the United States. Materials and Methods Published manuscripts were identified in PubMed, Embase, World of Science, and Cochrane. Phase 2 trials evaluating proton therapy for US patients were included. For each article in the study, data were collected comprising authors, title, and publication year, and clinical trial numbers were verified. Additional data included tumor site, primary institution, sample size, reported race/ethnicity, and raw number/percentile of race/ethnicity. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used. Results Overall, 970 titles were identified; 636 remained after duplicate screening, and 75 full-text articles were assessed. We identified 38 eligible manuscripts for inclusion comprising 2648 patients. Only 15 (39%) of the publications reported race/ethnicity. Of these, 8 (21%) and 10 (26%) documented Hispanic or Black trial participants, respectively; however, only 6 (16%) documented trial participation for both Hispanic and Black patients. Of the 1409 patients with a documented race/ethnicity, 89.0% (n = 1254) were non-Hispanic white, 5.3% (n = 75) were Black, and 2.2% (n = 31) were Hispanic. Other and unknown race/ethnicity comprised the remaining patients (3.5%; n = 49). Conclusion We identified underreporting of demographic data in published phase 2 proton therapy trials, which unfortunately mirrored underreporting for cancer drug clinical trials. We also noted dramatic Black and Hispanic patient underrepresentation across the trials in which race and ethnicity are reported. Findings highlight the urgent need to identify and address barriers to proton therapy trials for Black and Hispanic patients ensuring clinical trials in radiation oncology are representative of the patients seen in clinical practice.
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Affiliation(s)
- Jonathan S. Fakhry
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - M. Juliana Pena
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Ariel Pomputius
- University of Florida Health Science Center Libraries, Gainesville, FL, USA
| | - Fantine Giap
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Raymond B. Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
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Brooks ED, Vega RBM, Vivers E, Burchianti T, Liang X, Spiguel LR, Jasra B, Mendenhall NP, Oladeru OT, Bradley JA. Proton Therapy for Bilateral Breast Cancer Maximizes Normal-Tissue Sparing. Int J Part Ther 2023; 9:290-301. [PMID: 37169011 PMCID: PMC10166012 DOI: 10.14338/ijpt-22-00041.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 01/26/2023] [Indexed: 03/08/2023] Open
Abstract
Abstract
Purpose
Treatment for bilateral breast cancer with radiation therapy is technically challenging. We evaluated the clinical and dosimetric outcomes of a small series of patients with synchronous bilateral breast cancer, including a photon dosimetric comparison, to identify optimal treatment planning approaches.
Materials and Methods
We reviewed a registry of patients (simultaneously) diagnosed with synchronous bilateral breast cancers who underwent postoperative definitive adjuvant proton therapy at our institution between 2012 and 2021. All patients were treated with double-scattered proton or pencil-beam scanning therapies. For comparison, intensity-modulated radiation therapy photon plans optimized for organ sparing and coverage were generated after treatment.
Results
Six patients were included. The median patient age was 66 years; all were female with no history of breast cancer or radiation therapy. Two (33%) patients received breast/chest wall–only treatments, 1 (17%) required breast plus level I axillary treatment to one side and breast plus regional nodal irradiation (RNI) to the other, and 3 (50%) received bilateral breast/chest plus RNI; dosimetric results are reported for each group's median. Analysis showed clinical target coverage was comparable between proton and photon techniques (V95% of 96.4% with proton, 97.8% with photon). However, protons could deliver superior organ sparing at clinically relevant dose metrics for virtually all structures: a 6.7 Gy absolute reduction in the mean heart dose (7.5 Gy with photons to 0.7 Gy with protons), a 47% to 57% relative reduction in D0.1cm3 to coronary arteries, a 54% relative reduction in lung V20 Gy, and an absolute 7.6 Gy reduction to the brachial plexus. There was also greater esophagus and spinal cord sparing. The overall survival rate was 100% at 1.5 years of median follow-up (0.5-4.9), and all patients were free of disease. For toxicity, all patients had some form of acute side effects: 66% experienced grade 2 breast/chest pain or soreness; 100% had grade 2 radiation dermatitis or skin induration; 33% had grade 2 fatigue; and 17% had grade 2 esophagitis (per the Common Terminology Criteria for Adverse Events [CTCAE] version 5.0; US National Cancer Institute, Bethesda, Maryland). Subacute toxicity (within 6 months) was observed for 17% of patients with delayed onset of grade 3 dermatitis in the setting of preexisting lupus, 17% with a delayed surgical wound complication, and 17% with grade 2 soft tissue fibrosis. No grade 4 or 5 events were observed.
Conclusions
Substantial dose reductions to multiple organs at risk while maintaining target coverage make proton the preferred modality for bilateral breast cancer treatment when available.
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Affiliation(s)
- Eric D. Brooks
- 1 Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Raymond B. Mailhot Vega
- 1 Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Emma Vivers
- 2 University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Teena Burchianti
- 2 University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Xiaoying Liang
- 3 Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Lisa R. Spiguel
- 4 Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | | | - Nancy P. Mendenhall
- 1 Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Oluwadamilola T. Oladeru
- 1 Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Julie A. Bradley
- 1 Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
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Bradley JA, Liang X, Mailhot Vega RB, Liu C, Brooks ED, Burchianti T, Viviers E, Dagan R, Oladeru OT, Morris CG, Mendenhall NP. Incidence of Rib Fracture following Treatment with Proton Therapy for Breast Cancer. Int J Part Ther 2023; 9:269-278. [PMID: 37169006 PMCID: PMC10166011 DOI: 10.14338/ijpt-22-00034.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 01/30/2023] [Indexed: 05/13/2023] Open
Abstract
Purpose To determine the rib fracture rate in a cohort of patients with breast cancer treated with proton therapy. Patient and Methods From a prospective database, we identified 225 patients treated with proton therapy between 2012 and 2020 (223 women; 2 men). Clinical and dosimetric data were extracted, the cumulative incidence method assessed rib fracture rate, and Fine-Gray tests assessed prognostic significance of select variables. In-field rib fracture was defined as a fracture that occurred in a rib located within the 10% isodose line. Out-of-field rib fracture was defined as a fracture occurring in a rib location outside of the 10% isodose line. Results Of the patients, 74% had left-sided breast cancer; 5%, bilateral; and 21%, right-sided. Dual-energy x-ray absorptiometry scans showed normality in 20%, osteopenia in 34%, and osteoporosis in 6% (test not performed in 40%). Additionally, 57% received an aromatase inhibitor. Target volumes were breast ± internal mammary nodes (IMNs) (16%), breast and comprehensive regional lymphatics (32%), chest wall ± IMNs (1%), and chest wall/comprehensive regional lymphatics (51%). Passive-scattered proton therapy was used for 41% of patients, 58% underwent pencil-beam scanning (PBS), and 1% underwent a combination (passive scattering/PBS), with 85% of patients receiving a boost. Median follow-up was 3.1 years, with 97% having >12-month follow-up. The 3-year cumulative in-field rib fracture incidence was 3.7%. Eight patients developed in-field rib fractures (1 symptomatic, 7 imaging identified) for a 0.4% symptomatic rib fracture rate. Median time from radiation completion to rib fracture identification was 1.8 years (fractures were identified within 2.2 years for 7 of 8 patients). No variables were associated with rib fracture on univariate analysis. Three fractures developed outside the radiation field (0.9% cumulative incidence of out-of-field rib fracture). Conclusion In this series of patients with breast cancer treated with proton therapy, the 3-year rib fracture rates remain low (in-field 3.7%; symptomatic 0.4%). As in photon therapy, the asymptomatic rate may be underestimated owing to a lack of routine surveillance imaging. However, patients experiencing symptomatic rib fractures after proton therapy for breast cancer are rare.
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Affiliation(s)
- Julie A. Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | | | - Raymond B. Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Chunbo Liu
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Eric D. Brooks
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Teena Burchianti
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Emma Viviers
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Roi Dagan
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Oluwadamilola T. Oladeru
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Christopher G. Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Nancy P. Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
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Guida F, Kidman R, Ferlay J, Schüz J, Soerjomataram I, Kithaka B, Ginsburg O, Mailhot Vega RB, Galukande M, Parham G, Vaccarella S, Canfell K, Ilbawi AM, Anderson BO, Bray F, Dos-Santos-Silva I, McCormack V. Global and regional estimates of orphans attributed to maternal cancer mortality in 2020. Nat Med 2022; 28:2563-2572. [PMID: 36404355 PMCID: PMC9676732 DOI: 10.1038/s41591-022-02109-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 10/25/2022] [Indexed: 11/21/2022]
Abstract
Despite women being disproportionally affected by cancer deaths at young ages, there are no global estimates of the resulting maternal orphans, who experience health and education disadvantages throughout their lives. We estimated the number of children who became maternal orphans in 2020 due to their mother dying from cancer in that year, for 185 countries worldwide and by cause of cancer-related death. Female cancer deaths-by country, cancer type and age (derived from GLOBOCAN estimates)-were multiplied by each woman's estimated number of children under the age of 18 years at the time of her death (fertility data were derived from United Nations World Population Prospects for birth cohort), accounting for child mortality and parity-cancer risk associations. Globally, there were 1,047,000 such orphans. Over half of these were orphans due to maternal deaths from breast (258,000, 25%), cervix (210,000, 20%) and upper-gastrointestinal cancers (136,000, 13%), and most occurred in Asia (48%: India 15%, China 10%, rest of Asia 23%) and Africa (35%). Globally, there were 40 new maternal orphans due to cancer per 100,000 children, with a declining trend with a higher Human Development Index (range: 121 in Malawi to 15 in Malta). An estimated 7 million children were prevalent maternal orphans due to cancer in mid-2020. Accelerating the implementation of the World Health Organization's cervical and breast cancer initiatives has the potential to avert not only millions of preventable female cancer deaths but also the associated, often-overlooked, intergenerational consequences of these deaths.
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Affiliation(s)
- Florence Guida
- International Agency for Research on Cancer, Lyon, France.
| | - Rachel Kidman
- Program in Public Health and Department of Family, Population and Preventive Medicine, Stony Brook University (State University of New York), Stony Brook, NY, USA
| | - Jacques Ferlay
- International Agency for Research on Cancer, Lyon, France
| | - Joachim Schüz
- International Agency for Research on Cancer, Lyon, France
| | | | | | - Ophira Ginsburg
- Centre for Global Health, US National Cancer Institute, Rockville, MD, USA
| | | | | | - Groesbeck Parham
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | | | - Karen Canfell
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Andre M Ilbawi
- Global Breast Cancer Initiative, Department of Non-communicable Diseases, World Health Organization (WHO), Geneva, Switzerland
| | - Benjamin O Anderson
- Global Breast Cancer Initiative, Department of Non-communicable Diseases, World Health Organization (WHO), Geneva, Switzerland
| | - Freddie Bray
- International Agency for Research on Cancer, Lyon, France
| | - Isabel Dos-Santos-Silva
- Department of Non-Communicable Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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Baron JA, Wright CM, Maxwell R, Kim MM, Giap F, Mailhot Vega RB, Hoppe BS, LaRiviere MJ, Maity A, Plastaras JP, Paydar I. Proton Radiotherapy Following Chemotherapy in the Management of Aggressive Mediastinal non-Hodgkin Lymphomas: A PTCOG Lymphoma Subcommittee Collaboration. Adv Radiat Oncol 2022; 8:101090. [DOI: 10.1016/j.adro.2022.101090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 09/19/2022] [Indexed: 11/09/2022] Open
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15
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Giap F, O'steen L, Liu IC, Spiguel LE, Shaw CM, Morris CG, Mailhot Vega RB, Lightsey JL, Bradley JA, Mendenhall NP, Okunieff PG, Lockney NA. Intraoperative radiation therapy for early-stage breast cancer: a single-institution experience. Rep Pract Oncol Radiother 2022; 27:666-676. [PMID: 36196411 PMCID: PMC9521704 DOI: 10.5603/rpor.a2022.0075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 06/21/2022] [Indexed: 11/25/2022] Open
Abstract
Background To assess outcomes and toxicity after low-energy intraoperative radiotherapy (IORT) for early-stage breast cancer (ESBC). Materials and methods We reviewed patients with unilateral ESBC treated with breast-conserving surgery and 50-kV IORT at our institution. Patients were prescribed 20 Gy to the surface of the spherical applicator, fitted to the surgical cavity during surgery. Patients who did not meet institutional guidelines for IORT alone on final pathology were recommended adjuvant treatment, including additional surgery and/or external-beam radiation therapy (EBRT). We analyzed ipsilateral breast tumor recurrence, overall survival, recurrence-free survival and toxicity. Results Among 201 patients (median follow-up, 5.1 years; median age, 67 years), 88% were Her2 negative and ER positive and/or PR positive, 98% had invasive ductal carcinoma, 87% had grade 1 or 2, and 95% had clinical T1 disease. Most had pathological stage T1 (93%) N0 (95%) disease. Mean IORT applicator dose at 1-cm depth was 6.3 Gy. Post-IORT treatment included additional surgery, 10%; EBRT, 11%; adjuvant chemotherapy, 9%; and adjuvant hormonal therapy, 74%. Median total EBRT dose was 42.4 (range, 40.05–63) Gy and median dose per fraction was 2.65 Gy. At 5 years, the cumulative incidence of ipsilateral breast tumor recurrence was 2.7%, the overall survival rate was 95% with no breast cancer-related deaths, and the recurrence-free survival rate was 96%. For patients who were deemed unsuitable for postoperative IORT alone and did not receive recommended risk-adapted EBRT, the IBTR rate was 4.7% versus 1.7% (p = 0.23) for patients who were either suitable for IORT alone or unsuitable and received adjuvant EBRT. Cosmetic toxicity data was available for 83%, with 7% experiencing grade 3 breast toxicity and no grade 4–5 toxicity. Conclusions IORT for select patients with ESBC results in acceptable outcomes in regard to ipsilateral breast tumor recurrence and toxicity.
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Liu C, Bradley JA, Zheng D, Vega RBM, Beltran CJ, Mendenhall N, Liang X. RBE-weighted dose and its impact on the risk of acute coronary event for breast cancer patients treated with intensity modulated proton therapy. J Appl Clin Med Phys 2022; 23:e13527. [PMID: 35060317 PMCID: PMC8992952 DOI: 10.1002/acm2.13527] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 12/11/2021] [Accepted: 12/22/2021] [Indexed: 11/06/2022] Open
Abstract
PURPOSE To evaluate the relative biological effectiveness (RBE)-weighted dose to the heart and to estimate RBE uncertainties when assuming a constant RBE of 1.1, for breast cancer patients receiving intensity-modulated proton therapy (IMPT). Further, to study the impact of RBE uncertainties on the risk of an acute coronary event (ACE). MATERIAL AND METHODS We analyzed 20 patients who received IMPT to either the left breast (n = 10) or left chest wall (n = 10) and regional lymph nodes. The Monte Carlo simulation engine, MCsquare, was used to simulate the dose-averaged linear energy transfer (LETd) map. The RBE-weighted dose to the heart and its substructures was calculated using three different RBE models. The risk of ACE was estimated per its linear relationship with mean heart dose (MHD) as established by Darby et al. RESULTS The median MHD increased from 1.33 GyRBE assuming an RBE of 1.1 to 1.64, 1.87, and 1.99 GyRBE when using the RBE-weighted dose models. The median values (and ranges) of the excess absolute risk of ACE were 0.4% (0.1%-0.8%) when assuming an RBE of 1.1, and 0.6% (0.2%-1.0%), 0.6% (0.2%-1.1%), and 0.7% (0.2%-1.1%) with the RBE-weighted models. For our patient cohort, the maximum excess absolute risk of ACE increased by 0.3% with the RBE-weighted doses compared to the constant RBE of 1.1, reaching an excess absolute ACE risk of 1.1%. The interpatient LETd variation was small for the relevant high-dose regions of the heart. CONCLUSION All three RBE models predicted a higher biological dose compared to the clinical standard dose assuming a constant RBE of 1.1. An underestimation of the biological dose results in underestimation of the ACE risk. Analyzing the voxel-by-voxel biological dose and the LET map alongside clinical outcomes is warranted in the development of a more accurate normal-tissue complication probability model.
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Affiliation(s)
- Chunbo Liu
- University of Florida Health Proton Therapy InstituteJacksonvilleFloridaUSA
| | - Julie A. Bradley
- Department of Radiation OncologyUniversity of Florida College of MedicineJacksonvilleFloridaUSA
| | - Dandan Zheng
- Department of Radiation OncologyUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Raymond B. Mailhot Vega
- Department of Radiation OncologyUniversity of Florida College of MedicineJacksonvilleFloridaUSA
| | - Chris J. Beltran
- Mayo ClinicDepartment of Radiation OncologyJacksonvilleFloridaUSA
| | - Nancy Mendenhall
- Department of Radiation OncologyUniversity of Florida College of MedicineJacksonvilleFloridaUSA
| | - Xiaoying Liang
- Mayo ClinicDepartment of Radiation OncologyJacksonvilleFloridaUSA
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Mattes MD, Deville C, Vega RBM, Fung CY, Suneja G, Shumway JW, Chowdhary M, Shah C, Bates JE, Mohindra P, Siker ML, Winkfield KM, Vapiwala N, Royce TJ. Demographics of ASTRO Student Members and Potential Implications for Future U.S. Radiation Oncology Workforce Diversity. Adv Radiat Oncol 2022; 7:100834. [PMID: 34977427 PMCID: PMC8688878 DOI: 10.1016/j.adro.2021.100834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/06/2021] [Accepted: 09/28/2021] [Indexed: 11/20/2022] Open
Abstract
Purpose The radiation oncology workforce in the United States is comparatively less diverse than the U.S. population and U.S. medical school graduates. Workforce diversity correlates with higher quality care and outcomes. The purpose of this study was to determine whether student members of the American Society for Radiation Oncology (ASTRO) are any more diverse than resident members-in-training using the recently established medical student membership category. Methods and Materials Self-reported sex, race and Hispanic ethnicity, medical school, and degree(s) earned for all medical students (n = 268) and members-in-training (n = 713) were collected from the ASTRO membership database. International members were excluded. The χ2 test was used to assess for differences between subgroups. Results Compared with members-in-training, student members were more likely to be female (40.0% vs 31.5%, P = .032), black or African American (10.7% vs 4.8%, P = .009), candidates for or holders of a DO rather than MD degree (5.2% vs 1.5%, P = .002), and from a U.S. medical school that is not affiliated with a radiation oncology residency program (30.5% vs 20.9%, P = .001). There was no significant difference in self-reported Hispanic ethnicity (7.3% vs 5.4%, P = .356). There were no indigenous members in either category assessed. Conclusions Medical student members of ASTRO are more diverse in terms of black race, female sex, and osteopathic training, though not in terms of Hispanic ethnicity or nonmultiracial indigenous background, than the members-in-training. Longitudinal engagement with these students and assessment of the factors leading to specialty retention versus attrition may increase diversity, equity, and inclusion in radiation oncology.
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Affiliation(s)
- Malcolm D Mattes
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Curtiland Deville
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Claire Y Fung
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Gita Suneja
- Department of Radiation Oncology and Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - John W Shumway
- Department of Radiation Oncology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
| | - Mudit Chowdhary
- Department of Radiation Oncology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - James E Bates
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Malika L Siker
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Karen M Winkfield
- Meharry-Vanderbilt Alliance, Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Neha Vapiwala
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Trevor J Royce
- Department of Radiation Oncology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina.,Flatiron Health, New York, New York
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Butala AA, Huang CC, Bryant CM, Henderson RH, Hoppe BS, Mendenhall NP, Vapiwala N, Mailhot Vega RB. Heterogeneity in Radiotherapeutic Parameter Assumptions in Cost-Effectiveness Analyses in Prostate Cancer: A Call for Uniformity. Value Health 2022; 25:171-177. [PMID: 35094789 DOI: 10.1016/j.jval.2021.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 08/06/2021] [Accepted: 08/28/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Cost-effectiveness analyses (CEAs) may provide useful data to inform management decisions depending on the robustness of a model's input parameters. We sought to determine the level of heterogeneity in health state utility values, transition probabilities, and cost estimates across published CEAs assessing primarily radiotherapeutic management strategies in prostate cancer. METHODS We conducted a systematic review of prostate cancer CEAs indexed in MEDLINE between 2000 and 2018 comparing accepted treatment modalities across all cancer stages. Search terms included "cost effectiveness prostate," "prostate cancer cost model," "cost utility prostate," and "Markov AND prostate AND (cancer OR adenocarcinoma)." Included studies were agreed upon. A Markov model was designed using the parameter estimates from the systematic review to evaluate the effect of estimate heterogeneity on strategy cost acceptability. RESULTS Of 199 abstracts identified, 47 publications were reviewed and 37 were included; 508 model estimates were compared. Estimates varied widely across variables, including gastrointestinal toxicity risk (0%-49.5%), utility of metastatic disease (0.25-0.855), intensity-modulated radiotherapy cost ($21 193-$61 996), and recurrence after external-beam radiotherapy (1.5%-59%). Multiple studies assumed that different radiotherapy modalities delivering the same dose yielded varying cancer control rates. When using base estimates for similar parameters from included studies, the designed model resulted in 3 separate acceptability determinations. CONCLUSIONS Significant heterogeneity exists across parameter estimates used to perform CEAs evaluating treatment for prostate cancer. Heterogeneity across model inputs yields variable conclusions with respect to the favorability and cost-effectiveness of treatment options. Decision makers are cautioned to review estimates in CEAs to ensure they are up to date and relevant to setting and population.
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Affiliation(s)
- Anish A Butala
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Christina C Huang
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Curtis M Bryant
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Randal H Henderson
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Nancy P Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Neha Vapiwala
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA.
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19
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Indelicato DJ, Mailhot Vega RB, Viviers E, Morris CG, Bradfield SM, Gibbs CP, Bradley JA. Modern Therapy for Chest Wall Ewing Sarcoma: An Update of the XXX Experience. Int J Radiat Oncol Biol Phys 2022; 113:345-354. [DOI: 10.1016/j.ijrobp.2022.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 02/03/2022] [Accepted: 02/06/2022] [Indexed: 12/25/2022]
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Looi WS, Bradley JA, Liang X, Shaw CM, Leyngold M, Mailhot Vega RB, Brooks ED, Rutenberg MS, Spiguel LR, Giap F, Mendenhall NP. Hyperfractionated-Accelerated Reirradiation with Proton Therapy for Radiation-Associated Breast Angiosarcoma. Int J Part Ther 2022; 8:55-67. [PMID: 35530187 PMCID: PMC9009453 DOI: 10.14338/ijpt-21-00031.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 11/26/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose Radiation-associated angiosarcoma (RAAS) is a rare complication among patients treated with radiation therapy for breast cancer. Hyperfractionated-accelerated reirradiation (HART) improves local control after surgery. Proton therapy may further improve the therapeutic ratio by mitigating potential toxicity. Materials and Methods Six patients enrolled in a prospective registry with localized RAAS received HART with proton therapy between 2015 and 2021. HART was delivered twice or thrice daily in fraction sizes of 1.5 or 1.0 Gy, respectively. All patients received 45 Gy to a large elective volume followed by boosts to a median dose of 65 (range, 60-75) Gy. Toxicity was recorded prospectively by using the Common Terminology Criteria for Adverse Events, version 4.0. Results The median follow-up duration was 1.5 (range, 0.25-2.9) years. The median age at RAAS diagnosis was 73 (range, 60-83) years with a median latency of 8.9 (range, 5-14) years between radiation therapy completion and RAAS diagnosis. The median mean heart dose was 2.2 (range, 0.1-4.96) Gy. HART was delivered postoperatively (n = 1), preoperatively (n = 3), preoperatively for local recurrence after initial management with mastectomy (n = 1), and as definitive treatment (n = 1). All patients had local control of disease throughout follow-up. Three of 4 patients treated preoperatively had a pathologic complete response. The patient treated definitively had a complete metabolic response on her posttreatment PET/CT (positron emission tomography–computed tomography) scan. Two patients developed distant metastatic disease despite local control and died of their disease. Acute grade 3 toxicity occurred in 3 patients: 2 patients undergoing preoperative HART experienced wound dehiscence and 1 postoperatively developed grade 3 wound infection, which resolved. Conclusion HART with proton therapy appears effective for local control of RAAS with a high rate of pathologic complete response and no local recurrences to date. However, vigilant surveillance for distant metastasis should occur. Toxicity is comparable to that in photon/electron series. Proton therapy for RAAS may maximize normal tissue sparing in this large-volume reirradiation setting.
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Affiliation(s)
- Wen Shen Looi
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Julie A. Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Xiaoying Liang
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Christiana M. Shaw
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Mark Leyngold
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Raymond B. Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Eric D. Brooks
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Michael S. Rutenberg
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Lisa R. Spiguel
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Fantine Giap
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Nancy P. Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
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Indelicato DJ, Vega RBM, Viviers E, Morris CG, Bradfield SM, Ranalli NJ, Bradley JA. Modern Therapy for Spinal and Paraspinal Ewing Sarcoma: An Update of the XXX Experience. Int J Radiat Oncol Biol Phys 2022; 113:161-165. [PMID: 35033584 DOI: 10.1016/j.ijrobp.2022.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 01/04/2022] [Accepted: 01/07/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE In 2010, we published a comprehensive review of our institutional outcomes treating children with spinal and paraspinal Ewing sarcoma using photon therapy. Multimodality therapy was associated with fair disease control but also with serious toxicity, including a 37% rate of Grade ≥3 toxicity. We therefore sought to assess our more recent experience treating children with more modern technology and treatment regimens. METHODS AND MATERIALS Between 2010 and 2021, 32 pediatric patients with nonmetastatic spinal and paraspinal Ewing sarcoma were treated at XXX and enrolled in a retrospective outcome study. Median age at diagnosis was 9.8 (range, 2.1-21.8) years old. Three, 22, and 7 tumors arose within the cervical, thoracic, and lumbar spine regions, respectively. Median maximum tumor diameter was 5 (range, 3-19) cm. At diagnosis, 28/32 patients had motor, bowel, or bladder deficits. Chemotherapy was delivered per contemporary North American and European interval-compressed regimens. Before radiotherapy, 14 patients underwent gross total resection while 18 underwent a biopsy or subtotal resection with cord decompression. All patients were treated with proton therapy; 6 with hardware stabilization also received a component of intensity-modulated photon therapy. Median prescription dose was 50.4 (range, 45-54) GyRBE. Median maximum dose to the spinal cord was 50.2 (range, 0-54.9) GyRBE. RESULTS With a median follow-up of 4.1 (range, 0.7 - 9.4) years, the 5-year local control, progression-free survival, and overall survival rates were 92%, 79%, and 85%, respectively. Ten of 30 living patients have residual motor, bowel, or bladder deficits. Overall, 22% of patients experienced CTCAE grade 3 late toxicity related to multimodality treatment: kyphosis (n=4), esophagitis (n=2) and chronic kidney disease (n=1). No patients developed grade ≥4 toxicity, new neurologic deficits, or second malignancy. CONCLUSION Modern treatment advances may offer an improved therapeutic ratio for pediatric spinal and paraspinal Ewing sarcoma. With appropriate management, most patients can be cured with recovery of long-term neurologic function and modest side-effects.
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Affiliation(s)
- Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL.
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | - Emma Viviers
- University of Florida Health Proton Therapy Institute, Jacksonville, FL
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | - Scott M Bradfield
- Department of Pediatrics, Nemours Children's Specialty Care, Jacksonville, FL
| | - Nathan J Ranalli
- Department of Neurosurgery, University of Florida College of Medicine Jacksonville, Jacksonville, FL
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
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22
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Mailhot Vega RB, Sher DJ. ¡Aviso, Médicos!: The Effect of Direct Patient-Doctor Communication Cannot Be Overlooked. Int J Radiat Oncol Biol Phys 2021; 111:865-866. [PMID: 34655563 DOI: 10.1016/j.ijrobp.2021.07.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 07/15/2021] [Accepted: 07/16/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida.
| | - David J Sher
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
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23
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Parekh AD, Indelicato DJ, Hoppe BS, Vega RBM, Rotondo RL, Bradley JA. Pulmonary dose tolerance in hemithorax radiotherapy for Ewing sarcoma of the chest wall: Are we overestimating the risk of radiation pneumonitis? Pediatr Blood Cancer 2021; 68:e29287. [PMID: 34398486 DOI: 10.1002/pbc.29287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 07/28/2021] [Accepted: 08/02/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Children with chest wall Ewing sarcoma with malignant pulmonary effusion or pleural stranding require hemithorax radiation, often with plans that exceed lung constraints. We investigated disease control and pneumonitis in children requiring hemithorax radiation. PROCEDURE Eleven children (median age 13 years) received hemithorax radiotherapy. Symptomatic radiation pneumonitis was considered National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) grade 1+ with respiratory symptoms. Mean lung dose (MLD), volume of lung exposed to a dose ≥5 Gy (V5), ≥20 Gy (V20), and ≥35 Gy (V35) were recorded. Adult and pediatric lung constraints were obtained from Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC) guidelines and Children's Oncology Group (COG) protocols, respectively. RESULTS Median hemithorax dose was 15 Gy (1.5 Gy/fraction). Median total dose was 51 Gy (1.8 Gy/fraction). Most plans delivered both protons and photons. The ipsilateral MLD, V5, and V20 were 27.2 Gy, 100%, and 48.3%; the bilateral MLD, V20, and V35 were 14.1 Gy, 22.8%, and 14.3%, respectively. One hundred percent, 36%, and 91% of treatments exceeded recommended adult ipsilateral lung constraints of V5 <65%, V20 <52%, and MLD of 22 Gy; 64%, 45%, and 82% exceeded COG bilateral lung constraints of V20 <20%, MLD <15 Gy, and MLD <12 Gy, respectively; 82% of treatments exceeded the COG ipsilateral lung constraint of V20 <30%. At a median 36 months (range 12-129), the symptomatic radiation pneumonitis incidence was 0%. Two patients progressed with nonpulmonary metastatic disease and died at a median 12 months following radiotherapy. CONCLUSIONS Existing guidelines may overestimate pneumonitis risk, even among young children receiving multiagent chemotherapy. For children with chest wall Ewing sarcoma and other thoracic malignancies, more data are needed to refine pediatric dose-effect models for pulmonary toxicity.
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Affiliation(s)
- Akash D Parekh
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Ronny L Rotondo
- Department of Radiation Oncology, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
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24
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Mailhot Vega RB, Castellino SM, Pei Q, Parsons S, Roberts KB, Hodgson D, Charpentier AM, Fitzgerald TJ, Kessel SK, Keller FG, Kelly K, Hoppe BS. Evaluating Disparities in Proton Radiation Therapy Use in AHOD1331, a Contemporary Children's Oncology Group Trial for Advanced-Stage Hodgkin Lymphoma. Int J Part Ther 2021; 8:55-57. [PMID: 35127976 PMCID: PMC8768892 DOI: 10.14338/ijpt-21-00012.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 04/29/2021] [Indexed: 11/21/2022] Open
Affiliation(s)
| | - Sharon M. Castellino
- Department of Pediatrics, Emory University/Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA USA
| | - Qinglin Pei
- Department of Biostatistics, Children's Oncology Group, Statistics and Data Center, University of Florida, Gainesville, FL, USA
| | - Susan Parsons
- Institute for Clinical Research and Health Policy Studies and Tufts Cancer Center, Tufts Medical Center, Boston, MA, USA
| | - Kenneth B. Roberts
- Department of Radiation Oncology, Yale University School of Medicine, Yale Cancer Center, New Haven, Connecticut, USA
| | - David Hodgson
- Department of Radiation Oncology, Princess Margaret Cancer Center and University of Toronto, Toronto, Ontario, Canada
| | - Anne-Marie Charpentier
- Department of Radiation Oncology, Centre hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Thomas J. Fitzgerald
- Imaging and Radiation Oncology Core (IROC), Rhode Island, Lincoln, RI, USA
- Department of Radiation Oncology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Sandy K. Kessel
- Imaging and Radiation Oncology Core (IROC), Rhode Island, Lincoln, RI, USA
| | - Frank G. Keller
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Kara Kelly
- Department of Pediatrics, Roswell Park Comprehensive Cancer Center; University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Bradford S. Hoppe
- Department of Radiation Oncology, Mayo Clinic Florida, Jacksonville FL, USA
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25
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Way A, Ozdemir S, Berges B, Getman N, Liang X, Mendenhall NP, Collins G, Cutter D, Mailhot Vega RB. Pericardial Effusion during Proton Therapy in a Patient with Chemorefractory Hodgkin Lymphoma. Int J Part Ther 2021; 8:76-81. [PMID: 35530189 PMCID: PMC9009456 DOI: 10.14338/ijpt-21-00010] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 07/16/2021] [Indexed: 11/21/2022] Open
Abstract
We present a case of recurrent pericardial effusion presenting during proton therapy in a 24-year-old female receiving mediastinal treatment for classical Hodgkin lymphoma. Pericardial effusion is typically considered an event accompanying lymphoma diagnosis or as a subacute or late effect of radiotherapy. Rarely has it been described as occurring during radiation treatment with photon-based radiotherapy, let alone proton therapy. It is unclear what underlying cause triggered recurrent effusion in this patient. Identifying and managing pericardial effusion during treatment delivery is important to consider as it may affect radiation dosimetry, particularly with proton therapy. Doing so will help ensure patients receive optimal treatment and minimize the risks of morbidity and mortality.
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Affiliation(s)
- Ashley Way
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Savas Ozdemir
- Department of Radiology, Division of Nuclear Medicine and Molecular Imaging, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Barbara Berges
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Nataliya Getman
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Xiaoying Liang
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Nancy P. Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Graham Collins
- Oxford Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - David Cutter
- Department of Oncology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Raymond B. Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
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26
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Herremans KM, Cribbin MP, Riner AN, Neal DW, Hollen TL, Clevenger P, Munoz D, Blewett S, Giap F, Okunieff PG, Mendenhall NP, Bradley JA, Mendenhall WM, Vega RBM, Brooks E, Daily KC, Heldermon CD, Marshall JK, Hanna MW, Leyngold MM, Virk SS, Shaw CM, Spiguel LR. ASO Visual Abstract: A 5-Year Breast Surgeon Experience in LYMPHA at Time of ALND for Treatment of Clinical T1-4N1-3M0 Breast Cancer. Ann Surg Oncol 2021. [PMID: 34655351 DOI: 10.1245/s10434-021-10648-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Kelly M Herremans
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Morgan P Cribbin
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Andrea N Riner
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Dan W Neal
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Tracy L Hollen
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Pamela Clevenger
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Derly Munoz
- Department of Physical Therapy, University of Florida College of Public Health and Health Professions, Gainesville, FL, USA
| | - Shannon Blewett
- Department of Physical Therapy, University of Florida College of Public Health and Health Professions, Gainesville, FL, USA
| | - Fantine Giap
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Paul G Okunieff
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Nancy P Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - William M Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Eric Brooks
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Karen C Daily
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Coy D Heldermon
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Julia K Marshall
- Department of Radiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Mariam W Hanna
- Department of Radiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Mark M Leyngold
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Sarah S Virk
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Christiana M Shaw
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Lisa R Spiguel
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA.
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27
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Mutter RW, Choi JI, Jimenez RB, Kirova YM, Fagundes M, Haffty BG, Amos RA, Bradley JA, Chen PY, Ding X, Carr AM, Taylor LM, Pankuch M, Vega RBM, Ho AY, Nyström PW, McGee LA, Urbanic JJ, Cahlon O, Maduro JH, MacDonald SM. Proton Therapy for Breast Cancer: A Consensus Statement From the Particle Therapy Cooperative Group Breast Cancer Subcommittee. Int J Radiat Oncol Biol Phys 2021; 111:337-359. [PMID: 34048815 PMCID: PMC8416711 DOI: 10.1016/j.ijrobp.2021.05.110] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/12/2021] [Accepted: 05/17/2021] [Indexed: 12/23/2022]
Abstract
Radiation therapy plays an important role in the multidisciplinary management of breast cancer. Recent years have seen improvements in breast cancer survival and a greater appreciation of potential long-term morbidity associated with the dose and volume of irradiated organs. Proton therapy reduces the dose to nontarget structures while optimizing target coverage. However, there remain additional financial costs associated with proton therapy, despite reductions over time, and studies have yet to demonstrate that protons improve upon the treatment outcomes achieved with photon radiation therapy. There remains considerable heterogeneity in proton patient selection and techniques, and the rapid technological advances in the field have the potential to affect evidence evaluation, given the long latency period for breast cancer radiation therapy recurrence and late effects. In this consensus statement, we assess the data available to the radiation oncology community of proton therapy for breast cancer, provide expert consensus recommendations on indications and technique, and highlight ongoing trials' cost-effectiveness analyses and key areas for future research.
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Affiliation(s)
- Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota.
| | - J Isabelle Choi
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rachel B Jimenez
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Youlia M Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Marcio Fagundes
- Department of Radiation Oncology, Miami Cancer Institute, Miami, Florida
| | - Bruce G Haffty
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Richard A Amos
- Proton and Advanced Radiotherapy Group, Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida
| | - Peter Y Chen
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Xuanfeng Ding
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Antoinette M Carr
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Leslie M Taylor
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Mark Pankuch
- Department of Radiation Oncology, Northwestern Medicine Proton Center, Warrenville, Illinois
| | | | - Alice Y Ho
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, New York
| | - Petra Witt Nyström
- The Skandion Clinic, Uppsala, Sweden and the Danish Centre for Particle Therapy, Aarhus, Denmark
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, Arizona
| | - James J Urbanic
- Department of Radiation Medicine and Applied Sciences, UC San Diego Health, Encinitas, California
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - John H Maduro
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
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28
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Indelicato DJ, Ioakeim-Ioannidou M, Grippin AJ, Bradley JA, Mailhot Vega RB, Viviers E, Tarbell NJ, Yock TI, MacDonald SM. Bicentric Treatment Outcomes After Proton Therapy for Nonmyxopapillary High-Grade Spinal Cord Ependymoma in Children. Int J Radiat Oncol Biol Phys 2021; 112:335-341. [PMID: 34597719 DOI: 10.1016/j.ijrobp.2021.09.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 08/24/2021] [Accepted: 09/22/2021] [Indexed: 01/14/2023]
Abstract
PURPOSE Few studies report outcomes in children treated with radiation for nonmyxopapillary ependymoma of the spinal cord, and little evidence exists to inform decisions regarding target volume and prescription dose. Moreover, virtually no mature outcome data exist on proton therapy for this tumor. We describe our combined institutional experience treating pediatric classical/anaplastic ependymoma of the spinal cord with proton therapy. METHODS AND MATERIALS Between 2008 and 2019, 14 pediatric patients with nonmetastatic nonmyxopapillary grade II (n = 6) and grade III (n = 8) spinal ependymoma received proton therapy. The median age at radiation was 14 years (range, 1.5-18 years). Five tumors arose within the cervical cord, 3 within the thoracic cord, and 6 within the lumbosacral cord. Before radiation therapy, 3 patients underwent subtotal resection, and 11 underwent gross-total or near total resection. Two patients received chemotherapy. For radiation, the clinical target volume received 50.4 Gy (n = 8), 52.2 (n = 1), or 54 Gy (n = 5), with the latter receiving a boost to the gross tumor volume after the initial 50.4 Gy, modified to respect spinal cord tolerance. RESULTS With a median follow-up of 6.3 years (range, 1.5-14.8 years), no tumors progressed. Although most patients experienced neurologic sequela after surgery, only 1 developed additional neurologic deficits after radiation: An 18-year-old male who received 54 Gy after gross total resection of a lumbosacral tumor developed grade 2 erectile dysfunction. There were 2 cases of musculoskeletal toxicity attributable to surgery and radiation. At analysis, no patient had developed cardiac, pulmonary, or other visceral organ complications or a second malignancy. CONCLUSION Radiation to a total dose of 50 to 54 Gy can be safely delivered and plays a beneficial role in the multidisciplinary management of children with nonmyxopapillary spinal cord ependymoma. Proton therapy may reduce late radiation effects and is not associated with unexpected spinal cord toxicity.
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Affiliation(s)
- Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida.
| | - Myrsini Ioakeim-Ioannidou
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Adam J Grippin
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Emma Viviers
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Nancy J Tarbell
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Torunn I Yock
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
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29
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Vega RBM, Mohammadi H, Patel SH, Md ALH, Lockney NA, Lynch JW, Bansal MM, Liang X, Slayton WB, Parsons SK, Hoppe BS, Mendenhall NP. Establishing cost-effective allocation of proton therapy for patients with mediastinal Hodgkin lymphoma. Int J Radiat Oncol Biol Phys 2021; 112:158-166. [PMID: 34348176 DOI: 10.1016/j.ijrobp.2021.07.1711] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 07/09/2021] [Accepted: 07/27/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE For curative treatment of Hodgkin lymphoma, radiotherapy benefit must be weighed against toxicity. Although more costly, proton radiotherapy reduces dose to healthy tissue, potentially improving the therapeutic ratio compared to photons. We sought to determine the cost-effectiveness of proton versus photon therapy for mediastinal Hodgkin lymphoma (MHL) based on reduced heart disease. METHODS Our model approach was two-fold: (1) Utilize patient-level dosimetric information for a cost-effectiveness analysis using a Markov cohort model. (2) Utilize population-based data to develop guidelines for policy-makers to determine thresholds of proton therapy favorability for a given photon dose. The HD14 trial informed relapse risk; coronary heart disease risk was informed by the Framingham risk calculator modified by the mean heart dose (MHD) from radiation. Sensitivity analyses assessed model robustness and identified the most influential model assumptions. A 30-year-old adult with MHL was the base case using 30.6-Gy proton therapy versus photon intensity-modulated radiotherapy. RESULTS Proton therapy was not cost-effective in the base case for male ($129K/QALY) or female patients ($196/QALY). A 5-Gy MHD decrease was associated with proton therapy incremental cost-effectiveness ratio<$100K/QALY in 40% of scenarios. The hazard ratio associating MHD and heart disease was the most influential clinical parameter. CONCLUSION Proton therapy may be cost-effective a select minority of patients with MHLbased on age, sex, and MHD reduction. We present guidance for clinicians utilizing MHD to aid decision-making for radiotherapy modality.
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Affiliation(s)
- Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA.
| | - Homan Mohammadi
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Samir H Patel
- Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Adam L Holtzman Md
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Natalie A Lockney
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - James W Lynch
- Department of Medicine, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Manisha M Bansal
- Department of Pediatrics, Nemours Children's Hospital, Jacksonville, FL, USA
| | - Xiaoying Liang
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - William B Slayton
- Department of Pediatrics, Nemours Children's Hospital, Jacksonville, FL, USA
| | - Susan K Parsons
- Department of Medicine, Tufts University College of Medicine, Boston, MA, USA
| | - Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Nancy P Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
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30
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Bates JE, Terezakis S, Morris CG, Rao AD, Sehgal S, Kumar R, Mailhot Vega RB, Mendenhall NP, Hoppe BS. Comparative Effectiveness of Proton Therapy versus Photon Radiotherapy in Adolescents and Young Adults for Classical Hodgkin Lymphoma. Int J Part Ther 2021; 8:21-27. [PMID: 35127972 PMCID: PMC8768899 DOI: 10.14338/ijpt-21-00011.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/11/2021] [Indexed: 12/04/2022] Open
Abstract
Purpose Early stage (stages I-II) classical Hodgkin lymphoma (cHL) is a highly curable disease typically diagnosed in adolescents and young adults (AYAs). Proton therapy can also reduce the late toxicity burden in this population, but data on its comparative efficacy with photon radiotherapy in this population are sparse. We assessed outcomes in AYAs with cHL in a multi-institution retrospective review. Materials and Methods We identified 94 patients aged 15 to 40 years with stages I and II cHL treated with radiotherapy as part of their initial treatment between 2008 and 2017. We used Kaplan-Meier analyses and log-rank testing to evaluate survival differences between groups of patients. Results A total of 91 patients were included in the analysis. The 2-year progression-free survival (PFS) rate was 89%. Of the 12 patients who experienced progression after radiotherapy, 4 occurred out-of-field, 2 occurred in-field, and 6 experienced both in- and out-of-field progression. There was no significant difference in 2-year PFS among AYA patients by radiotherapy dose received (≥ 30 Gy, 91%; < 30 Gy, 86%; P = .82). Likewise, there was no difference in 2-year PFS among patients who received either proton or photon radiotherapy (proton, 94%; photon, 83%; P = .07). Conclusion Our cohort of AYA patients had comparable outcomes regardless of radiotherapy dose or modality used. For patients with significant risk of radiation-induced late effects, proton therapy is a reasonable treatment modality.
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Affiliation(s)
- James E. Bates
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Stephanie Terezakis
- Department of Radiation Oncology, University of Minnesota, Minneapolis, MN, USA
| | - Christopher G. Morris
- Department of Radiation Oncology, University of Florida, Gainesville, FL, USA
- University of Florida Proton Therapy Institute, Jacksonville, FL, USA
| | - Avani D. Rao
- Department of Radiation Oncology and Molecular Radiation Science, Johns Hopkins University, Baltimore, MD, USA
| | - Shuchi Sehgal
- Department of Radiation Oncology and Molecular Radiation Science, Johns Hopkins University, Baltimore, MD, USA
| | - Rahul Kumar
- School of Medical Sciences & Research, Sharda University, Greater Noida, India
| | | | - Nancy P. Mendenhall
- Department of Radiation Oncology, University of Florida, Gainesville, FL, USA
- University of Florida Proton Therapy Institute, Jacksonville, FL, USA
| | - Bradford S. Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
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Indelicato DJ, Bates JE, Mailhot Vega RB, Rotondo RL, Hoppe BS, Morris CG, Looi WS, Sandler ES, Aldana PR, Bradley JA. Second tumor risk in children treated with proton therapy. Pediatr Blood Cancer 2021; 68:e28941. [PMID: 33565257 DOI: 10.1002/pbc.28941] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Out-of-field neutron dissemination during double-scattered proton therapy has raised concerns of increased second malignancies, disproportionally affecting pediatric patients due to the proportion of body exposed to scatter dose and inherent radiosensitivity of developing tissue. We sought to provide empiric data on the incidence of early second tumors. METHODS Between 2006 and 2019, 1713 consecutive children underwent double-scattered proton therapy. Median age at treatment was 9.1 years; 371 were ≤3 years old. Thirty-seven patients (2.2%) had tumor predisposition syndromes. Median prescription dose was 54 Gy (range 15-75.6). Median follow-up was 3.3 years (range 0.1-12.8), including 6587 total person-years. Five hundred forty-nine patients had ≥5 years of follow-up. A second tumor was defined as any solid neoplasm throughout the body. RESULTS Eleven patients developed second tumors; the 5- and 10-year cumulative incidences were 0.8% (95% CI, 0.4-1.9%) and 3.1% (95% CI, 1.5-6.2%), respectively. Using age- and gender-specific data from the Surveillance, Epidemiology, and End Results (SEER) program, the standardized incidence ratio was 13.5; the absolute excess risk was 1.5/1000 person-years. All but one patient who developed second tumors were irradiated at ≤5 years old (p < .0005). There was also a statistically significant correlation between patients with tumor predisposition syndromes and second tumors (p < .0001). Excluding patients with tumor predisposition syndromes, 5- and 10-year rates were 0.6% (95% CI, 0.2-1.7%) and 1.7% (95% CI, 0.7-4.0%), respectively, with all five malignant second tumors occurring in the high-dose region. CONCLUSION Second tumors are rare within the decade following double-scattered proton therapy, particularly among children irradiated at >5 years old and those without tumor predisposition syndrome.
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Affiliation(s)
- Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - James E Bates
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Ronny L Rotondo
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Wen S Looi
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Eric S Sandler
- Department of Pediatrics, Nemours Children's Specialty Clinic, Jacksonville, Florida, USA
| | - Philipp R Aldana
- Department of Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
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Indelicato DJ, Rotondo RL, Mailhot Vega RB, Holtzman AL, Looi WS, Morris CG, Sandler ES, Aldana PR, Bradley JA. Local Control After Proton Therapy for Pediatric Chordoma. Int J Radiat Oncol Biol Phys 2021; 109:1406-1413. [PMID: 33253819 DOI: 10.1016/j.ijrobp.2020.11.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 11/10/2020] [Accepted: 11/18/2020] [Indexed: 11/20/2022]
Abstract
PURPOSE Due to the location and high dose required for disease control, pediatric chordomas are theoretically well-suited for treatment with proton therapy, but their low incidence limits the clinical outcome data available in the literature. We sought to report the efficacy and toxicity of proton therapy among a single-institution cohort. METHODS AND MATERIALS Between 2008 and 2019, 29 patients with a median age of 14.8 years (range, 3.8-21.8) received passive-scattered proton therapy for nonmetastatic chordoma. No patient received prior irradiation. Twenty-four tumors arose in the clivus/cervical spine region and 5 in the lumbosacral spine. Twenty-six tumors demonstrated classic well-differentiated histology and 3 were dedifferentiated or not otherwise specified. Approximately half of the tumors underwent specialized testing: 14 were brachyury-positive and 10 retained INI-1. Three patients had locally recurrent tumors after surgery alone (n = 2) or surgery + chemotherapy (n = 1), and 17 patients had gross disease at the time of radiation. The median radiation dose was 73.8 Gy relative biological effectivness (range, 69-75.6). RESULTS With a median follow-up of 4.3 years (range, 1.0-10.7), the 5-year estimates of local control, progression-free survival, and overall survival rates were 85%, 82%, and 86%, respectively. No disease progression was observed beyond 3 years. Excluding 3 patients with dedifferentiated/not-otherwise-specified chordoma, the 5-year local control, progression-free survival, and overall survival rates were 92%, 92%, and 91%, respectively. Serious toxicities included 3 patients with hardware failure or related infection requiring revision surgery, 2 patients with hormone deficiency, and 2 patients with Eustachian tube dysfunction causing chronic otitis media. No patient experienced brain stem injury, myelopathy, vision loss, or hearing loss after radiation. CONCLUSIONS In pediatric patients with chordoma, proton therapy is associated with a low risk of serious toxicity and high efficacy, particularly in well-differentiated tumors. Complete resection may be unnecessary for local control, and destabilizing operations requiring instrumentation may result in additional complications after therapy.
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Affiliation(s)
- Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida.
| | - Ronny L Rotondo
- Department of Radiation Oncology, University of Kansas, Kansas City, Kansas
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Adam L Holtzman
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Wen S Looi
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Eric S Sandler
- Department of Pediatrics, Nemours Childrens Specialty Clinic, Jacksonville, Florida
| | - Philipp R Aldana
- Department of Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
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Looi WS, Indelicato DJ, Mailhot Vega RB, Morris CG, Sandler E, Aldana PR, Bradley JA. Outcomes following limited-volume proton therapy for multifocal spinal myxopapillary ependymoma. Pediatr Blood Cancer 2021; 68:e28820. [PMID: 33226179 DOI: 10.1002/pbc.28820] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/03/2020] [Accepted: 11/04/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE Spinal myxopapillary ependymoma (MPE) often presents with a multifocal distribution, complicating attempts at resection. There remains no standard approach to irradiating these patients. We report disease control and toxicity in pediatric patients with multifocal spinal MPE treated with limited-volume proton therapy. MATERIALS/METHODS Twelve patients (≤21 years old) with multifocal spinal MPE were treated between 2009 and 2018 with limited-volume brain-sparing proton therapy. Median age was 13.5 years (range, 7-21). Radiotherapy was given as adjuvant therapy after primary surgery in five patients (42%) and for recurrence in seven (58%). No patient received prior radiation. Eleven patients (92%) had evidence of gross disease at radiotherapy. Eleven patients received 54 GyRBE; one received 50.4 GyRBE. Treatment toxicity was graded per the CTCAEv4.0. We estimated disease control and survival using the Kaplan-Meier product-limit method. RESULTS The median follow-up was 3.6 years (range, 1.8-10.6). The five-year actuarial rates of local control, progression-free survival, and overall survival were 100%, 92%, and 100%, respectively. One patient experienced an out-of-field recurrence in the spine superior to the irradiated region. No patients developed in-field recurrences. Following surgery and irradiation, one patient developed grade three spinal kyphosis and one patient developed grade 2 unilateral L5 neuropathy. CONCLUSION 54 GyRBE to a limited volume appears effective for disseminated spinal MPE in both the primary and salvage settings, sparing children the toxicity of full craniospinal irradiation. Compared with historical reports, this approach using proton therapy improves the therapeutic ratio, resulting in minimal side effects and high rates of disease control.
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Affiliation(s)
- Wen Shen Looi
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Eric Sandler
- Department of Pediatrics, Nemours Children's Specialty Clinic, Jacksonville, Florida
| | - Philipp R Aldana
- Department of Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
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Liu C, Zheng D, Bradley JA, Mailhot Vega RB, Zhang Y, Indelicato DJ, Mendenhall N, Liang X. Incorporation of the LETd-weighted biological dose in the evaluation of breast intensity-modulated proton therapy plans. Acta Oncol 2021; 60:252-259. [PMID: 33063569 DOI: 10.1080/0284186x.2020.1834141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To evaluate the LETd-weighted biological dose to OARs in proton therapy for breast cancer and to study the relationship of the LETd-weighted biological dose relative to the standard dose (RBE = 1.1) and thereby to provide estimations of the biological dose uncertainties with the standard dose calculations (RBE = 1.1) commonly used in clinical practice. METHOD This study included 20 patients who received IMPT treatment to the whole breast/chest wall and regional lymph nodes. The LETd distributions were calculated along with the physical dose using an open-source Monte Carlo simulation package, MCsquare. Using the McMahon linear model, the LETd-weighted biological dose was computed from the physical dose and LETd. OAR doses were compared between the Dose (RBE = 1.1) and the LETd-weighted biological dose, on brachial plexus, rib, heart, esophagus, and Ipsilateral lung. RESULTS On average, the LETd-weighted biological dose compared to the Dose (RBE = 1.1) was higher by 8% for the brachial plexus D0.1 cc, 13% for the ribs D0.5 cc, 24% for mean heart dose, and 10% for the esophagus D0.1 cc, respectively. The LETd-weighted doses to the Ipsilateral lung V5, V10, and V20 were comparable to the Dose (RBE = 1.1). No statistically significant difference in biological dose enhancement to OARs was observed between the intact breast group and the CW group, with the exception of the ribs: the CW group experienced slightly greater biological dose enhancement (13% vs. 12%, p = 0.04) to the ribs than the intact breast group. CONCLUSION Enhanced biological dose was observed compared to standard dose with assumed RBE of 1.1 for the heart, ribs, esophagus, and brachial plexus in breast/CW and regional nodal IMPT plans. Variable RBE models should be considered in the evaluation of the IMPT breast plans, especially for OARs located near the end of range of a proton beam. Clinical outcome studies are needed to validate model predictions for clinical toxicities.
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Affiliation(s)
- Chunbo Liu
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
- School of Physical Sciences, University of Science and Technology of China, Hefei, China
| | - Dandan Zheng
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Julie A. Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Raymond B. Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Yawei Zhang
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Daniel J. Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Nancy Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Xiaoying Liang
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
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Mailhot Vega RB, De La Mata D, Amendola B, Li B, Poitevin A, Sarria G, Sole S, Sher DJ, Hardenbergh P. Cross-Sectional International Survey to Determine the Educational Interests of Spanish-Speaking Latin American Radiation Oncologists. JCO Glob Oncol 2021; 7:29-34. [PMID: 33405959 PMCID: PMC8081543 DOI: 10.1200/go.20.00330] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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] [Indexed: 12/02/2022] Open
Abstract
PURPOSE With the existing oncology disparities in Latin America, physician expertise has been cited as a possible contributor to inferior oncologic outcomes in some cancers. As two-dimensional radiotherapy rapidly evolved to intensity-modulated radiation therapy in Latin America, adequate contouring education is an actionable target to improving physician knowledge and clinical outcomes. Yet, topics of interest to Latin American radiation oncologists are underreported. We assessed Latin American interest in a virtual platform for case discussion and identified the educational topics of most interest to them. MATERIALS AND METHODS A Spanish-language online survey was designed by a team of Latin American educators. The questions assessed professional nationality, desire for an online educational platform for case presentation, career length, and topics of interest. Educational topics included head and neck (H&N), CNS, GI, lung, gynecologic, breast, and pediatric cancers, lymphoma, sarcoma, stereotactic body radiotherapy (SBRT), brachytherapy, and medical physics. RESULTS One hundred thirty-three surveys were included for analysis. Overall, 127 respondents (98%) affirmed interest in participating in a virtual platform for case discussion and treatment advances. The most popular educational themes were H&N cancers (24%), SBRT (14%), and CNS cancers (13%). Of countries with > 10 respondents, the most popular educational topic remained H&N cancers for Argentina, Chile, and Mexico, but the most popular topic among Peruvian respondents was CNS cancer (27%). CONCLUSION With international collaboration and a large sample size, we present the first survey results describing Latin American radiation oncology educational interests. Participants were overwhelmingly interested in a virtual platform, and most were specifically interested in H&N cancer education. These results can be used for focused didactic preparation in Latin America. Future efforts should expand on improving representation and outreach among Central American radiation oncologists.
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Affiliation(s)
- Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | - Dolores De La Mata
- Department of Radiation Oncology, ABC Medical Center, Mexico City, Mexico
| | | | - Benjamin Li
- Department of Radiation Oncology, Stanford University, Stanford, CA
| | - Adela Poitevin
- Department of Radiation Oncology, Hospital Medica Sur, Sótano, Mexico
| | - Gustavo Sarria
- Department of Radiotherapy, Instituto Nacional de Enfermedades Neoplásicas (INEN), Lima, Peru
| | | | - David J Sher
- Department of Radiation Oncology, University of Texas Southwestern, Dallas, TX
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Affiliation(s)
- Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
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Tseng YD, Hoppe BS, Dedeckova K, Patel CG, Hill-Kayser CE, Miller DM, Maity A, Mendenhall NP, Mailhot Vega RB, Yock TI, Baliga S, Hess CB, Winkfield KM, Mohindra P, Rosen LR, Tsai H, Chang J, Hartsell WF, Plastaras JP. Risk of Pneumonitis and Outcomes After Mediastinal Proton Therapy for Relapsed/Refractory Lymphoma: A PTCOG and PCG Collaboration. Int J Radiat Oncol Biol Phys 2020; 109:220-230. [PMID: 32866566 DOI: 10.1016/j.ijrobp.2020.08.055] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 08/09/2020] [Accepted: 08/25/2020] [Indexed: 01/07/2023]
Abstract
PURPOSE Despite high response rates, there has been reluctance to use radiation therapy for patients with relapsed/refractory (r/r) Hodgkin (HL) or aggressive non-Hodgkin lymphoma (NHL) given concerns for subacute and late toxicities. Symptomatic pneumonitis, a subacute toxicity, has an incidence of 17% to 24% (≥grade 2) even with intensity modulated radiation therapy. Proton therapy (PT), which has no exit radiation dose, is associated with a lower dose to lung compared with other radiation techniques. As risk of radiation pneumonitis is associated with lung dose, we evaluated whether pneumonitis rates are lower with PT. METHODS AND MATERIALS Within an international, multi-institutional cohort, we retrospectively evaluated the incidence and grade of radiation pneumonitis (National Cancer Institute Common Terminology Criteria for Adverse Events v4) among patients with r/r HL or NHL treated with PT. RESULTS A total of 85 patients with r/r lymphoma (66% HL, 34% NHL; 46% primary chemorefractory) received thoracic PT from 2009 to 2017 in the consolidation (45%) or salvage (54%) setting. Median dose was 36 Gy(RBE). Before PT, patients underwent a median of 1 salvage systemic therapy (range, 0-4); 40% received PT within 4 months of transplant. With a median follow-up of 26.3 months among living patients, 11 patients developed symptomatic (grade 2) pneumonitis (12.8%). No grade 3 or higher pneumonitis was observed. Dose to lung, including mean lung dose, lung V5, and V20, significantly predicted risk of symptomatic pneumonitis, but not receipt of brentuximab, history of bleomycin toxicity, sex, or peritransplant radiation. CONCLUSIONS PT for relapsed/refractory lymphoma was associated with favorable rates of pneumonitis compared with historical controls. We confirm that among patients treated with PT, pneumonitis risk is associated with mean lung and lung V20 dose. These findings highlight how advancements in radiation delivery may improve the therapeutic ratio for patients with relapsed/refractory lymphoma. PT may be considered as a treatment modality for patients with relapsed/refractory lymphoma in the consolidation or salvage setting.
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Affiliation(s)
- Yolanda D Tseng
- Department of Radiation Oncology, University of Washington, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Proton Collaborative Group Registry Membership Site, Warrenville, Illinois.
| | - Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic Florida, Jacksonville, Florida
| | | | - Chirayu G Patel
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | - Christine E Hill-Kayser
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David M Miller
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amit Maity
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nancy P Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Torunn I Yock
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | - Sujith Baliga
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Clayton B Hess
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Karen M Winkfield
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Pranshu Mohindra
- Proton Collaborative Group Registry Membership Site, Warrenville, Illinois; Department of Radiation Oncology, University of Maryland School of Medicine and Maryland Proton Treatment Center, Baltimore, Maryland
| | - Lane R Rosen
- Department of Radiation Oncology, Willis-Knighton Cancer Center, Shreveport, Lousiana
| | - Henry Tsai
- Proton Collaborative Group Registry Membership Site, Warrenville, Illinois; Procure Proton Therapy Center, Somerset, New Jersey
| | - John Chang
- Proton Collaborative Group Registry Membership Site, Warrenville, Illinois; Oklahoma Proton Center, Oklahoma City, Oklahoma
| | - William F Hartsell
- Proton Collaborative Group Registry Membership Site, Warrenville, Illinois; Northwestern Medicine Proton Center, Warrenville, Illinois
| | - John P Plastaras
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
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Liu C, Zheng D, Bradley JA, Vega RBM, Li Z, Mendenhall NP, Liang X. Patient-specific quality assurance and plan dose errors on breast intensity-modulated proton therapy. Phys Med 2020; 77:84-91. [PMID: 32799050 DOI: 10.1016/j.ejmp.2020.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/26/2020] [Accepted: 08/05/2020] [Indexed: 01/28/2023] Open
Abstract
PURPOSE To investigate, in proton therapy, whether the Gamma passing rate (GPR) is related to the patient dose error and whether MU scaling can improve dose accuracy. METHODS Among 20 consecutively treated breast patients selected for analysis, two IMPT plans were retrospectively generated: (1) the pencil-beam (PB) plan and (2) the Monte Carlo (MC) plan. Patient-specific QA was performed. A 3%/3-mm Gamma analysis was conducted to compare the TPS-calculated PB algorithm dose distribution with the measured 2D dose. Dose errors were compared between the plans that passed the Gamma testing and those that failed. The MU was then scaled to obtain a better GPR. MU-scaled PB plan dose errors were compared to the original PB plan. RESULTS Of the 20 PB plans, 8 were passed Gamma testing (G_pass_group) and 12 failed (G_fail_group). Surprisingly, the G_pass_group had a greater dose error than the G_fail_group. The median (range) of the PTV DVH RMSE and PTV ΔDmean were 1.36 (1.00-1.91) Gy vs 1.18 (1.02-1.80) Gy and 1.23 (0.92-1.71) Gy vs 1.10 (0.87-1.49) Gy for the G_pass_group and the G_fail_group, respectively. MU scaling reduced overall dose error. However, for PTV D99 and D95, MU scaling worsened some cases. CONCLUSION For breast IMPT, the PB plans that passed the Gamma testing did not show smaller dose errors compared to the plans that failed. For individual plans, the MU scaling technique leads to overall smaller dose errors. However, we do not suggest use of the MU scaling technique to replace the MC plans when the MC algorithm is available.
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Affiliation(s)
- Chunbo Liu
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA; School of Physical Sciences, University of Science and Technology of China, Hefei, China
| | - Dandan Zheng
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Zuofeng Li
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Nancy P Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Xiaoying Liang
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA.
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Hoppe BS, Mailhot Vega RB, Mendenhall NP, Sandler ES, Slayton WB, Katzenstein H, Joyce MJ, Li Z, Flampouri S. Irradiating Residual Disease to 30 Gy with Proton Therapy in Pediatric Mediastinal Hodgkin Lymphoma. Int J Part Ther 2020; 6:11-16. [PMID: 32582815 PMCID: PMC7302731 DOI: 10.14338/ijpt-19-00077.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 11/15/2019] [Accepted: 03/05/2020] [Indexed: 11/24/2022] Open
Abstract
Background: Local relapse is a predominant form of recurrence among pediatric patients with Hodgkin lymphoma (PHL). Although PHL radiotherapy doses have been approximately 20 Gy, adults with Hodgkin lymphoma receiving 30 to 36 Gy experience fewer in-field relapses. We investigated the dosimetric effect of such a dose escalation to the organs at risk (OARs). Materials and Methods: Ten patients with PHL treated with proton therapy to 21 Gy involved-site radiation therapy (ISRT21Gy) were replanned to deliver 30 Gy by treating the ISRT to 30 Gy (ISRT30Gy), delivering 21 Gy to the ISRT plus a 9-Gy boost to postchemotherapy residual volume (rISRTboost), and delivering 30 Gy to the residual ISRT target only (rISRT30Gy). Radiation doses to the OARs were compared. Results: The ISRT30Gy escalated the dose to the target by 42% but also to the OARs. The rISRTboost escalated the residual target dose by 42%, and the OAR dose by only 17% to 26%. The rISRT30Gy escalated the residual target dose by 42% but reduced the OAR dose by 25% to 46%. Conclusion: Boosting the postchemotherapy residual target dose to 30Gy can allow for dose escalation with a slight OAR dose increase. Treating the residual disease for the full 30Gy, however, would reduce the OAR dose significantly compared with ISRT21Gy. Studies should evaluate these strategies to improve outcomes and minimize the late effects.
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Affiliation(s)
- Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | | | - Nancy P Mendenhall
- Department of Radiation Oncology, University of Florida, Jacksonville, FL, USA
| | - Eric S Sandler
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Nemours Children's Specialty Care, Jacksonville, FL, USA
| | - William B Slayton
- Department of Pediatric Hematology/Oncology, University of Florida, Gainesville, FL, USA
| | - Howard Katzenstein
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Nemours Children's Specialty Care, Jacksonville, FL, USA
| | - Michael J Joyce
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Nemours Children's Specialty Care, Jacksonville, FL, USA
| | - Zuofeng Li
- Department of Radiation Oncology, University of Florida, Jacksonville, FL, USA
| | - Stella Flampouri
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
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Bradley JA, Indelicato DJ, Uezono H, Morris CG, Sandler E, de Soto H, Mailhot Vega RB, Rotondo R. Patterns of Failure in Parameningeal Alveolar Rhabdomyosarcoma. Int J Radiat Oncol Biol Phys 2020; 107:325-333. [DOI: 10.1016/j.ijrobp.2020.01.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 01/29/2020] [Accepted: 01/31/2020] [Indexed: 12/19/2022]
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Suneja G, Mattes MD, Mailhot Vega RB, Escorcia FE, Lawton C, Greenberger J, Kesarwala AH, Spektor A, Vikram B, Deville C, Siker M. Pathways for Recruiting and Retaining Women and Underrepresented Minority Clinicians and Physician Scientists Into the Radiation Oncology Workforce: A Summary of the 2019 ASTRO/NCI Diversity Symposium Session at the ASTRO Annual Meeting. Adv Radiat Oncol 2020; 5:798-803. [PMID: 33083641 PMCID: PMC7557133 DOI: 10.1016/j.adro.2020.05.003] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/23/2020] [Accepted: 05/07/2020] [Indexed: 12/03/2022] Open
Abstract
Diversifying the radiation oncology workforce is an urgent and unmet need. During the American Society of Radiation Oncology (ASTRO) 2019 Annual Meeting, ASTRO's Committee on Health Equity, Diversity, and Inclusion (CHEDI) and the National Cancer Institute (NCI) collaborated on the ASTRO-NCI Diversity Symposium, entitled "Pathways for Recruiting and Retaining Women and Underrepresented Minority Clinicians and Physician Scientists Into the Radiation Oncology Workforce." Herein, we summarize the presented data and personal anecdotes with the goal of raising awareness of ongoing and future initiatives to improve recruitment and retention of underrepesented groups to radiation oncology. Common themes include the pivotal role of mentorship and standardized institutional practices – such as protected time and pay parity – as critical to achieving a more diverse and inclusive workplace.
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Affiliation(s)
- Gita Suneja
- Department of Radiation Oncology, University of Utah, Salt Lake City, Utah
| | - Malcolm D Mattes
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Brunswick, New Jersey
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Freddy E Escorcia
- National Cancer Institute, Center for Cancer Research, Bethesda, Maryland
| | - Colleen Lawton
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Joel Greenberger
- Department of Radiation Oncology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Aparna H Kesarwala
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Alexander Spektor
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts
| | - Bhadrasain Vikram
- Radiation Oncology Branch, National Cancer Institute, Bethesda, Maryland
| | - Curtiland Deville
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Malika Siker
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Uezono H, Indelicato DJ, Rotondo RL, Mailhot Vega RB, Bradfield SM, Morris CG, Bradley JA. Treatment Outcomes After Proton Therapy for Ewing Sarcoma of the Pelvis. Int J Radiat Oncol Biol Phys 2020; 107:974-981. [PMID: 32437922 DOI: 10.1016/j.ijrobp.2020.04.043] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 03/18/2020] [Accepted: 04/30/2020] [Indexed: 01/10/2023]
Abstract
PURPOSE Ewing sarcoma of the pelvis is associated with inferior local control compared with those arising from other primary sites. Despite its increased use, outcome data for treatment with proton therapy remain limited. We report 3-year disease control and toxicity in pediatric patients treated with proton therapy. METHODS AND MATERIALS Thirty-five patients aged ≤21 years (median, 14 years) with nonmetastatic pelvic Ewing sarcoma received proton therapy and chemotherapy between 2010 and 2018. Overall survival and tumor control rates were calculated using the Kaplan-Meier method. A log-rank test assessed significance between strata of prognostic factors. Significant toxicity was reported per the Common Terminology Criteria for Adverse Events, version 4.0. RESULTS Most patients received definitive radiation (n = 26; median dose 55.8 Gy relative biological effectiveness [RBE]; range, 54.0-64.8), 7 received preoperative radiation (50.4 Gy RBE), and 2 received postoperative radiation (45 Gy RBE and 54 Gy RBE). The median primary tumor size was 10.5 cm. With a median follow-up of 3 years (range, 0.3-9.0 years), the 3-year overall survival, progression-free survival, and local control rates were 83% (95% confidence interval [CI], 65%-93%), 64% (95% CI, 45%-79%), and 92% (95% CI, 74%-98%), respectively. There was no association between local control, progression-free survival, or overall survival and tumor size, patient age, radiation dose, or definitive versus pre-/postoperative radiation therapy. Median time to progression was 1 year (range, 0.1-1.9 years). All patients with large tumors (≥8 cm) who underwent definitive proton therapy with a higher dose (≥59.4 Gy RBE) remained free from tumor recurrence (n = 5). Five patients experienced grade ≥2 subacute/late toxicity, all of whom were treated with combined surgery and radiation. CONCLUSIONS Definitive proton therapy offers local control comparable to photon therapy in pediatric patients with pelvic Ewing sarcoma. These data lend preliminary support to radiation dose escalation without significant toxicity, which may contribute to the favorable outcomes. Combined surgery and radiation therapy, particularly preoperative radiation, is associated with postoperative complications, but not survival, compared with radiation alone.
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Affiliation(s)
- Haruka Uezono
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Ronny L Rotondo
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Scott M Bradfield
- Department of Pediatric Hematology/Oncology, Nemours Children's Specialty Care, Jacksonville, Florida
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida.
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Indelicato DJ, Rotondo RL, Krasin MJ, Mailhot Vega RB, Uezono H, Bradfield S, Agarwal V, Morris CG, Bradley JA. Outcomes Following Proton Therapy for Group III Pelvic Rhabdomyosarcoma. Int J Radiat Oncol Biol Phys 2020; 106:968-976. [DOI: 10.1016/j.ijrobp.2019.12.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 12/19/2019] [Accepted: 12/21/2019] [Indexed: 01/20/2023]
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Liang X, Mailhot Vega RB, Li Z, Zheng D, Mendenhall N, Bradley JA. Dosimetric consequences of image guidance techniques on robust optimized intensity-modulated proton therapy for treatment of breast Cancer. Radiat Oncol 2020; 15:47. [PMID: 32103762 PMCID: PMC7045466 DOI: 10.1186/s13014-020-01495-6] [Citation(s) in RCA: 7] [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: 12/23/2019] [Accepted: 02/17/2020] [Indexed: 01/30/2023] Open
Abstract
PURPOSE To investigate the consequences of residual setup error on target dose distribution using various image registration strategies for breast cancer treated with intensity-modulated proton therapy (IMPT). MATERIALS AND METHODS Among 11 post-lumpectomy patients who received IMPT, 44 dose distributions were computed. For each patient, the original plan (Plan-O) and three verification plans were calculated using different alignments: bony anatomy (VPlan-B), breast tissue (VPlan-T), and skin (VPlan-S). The target coverage were evaluated for each alignment technique. Additionally, 2 subvolumes-BreastNearSkin (1-cm rim of anterior CTV) and BreastNearCW (1-cm rim of posterior CTV)-were created to help localize CTV underdosing. Furthermore, we divided the setup error into the posture error and breast error. Patients with a large posture error and those with good posture setup but a large breast error were identified to evaluate the effect of posture error and breast error. RESULTS For Plan-O, VPlan-B, VPlan-T, and VPlan-S, respectively, the median (interquartile range) breast CTV D95 was 95.7%(94.7-96.3%), 95.1% (93.9-95.7%), 95.2% (94.8-95.6%), and 95.2% (94.9-95.7%); BreastNearCW D95 was 96.9% (95.6-97.3%), 94.8% (93.5-97.0%), 95.6% (94.8-97.0%), 95.6% (94.8-97.1%); and BreastNearSkin D95 was 94.1% (92.7-94.4%), 93.6% (92.2-94.5%), 93.5% (92.4-94.5%), and 94.4% (92.2-94.5%) of the prescription dose. 4/11 patients had ≥1% decrease in breast CTV D95, 1 of whom developed breast edema while the other 3 all had a > 2o posture error. The CTV D95 variation was within 1% for the patients with good posture setup but >2o breast error. CONCLUSION Acceptable target coverage was achieved with all three alignment strategies. Breast tissue and skin alignment maintained the breast target coverage marginally better than bony alignment, with which the posterior CTV along the chest wall is the predominant area affected by under-dosing. For target dose distribution, posture error appears more influential than breast error.
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Affiliation(s)
- Xiaoying Liang
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA.
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Zuofeng Li
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Dandan Zheng
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Nancy Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
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Kharod SM, Indelicato DJ, Rotondo RL, Mailhot Vega RB, Uezono H, Morris CG, Bradfield S, Sandler ES, Bradley JA. Outcomes following proton therapy for Ewing sarcoma of the cranium and skull base. Pediatr Blood Cancer 2020; 67:e28080. [PMID: 31736243 DOI: 10.1002/pbc.28080] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 10/08/2019] [Accepted: 10/27/2019] [Indexed: 12/15/2022]
Abstract
PURPOSE Despite the dosimetric advantages of proton therapy, little data exist on patients who receive proton therapy for Ewing sarcoma of the cranium and skull base. This study reports local disease control and toxicity in such patients. MATERIALS/METHODS We reviewed 25 patients (≤21 years old) with nonmetastatic Ewing sarcoma of the cranium and skull base treated between 2008 and 2018. Treatment toxicity was graded per the Common Terminology Criteria for Adverse Events v4.0. The Kaplan-Meier product limit method provided estimates of disease control and survival. RESULTS Median patient age was 5.9 years (range, 1-21.7). Tumor subsites included the skull base (48%), non-skull-base calvarial bones (28%), paranasal sinuses (20%), and nasal cavity (4%). All patients underwent multiagent alkylator- and anthracycline-based chemotherapy; 16% underwent gross total resection (GTR) before radiation. Clinical target volume (CTV) 1 received 45 GyRBE and CTV2 received 50.4 GyRBE following GTR or 54-55.8 GyRBE following biopsy or subtotal resection. Median follow-up was 3.7 years (range, 0.26-8.3); no patients were lost. The 4-year local control, disease-free survival, and overall survival rates were 96%, 86%, and 92%, respectively. Two patients experienced in-field recurrences. One patient experienced bilateral conductive hearing loss requiring aids, two patients developed intracranial vasculopathy, and 6 patients required hormone replacement therapy for neuroendocrine deficits. None developed a secondary malignancy. CONCLUSION Proton therapy is associated with a favorable therapeutic ratio in children with large Ewing tumors of the cranium and skull base. Despite its high conformality, we observed excellent local control and no marginal recurrences. Treatment dosimetry predicts limited long-term neurocognitive and neuroendocrine side effects.
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Affiliation(s)
- Shivam M Kharod
- Department of Radiation Oncology, College of Medicine, University of Florida, Jacksonville, Florida
| | - Daniel J Indelicato
- Department of Radiation Oncology, College of Medicine, University of Florida, Jacksonville, Florida
| | - Ronny L Rotondo
- Department of Radiation Oncology, College of Medicine, University of Florida, Jacksonville, Florida
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, College of Medicine, University of Florida, Jacksonville, Florida
| | - Haruka Uezono
- Department of Radiation Oncology, College of Medicine, University of Florida, Jacksonville, Florida
| | - Christopher G Morris
- Department of Radiation Oncology, College of Medicine, University of Florida, Jacksonville, Florida
| | - Scott Bradfield
- Department of Pediatric Oncology, Nemours Children's Health Systems, Jacksonville, Florida
| | - Eric S Sandler
- Department of Pediatric Oncology, Nemours Children's Health Systems, Jacksonville, Florida
| | - Julie A Bradley
- Department of Radiation Oncology, College of Medicine, University of Florida, Jacksonville, Florida
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Mailhot Vega RB, Hoppe BS. A positive approach: advances in proton therapy for the treatment of mediastinal lymphoma. Expert Rev Hematol 2020; 13:197-200. [PMID: 31976780 DOI: 10.1080/17474086.2020.1713745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Fl, USA
| | - Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
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Liang X, Bradley JA, Mailhot Vega RB, Rutenberg M, Zheng D, Getman N, Norton KW, Mendenhall N, Li Z. Using Robust Optimization for Skin Flashing in Intensity Modulated Radiation Therapy for Breast Cancer Treatment: A Feasibility Study. Pract Radiat Oncol 2020; 10:59-69. [PMID: 31627030 DOI: 10.1016/j.prro.2019.09.017] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 08/21/2019] [Accepted: 09/24/2019] [Indexed: 12/28/2022]
Abstract
PURPOSE To study the feasibility and the effectiveness of a novel implementation of robust optimization on 2 sets of computed tomography (CT) data simultaneously for skin flashing in intensity modulated radiation therapy for breast cancer. METHOD AND MATERIALS Five patients who received treatment to the breast and regional lymphatics were selected for this study. For each patient, 3 plans were generated using 3 different skin-flashing methods, including (1) a manual flash plan with optimization on the nominal planning target volume (PTV) not extending beyond the skin that required manually postplanning the opening of the multi-leaf collimator and jaw to obtain flash; (2) an expanded PTV plan with optimization on an expanded PTV that included the target in the air beyond the skin; and (3) a robust-optimized (RO) plan using robust optimization that simultaneously optimizes on the nominal CT data set and a simulated geometry error CT data set. The feasibility and the effectiveness of the robust optimization approach was investigated by comparing it with the 2 other methods. The robustness of the plan against target position variations was studied by simulating 0-, 5-, 10-, and 15-mm geometry errors. RESULTS The RO plans were the only ones able to meet acceptable criteria for all patients in both the nominal and simulated geometry error scenarios. The expanded PTV plans developed major deviation on the maximum dose to the PTV for 1 patient. For the manual flash plans, every patient developed major deviation either on 95% of the dose to the PTV or the maximum dose to the PTV in the simulated geometry error scenarios. The RO plan demonstrated the best robustness against the target position variation among the 3 methods of skin flashing. The doses to the lung and heart were comparable for all 3 planning techniques. CONCLUSION Using robust optimization for skin flash in breast intensity modulated radiation therapy planning is feasible. Further investigation is warranted to confirm the clinical effectiveness of this novel approach.
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Affiliation(s)
- Xiaoying Liang
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida.
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Michael Rutenberg
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Dandan Zheng
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Nataliya Getman
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Kelly W Norton
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Nancy Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Zuofeng Li
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
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Mailhot Vega RB, Ishaq OF, Ahmed I, Rene L, Amendola BE, Hu KS. Novel Pilot Curriculum for International Education of Lymphoma Management Using E-Contouring. J Glob Oncol 2019; 4:1-9. [PMID: 30241149 PMCID: PMC6223383 DOI: 10.1200/jgo.2016.008755] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE The International Lymphoma Radiation Oncology Group (ILROG) published consensus guidelines on the management of Hodgkin disease (HD) and nodal non-Hodgkin lymphoma (NHL), which became the most downloaded articles from International Journal of Radiation Oncology, Biology, and Physics. E-contouring workshops allow for interactive didactic sessions, allowing participants to see case-based contouring in real time. A pilot 1-hour curriculum was developed with the objective of reviewing ILROG guidelines for HD and NHL management with incorporation of e-contouring tools. This represents the first international education intervention in Spanish using e-contouring with a pre- and postintervention questionnaire. METHODS A 1-hour presentation was prepared in Spanish reviewing the ILROG recommendations for HD and NHL. The review was followed by the author's demonstration of contour creation using patients with HD and NHL prepared for the American Society for Radiation Oncology's 2015 e-contouring lymphoma session. A five- question evaluation was prepared and administered before and after intervention. A two-tailed paired t test was performed to evaluate any significant change in test value before and after intervention. RESULTS A total of nine quizzes were collected before and after the intervention. The average test score before the intervention was 75.6%, and the average test score after the intervention was 86.7% ( P = .051). Four students scored 100% on both the pre- and postintervention evaluations, and no student had a decrease in score from pre- to postintervention evaluation. The topic with the lowest score tested dose consideration. CONCLUSION A substantial but nonsignificant improvement in test evaluation was seen with this pilot curriculum. This pilot intervention identified obstacles for truly interactive didactic sessions that, when addressed, can lead to fully developed interactive didactic sessions.
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Affiliation(s)
- Raymond B Mailhot Vega
- Raymond B. Mailhot Vega, Omar F. Ishaq, Inaya Ahmed, and Kenneth S. Hu, Laura and Isaac Perlmutter Cancer Center, New York University School of Medicine, New York, NY; Luis Rene, Centro de Radioterapia, Rosario, Argentina; and Beatriz E. Amendola, Innovative Cancer Institute, Miami, FL
| | - Omar F Ishaq
- Raymond B. Mailhot Vega, Omar F. Ishaq, Inaya Ahmed, and Kenneth S. Hu, Laura and Isaac Perlmutter Cancer Center, New York University School of Medicine, New York, NY; Luis Rene, Centro de Radioterapia, Rosario, Argentina; and Beatriz E. Amendola, Innovative Cancer Institute, Miami, FL
| | - Inaya Ahmed
- Raymond B. Mailhot Vega, Omar F. Ishaq, Inaya Ahmed, and Kenneth S. Hu, Laura and Isaac Perlmutter Cancer Center, New York University School of Medicine, New York, NY; Luis Rene, Centro de Radioterapia, Rosario, Argentina; and Beatriz E. Amendola, Innovative Cancer Institute, Miami, FL
| | - Luis Rene
- Raymond B. Mailhot Vega, Omar F. Ishaq, Inaya Ahmed, and Kenneth S. Hu, Laura and Isaac Perlmutter Cancer Center, New York University School of Medicine, New York, NY; Luis Rene, Centro de Radioterapia, Rosario, Argentina; and Beatriz E. Amendola, Innovative Cancer Institute, Miami, FL
| | - Beatriz E Amendola
- Raymond B. Mailhot Vega, Omar F. Ishaq, Inaya Ahmed, and Kenneth S. Hu, Laura and Isaac Perlmutter Cancer Center, New York University School of Medicine, New York, NY; Luis Rene, Centro de Radioterapia, Rosario, Argentina; and Beatriz E. Amendola, Innovative Cancer Institute, Miami, FL
| | - Kenneth S Hu
- Raymond B. Mailhot Vega, Omar F. Ishaq, Inaya Ahmed, and Kenneth S. Hu, Laura and Isaac Perlmutter Cancer Center, New York University School of Medicine, New York, NY; Luis Rene, Centro de Radioterapia, Rosario, Argentina; and Beatriz E. Amendola, Innovative Cancer Institute, Miami, FL
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Mendenhall WM, Smith S, Morris CG, Bradley JA, Mailhot Vega RB, McIntyre K, Klein SL, Mendenhall NP. Insurance Coverage for Adjuvant Proton Therapy in the Definitive Treatment of Breast Cancer. Int J Part Ther 2019; 6:26-30. [PMID: 31998818 DOI: 10.14338/ijpt-19-00070.1] [Citation(s) in RCA: 2] [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: 07/18/2019] [Accepted: 09/09/2019] [Indexed: 11/21/2022] Open
Abstract
Purpose To determine factors that influence insurance approval for breast cancer patients for whom adjuvant proton therapy (PT) is recommended. Patients and Methods We sought to identify factors associated with PT approval among 131 insured patients seen in consultation between 2014 and 2018 and recommended adjuvant PT. Insurance status included: commercial, 76 patients (58%); Medicare, 41 (31%); and Medicaid, 14 (11%). Ninety-six patients (73%) had policies that "covered" PT. Insurance "coverage" for PT was not associated with final approval nor was lack of "coverage" associated with denial despite additional steps of medical review, peer-to-peer discussion, patient appeal, and judicial review.In seeking approval, the following steps were required: medical review, 73 patients (56%); comparative dosimetry, 34 patients (26%); peer-to-peer discussion, 20 patients (15%); and administrative law judge, 1 patient (1%). A multivariate analysis of predictors for final insurance approval was conducted including the following covariates: T stage (Tis-T2 vs T3-T4); N stage (N0 vs N1-N3); laterality (left or bilateral vs right); insurance type (commercial vs Medicare/Medicaid) combined with potential insurance coverage (covered vs not covered); time period (2014-2016 vs 2017-2018); and age (<57 years vs 57 and older). Results Insurance approval was obtained for 93/96 patients (97%) with insurance that covered PT versus 23/35 patients (66%) whose insurance did not cover PT. Insurance approval stratified by insurance type and coverage was: commercial-covered, 52/52 patients (100%); Medicare or Medicaid-covered, 41/44 (93%); commercial-not covered, 16/22 (73%); and Medicare or Medicaid-not covered, 7/13 (54%).On multivariate analysis, factors impacting approval revealed T stage, p=0.3127; N stage, p=0.8524; laterality, p=0.1829; insurance type combined with potential coverage, p<0.0001; time period, p=0.2731; and age, p=0.6678. Conclusion The only parameter that significantly influenced approval for treatment with PT was insurance type combined with potential coverage with ultimate approval rates ranging from 54% to 100%.
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Affiliation(s)
| | - Stephanie Smith
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | | | - Julie A Bradley
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | | | - Kathy McIntyre
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Stuart L Klein
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Nancy P Mendenhall
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
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Indelicato DJ, Rotondo RL, Mailhot Vega RB, Uezono H, Bradfield S, Agarwal V, Hol ML, Bradley JA. 45 GyRBE for group III orbital embryonal rhabdomyosarcoma. Acta Oncol 2019; 58:1404-1409. [PMID: 31530120 DOI: 10.1080/0284186x.2019.1627412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Purpose: Despite widespread concerns of radiotherapy toxicity in children with head and neck tumors, recent Children's Oncology Group (COG) findings suggest that the use of 45 Gy results in an unacceptably high rate of local recurrences in patients with low-risk orbital rhabdomyosarcoma. We therefore evaluated outcomes in our pediatric patients who received 45 GyRBE using proton therapy. Material and methods: To assess disease control and toxicity, we reviewed the medical records of 30 children (≤21 years old) with COG stage 1, group III embryonal orbital rhabdomyosarcoma enrolled on a prospective outcome study and treated with proton therapy between 2007 and 2018. Results: Median age at the time of radiation was 4.8 years old. Twenty-one and nine patients received ifosfamide- and cyclophosphamide-based chemotherapy according to their respective cooperative group regimens. Median duration between the start of induction chemotherapy and radiation was 12 weeks. Two patients had a complete response to induction chemotherapy and two had stable disease. Twenty-six patients had a partial response to induction chemotherapy, with a median volume reduction of 66%. With a median follow-up of 4.0 years (range, 0.5-9.5 years), we observed 1 local failure 6 months following treatment in a patient who had a partial response to cyclosphophomide-based induction chemotherapy. The 5-year local control, progression-free survival, and overall survival rates were 97%, 97%, and 100%, respectively. Serious late toxicities included 18 patients with cataracts, 4 with exposure keratoconjunctivitis resulting in permanently reduced visual acuity, and 1 with chronic sinusitis. Conclusion: 45 GyRBE offers effective local control for most patients with group III orbital rhabdomyosarcoma. The delivery of proton therapy to the postinduction tumor volume plus a small margin can mitigate early- and intermediate-term toxicity, but side effects still occur and long-term data are needed to demonstrate the dosimetric advantage of proton therapy.
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Affiliation(s)
- Daniel J. Indelicato
- Department of Radiation Oncology, College of Medicine, University of Florida, Jacksonville, FL, USA
| | - Ronny L. Rotondo
- Department of Radiation Oncology, College of Medicine, University of Florida, Jacksonville, FL, USA
| | - Raymond B. Mailhot Vega
- Department of Radiation Oncology, College of Medicine, University of Florida, Jacksonville, FL, USA
| | - Haruka Uezono
- Department of Radiation Oncology, College of Medicine, University of Florida, Jacksonville, FL, USA
| | - Scott Bradfield
- Department of Pediatric Oncology, Nemours Children’s Health System, Jacksonville, FL, USA
| | - Vibhuti Agarwal
- Department of Pediatric Oncology, Nemours Children’s Health System, Jacksonville, FL, USA
| | - Marinka L. Hol
- Department of Oral and Maxillofacial Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Julie A. Bradley
- Department of Radiation Oncology, College of Medicine, University of Florida, Jacksonville, FL, USA
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