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Van Damme A, Tummers P, De Visschere P, Van Dorpe J, Van de Vijver K, Vercauteren T, De Gersem W, Denys H, Naert E, Makar A, De Neve W, Vandecasteele K. Exclusion of non-Involved uterus from the target volume (EXIT-trial): An individualized treatment for locally advanced cervical cancer using modern radiotherapy and imaging techniques followed by completion surgery. Clin Transl Radiat Oncol 2024; 47:100793. [PMID: 38798749 PMCID: PMC11126536 DOI: 10.1016/j.ctro.2024.100793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 04/29/2024] [Accepted: 05/09/2024] [Indexed: 05/29/2024] Open
Abstract
Background and purpose Chemoradiotherapy followed by brachytherapy is the standard of care for locally advanced cervical cancer (LACC). In this study, we postulate that omitting an iconographical unaffected uterus (+12 mm distance from the tumour) from the treatment volume is safe and that no tumour will be found in the non-targeted uterus (NTU) leading to reduction of high-dose volumes of surrounding organs at risk (OARs). Material and Methods In this single-arm phase 2 study, two sets of target volumes were delineated: one standard-volume (whole uterus) and an EXIT-volume (exclusion of non-tumour-bearing parts of the uterus with a minimum 12 mm margin from the tumour). All patients underwent chemoradiotherapy targeting the EXIT-volume, followed by completion hysterectomy. In 15 patients, a plan comparison between two treatment plans (PTV vs PTV_EXIT) was performed. The primary endpoint was the pathological absence of tumour involvement in the non-targeted uterus (NTU). Secondary endpoints included dosimetric impact of target volume reduction on OARs, acute and chronic toxicity, overall survival (OS), locoregional recurrence-free survival (LRFS), and progression-free survival (PFS). Results In all 21 (FIGO stage I: 2; II: 14;III: 3; IV: 2) patients the NTU was pathologically negative. Ssignificant reductions in Dmean in bladder, sigmoid and rectum; V15Gy in sigmoid and rectum, V30Gy in bladder, sigmoid and rectum; V40Gy and V45Gy in bladder, bowel bag, sigmoid and rectum; V50Gy in rectum were achieved. Median follow-up was 54 months (range 7-79 months). Acute toxicity was mainly grade 2 and 5 % grade 3 urinary. The 3y- OS, PFS and LRFS were respectively 76,2%, 64,9% and 81 %. Conclusion MRI-based exclusion of the non-tumour-bearing parts of the uterus at a minimum distance of 12 mm from the tumour out of the target volume in LACC can be done without risk of residual disease in the NTU, leading to a significant reduction of the volume of surrounding OARS treated to high doses.
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Affiliation(s)
- Axel Van Damme
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Philippe Tummers
- Department of Gynaecology, Ghent University Hospital, Ghent, Belgium
- Gynecological Pelvic Oncology Network (GYPON), Ghent University (Hospital), Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Pieter De Visschere
- Gynecological Pelvic Oncology Network (GYPON), Ghent University (Hospital), Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium
- Departement of Radiology and Nuclear Medicine, Ghent University Hospital, Belgium
| | - Jo Van Dorpe
- Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium
- Department of Pathology, Ghent University Hospital, Ghent, Belgium
| | - Koen Van de Vijver
- Gynecological Pelvic Oncology Network (GYPON), Ghent University (Hospital), Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium
- Department of Pathology, Ghent University Hospital, Ghent, Belgium
| | - Tom Vercauteren
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Werner De Gersem
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Hannelore Denys
- Department of Gynaecology, Ghent University Hospital, Ghent, Belgium
- Gynecological Pelvic Oncology Network (GYPON), Ghent University (Hospital), Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium
- Department of Gynaecology, Division of Gynecologic Oncology, ZNA Middelheim Antwerpen, Belgium
| | - Eline Naert
- Department of Gynaecology, Ghent University Hospital, Ghent, Belgium
- Gynecological Pelvic Oncology Network (GYPON), Ghent University (Hospital), Ghent, Belgium
- Department of Gynaecology, Division of Gynecologic Oncology, ZNA Middelheim Antwerpen, Belgium
| | - Amin Makar
- Gynecological Pelvic Oncology Network (GYPON), Ghent University (Hospital), Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium
- Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Wilfried De Neve
- Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Katrien Vandecasteele
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
- Gynecological Pelvic Oncology Network (GYPON), Ghent University (Hospital), Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
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2
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Corbeau A, Heemsbergen WD, Kuipers SC, Godart J, Creutzberg CL, Nout RA, de Boer SM. Predictive Factors for Toxicity After Primary Chemoradiation for Locally Advanced Cervical Cancer: A Systematic Review. Int J Radiat Oncol Biol Phys 2024; 119:127-142. [PMID: 37979708 DOI: 10.1016/j.ijrobp.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 11/01/2023] [Accepted: 11/04/2023] [Indexed: 11/20/2023]
Abstract
PURPOSE Women with locally advanced cervical cancer (LACC) undergoing primary platinum-based chemoradiotherapy and brachytherapy often experience toxicities. Normal-tissue complication probability (NTCP) models quantify toxicity risk and aid in optimizing radiation therapy to minimize side effects. However, it is unclear which predictors to include in an NTCP model. The aim of this systematic review was to provide an overview of the identified predictors contributing to gastrointestinal (GI), genitourinary (GU), and vaginal toxicities and insufficiency fractures for LACC. METHODS AND MATERIALS A systematic search was performed and articles evaluating the relationship between predictors and toxicities in women with LACC treated with primary chemoradiation were included. The Quality In Prognosis Studies tool was used to assess risk of bias, with high-risk studies being excluded from further analysis. Relationships between dose-volume parameters, patient and treatment characteristics, and toxicity endpoints were analyzed. RESULTS Seventy-three studies were identified. Twenty-six had a low or moderate risk of bias and were therefore included. Brachytherapy-related dose-volume parameters of the GI tract, including rectum and bowel equivalent dose in 2 Gy fractions (EQD2) D2 cm3, were frequently related to toxicities, unlike GU dose-volume parameters. Furthermore, (recto)vaginal point doses predicted toxicities. Few studies evaluated external beam radiation therapy dose-volume parameters and identified rectum EQD2 V30 Gy, V40 Gy, and V55 Gy, bowel and bladder EQD2 V40 Gy as toxicity predictors. Also, total reference air kerma and vaginal reference length were associated with toxicities. Relationships between patient characteristics and GI toxicity were inconsistent. The extent of vaginal involvement at diagnosis, baseline symptoms, and obesity predicted GU or vaginal toxicities. Only 1 study evaluated insufficiency fractures and demonstrated lower pretreatment bone densities to be associated. CONCLUSIONS This review detected multiple candidate predictors of toxicity. Larger studies should consider insufficiency fractures, assess dose levels from external beam radiation therapy, and quantify the relationship between the predictors and treatment-related toxicities in women with LACC to further facilitate NTCP model development for clinical use.
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Affiliation(s)
- Anouk Corbeau
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands.
| | - Wilma D Heemsbergen
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sander C Kuipers
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Medical Physics & Informatics, HollandPTC, Delft, The Netherlands
| | - Jeremy Godart
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Medical Physics & Informatics, HollandPTC, Delft, The Netherlands
| | - Carien L Creutzberg
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Remi A Nout
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Stephanie M de Boer
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
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3
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Barten DLJ, van Kesteren Z, Laan JJ, Dassen MG, Westerveld GH, Pieters BR, de Jonge CS, Stoker J, Bel A. Precision assessment of bowel motion quantification using 3D cine-MRI for radiotherapy. Phys Med Biol 2024; 69:04NT01. [PMID: 38232395 DOI: 10.1088/1361-6560/ad1f89] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 01/17/2024] [Indexed: 01/19/2024]
Abstract
Objective. The bowel is an important organ at risk for toxicity during pelvic and abdominal radiotherapy. Identifying regions of high and low bowel motion with MRI during radiotherapy may help to understand the development of bowel toxicity, but the acquisition time of MRI is rather long. The aim of this study is to retrospectively evaluate the precision of bowel motion quantification and to estimate the minimum MRI acquisition time.Approach. We included 22 gynaecologic cancer patients receiving definitive radiotherapy with curative intent. The 10 min pre-treatment 3D cine-MRI scan consisted of 160 dynamics with an acquisition time of 3.7 s per volume. Deformable registration of consecutive images generated 159 deformation vector fields (DVFs). We defined two motion metrics, the 50th percentile vector lengths (VL50) of the complete set of DVFs was used to measure median bowel motion. The 95th percentile vector lengths (VL95) was used to quantify high motion of the bowel. The precision of these metrics was assessed by calculating their variation (interquartile range) in three different time frames, defined as subsets of 40, 80, and 120 consecutive images, corresponding to acquisition times of 2.5, 5.0, and 7.5 min, respectively.Main results. For the full 10 min scan, the minimum motion per frame of 50% of the bowel volume (M50%) ranged from 0.6-3.5 mm for the VL50 motion metric and 2.3-9.0 mm for the VL95 motion metric, across all patients. At 7.5 min scan time, the variation in M50% was less than 0.5 mm in 100% (VL50) and 95% (VL95) of the subsets. A scan time of 5.0 and 2.5 min achieved a variation within 0.5 mm in 95.2%/81% and 85.7%/57.1% of the subsets, respectively.Significance. Our 3D cine-MRI technique quantifies bowel loop motion with 95%-100% confidence with a precision of 0.5 mm variation or less, using a 7.5 min scan time.
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Affiliation(s)
- D L J Barten
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, 1105 AZAmsterdam, The Netherlands
| | - Z van Kesteren
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, 1105 AZAmsterdam, The Netherlands
| | - J J Laan
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, 1105 AZAmsterdam, The Netherlands
| | - M G Dassen
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, 1105 AZAmsterdam, The Netherlands
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - G H Westerveld
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, 1105 AZAmsterdam, The Netherlands
- Erasmus MC Cancer Institute, Erasmus University Medical Center, Department of Radiation Oncology, Rotterdam, The Netherlands
| | - B R Pieters
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, 1105 AZAmsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - C S de Jonge
- Amsterdam UMC location University of Amsterdam, Department of Radiology and Nuclear Medicine, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - J Stoker
- Amsterdam UMC location University of Amsterdam, Department of Radiology and Nuclear Medicine, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - A Bel
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, 1105 AZAmsterdam, The Netherlands
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Pelizzola M, Tanderup K, Chopra S, Jürgenliemk-Schulz IM, Nout R, Kirchheiner K, Spampinato S. Co-occurrence of symptoms after radiochemotherapy in locally advanced cervix cancer patients: a cluster analysis. Acta Oncol 2023; 62:1479-1487. [PMID: 37906286 DOI: 10.1080/0284186x.2023.2271252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 10/06/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND State of the art combined radiochemotherapy and image-guided brachytherapy for locally advanced cervical cancer (LACC) has shown improved disease control and survival as well as a significant reduction of organ related morbidity. However, LACC cancer survivors are still experiencing a spectrum of symptoms. The aim of this study was to identify co-occurring symptoms in cervix cancer survivors by using patient-reported outcome and physician assessed morbidity. MATERIALS AND METHOD EMBRACE I is a multicenter prospective observational study with 1416 LACC patients (2008-2015). Information on physician-assessed morbidity and patient-reported outcome was assessed at baseline and at regular follow-ups up with the CTCAE v.3 and EORTC-C30/CX24, respectively. Patients with at least 2 years of follow-up were included and data from 3 months to 2 years was used in the analysis. Factor analysis was used on both EORTC and CTCAE data with symptoms and follow-ups as observations. The extracted factors represent clusters of symptoms. Subsequently, regression models were built to investigate associations between the symptom clusters and QOL. RESULTS The analysis included 742 patients. Despite the differences in the definition of physician-assessed and patient-reported symptoms, similar clusters are identified by the two assessment methods. Three main organ-related clusters are recognized for urinary, gastro-intestinal and vaginal morbidity. Furthermore, a general symptoms cluster where fatigue, pain, insomnia, neuropathy, and hot flashes have large weights is found. Lastly, a cluster with nausea, vomit and lack of appetite is also identified. The general, gastrointestinal and nausea clusters show significant associations with general QOL. CONCLUSIONS This analysis on both PRO and physician-assessed morbidity found a cluster associated with general symptoms and organ-related symptom clusters (urinary, gastrointestinal, vaginal). This shows that LACC survivors experience a variety of co-occurring symptoms. Our analysis also shows that the cluster of general symptoms is associated with a decrease in QOL.
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Affiliation(s)
- Marta Pelizzola
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Supriya Chopra
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Navi Mumbai, India
| | - Ina M Jürgenliemk-Schulz
- Department of Radiation Oncology, University Medical Centre Utrecht, Utrecht, CX, The Netherlands
| | - Remi Nout
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, The Netherlands
| | - Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Sofia Spampinato
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
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5
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Vittrup AS, Spampinato S, Jensen NBK, Tanderup K, Kirchheiner K, Pötter R, Nout R, Jürgenliemk-Schulz IM. In Reply to Murakami et al. Int J Radiat Oncol Biol Phys 2023; 116:964-965. [PMID: 37355314 DOI: 10.1016/j.ijrobp.2023.03.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 03/26/2023] [Indexed: 06/26/2023]
Affiliation(s)
| | - Sofia Spampinato
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna/General Hospital of Vienna, Vienna, Austria
| | - Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna/General Hospital of Vienna, Vienna, Austria
| | - Remi Nout
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
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Chargari C, Tanderup K, Planchamp F, Chiva L, Humphrey P, Sturdza A, Tan LT, van der Steen-Banasik E, Zapardiel I, Nout RA, Fotopoulou C. ESGO/ESTRO quality indicators for radiation therapy of cervical cancer. Radiother Oncol 2023; 183:109589. [PMID: 37268359 DOI: 10.1016/j.radonc.2023.109589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 01/11/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND The European Society of Gynaecological Oncology (ESGO) has previously defined and established a list of quality indicators for the surgical treatment of cervical cancer. As a continuation of this effort to improve overall quality of care for cervical cancer patients across all aspects, ESGO and the European SocieTy for Radiotherapy and Oncology (ESTRO) initiated the development of quality indicators for radiation therapy of cervical cancer. OBJECTIVE To develop a list of quality indicators for radiation therapy of cervical cancer that can be used to audit and improve clinical practice by giving to practitioners and administrators a quantitative basis to improve care and organizational processes, notably for recognition of the increased complexity of modern external radiotherapy and brachytherapy techniques. METHODS Quality indicators were based on scientific evidence and/or expert consensus. The development process included a systematic literature search for identification of potential quality indicators and documentation of scientific evidence, consensus meetings of a group of international experts, an internal validation process, and external review by a large international panel of clinicians (n = 99). RESULTS Using a structured format, each quality indicator has a description specifying what the indicator is measuring. Measurability specifications are detailed to define how the quality indicators will be measured in practice. Targets were also defined for specifying the level which each unit or center should be aiming to achieve. Nineteen structural, process, and outcome indicators were defined. Quality indicators 1-6 are general requirements related to pretreatment workup, time to treatment, upfront radiation therapy, and overall management, including active participation in clinical research and the decision making process within a structured multidisciplinary team. Quality indicators 7-17 are related to treatment indicators. Quality indicators 18 and 19 are related to patient outcomes. DISCUSSION This set of quality indicators is a major instrument to standardize the quality of radiation therapy in cervical cancer. A scoring system combining surgical and radiotherapeutic quality indicators will be developed within an envisaged future ESGO accreditation process for the overall management of cervical cancer, in an effort to support institutional and governmental quality assurance programs.
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Affiliation(s)
| | | | | | - Luis Chiva
- Obstetrics and Gynecology, Clinica Universidad de Navarra, Madrid, Spain
| | - Pauline Humphrey
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Wien, Austria
| | - Li T Tan
- Addenbrooke's Hospital, Cambridge, UK
| | | | | | - Remi A Nout
- Radiotherapy, Erasmus MC Cancer Centre, Rotterdam, the Netherlands
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7
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Chargari C, Tanderup K, Planchamp F, Chiva L, Humphrey P, Sturdza A, Tan LT, van der Steen-Banasik E, Zapardiel I, Nout RA, Fotopoulou C. ESGO/ESTRO quality indicators for radiation therapy of cervical cancer. Int J Gynecol Cancer 2023:ijgc-2022-004180. [PMID: 37258414 DOI: 10.1136/ijgc-2022-004180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND The European Society of Gynaecological Oncology (ESGO) has previously defined and established a list of quality indicators for the surgical treatment of cervical cancer. As a continuation of this effort to improve overall quality of care for cervical cancer patients across all aspects, ESGO and the European SocieTy for Radiotherapy and Oncology (ESTRO) initiated the development of quality indicators for radiation therapy of cervical cancer. OBJECTIVE To develop a list of quality indicators for radiation therapy of cervical cancer that can be used to audit and improve clinical practice by giving to practitioners and administrators a quantitative basis to improve care and organizational processes, notably for recognition of the increased complexity of modern external radiotherapy and brachytherapy techniques. METHODS Quality indicators were based on scientific evidence and/or expert consensus. The development process included a systematic literature search for identification of potential quality indicators and documentation of scientific evidence, consensus meetings of a group of international experts, an internal validation process, and external review by a large international panel of clinicians (n=99). RESULTS Using a structured format, each quality indicator has a description specifying what the indicator is measuring. Measurability specifications are detailed to define how the quality indicators will be measured in practice. Targets were also defined for specifying the level which each unit or center should be aiming to achieve. Nineteen structural, process, and outcome indicators were defined. Quality indicators 1-6 are general requirements related to pretreatment workup, time to treatment, upfront radiation therapy, and overall management, including active participation in clinical research and the decision making process within a structured multidisciplinary team. Quality indicators 7-17 are related to treatment indicators. Quality indicators 18 and 19 are related to patient outcomes. DISCUSSION This set of quality indicators is a major instrument to standardize the quality of radiation therapy in cervical cancer. A scoring system combining surgical and radiotherapeutic quality indicators will be developed within an envisaged future ESGO accreditation process for the overall management of cervical cancer, in an effort to support institutional and governmental quality assurance programs.
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Affiliation(s)
| | | | | | - Luis Chiva
- Obstetrics and Gynecology, Clinica Universidad de Navarra, Madrid, Spain
| | - Pauline Humphrey
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Wien, Austria
| | - Li T Tan
- Addenbrooke's Hospital, Cambridge, UK
| | | | | | - Remi A Nout
- Radiotherapy, Erasmus MC Cancer Centre, Rotterdam, Netherlands
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8
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Jiang Y, Wang J, Jiang P, Wang X, Zhang L, Zhang Y. Clinical research of the value of high-risk CTV setting on intensity-modulated radiotherapy for stage IIB-IVA cervical cancer. BMC Cancer 2023; 23:481. [PMID: 37245053 DOI: 10.1186/s12885-023-10931-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 05/08/2023] [Indexed: 05/29/2023] Open
Abstract
BACKGROUND This study aims to evaluate the clinical efficacy and side effects of setting up a high-risk clinical target volume (CTV-hr) alongside simultaneous integrated boost intensity-modulated radiotherapy (IMRT-SIB) in patients diagnosed with stage IIB-IVA cervical cancer. METHODS This study retrospectively analysed patients with stage IIB-IVA cervical cancer who received radical radiotherapy at the Affiliated Hospital of Qingdao University between November 2014 and September 2019. The patients were divided into experimental and control groups based on whether CTV-hr was set. All patients received a combined treatment of radiotherapy and chemotherapy. The dosage for paclitaxel was 135 mg/m2, while for cisplatin it was 75 mg/m2 or for carboplatin it was AUC 4-6, given in a cycle of 21 days. Radiotherapy (RT) included external beam radiation therapy (EBRT) and intracavitary brachytherapy (ICBT). In the control group, positive lymph nodes (GTV-n) were treated at a dose of 58-62 Gy/26-28 fractions(f), while clinical target volumes (CTV) were treated with a dose of 46-48 Gy/26-28f. The experimental group received a simultaneous integrated boost (SIB) to CTV-hr at a dose of 54-56 Gy/26-28f, with the same CTV and GTV-n as the control group. Both groups were combined with brachytherapy with a total dose (EQD2, the equivalent dose in 2 Gy/f) of 80-90 Gy. The study measured objective remission rate (ORR), 3-year progression-free survival (PFS) rate, 3-year overall survival (OS) rate, recurrence rate, and side effects as endpoints. RESULTS The study enrolled 217 patients, with 119 in the experimental group and 98 in the control group. Results showed that the experimental group had a higher 3-year OS rate (87.4% vs. 71.4%, p = 0.001) and 3-year PFS rate (72.3% vs. 51.0%, p = 0.000) compared to the control group. Additionally, the experimental group had significantly lower rates of overall recurrence (26.1% vs. 50.0%, p = 0.003), in-field recurrence (15.1% vs. 36.7%, p = 0.000), and out-field recurrence(13.4% vs. 35.7%, p = 0.000) compared to the control group. All observed differences were found to be statistically significant. However, the experimental and control groups had no statistically significant difference in ORR and radiological side effects, such as radiation cystitis and enteritis (p > 0.05). CONCLUSIONS Setting CTV-hr and performing IMRT-SIB on patients with stage IIB-IVA cervical cancer effectively increased the 3-year OS rate, 3-year PFS rate and reduced recurrence rate, with no significant differences in side effects.
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Affiliation(s)
- Yuqi Jiang
- Department of Radiation Oncology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, China
| | - Jing Wang
- Department of Radiation Oncology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, China
| | - Peng Jiang
- Department of Radiation Oncology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, China
| | - Xiang Wang
- Department of Radiation Oncology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, China
| | - Lei Zhang
- Department of Radiation Oncology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, China
| | - Yongchun Zhang
- Department of Radiation Oncology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, China.
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9
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Shelley CE, Bolt MA, Hollingdale R, Chadwick SJ, Barnard AP, Rashid M, Reinlo SC, Fazel N, Thorpe CR, Stewart AJ, South CP, Adams EJ. Implementing cone-beam computed tomography-guided online adaptive radiotherapy in cervical cancer. Clin Transl Radiat Oncol 2023; 40:100596. [PMID: 36910024 PMCID: PMC9999162 DOI: 10.1016/j.ctro.2023.100596] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 02/12/2023] [Indexed: 02/16/2023] Open
Abstract
Background and purpose Adaptive radiotherapy (ART) in locally advanced cervical cancer (LACC) has shown promising outcomes. This study investigated the feasibility of cone-beam computed tomography (CBCT)-guided online ART (oART) for the treatment of LACC. Material and methods The quality of the automated radiotherapy treatment plans and artificial intelligence (AI)-driven contour delineation for LACC on a novel CBCT-guided oART system were assessed. Dosimetric analysis of 200 simulated oART sessions were compared with standard treatment. Feasibility of oART was assessed from the delivery of 132 oART fractions for the first five clinical LACC patients. The simulated and live oART sessions compared a fixed planning target volume (PTV) margin of 1.5 cm around the uterus-cervix clinical target volume (CTV) with an internal target volume-based approach. Workflow timing measurements were recorded. Results The automatically-generated 12-field intensity-modulated radiotherapy plans were comparable to manually generated plans. The AI-driven organ-at-risk (OAR) contouring was acceptable requiring, on average, 12.3 min to edit, with the bowel performing least well and rated as unacceptable in 16 % of cases. The treated patients demonstrated a mean PTV D98% (+/-SD) of 96.7 (+/- 0.2)% for the adapted plans and 94.9 (+/- 3.7)% for the non-adapted scheduled plans (p<10-5). The D2cc (+/-SD) for the bowel, bladder and rectum were reduced by 0.07 (+/- 0.03)Gy, 0.04 (+/-0.05)Gy and 0.04 (+/-0.03)Gy per fraction respectively with the adapted plan (p <10-5). In the live.setting, the mean oART session (+/-SD) from CBCT acquisition to beam-on was 29 +/- 5 (range 21-44) minutes. Conclusion CBCT-guided oART was shown to be feasible with dosimetric benefits for patients with LACC. Further work to analyse potential reductions in PTV margins is ongoing.
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Affiliation(s)
- Charlotte E Shelley
- Department of Oncology, St. Luke's Cancer Centre, Royal Surrey Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK
| | - Matthew A Bolt
- Department of Oncology, St. Luke's Cancer Centre, Royal Surrey Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK
| | - Rachel Hollingdale
- Department of Oncology, St. Luke's Cancer Centre, Royal Surrey Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK
| | - Susan J Chadwick
- Department of Oncology, St. Luke's Cancer Centre, Royal Surrey Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK
| | - Andrew P Barnard
- Department of Oncology, St. Luke's Cancer Centre, Royal Surrey Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK
| | - Miriam Rashid
- Department of Oncology, St. Luke's Cancer Centre, Royal Surrey Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK
| | - Selina C Reinlo
- Department of Oncology, St. Luke's Cancer Centre, Royal Surrey Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK
| | - Nawda Fazel
- Department of Oncology, St. Luke's Cancer Centre, Royal Surrey Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK
| | - Charlotte R Thorpe
- Department of Oncology, St. Luke's Cancer Centre, Royal Surrey Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK
| | - Alexandra J Stewart
- Department of Oncology, St. Luke's Cancer Centre, Royal Surrey Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK.,University of Surrey, Guildford GU2 7XX, UK
| | - Chris P South
- Department of Oncology, St. Luke's Cancer Centre, Royal Surrey Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK
| | - Elizabeth J Adams
- Department of Oncology, St. Luke's Cancer Centre, Royal Surrey Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX, UK
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Spampinato S, Tanderup K, Lindegaard JC, Schmid MP, Sturdza A, Segedin B, Jürgenliemk-Schulz IM, De Leeuw A, Bruheim K, Mahantshetty U, Chargari C, Rai B, Cooper R, van der Steen-Banasik E, Sundset M, Wiebe E, Villafranca E, Van Limbergen E, Pieters BR, Tee Tan L, Lutgens LCHW, Hoskin P, Smet S, Pötter R, Nout R, Chopra S, Kirchheiner K. Association of persistent morbidity after radiotherapy with quality of life in locally advanced cervical cancer survivors. Radiother Oncol 2023; 181:109501. [PMID: 36720348 DOI: 10.1016/j.radonc.2023.109501] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/13/2023] [Accepted: 01/22/2023] [Indexed: 01/31/2023]
Abstract
PURPOSE To quantify the association of persistent morbidity with different aspects of quality of life (QOL) in locally advanced cervical cancer (LACC) survivors. MATERIAL AND METHODS Longitudinal outcome from the EMBRACE-I study was evaluated. Patient-reported symptoms and QOL were prospectively scored (EORTC-C30/CX24) at baseline and regular follow-ups. Physician-assessed symptoms were also reported (CTCAEv.3). Persistent symptoms were defined if present in at least half of the follow-ups. QOL items were linearly transformed into a continuous scale. Linear mixed-effects models (LMM) were applied to evaluate and quantify the association of persistent symptoms with QOL. Overall QOL deterioration was evaluated by calculating the integral difference in QOL over time obtained with LMM for patients without and with persistent symptoms. RESULTS Out of 1416 patients enrolled, 741 with baseline and ≥ 3 late follow-ups were analyzed (median 59 months). Proportions of persistent EORTC symptoms ranged from 21.8 % to 64.9 % (bowel control and tiredness). For CTCAE the range was 11.3-28.6 % (limb edema and fatigue). Presence of any persistent symptom was associated with QOL, although with varying magnitude. Role functioning and Global health/QOL were the most impaired aspects. Fatigue and pain showed large differences, with reductions of around 20 % for most of the QOL aspects. Among organ-related symptoms, abdominal cramps showed the largest effect. CONCLUSION Persistent symptoms are associated with QOL reductions in LACC survivors. Organ-related symptoms showed smaller differences than general symptoms such as fatigue and pain. In addition to optimizing treatment to minimize organ-related morbidity, effort should be directed towards a more comprehensive and targeted morbidity management.
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Affiliation(s)
- Sofia Spampinato
- Danish Center for Particle Therapy, Aarhus University Hospital, 8200 Aarhus, Denmark.
| | - Kari Tanderup
- Danish Center for Particle Therapy, Aarhus University Hospital, 8200 Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark.
| | - Jacob C Lindegaard
- Department of Oncology, Aarhus University Hospital, 8200 Aarhus, Denmark.
| | - Maximilian P Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, 1090 Vienna, Austria.
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, 1090 Vienna, Austria.
| | - Barbara Segedin
- Department of Radiotherapy, Institute of Oncology, 1000 Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia.
| | - Ina M Jürgenliemk-Schulz
- Department of Radiation Oncology, University Medical Centre Utrecht, 3584 CX Utrecht, the Netherlands.
| | - Astrid De Leeuw
- Department of Radiation Oncology, University Medical Centre Utrecht, 3584 CX Utrecht, the Netherlands.
| | - Kjersti Bruheim
- Department of Oncology, Oslo University Hospital, 0450 Oslo, Norway.
| | - Umesh Mahantshetty
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai and Homi Bhabha Cancer Hospital and Research Centre, Visakhapatnam, Andhra Pradesh 530053, India.
| | - Cyrus Chargari
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, 94805 Villejuif, France.
| | - Bhavana Rai
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
| | - Rachel Cooper
- Leeds Cancer Centre, St James's University Hospital, Leeds LS9 7LP, United Kingdom.
| | | | - Marit Sundset
- Clinic of Oncology and Women's Clinic, St. Olavs Hospital, 7030 Trondheim, Norway.
| | - Ericka Wiebe
- Department of Oncology, Cross Cancer Institute and University of Alberta, Edmonton AB T6G 1Z2, Canada.
| | - Elena Villafranca
- Department of Radiation Oncology, Hospital of Navarra, 31008 Pamplona, Navarra, Spain.
| | - Erik Van Limbergen
- Department of Radiation Oncology, University Hospital Leuven, 3000 Leuven, Belgium.
| | - Bradley R Pieters
- Department of Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, 1081 HV Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, 1081 HV Amsterdam, the Netherlands.
| | - Li Tee Tan
- Oncology Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom.
| | - Ludy C H W Lutgens
- Maastricht Radiation Oncology (MAASTRO) clinic, 6229 ET Maastricht, the Netherlands.
| | - Peter Hoskin
- Mount Vernon Cancer Centre, Mount Vernon Hospital, Northwood HA6 2RN, United Kingdom.
| | - Stéphanie Smet
- Department of Radiation Oncology, Algemeen Ziekenhuis Turnhout, 2300 Turnhout, Belgium.
| | - Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, 1090 Vienna, Austria.
| | - Remi Nout
- Department of Clinical Oncology, Leiden University Medical Center, 2333 ZA Leiden, the Netherlands.
| | - Supriya Chopra
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Navi Mumbai 410210, India.
| | - Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, 1090 Vienna, Austria.
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11
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Vittrup AS, Kirchheiner K, Pötter R, Fokdal LU, Jensen NBK, Spampinato S, Haie-Meder C, Schmid MP, Sturdza AE, Mahantshetty U, Hoskin P, Segedin B, Bruheim K, Rai B, Wiebe E, van der Steen-Banasik E, Cooper R, Van Limbergen E, Sundset M, Pieters BR, Kirisits C, Lindegaard JC, Jürgenliemk-Schulz IM, Nout R, Tanderup K. Overall Severe Morbidity After Chemo-Radiation Therapy and Magnetic Resonance Imaging-Guided Adaptive Brachytherapy in Locally Advanced Cervical Cancer: Results From the EMBRACE-I Study. Int J Radiat Oncol Biol Phys 2023:S0360-3016(23)00007-X. [PMID: 36641039 DOI: 10.1016/j.ijrobp.2023.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 12/10/2022] [Accepted: 01/04/2023] [Indexed: 01/13/2023]
Abstract
PURPOSE To evaluate overall severe late morbidity (grade ≥3) in patients with locally advanced cervical cancer treated with chemo-radiation therapy and magnetic resonance image guided adaptive brachytherapy within the prospective EMBRACE-I study, and to compare the results with published literature after standard radiograph based brachytherapy (BT). METHODS AND MATERIALS From 2008 to 2015 the EMBRACE-I study enrolled 1416 patients. Morbidity was assessed (Common Terminology Criteria for Adverse Events version 3.0) every 3 months the 1st year, every 6 months the second and third year, and yearly thereafter and 1251 patients had available follow-up on late morbidity. Morbidity events (grade 3-5) were summarized as the maximum grade during follow-up (crude incidence rates) and actuarial estimates at 3 and 5 years. To compare with the published literature on standard radiograph based BT, Common Terminology Criteria for Adverse Events scores from the EMBRACE-I study were retrospectively converted into a corresponding score in the Radiation Therapy Oncology Group and European Organization for Research and Treatment of Cancer system. RESULTS In total, 534 severe events occurred in 270 patients; 429 events were grade 3 and 105 were grade 4 events. Actuarial estimates for grade ≥3 gastrointestinal (GI), genitourinary (GU), vaginal and fistula events at 5 years were 8.5% (95% confidence interval [CI], 6.9%-10.6%), 6.8% (95% CI, 5.4%-8.6%), 5.7% (95% CI, 4.3%-7.6%), and 3.2% (95% CI, 2.2%-4.5%), respectively. The 5-year actuarial estimate for organ-related events (GI, GU, vaginal, or fistula) was 18.4% (95% CI, 16.0%-21.2%). The 5-year actuarial estimate when aggregating all G≥3 endpoints (GI, GU, vaginal, fistulas, and non-GI/GU/vaginal) was 26.6% (95% CI, 23.8%-29.6%). Thirteen patients had a treatment-related death, 8 of which were associated with GI morbidity. CONCLUSIONS This report assesses severe morbidity from the largest prospective study on chemo-radiation therapy and image guided adaptive brachytherapy for locally advanced cervical cancer to date. Severe late morbidity was limited per endpoint and organ category, but considerable when aggregated across organs and all endpoints. The late morbidity results in the EMBRACE-I study compare favorably with published literature on standard radiograph based BT for GI morbidity, vaginal morbidity, and fistulas.
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Affiliation(s)
| | - Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna/General Hospital of Vienna, Vienna, Austria
| | - Richard Pötter
- Department of Radiation therapy, Gustave-Roussy, Villejuif, France
| | | | | | - Sofia Spampinato
- Department of Oncology Aarhus University Hospital, Aarhus, Denmark
| | | | - Maximilian Paul Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna/General Hospital of Vienna, Vienna, Austria
| | - Alina Emiliana Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna/General Hospital of Vienna, Vienna, Austria
| | | | - Peter Hoskin
- Cancer Centre, Mount Vernon Hospital, Northwood, United Kingdom
| | - Barbara Segedin
- Department of Radiation therapy, Institute of Oncology Ljubljana, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Kjersti Bruheim
- Department of Oncology, The Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Bhavana Rai
- Department of Radiation therapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ericka Wiebe
- Department of Oncology, Cross Cancer Institute and University of Alberta, Edmonton, Canada
| | | | - Rachel Cooper
- Leeds Cancer Centre, St James's University Hospital, Leeds, United Kingdom
| | | | - Marit Sundset
- Clinic of Oncology and Women's Clinic, St. Olavs Hospital, Trondheim, Norway
| | - Bradley Rumwell Pieters
- Department of Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Christian Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna/General Hospital of Vienna, Vienna, Austria
| | | | | | - Remi Nout
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Kari Tanderup
- Department of Oncology Aarhus University Hospital, Aarhus, Denmark
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12
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Radzishevska Y, Sukhina О, Vasylyev L, Sukhin V, Nemaltsova К, Kulinich H, Solodovnikova O. Treatment strategy and clinical characteristics of patients with cervical cancer as prognostic parameters of survival. УКРАЇНСЬКИЙ РАДІОЛОГІЧНИЙ ТА ОНКОЛОГІЧНИЙ ЖУРНАЛ 2022. [DOI: 10.46879/ukroj.3.2022.65-78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background. Cervical cancer (CRC) ranks second in the world among all malignant neoplasms of the female genital organs. According to the WHO, more than 500000 new cases of CRC are detected annually in the world. In 2021, 3398 new cases of the disease were registered in Ukraine. Currently a number of factors that have a rather high individual prognostic significance influences the CRC development. Among these factors are those which are associated with an adverse outcome: heavy hereditary anamnesis, growth form of tumor and its localization, variant of spread, depth of invasion into the stroma, morphological structure, methods of treatment, etc. Over the last decade, there has been an unfavorable trend towards an increase in the number of young patients who have an advanced tumor process, which significantly restricts methods and reduces the chances of the successful treatment. Thereby, the high level of morbidity and mortality from CRC, especially among young patients, as well as the unsatisfactory results of 5-year survival after traditional methods of treatment, indicate that the cancer of this type is the prior problem in domestic oncology.
Purpose. To make scientific analysis of modern treatment strategies and characteristics of CRC as prognostic survival parameters.
Materials and methods. The literature review included available full-text publications, which were obtained as a result of an in-depth analysis of foreign and domestic scientific publications.
Results. Authors gave analysis of modern domestic and foreign literature on the evaluation of the effectiveness of treatment of cervical cancer patients; namely, how treatment strategies, individual characteristics of patients and characteristics of the tumor affect the results of treatment and prognosis of patient survival. It is shown which parameters, factors and important nuances of the disease should be taken into account, which is decisive in choosing treatment tactics and preventing complications.
Conclusions. Knowing and taking into account the prognostic parameters of the survival of cervical cancer patients is important for the assessment of treatment standards, as well as the development of personalized tactics for the treatment and monitoring of this disease.
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13
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Urban R, Wong J, Lim P, Zhang S, Spadinger I, Olson R, Bachand F, Ho C, Tinker AV, Gondara L, Hamilton SN. Cervical cancer patient reported gastrointestinal outcomes: intensity/volumetric modulated vs. 3D conformal radiation therapy. J Gynecol Oncol 2022; 33:e70. [PMID: 35882607 PMCID: PMC9428301 DOI: 10.3802/jgo.2022.33.e70] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 06/12/2022] [Accepted: 06/21/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To evaluate gastrointestinal (GI) patient reported outcomes (PROs) in cervical cancer patients treated with definitive radiotherapy (RT), comparing 3D conformal RT (3DCRT) vs. intensity modulated/volumetric modulated arc therapy (IMRT/VMAT). METHODS An analysis of patients treated with definitive RT between 2015-2018 was performed. GI PROs were prospectively collected at baseline, during RT (acute), ≤12 weeks after RT (subacute), and >12 weeks after RT (late). GI PROs evaluated three symptom domains: bowel problems (BPs), bowel bother (BB), and abdominal problems (APs). Multiple linear regression analysis was performed to investigate associations between mean changes of symptom scores with clinical and dosimetric variables. RESULTS The cohort included 167 patients. A total of 100 (60%) patients were treated with IMRT/VMAT and 67 (40%) with 3DCRT. In the subacute phase, the mean change of symptom scores from baseline in 3DCRT vs. IMRT/VMAT were +0.9 vs. -1.15 (p=0.004) for BP, +2.18 vs. -0.10 (p=0.019) for BB, and +1.41 vs. -0.38 (p=0.021) for AP. Likewise, in the late phase, mean changes were +0.72 vs. -0.82 (p=0.014) for BP, +1.98 vs. -0.03 (p=0.008) for BB, and +1.29 vs. -0.31 (p<0.001) for AP. On multiple linear regression, use of 3DCRT vs. IMRT/VMAT was associated with greater mean changes in subacute BP (p=0.023) and late phase AP (p=0.019). A higher small bowel V50Gy was associated increased symptom scores in late AP (p=0.012). CONCLUSION 3DCRT was associated with significantly greater worsening of GI PRO symptom scores in the subacute and late phase. These data support the ongoing use of IMRT/VMAT in routine practice.
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Affiliation(s)
- Ryan Urban
- Department of Medicine, The University of British Columbia, Vancouver, BC, Canada.,Department of Radiation Oncology, BC Cancer - Vancouver, Vancouver, BC, Canada
| | - Justin Wong
- Department of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Peter Lim
- Department of Medicine, The University of British Columbia, Vancouver, BC, Canada.,Department of Radiation Oncology, BC Cancer - Vancouver, Vancouver, BC, Canada
| | - Susan Zhang
- Department of Medicine, The University of British Columbia, Vancouver, BC, Canada.,Department of Medical Physics, BC Cancer - Vancouver, Vancouver, BC, Canada
| | - Ingrid Spadinger
- Department of Medicine, The University of British Columbia, Vancouver, BC, Canada.,Department of Medical Physics, BC Cancer - Vancouver, Vancouver, BC, Canada
| | - Robert Olson
- Department of Medicine, The University of British Columbia, Vancouver, BC, Canada.,Department of Radiation Oncology, BC Cancer - Prince George, Prince George, BC, Canada
| | - Francois Bachand
- Department of Medicine, The University of British Columbia, Vancouver, BC, Canada.,Department of Radiation Oncology, BC Cancer - Kelowna, Kelowna, BC, Canada
| | - Clement Ho
- Department of Medicine, The University of British Columbia, Vancouver, BC, Canada.,Department of Radiation Oncology, BC Cancer - Surrey, Surrey, BC, Canada
| | - Anna V Tinker
- Department of Medicine, The University of British Columbia, Vancouver, BC, Canada.,Department of Medical Oncology, BC Cancer - Vancouver, Vancouver, BC, Canada
| | - Lovedeep Gondara
- Department of Population Oncology, BC Cancer - Vancouver, Vancouver, BC, Canada
| | - Sarah Nicole Hamilton
- Department of Medicine, The University of British Columbia, Vancouver, BC, Canada.,Department of Radiation Oncology, BC Cancer - Vancouver, Vancouver, BC, Canada.
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14
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Rogowski P, Rottler M, Walter F, Saicic S, Niyazi M, Well J, Nierer L, Trillsch F, Burges A, Mahner S, Belka C, Corradini S. Clinical outcome of combined intracavitary / interstitial brachytherapy using a hybrid applicator in locally advanced cervical cancer. Gynecol Oncol 2022; 166:576-581. [PMID: 35764443 DOI: 10.1016/j.ygyno.2022.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/14/2022] [Accepted: 06/20/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the clinical outcome in locally advanced cervical cancer (LACC) after image-guided adaptive brachytherapy (IGABT) with combined intracavitary and interstitial (IC/IS) techniques using the hybrid Venezia applicator (Elekta AB, Sweden). METHODS LACC patients (UICC Stage IIB - IVB) treated with radiochemotherapy followed by IGABT with the hybrid IC/IS Venezia applicator at a single institution were retrospectively analyzed. Treatment comprised EBRT of the pelvis with 45 Gy and concomitant weekly cisplatin chemotherapy (40 mg/m2) followed by MRI-based IGABT. Dosimetry, oncological outcome and toxicity were investigated. RESULTS Forty-six patients underwent a total of 184 fractions of IGABT between 2017 and 2020. Median follow-up was 24 months. Combined IC/IS techniques were used in 40 patients (87%). The median HRCTV volume was 31.2 cm3 and the median HRCTV D90% was 92.3 Gy (EQD210). The median D2cm3 was 74.8 Gy for bladder, 57.9 Gy for rectum, 60.0 Gy for sigmoid and 52.2 Gy for bowel (EQD23). The 3-yr actuarial rates were 97.6% for local control, 97.6% for pelvic control, 59.9% for distant metastasis-free survival and 81.6% for overall survival. The crude rate for G2 and G3 late toxicity was 21.7% and 4.3%. CONCLUSIONS IGABT with the hybrid Venezia applicator and a pronounced use of a combined IC/IS technique achieved high target doses, while maintaining low doses to organs at risk, leading to excellent local control and overall survival rates with acceptable toxicity.
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Affiliation(s)
- Paul Rogowski
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany.
| | - Maya Rottler
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Franziska Walter
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Stefan Saicic
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Justus Well
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Lukas Nierer
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Fabian Trillsch
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Germany
| | - Alexander Burges
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Germany
| | - Sven Mahner
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany; German Cancer Consortium (DKTK), Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany
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15
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Chen A, Chen F, Li X, Zhang Y, Chen L, Chen L, Zhu J. A Feasibility Study of Deep Learning-Based Auto-Segmentation Directly Used in VMAT Planning Design and Optimization for Cervical Cancer. Front Oncol 2022; 12:908903. [PMID: 35719942 PMCID: PMC9198405 DOI: 10.3389/fonc.2022.908903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/06/2022] [Indexed: 12/02/2022] Open
Abstract
Purpose To investigate the dosimetric impact on target volumes and organs at risk (OARs) when unmodified auto-segmented OAR contours are directly used in the design of treatment plans. Materials and Methods A total of 127 patients with cervical cancer were collected for retrospective analysis, including 105 patients in the training set and 22 patients in the testing set. The 3D U-net architecture was used for model training and auto-segmentation of nine types of organs at risk. The auto-segmented and manually segmented organ contours were used for treatment plan optimization to obtain the AS-VMAT (automatic segmentations VMAT) plan and the MS-VMAT (manual segmentations VMAT) plan, respectively. Geometric accuracy between the manual and predicted contours were evaluated using the Dice similarity coefficient (DSC), mean distance-to-agreement (MDA), and Hausdorff distance (HD). The dose volume histogram (DVH) and the gamma passing rate were used to identify the dose differences between the AS-VMAT plan and the MS-VMAT plan. Results Average DSC, MDA and HD95 across all OARs were 0.82–0.96, 0.45–3.21 mm, and 2.30–17.31 mm on the testing set, respectively. The D99% in the rectum and the Dmean in the spinal cord were 6.04 Gy (P = 0.037) and 0.54 Gy (P = 0.026) higher, respectively, in the AS-VMAT plans than in the MS-VMAT plans. The V20, V30, and V40 in the rectum increased by 1.35% (P = 0.027), 1.73% (P = 0.021), and 1.96% (P = 0.008), respectively, whereas the V10 in the spinal cord increased by 1.93% (P = 0.011). The differences in other dosimetry parameters were not statistically significant. The gamma passing rates in the clinical target volume (CTV) were 92.72% and 98.77%, respectively, using the 2%/2 mm and 3%/3 mm criteria, which satisfied the clinical requirements. Conclusions The dose distributions of target volumes were unaffected when auto-segmented organ contours were used in the design of treatment plans, whereas the impact of automated segmentation on the doses to OARs was complicated. We suggest that the auto-segmented contours of tissues in close proximity to the target volume need to be carefully checked and corrected when necessary.
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Affiliation(s)
- Along Chen
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Fei Chen
- School of Biomedical Engineering, Guangzhou Xinhua University, Guangzhou, China
| | - Xiaofang Li
- Department of Radiation Oncology, The Second Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yazhi Zhang
- Department of Oncology and Hematology, The Six People’s Hospital of Huizhou City, Huiyang Hospital Affiliated to Southern Medical University, Huizhou, China
| | - Li Chen
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Lixin Chen
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- *Correspondence: Lixin Chen, ; Jinhan Zhu,
| | - Jinhan Zhu
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- *Correspondence: Lixin Chen, ; Jinhan Zhu,
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Lindegaard JC, Petric P, Schmid MP, Nesvacil N, Haie-Meder C, Fokdal LU, Sturdza AE, Hoskin P, Mahantshetty U, Segedin B, Bruheim K, Huang F, Rai B, Cooper R, van der Steen-Banasik E, Van Limbergen E, Pieters BR, Tan LT, Nout RA, De Leeuw AAC, Kirchheiner K, Spampinato S, Jürgenliemk-Schulz I, Tanderup K, Kirisits C, Pötter R. Prognostic Implications of Uterine Cervical Cancer Regression During Chemoradiation Evaluated by the T-Score in the Multicenter EMBRACE I Study. Int J Radiat Oncol Biol Phys 2022; 113:379-389. [PMID: 35157992 DOI: 10.1016/j.ijrobp.2022.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/31/2022] [Accepted: 02/03/2022] [Indexed: 12/11/2022]
Abstract
PURPOSE A simple scoring system (T-score, TS) for integrating findings from clinical examination and magnetic resonance imaging (MRI) of the primary tumor at diagnosis has shown strong prognostic capability for predicting local control and survival in locally advanced cervical cancer treated with chemoradiation and MRI-guided brachytherapy (BT). The aim was to validate the performance of TS using the multicenter EMBRACE I study and to evaluate the prognostic implications of TS regression obtained during initial chemoradiation. METHODS AND MATERIALS EMBRACE I recruited 1416 patients, of whom 1318 were available for TS. Patients were treated with chemoradiation followed by MRI-guided BT. A ranked ordinal scale of 0 to 3 points was used to assess 8 anatomic locations typical for local invasion of cervical cancer. TS was calculated separately at diagnosis (TSD) and at BT (TSBT) by the sum of points obtained from the 8 locations at the 2 occasions. RESULTS Median TSD and TSBT was 5 and 4, respectively. TS regression was observed in 71% and was an explanatory variable for BT technique (intracavitary vs intracavitary/interstitial) and major dose-volume histogram parameters for BT, such as high-risk clinical target (CTVHR), CTVHR D90 (minimal dose to 90% of the target volume), D2cm3 bladder (minimal dose to the most exposed 2 cm3 of the bladder), and D2cm3 rectum. TS regression (TSBT≤5) was associated with improved local control and survival and with less morbidity compared with patients with TSBT remaining high (>5) despite initial chemoradiation. TS regression was significant in multivariate analysis for both local control and survival when analyzed in consort with already established prognostic parameters related to the patient, disease, and treatment. CONCLUSIONS TS was validated in a multicenter setting and proven to be a strong multidisciplinary platform for integration of clinical findings and imaging with the ability to quantitate local tumor regression and its prognostic implications regarding BT technique, dose-volume histogram parameters, local control, survival, and morbidity.
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Affiliation(s)
| | - Primoz Petric
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark; Department of Radiation Oncology, University Hospital Zürich, Switzerland
| | - Maximilian Paul Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Nicole Nesvacil
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | | | | | - Alina Emiliana Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Peter Hoskin
- Mount Vernon Cancer Centre, Northwood, United Kingdom
| | - Umesh Mahantshetty
- Homi Bhabha Cancer Hospital & Research Centre, Visakhapatnam, (A Unit of Tata Memorial Centre, Mumbai), India
| | - Barbara Segedin
- Department of Radiotherapy, Institute of Oncology Ljubljana, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Kjersti Bruheim
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Fleur Huang
- Department of Oncology, Cross Cancer Institute and University of Alberta, Edmonton, Alberta, Canada
| | - Bhavana Rai
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rachel Cooper
- St James's University Hospital, Leeds Cancer Centre, Leeds, United Kingdom
| | | | | | - Bradley Rumwell Pieters
- Department of Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Li-Tee Tan
- Department of Oncology, Addenbrooke's Hospital, Cambridge University Hospitals, United Kingdom
| | - Remi A Nout
- Department of Radiation Oncology, Leiden University Medical Center, The Netherlands
| | | | - Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Sofia Spampinato
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Ina Jürgenliemk-Schulz
- Department of Radiation Oncology, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
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17
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Chua VH, Yu KK, Chua PA, Chua RJ, Chua RM, Chun YN, Mariano J, Gonzalez G, Ortin TS, Bacorro W. Quality of Life among Survivors of Locally Advanced Cervical Cancer Treated with Definitive Chemoradiotherapy in a Decade of Transition. ASIAN JOURNAL OF ONCOLOGY 2022. [DOI: 10.1055/s-0042-1744300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Abstract
Introduction The standard treatment for locally advanced cervical cancer (LACC) is concurrent chemoradiotherapy (CRT). External beam radiotherapy (EBRT) and brachytherapy (BRT) advances in the last decade have resulted in improved local control and survival. There is a lack of data on quality of life (QoL) among survivors.
Objective This systematic review aimed to synthesize published data on QoL among LACC survivors treated with CRT and determine clinical factors of QoL.
Methods Systematic literature search was conducted in PubMed, EBSCO, and ScienceDirect for relevant articles published in 2010 to 2020. Eligible studies on LACC survivors aged 18 years and above, who reported QoL after CRT, were included. Screening and data extraction were done by two pairs of independent reviewers.
Results Five cohort studies, three cross sectional studies, and one clinical trial were included. Reported temporal evolution of QoL varied: two studies reported improvement of overall QoL, while four reported worsening of symptoms. Gastrointestinal, genitourinary, sexual, and psychosocial domains showed significant impairment. Age, stage, and baseline distress and physical condition were clinical determinants of body image, sexual activity, menopausal symptoms, distress, and dyspnea. Peripheral neuropathy, lymphedema, and dyspnea were reported, while grade 3 to 4 gastrointestinal, genitourinary, and musculoskeletal toxicities were rare.
Conclusion Use of advanced EBRT and BRT techniques is associated with improving QoL in the first 3 years from treatment completion. Gastrointestinal, genitourinary, sexual, and psychosocial functions remain impaired on the long-term. Other late toxicities worth noting include peripheral neuropathy, lower limb edema, and insufficiency fractures.
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Affiliation(s)
- Vannesza Hendricke Chua
- Department of Clinical Epidemiology, University of Santo Tomas, Faculty of Medicine and Surgery, Manila, Philippines
| | - Kelvin Ken Yu
- Department of Radiation Oncology, University of Santo Tomas Hospital, Benavides Cancer Institute, Manila, Philippines
| | - Patricia Andrea Chua
- Department of Clinical Epidemiology, University of Santo Tomas, Faculty of Medicine and Surgery, Manila, Philippines
| | - Raphael Joseph Chua
- Department of Clinical Epidemiology, University of Santo Tomas, Faculty of Medicine and Surgery, Manila, Philippines
| | - Robeley May Chua
- Department of Clinical Epidemiology, University of Santo Tomas, Faculty of Medicine and Surgery, Manila, Philippines
| | - Yae Na Chun
- Department of Clinical Epidemiology, University of Santo Tomas, Faculty of Medicine and Surgery, Manila, Philippines
| | - Jocelyn Mariano
- Department of Obstetrics and Gynecology, University of Santo Tomas, Faculty of Medicine and Surgery, Manila, Philippines
- Gynecologic Oncology Unit, University of Santo Tomas Hospital, Benavides Cancer Institute, Manila, Philippines
| | - Gil Gonzalez
- Department of Obstetrics and Gynecology, University of Santo Tomas, Faculty of Medicine and Surgery, Manila, Philippines
- Gynecologic Oncology Unit, University of Santo Tomas Hospital, Benavides Cancer Institute, Manila, Philippines
| | - Teresa Sy Ortin
- Department of Radiation Oncology, University of Santo Tomas Hospital, Benavides Cancer Institute, Manila, Philippines
- Gynecologic Oncology Unit, University of Santo Tomas Hospital, Benavides Cancer Institute, Manila, Philippines
| | - Warren Bacorro
- Department of Clinical Epidemiology, University of Santo Tomas, Faculty of Medicine and Surgery, Manila, Philippines
- Department of Radiation Oncology, University of Santo Tomas Hospital, Benavides Cancer Institute, Manila, Philippines
- Gynecologic Oncology Unit, University of Santo Tomas Hospital, Benavides Cancer Institute, Manila, Philippines
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Moschen AR, Sammy Y, Marjenberg Z, Heptinstall AB, Pooley N, Marczewska AM. The Underestimated and Overlooked Burden of Diarrhea and Constipation in Cancer Patients. Curr Oncol Rep 2022; 24:861-874. [PMID: 35325401 DOI: 10.1007/s11912-022-01267-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW This review aims to summarize and discuss the diverse causes of two major gastrointestinal dysfunction symptoms, diarrhea and constipation, in cancer patients. We also discuss short- and long-term clinical, economic, and humanistic consequences, including the impact on cancer treatment regimens and patient quality of life, highlighting the limitations of the literature. RECENT FINDINGS Diarrhea and constipation as a result of cancer and its treatment can risk the success of anti-cancer therapies by requiring treatment delay or withdrawal, and imposes a substantial humanistic burden in patients with cancer. Despite its importance and frequency, gastrointestinal side effects may be overlooked due to the focus on cancer treatment, and the impact on patients may be underestimated. Additionally, the burden reported may not fully reflect current cancer management, particularly the true impact of economic consequences. A full understanding of the burden of diarrhea and constipation in patients with cancer is required, including broad evaluation of clinical considerations, the patient experience, and an updated assessment of economic burden. This would improve caregivers' appreciation of the impact of gastrointestinal dysfunction and aid the prioritization of future research efforts.
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Sturdza AE, Knoth J. Image-guided brachytherapy in cervical cancer including fractionation. Int J Gynecol Cancer 2022; 32:273-280. [DOI: 10.1136/ijgc-2021-003056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 12/14/2021] [Indexed: 02/02/2023] Open
Abstract
Image-guided brachytherapy in cervical cancer has been developed to be a feasible and very efficient component of the treatment of locally advanced cervical cancer in addition to concurrent chemoradiation treatment. This technique allows effective dose coverage of the target while sparing the organs at risk through adjustment of the implants (intracavitary and interstitial needles) and multi-pararametric three-dimensional treatment planning. Emerging evidence from prospective studies shows a high rate of local control throughout all stages, superior to two-dimensional brachytherapy, with limited toxicity for each organ site. This is associated with a high rate of pelvic control and overall survival. Based on clinical evidence, there is a dose–effect relationship for both disease and morbidity endpoints from which clear dose constraints for the target and organs at risk were derived. This review gives an overview of the major milestones that occurred in the development of image-guided adaptive brachytherapy in the last two decades, including outcome data and a summary of the hard and soft dose constraints recommended for targets and organs at risk.
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20
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Zhang W, Li X, Lin T, Ma F, Ma X, Wu X, Sun Y, Sun X. A model to guide the management and decision of re-planning during radiotherapy for cervical cancer. Transl Cancer Res 2021; 10:5352-5363. [PMID: 35116382 PMCID: PMC8797880 DOI: 10.21037/tcr-21-2545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 12/17/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND To establish a model to predict whether re-planning is needed in the process of cervical cancer radiotherapy. METHODS We collected the clinical indexes of 132 patients diagnosed with cervical cancer receiving concurrent chemotherapy and radiotherapy, including 33 factors about tumor markers [carcinoembryonic antigen (CEA), cancer antigen 125 (CA-125), squamous cell carcinoma antigen (SCC)], tumor volume, rectal volume, bladder volume, volumes receiving 30-50 Gy in organs-at-risk (OARs), and the maximum dose (Dmax) received by 1-2 cc in OARs. We established a multivariate model for re-planning evaluation via principal component analysis, and then verified the model based on the internal data. RESULTS We identified the dose index (P1), tumor size index (P2), and volumes receiving 30-50 Gy in OARs and the tumor (P3) as the three most weighted factors of the re-planning model. We set the cut-off for the re-planning modification requirement at 1. The model was consistent with R = 0.12P1 + 0.21P2 + 0.31P3, and it performed accurately that area under the test set characteristics curve (AUC) =0.826]. CONCLUSIONS Our proposed method can help to reduce image re-examination during treatment, decrease toxicities in OARs, shorten the radiotherapy course, lessen oncologists' efforts, and save medical resources.
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Affiliation(s)
- Wei Zhang
- Department of Radiation Oncology, Affiliated People’s Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Xiuhua Li
- Department of Gynaecology, Fujian Cancer Hospital, The Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Tingting Lin
- Department of Radiation and Medical Oncology, Affiliated Sanming First Hospital of Fujian Medical University, Sanming, China
| | - Fang Ma
- Department of Radiation Oncology, Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Xiaoyu Ma
- Department of Radiation Oncology, Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Xiaoli Wu
- Department of Radiation Oncology, Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Yingming Sun
- Department of Radiation and Medical Oncology, Affiliated Sanming First Hospital of Fujian Medical University, Sanming, China
| | - Xiaoge Sun
- Department of Radiation Oncology, Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
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21
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Smet S, Spampinato S, Pötter R, Jürgenliemk-Schulz IM, Nout RA, Chargari C, Mahantshetty U, Sturdza A, Segedin B, Bruheim K, Hoskin P, Rai B, Huang F, Cooper R, Van der Steen-Banasik E, Sundset M, Van Limbergen E, Tan LT, Lutgens LCHW, Villafranca E, Pieters BR, Tanderup K, Kirchheiner K. Risk factors for late persistent fatigue after chemoradiotherapy in locally advanced cervical cancer: an analysis from the EMBRACE-I study. Int J Radiat Oncol Biol Phys 2021; 112:1177-1189. [PMID: 34838868 DOI: 10.1016/j.ijrobp.2021.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 11/10/2021] [Accepted: 11/19/2021] [Indexed: 11/17/2022]
Abstract
Objective To evaluate patient- and treatment-related risk factors for late persistent fatigue within the prospective, multi-center XXX study. Methods Fatigue was prospectively assessed (CTCAE v.3) at baseline and during regular follow-up in 993 locally advanced cervical cancer patients, after treatment with chemoradiotherapy and MRI-guided brachytherapy. Risk factors for baseline and late persistent fatigue were evaluated with multivariable logistic regression. Late persistent fatigue was defined, when either G≥1 or G≥2 was scored in at least half of follow-ups. Results Median follow-up was 57 months. Baseline fatigue G≥1/G≥2 (35.8%/6.3%, respectively) was associated with pre-existing co-morbidities, WHO Performance Status, underweight, severe pain and tumor volume. Late persistent G≥1/G≥2 fatigue (36.3%/5.8%, respectively) was associated with patient-related factors (baseline fatigue, younger age, obesity), alongside the size of irradiated volumes and the level of radiation doses from external beam radiotherapy (EBRT) and brachytherapy (EBRT: V43Gy, V57Gy; EBRT+brachytherapy: V60Gy EQD2). Large volume lymph node (LN) boost compared to no LN boost, increased the risk for late persistent fatigue G≥2 by 18% and 5% (in patients with and without baseline fatigue, respectively). The risk for late persistent fatigue G≥1 increased by 7% and 4% with V43Gy <2000cm³ versus >3000cm³ (in patients with and without baseline fatigue, respectively). Late persistent G≥1 fatigue occurred in 13% of patients without late persistent organ-related symptoms (gastro-intestinal, genito-urinary and vaginal), versus 34-43%, 50-58% and 73% in patients suffering from persistent symptoms involving 1,2 or 3 organs, respectively. Conclusion Late persistent fatigue occurs in a considerable number of patients after chemoradiotherapy. It is associated with patient-related factors, the size of volumes irradiated to intermediate and high EBRT and brachytherapy doses, and other persistent organ-related morbidity. These findings support the importance of ongoing efforts to better tailor the target dose and reduce irradiation of healthy tissue without compromising target coverage, using highly conformal EBRT and brachytherapy techniques.
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Affiliation(s)
- Stéphanie Smet
- Department of Radiation Oncology, AZ Turnhout, Turnhout, Belgium; Iridium Cancer Network, Antwerp, Belgium
| | - Sofia Spampinato
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University Hospital of Vienna, Vienna, Austria
| | | | - Remi A Nout
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands; Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Cyrus Chargari
- Department of Radiotherapy, Gustave-Roussy, Villejuif, France
| | - Umesh Mahantshetty
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India; Homi Bhabha Cancer Hospital and Research Centre, Visakhapatnam, India
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University Hospital of Vienna, Vienna, Austria
| | - Barbara Segedin
- Department of Radiotherapy, Institute of Oncology, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Kjersti Bruheim
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Peter Hoskin
- Mount Vernon Cancer Centre, Mount Vernon Hospital, Northwood, United Kingdom
| | - Bhavana Rai
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Fleur Huang
- Department of Oncology, Cross Cancer Institute and University of Alberta, Edmonton, Canada
| | - Rachel Cooper
- Leeds Cancer Centre, St James's University Hospital, Leeds, United Kingdom
| | | | - Marit Sundset
- Clinic of Oncology and Women's Clinic, St. Olavs Hospital, Trondheim, Norway
| | - Erik Van Limbergen
- Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Li Tee Tan
- Oncology Centre, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Ludy C H W Lutgens
- Maastricht Radiation Oncology (MAASTRO) clinic, Maastricht, The Netherlands
| | - Elena Villafranca
- Department of Radiation Oncology, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Bradley R Pieters
- Department of Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University Hospital of Vienna, Vienna, Austria.
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22
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Spampinato S, Jensen NBK, Pötter R, Fokdal LU, Chargari C, Lindegaard JC, Schmid MP, Sturdza A, Jürgenliemk-Schulz IM, Mahantshetty U, Hoskin P, Segedin B, Rai B, Bruheim K, Wiebe E, Van der Steen-Banasik E, Cooper R, Van Limbergen E, Sundset M, Pieters BR, Lutgens LCHW, Tan LT, Villafranca E, Smet S, Jastaniyah N, Nout RA, Kirisits C, Chopra S, Kirchheiner K, Tanderup K. Severity and persistency of late gastrointestinal morbidity in locally advanced cervical cancer: lessons learned from EMBRACE-I and implications for the future. Int J Radiat Oncol Biol Phys 2021; 112:681-693. [PMID: 34678431 DOI: 10.1016/j.ijrobp.2021.09.055] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/23/2021] [Accepted: 09/30/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate patient- and treatment-related risk factors for physician-assessed and patient-reported gastrointestinal (GI) symptoms after radio(chemo)therapy and image guided adaptive brachytherapy (IGABT) in locally advanced cervical cancer (LACC). MATERIAL AND METHODS Of 1416 patients from the XXX study, 1199 and 1002 were prospectively evaluated using physician-assessed (CTCAE) and patient-reported (EORTC) GI symptoms, respectively. CTCAE severe grade (G≥3) events were pooled according to the location in the GI tract (anus/rectum, sigmoid and colon/small bowel). CTCAE G≥2 and EORTC "very much" and "quite a bit"+"very much" scores (≥"quite a bit") were analyzed for individual symptoms with Cox regression. Logistic regression was used for persistent G≥1 and EORTC ≥"quite a bit" symptoms, defined if present in at least half of follow-ups. RESULTS Incidence of G≥3 events was 2.8%, 1.8% and 2.3% for G≥3 anus/rectum, sigmoid and colon/small bowel events, respectively. Among G≥2 symptoms, diarrhea and flatulence were the most prevalent (8.4% and 9.9%, respectively). Among patient-related factors, baseline morbidity, increasing age, smoking status and low body-mass-index were associated to GI symptoms with different impact. Among treatment-related factors, rectum D2cm3 and ICRU recto-vaginal reference point (RV-RP) correlated with G≥3 anus/rectum events, and moderate/persistent diarrhea, proctitis, bleeding, abdominal cramps and difficulty in bowel control. Bowel D2cm3 correlated with G≥3 sigmoid and colon/small bowel events, and moderate/persistent diarrhea and flatulence. For external beam radiotherapy (EBRT), prescription dose correlated with G≥3 anus/rectum, diarrhea and difficulty in bowel control. Patients with large lymph-node boost (V57Gy) were at higher risk for G≥3 sigmoid events, moderate/persistent diarrhea, proctitis and cramps. CONCLUSION The analysis showed that both EBRT and IGABT contribute to GI symptoms after LACC treatment. Rectum D2cm3, ICRU RV-RP and bowel D2cm3 are risk factors for GI morbidity. The risk for various symptoms was lower with an EBRT prescription of 45Gy than 50Gy, and increased with larger V57Gy.
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Affiliation(s)
- Sofia Spampinato
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark.
| | - Nina B K Jensen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark.
| | - Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Lars U Fokdal
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Cyrus Chargari
- Department of Radiotherapy, Gustave-Roussy, Villejuif, France
| | | | - Maximilian P Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | | | - Umesh Mahantshetty
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Navi Mumbai, India
| | - Peter Hoskin
- Mount Vernon Cancer Centre, Mount Vernon Hospital, Northwood, United Kingdom
| | - Barbara Segedin
- Department of Radiotherapy, Institute of Oncology, Ljubljana, Slovenia; Faculty of medicine, University of Ljubljana
| | - Bhavana Rai
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kjersti Bruheim
- Department of Oncology, Oslo University Hospital, Oslo Norway
| | - Ericka Wiebe
- Department of Oncology, Cross Cancer Institute and University of Alberta, Edmonton, Canada
| | | | - Rachel Cooper
- Leeds Cancer Centre, St James's University Hospital, Leeds, United Kingdom
| | - Erik Van Limbergen
- Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Marit Sundset
- Clinic of Oncology and Women's Clinic, St. Olavs Hospital, Trondheim, Norway
| | - Bradley R Pieters
- Department of Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Ludy C H W Lutgens
- Maastricht Radiation Oncology (MAASTRO) clinic, Maastricht, The Netherlands
| | - Li Tee Tan
- Oncology Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Elena Villafranca
- Department of Radiation Oncology, Hospital of Navarra, Pamplona, Spain
| | - Stéphanie Smet
- Department of Radiation Oncology, Algemeen Ziekenhuis Turnhout, Turnhout, Belgium
| | - Noha Jastaniyah
- Radiation Oncology Section, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Remi A Nout
- Department of Clinical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Christian Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Supriya Chopra
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Navi Mumbai, India
| | - Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria.
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark.
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23
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Peters M, de Leeuw AAC, Nomden CN, Tanderup K, Kirchheiner K, Lindegaard JC, Kirisits C, Haie-Meder C, Sturdza A, Fokdal L, Mahantshetty U, Hoskin P, Segedin B, Bruheim K, Rai B, Huang F, Cooper R, van der Steen-Banasik E, van Limbergen E, Pieters BR, Tan LT, van Rossum PSN, Nesvacil N, Nout R, Schmid MP, Pötter R, Jürgenliemk-Schulz IM. Risk factors for nodal failure after radiochemotherapy and image guided brachytherapy in locally advanced cervical cancer: An EMBRACE analysis. Radiother Oncol 2021; 163:150-158. [PMID: 34480958 DOI: 10.1016/j.radonc.2021.08.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 07/22/2021] [Accepted: 08/26/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To assess risk factors for nodal failure (NF) after definitive (chemo)radiotherapy and image-guided brachytherapy for locally advanced cervical cancer (LACC) for patients treated in the EMBRACE I study. MATERIALS AND METHODS Data for pelvic NF and para-aortic (PAO) NF (NFPAO) were analysed. After multiple imputation, univariable and multivariable Cox-regression was performed for clinical and treatment-related variables. For patients with affected pelvic nodes but no PAO nodes at diagnosis, additional analyses were performed for two subgroups: 1. 'small pelvis' nodes in internal and external iliac, obturator, parametrial, presacral and/or common iliac (CI) region and 2. any CI nodes (subgroup of 1). RESULTS 1338 patients with 152 NF and 104 NFPAO events were analysed with a median follow-up of 34.2 months (IQR 16.4-52.7). For the entire group, larger tumour width, nodal risk groups (in particular any CI nodes without PAO nodes), local failure, and lower Hb-nadir increased the risk of NF. Elective PAO-irradiation was independently associated with a decreased risk of NFPAO (HR 0.53, 95%-CI 0.28-1.00, p = 0.05). For subgroup 1, having 'any CI nodes without PAO nodes' and local failure significantly increased NF risk. Additionally, elective PAO-irradiation was associated with less risk of NFPAO (HR 0.38, 95%-CI 0.17-0.86, p = 0.02). For subgroup 2 only local failure was associated with higher risk of NF. CONCLUSION In this patient cohort, nodal disease and tumour width at diagnosis, as well as local failure, are risk factors for NF after definitive treatment. Having either 'any PAO nodes' (with or without pelvic nodes) or 'any CI nodes' (without PAO nodes) are stronger risk factors than involvement of nodes in the small pelvis alone. Elective PAO-irradiation was associated with significantly less NFPAO, particularly in patients with nodal disease in the 'small pelvis' and/or CI region at time of diagnosis.
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Affiliation(s)
- Max Peters
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands.
| | - Astrid A C de Leeuw
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | - Christel N Nomden
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | - Kari Tanderup
- Aarhus University Hospital, Department of Oncology, Aarhus, Denmark
| | - Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | | | - Christian Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | | | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | - Lars Fokdal
- Aarhus University Hospital, Department of Oncology, Aarhus, Denmark
| | | | - Peter Hoskin
- Mount Vernon Cancer Centre, Northwood, United Kingdom
| | - Barbara Segedin
- Institute of Oncology Ljubljana, Department of Radiotherapy, Ljubljana, Slovenia
| | - Kjersti Bruheim
- The Norwegian Radium Hospital-Oslo University Hospital, Department of Oncology, Oslo, Norway
| | - Bhavana Rai
- Postgraduate Institute of Medical Education and Research, Department of Radiotherapy and Oncology, Chandigarh, India
| | - Fleur Huang
- Department of Oncology, Cross Cancer Institute and University of Alberta, Edmonton, Canada
| | - Rachel Cooper
- St James's University Hospital, Leeds Cancer Centre, Leeds, United Kingdom
| | | | | | - Bradley R Pieters
- Department of Radiation Oncology, Amsterdam University Medical Centers, University of Amsterdam, the Netherlands
| | - Li Tee Tan
- Department of Oncology, Addenbrooke's Hospital, Cambridge University Hospitals, United Kingdom
| | - Peter S N van Rossum
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | - Nicole Nesvacil
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | - Remi Nout
- Leiden University Medical Center, Department of Radiation Oncology, Leiden, the Netherlands
| | - Maximilian P Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
| | - Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital of Vienna, Austria
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Musunuru HB, Pifer PM, Mohindra P, Albuquerque K, Beriwal S. Advances in management of locally advanced cervical cancer. Indian J Med Res 2021; 154:248-261. [PMID: 35142642 PMCID: PMC9131769 DOI: 10.4103/ijmr.ijmr_1047_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Globally, cervical cancer has the fourth highest cancer incidence and mortality in women. Cervical cancer is unique because it has effective prevention, screening, and treatment options. This review discusses the current cervical cancer advances with a focus on locally advanced cervical cancer. Topics discussed include diagnostic imaging principles, surgical management with adjuvant therapy and definitive concurrent chemoradiotherapy. Emphasis is given on current advances and future research directions in radiation therapy (RT) with an emphasis on three-dimensional brachytherapy, intensity-modulated RT, image-guided RT, proton RT and hyperthermia.
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Affiliation(s)
- Hima Bindu Musunuru
- Department of Radiation Oncology, University of Pittsburgh Medical Center Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - Phillip M Pifer
- Department of Radiation Oncology, University of Pittsburgh Medical Center Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Maryland Proton Treatment Center, Baltimore, Maryland, USA
| | - Kevin Albuquerque
- Department of Radiation Oncology, Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sushil Beriwal
- Department of Radiation Oncology, University of Pittsburgh Medical Center Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
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Shelley CE, Barraclough LH, Nelder CL, Otter SJ, Stewart AJ. Adaptive Radiotherapy in the Management of Cervical Cancer: Review of Strategies and Clinical Implementation. Clin Oncol (R Coll Radiol) 2021; 33:579-590. [PMID: 34247890 DOI: 10.1016/j.clon.2021.06.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/19/2021] [Accepted: 06/11/2021] [Indexed: 02/08/2023]
Abstract
The complex and varied motion of the cervix-uterus target during external beam radiotherapy (EBRT) underscores the clinical benefits afforded by adaptive radiotherapy (ART) techniques. These gains have already been realised in the implementation of image-guided adaptive brachytherapy, where adapting to anatomy at each fraction has seen improvements in clinical outcomes and a reduction in treatment toxicity. With regards to EBRT, multiple adaptive strategies have been implemented, including a personalised internal target volume, offline replanning and a plan of the day approach. With technological advances, there is now the ability for real-time online ART using both magnetic resonance imaging and computed tomography-guided imaging. However, multiple challenges remain in the widespread dissemination of ART. This review investigates the ART strategies and their clinical implementation in EBRT delivery for cervical cancer.
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Affiliation(s)
- C E Shelley
- Department of Clinical Oncology, St. Luke's Cancer Centre, Royal Surrey County Hospital, Guildford, UK.
| | - L H Barraclough
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - C L Nelder
- Department of Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK
| | - S J Otter
- Department of Clinical Oncology, St. Luke's Cancer Centre, Royal Surrey County Hospital, Guildford, UK
| | - A J Stewart
- Department of Clinical Oncology, St. Luke's Cancer Centre, Royal Surrey County Hospital, Guildford, UK; University of Surrey, Guildford, UK
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Mahantshetty U, Gurram L, Bushra S, Ghadi Y, Aravindakshan D, Paul J, Hande V, Pilar A, Chopra S, Ghosh J, Shylasree TS, Popat P, Sable N, Maheswari A, Gupta S. Single Application Multifractionated Image Guided Adaptive High-Dose-Rate Brachytherapy for Cervical Cancer: Dosimetric and Clinical Outcomes. Int J Radiat Oncol Biol Phys 2021; 111:826-834. [PMID: 34146636 DOI: 10.1016/j.ijrobp.2021.06.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 05/29/2021] [Accepted: 06/08/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE A prospective phase 2 study was conducted to evaluate the feasibility and safety of single-application multifractionated (SA-MF), high-dose-rate (HDR), image guided adaptive brachytherapy (IGABT) for cervical cancer. METHODS AND MATERIALS Patients (N = 41) with International Federation of Gynaecology and Obstetrics 2009 stage IIB-IVA disease recruited between 2017 and 2019 underwent SA-MF. After completion of external beam radiation therapy of 50 Gy in 25 fractions, patients received magnetic resonance IGABT. The IGABT protocol consisted of a single brachytherapy (BT) application and treatment with 3 fractions of HDR (9 Gy on day 1; 2 fractions of 7 Gy with a minimum 6-hour gap on day 2) after achieving planning aims of the high-risk clinical target volume (HRCTV) receiving >84 Gy EQD2 and 2 cm3 of the bladder and rectum/sigmoid receiving ≤85 Gy and <71 Gy, respectively. Interfraction variation was addressed by performing computed tomography planning and coregistration using a mutual information-based coordinate system on day 2 before the second fraction. Organ at risk contouring was done on computed tomography, and doses were re-evaluated and reoptimized if required. RESULTS Thirty-eight patients were treated as per the protocol. All patients underwent Intracavitary + Interstitial BT with needles (median, 4; range, 3-11). The mean ± standard deviation HRCTV volume was 41 ± 21 cm3 and HRCTV D90 dose was 87.2 ± 3.6Gy. The 0.1 cm3 and 2 cm3 to bladder, rectum, and sigmoid were -103.2 ± 10.6 Gy and -84.6 ± 6.8 Gy, 82.2 ± 9.5 Gy and -68.3 ± 5.7 Gy, and 83.5 ± 9.8 Gy and -69.5 ± 5.9 Gy, respectively. Six patients required reoptimization before the second fraction to meet planning aims. Mean overall treatment time was 47 ± 6 days. With a median follow up of 22 months (range, 2-37), 2-year local control and disease-free and overall survival were 90.1%, 85%, and 94.5%, respectively. So far 1 patient with grade II and 2 patients with grade III rectal toxicities have been reported. CONCLUSION Magnetic resonance IGABT with SA-MF BT was feasible in 95% of patients. The dosimetric parameters and clinical results achieved so far look promising.
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Affiliation(s)
- Umesh Mahantshetty
- Department of Radiation Oncology & Medical Physics, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, India; Department of Radiation Oncology & Medical Physics, Homi Bhabha Cancer Hospital & Research Centre, Visakhapatnam, India.
| | - Lavanya Gurram
- Department of Radiation Oncology & Medical Physics, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, India
| | | | - Yogesh Ghadi
- Department of Radiation Oncology & Medical Physics, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Dheera Aravindakshan
- Department of Radiation Oncology & Medical Physics, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - John Paul
- Department of Radiation Oncology & Medical Physics, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Vinod Hande
- Department of Radiation Oncology & Medical Physics, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Avinash Pilar
- Department of Radiation Oncology & Medical Physics, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Supriya Chopra
- Department of Radiation Oncology & Medical Physics, ACTREC, Tata Memorial Centre, HBNI, Mumbai, India
| | - Jaya Ghosh
- Department of Medical Oncology, Tata Memorial Hospital, HBNI, Mumbai, India
| | - T S Shylasree
- Department of Gynecology Oncology, Tata Memorial Hospital, HBNI, Mumbai, India
| | - Palak Popat
- Department of Radiodiagnosis, Tata Memorial Hospital, HBNI, Mumbai, India
| | - Nilesh Sable
- Department of Radiodiagnosis, Tata Memorial Hospital, HBNI, Mumbai, India
| | - Amita Maheswari
- Department of Gynecology Oncology, Tata Memorial Hospital, HBNI, Mumbai, India
| | - Sudeep Gupta
- Department of Medical Oncology, Tata Memorial Hospital, HBNI, Mumbai, India
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27
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Pötter R, Tanderup K, Schmid MP, Jürgenliemk-Schulz I, Haie-Meder C, Fokdal LU, Sturdza AE, Hoskin P, Mahantshetty U, Segedin B, Bruheim K, Huang F, Rai B, Cooper R, van der Steen-Banasik E, Van Limbergen E, Pieters BR, Tan LT, Nout RA, De Leeuw AAC, Ristl R, Petric P, Nesvacil N, Kirchheiner K, Kirisits C, Lindegaard JC. MRI-guided adaptive brachytherapy in locally advanced cervical cancer (EMBRACE-I): a multicentre prospective cohort study. Lancet Oncol 2021; 22:538-547. [PMID: 33794207 DOI: 10.1016/s1470-2045(20)30753-1] [Citation(s) in RCA: 248] [Impact Index Per Article: 82.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/10/2020] [Accepted: 12/11/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND The concept of the use of MRI for image-guided adaptive brachytherapy (IGABT) in locally advanced cervical cancer was introduced 20 years ago. Here, we report on EMBRACE-I, which aimed to evaluate local tumour control and morbidity after chemoradiotherapy and MRI-based IGABT. METHODS EMBRACE-I was a prospective, observational, multicentre cohort study. Data from patients from 24 centres in Europe, Asia, and North America were prospectively collected. The inclusion criteria were patients older than 18 years, with biopsy-proven squamous cell carcinoma, adenocarcinoma, or adenosquamous carcinoma of the uterine cervix, The International Federation of Gynecology and Obstetrics (FIGO) stage IB-IVA disease or FIGO stage IVB disease restricted to paraaortic lymph metastasis below the L1-L2 interspace, suitable for curative treatment. Treatment consisted of chemoradiotherapy (weekly intravenous cisplatin 40 mg/m2, 5-6 cycles, 1 day per cycle, plus 45-50 Gy external-beam radiotherapy delivered in 1·8-2 Gy fractions) followed by MRI-based IGABT. The MRI-based IGABT target volume definition and dose reporting was according to Groupe Européen de Curiethérapie European Society for Radiation Oncology recommendations. IGABT dose prescription was open according to institutional practice. Local control and late morbidity were selected as primary endpoints in all patients available for analysis. The study was registered with ClinicalTrials.gov, NCT00920920. FINDINGS Patient accrual began on July 30, 2008, and closed on Dec 29, 2015. A total of 1416 patients were registered in the database. After exclusion for not meeting patient selection criteria before treatment, being registered but not entered in the database, meeting the exclusion criteria, and being falsely excluded, data from 1341 patients were available for analysis of disease and data from 1251 patients were available for assessment of morbidity outcome. MRI-based IGABT including dose optimisation was done in 1317 (98·2%) of 1341 patients. Median high-risk clinical target volume was 28 cm3 (IQR 20-40) and median minimal dose to 90% of the clinical target volume (D90%) was 90 Gy (IQR 85-94) equi-effective dose in 2 Gy per fraction. At a median follow-up of 51 months (IQR 20-64), actuarial overall 5-year local control was 92% (95% CI 90-93). Actuarial cumulative 5-year incidence of grade 3-5 morbidity was 6·8% (95% CI 5·4-8·6) for genitourinary events, 8·5% (6·9-10·6) for gastrointestinal events, 5·7% (4·3-7·6) for vaginal events, and 3·2% (2·2-4·5) for fistulae. INTERPRETATION Chemoradiotherapy and MRI-based IGABT result in effective and stable long-term local control across all stages of locally advanced cervical cancer, with a limited severe morbidity per organ. These results represent a positive breakthrough in the treatment of locally advanced cervical cancer, which might be used as a benchmark for clinical practice and all future studies. FUNDING Medical University of Vienna, Aarhus University Hospital, Elekta AB, and Varian Medical Systems.
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Affiliation(s)
- Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Maximilian Paul Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria.
| | - Ina Jürgenliemk-Schulz
- Department of Radiation Oncology, University Medical Centre Utrecht, Utrecht, Netherlands
| | | | | | - Alina Emiliana Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Peter Hoskin
- Mount Vernon Hospital, Mount Vernon Cancer Centre, Northwood, London, UK; Division of Cancer Sciences, University of Manchester, Manchester, UK
| | | | - Barbara Segedin
- Department of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Kjersti Bruheim
- Department of Oncology, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Fleur Huang
- Department of Oncology, Cross Cancer Institute and University of Alberta, Edmonton, AB, Canada
| | - Bhavana Rai
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rachel Cooper
- St James's University Hospital, Leeds Cancer Centre, Leeds, UK
| | | | | | - Bradley Rumwell Pieters
- Department of Radiation Oncology, Amsterdam University Medical Center, Academic Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Li-Tee Tan
- Department of Oncology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Remi Abubakar Nout
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, Netherlands; Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Robin Ristl
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Primoz Petric
- Department of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Nicole Nesvacil
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Christian Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
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Interstitial brachytherapy for gynecologic malignancies: Complications, toxicities, and management. Brachytherapy 2021; 20:995-1004. [PMID: 33789823 DOI: 10.1016/j.brachy.2020.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 12/15/2020] [Accepted: 12/17/2020] [Indexed: 11/21/2022]
Abstract
From both a disease and management perspective, locally advanced gynecologic cancers present a significant challenge. Dose escalation with brachytherapy serves as a key treatment, providing conformal radiation while sparing at-risk organs. Intracavitary brachytherapy techniques have been shown to be effective, with improving tumor control and toxicity profiles with the advent of three-dimensional image planning. Despite this, the variations in tumor size, location, and pelvic anatomy may lead to suboptimal dosimetry with standard intracavitary applicators in some clinical scenarios. The addition of interstitial needles (interstitial brachytherapy (ISBT)) can improve the conformality of brachytherapy treatments by adding needles to peripheral (and central) regions of the target volume, improving the ability to escalate doses in these undercovered regions while sparing organs at risk. Interstitial brachytherapy can be delivered by intracavitary and interstitial hybrid applicators (ICBT/ISBT), perineal template (P-ISBT), or by free-hand technique. ISBT has however yet to be widely available because of concerns of complications and toxicities from this specialized treatment. However, with the increasing use of three-dimensional image-guided brachytherapy, there is an opportunity to increase the level of expertise in the gynecologic radiation oncology community with an improved understanding of the potential complications and morbidity. In this article, we review the acute and long-term toxicity in both ICBT/ISBT and P-ISBT using image-guided brachytherapy.
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Ballari N, Rai B, Bahl A, Mittal BR, Ghoshal S. Prospective observational study evaluating acute and delayed treatment related toxicities of prophylactic extended field volumetric modulated arc therapy with concurrent cisplatin in cervical cancer patients with pelvic lymph node metastasis. Tech Innov Patient Support Radiat Oncol 2021; 17:48-56. [PMID: 33748442 PMCID: PMC7970137 DOI: 10.1016/j.tipsro.2021.02.009] [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: 10/30/2020] [Revised: 02/10/2021] [Accepted: 02/15/2021] [Indexed: 11/30/2022] Open
Abstract
PURPOSE To evaluate the treatment related acute and delayed toxicities of extended field Volumetric modulated arc therapy (VMAT) with concurrent chemotherapy in patients of locally advanced cervical cancer with pelvic lymph nodes. MATERIAL AND METHODS From 2014 to 2016, 15 patients of locally advanced cervical cancer with Fluoro-deoxyglucose positron emission tomography (FDG-PET) positive pelvic lymph nodes were treated with extended field Simultaneous integrated boost (SIB)-VMAT 45 Gy/55 Gy/25#/5weeks and concurrent cisplatin. Acute toxicities were documented according to common terminology criteria for adverse events version 4 (CTCAE v.4). Dose volume parameters and patient characteristics were analyzed for association with toxicities. RESULTS Median age of patients at diagnosis was 48 years. 40% (6 patients) were stage IIB & 60% (9 patients) were stage IIIB. Median number of involved pelvic lymph nodes was 2 (range, 1-4), commonest location was external iliac lymph node region (86%). Median number of concurrent chemotherapy cycles received was five. Treatment was well tolerated and there were no grade ≥ 3 acute toxicities. Commonest acute toxicities observed were vomiting (≥grade2 -13.3%) followed by & nausea (grade ≥ 2 in 6%) and were associated with volume of bowel bag receiving 45 Gy. Constitutional symptoms (≥grade 2) were observed in 6% patients and had no dosimetric associations. At a median follow up of 43 months, delayed ≥ grade1, 2, 3 toxicity were observed in 80%, 0%, and 0% respectively with diarrhea being the commonest. CONCLUSION Prophylactic para aortic extended field VMAT with concurrent chemotherapy for locally advanced cervical cancer is well tolerated with acceptable acute toxicity profile. Significant grade 3 acute/delayed toxicities were not observed in this cohort of patients.
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Affiliation(s)
- N Ballari
- Departments of Radiotherapy, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - B Rai
- Departments of Radiotherapy, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - A Bahl
- Departments of Radiotherapy, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - B R Mittal
- Nuclear Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - S Ghoshal
- Departments of Radiotherapy, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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