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M S, Spampinato S, de Leeuw A, Fortin I, Kirisits C, Ye XY, Schmid M, Hoskin P, Mahantshetty U, Segedin B, Bruheim K, Huang F, Bhavana R, Cooper R, Steen Banasik E VD, Limbergen EV, Pieters BR, Tan LT, Chopra S, Nout R, Nesvascil N, Kirchheiner K, Pötter R, Jürgenliemk-Schulz IM, Tanderup K. Evaluation of brachytherapy applicators and their association with morbidity and local control in cervix cancer: An EMBRACE I analysis. Radiother Oncol 2025:110954. [PMID: 40449684 DOI: 10.1016/j.radonc.2025.110954] [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: 02/21/2025] [Revised: 05/20/2025] [Accepted: 05/22/2025] [Indexed: 06/03/2025]
Abstract
PURPOSE To investigate the effects of brachytherapy (BT) applicator and implant type on morbidity and local control (LC) in locally advanced cervix cancer patients. METHODS 1071 patients treated with radiochemotherapy including MRI-guided BT using tandem&ring (T&R) or tandem&ovoids (T&O) from 19 EMBRACE-I centers were analyzed. Intracavitary (IC) or intracavitary/interstitial (IC/IS) implants were used. Centers came from different brachytherapy traditions and followed their institutional dose aims and planning strategies. LC and physician-assessed morbidity (median follow-up 48 months) was compared between applicator/implant types using Cox proportional hazard model adjusting for patient characteristics and treatment-related potential confounders. Moderate-to-severe (G ≥ 2) genito-urinary (cystitis/frequency/incontinence), gastro-intestinal (proctitis/bleeding/diarrhea) and vaginal (stenosis/mucositis) symptoms were analysed individually. Severe events (G ≥ 3) were pooled per organ. RESULTS The T&O (n = 346) compared to T&R (n = 725) had a higher risk of morbidity, with HRs > 1.3 in 14/16 individual G ≥ 2 symptoms and in 3/4 G ≥ 3 pooled organ symptoms. Patients treated with IC/IS (n = 512) compared to IC (n = 559) were not at higher risk of G ≥ 2 symptoms, with HRs < 1 in 6/8 MVAs. Crude incidence of local failure was 7.3 % (25/343) for T&O and 6.6 % (47/712) for T&R. CONCLUSIONS In this patient cohort, treated between 2008-2015, T&R and T&O demonstrated comparable LC. However, a higher risk of morbidity is reported for T&O. This increased risk was partly explained by hotspot doses, with factors such as irradiated volumes and organ irradiation length also contributing. Additionally, implant quality, dose planning aims and strategies, and morbidity reporting may have impacted the observed differences in morbidity. IC/IS applicators did not increase morbidity risk compared to IC applicators.
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Affiliation(s)
- Serban M
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada; Danish Centre for Particle Therapy, Aarhus University Hospital, Denmark.
| | - S Spampinato
- Danish Centre for Particle Therapy, Aarhus University Hospital, Denmark; Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, the Netherlands
| | - A de Leeuw
- Department of Radiation Oncology, University Medical Centre Utrecht, the Netherlands
| | - I Fortin
- Department of Radiation Oncology, University of Montreal, Maisonneuve-Rosemont Hospital, Canada
| | - C Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital Vienna, Austria
| | - X Y Ye
- Biostatistics Department, University Health Network, Toronto, Canada
| | - M Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital Vienna, Austria
| | - P Hoskin
- Cancer Centre, Mount Vernon Hospital, London, UK
| | - U Mahantshetty
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, India
| | - B Segedin
- Department of Radiotherapy, Institute of Oncology Ljubljana, Medical Faculty, University of Ljubljana, Slovenia
| | - K Bruheim
- Department of Oncology, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - F Huang
- Department of Oncology, Cross Cancer Institute and University of Alberta, Edmonton, Canada
| | - R Bhavana
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - R Cooper
- Leeds Cancer Centre, St James's University Hospital, Leeds, UK
| | | | | | - B R Pieters
- Department of Radiation Oncology, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
| | - L T Tan
- Oncology Centre, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - S Chopra
- Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, India
| | - R Nout
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, the Netherlands
| | - N Nesvascil
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital Vienna, Austria
| | - K Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital Vienna, Austria
| | - R Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, General Hospital Vienna, Austria
| | | | - K Tanderup
- Danish Centre for Particle Therapy, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
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Parfenov AI, Indejkina LK, Sabelnikova EA, Leontiev AV, Makarova AA. [Radiation-induced intestinal injury]. TERAPEVT ARKH 2025; 97:101-108. [PMID: 40237744 DOI: 10.26442/00403660.2025.02.203116] [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: 10/08/2024] [Accepted: 02/19/2025] [Indexed: 04/18/2025]
Abstract
This article addresses theoretical and clinical aspects of radiation-induced intestinal injuries, which complicate radiation therapy for malignant neoplasms of the abdominal and pelvic organs. Many clinical aspects of this issue remain unknown due to the lack of awareness among doctors and patients. Further study of radiation-induced intestinal injuries and the development of personalized approaches to their prevention and treatment represent a relevant direction in internal medicine.
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Affiliation(s)
| | - L K Indejkina
- Loginov Moscow Clinical Scientific Center
- Research Institute for Healthcare and Medical Management
| | - E A Sabelnikova
- Loginov Moscow Clinical Scientific Center
- Russian University of Medicine
| | - A V Leontiev
- Loginov Moscow Clinical Scientific Center
- Moscow University for Industry and Finance "Synergy"
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Leontiev AV, Indejkina LK, Danilov MA, Sabelnikova EA, Orlyuk MA, Abramov KO, Makarova AA, Parfenov AI. [Chronic small bowel obstruction in a patient with post-radiation enteropathy. Case report]. TERAPEVT ARKH 2025; 97:193-197. [PMID: 40237757 DOI: 10.26442/00403660.2025.02.203119] [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: 11/06/2024] [Accepted: 01/20/2025] [Indexed: 04/18/2025]
Abstract
Сase report of late radiation damage to the small intestine in a patient who underwent laparoscopic extirpation of uterine cancer and radiation therapy is presented. The article shows the clinical manifestations of chronic post-radiation enteritis with a long progressive course and the development of partial intestinal obstruction, demonstrating the importance of timely diagnosis and the implementation of a multidisciplinary approach in the treatment of patients with late radiation damage to the intestine.
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Affiliation(s)
- A V Leontiev
- Loginov Moscow Clinical Scientific Center
- Moscow University for Industry and Finance "Synergy"
| | - L K Indejkina
- Loginov Moscow Clinical Scientific Center
- Research Institute for Healthcare Organization and Medical Management
| | | | - E A Sabelnikova
- Loginov Moscow Clinical Scientific Center
- Russian University of Medicine
| | - M A Orlyuk
- Moscow University for Industry and Finance "Synergy"
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Gautam S, Flower E, Richeson D, Sangha I, Ma T, Song WY. Improving plan quality in cervical cancer brachytherapy using knowledge-based planning for direction modulated brachytherapy tandem applicator. Brachytherapy 2025; 24:144-153. [PMID: 39645407 DOI: 10.1016/j.brachy.2024.11.001] [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: 09/15/2024] [Revised: 10/29/2024] [Accepted: 11/11/2024] [Indexed: 12/09/2024]
Abstract
PURPOSE The bladder and rectal toxicities in cervical cancer brachytherapy are positively correlated with the DVH parameter: D2cc. This study evaluates the feasibility of knowledge-based planning to predict the D2cc, identify suboptimal plans, and improve the plan quality with Direction Modulated Brachytherapy (DMBT) applicators using knowledge-based planning based on linear relationship between overlap distances and D2cc. METHODS The overlap volume histogram (OVH) method was used to determine the distances for 2 cm3 of overlap between the Organs at Risks (OAR) and High-Risk Clinical Target Volume (CTVHR). Linear plots were utilized to model the OAR D2cc and 2 cm3 overlap distances. Two datasets from 45 patients (125 plans) were used to create 2 independent models: Model 1 from 59 Intracavitary (IC) and Model 2 from 66 Intracavitary-Interstitial (ICIS) plans. Performances were compared using 5-fold cross-validation. The predicted D2cc values were used as the maximum constraints in the inverse planning optimization. RESULTS The mean bladder D2cc decreased by 4.3% and 10.3% for conventional applicators, and 4.4% and 3.6% for DMBT applicators for Models 1 and 2, respectively. The rectum D2cc decreased by 3.4% and 10.7% for conventional and 3.0% and 5.0% for DMBT applicators, respectively. The sigmoid D2cc decreased by 3.1% and 6.9% for conventional and 3.2% and 5.9% for DMBT applicators, respectively. There were also significant reductions for the recto-vaginal (RV-RP) point and posterior-inferior border of symphysis (PIBS) reference points: PIBS+2cm, PIBS+1cm, PIBS-1cm, and PIBS-2cm, for both models as well. CONCLUSIONS A knowledge-based planning method successfully predicted D2cc and optimized brachytherapy plans for cervical cancer. The proposed model demonstrates the feasibility of predicting D2cc, detecting suboptimal plans, and improving the plan quality especially for DMBT where cumulative clinical experience is limited.
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Affiliation(s)
- Suman Gautam
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA
| | - Emily Flower
- Sydney West Radiation Oncology Network, Westmead, New South Wales, Australia; Institute of Medical Physics, University of Sydney, Camperdown, New South Wales, Australia
| | - Dylan Richeson
- Department of Radiation Oncology, Inova Schar Cancer Institute, Fairfax, VA
| | - Ikchit Sangha
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA
| | - Tianjun Ma
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA
| | - William Y Song
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA.
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Rai B, Dey T, Ballari N, Singh M, Miryala R, Srinivasa GY, Kataria V, Naseem R, Thakur S, Arun Singh O, Ghoshal S. Three-Dimensional Conformal Radiotherapy Versus Image-Guided Intensity Modulated External Beam Radiotherapy in Locally Advanced Cervical Cancer: A Phase III Randomized Control Study. Clin Oncol (R Coll Radiol) 2024; 36:728-737. [PMID: 39209678 DOI: 10.1016/j.clon.2024.08.004] [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: 01/04/2024] [Revised: 08/04/2024] [Accepted: 08/08/2024] [Indexed: 09/04/2024]
Abstract
AIMS The standard treatment of locally advanced cervical carcinoma is radical chemoradiation followed by brachytherapy which has improved survival. Hence, a major concern is our attempt to reduce the incidence of acute and late toxicities. IMRT has been shown to reduce toxicities. In this study, we have compared 3DCRT with IG-IMRT using patient-specific margins to evaluate tumor control as well as OAR-related toxicities. MATERIALS AND METHODS This was a single institution prospective phase III randomised control study including patients of squamous cell carcinoma of cervix (stage II-IIIB, FIGO 2009) without pelvic lymph node involvement. All patients were simulated using intermediate bladder filling protocol and those in the IG-IMRT arm, underwent additional scans with full and empty bladder to assess the range of internal motion and generate individualised ITV margin. EBRT dose of 46Gy/23#/4.5 weeks was delivered with weekly concurrent cisplatin followed by brachytherapy. All toxicities during EBRT and till 3 months post brachytherapy were considered acute toxicity. Post-treatment, patients were followed up every 2 months for first 2 years and then once every 6 months. Disease-related outcomes were assessed with clinical examination and symptom-directed imaging. RESULTS Two hundred patients were screened for inclusion and of them, 89 patients in 3DCRT and 84 patients in IG-IMRT arms were considered for final analysis. The baseline characteristics were comparable in both arms, majority of patients in both arms having stage II disease. For OARs, all dosimetric parameters were significantly better in the IG-IMRT arm. Acute radiation induced toxicities (dermatitis, genito-urinary and gastrointestinal toxicities) were significantly less in the IG-IMRT arm. The local, pelvic, and distant control were comparable in both arms. CONCLUSION Based on our experience, the use of IG-IMRT with patient-specific ITV margins results in reduction in acute OAR toxicities in patients without compromising on tumor control.
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Affiliation(s)
- B Rai
- Dept of Radiotherapy and Oncology, PGIMER, Chandigarh, India.
| | - T Dey
- Dept of Radiotherapy and Oncology, PGIMER, Chandigarh, India.
| | - N Ballari
- Dept of Radiation Oncology, Homi Bhabha Cancer Hospital and Research Centre, Mullanpur, India.
| | - M Singh
- University Hospitals Birmingham, NHS Foundation Trust, India.
| | - R Miryala
- Dept of Radiation Oncology, Homi Bhabha Cancer Hospital and Research Centre, Vishakhapatnam, India.
| | - G Y Srinivasa
- Dept of Radiotherapy and Oncology, PGIMER, Chandigarh, India.
| | - V Kataria
- Dept of Radiotherapy and Oncology, PGIMER, Chandigarh, India.
| | - R Naseem
- Torbay and South Devon, NHS Foundation Trust, India.
| | - S Thakur
- Dept of Radiotherapy, Chitwan Medical College, Bharatpur, Nepal.
| | - O Arun Singh
- Dept of Radiotherapy and Oncology, PGIMER, Chandigarh, India.
| | - S Ghoshal
- Dept of Radiotherapy and Oncology, PGIMER, Chandigarh, India.
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Tozzi R, Bigardi S, Spagnol G, Ferrari F, Saccardi C, Noventa M, Marchetti M. Nerve-Sparing Laparoscopic Radical Hysterectomy (nsLRH) without Adjuvant Therapy in FIGO Stage IB3 Cervical Cancer Patients: Surgical Technique and Survival Outcomes. Cancers (Basel) 2024; 16:3355. [PMID: 39409974 PMCID: PMC11475574 DOI: 10.3390/cancers16193355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2024] [Revised: 09/16/2024] [Accepted: 09/25/2024] [Indexed: 10/20/2024] Open
Abstract
(1) Background: In 2018 FIGO reclassified tumors confined to the cervix larger than 4 cm as stage IB3. Although concurrent CTRT has been the standard of care and surgery the alternative, optimal management remains controversial due to the lack of direct comparison between surgery and CTRT. (2) Methods: This prospective observational study investigated the efficacy, safety and oncologic outcomes of nerve-sparing laparoscopic radical hysterectomy (nsLRH) for FIGO stage IB3 cervical cancer patients (IB3). From 2009 to 2023, IB3 patients underwent laparoscopic pelvic lymphadenectomies with frozen section analysis, followed by a nsLRH if the lymph nodes were tumor-free. No uterine manipulator was used and the vaginal cuff was sealed before retrieving the specimen. Intermediate-risk patients were under close observation without adjuvant therapy. Outcomes were monitored until 2023. (3) Results: During the study period, 74 IB3 patients were treated. Sixty-eight (91.9%) underwent a nsLRH. A complete resection with negative margins was achieved in all cases. At a median of 68 months of follow-up, the disease-free survival (DFS) rate was 89.7% and the overall survival (OS) rate was 93.1%. The overall complication rate was 23.5% and there were no grade 4-5 complications. (4) Conclusions: In patients with IB3 cervical cancer, a nsLRH is safe and effective. While awaiting the results from ongoing randomized trials, these findings support nsLRH as a viable treatment.
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Affiliation(s)
- Roberto Tozzi
- Department of Gynecology and Obstetrics, Division of Women and Children’s Health, University of Padua, 35128 Padua, Italy (G.S.); (C.S.); (M.N.); (M.M.)
| | - Sofia Bigardi
- Department of Gynecology and Obstetrics, Division of Women and Children’s Health, University of Padua, 35128 Padua, Italy (G.S.); (C.S.); (M.N.); (M.M.)
| | - Giulia Spagnol
- Department of Gynecology and Obstetrics, Division of Women and Children’s Health, University of Padua, 35128 Padua, Italy (G.S.); (C.S.); (M.N.); (M.M.)
| | - Federico Ferrari
- Department of Clinical and Experimental Sciences, University of Brescia, 35122 Brescia, Italy
| | - Carlo Saccardi
- Department of Gynecology and Obstetrics, Division of Women and Children’s Health, University of Padua, 35128 Padua, Italy (G.S.); (C.S.); (M.N.); (M.M.)
| | - Marco Noventa
- Department of Gynecology and Obstetrics, Division of Women and Children’s Health, University of Padua, 35128 Padua, Italy (G.S.); (C.S.); (M.N.); (M.M.)
| | - Matteo Marchetti
- Department of Gynecology and Obstetrics, Division of Women and Children’s Health, University of Padua, 35128 Padua, Italy (G.S.); (C.S.); (M.N.); (M.M.)
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Nuijens AC, Oei AL, Koster L, Hoebe RA, Franken NAP, Rasch CRN, Stalpers LJA. Genetic markers of late radiation toxicity in the era of image-guided radiotherapy: lower toxicity rates reduce the predictive value of γ-H2AX foci decay ratio in patients undergoing pelvic radiotherapy. Radiat Oncol 2024; 19:116. [PMID: 39223539 PMCID: PMC11370123 DOI: 10.1186/s13014-024-02501-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 08/01/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND A predictive assay for late radiation toxicity would allow more personalized treatment planning, reducing the burden of toxicity for the more sensitive minority, and improving the therapeutic index for the majority. In a previous study in prostate cancer patients, the γ-H2AX foci decay ratio (γ-FDR) was the strongest predictor of late radiation toxicity. The current study aimed to validate this finding in a more varied group of patients with pelvic cancer. Additionally, the potential correlation between the γ-FDR and patient-reported outcomes was investigated. METHODS Prostate and gynecological cancer patients with ≥ 24 months of follow-up were included in the current analysis. Toxicity was evaluated by physician (CTCAE version 4) and patient (EORTC questionnaires). γ-FDRs were determined in ex vivo irradiated lymphocytes. Correlation between γ-FDR and toxicity was assessed using both linear and logistic regression analyses. The highest toxicity grade recorded during follow-up was used. The association between global quality of life and γ-FDR was tested by comparing the change in quality of life over time in patients with γ-FDR < or ≥ 3.41, a previously established threshold. RESULTS Eighty-eight patients were included. Physician-assessed and patient-reported cumulative grade ≥ 2 toxicity was 25% and 29%, respectively; which is much lower than in the previous cohort (i.e., 51% CTCAE grade ≥ 2). Patients with toxicity exhibited less favorable dose-volume parameters. In men, these parameters showed significant improvement compared to the previous cohort. The proportion of patients with a low γ-FDR increased with severity of toxicity, but this trend was not statistically significant. In addition, a γ-FDR < 3.41 was not correlated with the development of moderate to severe toxicity. Post-treatment decline in global quality of life was minimal, and similar for patients with γ-FDR < or ≥ 3.41. CONCLUSIONS In the present study, the γ-H2AX foci decay ratio could not be validated as a predictor of late radiation toxicity in patients with pelvic cancer. Improved radiotherapy techniques with smaller irradiated bladder and bowel volumes have probably resulted in less toxicities. Future studies on genetic markers of toxicity should be powered on these lower incidences. We further recommend taking persistency, next to severity, into consideration.
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Affiliation(s)
- Anna C Nuijens
- Department of Radiation Oncology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Laboratory for Experimental Oncology and Radiobiology (LEXOR), Center for Experimental and Molecular Medicine (CEMM), Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Arlene L Oei
- Department of Radiation Oncology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
- Laboratory for Experimental Oncology and Radiobiology (LEXOR), Center for Experimental and Molecular Medicine (CEMM), Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands.
| | - Lisa Koster
- Department of Radiation Oncology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Ron A Hoebe
- Department of Medical Biology and Core Facility Cellular Imaging, Van Leeuwenhoek Centre for Advanced Microscopy-Academic Medical Center (LCAM-AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Nicolaas A P Franken
- Department of Radiation Oncology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Laboratory for Experimental Oncology and Radiobiology (LEXOR), Center for Experimental and Molecular Medicine (CEMM), Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands
| | - Coen R N Rasch
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Lukas J A Stalpers
- Department of Radiation Oncology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
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Van Vliet-van den Ende KM, Hoogendoorn-Mulder PG, Schokker RI, Moerland MA, Kroon PS, Roesink JM, Fajardo RD, Van der Leij F, Jürgenliemk-Schulz IM. Adaptive brachytherapy for cervical cancer in combined 1.5 T MR/HDR suite: Impact of repeated imaging. Tech Innov Patient Support Radiat Oncol 2024; 31:100262. [PMID: 39224832 PMCID: PMC11367091 DOI: 10.1016/j.tipsro.2024.100262] [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: 04/25/2024] [Revised: 07/11/2024] [Accepted: 07/12/2024] [Indexed: 09/04/2024] Open
Abstract
Introduction At our department we have a dedicated 1.5 Tesla MRI/HDR brachytherapy suite, which provides the possibility of repeated MRI scanning before, during and after applicator insertion and before and/or after irradiation for patients with advanced cervical cancer. In this study we analysed the effect of this adaptive workflow. We investigated the number of interventions, their impact on organ doses (OAR) and the respective dose differences between total prescribed and total delivered doses. Materials and methods Seventy patients with locally advanced cervical cancer FIGO2009 stages IB-IVA, treated from June 2016 till August 2020, were retrospectively analysed. The standard brachytherapy schedule consisted of two applicator insertions and delivery of three or four HDR fractions.OARs were recontoured on the repeated MRI scans. The D2cm3 dose difference between total prescribed and total delivered dose for bladder, rectum, sigmoid and bowel were calculated. Results In total 153 interventions were performed, 3 replacements of the applicator, 23 adaptations of needle positions, bladder filling was changed 74 times and repeated rectal degassing 53 times. The impact of the rectal interventions was on average -1.2 Gy EQD23. Dose differences between total delivered and total prescribed D2cm3 for bladder, rectum, sigmoid and bowel were -0.6, 0.3, 2.2 and -0.6 Gy EQD23, respectively. Conclusions An MRI scanner integrated into the brachytherapy suite enables multiple interventions based on the scans before treatment planning and dose delivery. This allows for customized treatment according to the changing anatomy of the individual patient and a better estimation of the delivered dose.
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Affiliation(s)
| | | | - Rogier I. Schokker
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marinus A. Moerland
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Petra S. Kroon
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Judith M. Roesink
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Raquel Dávila Fajardo
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Femke Van der Leij
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
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Sauvage LM, Bentahila R, Tran Y, Guénégou-Arnoux A, Fabiano E, Bats AS, Borghese B, Durdux C. Radiation Proctitis in Patients With Locally Advanced Cervical Cancer Treated by Chemoradiation: Analysis and Predictive Factors From a Retrospective Cohort. Am J Clin Oncol 2024; 47:311-316. [PMID: 38557436 DOI: 10.1097/coc.0000000000001092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
OBJECTIVES Radiation proctitis is a misunderstanding complication of chemoradiation in locally advanced cervical cancer. The objective of our study is to provide a detailed description and analysis of predictive factors associated with radiation proctitis in a retrospective cohort of patients treated by chemoradiation for locally advanced cervical cancer. METHODS All patients treated by exclusive chemoradiation or chemoradiation followed by brachytherapy for locally advanced cervical cancer from 2011 to 2017 were included in the study. A bivariate analysis was conducted to establish correlations between the occurrence of radiation proctitis and various clinical and technical variables. RESULTS A total of 128 patients were included in the study. The mean dose (SD) to the planning target volume was 47.1 Gy (6.2). Fifty-nine (46.1%) patients underwent brachytherapy. Sixteen patients (12.5%) developed radiation proctitis, grade 2 or higher in 12 patients (9.3%). In univariate analysis, anticoagulant or antiplatelet treatments ( P =0.039), older age ( P =0.049), rectal volume irradiated at 40 Gy ( P =0.01) and 30 Gy ( P =0.037) were significantly associated with the occurrence of a grade ≥2 radiation proctitis. The delivered dose to 2 cm 3 of rectum (D2cm 3 ) showed a potential association with the occurrence of radiation proctitis of all grades ( P =0.064). CONCLUSIONS This study highlights clinical and technical factors that should be considered in assessing the risk of radiation proctitis. These results contribute to a better understanding of this complication.
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Affiliation(s)
| | | | - Yohan Tran
- Department of Clinical Research, Clinical Investigations-Epidemiology Center, INSERM
| | | | | | | | - Bruno Borghese
- Department of Gynecology, Cochin-Port Royal Hospital, Paris-Cité University, Paris, France
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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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11
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Yen A, Zhong X, Lin MH, Nwachukwu C, Albuquerque K, Hrycushko B. Improved Dosimetry with Daily Online Adaptive Radiotherapy for Cervical Cancer: Waltzing the Pear. Clin Oncol (R Coll Radiol) 2024; 36:165-172. [PMID: 38246849 DOI: 10.1016/j.clon.2024.01.005] [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: 06/29/2023] [Revised: 12/04/2023] [Accepted: 01/09/2024] [Indexed: 01/23/2024]
Abstract
AIMS Standard of care radiotherapy for locally advanced cervical cancer includes large margins to ensure the uterocervix remains within the treatment fields over the course of treatment. Daily online cone-beam adaptive radiotherapy corrects for interfractional changes by adjusting the plan to match the target position during each treatment session, thus allowing for significantly reduced clinical target volume (CTV) to planning target volume (PTV) margins. We hypothesise that reduced margins from daily online adaptive radiotherapy will reduce organ at risk dose without compromising target coverage. MATERIALS AND METHODS Ten patients with cervical cancer (stage IIB-IIIC2) were treated with definitive chemoradiation using daily online cone-beam adaptive radiotherapy in 25-27 fractions. Initial and all adapted treatment plans were generated with CTV to PTV margins versus standard of care image-guided radiotherapy (IGRT) plans as follows: cervix/uterus/gross tumour volume (0.5 versus 1.5 cm), parametria/vagina (0.5 versus 1.0 cm) and nodal chains and gross nodes (0.5 versus 0.5 cm). IGRT plans were created and copied to synthetic computed tomography scans and contours generated from each daily adapted fraction. The dosimetry of each clinically treated online adapted fraction was compared with emulated IGRT plans. Statistical significance was defined as P < 0.05. RESULTS Daily online cone-beam adaptive radiotherapy significantly improves bowel bag dosimetry compared with IGRT, with a reduction in V40 by an average of 91.3 cm3 [V40 (-6.2%) and V45 (-6.1%)]. The daily adapted plans showed significant improvements in bladder and rectum [V40 (-25.2% and -36.0%) and V30 (-9.7% and -17.1%), respectively]. Additionally, bone marrow had a significantly reduced dose [V10 (-2.7%) and V20 (-3.3%)]. Daily online cone-beam adaptive radiotherapy improved uterocervix CTV coverage and reduced hotspots compared with IGRT [D95% (+1.6%) and Dmax (-0.9%)]. CONCLUSIONS Reduced CTV to PTV margins achievable with daily online adaptive radiotherapy improves organ at risk dosimetry and target coverage when compared with standard of care IGRT for locally advanced cervical cancer. The clinical impact of improved dosimetry is currently undergoing investigation.
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Affiliation(s)
- A Yen
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - X Zhong
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - M-H Lin
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - C Nwachukwu
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - K Albuquerque
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - B Hrycushko
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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12
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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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13
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Zhang H, Zhang Z, Yuan S. Chinese clinical practice guidelines for the prevention and treatment of radiation-induced rectal injury. PRECISION RADIATION ONCOLOGY 2023; 7:237-255. [PMID: 40336868 PMCID: PMC11935203 DOI: 10.1002/pro6.1217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/19/2023] [Accepted: 11/20/2023] [Indexed: 05/09/2025] Open
Abstract
Although radiotherapy plays an important role in the treatment of cancer, it may have negative effects in some individuals. Rectal injury is a common adverse effect of abdominal and pelvic radiotherapy. This injury is caused by administering radiation to the abdomen. Appropriate treatment techniques can be determined if doctors have a better understanding of the incidence, risk factors, and clinical symptoms of radiation-induced rectal injuries. Studies on the underlying pathophysiology of radiation-induced rectal injury may aid in the development of effective treatment and prevention strategies. The implementation of efficient preventive measures can improve the quality of life of patients with cancer and make it easier for them to complete their treatment. Therefore, comprehensive and accurate assessments are crucial for developing holistic and individualized treatment plans for patients who have already developed symptoms, with early intervention being a priority.
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Affiliation(s)
- Hui Zhang
- Department of Radiation OncologyFudan University Shanghai Cancer CenterShanghaiChina
| | - Zhen Zhang
- Department of Radiation OncologyFudan University Shanghai Cancer CenterShanghaiChina
- China Anti‐Cancer Association Tumor Support Therapy Committee
- China Anti‐Cancer Association Tumor Radiation Protection Committee
- Chinese Radiation Therapy Oncology Group
| | - Shuanghu Yuan
- China Anti‐Cancer Association Tumor Support Therapy Committee
- China Anti‐Cancer Association Tumor Radiation Protection Committee
- Chinese Radiation Therapy Oncology Group
- Department of RadiologyShandong Cancer HospitalJinanChina
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14
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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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15
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Ecker S, Kirisits C, Schmid M, Knoth J, Heilemann G, De Leeuw A, Sturdza A, Kirchheiner K, Jensen N, Nout R, Jürgenliemk-Schulz I, Pötter R, Spampinato S, Tanderup K, Eder-Nesvacil N. EviGUIDE - a tool for evidence-based decision making in image-guided adaptive brachytherapy for cervical cancer. Radiother Oncol 2023; 186:109748. [PMID: 37330055 DOI: 10.1016/j.radonc.2023.109748] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 06/06/2023] [Accepted: 06/08/2023] [Indexed: 06/19/2023]
Abstract
PURPOSE To develop a novel decision-support system for radiation oncology that incorporates clinical, treatment and outcome data, as well as outcome models from a large clinical trial on magnetic resonance image-guided adaptive brachytherapy (MR-IGABT) for locally advanced cervical cancer (LACC). METHODS A system, called EviGUIDE, was developed that combines dosimetric information from the treatment planning system, patient and treatment characteristics, and established tumor control probability (TCP), and normal tissue complication probability (NTCP) models, to predict clinical outcome of radiotherapy treatment of LACC. Six Cox Proportional Hazards models based on data from 1341 patients of the EMBRACE-I study have been integrated. One TCP model for local tumor control, and five NTCP models for OAR morbidities. RESULTS EviGUIDE incorporates TCP-NTCP graphs to help users visualize the clinical impact of different treatment plans and provides feedback on achievable doses based on a large reference population. It enables holistic assessment of the interplay between multiple clinical endpoints and tumour and treatment variables. Retrospective analysis of 45 patients treated with MR-IGABT showed that there exists a sub-cohort of patients (20%) with increased risk factors, that could greatly benefit from the quantitative and visual feedback. CONCLUSION A novel digital concept was developed that can enhance clinical decision- making and facilitate personalized treatment. It serves as a proof of concept for a new generation of decision support systems in radiation oncology, which incorporate outcome models and high-quality reference data, and aids the dissemination of evidence-based knowledge about optimal treatment and serve as a blueprint for other sites in radiation oncology.
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Affiliation(s)
- Stefan Ecker
- Medical University of Vienna, Department of Radiation Oncology, Vienna, Austria.
| | - Christian Kirisits
- Medical University of Vienna, Department of Radiation Oncology, Vienna, Austria
| | - Maximilian Schmid
- Medical University of Vienna, Department of Radiation Oncology, Vienna, Austria
| | - Johannes Knoth
- Medical University of Vienna, Department of Radiation Oncology, Vienna, Austria
| | - Gerd Heilemann
- Medical University of Vienna, Department of Radiation Oncology, Vienna, Austria
| | - Astrid De Leeuw
- University Medical Centre Utrecht, Department of Radiation Oncology, Utrecht, the Netherlands
| | - Alina Sturdza
- Medical University of Vienna, Department of Radiation Oncology, Vienna, Austria
| | - Kathrin Kirchheiner
- Medical University of Vienna, Department of Radiation Oncology, Vienna, Austria
| | - Nina Jensen
- Aarhus University Hospital, Department of Oncology, Aarhus, Denmark
| | - Remi Nout
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands
| | - Ina Jürgenliemk-Schulz
- University Medical Centre Utrecht, Department of Radiation Oncology, Utrecht, the Netherlands
| | - Richard Pötter
- Medical University of Vienna, Department of Radiation Oncology, Vienna, Austria
| | - Sofia Spampinato
- Aarhus University Hospital, Department of Oncology, Aarhus, Denmark
| | - Kari Tanderup
- Aarhus University Hospital, Department of Oncology, Aarhus, Denmark
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16
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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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17
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Ong WL, Millar J. Late, persistent, substantial treatment-related symptoms (LAPERS) following low-dose-rate brachytherapy for prostate cancer. Brachytherapy 2023; 22:524-530. [PMID: 36707331 DOI: 10.1016/j.brachy.2023.01.001] [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: 04/25/2022] [Revised: 09/25/2022] [Accepted: 01/03/2023] [Indexed: 01/26/2023]
Abstract
PURPOSE We aim to report 1) prevalence, 2) incidence, and 3) late, persistent, substantial treatment-related symptoms (LAPERS) after low-dose-rate brachytherapy (LDRBT) for prostate cancer. METHODS AND MATERIALS The study comprised men treated with LDRBT in a single Australian institution between 2014 and 2019. All men completed the Expanded Prostate Cancer Index Composite 26 (EPIC-26) questionnaire pretreatment, and at regular intervals posttreatment. 'Substantial' symptoms were defined as 'moderate' or 'big' problems in EPIC-26 which assesses the degree of symptom bother for each functional domain. 'Persistent' symptoms were defined as 'substantial' symptoms that present in at least half of the 'late' followup assessments. This provided a binary LAPERS outcome (yes/no). Prevalence (at each time point) and cumulative incidence of substantial symptoms were also reported. RESULTS A total of 172 men with 'baseline' and at least three 'late' followup EPIC-26 were included in the study. The median followup was 60 months (IQR: 36-74 months). For overall urinary function, prevalence of substantial symptoms was highest at 10% 6-month posttreatment, with 5-year cumulative incidence of 18%, but only 2% had LAPERS. For overall bowel function, prevalence of substantial symptoms was highest at 7% 12-months posttreatment, with 5-year cumulative incidence of 15%, and only 2% had LAPERS. For sexual function, prevalence of substantial symptoms was highest at 28% 6-months posttreatment, with 5-year cumulative incidence of 49%, and 22% had LAPERS (baseline-adjusted LAPERS 17%). CONCLUSIONS There were considerable differences in late toxicities using different toxicity-reporting approaches. LAPERS approach is more reflective of 'true' late toxicities considering duration and persistence of symptoms.
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Affiliation(s)
- Wee Loon Ong
- Alfred Health Radiation Oncology, Melbourne VIC, Australia; Central Clinical School, Monash University, Melbourne VIC, Australia; Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Odette Cancer Centre, University of Toronto, Toronto, ON, Canada..
| | - Jeremy Millar
- Alfred Health Radiation Oncology, Melbourne VIC, Australia; Central Clinical School, Monash University, Melbourne VIC, Australia
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18
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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; 33:862-875. [PMID: 37258414 PMCID: PMC10313976 DOI: 10.1136/ijgc-2022-004180] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 01/12/2023] [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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19
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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: 10] [Impact Index Per Article: 5.0] [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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20
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Bindal A, Mittal P, Shinghal A, Scaria L, Prajapati K, Swamidas J, Gurram L, Berger D, Sturdza A, Chopra S. Sigmoid dose accumulation and reporting for multifractionated brachytherapy for cervical cancer: Methodological development of sigmoid points through virtual endoscopic method. Brachytherapy 2023; 22:325-333. [PMID: 36882345 DOI: 10.1016/j.brachy.2023.01.003] [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: 09/13/2022] [Revised: 11/09/2022] [Accepted: 01/13/2023] [Indexed: 03/07/2023]
Abstract
PURPOSE The sigmoid is an important organ at risk for gynecological brachytherapy (BT). However, the reliability of localization of high-dose regions during multi-fractionated treatment is limited. This work reports the methodological development of sigmoid points to summate multi-fractionated doses. METHODS AND MATERIAL Ten paired MRI data sets of ring-based intracavitary brachytherapy were obtained. Simulating a virtual endoscope, a reference line was created along the central axis of the anorectosigmoid for each implant. A trendline was generated, and linear dose was determined. Three-dimensional (3D) coordinates of high-dose regions were identified, and overlap was determined. In the next step, 3D coordinates of high-dose sigmoid points were localized in reference to cervical os and re-verified for location in reference to sigmoid lumen and corroboration with 2cc doses. With minor modifications, sigmoid points were proposed. RESULTS In 6 of 10 patients, high-dose regions co-localized in subsequent fractions of BT. Three high-dose regions were identified along the sigmoid length and proposed as sigmoid points in reference to cervical os. (S1'= 0.5 cm right, 1.5 cm posterior, and 2.4 cm cranial; S2' = 0.3 cm anterior and 4.5 cm cranial; S3' = 2.7 cm left, 3 cm anterior, and 3.6 cm cranial to the cervical os). S1' and S2' were located in the sigmoid in 70% and 60% of data sets. The mean difference between D2cc and S1'/S2' was 0.30 Gy and 1.06 Gy respectively. S3' had limited corroboration to sigmoid lumen or 2 cc doses. The points S1' and S2' were further modified (minor) for applicability and proposed as sigmoid points 1 and 2 (SP1 0.5 right,1.5 posterior and 2.5 cm cranial to cervical os and SP2 (0.5 cm anterior and 4.5 cm cranial to cervical os)). CONCLUSION SP1 and SP 2 are proposed as a surrogate for 2 cc sigmoid doses and may provide a method of reliable inter-fraction dose summation. This pilot work requires further validation.
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Affiliation(s)
- Arpita Bindal
- Department of Radiation Oncology and Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Prachi Mittal
- Department of Radiation Oncology and Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Abhishek Shinghal
- Department of Radiation Oncology and Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Libin Scaria
- Department of Radiation Oncology and Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Kunal Prajapati
- Department of Radiation Oncology and Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Jamema Swamidas
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Lavanya Gurram
- Department of Radiation Oncology and Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Daniel Berger
- Department of Radiation Oncology and Medical Physics, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Alina Sturdza
- Department of Radiation Oncology and Medical Physics, 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, Mumbai, Maharashtra, India.
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21
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Suvaal I, Kirchheiner K, Nout RA, Sturdza AE, Van Limbergen E, Lindegaard JC, Putter H, Jürgenliemk-Schulz IM, Chargari C, Tanderup K, Pötter R, Creutzberg CL, Ter Kuile MM. Vaginal changes, sexual functioning and distress of women with locally advanced cervical cancer treated in the EMBRACE vaginal morbidity substudy. Gynecol Oncol 2023; 170:123-132. [PMID: 36682090 DOI: 10.1016/j.ygyno.2023.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/05/2023] [Accepted: 01/05/2023] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The EMBRACE-vaginal morbidity substudy prospectively evaluated physician-assessed vaginal changes and patient-reported-outcomes (PRO) on vaginal and sexual functioning problems and distress in the first 2-years after image-guided radio(chemo)therapy and brachytherapy for locally advanced cervical cancer. METHODS Eligible patients had stage IB1-IIIB cervical cancer with ≤5 mm vaginal involvement. Assessment of vaginal changes was graded using CTCAE. PRO were assessed using validated Quality-of-Life and sexual questionnaires. Statistical analysis included Generalized-Linear-Mixed-Models and Spearman's rho-correlation coefficients. RESULTS 113 eligible patients were included. Mostly mild (grade 1) vaginal changes were reported over time in about 20% (range 11-37%). At 2-years, 47% was not sexually active. Approximately 50% of the sexually active women reported any vaginal and sexual functioning problems and distress over time; more substantial vaginal and sexual problems and distress were reported by up to 14%, 20% and 8%, respectively. Physician-assessed vaginal changes and PRO sexual satisfaction differed significantly (p ≤ .05) between baseline and first follow-up, without further significant changes over time. No or only small associations between physician-assessed vaginal changes and PRO vaginal functioning problems and sexual distress were found. CONCLUSIONS Mild vaginal changes were reported after image-guided radio(chemo)therapy and brachytherapy, potentially due to the combination of tumors with limited vaginal involvement, EMBRACE-specific treatment optimization and rehabilitation recommendations. Although vaginal and sexual functioning problems and sexual distress were frequently reported, the rate of substantial problems and distress was low. The lack of association between vaginal changes, vaginal functioning problems and sexual distress shows that sexual functioning is more complex than vaginal morbidity alone.
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Affiliation(s)
- I Suvaal
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Zone K6-T, PO Box 9600, 2300 RC Leiden, the Netherlands
| | - K Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - R A Nout
- Department of Radiotherapy, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - A E Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - E Van Limbergen
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - J C Lindegaard
- Department of Radiation Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - H Putter
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, the Netherlands
| | - I M Jürgenliemk-Schulz
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - C Chargari
- Department of Radiation Oncology, Institute Gustave-Roussy, Paris, France
| | - K Tanderup
- Department of Radiation Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - R Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - C L Creutzberg
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - M M Ter Kuile
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Zone K6-T, PO Box 9600, 2300 RC Leiden, the Netherlands.
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