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Weil BR, Murphy AJ, Liu Q, Howell RM, Smith SA, Weldon CB, Mullen EA, Madenci AL, Leisenring WM, Neglia JP, Turcotte LM, Oeffinger KC, Termuhlen AM, Mostoufi-Moab S, Levine JM, Krull KR, Yasui Y, Robison LL, Armstrong GT, Chow EJ, Armenian SH. Late Health Outcomes Among Survivors of Wilms Tumor Diagnosed Over Three Decades: A Report From the Childhood Cancer Survivor Study. J Clin Oncol 2023; 41:2638-2650. [PMID: 36693221 PMCID: PMC10414738 DOI: 10.1200/jco.22.02111] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/29/2022] [Accepted: 12/09/2022] [Indexed: 01/25/2023] Open
Abstract
PURPOSE To evaluate long-term morbidity and mortality among unilateral, nonsyndromic Wilms tumor (WT) survivors according to conventional treatment regimens. METHODS Cumulative incidence of late mortality (≥ 5 years from diagnosis) and chronic health conditions (CHCs) were evaluated in WT survivors from the Childhood Cancer Survivor Study. Outcomes were evaluated by treatment, including nephrectomy combined with vincristine and actinomycin D (VA), VA + doxorubicin + abdominal radiotherapy (VAD + ART), VAD + ART + whole lung radiotherapy, or receipt of ≥ 4 chemotherapy agents. RESULTS Among 2,008 unilateral WT survivors, 142 deaths occurred (standardized mortality ratio, 2.9, 95% CI, 2.5 to 3.5; 35-year cumulative incidence of death, 7.8%, 95% CI, 6.3 to 9.2). The 35-year cumulative incidence of any grade 3-5 CHC was 34.1% (95% CI, 30.7 to 37.5; rate ratio [RR] compared with siblings 3.0, 95% CI, 2.6 to 3.5). Survivors treated with VA alone had comparable risk for all-cause late mortality relative to the general population (standardized mortality ratio, 1.0; 95% CI, 0.5 to 1.7) and modestly increased risk for grade 3-5 CHCs compared with siblings (RR, 1.5; 95% CI, 1.1 to 2.0), but remained at increased risk for intestinal obstruction (RR, 9.4; 95% CI, 3.9 to 22.2) and kidney failure (RR, 11.9; 95% CI, 4.2 to 33.6). Magnitudes of risk for grade 3-5 CHCs, including intestinal obstruction, kidney failure, premature ovarian insufficiency, and heart failure, increased by treatment group intensity. CONCLUSION With approximately 40% of patients with newly diagnosed WT currently treated with VA alone, the burden of late mortality/morbidity in future decades is projected to be lower than that for survivors from earlier eras. Nevertheless, the risk of late effects such as intestinal obstruction and kidney failure was elevated across all treatment groups, and there was a dose-dependent increase in risk for all grade 3-5 CHCs by treatment group intensity.
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Affiliation(s)
- Brent R. Weil
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
| | - Andrew J. Murphy
- Department of Surgery, St Jude Children's Research Hospital, Memphis, TN
| | - Qi Liu
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Rebecca M. Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Susan A. Smith
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Christopher B. Weldon
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Elizabeth A. Mullen
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
| | - Arin L. Madenci
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Wendy M. Leisenring
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Center, Seattle, WA
| | - Joseph P. Neglia
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | - Lucie M. Turcotte
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | | | - Amanda M. Termuhlen
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | - Sogol Mostoufi-Moab
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Kevin R. Krull
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Eric J. Chow
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Center, Seattle, WA
| | - Saro H. Armenian
- Department of Population Sciences, City of Hope, Duarte, CA
- Department of Pediatrics, City of Hope, Duarte, CA
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Kalapurakal JA, Lee B, Bautista J, Rigsby C, Helenowski I, Gopalakrishnan M. Cardiac-Sparing Whole Lung Intensity Modulated Radiation Therapy in Children With Wilms Tumor: Final Report on Technique and Abdominal Field Matching to Maximize Normal Tissue Protection. Pract Radiat Oncol 2018; 9:e62-e73. [PMID: 30096378 DOI: 10.1016/j.prro.2018.07.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 07/23/2018] [Accepted: 07/28/2018] [Indexed: 11/15/2022]
Abstract
PURPOSE Cardiac-sparing whole lung intensity modulated radiation therapy (WL IMRT) has been shown to improve cardiac protection and lung volume dose coverage compared with standard anteroposterior techniques. This dosimetry study had 2 aims: To determine the dosimetric advantages of a modified WL IMRT (M-WL IMRT) technique, designed to reduce radiation exposure to the thyroid gland and breast tissues, compared with standard WL IMRT (S-WL IMRT) and to determine the dosimetric advantages of M-WL IMRT and dosimetrically matched abdomen and flank radiation therapy (RT) fields designed to reduce normal tissue exposure compared with standard field matching techniques. METHODS AND MATERIALS Computed tomography scans of the chest and abdomen that were obtained during computed tomography simulation of 10 female children were used. For Aim 1, for S-WL IMRT, the planning target volume (PTV) was obtained with a 1-cm expansion of the 4-dimensional lung volume (internal target volume). For M-WL IMRT, the PTV was reduced around the breast and thyroid gland to facilitate thyroid and breast sparing. For Aim 2, standard matching techniques for 3-dimensional anterior/posterior-posterior/anteriorwhole lung and abdominal RT fields were compared with a new dosimetric matching technique for WL IMRT and abdomen and flank fields. For both aims, the dose coverage of the lungs and radiation exposure to normal tissues (heart, thyroid, breasts) were statistically compared. RESULTS Compared with S-WL IMRT, the M-WL IMRT technique provided similar lung PTV dose coverage and a significantly superior reduction in mean breast and thyroid doses, without compromising cardiac protection. The M-WL IMRT technique combined with a dosimetrically matched abdomen and flank fields showed significantly superior normal tissue protection compared with standard matched anterior/posterior-posterior/anteriorlung and abdomen and flank RT fields. CONCLUSIONS This study has shown that the M-WL IMRT technique can reduce radiation exposure to the thyroid gland and breast tissue without compromising cardiac protection and 4-dimensional lung volume dose coverage. This report also describes a new dosimetric matching technique between WL IMRT and abdomen and flank fields that will improve normal tissue sparing compared with standard techniques.
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Affiliation(s)
- John A Kalapurakal
- Northwestern University, Chicago, Illinois; Northwestern Memorial Hospital, Chicago, Illinois.
| | - Bryan Lee
- Northwestern Memorial Hospital, Chicago, Illinois
| | | | - Cynthia Rigsby
- Northwestern Memorial Hospital, Chicago, Illinois; Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois
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