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Gao H, Wu H, Zhang Y, Wang S, Li X, Qi Z, Wang M. Dose-volume constraints for severe acute gastrointestinal toxicity in cervical cancer patients receiving extended-field intensity-modulated radiotherapy and concurrent chemotherapy. Radiother Oncol 2025; 205:110777. [PMID: 39914743 DOI: 10.1016/j.radonc.2025.110777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2024] [Revised: 01/30/2025] [Accepted: 02/01/2025] [Indexed: 02/12/2025]
Abstract
BACKGROUND AND PURPOSE Extended-field intensity-modulated radiotherapy (IMRT) and concurrent chemotherapy may lead to severe toxicity. This study aims to investigate the incidence and dosimetric predictors of acute gastrointestinal toxicity in cervical cancer patients. METHODS AND MATERIALS Dosimetric data of the duodenum and small bowel loop from 273 eligible patients were analyzed. Logistic regression and Pearson's pairwise correlation were used to identify the best predictors. Receiver operating characteristic curves were used to determine the optimal cutoff values. Logistic models were established to predict the normal tissue complication probability. RESULTS Twenty-six patients experienced grades ≥ 3 (G3+) vomiting, while seven experienced G3+ diarrhea. Either the duodenal volume receiving ≥ 29 Gy (V29; p = 0.002) or V49 (p = 0.014) could predict the incidence of G3+ vomiting. The incidence was 1.3 % vs. 12.8 % in patients with V29 ≤ 43.5 % vs. > 43.5 % (p = 0.008). For patients with V49 ≤ 9.2 % vs. > 9.2 %, the incidence was 7.6 % vs. 16.1 % (p = 0.077). The plans for 22 patients had to be modified due to vomiting. It was found that duodenal V29 (p = 0.012) was a predictor for replanning, with an incidence of 3.3 % vs. 17.6 % in patients with V29 ≤ 51.3 % vs. > 51.3 % (p < 0.001). The V22 of the small bowel was selected to predict the incidence of G3+ diarrhea, which were 0.6 % and 5.6 % in patients with V22 ≤ 62.3 % and > 62.3 %, respectively (p = 0.031). CONCLUSION Limiting V29 and V49 of the duodenum, as well as V22 of the small bowel loop, may help reduce the risk of acute G3+ gastrointestinal toxicity when treating cervical cancer with extended-field concurrent IMRT.
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Affiliation(s)
- Hui Gao
- Department of Oncology, General Hospital of Western Theater Command Chengdu Sichuan People's Republic of China.
| | - Haijing Wu
- Department of Gynecological Oncology Sichuan Cancer Hospital & Institute, Cancer Hospital Affiliated to School of Medicine, University of Electronic Science and Technology of China Chengdu Sichuan People's Republic of China
| | - Yue Zhang
- Department of Oncology, General Hospital of Western Theater Command Chengdu Sichuan People's Republic of China
| | - Shuai Wang
- Outpatient Department, General Hospital of Western Theater Command Chengdu Sichuan People's Republic of China
| | - Xiaokai Li
- Department of Oncology, General Hospital of Western Theater Command Chengdu Sichuan People's Republic of China
| | - Zhongchun Qi
- Department of Oncology, General Hospital of Western Theater Command Chengdu Sichuan People's Republic of China
| | - Mingyi Wang
- Department of Obstetrics & Gynecology, General Hospital of Western Theater Command Chengdu Sichuan People's Republic of China
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Wang L, Mohajer J, McNair H, Harris E, Lalondrelle S. Implementing Plan of the Day for Cervical Cancer: A Comparison of Target Volume Generation Methods. Adv Radiat Oncol 2024; 9:101560. [PMID: 39155886 PMCID: PMC11328065 DOI: 10.1016/j.adro.2024.101560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 06/04/2024] [Indexed: 08/20/2024] Open
Abstract
Purpose Owing to substantial interfraction motion in cervical cancer, plan-of-the-day (PotD) adaptive radiation therapy may be of benefit to patients. Implementation is limited by uncertainty over how to generate the planning target volumes (PTVs). We compared published methods on our own patients. Methods and Materials Forty patients each had 3 planning scans with variable bladder filling and daily cone beam computed tomographies (cone beam CTs) during radiation therapy; 5 to 11 cone beam CTs were selected to represent interfraction motion. Clinical target volumes (CTVs) and organs at risk were contoured following EMBRACE-II guidelines. A literature search identified 30 adaptive and nonadaptive solutions to PTV generation, which we applied to our patients. PTV sizes and mean coverage of the daily CTV were determined. For 11 patients, the clinically implemented, subjectively edited plan library was also investigated. Results Eleven studies assessed 15 PotD strategies against nonadaptive comparators on a median of 14 patients (range, 9-23). Some PotD approaches applied margin recipes to the CTV on each planning scan, some modeled the CTV against bladder volume, and others applied incremental isotropic margins to the CTV with a single planning scan. Generally, coverage improved as PTV size increased. The fixed isotropic margin required to provide 100% coverage of all patients was 44 mm, with a mean PTV size of 3316 cm3. The PotD strategy with the best coverage was a 2-plan library formed by modeling the CTV against bladder volume with extrapolation; it provided 98% mean coverage with 1419-cm3 mean PTV size. A 3-plan library consisting of the CTV on each planning scan with 10-mm margin provided 96% mean coverage with 1346-cm3 mean PTV size. The clinically implemented solution that employed subjective extrapolation had mean 100% coverage and 1282-cm3 PTV size on the 11-patient subset. Coverage provided by the best nonadaptive strategies was not statistically superior to the best PotD strategy (P = .13), but PTVs were larger (P = .02). Conclusions We identified a modeled 2-plan method and a simple 3-plan method, both of which provided excellent coverage with small PTVs compared with nonadaptive strategies.
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Affiliation(s)
- Lei Wang
- The Joint Department of Physics at the Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, Sutton, Surrey, United Kingdom
| | - Jonathan Mohajer
- The Joint Department of Physics at the Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, Sutton, Surrey, United Kingdom
| | - Helen McNair
- The Joint Department of Physics at the Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, Sutton, Surrey, United Kingdom
| | - Emma Harris
- The Joint Department of Physics at the Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, Sutton, Surrey, United Kingdom
| | - Susan Lalondrelle
- The Joint Department of Physics at the Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, Sutton, Surrey, United Kingdom
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Sauvage LM, Bentahila R, Tran Y, Guénégou-Arnoux A, Fabiano E, Bats AS, Borghese B, Durdux C. Radiation Proctitis in Patients With Locally Advanced Cervical Cancer Treated by Chemoradiation: Analysis and Predictive Factors From a Retrospective Cohort. Am J Clin Oncol 2024; 47:311-316. [PMID: 38557436 DOI: 10.1097/coc.0000000000001092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
OBJECTIVES Radiation proctitis is a misunderstanding complication of chemoradiation in locally advanced cervical cancer. The objective of our study is to provide a detailed description and analysis of predictive factors associated with radiation proctitis in a retrospective cohort of patients treated by chemoradiation for locally advanced cervical cancer. METHODS All patients treated by exclusive chemoradiation or chemoradiation followed by brachytherapy for locally advanced cervical cancer from 2011 to 2017 were included in the study. A bivariate analysis was conducted to establish correlations between the occurrence of radiation proctitis and various clinical and technical variables. RESULTS A total of 128 patients were included in the study. The mean dose (SD) to the planning target volume was 47.1 Gy (6.2). Fifty-nine (46.1%) patients underwent brachytherapy. Sixteen patients (12.5%) developed radiation proctitis, grade 2 or higher in 12 patients (9.3%). In univariate analysis, anticoagulant or antiplatelet treatments ( P =0.039), older age ( P =0.049), rectal volume irradiated at 40 Gy ( P =0.01) and 30 Gy ( P =0.037) were significantly associated with the occurrence of a grade ≥2 radiation proctitis. The delivered dose to 2 cm 3 of rectum (D2cm 3 ) showed a potential association with the occurrence of radiation proctitis of all grades ( P =0.064). CONCLUSIONS This study highlights clinical and technical factors that should be considered in assessing the risk of radiation proctitis. These results contribute to a better understanding of this complication.
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Affiliation(s)
| | | | - Yohan Tran
- Department of Clinical Research, Clinical Investigations-Epidemiology Center, INSERM
| | | | | | | | - Bruno Borghese
- Department of Gynecology, Cochin-Port Royal Hospital, Paris-Cité University, Paris, France
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Kuipers SC, Godart J, Corbeau A, Breedveld S, Mens JWM, de Boer SM, Nout RA, Hoogeman MS. Dosimetric impact of bone marrow sparing for robustly optimized IMPT for locally advanced cervical cancer. Radiother Oncol 2024; 195:110222. [PMID: 38471634 DOI: 10.1016/j.radonc.2024.110222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 03/07/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND AND PURPOSE To investigate the trade-off between bone marrow sparing (BMS) and dose to organs at risk (OARs) for intensity modulated proton therapy (IMPT) for women with locally advanced cervical cancer (LACC). MATERIALS AND METHODS Twenty LACC patients were retrospectively included. IMPT plans were created for each patient using automated treatment planning. These plans progressively reduced bone marrow mean doses by steps of 1 GyRBE, while constraining target coverage and conformality. The relation between bone marrow dose and bladder, small bowel, rectum, and sigmoid doses was evaluated. RESULTS A total of 140 IMPT plans were created. Plans without BMS had an average [range] bone marrow mean dose of 17.3 [14.7-21.6] GyRBE , which reduced to 12.0 [10.0-14.0] GyRBE with maximum BMS. The mean OAR dose [range] increased modestly for 1 GyRBE BMS: 0.2 [0.0 - 0.6] GyRBE for bladder, 0.3 [-0.2 - 0.7] GyRBE for rectum, 0.4 [0.1 - 0.8] GyRBE for small bowel, and 0.2 [-0.2 - 0.4] GyRBE for sigmoid. Moreover, for maximum BMS, mean OAR doses [range] escalated by 3.3 [0.1 - 6.7] GyRBE for bladder, 5.8 [1.8 - 12.4] GyRBE for rectum, 3.9 [1.6 - 5.9] GyRBE for small bowel, and 2.7 [0.6 - 5.9] GyRBE for sigmoid. CONCLUSION Achieving 1 GyRBE BMS for IMPT is feasible for LACC patients with limited dosimetric impact on other OARs. While further bone marrow dose reduction is possible for some patients, it may increase OAR doses substantially for others. Hence, we recommend a personalized approach when introducing BMS into clinical IMPT treatment planning to carefully assess individual patient benefits and risks.
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Affiliation(s)
- S C Kuipers
- Department of Radiotherapy, Erasmus MC Cancer Institute - University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Medical Physics & Informatics, HollandPTC, Delft, the Netherlands.
| | - J Godart
- Department of Radiotherapy, Erasmus MC Cancer Institute - University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Medical Physics & Informatics, HollandPTC, Delft, the Netherlands
| | - A Corbeau
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - S Breedveld
- Department of Radiotherapy, Erasmus MC Cancer Institute - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - J W M Mens
- Department of Radiotherapy, Erasmus MC Cancer Institute - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - S M de Boer
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - R A Nout
- Department of Radiotherapy, Erasmus MC Cancer Institute - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - M S Hoogeman
- Department of Radiotherapy, Erasmus MC Cancer Institute - University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Medical Physics & Informatics, HollandPTC, Delft, the Netherlands
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Corbeau A, Heemsbergen WD, Kuipers SC, Godart J, Creutzberg CL, Nout RA, de Boer SM. Predictive Factors for Toxicity After Primary Chemoradiation for Locally Advanced Cervical Cancer: A Systematic Review. Int J Radiat Oncol Biol Phys 2024; 119:127-142. [PMID: 37979708 DOI: 10.1016/j.ijrobp.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 11/01/2023] [Accepted: 11/04/2023] [Indexed: 11/20/2023]
Abstract
PURPOSE Women with locally advanced cervical cancer (LACC) undergoing primary platinum-based chemoradiotherapy and brachytherapy often experience toxicities. Normal-tissue complication probability (NTCP) models quantify toxicity risk and aid in optimizing radiation therapy to minimize side effects. However, it is unclear which predictors to include in an NTCP model. The aim of this systematic review was to provide an overview of the identified predictors contributing to gastrointestinal (GI), genitourinary (GU), and vaginal toxicities and insufficiency fractures for LACC. METHODS AND MATERIALS A systematic search was performed and articles evaluating the relationship between predictors and toxicities in women with LACC treated with primary chemoradiation were included. The Quality In Prognosis Studies tool was used to assess risk of bias, with high-risk studies being excluded from further analysis. Relationships between dose-volume parameters, patient and treatment characteristics, and toxicity endpoints were analyzed. RESULTS Seventy-three studies were identified. Twenty-six had a low or moderate risk of bias and were therefore included. Brachytherapy-related dose-volume parameters of the GI tract, including rectum and bowel equivalent dose in 2 Gy fractions (EQD2) D2 cm3, were frequently related to toxicities, unlike GU dose-volume parameters. Furthermore, (recto)vaginal point doses predicted toxicities. Few studies evaluated external beam radiation therapy dose-volume parameters and identified rectum EQD2 V30 Gy, V40 Gy, and V55 Gy, bowel and bladder EQD2 V40 Gy as toxicity predictors. Also, total reference air kerma and vaginal reference length were associated with toxicities. Relationships between patient characteristics and GI toxicity were inconsistent. The extent of vaginal involvement at diagnosis, baseline symptoms, and obesity predicted GU or vaginal toxicities. Only 1 study evaluated insufficiency fractures and demonstrated lower pretreatment bone densities to be associated. CONCLUSIONS This review detected multiple candidate predictors of toxicity. Larger studies should consider insufficiency fractures, assess dose levels from external beam radiation therapy, and quantify the relationship between the predictors and treatment-related toxicities in women with LACC to further facilitate NTCP model development for clinical use.
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Affiliation(s)
- Anouk Corbeau
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands.
| | - Wilma D Heemsbergen
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sander C Kuipers
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Medical Physics & Informatics, HollandPTC, Delft, The Netherlands
| | - Jeremy Godart
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Medical Physics & Informatics, HollandPTC, Delft, The Netherlands
| | - Carien L Creutzberg
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Remi A Nout
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Stephanie M de Boer
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
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Van Anh DT, Thang VH, Dung TA, Huyen TT, Nhan DTT, Van Giang B, Huyen PT. Outcome and toxicity of chemoradiation using volumetric modulated arc therapy followed by 3D image-guided brachytherapy for cervical cancer: Vietnam National Cancer Hospital experience. Rep Pract Oncol Radiother 2024; 28:784-793. [PMID: 38515819 PMCID: PMC10954271 DOI: 10.5603/rpor.98735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 12/20/2023] [Indexed: 03/23/2024] Open
Abstract
Background Volumetric modulated arc therapy (VMAT) and 3D image-guided brachytherapy (3D-IGBT) have recently been introduced in Vietnam for the treatment of locally advanced cervical cancer. This study aims to assess the outcomes and toxicities of chemoradiation using VMAT followed by 3D-IGBT in Vietnamese cervical cancer patients. Materials and methods A prospective interventional study on 72 patients with 2018 International Federation of Gynecology and Obstetrics (FIGO) stage IB3-IIIC2 disease who underwent concurrent chemoradiation using VMAT, followed by 3D-IGBT according to EMBRACE-II protocol. Primary endpoints were locoregional control; secondary endpoints were systemic control and toxicity. Results Median body volume received 43 Gy was 1589.1 cm3 (range 1214.8-2574.8). Median high-risk clinical target volume (CTV-HR) was 18.8 cm3 (range 8.6-61.2) with a median dose to 90% (D90) of CTV-HR of 90.6 Gy (range 86.8-99.6). Mean doses to 2cc (D2cc) of bladder, rectum, and sigmoid were 75.8, 55.2, and 62.1 Gy, respectively. At median 19-month follow-up (range 12-25), locoregional control and systemic control were 95.8% and 81.9%, respectively. Systemic control was the lowest in N2 disease (54.5%). Grade ≥ 3 acute toxicities were less than 10%, except neutropenia (31.9%). Extended-field radiation increased significantly nausea, fatigue, and thrombocytopenia. No grade ≥ 3 proctitis or cystitis; 8.3% had grade 3 vaginal stenosis. Conclusions VMAT-based chemoradiation therapy followed by 3D-IGBT achieved high locoregional control with manageable toxicities in locally advanced cervical cancer. Systemic control correlated with disease stage.
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Affiliation(s)
- Dang Thi Van Anh
- Hanoi Medical University, Hanoi, Vietnam
- Department of Breast and Gynecological Radiation Therapy, Vietnam National Cancer Hospital, Hanoi, Vietnam
| | - Vu Hong Thang
- Hanoi Medical University, Hanoi, Vietnam
- Department of Medical Oncology 4, Vietnam National Cancer Hospital, Hanoi, Vietnam
| | - To Anh Dung
- Department of Breast and Gynecological Radiation Therapy, Vietnam National Cancer Hospital, Hanoi, Vietnam
| | | | - Dao Thi Thanh Nhan
- Department of Breast and Gynecological Radiation Therapy, Vietnam National Cancer Hospital, Hanoi, Vietnam
| | | | - Phung Thi Huyen
- Department of Medical Oncology 6, Vietnam National Cancer Hospital, Hanoi, Vietnam
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Asakitogum DA, Nutor JJ, Pozzar R, Hammer M, Miaskowski C. Systematic Review of the Literature on Multiple Co-occurring Symptoms in Patients Receiving Treatment for Gynecologic Cancers. Semin Oncol Nurs 2024; 40:151572. [PMID: 38246840 DOI: 10.1016/j.soncn.2023.151572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 11/23/2023] [Accepted: 12/07/2023] [Indexed: 01/23/2024]
Abstract
OBJECTIVE Patients with gynecologic cancers experience a very high symptom burden that has a negative impact on their quality of life. This systematic review aims to identify the common co-occurring symptoms, the prevalence of common symptoms, common instruments used to measure symptoms, associated risk factors, and the symptom burden in patients with gynecologic cancers. DATA SOURCES A search of four databases (ie, PubMed, Embase, Web of Science, and CINAHL) was done from January 1, 2012, through September 5, 2022. A qualitative synthesis of the extant literature was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines (PRISMA 2020). CONCLUSION A total of 118 studies met the prespecified inclusion criteria. Ninety-six symptoms were assessed across these studies. The top six symptoms and their grand mean prevalence rates were lack of energy (64.4%), fatigue (62.1%), abdominal pain (53.3%), depression (52.6%), concentration dysfunction (52.0%), and drowsiness (51.9%). Numerous methodologic challenges were evident across studies. Future research needs to develop a disease-specific symptom assessment measure, evaluate for risk factors associated with a higher symptom burden, and determine the impact of multiple symptoms on patient outcomes. IMPLICATION FOR NURSING PRACTICE The results are relevant for oncology clinicians to assess patients with gynecologic cancers for the presence of common symptoms and risk factors for higher symptom burden in the patients and to offer effective management interventions.
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Affiliation(s)
- David Ayangba Asakitogum
- Doctoral student, Department of Family Health Care Nursing, School of Nursing, University of California, San Francisco, CA.
| | - Jerry John Nutor
- Assistant Professor, Department of Family Health Care Nursing, School of Nursing, University of California, San Francisco, CA
| | - Rachel Pozzar
- Nurse Scientist and Instructor, Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, MA
| | - Marilyn Hammer
- Nurse Scientist and Instructor, Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, MA; Director, Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, MA
| | - Christine Miaskowski
- Professor, Departments of Physiological Nursing and Anesthesia, School of Nursing and Medicine, University of California, San Francisco, CA
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Barten DLJ, van Kesteren Z, Laan JJ, Dassen MG, Westerveld GH, Pieters BR, de Jonge CS, Stoker J, Bel A. Precision assessment of bowel motion quantification using 3D cine-MRI for radiotherapy. Phys Med Biol 2024; 69:04NT01. [PMID: 38232395 DOI: 10.1088/1361-6560/ad1f89] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 01/17/2024] [Indexed: 01/19/2024]
Abstract
Objective. The bowel is an important organ at risk for toxicity during pelvic and abdominal radiotherapy. Identifying regions of high and low bowel motion with MRI during radiotherapy may help to understand the development of bowel toxicity, but the acquisition time of MRI is rather long. The aim of this study is to retrospectively evaluate the precision of bowel motion quantification and to estimate the minimum MRI acquisition time.Approach. We included 22 gynaecologic cancer patients receiving definitive radiotherapy with curative intent. The 10 min pre-treatment 3D cine-MRI scan consisted of 160 dynamics with an acquisition time of 3.7 s per volume. Deformable registration of consecutive images generated 159 deformation vector fields (DVFs). We defined two motion metrics, the 50th percentile vector lengths (VL50) of the complete set of DVFs was used to measure median bowel motion. The 95th percentile vector lengths (VL95) was used to quantify high motion of the bowel. The precision of these metrics was assessed by calculating their variation (interquartile range) in three different time frames, defined as subsets of 40, 80, and 120 consecutive images, corresponding to acquisition times of 2.5, 5.0, and 7.5 min, respectively.Main results. For the full 10 min scan, the minimum motion per frame of 50% of the bowel volume (M50%) ranged from 0.6-3.5 mm for the VL50 motion metric and 2.3-9.0 mm for the VL95 motion metric, across all patients. At 7.5 min scan time, the variation in M50% was less than 0.5 mm in 100% (VL50) and 95% (VL95) of the subsets. A scan time of 5.0 and 2.5 min achieved a variation within 0.5 mm in 95.2%/81% and 85.7%/57.1% of the subsets, respectively.Significance. Our 3D cine-MRI technique quantifies bowel loop motion with 95%-100% confidence with a precision of 0.5 mm variation or less, using a 7.5 min scan time.
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Affiliation(s)
- D L J Barten
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, 1105 AZAmsterdam, The Netherlands
| | - Z van Kesteren
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, 1105 AZAmsterdam, The Netherlands
| | - J J Laan
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, 1105 AZAmsterdam, The Netherlands
| | - M G Dassen
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, 1105 AZAmsterdam, The Netherlands
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - G H Westerveld
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, 1105 AZAmsterdam, The Netherlands
- Erasmus MC Cancer Institute, Erasmus University Medical Center, Department of Radiation Oncology, Rotterdam, The Netherlands
| | - B R Pieters
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, 1105 AZAmsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - C S de Jonge
- Amsterdam UMC location University of Amsterdam, Department of Radiology and Nuclear Medicine, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - J Stoker
- Amsterdam UMC location University of Amsterdam, Department of Radiology and Nuclear Medicine, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - A Bel
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, 1105 AZAmsterdam, The Netherlands
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Roeder F, Jensen AD, Lindel K, Mattke M, Wolf F, Gerum S. Geriatric Radiation Oncology: What We Know and What Can We Do Better? Clin Interv Aging 2023; 18:689-711. [PMID: 37168037 PMCID: PMC10166100 DOI: 10.2147/cia.s365495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 04/22/2023] [Indexed: 05/13/2023] Open
Abstract
Elderly patients represent a growing subgroup of cancer patients for whom the role of radiation therapy is poorly defined. Older patients are still clearly underrepresented in clinical trials, resulting in very limited high-level evidence. Moreover, elderly patients are less likely to receive radiation therapy in similar clinical scenarios compared to younger patients. However, there is no clear evidence for a generally reduced radiation tolerance with increasing age. Modern radiation techniques have clearly reduced acute and late side effects, thus extending the boundaries of the possible regarding treatment intensity in elderly or frail patients. Hypofractionated regimens have further decreased the socioeconomic burden of radiation treatments by reducing the overall treatment time. The current review aims at summarizing the existing data for the use of radiation therapy or chemoradiation in elderly patients focusing on the main cancer types. It provides an overview of treatment tolerability and outcomes with current standard radiation therapy regimens, including possible predictive factors in the elderly population. Strategies for patient selection for standard or tailored radiation therapy approaches based on age, performance score or comorbidity, including the use of prediction tests or geriatric assessments, are discussed. Current and future possibilities for improvements of routine care and creation of high-level evidence in elderly patients receiving radiation therapy are highlighted.
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Affiliation(s)
- Falk Roeder
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
| | - Alexandra D Jensen
- Department of Radiation Oncology, University Hospital Marburg-Giessen, Giessen, Germany
| | - Katja Lindel
- Department of Radiation Oncology, Städtisches Klinikum, Karlsruhe, Germany
| | - Matthias Mattke
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
| | - Frank Wolf
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
| | - Sabine Gerum
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
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Shelley CE, Bolt MA, Hollingdale R, Chadwick SJ, Barnard AP, Rashid M, Reinlo SC, Fazel N, Thorpe CR, Stewart AJ, South CP, Adams EJ. Implementing cone-beam computed tomography-guided online adaptive radiotherapy in cervical cancer. Clin Transl Radiat Oncol 2023; 40:100596. [PMID: 36910024 PMCID: PMC9999162 DOI: 10.1016/j.ctro.2023.100596] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 02/12/2023] [Indexed: 02/16/2023] Open
Abstract
Background and purpose Adaptive radiotherapy (ART) in locally advanced cervical cancer (LACC) has shown promising outcomes. This study investigated the feasibility of cone-beam computed tomography (CBCT)-guided online ART (oART) for the treatment of LACC. Material and methods The quality of the automated radiotherapy treatment plans and artificial intelligence (AI)-driven contour delineation for LACC on a novel CBCT-guided oART system were assessed. Dosimetric analysis of 200 simulated oART sessions were compared with standard treatment. Feasibility of oART was assessed from the delivery of 132 oART fractions for the first five clinical LACC patients. The simulated and live oART sessions compared a fixed planning target volume (PTV) margin of 1.5 cm around the uterus-cervix clinical target volume (CTV) with an internal target volume-based approach. Workflow timing measurements were recorded. Results The automatically-generated 12-field intensity-modulated radiotherapy plans were comparable to manually generated plans. The AI-driven organ-at-risk (OAR) contouring was acceptable requiring, on average, 12.3 min to edit, with the bowel performing least well and rated as unacceptable in 16 % of cases. The treated patients demonstrated a mean PTV D98% (+/-SD) of 96.7 (+/- 0.2)% for the adapted plans and 94.9 (+/- 3.7)% for the non-adapted scheduled plans (p<10-5). The D2cc (+/-SD) for the bowel, bladder and rectum were reduced by 0.07 (+/- 0.03)Gy, 0.04 (+/-0.05)Gy and 0.04 (+/-0.03)Gy per fraction respectively with the adapted plan (p <10-5). In the live.setting, the mean oART session (+/-SD) from CBCT acquisition to beam-on was 29 +/- 5 (range 21-44) minutes. Conclusion CBCT-guided oART was shown to be feasible with dosimetric benefits for patients with LACC. Further work to analyse potential reductions in PTV margins is ongoing.
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Affiliation(s)
- Charlotte E Shelley
- Department of Oncology, St. Luke's Cancer Centre, Royal Surrey Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK
| | - Matthew A Bolt
- Department of Oncology, St. Luke's Cancer Centre, Royal Surrey Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK
| | - Rachel Hollingdale
- Department of Oncology, St. Luke's Cancer Centre, Royal Surrey Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK
| | - Susan J Chadwick
- Department of Oncology, St. Luke's Cancer Centre, Royal Surrey Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK
| | - Andrew P Barnard
- Department of Oncology, St. Luke's Cancer Centre, Royal Surrey Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK
| | - Miriam Rashid
- Department of Oncology, St. Luke's Cancer Centre, Royal Surrey Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK
| | - Selina C Reinlo
- Department of Oncology, St. Luke's Cancer Centre, Royal Surrey Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK
| | - Nawda Fazel
- Department of Oncology, St. Luke's Cancer Centre, Royal Surrey Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK
| | - Charlotte R Thorpe
- Department of Oncology, St. Luke's Cancer Centre, Royal Surrey Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK
| | - Alexandra J Stewart
- Department of Oncology, St. Luke's Cancer Centre, Royal Surrey Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK.,University of Surrey, Guildford GU2 7XX, UK
| | - Chris P South
- Department of Oncology, St. Luke's Cancer Centre, Royal Surrey Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK
| | - Elizabeth J Adams
- Department of Oncology, St. Luke's Cancer Centre, Royal Surrey Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK
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Wang L, Alexander S, Mason S, Blasiak-Wal I, Harris E, McNair H, Lalondrelle S. Carpe Diem: Making the Most of Plan-of-the-Day for Cervical Cancer Radiation Therapy. Pract Radiat Oncol 2023; 13:132-147. [PMID: 36481683 DOI: 10.1016/j.prro.2022.11.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 10/26/2022] [Accepted: 11/03/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE Radiation therapy is the key treatment for locally advanced cervical cancer. Organ motion presents a challenge to accurate targeting of external beam radiation therapy. The plan-of-the-day (PotD) adaptive approach is therefore an attractive option. We present our experience and the procedural steps required to implement PotD for cervix cancer. METHODS AND MATERIALS We reviewed relevant studies on organ motion and adaptive radiation therapy identified through a literature search and cross referencing. These included 10 dosimetric and 3 quality of life studies directly assessing the PotD approach to radiation therapy in cervix cancer. RESULTS Studies show improvements in target coverage and reduction of dose received by normal tissues and suggest improved toxicity. Clinical implementation of PotD has been slow because of a number of difficulties and uncertainties, which we discuss with the aim of helping teams to implement PotD at their center. CONCLUSIONS The PotD approach improves dosimetry and may improve toxicity. We describe a framework to assist with practical implementation.
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Affiliation(s)
- Lei Wang
- The Joint Department of Physics at the Institute of Cancer Research, Sutton, Surrey, United Kingdom.
| | - Sophie Alexander
- Radiotherapy Department, Royal Marsden NHS Foundation Trust, Sutton, Surrey, United Kingdom
| | - Sarah Mason
- The Joint Department of Physics at the Institute of Cancer Research, Sutton, Surrey, United Kingdom
| | - Irena Blasiak-Wal
- The Joint Department of Physics at the Institute of Cancer Research, Sutton, Surrey, United Kingdom
| | - Emma Harris
- The Joint Department of Physics at the Institute of Cancer Research, Sutton, Surrey, United Kingdom
| | - Helen McNair
- Radiotherapy Department, Royal Marsden NHS Foundation Trust, Sutton, Surrey, United Kingdom
| | - Susan Lalondrelle
- The Joint Department of Physics at the Institute of Cancer Research, Sutton, Surrey, United Kingdom
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12
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Ma CY, Zhao J, Gan GH, He XL, Xu XT, Qin SB, Wang LL, Li L, Zhou JY. Establishment of a prediction model for severe acute radiation enteritis associated with cervical cancer radiotherapy. World J Gastroenterol 2023; 29:1344-1358. [PMID: 36925455 PMCID: PMC10011961 DOI: 10.3748/wjg.v29.i8.1344] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 01/13/2023] [Accepted: 02/15/2023] [Indexed: 02/28/2023] Open
Abstract
BACKGROUND Cervical cancer is one of the most common gynecological malignant tumors. Radiation enteritis (RE) leads to radiotherapy intolerance or termination of radiotherapy, which negatively impacts the therapeutic effect and seriously affects the quality of life of patients. If the incidence of RE in patients can be predicted in advance, and targeted clinical preventive treatment can be carried out, the side effects of radiotherapy in cervical cancer patients can be significantly reduced. Furthermore, accurate prediction of RE is essential for the selection of individualized radiation dose and the optimization of the radiotherapy plan.
AIM To analyze the relationships between severe acute RE (SARE) of cervical cancer radiotherapy and clinical factors and dose-volume parameters retrospectively.
METHODS We included 50 cervical cancer patients who received volumetric modulated arc therapy (VMAT) from September 2017 to June 2018 in the Department of Radiotherapy at The First Affiliated Hospital Soochow University. Clinical and dose-volume histogram factors of patients were collected. Logistic regression analysis was used to evaluate the predictive value of each factor for SARE. A nomogram to predict SARE was developed (SARE scoring system ≥ 3 points) based on the multiple regression coefficients; validity was verified by an internal verification method.
RESULTS Gastrointestinal and hematological toxicity of cervical cancer VMAT gradually increased with radiotherapy and reached the peak at the end of radiotherapy. The main adverse reactions were diarrhea, abdominal pain, colitis, anal swelling, and blood in the stool. There was no significant difference in the incidence of gastrointestinal toxicity between the radical and postoperative adjuvant radiotherapy groups (P > 0.05). There were significant differences in the small intestine V20, V30, V40, and rectal V40 between adjuvant radiotherapy and radical radiotherapy after surgery (P < 0.05). Univariate and multivariate analyses revealed anal bulge rating (OR: 14.779, 95%CI: 1.281-170.547, P = 0.031) and disease activity index (DAI) score (OR: 53.928, 95%CI: 3.822-760.948, P = 0.003) as independent predictors of SARE.
CONCLUSION Anal bulge rating (> 0.500 grade) and DAI score (> 2.165 points) can predict SARE. The nomogram shows potential value in clinical practice.
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Affiliation(s)
- Chen-Ying Ma
- Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou 215123, Jiangsu Province, China
| | - Jing Zhao
- Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou 215123, Jiangsu Province, China
| | - Guang-Hui Gan
- Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou 215123, Jiangsu Province, China
| | - Xiao-Lan He
- Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou 215123, Jiangsu Province, China
| | - Xiao-Ting Xu
- Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou 215123, Jiangsu Province, China
| | - Song-Bing Qin
- Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou 215123, Jiangsu Province, China
| | - Li-Li Wang
- Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou 215123, Jiangsu Province, China
| | - Li Li
- Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou 215123, Jiangsu Province, China
| | - Ju-Ying Zhou
- Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou 215123, Jiangsu Province, China
- State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou 215123, Jiangsu Province, China
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13
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Delpon G, Barateau A, Beneux A, Bessières I, Latorzeff I, Welmant J, Tallet A. [What do we need to deliver "online" adapted radiotherapy treatment plans?]. Cancer Radiother 2022; 26:794-802. [PMID: 36028418 DOI: 10.1016/j.canrad.2022.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 06/27/2022] [Accepted: 06/29/2022] [Indexed: 11/17/2022]
Abstract
During the joint SFRO/SFPM session of the 2019 congress, a state of the art of adaptive radiotherapy announced a strong impact in our clinical practice, in particular with the availability of treatment devices coupled to an MRI system. Three years later, it seems relevant to take stock of adaptive radiotherapy in practice, and especially the "online" strategy because it is indeed more and more accessible with recent hardware and software developments, such as coupled accelerators to a three-dimensional imaging device and algorithms based on artificial intelligence. However, the deployment of this promising strategy is complex because it contracts the usual time scale and upsets the usual organizations. So what do we need to deliver adapted treatment plans with an "online" strategy?
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Affiliation(s)
- G Delpon
- Institut de cancérologie de l'Ouest, Saint-Herblain et IMT Atlantique, Nantes université, CNRS/IN2P3, Subatech, Nantes, France.
| | - A Barateau
- Université Rennes, CLCC Eugène-Marquis, Inserm, LTSI-UMR 1099, Rennes, France
| | - A Beneux
- Hospices Civils de Lyon, Lyon, France
| | - I Bessières
- Centre Georges-François Leclerc, Dijon, France
| | | | - J Welmant
- Institut du cancer de Montpellier, Montpellier, France
| | - A Tallet
- Institut Paoli-Calmettes, Marseille, France
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