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Nair A, Waack A, Sharma S, Hoyt A, Schroeder J. Letter to editor regarding "Neurosurgical emergencies during pregnancy-management dilemmas". Surg Neurol Int 2023; 14:421. [PMID: 38213423 PMCID: PMC10783692 DOI: 10.25259/sni_729_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/07/2023] [Indexed: 01/13/2024] Open
Affiliation(s)
- Ajay Nair
- Department of Neurosurgery, College of Medicine and Life Sciences, University of Toledo, Toledo, United States
| | - Andrew Waack
- Department of Neurosurgery, College of Medicine and Life Sciences, University of Toledo, Toledo, United States
| | - Soumya Sharma
- Department of Neurosurgery, College of Medicine and Life Sciences, University of Toledo, Toledo, United States
| | - Alastair Hoyt
- Department of Neurosurgery, University of Toledo Medical Center, Toledo, United States
| | - Jason Schroeder
- Department of Surgery, University of Toledo Medical Center, Toledo, United States
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Wong YM, Koh CWY, Lew KS, Chua CGA, Nei W, Tan HQ, Lee JCL, Mazonakis M, Damilakis J. A review on fetal dose in Radiotherapy: A historical to contemporary perspective. Phys Med 2023; 105:102513. [PMID: 36565555 DOI: 10.1016/j.ejmp.2022.102513] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/09/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
This paper aims to review on fetal dose in radiotherapy and extends and updates on a previous work1 to include proton therapy. Out-of-field doses, which are the doses received by regions outside of the treatment field, are unavoidable regardless of the treatment modalities used during radiotherapy. In the case of pregnant patients, fetal dose is a major concern as it has long been recognized that fetuses exposed to radiation have a higher probability of suffering from adverse effects such as anatomical malformations and even fetal death, especially when the 0.1Gy threshold is exceeded. In spite of the low occurrence of cancer during pregnancy, the radiotherapy team should be equipped with the necessary knowledge to deal with fetal dose. This is crucial so as to ensure that the fetus is adequately protected while not compromising the patient treatment outcomes. In this review paper, various aspects of fetal dose will be discussed ranging from biological, clinical to the physics aspects. Other than fetal dose resulting from conventional photon therapy, this paper will also extend the discussion to modern treatment modalities and techniques, namely proton therapy and image-guided radiotherapy, all of which have seen a significant increase in use in current radiotherapy. This review is expected to provide readers with a comprehensive understanding of fetal dose in radiotherapy, and to be fully aware of the steps to be taken in providing radiotherapy for pregnant patients.
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Affiliation(s)
- Yun Ming Wong
- Division of Physics and Applied Physics, Nanyang Technological University, Singapore
| | | | - Kah Seng Lew
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | | | - Wenlong Nei
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - Hong Qi Tan
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore.
| | - James Cheow Lei Lee
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore; Division of Physics and Applied Physics, Nanyang Technological University, Singapore
| | - Michael Mazonakis
- Department of Medical Physics, School of Medicine, University of Crete, Greece
| | - John Damilakis
- Department of Medical Physics, School of Medicine, University of Crete, Greece
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Karbhari N, Thomas AA. Clinical management of brain tumors in pregnancy. Curr Opin Oncol 2022; 34:691-697. [PMID: 36170169 DOI: 10.1097/cco.0000000000000894] [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: 11/25/2022]
Abstract
PURPOSE OF REVIEW We review the diagnostic tools, treatment options, and clinical management for brain tumors diagnosed in pregnancy with consideration for management approaches that are best suited to preserve maternal and fetal health. RECENT FINDINGS Women of child-bearing age are at risk of developing brain tumors and are at increased risk compared with male counterparts for tumors that are hormonally driven. Brain tumors are rare neoplasms, and diagnosis of brain tumors in pregnancy is uncommon, such that management guidelines and treatment recommendations are lacking for most tumor types. We discuss the standard treatment options for brain tumors and the relative risks and safety when these treatments are considered during pregnancy. We review the neoplasms most commonly affecting pregnant women and the existing literature and guidelines. SUMMARY Pregnancy is a unique phase of life in which hormonal, immunologic, and vascular changes may impact tumor growth and presentation. Treatment decisions should consider the symptoms and stability of the pregnant patients, the gestational age and health of the fetus, and the location and behavior of the neoplasm.
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Affiliation(s)
- Nishika Karbhari
- Department of Neurology, Dartmouth Hitchcock Medical Center, Hanover, NH
| | - Alissa A Thomas
- Department of Neurological Sciences, University of Vermont Larner College of Medicine, Burlington, VT, USA
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Abstract
We present the updated recommendations of the French society for radiation oncology on radiotherapy and pregnancy. The occurrence of cancer during pregnancy is a rare event (approximately 1 in 1000 pregnancies). The risks for the embryo or the foetus depend on the gestational age at the time of irradiation. The main risks are malformations with microcephaly and mental retardation. There is also a risk of radiation-induced cancer in the unborn child. In the case of only supradiaphragmatic irradiation, radiotherapy can be performed most often in pregnant women without risk to the foetus. On the other hand, in the case of an indication for subdiaphragmatic irradiation, therapeutic termination of the pregnancy should be proposed. In all cases, when radiotherapy is chosen, a phantom estimation of the dose delivered to the foetus, confirmed by in vivo measurement, is recommended. Conformational radiotherapy is the preferred technique because of the lower dose delivered to the foetus (except in tumour locations where other techniques such as IMRT are recommended).
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Affiliation(s)
- M Michalet
- Institut du cancer de Montpellier, 208, avenue des Apothicaires, 34298 Montpellier, France.
| | - C Dejean
- Centre Antoine-Lacassagne, 33, avenue de Valombrose, 06100 Nice, France
| | - U Schick
- CHRU de Brest, 2, avenue Foch, 29200 Brest, France
| | - C Durdux
- Hôpital européen Georges-Pompidou, APHP, 20, rue Leblanc, 75015 Paris, France
| | - A Fourquet
- Institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - Y Kirova
- Institut Curie, 26, rue d'Ulm, 75005 Paris, France
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Kang S, Kim KH, Kang SW, Shin DS, Lee S, Chung JB. Evaluation of a new foetal shielding device for pregnant brain tumour patients. Radiat Oncol 2021; 16:109. [PMID: 34120633 PMCID: PMC8201726 DOI: 10.1186/s13014-021-01836-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 06/10/2021] [Indexed: 11/29/2022] Open
Abstract
Background The present study aimed to propose a new foetal shielding device for pregnant cancer patients to reduce the foetal dose associated with treatment techniques using multiple gantry angles, such as intensity-modulated radiation therapy (IMRT) or volumetric modulated arc therapy (VMAT). Methods Three shielding structures were designed to minimise the scattered and leaked radiation from various gantry angles and radiation scattering within the patient. The base-plate part that can be placed on the treatment couch was designed to reduce the scattered and leaked radiation generated at gantry angles located near 180°. A body shielding part that can cover the lower chest and abdomen was designed, and a neck-shielding structure was added to reduce the internal and external radiation scattering from the treatment area. Evaluation plans were generated to assess the foetal dose reduction by the foetal shielding device in terms of the shielding material thickness, distance from the field edge, and shielding component using the flattened 6 MV photon beam (6MV) and flattening filter-free 6 MV photon beam (6MV-FFF). In addition, the effectiveness of the foetal shielding device was evaluated in a pregnant brain tumour patient. Results The shielding material consisting of three parts was placed on frames composed of four arch shapes with a vertical curved structure, connection bar at the top position, and base plate. Each shielding part resulted in reductions in the radiation dose according to the treatment technique, as the thickness of the shielding material increased and the foetal dose decreased. In addition, a foetal dose reduction of approximately 50% was confirmed at 50 cm from the field edge by using the designed shielding device in most delivery techniques. In patients, the newly designed shielding structures can effectively eliminate up to about 49% of the foetal dose generated from various gantry angles used in VMAT or IMRT. Conclusions We designed a foetal shielding device consisting of three parts to effectively reduce the dose delivered to the foetus, and evaluated the device with various treatment techniques for a pregnant patient with brain tumour. The foetal shielding device shielded the scattered/leaked radiation from the treatment machine, and also effectively reduced internal scattering from the treatment area in the patient.
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Affiliation(s)
- Seonghee Kang
- Department of Radiation Oncology, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea.,Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyeong-Hyeon Kim
- Department of Biomedical Engineering, Research Institute of Biomedical Engineering, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang-Won Kang
- Department of Biomedical Engineering, Research Institute of Biomedical Engineering, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong-Seok Shin
- Department of Biomedical Engineering, Research Institute of Biomedical Engineering, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seungwan Lee
- Department of Radiological Science, Konyang University, Daejeon, Korea
| | - Jin-Beom Chung
- Department of Radiation Oncology, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea.
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Qin C, Long W, Zhang C, Xie Y, Wu C, Li Y, Xiao Q, Ji N, Liu Q. Multidisciplinary Therapy Managed Recurrent Glioblastoma in a BRAF-V600E Mutant Pregnant Female: A Case Report and Review of the Literature. Front Oncol 2020; 10:522816. [PMID: 33117675 PMCID: PMC7550879 DOI: 10.3389/fonc.2020.522816] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/31/2020] [Indexed: 12/14/2022] Open
Abstract
Background: Glioblastoma (GBM) is the most malignant intracranial tumor in adults. However, the overall management of GBM in pregnancy is rarely reported. How to balance the therapeutic benefits to the mother and risks to the fetus remains hugely challenging for clinicians. The application of specific targeting therapy combined with conventional treatment sheds light on a longer lifetime for the patients suffering from GBM. Case Presentation: We present a pregnant female at 20 weeks gestation diagnosed with GBM. Surgical resection was initially performed without adjuvant therapy, and the tumor recurred de novo 2 months later. A secondary craniotomy and cesarean section were performed simultaneously at 32 weeks gestation, both the patient and infant were survived. She was subsequently treated with traditional chemo-radiotherapy. No other identified genetic alterations indicating an optimistic prognosis were detected except for BRAF V600E mutation. Thus, the BRAF inhibitor was placed on her with achieving a good clinical outcome of more than 2-year survival without recurrence. Conclusion: Personalized multidisciplinary therapy should be considered when GBMs occur in pregnancy. Response to the therapy in this presenting case suggests that BRAF V600E mutation is a favorable biomarker for GBM. The mortality of GBM might be reduced through genetic testing and targeted treatment. However, more studies must be conducted to confirm our observation.
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Affiliation(s)
- Chaoying Qin
- Department of Neurosurgery in Xiangya Hospital, Central South University, Changsha, China
| | - Wenyong Long
- Department of Neurosurgery in Xiangya Hospital, Central South University, Changsha, China
| | - Chi Zhang
- Department of Neurosurgery in Xiangya Hospital, Central South University, Changsha, China
| | - Yuanyang Xie
- Department of Neurosurgery in Xiangya Hospital, Central South University, Changsha, China
| | - Changwu Wu
- Department of Neurosurgery in Xiangya Hospital, Central South University, Changsha, China
| | - Yang Li
- Department of Neurosurgery in Xiangya Hospital, Central South University, Changsha, China
| | - Qun Xiao
- Department of Neurosurgery in Xiangya Hospital, Central South University, Changsha, China
| | - Nan Ji
- Department of Neurosurgery in Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qing Liu
- Department of Neurosurgery in Xiangya Hospital, Central South University, Changsha, China
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Labby ZE, Barraclough B, Bayliss RA, Besemer AE, Dunkerley DAP, Howard SP. Radiation treatment planning and delivery strategies for a pregnant brain tumor patient. J Appl Clin Med Phys 2018; 19:368-374. [PMID: 30062720 PMCID: PMC6123144 DOI: 10.1002/acm2.12262] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 12/07/2017] [Accepted: 12/18/2017] [Indexed: 11/12/2022] Open
Abstract
The management of a pregnant patient in radiation oncology is an infrequent event requiring careful consideration by both the physician and physicist. The aim of this manuscript was to highlight treatment planning techniques and detail measurements of fetal dose for a pregnant patient recently requiring treatment for a brain cancer. A 27-year-old woman was treated during gestational weeks 19-25 for a resected grade 3 astrocytoma to 50.4 Gy in 28 fractions, followed by an additional 9 Gy boost in five fractions. Four potential plans were developed for the patient: a 6 MV 3D-conformal treatment plan with enhanced dynamic wedges, a 6 MV step-and-shoot (SnS) intensity-modulated radiation therapy (IMRT) plan, an unflattened 6 MV SnS IMRT plan, and an Accuray TomoTherapy HDA helical IMRT treatment plan. All treatment plans used strategies to reduce peripheral dose. Fetal dose was estimated for each treatment plan using available literature references, and measurements were made using thermoluminescent dosimeters (TLDs) and an ionization chamber with an anthropomorphic phantom. TLD measurements from a full-course radiation delivery ranged from 1.0 to 1.6 cGy for the 3D-conformal treatment plan, from 1.0 to 1.5 cGy for the 6 MV SnS IMRT plan, from 0.6 to 1.0 cGy for the unflattened 6 MV SnS IMRT plan, and from 1.9 to 2.6 cGy for the TomoTherapy treatment plan. The unflattened 6 MV SnS IMRT treatment plan was selected for treatment for this particular patient, though the fetal doses from all treatment plans were deemed acceptable. The cumulative dose to the patient's unshielded fetus is estimated to be 1.0 cGy at most. The planning technique and distance between the treatment target and fetus both contributed to this relatively low fetal dose. Relevant treatment planning strategies and treatment delivery considerations are discussed to aid radiation oncologists and medical physicists in the management of pregnant patients.
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Affiliation(s)
- Zacariah E Labby
- Department of Human Oncology, University of Wisconsin - Madison, Madison, WI, USA
| | - Brendan Barraclough
- Department of Human Oncology, University of Wisconsin - Madison, Madison, WI, USA
| | - R Adam Bayliss
- Department of Human Oncology, University of Wisconsin - Madison, Madison, WI, USA
| | - Abigail E Besemer
- Department of Human Oncology, University of Wisconsin - Madison, Madison, WI, USA
| | - David A P Dunkerley
- Department of Human Oncology, University of Wisconsin - Madison, Madison, WI, USA
| | - Steven P Howard
- Department of Human Oncology, University of Wisconsin - Madison, Madison, WI, USA
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Yoon J, Xie Y, Zhang R. Evaluation of surface and shallow depth dose reductions using a Superflab bolus during conventional and advanced external beam radiotherapy. J Appl Clin Med Phys 2018; 19:137-143. [PMID: 29427312 PMCID: PMC5849823 DOI: 10.1002/acm2.12269] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 12/12/2017] [Accepted: 12/15/2017] [Indexed: 01/07/2023] Open
Abstract
The purpose of this study was to evaluate a methodology to reduce scatter and leakage radiations to patients’ surface and shallow depths during conventional and advanced external beam radiotherapy. Superflab boluses of different thicknesses were placed on top of a stack of solid water phantoms, and the bolus effect on surface and shallow depth doses for both open and intensity‐modulated radiotherapy (IMRT) beams was evaluated using thermoluminescent dosimeters and ion chamber measurements. Contralateral breast dose reduction caused by the bolus was evaluated by delivering clinical postmastectomy radiotherapy (PMRT) plans to an anthropomorphic phantom. For the solid water phantom measurements, surface dose reduction caused by the Superflab bolus was achieved only in out‐of‐field area and on the incident side of the beam, and the dose reduction increased with bolus thickness. The dose reduction caused by the bolus was more significant at closer distances from the beam. Most of the dose reductions occurred in the first 2‐cm depth and stopped at 4‐cm depth. For clinical PMRT treatment plans, surface dose reductions using a 1‐cm Superflab bolus were up to 31% and 62% for volumetric‐modulated arc therapy and 4‐field IMRT, respectively, but there was no dose reduction for Tomotherapy. A Superflab bolus can be used to reduce surface and shallow depth doses during external beam radiotherapy when it is placed out of the beam and on the incident side of the beam. Although we only validated this dose reduction strategy for PMRT treatments, it is applicable to any external beam radiotherapy and can potentially reduce patients’ risk of developing radiation‐induced side effects.
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Affiliation(s)
- Jihyung Yoon
- Physics and Astronomy, Louisiana State University, Baton Rouge, LA, USA
| | - Yibo Xie
- Physics and Astronomy, Louisiana State University, Baton Rouge, LA, USA
| | - Rui Zhang
- Physics and Astronomy, Louisiana State University, Baton Rouge, LA, USA.,Mary Bird Perkins Cancer Center, Baton Rouge, LA, USA
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Morton SK, Morton AP. Melanoma and pregnancy. Australas J Dermatol 2017; 58:259-267. [PMID: 28185271 DOI: 10.1111/ajd.12568] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 08/15/2016] [Indexed: 12/28/2022]
Abstract
Melanoma is the most common cancer in women during their reproductive years and kills more young Australians than any other single cancer. Care of women whose pregnancy is complicated by a diagnosis of malignancy is complex. The risk of delaying treatment to the mother, the short-term and long-term risks of premature delivery to the child, and the immediate risks to the foetus and long-term risks to the child of maternal treatment with surgery, radiotherapy or medical therapies must be considered.
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Affiliation(s)
- Sarah Kym Morton
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Adam Park Morton
- Department of Obstetric Medicine, Mater Health Services, Brisbane, Queensland, Australia
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Pantelis E, Antypas C, Frassanito MC, Sideri L, Salvara K, Lekas L, Athanasiou O, Piperis M, Salvaras N, Romanelli P. Radiation dose to the fetus during CyberKnife radiosurgery for a brain tumor in pregnancy. Phys Med 2016; 32:237-41. [DOI: 10.1016/j.ejmp.2015.09.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 09/08/2015] [Accepted: 09/15/2015] [Indexed: 10/22/2022] Open
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Geng C, Moteabbed M, Seco J, Gao Y, George Xu X, Ramos-Méndez J, Faddegon B, Paganetti H. Dose assessment for the fetus considering scattered and secondary radiation from photon and proton therapy when treating a brain tumor of the mother. Phys Med Biol 2015; 61:683-95. [DOI: 10.1088/0031-9155/61/2/683] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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