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Briere TM, Agrusa JE, Martel MK, Jackson A, Olch AJ, Ronckers CM, Kremer LCM, Constine LS, McAleer MF. Acute and Late Pulmonary Effects After Radiation Therapy in Childhood Cancer Survivors: A PENTEC Comprehensive Review. Int J Radiat Oncol Biol Phys 2024; 119:533-548. [PMID: 35525723 DOI: 10.1016/j.ijrobp.2022.01.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 12/07/2021] [Accepted: 01/29/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The Pediatric Normal Tissue Effects in the Clinic (PENTEC) pulmonary task force reviewed dosimetric and clinical factors associated with radiation therapy (RT)-associated pulmonary toxicity in children. METHODS Comprehensive search of PubMed (1965-2020) was conducted to assess available evidence and predictive models of RT-induced lung injury in pediatric cancer patients (<21 years old). Lung dose for radiation pneumonitis (RP) was obtained from dose-volume histogram (DVH) data. RP grade was obtained from standard criteria. Clinical pulmonary outcomes were evaluated using pulmonary function tests (PFTs), clinical assessment, and questionnaires. RESULTS More than 2,400 abstracts were identified; 460 articles had detailed treatment and toxicity data; and 11 articles with both detailed DVH and toxicity data were formally reviewed. Pooled cohorts treated during 1999 to 2016 included 277 and 507 patients age 0.04 to 22.7 years who were evaluable for acute and late RP analysis, respectively. After partial lung RT, there were 0.4% acute and 2.8% late grade 2, 0.4% acute and 0.8% late grade 3, and no grade 4 to 5 RP. RP risk after partial thoracic RT with mean lung dose (MLD) <14 Gy and total lung V20Gy <30% is low. Clinical and self-reported pulmonary outcomes data included 8,628 patients treated during 1970 to 2013, age 0 to 21.9 years. At a median 2.9- to 21.9-year follow-up, patients were often asymptomatic; abnormal PFTs were common and severity correlated with lung dose. At ≥10-year follow-up, multi-institutional studies suggested associations between total or ipsilateral lung doses >10 Gy and pulmonary complications and deaths. After whole lung irradiation (WLI), pulmonary toxicity is higher; no dose response relationship was identified. Bleomycin and other chemotherapeutics at current dose regimens do not contribute substantially to adverse pulmonary outcomes after partial lung irradiation but increase risk with WLI. CONCLUSIONS After partial lung RT, acute pulmonary toxicity is uncommon; grade 2 to 3 RP incidences are <1%. Late toxicities, including subclinical/asymptomatic impaired pulmonary function, are more common (<4%). Incidence and severity appear to increase over time. Upon review of available literature, there appears to be low risk of pulmonary complications in children with MLD < 14 Gy and V20Gy <30% using standard fractionated RT to partial lung volumes. A lack of robust data limit guidance on lung dose/volume constraints, highlighting the need for additional work to define factors associated with RT-induced lung injury.
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Affiliation(s)
- Tina Marie Briere
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jennifer E Agrusa
- Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Mary K Martel
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Arthur J Olch
- Department of Radiation Oncology University of Southern California Keck School of Medicine and Children's Hospital Los Angeles, Los Angeles, California; Radiation Oncology Program, Children's Hospital Los Angeles, Los Angeles, California
| | - Cécile M Ronckers
- Department of Pediatrics, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Institute of Biostatistics and Registry Research, Medical University Brandenburg Medical School-Theodor Fontane, Neuruppin, Germany
| | - Leontien C M Kremer
- Department of Pediatrics, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Department of Pediatrics, UMC Amsterdam, Location AMC, Amsterdam, the Netherlands
| | - Louis S Constine
- Departments of Radiation Oncology and Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Mary Frances McAleer
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas.
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Snyder EJ, Sarma A, Krishnasarma R, Pruthi S. Complications of Cancer Therapy in Children: A Comprehensive Review of Body Imaging Findings. J Comput Assist Tomogr 2023; 47:833-843. [PMID: 37707415 DOI: 10.1097/rct.0000000000001489] [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: 07/23/2023]
Abstract
ABSTRACT Complications of cancer therapy in children can result in a spectrum of toxicities that can affect any organ system and result in a range of morbidity. Complications may occur at the initiation of therapy or years following treatment. Although childhood cancer remains rare, increasing survival rates means more children are living longer following their treatment. Radiologists often play an important role in the diagnosis and evaluation of these complications, and thus, awareness of their imaging findings is essential to guide management and avoid misdiagnosis. This second part of a 2-part review aims to illustrate the typical body imaging findings of cancer therapy-related toxicities, including both early and late treatment effects. The article also discusses the differential diagnosis of imaging findings, highlighting pearls and pitfalls in making the appropriate diagnosis.
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Affiliation(s)
- Elizabeth J Snyder
- From the Department of Radiology, Vanderbilt University Medical Center, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
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Laughlin BS, Stoker J, Vern-Gross T. Proton Beam Therapy for Unresectable Mediastinal and Pericardial Spindle Cell Sarcoma: A Case Report. Int J Part Ther 2023; 10:43-50. [PMID: 37823013 PMCID: PMC10563663 DOI: 10.14338/ijpt-23-00001.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 03/29/2023] [Indexed: 10/13/2023] Open
Abstract
Unresectable mediastinal soft tissue sarcomas are often aggressive and associated with a poor prognosis. A 17-year-old male presented with progressive fatigue, shortness of breath, and heart palpitations secondary to an extensive mass involving the mediastinum and pericardium. He was treated with chemotherapy per protocol Children's Oncology Group Protocol ARST0332 and proton beam therapy to the involved mediastinum, pericardium, and heart. At the 5-year follow-up evaluation, he remained disease-free on surveillance imaging. An echocardiogram revealed a 55% to 60% left ventricular ejection fraction. Given the patient's extended survival, we present the oncologic rationale for treatment and considerations of late toxicity.
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Affiliation(s)
| | - Joshua Stoker
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
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Parekh AD, Indelicato DJ, Hoppe BS, Vega RBM, Rotondo RL, Bradley JA. Pulmonary dose tolerance in hemithorax radiotherapy for Ewing sarcoma of the chest wall: Are we overestimating the risk of radiation pneumonitis? Pediatr Blood Cancer 2021; 68:e29287. [PMID: 34398486 DOI: 10.1002/pbc.29287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 07/28/2021] [Accepted: 08/02/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Children with chest wall Ewing sarcoma with malignant pulmonary effusion or pleural stranding require hemithorax radiation, often with plans that exceed lung constraints. We investigated disease control and pneumonitis in children requiring hemithorax radiation. PROCEDURE Eleven children (median age 13 years) received hemithorax radiotherapy. Symptomatic radiation pneumonitis was considered National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) grade 1+ with respiratory symptoms. Mean lung dose (MLD), volume of lung exposed to a dose ≥5 Gy (V5), ≥20 Gy (V20), and ≥35 Gy (V35) were recorded. Adult and pediatric lung constraints were obtained from Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC) guidelines and Children's Oncology Group (COG) protocols, respectively. RESULTS Median hemithorax dose was 15 Gy (1.5 Gy/fraction). Median total dose was 51 Gy (1.8 Gy/fraction). Most plans delivered both protons and photons. The ipsilateral MLD, V5, and V20 were 27.2 Gy, 100%, and 48.3%; the bilateral MLD, V20, and V35 were 14.1 Gy, 22.8%, and 14.3%, respectively. One hundred percent, 36%, and 91% of treatments exceeded recommended adult ipsilateral lung constraints of V5 <65%, V20 <52%, and MLD of 22 Gy; 64%, 45%, and 82% exceeded COG bilateral lung constraints of V20 <20%, MLD <15 Gy, and MLD <12 Gy, respectively; 82% of treatments exceeded the COG ipsilateral lung constraint of V20 <30%. At a median 36 months (range 12-129), the symptomatic radiation pneumonitis incidence was 0%. Two patients progressed with nonpulmonary metastatic disease and died at a median 12 months following radiotherapy. CONCLUSIONS Existing guidelines may overestimate pneumonitis risk, even among young children receiving multiagent chemotherapy. For children with chest wall Ewing sarcoma and other thoracic malignancies, more data are needed to refine pediatric dose-effect models for pulmonary toxicity.
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Affiliation(s)
- Akash D Parekh
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Ronny L Rotondo
- Department of Radiation Oncology, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
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Palmer JD, Tsang DS, Tinkle CL, Olch AJ, Kremer LCM, Ronckers CM, Gibbs IC, Constine LS. Late effects of radiation therapy in pediatric patients and survivorship. Pediatr Blood Cancer 2021; 68 Suppl 2:e28349. [PMID: 33818893 DOI: 10.1002/pbc.28349] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 03/19/2020] [Accepted: 03/20/2020] [Indexed: 11/08/2022]
Abstract
Advances in multimodality therapy have led to childhood cancer cure rates over 80%. However, surgery, chemotherapy, and radiotherapy may lead to debilitating or even fatal long-term effects among childhood survivors beyond those inflicted by the primary disease process. It is critical to understand, mitigate, and prevent these late effects of cancer therapy to improve the quality of life of childhood cancer survivors. This review summarizes the various late effects of radiotherapy and acknowledges the Pediatric Normal Tissue Effects in the Clinic (PENTEC), an international collaboration that is systematically analyzing the association between radiation treatment dose/volume and consequential organ toxicities, in developing children as a basis to formulate recommendations for clinical practice of pediatric radiation oncology. We also summarize initiatives for survivorship and surveillance of late normal tissue effects related to radiation therapy among long-term survivors of childhood cancer treated in the past.
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Affiliation(s)
- Joshua D Palmer
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center and Nationwide Children's Hospital, Ohio, Columbus
| | - Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, Division of Haematology/Oncology, Hospital for Sick Children, University Health Network, Toronto, Canada
| | - Christopher L Tinkle
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Arthur J Olch
- Department of Radiation Oncology, Keck School of Medicine of USC and Children's' Hospital Los Angeles, Los Angeles, California
| | - Leontien C M Kremer
- Department of Pediatrics, Amsterdam UMC, Emma Children's Hospital, Amsterdam, the Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Cecile M Ronckers
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands.,Brandenburg Medical School, Institute for Biostatistics and Registry Research, Neuruppin, Germany
| | - Iris C Gibbs
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford University, Stanford, California
| | - Louis S Constine
- Department of Radiation Oncology, University of Rochester, Rochester, New York
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Dewan A, Chufal KS, Tandon S, Ahmad I, Suresh T, Dewan A, Pahuja A. A case report evaluating combined effect of intensity-modulated radiotherapy and deep inspiratory breath-hold for mediastinal lymphoma: A dosimetric analysis. Lung India 2020; 37:57-62. [PMID: 31898622 PMCID: PMC6961102 DOI: 10.4103/lungindia.lungindia_88_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Excellent survival has been reported after combined modality treatment in bulky mediastinal Hodgkin's lymphoma. Late effects such as cardiac morbidity and secondary cancers have been reported after radiotherapy (RT), especially in young adults. Advanced RT techniques such as deep inspiratory breath-hold (DIBH), intensity-modulated RT (IMRT), and volumetric arc therapy have been used recently to reduce these late effects with encouraging results. We hereby present a case report evaluating combined effect of DIBH and IMRT in a young adult with mediastinal lymphoma.
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Affiliation(s)
- Abhinav Dewan
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Kundan Singh Chufal
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Sarthak Tandon
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Irfan Ahmad
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - T Suresh
- Department of Radiation Oncology, Division of Medical Physics, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Ajay Dewan
- Department of Surgical Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Anjali Pahuja
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
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Khan F, Williams AM, Weiner DJ, Constine LS. Impact of Respiratory Developmental Stage on Sensitivity to Late Effects of Radiation in Pediatric Cancer Survivors. Adv Radiat Oncol 2019; 5:426-433. [PMID: 32529137 PMCID: PMC7276690 DOI: 10.1016/j.adro.2019.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 11/19/2019] [Accepted: 12/04/2019] [Indexed: 01/01/2023] Open
Abstract
Purpose Pulmonary dysfunction is a prevalent and potentially debilitating late effect of pediatric cancer treatment. We postulated that age, as a surrogate for respiratory developmental status, might be associated with vulnerability to pulmonary injury. Materials and Methods Sixty-one children treated with lung radiation at our institution who had undergone a pulmonary function test (PFT) between 1995 and 2016 were analyzed. Data collection included age at diagnosis and treatment, radiation dose and location, spirometry, and plethysmography results. PFTs were normalized according to age, sex, height, and ethnicity, and transformed into standardized z-scores. Obstructive disease was defined as forced expiratory volume in 1 second z score/forced vital capacity z score < −1.645, restrictive as total lung capacity z score < –1.645, and abnormal diffusion as diffusing capacity of the lung for carbon monoxide z score < −1.645. We determined the incidence of PFT abnormalities in our population and estimated the relative risk of developing pulmonary abnormalities using models adjusted for age. Results At a mean age of 24 years (range, 12-31) and time from radiation of 9 years (range, 1-20), the cumulative incidence of any pulmonary abnormality was 34.4%. Among patients with an abnormal PFT, diffusing and restrictive abnormalities were most common (57.1% and 52.4%). When stratified by age at radiation treatment, 66.7% of patients <5 years had a PFT abnormality, compared with 47.6% for aged 5 to 13 and 20.6% for patients >13. Compared with patients >13 years, those <5 years and 5 to 13 years at radiation treatment had a significantly increased risk of an abnormal PFT with an odds ratio of 7.71 (95% confidence interval, 1.17, 51.06) and 3.51 (95% confidence interval, 1.06, 11.57), respectively (P <. 035). Furthermore, this association remained when examining each type of abnormality (P > .05). Conclusions PFT abnormalities were common among our cohort of childhood cancer survivors treated with lung radiation. Younger age at treatment is associated with an increased risk of developing pulmonary dysfunction, presumably owing to developmental immaturity.
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Affiliation(s)
- Fatima Khan
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Annalynn M Williams
- Department of Medicine, Wilmot Cancer Institute, University of Rochester, Rochester, New York
| | - Daniel J Weiner
- Division of Pulmonary Medicine, Allergy and Immunology, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Louis S Constine
- Departments of Radiation Oncology and Pediatrics, University of Rochester Medical Center, Rochester, New York
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Vinogradskiy Y, Faught A, Castillo R, Castillo E, Guerrero T, Miften M, Liu AK. Using 4DCT-ventilation to characterize lung function changes for pediatric patients getting thoracic radiotherapy. J Appl Clin Med Phys 2018; 19:407-412. [PMID: 29943892 PMCID: PMC6123142 DOI: 10.1002/acm2.12397] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 05/14/2018] [Accepted: 05/21/2018] [Indexed: 11/09/2022] Open
Abstract
PURPOSE A form of lung functional imaging has been developed that uses 4DCT data to calculate ventilation (4DCT-ventilation). Because 4DCTs are acquired as standard-of-care to manage breathing motion during radiotherapy, 4DCT-ventilation provides functional information at no extra dosimetric or monetary cost. 4DCT-ventilation has yet to be described in children. 4DCT-ventilation can be used as a tool to help assess post-treatment lung function and predict for future clinical thoracic toxicities for pediatric patients receiving radiotherapy to the chest. The purpose of this work was to perform a preliminary evaluation of 4DCT-ventilation-based lung function changes for pediatric patients receiving radiotherapy to the lungs. METHODS The study used four patients with pre and postradiotherapy 4DCTs. The 4DCTs, deformable image registration, and a density-change-based algorithm were used to compute pre and post-treatment 4DCT-ventilation images. The post-treatment 4DCT-ventilation images were compared to the pretreatment 4DCT-ventilation images for a global lung response and for an intrapatient dose-response (providing an assessment for dose-dependent regional dose-response). RESULTS For three of the four patients, a global ventilation decline of 7-37% was observed, while one patient did not demonstrate a global functional decline. Dose-response analysis did not reveal an intrapatient dose-response from 0 to 20 Gy for three patients while one patient demonstrated increased 4DCT-ventilation decline as a function of increasing lung doses up to 50 Gy. CONCLUSIONS Compared to adults, pediatric patients have unique lung function, dosimetric, and toxicity profiles. The presented work is the first to evaluate spatial lung function changes in pediatric patients using 4DCT-ventilation and showed lung function changes for three of the four patients. The early changes demonstrated with lung function imaging warrant further longitudinal work to determine whether the imaging-based early changes can be predicted for long-term clinical toxicity.
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Affiliation(s)
- Yevgeniy Vinogradskiy
- Department of Radiation OncologyUniversity of Colorado School of MedicineAuroraCOUSA
| | - Austin Faught
- Department of Radiation OncologyUniversity of Colorado School of MedicineAuroraCOUSA
| | | | - Edward Castillo
- Department of Radiation OncologyBeaumont Health SystemRoyal OakMIUSA
| | - Thomas Guerrero
- Department of Radiation OncologyBeaumont Health SystemRoyal OakMIUSA
| | - Moyed Miften
- Department of Radiation OncologyUniversity of Colorado School of MedicineAuroraCOUSA
| | - Arthur K. Liu
- Department of Radiation OncologyUniversity of Colorado School of MedicineAuroraCOUSA
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Radiation pneumonitis in pediatric Hodgkin lymphoma patients receiving radiation therapy to the chest. Pract Radiat Oncol 2018; 8:e364-e368. [DOI: 10.1016/j.prro.2018.01.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 01/18/2018] [Accepted: 01/29/2018] [Indexed: 12/25/2022]
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Boros A, Ribrag V, Deutsch É, Chargari C, Izar F. [Radiation therapy planning for Hodgkin lymphoma: Focus on intensity-modulated radiotherapy, gating, protons. Which techniques to best deliver radiation?]. Cancer Radiother 2018; 22:404-410. [PMID: 30076071 DOI: 10.1016/j.canrad.2018.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 06/21/2018] [Indexed: 11/28/2022]
Abstract
The optimization of radiotherapy in these young and long-lived survivors raises the question about the interest of using modern techniques to allow a better distribution of the dose. The choice of the irradiation technique must take into account the incidence of side effects related to radiation. In this context, the definition of the target volumes as well as the verification and monitoring of the delivered processing are essential. International recommendations for treatment fields are based on the "involved node radiotherapy" concept. The best irradiation technique to use remains to be defined. The use of intensity-modulated radiotherapy improves the coverage and reduces the dose to the organs at risk with a variable gain depending on the topography of the lymph nodes: upper or lower mediastinum, right or left lateralization, the techniques used. The deep inspiration breath-hold technique allows an increase of the pulmonary volume, extension of the mediastinum with an up down of the heart which make possible to move the planning target volume away from the cardiac structures. The volumetric-modulated arctherapy technique with several arches can be particularly interesting to reduce the dose to the breasts, as well as tomotherapy when bulky disease. Proton therapy with the Bragg peak specificity can play a key role in limiting doses to organs at risk, when robust planning that will take into account geometric and physical uncertainties is available. The heterogeneity of Hodgkin lymphomas in terms of volume, shape and initial location are the key elements to take into account when choosing the preferred radiotherapy technique.
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Affiliation(s)
- A Boros
- Département de radiothérapie, Cancer campus Grand-Paris, Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France; Université Paris Sud, université Paris Saclay, 94270 Le Kremlin-Bicêtre, France.
| | - V Ribrag
- Département d'hématologie, Cancer campus Grand-Paris, Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France; Département des innovations thérapeutiques et essais précoces, Cancer campus Grand-Paris, Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - É Deutsch
- Département de radiothérapie, Cancer campus Grand-Paris, Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France; Université Paris Sud, université Paris Saclay, 94270 Le Kremlin-Bicêtre, France; U1030, Inserm, molecular radiotherapy, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - C Chargari
- Département de radiothérapie, Cancer campus Grand-Paris, Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France; Université Paris Sud, université Paris Saclay, 94270 Le Kremlin-Bicêtre, France; D19, institut de recherche biomédicale des armées, 91220 Brétigny-sur-Orge, France; Service de santé des armées, école du Val-de-Grâce, 74, boulevard de Port-Royal, 75005 Paris, France
| | - F Izar
- Département de radiothérapie, Institut universitaire du cancer de Toulouse, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex 9, France
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Using benchmarked lung radiation dose constraints to predict pneumonitis risk: Developing a nomogram for patients with mediastinal lymphoma. Adv Radiat Oncol 2018; 3:372-381. [PMID: 30202805 PMCID: PMC6128097 DOI: 10.1016/j.adro.2018.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 03/12/2018] [Accepted: 03/26/2018] [Indexed: 12/25/2022] Open
Abstract
Purpose We identified lung dosimetric constraints to assist in predicting the radiation pneumonitis (RP) risk in patients with mediastinal lymphoma and then identified the clinical prognostic factors that were associated with the achievement of key dosimetric constraints. Methods and Materials In 190 patients who received mediastinal intensity modulated radiation therapy, we used univariate χ2 and multivariate logistic models to identify the predictors of RP and achievement of lung dose-volume histogram (DVH) constraints and build a predictive nomogram for RP. Results An increased risk of RP was strongly associated with mean lung dose (MLD) > 13.5 Gy (odds ratio [OR]: 8.13; 95% confidence interval [CI], 3.01-21.93; P < .001) and the percent of lung volume receiving ≥5 Gy (V5) > 55% (OR: 7.01; 95% CI, 2.94-16.72; P < .001). Therefore, patients had low RP risk (8%) if both MLD ≤13.5 and V5 ≤55 constraints were achieved, moderate risk (24%) if only MLD was achieved, and the highest risk (48%) if MLD was not achieved. Deep-inspiration breath-hold (DIBH) technique during treatment strongly prognosticated achieving MLD and V5 DVH constraints (OR,3.88; 95% CI, 1.84-8.19; P < .001). Specifically, 86% of patients who were treated with DIBH versus 63% without DIBH achieved DVH constraints (P < .001). This translated into a “number needed to treat” with DIBH of 4 patients to enable 1 additional patient to achieve both constraints. In comparison, the clinical characteristics were marginal prognosticators: DVH constraints were more likely achieved in nonbulky disease (OR: 3.01; 95% CI, 0.89-4.53; P = .09) and patients who had not previously received salvage chemotherapy (OR, 2.44; 95% CI, 0.98-6.11; P = .06). Nomogram-predicted risks of RP ranged from 4% to 60% on the basis of MLD and V5, total radiation dose, and use of salvage chemotherapy. Conclusions Achieving mean lung and V5 DVH constraints is critical to reduce RP risk in patients with lymphoma who receive mediastinal intensity modulated radiation therapy. The use of the DIBH technique is a promising risk-modifying treatment approach in patients with mediastinal lymphoma and especially in patients with a history of nonmodifiable risk factors for RP such as bulky disease and salvage chemotherapy.
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Lung toxicity after radiation in childhood: Results of the International Project on Prospective Analysis of Radiotoxicity in Childhood and Adolescence. Radiother Oncol 2017; 125:286-292. [PMID: 29050956 DOI: 10.1016/j.radonc.2017.09.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Revised: 08/09/2017] [Accepted: 09/23/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE This study presents the evaluation of acute and late toxicities of the lung in children and adolescents after irradiation in terms of dose-volume effects. MATERIALS AND METHODS Irradiated children and adolescents in Germany have prospectively been documented since 2001 in the "Registry for the Evaluation of Side-Effects after Radiotherapy in Childhood and Adolescence (RiSK)"; in Sweden since 2008 in the RADTOX registry. RESULTS Up to April 2012, 1,392 children were recruited from RiSK, and up to June 2013, 485 from the RADTOX-registry. Of these patients, 295 were irradiated to the lung. Information about acute toxicity was available for 228 patients. 179 patients have been documented concerning late toxicity (≥grade 1: n = 28). The acute toxicity rate was noticeably higher in children irradiated with 5-20Gy (p < 0.05). In the univariate analysis, a shorter time until late toxicity was noticeably associated with irradiation with 5-15Gy (p < 0.05). CONCLUSION Acute and late toxicities appear to be correlated with higher irradiation volumes and low doses. Our data indicate that similar to the situation in adult patients, V5, V10, V15 and V20 should be kept as low as possible (e.g., at least V5 < 50%, V10 and V15 < 35% and V20 < 30%) in children and adolescents to lower the risk of toxicity.
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Nanda R, Flampouri S, Mendenhall NP, Indelicato DJ, Jones LM, Seeram VK, Hoppe BS. Pulmonary Toxicity Following Proton Therapy for Thoracic Lymphoma. Int J Radiat Oncol Biol Phys 2017; 99:494-497. [DOI: 10.1016/j.ijrobp.2017.04.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Indexed: 01/17/2023]
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Lucas JT, Fernandez-Pineda I, Tinkle CL, Bishop MW, Kaste SC, Heda R, Davidoff AM, Krasin MJ. Late toxicity and outcomes following radiation therapy for chest wall sarcomas in pediatric patients. Pract Radiat Oncol 2017; 7:411-417. [PMID: 28676226 DOI: 10.1016/j.prro.2017.04.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 04/06/2017] [Accepted: 04/21/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE To investigate the contribution of radiation therapy to acute and late toxicity in pediatric chest wall sarcoma patients and evaluate dosimetric correlates of higher incidence toxicities such as scoliosis and pneumonitis. METHODS AND MATERIALS The data from 23 consecutively treated pediatric patients with chest wall sarcomas of various histologies (desmoid, Ewing, rhabdomyosarcoma, nonrhabdomyosarcoma-soft tissue sarcomas) were reviewed to evaluate the relationship between end-organ radiation dose, clinical factors, and the risk of subsequent late effects (scoliosis, pneumonitis). Cobb angles were used to quantify the extent of scoliosis. Doses to the spine and lung were calculated from the radiation treatment plan. RESULTS The range of scoliosis identified on follow-up imaging ranged from -47.6 to 64° (median, 2.95°). No relationship was identified between either radiation dose to the ipsilateral or contralateral vertebral body or tumor size and the degree or direction of scoliosis. The extent of surgical resection and number and location of resected ribs affected the extent of scoliosis. The dominant predictor of extent of scoliosis at long-term follow-up was the extent of scoliosis following surgical resection. Radiation pneumonitis was uncommon and was not correlated with mean dose or volume of lung receiving 24 Gy; however, 1 of 3 surviving patients who received whole pleural surface radiation therapy developed significant restrictive lung disease. CONCLUSIONS Acute and late radiation therapy-associated toxicities in pediatric chest wall sarcoma patients are modest. The degree of scoliosis following resection is a function of the extent of resection and of the number and location of ribs resected, and the degree of scoliosis at the last follow-up visit is a function of the extent of scoliosis following surgery. Differential radiation therapy dose across the vertebral body does not increase the degree of scoliosis. Severe restrictive pulmonary disease is a late complication of survivors after whole pleural surface radiation therapy.
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Affiliation(s)
- John T Lucas
- Department of Radiation Oncology, St. Jude Children's Research Hospital Memphis, Tennessee.
| | | | - Christopher L Tinkle
- Department of Radiation Oncology, St. Jude Children's Research Hospital Memphis, Tennessee
| | - Michael W Bishop
- Department of Oncology, St. Jude Children's Research Hospital Memphis, Tennessee
| | - Sue C Kaste
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital Memphis, Tennessee; Department of Radiology, University of Tennessee Health Sciences, Memphis, Tennessee
| | | | - Andrew M Davidoff
- Department of Surgery, St. Jude Children's Research Hospital Memphis, Tennessee
| | - Matthew J Krasin
- Department of Radiation Oncology, St. Jude Children's Research Hospital Memphis, Tennessee
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15
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Abou Yehia Z, Mikhaeel GN, Smith G, Pinnix CC, Milgrom SA, Tang C, Jiang W, Fanale MA, Oki Y, Shank JH, Horace T, Reddy J, Akhtari M, Gunther JR, Suki T, Allen PK, Turner S, Mawlawi O, Dabaja BS. Does Bleomycin Lung Toxicity Increase the Risk of Radiation Pneumonitis in Hodgkin Lymphoma? Int J Radiat Oncol Biol Phys 2016; 96:951-958. [PMID: 27742539 DOI: 10.1016/j.ijrobp.2016.08.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 07/17/2016] [Accepted: 08/15/2016] [Indexed: 11/15/2022]
Abstract
PURPOSE Bleomycin pulmonary toxicity (BPT) is a well-known complication of treatment in patients with Hodgkin lymphoma (HL). We undertook the present study to investigate the risk of radiation pneumonitis (RP) in the setting of BPT and to determine the need for delay or omission of radiation therapy (RT) in these patients. METHODS AND MATERIALS We identified 123 HL patients treated with ABVD (Adriamycin, bleomycin, vinblastine, dacarbazine) followed by RT to the chest from January 2009 to December 2014. The medical records were reviewed for clinical, pathologic, and treatment information and toxicities. Our primary outcome was RP of any grade. Univariate and multivariate analyses were used to assess the association of BPT, baseline patient characteristics, and treatment variables with the incidence of RP. RESULTS A total of 123 patients were included, of whom 99 (80%) received consolidation intensity modulated RT after ABVD treatment. We identified 31 patients (25.2%) with BPT after frontline ABVD. Seventeen patients (13.8%) developed RP a median of 8 weeks (range 1-39) after RT completion. BPT did not correlate with the risk of developing RP (P=.36). We evaluated the RP outcomes with respect to the bleomycin to RT interval (≤6 weeks vs >6 weeks), and we found that this interval did not predict for RP risk (P=.60). Dosimetric parameters such as the volume covered by 5 Gy and the mean lung dose were analyzed. A volume covered by 5 Gy of >55% and mean lung dose >13.5 Gy increased the risk of RP by 1.14-fold (P=.002) and 4.24-fold (P=.007), respectively. CONCLUSIONS The results of our study suggest that BPT does not increase the risk of developing RP. Furthermore, RT initiation does not need to be delayed after chemotherapy, except to allow for the completion of steroid therapy or clinical recovery from BPT.
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Affiliation(s)
- Zeinab Abou Yehia
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - George N Mikhaeel
- Department of Clinical Oncology, Guy's & St Thomas' Hospital, London, United Kingdom
| | - Grace Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Chelsea C Pinnix
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sarah A Milgrom
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Chad Tang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Wen Jiang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michelle A Fanale
- Department of Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yasuhiro Oki
- Department of Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - JoAnn H Shank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Trisha Horace
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jay Reddy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mani Akhtari
- Department of Radiation Oncology, The University of Texas Medical Branch Hospitals, Galveston, Texas
| | - Jillian R Gunther
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Tina Suki
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Pamela K Allen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shryll Turner
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Osama Mawlawi
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bouthaina S Dabaja
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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16
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Pinnix CC, Smith GL, Milgrom S, Osborne EM, Reddy JP, Akhtari M, Reed V, Arzu I, Allen PK, Wogan CF, Fanale MA, Oki Y, Turturro F, Romaguera J, Fayad L, Fowler N, Westin J, Nastoupil L, Hagemeister FB, Rodriguez MA, Ahmed S, Nieto Y, Dabaja B. Predictors of radiation pneumonitis in patients receiving intensity modulated radiation therapy for Hodgkin and non-Hodgkin lymphoma. Int J Radiat Oncol Biol Phys 2015; 92:175-82. [PMID: 25863764 DOI: 10.1016/j.ijrobp.2015.02.010] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 01/29/2015] [Accepted: 02/05/2015] [Indexed: 11/16/2022]
Abstract
PURPOSE Few studies to date have evaluated factors associated with the development of radiation pneumonitis (RP) in patients with Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL), especially in patients treated with contemporary radiation techniques. These patients represent a unique group owing to the often large radiation target volumes within the mediastinum and to the potential to receive several lines of chemotherapy that add to pulmonary toxicity for relapsed or refractory disease. Our objective was to determine the incidence and clinical and dosimetric risk factors associated with RP in lymphoma patients treated with intensity modulated radiation therapy (IMRT) at a single institution. METHODS AND MATERIALS We retrospectively reviewed clinical charts and radiation records of 150 consecutive patients who received mediastinal IMRT for HL and NHL from 2009 through 2013. Clinical and dosimetric predictors associated with RP according to Radiation Therapy Oncology Group (RTOG) acute toxicity criteria were identified in univariate analysis using the Pearson χ(2) test and logistic multivariate regression. RESULTS Mediastinal radiation was administered as consolidation therapy in 110 patients with newly diagnosed HL or NHL and in 40 patients with relapsed or refractory disease. The overall incidence of RP (RTOG grades 1-3) was 14% in the entire cohort. Risk of RP was increased for patients who received radiation for relapsed or refractory disease (25%) versus those who received consolidation therapy (10%, P=.019). Several dosimetric parameters predicted RP, including mean lung dose of >13.5 Gy, V20 of >30%, V15 of >35%, V10 of >40%, and V5 of >55%. The likelihood ratio χ(2) value was highest for V5 >55% (χ(2) = 19.37). CONCLUSIONS In using IMRT to treat mediastinal lymphoma, all dosimetric parameters predicted RP, although small doses to large volumes of lung had the greatest influence. Patients with relapsed or refractory lymphoma who received salvage chemotherapy and hematopoietic stem cell transplantation were at higher risk for symptomatic RP.
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Affiliation(s)
- Chelsea C Pinnix
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Grace L Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sarah Milgrom
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eleanor M Osborne
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jay P Reddy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mani Akhtari
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Valerie Reed
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Isidora Arzu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Pamela K Allen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Christine F Wogan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michele A Fanale
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yasuhiro Oki
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Francesco Turturro
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jorge Romaguera
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Luis Fayad
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nathan Fowler
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Westin
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Loretta Nastoupil
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Fredrick B Hagemeister
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - M Alma Rodriguez
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sairah Ahmed
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yago Nieto
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bouthaina Dabaja
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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De A, Kamath S, Wong K, Olch AJ, Malvar J, Sposto R, Mascarenhas L, Keens TG, Venkatramani R. Correlation of pulmonary function abnormalities with dose volume histograms in children treated with lung irradiation. Pediatr Pulmonol 2015; 50:596-603. [PMID: 24644268 DOI: 10.1002/ppul.23034] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 02/20/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND There is limited data on pulmonary function test (PFT) abnormalities in children treated with modern irradiation techniques. PFT abnormalities have not been correlated with the dose and volume of irradiation. METHODS A retrospective chart review of PFTs and clinical outcomes in children who received radiation therapy (RT) at Children's Hospital Los Angeles between 1999 and 2009 was performed. Radiation dose distribution to normal lung tissue was calculated. RESULTS Forty-nine patients had PFTs available post-RT at a median time of 2.91 years (range, 0.01-8.28) from irradiation. Sixty-seven percent of patients had at least one PFT abnormality on their last available study. The most common abnormality was obstructive lung disease (24%) followed by hyperinflation (20%). Thoracic surgery prior to RT increased the odds of an abnormal FEV1, RV/TLC, and obstructive disease. The sex of the patient, age at the time of irradiation, and time of the PFT after irradiation did not have a significant association with abnormalities. The mean lung dose, maximum lung dose, and prescribed dose of radiation were significantly associated with the development of PFT abnormalities. The odds of developing an abnormal PFT increased with increase in the minimum threshold dose (V(dose)) of radiation, mostly above V(20). CONCLUSION PFT abnormalities are common even when modern radiation techniques are used. A significant correlation between radiation parameters and PFT abnormalities was noted.
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Affiliation(s)
- Aliva De
- Division of Pulmonology, Children's Hospital Los Angeles, Los Angeles, California
| | - Sunil Kamath
- Division of Pulmonology, Children's Hospital Los Angeles, Los Angeles, California
| | - Kenneth Wong
- Division of Hematology/Oncology, Children's Hospital Los Angeles, Los Angeles, California.,Department of Radiation Oncology, University of California, Los Angeles, California
| | - Arthur J Olch
- Division of Hematology/Oncology, Children's Hospital Los Angeles, Los Angeles, California.,Department of Radiation Oncology, University of Southern California, Los Angeles, California
| | - Jemily Malvar
- Division of Hematology/Oncology, Children's Hospital Los Angeles, Los Angeles, California
| | - Richard Sposto
- Division of Hematology/Oncology, Children's Hospital Los Angeles, Los Angeles, California.,Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Leo Mascarenhas
- Division of Hematology/Oncology, Children's Hospital Los Angeles, Los Angeles, California.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Thomas G Keens
- Division of Pulmonology, Children's Hospital Los Angeles, Los Angeles, California.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Rajkumar Venkatramani
- Division of Hematology/Oncology, Children's Hospital Los Angeles, Los Angeles, California.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
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18
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Hodgson DC, Dieckmann K, Terezakis S, Constine L. Implementation of contemporary radiation therapy planning concepts for pediatric Hodgkin lymphoma: Guidelines from the International Lymphoma Radiation Oncology Group. Pract Radiat Oncol 2015; 5:85-92. [DOI: 10.1016/j.prro.2014.05.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 05/12/2014] [Accepted: 05/16/2014] [Indexed: 11/16/2022]
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19
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Venkatramani R, Kamath S, Wong K, Olch AJ, Malvar J, Sposto R, Goodarzian F, Freyer DR, Keens TG, Mascarenhas L. Pulmonary outcomes in patients with Hodgkin lymphoma treated with involved field radiation. Pediatr Blood Cancer 2014; 61:1277-81. [PMID: 24482138 DOI: 10.1002/pbc.24969] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 01/07/2014] [Indexed: 11/12/2022]
Abstract
BACKGROUND Abnormalities in pulmonary function tests (PFT) and clinical symptoms have been reported in up to one third of patients with Hodgkin lymphoma (HL) treated with irradiation. The purpose of this study is to describe the prevalence of pulmonary complications in HL patients treated using contemporary protocols. PROCEDURES Eligible patients at Children's Hospital Los Angeles from 1999 to 2009 were identified from the radiation oncology database. Clinical features, radiographic findings, PFT, and radiation details were retrospectively ascertained. RESULTS The median age at diagnosis of 65 patients with HL was 13.6 years and the median follow-up was 3.7 years. The median prescribed radiation dose was 21 Gy. The prevalence of clinical symptoms was low: chronic cough (3%), dyspnea (9.2%), and supplemental oxygen requirement (1.5%). Radiological interstitial lung changes were observed in 31% of the patients. PFT results following irradiation were available in 38 patients. Forced expiratory volume in 1 second (FEV1) and forced expiratory flow 25-75% (FEF25-75%) were decreased in 13% and 11% of patients respectively. Residual volume (RV) was elevated in 21%. Total Lung capacity (TLC) was decreased in 8%. Age at irradiation (P = 0.004), maximum lung dose (P = 0.03), and volume of lung receiving >25 Gy were associated with development of adverse pulmonary outcomes on univariate analysis. On multivariate analysis, older age was associated with worse outcomes. CONCLUSION In survivors of pediatric HL, involved field irradiation was accompanied by a low prevalence of pulmonary symptoms but substantial subclinical dysfunction. Older age at irradiation was associated with worse pulmonary outcomes.
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Affiliation(s)
- Rajkumar Venkatramani
- Division of Hematology/Oncology, Children's Hospital Los Angeles, Los Angeles, California; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
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20
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van Dijk IWEM, van Os RM, van de Kamer JB, Franken NAP, van der Pal HJH, Koning CCE, Caron HN, Ronckers CM, Kremer LCM. The use of equivalent radiation dose in the evaluation of late effects after childhood cancer treatment. J Cancer Surviv 2014; 8:638-46. [DOI: 10.1007/s11764-014-0373-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 05/28/2014] [Indexed: 12/25/2022]
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22
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Charpentier AM, Conrad T, Sykes J, Ng A, Zhou R, Parent A, Coolens C, Tsang RW, Gospodarowicz MK, Sun A, Hodgson DC. Active breathing control for patients receiving mediastinal radiation therapy for lymphoma: Impact on normal tissue dose. Pract Radiat Oncol 2014; 4:174-180. [DOI: 10.1016/j.prro.2013.07.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 07/30/2013] [Accepted: 07/31/2013] [Indexed: 10/26/2022]
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23
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Hill-Kayser C, Tochner Z, Both S, Lustig R, Reilly A, Balamuth N, Womer R, Maris J, Grupp S, Bagatell R. Proton versus photon radiation therapy for patients with high-risk neuroblastoma: the need for a customized approach. Pediatr Blood Cancer 2013; 60:1606-11. [PMID: 23737005 DOI: 10.1002/pbc.24606] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 04/29/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND Proton therapy for treatment for high-risk neuroblastoma may offer sparing of organs at risk (OAR) when compared to intensity-modulated X-ray therapy (IMXT). PROCEDURE Double-scattered proton plans and IMXT plans delivering 2,160 cGy to the primary tumor site and other residual disease were developed for 13 consecutive HR-NBL patients. Radiation doses to target volumes and OAR were calculated to determine the optimal modality for each. RESULTS All patients received radiation (5/13 ≥ 2 sites). No patient has experienced local recurrence or clinical organ toxicity. Coverage was excellent using both protons and IMXT: median % dose delivered to 95% clinical target volume was 99% and 100%, respectively. For nine patients with lateralized disease, proton therapy offered sparing of the contralateral kidney both with regard to median dose and dose to 20% (median <1 cGy vs. 362 cGy, P = 0.01; median 100 cGy vs. 634 cGy, P = 0.02, respectively). Proton therapy did not reduce ipsilateral kidney dose, and for 2 select patients with lateralized disease IMXT improved overall bilateral renal sparing. Proton therapy improved median bowel (median 33 cGy vs. 590 cGy, P = 0.01), total body (median <1 cGy vs. 30 cGy, P = 0.15), and liver dose (median <1 cGy vs. 529, P < 0.001). When chest RT was required, proton therapy decreased median heart dose and mean lung dose. CONCLUSIONS For most patients (11/13), proton therapy offered the optimal combination of target coverage and organ sparing, and is a feasible treatment for HR-NBL. We recommend a customized approach with careful evaluation of renal dosimetry; IMXT may be preferred for select patients.
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Affiliation(s)
- Christine Hill-Kayser
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA.
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Chargari C, Riet F, Mazevet M, Morel E, Lepechoux C, Deutsch E. Complications of thoracic radiotherapy. Presse Med 2013; 42:e342-51. [PMID: 23972736 DOI: 10.1016/j.lpm.2013.06.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 06/12/2013] [Indexed: 12/25/2022] Open
Abstract
The issue of toxicity is a primary concern for chest irradiation, because it is a dose-limiting toxicity and because in some circumstances it can alleviate the survival benefit of radiation therapy. Potential acute and delayed side effects can compromise the patients' prognosis and generate significant morbidity. Here we review on chest complications of radiation therapy, with focus on cardiac and pulmonary radio-induced side effects. Most radiographic changes associated with thoracic irradiation are asymptomatic. However, chest irradiation generated by treatment of breast cancer, bronchopulmonary malignancies, or mediastinal lymphoma has been associated with a risk of acute radiation pneumonitis and late lung fibrosis. An increasing number of clinical studies suggest that some dosimetric factors (e.g. V20, V30, mean lung dose) should be considered for limiting the risk of lung toxicity. Improvements in radiation techniques as well as changes in indications, volumes and prescribed doses of radiation therapy should help to better spare lungs from irradiation and thus decreasing the risk of subsequent toxicity. Numerous other contributing factors should also be considered, such as chemotherapeutic agents, smoking, tumor topography, or intrinsic sensitivity. Cardiac toxicity is another clinically relevant issue in patients receiving radiation therapy for breast cancer or for lymphoma. This life threatening toxicity should be analyzed in the light of dosimetric factors (including low doses) but also associated systemic agents which almost carry a potential for additive toxicity toward myocardium or coronaries. A long-term follow-up of patients as well as an increasing knowledge of the underlying biological pathways involved in cardiac toxicity should help designing effective preventing strategies.
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Affiliation(s)
- Cyrus Chargari
- Université Paris-Sud, institut Gustave-Roussy, LabEx Lermit - DHU Torino, radiothérapie moléculaire, Inserm 1030, 94805 Villejuif, France
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25
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Venkatramani R, Kamath S, Wong K, Olch AJ, Malvar J, Sposto R, Goodarzian F, Freyer DR, Keens TG, Mascarenhas L. Correlation of Clinical and Dosimetric Factors With Adverse Pulmonary Outcomes in Children After Lung Irradiation. Int J Radiat Oncol Biol Phys 2013; 86:942-8. [DOI: 10.1016/j.ijrobp.2013.04.037] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Revised: 04/14/2013] [Accepted: 04/17/2013] [Indexed: 12/25/2022]
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26
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Jordán Z, Tokodi Z, Németh A, Müller J, Csóka M, Mohl A, Erdélyi D, Kovács G. [Examination of late pulmonary toxicity in children treated for malignancies]. Orv Hetil 2013; 154:345-50. [PMID: 23434884 DOI: 10.1556/oh.2013.29549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The present investigation was based on a survey in 2005, in which the authors found pulmonary function abnormalities in survivors of childhood cancer, who were treated with anticancer therapy. AIM The purpose of the present study was to follow-up childhood cancer survivors and detect late pulmonary toxicity. PATIENTS AND METHODS Lung function test was performed with spirometry in 26 survivors participated in this study (10 females and 16 males; mean age, 19.4 years at the time of the second follow-up evaluation). The average time periods from treatment until the first and second follow-up evaluation were 4.5 and 10 years, respectively. RESULTS The authors found 14 patients with pathological pulmonary function tests results at the time of the first follow-up evaluation, from which 7 patients had obstructive, 5 patients had mixed and 2 patients had restrictive abnormalities. However, there were only 6 patients who had abnormal pulmonary function at the time of the second follow-up evaluation (2 patients with obstructive and 4 patients with restrictive pulmonary function tests (p<0.05). CONCLUSION Restrictive pulmonary disorder was detected in only small part of the treated patients. The obstructive pulmonary abnormalities caused by the treatment showed an improving tendency over time.
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Affiliation(s)
- Zsófia Jordán
- Semmelweis Egyetem, Általános Orvostudományi Kar Budapest
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Venkatramani R, Olch AJ, Mascarenhas L, Yoon S, Suterwala B, Mehta B, Wong K. Correlation of long-term pulmonary injury with radiation dose distribution in childhood cancer survivors. Pract Radiat Oncol 2012; 2:237-240. [PMID: 24674127 DOI: 10.1016/j.prro.2011.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Revised: 07/02/2011] [Accepted: 07/07/2011] [Indexed: 12/25/2022]
Affiliation(s)
- Rajkumar Venkatramani
- Division of Hematology/Oncology, Children's Hospital Los Angeles, Los Angeles, California.
| | - Arthur J Olch
- Division of Hematology/Oncology, Children's Hospital Los Angeles, Los Angeles, California; Radiation Oncology Program, Children's Hospital Los Angeles, Los Angeles, California
| | - Leo Mascarenhas
- Division of Hematology/Oncology, Children's Hospital Los Angeles, Los Angeles, California; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Susanne Yoon
- Radiation Oncology Program, Children's Hospital Los Angeles, Los Angeles, California
| | - Batul Suterwala
- Division of Hematology/Oncology, Children's Hospital Los Angeles, Los Angeles, California
| | - Bhakti Mehta
- Division of Hematology/Oncology, Children's Hospital Los Angeles, Los Angeles, California
| | - Kenneth Wong
- Division of Hematology/Oncology, Children's Hospital Los Angeles, Los Angeles, California; Radiation Oncology Program, Children's Hospital Los Angeles, Los Angeles, California
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McCurdy MR, Castillo R, Martinez J, Al Hallack MN, Lichter J, Zouain N, Guerrero T. [18F]-FDG uptake dose-response correlates with radiation pneumonitis in lung cancer patients. Radiother Oncol 2012; 104:52-7. [PMID: 22578806 DOI: 10.1016/j.radonc.2012.04.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 03/23/2012] [Accepted: 04/03/2012] [Indexed: 11/16/2022]
Abstract
PURPOSE To quantify the post-radiotherapy 2-[(18)F]-fluoro-2-deoxyglucose (FDG) pulmonary uptake dose-response in lung cancer patients and determine its relationship with radiation pneumonitis symptoms. METHODS AND MATERIALS The data from 24 patients treated for lung cancer with thoracic radiotherapy who received restaging PET/CT imaging between 4 and 12 weeks after radiotherapy completion were evaluated. Their radiation dose distribution was registered with the post-treatment restaging PET/CT. Using histogram analysis, the voxel average FDG-PET uptake vs. radiation dose was obtained for each case and linear regression was performed. The resulting slope, the pulmonary metabolic radiation response (PMRR), was used to characterize the dose-response. The Common Toxicity Criteria version 3 was used to score clinical pulmonary toxicity symptoms. Receiver operating characteristic (ROC) curves were used to determine the level of FDG uptake vs. dose, MLD, V(5), V(10), V(20), and V(30) that can best predict symptomatic and asymptomatic patients. RESULTS The median time between radiotherapy completion and FDG-PET imaging was 59 days (range, 26-70 days). The median of the mean SUV from lung that received 0-5 Gy was 1.00 (range, 0.37-1.48), 5-10 Gy was 1.01 (range, 0.37-1.77), 10-20 Gy was 1.04 (0.42-1.53), and >20 Gy was 1.29 (range, 0.41-8.01). Using the dose range of 0 Gy to the maximum dose minus 10 Gy, hierarchical linear regression model of the radiation dose and normalized FDG uptake per case found an adequate fit with the linear model. Pneumonitis scores were: Grade 0 for 13, Grade 1 for 5, Grade 2 for 6, and Grade 3, 4 or 5 for none. Using a PMRR threshold of 0.017 yields an associated true positive rate of 0.67 and false positive rate of 0.15 with average error of 30%. A V(5) threshold of 57.6 gives an associated true positive rate of 0.67 and false positive rate of 0.05 with a 20% average error. CONCLUSION The metabolic radiation pneumonitis dose-response was evaluated from post-treatment FDG-PET/CT imaging. Statistical modeling found a linear relationship. The FDG uptake dose-response and V(5) correlated with symptomatic radiation pneumonitis.
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Affiliation(s)
- Matthew R McCurdy
- Division of Medicine, University of North Dakota School of Medicine, Grand Forks, USA
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Fox AM, Dosoretz AP, Mauch PM, Chen YH, Fisher DC, LaCasce AS, Freedman AS, Silver B, Ng AK. Predictive Factors for Radiation Pneumonitis in Hodgkin Lymphoma Patients Receiving Combined-Modality Therapy. Int J Radiat Oncol Biol Phys 2012; 83:277-83. [DOI: 10.1016/j.ijrobp.2011.05.078] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2011] [Revised: 05/27/2011] [Accepted: 05/31/2011] [Indexed: 11/17/2022]
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Guerrero T, Martinez J, McCurdy MR, Wolski M, McAleer MF. Elevation in exhaled nitric oxide predicts for radiation pneumonitis. Int J Radiat Oncol Biol Phys 2012; 82:981-8. [PMID: 21377296 PMCID: PMC3626498 DOI: 10.1016/j.ijrobp.2010.08.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2010] [Revised: 08/11/2010] [Accepted: 08/14/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE Radiation pneumonitis is a major toxicity after thoracic radiotherapy (RT), with no method available to accurately predict the individual risk. This was a prospective study to evaluate exhaled nitric oxide as a predictive biomarker for radiation pneumonitis in esophageal cancer patients. PATIENTS AND METHODS A total of 34 patients prescribed neoadjuvant chemoradiotherapy for esophageal cancer were enrolled in the present trial. Each patient underwent respiratory surveys and exhaled nitric oxide (NO) measurements before, at the end of, and 1 to 2 months after completing RT. Pneumonitis toxicity was scored using the Common Terminology Criteria for Adverse Events, version 4.0. The demographics, dosimetric factors, and exhaled NO levels were evaluated for correlation with symptomatic patients (scores ≥ 2). RESULTS Of the 34 patients, 28 were evaluable. All had received 50.4 Gy RT with concurrent chemotherapy. The pneumonitis toxicity score was Grade 3 for 1, Grade 2 for 3, Grade 1 for 7, and Grade 0 for 17. The dosimetric factors were not predictive of symptoms. The mean exhaled NO level measured before, at completion, and at restaging was 17.3 ± 8.5 (range, 5.5-36.7), 16.0 ± 14.2 (range, 5.8-67.7), and 14.7 ± 6.2 (range, 5.5-28.0) parts per billion, respectively. The ratio of exhaled NO at the end of RT vs. before treatment was 3.4 (range, 1.7-6.7) for the symptomatic and 0.8 (range, 0.3-1.3) for the asymptomatic (p = .0017) patients. The elevation in exhaled NO preceded the peak symptoms by 33 days (range, 21-50). The interval to peak symptoms was inversely related to the exhaled NO elevation. CONCLUSIONS Elevations in exhaled NO at the end of RT was found to predict for radiation pneumonitis symptoms.
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Affiliation(s)
- Thomas Guerrero
- Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
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McCurdy MR, Wazni MW, Martinez J, McAleer MF, Guerrero T. Exhaled nitric oxide predicts radiation pneumonitis in esophageal and lung cancer patients receiving thoracic radiation. Radiother Oncol 2011; 101:443-8. [PMID: 21981878 DOI: 10.1016/j.radonc.2011.08.035] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Revised: 08/24/2011] [Accepted: 08/26/2011] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE Radiation pneumonitis is a significant toxicity following thoracic radiotherapy with no method to predict individual risk. MATERIALS AND METHODS Sixty-five patients receiving thoracic radiation for lung or esophageal cancer were enrolled in a phase II study. Each patient received respiratory surveys and exhaled nitric oxide measurements before, on the last day of, and 30-60 days after completing radiotherapy (RT). Pneumonitis toxicity was scored using the common terminology criteria for adverse events, version 4.0. The demographics, dosimetric factors, and nitric oxide ratio (NOR) of end RT/pre-RT were evaluated for correlation with symptomatic patients (Grade ≥ 2). RESULTS Fifty patients completed the trial. The pneumonitis toxicity score was: Grade 3 for 1 patient, Grade 2 for 6 patients, Grade 1 for 18 patients, and Grade 0 for 25 patients. Dosimetric factors were not predictive of symptoms. The NOR was 3.0 ± 1.8 (range 1.47-6.73) for the symptomatic and 0.78 ± 0.29 (range 0.33-1.37) for the asymptomatic patients (p=0.006). A threshold NOR of 1.4 separated symptomatic and asymptomatic patients (p<0.001). The average error was 4%. CONCLUSIONS Elevation in eNO on the last day of radiotherapy predicted subsequent symptomatic radiation pneumonitis weeks to months after treatment.
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Affiliation(s)
- Matthew R McCurdy
- Division of Radiation Oncology, Baylor College of Medicine, Houston, TX, USA
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