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Aleman BMP, Ricardi U, van der Maazen RWM, Meijnders P, Beijert M, Boros A, Izar F, Janus CPM, Levis M, Martin V, Specht L, Corning C, Clementel E, Raemaekers JM, André MP, Federico M, Fortpied C, Girinsky T. A Quality Control Study on Involved Node Radiation Therapy in the European Organisation for Research and Treatment of Cancer/Lymphoma Study Association/Fondazione Italiana Linfomi H10 Trial on Stages I and II Hodgkin Lymphoma: Lessons Learned. Int J Radiat Oncol Biol Phys 2023; 117:664-674. [PMID: 37179034 DOI: 10.1016/j.ijrobp.2023.05.011] [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: 01/04/2023] [Revised: 04/29/2023] [Accepted: 05/05/2023] [Indexed: 05/15/2023]
Abstract
PURPOSE Involved node radiation therapy (INRT) was introduced in the European Organisation for Research and Treatment of Cancer/Lymphoma Study Association/Fondazione Italiana Linfomi H10 trial, a large multicenter trial in early-stage Hodgkin Lymphoma. The present study aimed to evaluate the quality of INRT in this trial. METHODS AND MATERIALS A retrospective, descriptive study was initiated to evaluate INRT in a representative sample encompassing approximately 10% of all irradiated patients in the H10 trial. Sampling was stratified by academic group, year of treatment, size of the treatment center, and treatment arm, and it was done proportional to the size of the strata. The sample was completed for all patients with known recurrences to enable future research on relapse patterns. Radiation therapy principle, target volume delineation and coverage, and applied technique and dose were evaluated using the EORTC Radiation Therapy Quality Assurance platform. Each case was reviewed by 2 reviewers and, in case of disagreement also by an adjudicator for a consensus evaluation. RESULTS Data were retrieved for 66 of 1294 irradiated patients (5.1%). Data collection and analysis were hampered more than anticipated by changes in archiving of diagnostic imaging and treatment planning systems during the running period of the trial. A review could be performed on 61 patients. The INRT principle was applied in 86.6%. Overall, 88.5% of cases were treated according to protocol. Unacceptable variations were predominately due to geographic misses of the target volume delineations. The rate of unacceptable variations decreased during trial recruitment. CONCLUSIONS The principle of INRT was applied in most of the reviewed patients. Almost 90% of the evaluated patients were treated according to the protocol. The present results should, however, be interpreted with caution because the number of patients evaluated was limited. Individual case reviews should be done in a prospective fashion in future trials. Radiation therapy Quality Assurance tailored to the clinical trial objectives is strongly recommended.
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Affiliation(s)
- Berthe M P Aleman
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands.
| | | | | | - Paul Meijnders
- Department of Radiotherapy, Iridium Network, Centre for Oncological Research of the University of Antwerp, Antwerp, Belgium
| | - Max Beijert
- Department of Radiotherapy, University Medical Center Groningen, Groningen, Netherlands
| | - Angela Boros
- Radiation Oncology Department, Center Hospitalier Lyon Sud, Pierre Benite, France
| | - Françoise Izar
- Department of Radiotherapy, Institut universitaire du cancer de Toulouse, Toulouse, France
| | - Cécile P M Janus
- Department of Radiotherapy, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Mario Levis
- Department of Oncology, University of Turin, Turin, Italy
| | - Valentine Martin
- Department of Radiotherapy, Institut Gustave Roussy, Villejuif, France
| | - Lena Specht
- Department of Oncology, Rigshospitalet, University of Copenhagen, Denmark
| | - Coreen Corning
- The European Organisation for Research and Treatment of Cancer (EORTC) Headquarters, Brussels, Belgium
| | - Enrico Clementel
- The European Organisation for Research and Treatment of Cancer (EORTC) Headquarters, Brussels, Belgium
| | - John M Raemaekers
- Department of Internal Medicine, Rijnstate Hospital, Arnhem, Netherlands
| | - Marc P André
- Department of Hematology, CHU UCL Namur, Yvoir, Belgium
| | - Massimo Federico
- CHIMOMO Department, University of Modena and Reggio Emilia, Modena, Italy
| | - Catherine Fortpied
- The European Organisation for Research and Treatment of Cancer (EORTC) Headquarters, Brussels, Belgium
| | - Theodore Girinsky
- Department of Radiotherapy, Institut Gustave Roussy, Villejuif, France
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2
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Oertel M, Hering D, Nacke N, Kittel C, Kröger K, Kriz J, Fuchs M, Baues C, Vordermark D, Engenhart-Cabillic R, Herfarth K, Lukas P, Schmidberger H, Marnitz S, Borchmann P, Engert A, Haverkamp U, Eich HT. Radiation Therapy in the German Hodgkin Study Group HD 16 and HD 17 Trials: Quality Assurance and Dosimetric Analysis for Hodgkin Lymphoma in the Modern Era. Adv Radiat Oncol 2023; 8:101169. [PMID: 36896214 PMCID: PMC9991533 DOI: 10.1016/j.adro.2022.101169] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 12/23/2022] [Indexed: 12/31/2022] Open
Abstract
Purpose Radiation therapy (RT) is an integral part of treatment concepts for early-stage Hodgkin lymphoma. This analysis reports on RT quality in the recent HD16 and 17 trials of the German Hodgkin Study Group (GHSG). Methods and Materials All RT plans of involved-node radiation therapy (INRT) in HD 17 were requested for analysis, along with 100 and 50 involved-field radiation therapy (IFRT) plans in HD 16 and 17, respectively. A structured assessment regarding field design and protocol adherence was performed by the reference radiation oncology panel of the GHSG. Results Overall, 100 (HD 16) and 176 (HD 17) patients were eligible for analysis. In HD 16, 84% of RT series were evaluated as correct, with significant improvement compared with the predecessor studies (P < .001). In HD 17, 76.1% of INRT cases revealed a correct RT design compared with 69.0% of IFRT-cases, which was superior to previous studies (P < .001). Comparing INRT and IFRT, we found no significant differences in the percentage of any deviation (P = .418) or major deviations (P = .466). Regarding dosimetry, INRT was accompanied by an improvement in thyroid doses. Comparing different RT techniques, we found that intensity-modulated RT showed a reduction of high doses in the lung at the expense of an increased low-dose exposure in HD 17. Conclusions The latest study generation of the GHSG demonstrates an improved quality in RT. A modern INRT design could be established without deterioration in quality. On a conceptual level, an individual consideration of the appropriate RT technique has to be performed.
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Affiliation(s)
- Michael Oertel
- Department of Radiation Oncology, University Hospital Muenster, Muenster, Germany
| | - Dominik Hering
- Department of Radiation Oncology, University Hospital Muenster, Muenster, Germany
| | - Nina Nacke
- Department of Radiation Oncology, University Hospital Muenster, Muenster, Germany
| | - Christopher Kittel
- Department of Radiation Oncology, University Hospital Muenster, Muenster, Germany
| | - Kai Kröger
- Department of Radiation Oncology, University Hospital Muenster, Muenster, Germany
| | - Jan Kriz
- Department of Radiation Oncology, Alexianer Clemenshospital Muenster, Muenster, Germany
| | - Michael Fuchs
- Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne, Düsseldorf, University Hospital of Cologne, Cologne, Germany
| | - Christian Baues
- Department of Radiation Oncology and Cyberknife Center, University Hospital of Cologne, Cologne, Germany
| | - Dirk Vordermark
- Department of Radiation Oncology, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Rita Engenhart-Cabillic
- Department of Radiotherapy and Radiation Oncology, University Hospital Giessen-Marburg, Marburg, Germany
| | - Klaus Herfarth
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Peter Lukas
- Department of Radiooncology, Medical University Innsbruck, Innsbruck, Austria
| | - Heinz Schmidberger
- Department of Radiotherapy and Radiation Oncology, University Hospital Mainz, Mainz, Germany
| | - Simone Marnitz
- Department of Radiation Oncology and Cyberknife Center, University Hospital of Cologne, Cologne, Germany
| | - Peter Borchmann
- Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne, Düsseldorf, University Hospital of Cologne, Cologne, Germany
| | - Andreas Engert
- Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne, Düsseldorf, University Hospital of Cologne, Cologne, Germany
| | - Uwe Haverkamp
- Department of Radiation Oncology, University Hospital Muenster, Muenster, Germany
| | - Hans Theodor Eich
- Department of Radiation Oncology, University Hospital Muenster, Muenster, Germany
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3
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Oertel M, Hering D, Baues C, Kittel C, Fuchs M, Kriz J, Kröger K, Vordermark D, Herfarth K, Engenhart-Cabillic R, Lukas P, Haverkamp U, Borchmann P, Eich HT. Radiation doses to mediastinal organs at risk in early-stage unfavorable Hodgkin lymphoma- a risk stratified analysis of the GHSG HD17 trial. Front Oncol 2023; 13:1183906. [PMID: 37213291 PMCID: PMC10196378 DOI: 10.3389/fonc.2023.1183906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 04/14/2023] [Indexed: 05/23/2023] Open
Abstract
Introduction The German Hodgkin Study Group (GHSG) HD17 trial established the omission of radiotherapy (RT) for patients with early-stage unfavorable Hodgkin lymphoma being PET-negative after 2 cycles of BEACOPP escalated plus 2 cycles of ABVD. This patient group reveals heterogeneity in characteristics and disease extent which prompted us to perform a decisive dosimetric analysis according to GHSG risk factors. This may help to tailor RT individually balancing risks and benefits. Methods For quality assurance, RT-plans were requested from the treating facilities (n= 141) and analyzed centrally. Dose-volume histograms were scanned either paper-based or digitally to obtain doses to mediastinal organs. These were registered and compared according to GHSG risk factors. Results Overall, RT plans of 176 patients were requested, 139 of which had dosimetric information on target volumes within the mediastinum. Most of these patients were stage II (92.8%), had no B-symptoms (79.1%) and were aged < 50 years (89.9%). Risk factors were present in 8.6% (extranodal involvement), 31.7% (bulky disease), 46.0% (elevated erythrocyte sedimentation rate) and 64.0% (three involved areas), respectively. The presence of bulky disease significantly affected the mean RT doses to the heart (p=0.005) and to the left lung (median: 11.3 Gy vs. 9.9 Gy; p=0.042) as well as V5 of the right and left lung, respectively (median right lung: 67.4% vs. 51.0%; p=0.011; median left lung: 65.9% vs. 54.2%; p=0.008). Significant differences in similar organs at risk parameters could be found between the sub-cohorts with the presence or absence of extranodal involvement, respectively. In contrast, an elevated erythrocyte sedimentation rate did not deteriorate dosimetry significantly. No association of any risk factor with radiation doses to the female breast was found. Conclusion Pre-chemotherapy risk factors may help to predict potential RT exposure to normal organs and to critically review treatment indication. Individualized risk-benefit evaluations for patients with HL in early-stage unfavorable disease are mandatory.
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Affiliation(s)
- Michael Oertel
- Department of Radiation Oncology, University Hospital Muenster, Muenster, Germany
| | - Dominik Hering
- Department of Radiation Oncology, University Hospital Muenster, Muenster, Germany
| | - Christian Baues
- Department of Radiation Oncology and Cyberknife Center, University Hospital of Cologne, Cologne, Germany
| | - Christopher Kittel
- Department of Radiation Oncology, University Hospital Muenster, Muenster, Germany
| | - Michael Fuchs
- Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne, Dusseldorf, University Hospital of Cologne, Cologne, Germany
| | - Jan Kriz
- Department of Radiation Oncology, Alexianer Clemenshospital Muenster, Muenster, Germany
| | - Kai Kröger
- Department of Radiation Oncology, University Hospital Muenster, Muenster, Germany
| | - Dirk Vordermark
- Department of Radiation Oncology, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Klaus Herfarth
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Rita Engenhart-Cabillic
- Department of Radiotherapy and Radiation Oncology, University Hospital Giessen-Marburg, Marburg, Germany
| | - Peter Lukas
- Department of Radiooncology, Medical University Innsbruck, Innsbruck, Austria
| | - Uwe Haverkamp
- Department of Radiation Oncology, University Hospital Muenster, Muenster, Germany
| | - Peter Borchmann
- Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne, Dusseldorf, University Hospital of Cologne, Cologne, Germany
| | - Hans Theodor Eich
- Department of Radiation Oncology, University Hospital Muenster, Muenster, Germany
- *Correspondence: Hans Theodor Eich,
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Hoppe BS, Hill-Kayser CE, Tseng YD, Flampouri S, Elmongy HM, Cahlon O, Mendenhall NP, Maity A, McGee LA, Plastaras JP. Consolidative proton therapy after chemotherapy for patients with Hodgkin lymphoma. Ann Oncol 2018; 28:2179-2184. [PMID: 28911093 PMCID: PMC5834068 DOI: 10.1093/annonc/mdx287] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background We investigated early outcomes for patients receiving chemotherapy followed by consolidative proton therapy (PT) for the treatment of Hodgkin lymphoma (HL). Patients and methods From June 2008 through August 2015, 138 patients with HL enrolled on either IRB-approved outcomes tracking protocols or registry studies received consolidative PT. Patients were excluded due to relapsed or refractory disease. Involved-site radiotherapy field designs were used for all patients. Pediatric patients received a median dose of 21 Gy(RBE) [range 15–36 Gy(RBE)]; adult patients received a median dose of 30.6 Gy(RBE) [range, 20–45 Gy(RBE)]. Patients receiving PT were young (median age, 20 years; range 6–57). Overall, 42% were pediatric (≤18 years) and 93% were under the age of 40 years. Thirty-eight percent of patients were male and 62% female. Stage distribution included 73% with I/II and 27% with III/IV disease. Patients predominantly had mediastinal involvement (96%) and bulky disease (57%), whereas 37% had B symptoms. The median follow-up was 32 months (range, 5–92 months). Results The 3-year relapse-free survival rate was 92% for all patients; it was 96% for adults and 87% for pediatric patients (P = 0.18). When evaluated by positron emission tomography/computed tomography scan response at the end of chemotherapy, patients with a partial response had worse 3-year progression-free survival compared with other patients (78% versus 94%; P = 0.0034). No grade 3 radiation-related toxicities have occurred to date. Conclusion Consolidative PT following standard chemotherapy in HL is primarily used in young patients with mediastinal and bulky disease. Early relapse-free survival rates are similar to those reported with photon radiation treatment, and no early grade 3 toxicities have been observed. Continued follow-up to assess late effects is critical.
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Affiliation(s)
- B S Hoppe
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville.,University of Florida Health Proton Therapy Institute, Jacksonville
| | - C E Hill-Kayser
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia
| | - Y D Tseng
- Department of Radiation Oncology, University of Washington, Seattle.,Proton Collaborative Group Registry Membership Site, Warrenville.,Seattle Cancer Care Alliance Proton Therapy Center, Seattle
| | - S Flampouri
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville
| | - H M Elmongy
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia
| | - O Cahlon
- Proton Collaborative Group Registry Membership Site, Warrenville.,Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York.,Procure Proton Therapy Center, Somerset
| | - N P Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville.,University of Florida Health Proton Therapy Institute, Jacksonville
| | - A Maity
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia
| | - L A McGee
- Proton Collaborative Group Registry Membership Site, Warrenville.,Mayo Clinic, Scottsdale, USA
| | - J P Plastaras
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia
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5
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Radiation Therapy in Hodgkin’s Lymphoma. Radiat Oncol 2017. [DOI: 10.1007/978-3-319-52619-5_19-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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6
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Baues C, Semrau R, Gaipl US, Bröckelmann PJ, Rosenbrock J, Engert A, Marnitz S. Checkpoint inhibitors and radiation treatment in Hodgkin's lymphoma : New study concepts of the German Hodgkin Study Group. Strahlenther Onkol 2016; 193:95-99. [PMID: 27704149 DOI: 10.1007/s00066-016-1050-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Accepted: 09/01/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with classical Hodgkin's lymphoma (cHL) have a good prognosis even in advanced stages. However, combined chemo- and radiotherapy, as the standard of care, is also associated with treatment-related toxicities such as organ damage, secondary neoplasias, infertility, or fatigue and long-term fatigue. Many patients suffer from this burden although their cHL was cured. Therefore, the efficacy of immune checkpoint inhibitors like anti-PD1/PD-L1 antibodies in the treatment of solid cancers and also in HL offers new options. A remarkable and durable response rate with a favorable toxicity profile was observed in heavily pretreated cHL patients. METHODS Planning to perform prospective randomized clinical trials in the content of radio-immune treatment in patients with Hodgkin's lymphoma (HL), we transferred the results of preliminary clinical studies and basic research in clinical relevant study concepts. RESULTS Based on these promising early phase trial data, the German Hodgkin Study Group (GHSG) will investigate innovative treatment regimens in upcoming phase II trials. CONCLUSION The therapeutic efficacy and potential synergies of anti-PD1 antibodies in combination with chemo- or radiotherapy will be investigated in various settings of HL.
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Affiliation(s)
- C Baues
- Medical Faculty, Department of Radiooncology, University of Cologne, Cologne, Germany. .,German Hodgkin Study Group (GHSG), University of Cologne, Cologne, Germany.
| | - R Semrau
- Medical Faculty, Department of Radiooncology, University of Cologne, Cologne, Germany.,German Hodgkin Study Group (GHSG), University of Cologne, Cologne, Germany
| | - U S Gaipl
- Department of Radiooncology, University hospital Erlangen, Erlangen, Germany
| | - P J Bröckelmann
- German Hodgkin Study Group (GHSG), University of Cologne, Cologne, Germany.,Medical Faculty, Department of Internal Medicine I, University of Cologne, Cologne, Germany
| | - J Rosenbrock
- Medical Faculty, Department of Radiooncology, University of Cologne, Cologne, Germany
| | - A Engert
- German Hodgkin Study Group (GHSG), University of Cologne, Cologne, Germany.,Medical Faculty, Department of Internal Medicine I, University of Cologne, Cologne, Germany
| | - S Marnitz
- Medical Faculty, Department of Radiooncology, University of Cologne, Cologne, Germany.,German Hodgkin Study Group (GHSG), University of Cologne, Cologne, Germany
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