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Bates JE, Rancati T, Keshavarz H, Gagliardi G, Aznar MC, Howell RM, Shrestha S, Moiseenko V, Yorke E, Armenian S, Kremer L, Chen MH, van der Pal HJ, Cutter DJ, Constine LS, Hodgson D. Cardiac Disease in Childhood Cancer Survivors Treated With Radiation Therapy: A PENTEC Comprehensive Review. Int J Radiat Oncol Biol Phys 2024; 119:522-532. [PMID: 37061912 DOI: 10.1016/j.ijrobp.2023.03.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 02/10/2023] [Accepted: 03/10/2023] [Indexed: 04/17/2023]
Abstract
PURPOSE Radiation therapy (RT) is an essential component in the treatment of many pediatric malignancies. Thoracic RT may expose the heart to radiation dose and thereby increase the risk of late cardiac disease. This comprehensive review from the Pediatric Normal Tissue Effects in the Clinic (PENTEC) initiative focused on late cardiac disease in survivors of childhood cancer treated with RT. METHODS AND MATERIALS This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. We identified 1496 articles; 4 were included for dose-response modeling between mean cardiac radiation dose and risk of late coronary artery disease, heart failure (HF), valvular disease, and any cardiac disease. RESULTS For each 10-Gy increase in corrected mean cardiac radiation dose in 1.8- to 2.0-Gy fractions, we estimated a hazard ratio of 2.01 (95% confidence interval [CI], 1.79-2.25) for coronary artery disease, of 1.87 (95% CI, 1.70-2.06) for HF, of 1.87 (95% CI, 1.78-1.96) for valvular disease, and of 1.88 (95% CI, 1.75-2.03) for any cardiac disease. From the same model, for each 100-mg/m2 increase in cumulative anthracycline dose, the hazard ratio for the development of HF was 1.93 (95% CI, 1.58-2.36), equivalent to an increase in mean heart dose of approximately 10.5 Gy. Other nontreatment factors were inconsistently reported in the analyzed articles. CONCLUSIONS Radiation dose to the heart increases the risk of late cardiac disease, but survivors of childhood cancer who receive a mean dose <10 Gy at standard fractionation are at low absolute risk (<∼2% approximately 30 years after exposure) of late cardiac disease in the absence of anthracycline exposure. Minimizing cardiac radiation dose is especially relevant in children receiving anthracyclines. When cardiac sparing is not possible, we recommend prioritizing target coverage. It is likely that individual cardiac substructure doses will be a better predictor of specific cardiac diseases than mean dose, and we urge the pediatric oncology community to further study these relationships.
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Affiliation(s)
- James E Bates
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia.
| | - Tiziana Rancati
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Giovanna Gagliardi
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Marianne C Aznar
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Rebecca M Howell
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas; Graduate School of Biomedical Sciences, MD Anderson UT Health, Houston, Texas
| | - Suman Shrestha
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas; Graduate School of Biomedical Sciences, MD Anderson UT Health, Houston, Texas
| | - Vitali Moiseenko
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Saro Armenian
- Department of Pediatrics, City of Hope, Duarte, California
| | - Leontien Kremer
- Princess Maxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Ming Hui Chen
- Departments of Cardiology and Pediatrics, Boston Children's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | | | - David J Cutter
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Louis S Constine
- Departments of Radiation Oncology and Pediatrics, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - David Hodgson
- Department of Radiation Oncology, Princess Margaret Hospital, Toronto, Ontario, Canada
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Jackson A, Hua CH, Olch A, Yorke ED, Rancati T, Milano MT, Constine LS, Marks LB, Bentzen SM. Reporting Standards for Complication Studies of Radiation Therapy for Pediatric Cancer: Lessons From PENTEC. Int J Radiat Oncol Biol Phys 2024; 119:697-707. [PMID: 38760117 DOI: 10.1016/j.ijrobp.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 01/14/2024] [Accepted: 02/08/2024] [Indexed: 05/19/2024]
Abstract
The major aim of Pediatric Normal Tissue Effects in the Clinic (PENTEC) was to synthesize quantitative published dose/-volume/toxicity data in pediatric radiation therapy. Such systematic reviews are often challenging because of the lack of standardization and difficulty of reporting outcomes, clinical factors, and treatment details in journal articles. This has clinical consequences: optimization of treatment plans must balance between the risks of toxicity and local failure; counseling patients and their parents requires knowledge of the excess risks encountered after a specific treatment. Studies addressing outcomes after pediatric radiation therapy are particularly challenging because: (a) survivors may live for decades after treatment, and the latency time to toxicity can be very long; (b) children's maturation can be affected by radiation, depending on the developmental status of the organs involved at time of treatment; and (c) treatment regimens frequently involve chemotherapies, possibly modifying and adding to the toxicity of radiation. Here we discuss: basic reporting strategies to account for the actuarial nature of the complications; the reporting of modeling of abnormal development; and the need for standardized, comprehensively reported data sets and multivariate models (ie, accounting for the simultaneous effects of radiation dose, age, developmental status at time of treatment, and chemotherapy dose). We encourage the use of tools that facilitate comprehensive reporting, for example, electronic supplements for journal articles. Finally, we stress the need for clinicians to be able to trust artificial intelligence models of outcome of radiation therapy, which requires transparency, rigor, reproducibility, and comprehensive reporting. Adopting the reporting methods discussed here and in the individual PENTEC articles will increase the clinical and scientific usefulness of individual reports and associated pooled analyses.
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Affiliation(s)
- Andrew Jackson
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York.
| | - Chia-Ho Hua
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Arthur Olch
- Radiation Oncology Department, University of Southern California and Children's Hospital, Los Angeles, California
| | - Ellen D Yorke
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Tiziana Rancati
- Data Science Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester Medical Center, Wilmot Cancer Institute, Rochester, New York
| | - Louis S Constine
- Department of Radiation Oncology, University of Rochester Medical Center, Wilmot Cancer Institute, Rochester, New York; Pediatrics, University of Rochester Medical Center, Wilmot Cancer Institute, Rochester, New York
| | - Lawrence B Marks
- Department of Radiation Oncology and Lineberger Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Soren M Bentzen
- Department of Epidemiology and Public Health, University of Maryland, Baltimore, Maryland
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Martin CJ, Barnard M, de Vocht F. Evaluation of risks of cardiovascular disease from radiation exposure linked to computed tomography scans in the UK. J Radiol Prot 2024; 44:011513. [PMID: 38422514 DOI: 10.1088/1361-6498/ad2ebd] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 02/29/2024] [Indexed: 03/02/2024]
Abstract
Epidemiological studies of patient populations have shown that high doses of radiation increase risks of cardiovascular disease (CVD). Results from a recent meta-analysis of 93 epidemiological studies covering a wide range of doses provided evidence of a causal association between radiation exposure and CVD, and indicated excess relative risk per Gy for maximum dose below 500 mGy or delivered at low dose rates. These doses cover the range of organ doses expected from multiple diagnostic computed tomography (CT) scans. Dose-effect factors for the excess absolute risk of mortality from CVD following radiation exposure were derived from the meta-analysis. The present study uses these factors to estimate excess risks of mortality for various types of CVD, including cerebrovascular disease (CeVD), from CT scans of the body and head, assuming that the meta-analytic factors were accurate and represented a causal relationship. Estimates are based on cumulative doses to the heart and brain from CT scans performed on 105 574 patients on 12 CT scanners over a period of 5½ years. The results suggest that the excess number of deaths from CeVD could be 7 or 26 per 100 000 patients depending whether threshold brain doses of 200 mGy or 50 mGy, respectively are assumed. These results could have implications for head CT scans. However, the results rely on the validity of risk factors derived in the meta-analysis informing this assessment and which include significant uncertainties. Further incidence studies should provide better information on risk factors and dose thresholds, particularly for CeVD following head CT scans.
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Affiliation(s)
- Colin J Martin
- Department of Clinical Physics and Bioengineering, University of Glasgow, Glasgow, United Kingdom
| | - Michael Barnard
- Department of Radiation Physics and Protection, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Frank de Vocht
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- NIHR Applied Research Collaboration West (ARC West), Bristol, United Kingdom
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Kesting S, Giordano U, Weil J, McMahon CJ, Albert DC, Berger C, Budts W, Fritsch P, Hidvégi EV, Oberhoffer-Fritz R, Milano GM, Wacker-Gußmann A, Herceg-Čavrak V. Association of European Paediatric and Congenital Cardiology practical recommendations for surveillance and prevention of cardiac disease in childhood cancer survivors: the importance of physical activity and lifestyle changes From the Association of European Paediatric and Congenital Cardiology Working Group Sports Cardiology, Physical Activity and Prevention, Working Group Adult Congenital Heart Disease, Working Group Imaging and Working Group Heart Failure. Cardiol Young 2024; 34:250-261. [PMID: 38174736 DOI: 10.1017/s1047951123004213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
BACKGROUND Childhood cancer survivors are at increased risk of developing cardiovascular diseases, presenting as the main causes of morbidity and mortality within this group. Besides the usual primary and secondary prevention in combination with screening during follow-up, the modifiable lifestyle factors of physical activity, nutrition, and body weight have not yet gained enough attention regarding potential cardiovascular risk reduction. OBJECTIVE These practical recommendations aim to provide summarised information and practical implications to paediatricians and health professionals treating childhood cancer survivors to reduce the risk of cardiovascular late effects. METHODS The content derives from either published guidelines or expert opinions from Association of European Paediatric and Congenital Cardiology working groups and is in accordance with current state-of-the-art. RESULTS All usual methods of prevention and screening regarding the risk, monitoring, and treatment of occurring cardiovascular diseases are summarised. Additionally, modifiable lifestyle factors are explained, and clear practical implications are named. CONCLUSION Modifiable lifestyle factors should definitely be considered as a cost-effective and complementary approach to already implemented follow-up care programs in cardio-oncology, which can be actively addressed by the survivors themselves. However, treating physicians are strongly encouraged to support survivors to develop and maintain a healthy lifestyle, including physical activity as one of the major influencing factors. This article summarises relevant background information and provides specific practical recommendations on how to advise survivors to increase their level of physical activity.
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Affiliation(s)
- Sabine Kesting
- Institute of Preventive Paediatrics, Department Health and Sport Sciences, TUM School of Medicine and Health, Technical University of Munich, Munich, Germany
- Kinderklinik München Schwabing, Department of Paediatrics and Children's Cancer Research Centre, Department Clinical Medicine, TUM School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Ugo Giordano
- Pediatric Cardiac Surgery, Cardiology and Heart/Lung Transplantation Department, Bambino Gesù Children's Hospital, Rome, Italy
| | - Jochen Weil
- Department of Paediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Colin J McMahon
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Dimpna C Albert
- Heart Centre, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Claire Berger
- Department of Paediatric Haematology and Oncology, University Jean Monnet, University-Hospital of Saint-Etienne, Saint-Etienne, France
| | - Werner Budts
- Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Peter Fritsch
- Private Practice, Institute for Pediatric Cardiology, Graz, Austria
| | | | - Renate Oberhoffer-Fritz
- Institute of Preventive Paediatrics, Department Health and Sport Sciences, TUM School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Giuseppe M Milano
- Department of Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCSS), Rome, Italy
| | - Annette Wacker-Gußmann
- Institute of Preventive Paediatrics, Department Health and Sport Sciences, TUM School of Medicine and Health, Technical University of Munich, Munich, Germany
- Department of Paediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Vesna Herceg-Čavrak
- Faculty of Health Science, Libertas International University, Zagreb, Croatia
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Khong J, Tee H, Gorayski P, Le H, Penniment M, Jessop S, Hansford J, Penfold M, Green J, Skelton K, Saran F. Proton beam therapy in paediatric cancer: Anticipating the opening of the Australian Bragg Centre for Proton Therapy and Research. J Med Imaging Radiat Oncol 2023. [PMID: 38146017 DOI: 10.1111/1754-9485.13614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 12/09/2023] [Indexed: 12/27/2023]
Abstract
Proton Beam Therapy (PBT) has the potential to improve paediatric cancer care by reducing radiation exposure and thus long-term toxicities. Ethical concerns and debates surrounding the treatment, such as eligibility and accessibility, are ongoing in Australia. The Australian Bragg Centre for Proton Therapy and Research (ABCPTR) (named after Sir William Henry Bragg who described the Bragg peak in his laboratory at the University of Adelaide in 1903) aims to increase access to PBT in Australasia and offer a patient-centred care approach. Research is underway to assess PBT's safety and cost-effectiveness, using tools including Normal Tissue Complication Probability (NTCP) models. Collaborative efforts are focused on developing tailored survivorship clinics to enhance patient follow-up and quality of life. With the anticipated opening of the ABCPTR, Australia is preparing to take a significant step in radiation oncology, offering new research opportunities and creating a publicly funded treatment centre. The initiative aims to balance treatment efficacy with patient care, setting the stage for a future in which radiation therapy will reduce long-term side effects compared to the current standard of care. The implementation of PBT in Australia represents a complex and promising approach to paediatric oncology. This article provides an overview of the current landscape, highlighting the potential benefits and challenges of a treatment that could redefine the quality of survivorship and contribute to global research and best clinical practice.
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Affiliation(s)
- Jeremy Khong
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Hui Tee
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
- South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Peter Gorayski
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
- South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia
- Australian Bragg Centre for Proton Therapy and Research, Adelaide, South Australia, Australia
- Allied Health and Human Performance Academic Unit, University of South Australia, Adelaide, South Australia, Australia
| | - Hien Le
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
- South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia
- Australian Bragg Centre for Proton Therapy and Research, Adelaide, South Australia, Australia
- Allied Health and Human Performance Academic Unit, University of South Australia, Adelaide, South Australia, Australia
| | - Michael Penniment
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
- South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia
- Australian Bragg Centre for Proton Therapy and Research, Adelaide, South Australia, Australia
| | - Sophie Jessop
- Michael Rice Centre for Haematology and Oncology, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Jordan Hansford
- South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia
- Michael Rice Centre for Haematology and Oncology, Women's and Children's Hospital, Adelaide, South Australia, Australia
- South Australia ImmunoGenomics Cancer Institute, University of Adelaide, Adelaide, South Australia, Australia
| | - Melanie Penfold
- South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia
- Australian Bragg Centre for Proton Therapy and Research, Adelaide, South Australia, Australia
| | - Julia Green
- South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia
- Australian Bragg Centre for Proton Therapy and Research, Adelaide, South Australia, Australia
| | - Kelly Skelton
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
- South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia
- Australian Bragg Centre for Proton Therapy and Research, Adelaide, South Australia, Australia
- Allied Health and Human Performance Academic Unit, University of South Australia, Adelaide, South Australia, Australia
| | - Frank Saran
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
- South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia
- Australian Bragg Centre for Proton Therapy and Research, Adelaide, South Australia, Australia
- Allied Health and Human Performance Academic Unit, University of South Australia, Adelaide, South Australia, Australia
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Krittanawong C, Isath A, Kaplin S, Virk HUH, Fogg S, Wang Z, Shepanek M, Scheuring RA, Lavie CJ. Cardiovascular disease in space: A systematic review. Prog Cardiovasc Dis 2023; 81:33-41. [PMID: 37531984 DOI: 10.1016/j.pcad.2023.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 07/29/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND With expanding commercial space programs, uncertainty remains about the cardiovascular effects of space environmental exposures including microgravity, confinement, isolation, space radiation, and altered bacterial virulence. Current limited data suggests additional health threats compared to Earth. METHODS We systematically reviewed PubMed, CENTRAL, Web of Science, EMBASE and Cochrane databases for prospective studies on spaceflight and cardiovascular outcomes. Search terms combined cardiovascular disease topics with spaceflight concepts. No date or language restrictions were imposed. RESULTS 35 studies representing 2696 space travelers met inclusion criteria. Studies were grouped into spaceflight associations with: atherosclerosis, mortality, cardiac function, orthostatic intolerance, and arrhythmias. Atherosclerosis evidence was limited, with animal studies linking space radiation to endothelial damage, oxidative stress, and inflammation. However, human data showed no significantly increased atherosclerotic disease in astronauts. Mortality studies demonstrated lower cardiovascular mortality in astronauts compared to the general population however there was conflicting data. Cardiac function studies revealed physiologic ventricular atrophy, increased arterial stiffness, and altered blood flow distribution attributed to microgravity exposure. Effects appeared transient and reversible post-flight. Orthostatic intolerance studies found astronauts experienced altered heart rate variability, baroreflex response, and blood pressure changes post-flight. Arrhythmia studies showed increased ventricular ectopy during spaceflight, but limited data on long term flights. CONCLUSIONS Environmental space hazards impact the cardiovascular system through multiple mechanisms. Microgravity causes cardiac atrophy and orthostatic intolerance while space radiation may potentially accelerate atherosclerosis. Further research is needed, especially regarding long-term spaceflights.
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Affiliation(s)
| | - Ameesh Isath
- Department of Cardiology, Westchester Medical Centre and New York Medical College, Valhalla, NY, USA
| | - Scott Kaplin
- Cardiology Division, NYU Langone Health and NYU School of Medicine, New York, NY, USA
| | - Hafeez Ul Hassan Virk
- Harrington Heart & Vascular Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, OH, USA
| | - Sonya Fogg
- Library and Learning Resource Center, Texas Heart Institute, Houston, USA
| | - Zhen Wang
- Mayo Clinic Evidence-based Practice Center, Rochester, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery; Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Marc Shepanek
- Office of the Chief Health and Medical Officer, NASA, Washington, DC 20546, USA
| | | | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, USA
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Berrington de González A, Gibson TM, Lee C, Albert PS, Griffin KT, Kitahara CM, Liu D, Mille MM, Shin J, Bajaj BV, Flood TE, Gallotto SL, Paganetti H, Ahmed SK, Eaton BR, Indelicato DJ, Milgrom SA, Palmer JD, Baliga S, Poppe MM, Tsang DS, Wong K, Yock TI. The Pediatric Proton and Photon Therapy Comparison Cohort: Study Design for a Multicenter Retrospective Cohort to Investigate Subsequent Cancers After Pediatric Radiation Therapy. Adv Radiat Oncol 2023; 8:101273. [PMID: 38047226 PMCID: PMC10692298 DOI: 10.1016/j.adro.2023.101273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 05/08/2023] [Indexed: 12/05/2023] Open
Abstract
Purpose The physical properties of protons lower doses to surrounding normal tissues compared with photons, potentially reducing acute and long-term adverse effects, including subsequent cancers. The magnitude of benefit is uncertain, however, and currently based largely on modeling studies. Despite the paucity of directly comparative data, the number of proton centers and patients are expanding exponentially. Direct studies of the potential risks and benefits are needed in children, who have the highest risk of radiation-related subsequent cancers. The Pediatric Proton and Photon Therapy Comparison Cohort aims to meet this need. Methods and Materials We are developing a record-linkage cohort of 10,000 proton and 10,000 photon therapy patients treated from 2007 to 2022 in the United States and Canada for pediatric central nervous system tumors, sarcomas, Hodgkin lymphoma, or neuroblastoma, the pediatric tumors most frequently treated with protons. Exposure assessment will be based on state-of-the-art dosimetry facilitated by collection of electronic radiation records for all eligible patients. Subsequent cancers and mortality will be ascertained by linkage to state and provincial cancer registries in the United States and Canada, respectively. The primary analysis will examine subsequent cancer risk after proton therapy compared with photon therapy, adjusting for potential confounders and accounting for competing risks. Results For the primary aim comparing overall subsequent cancer rates between proton and photon therapy, we estimated that with 10,000 patients in each treatment group there would be 80% power to detect a relative risk of 0.8 assuming a cumulative incidence of subsequent cancers of 2.5% by 15 years after diagnosis. To date, 9 institutions have joined the cohort and initiated data collection; additional centers will be added in the coming year(s). Conclusions Our findings will affect clinical practice for pediatric patients with cancer by providing the first large-scale systematic comparison of the risk of subsequent cancers from proton compared with photon therapy.
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Affiliation(s)
| | - Todd M. Gibson
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Choonsik Lee
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Paul S. Albert
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Keith T. Griffin
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Cari Meinhold Kitahara
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Danping Liu
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Matthew M. Mille
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Jungwook Shin
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Benjamin V.M. Bajaj
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Tristin E. Flood
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Sara L. Gallotto
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Safia K. Ahmed
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Bree R. Eaton
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Daniel J. Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Sarah A. Milgrom
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Joshua D. Palmer
- Department of Radiation Oncology, James Cancer Hospital at the Ohio State University Wexner Medical Center and Nationwide Children's Hospital, Columbus, Ohio
| | - Sujith Baliga
- Department of Radiation Oncology, James Cancer Hospital at the Ohio State University Wexner Medical Center and Nationwide Children's Hospital, Columbus, Ohio
| | - Matthew M. Poppe
- Department of Radiation Oncology, University of Utah–Huntsman Cancer Institute, Salt Lake City, Utah
| | - Derek S. Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Kenneth Wong
- Radiation Oncology Program, Children's Hospital Los Angeles, Los Angeles, California
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Torunn I. Yock
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
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8
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Bates JE, Shrestha S, Liu Q, Smith SA, Mulrooney DA, Leisenring W, Gibson T, Robison LL, Chow EJ, Oeffinger KC, Armstrong GT, Constine LS, Hoppe BS, Lee C, Yasui Y, Howell RM. Cardiac Substructure Radiation Dose and Risk of Late Cardiac Disease in Survivors of Childhood Cancer: A Report From the Childhood Cancer Survivor Study. J Clin Oncol 2023; 41:3826-3838. [PMID: 37307512 PMCID: PMC10419575 DOI: 10.1200/jco.22.02320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 04/11/2023] [Accepted: 04/18/2023] [Indexed: 06/14/2023] Open
Abstract
PURPOSE Radiation-associated cardiac disease is a major cause of morbidity/mortality among childhood cancer survivors. Radiation dose-response relationships for cardiac substructures and cardiac diseases remain unestablished. METHODS Using the 25,481 5-year survivors of childhood cancer treated from 1970 to 1999 in the Childhood Cancer Survivor Study, we evaluated coronary artery disease (CAD), heart failure (HF), valvular disease (VD), and arrhythmia. We reconstructed radiation doses for each survivor to the coronary arteries, chambers, valves, and whole heart. Excess relative rate (ERR) models and piecewise exponential models evaluated dose-response relationships. RESULTS The cumulative incidence 35 years from diagnosis was 3.9% (95% CI, 3.4 to 4.3) for CAD, 3.8% (95% CI, 3.4 to 4.2) for HF, 1.2% (95% CI, 1.0 to 1.5) for VD, and 1.4% (95% CI, 1.1 to 1.6) for arrhythmia. A total of 12,288 survivors (48.2%) were exposed to radiotherapy. Quadratic ERR models improved fit compared with linear ERR models for the dose-response relationship between mean whole heart and CAD, HF, and arrhythmia, suggesting a potential threshold dose; however, such departure from linearity was not observed for most cardiac substructure end point dose-response relationships. Mean doses of 5-9.9 Gy to the whole heart did not increase the risk of any cardiac diseases. Mean doses of 5-9.9 Gy to the right coronary artery (rate ratio [RR], 2.6 [95% CI, 1.6 to 4.1]) and left ventricle (RR, 2.2 [95% CI, 1.3 to 3.7]) increased risk of CAD, and to the tricuspid valve (RR, 5.5 [95% CI, 2.0 to 15.1]) and right ventricle (RR, 8.4 [95% CI, 3.7 to 19.0]) increased risk of VD. CONCLUSION Among children with cancer, there may be no threshold dose below which radiation to the cardiac substructures does not increase the risk of cardiac diseases. This emphasizes their importance in modern treatment planning.
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Affiliation(s)
- James E. Bates
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Suman Shrestha
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Qi Liu
- Department of Public Health Sciences, University of Alberta, Edmonton, AB
| | - Susan A. Smith
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Daniel A. Mulrooney
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Wendy Leisenring
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Todd Gibson
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD
| | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Eric J. Chow
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Louis S. Constine
- Department of Radiation Oncology, Wilmot Cancer Institute, University of Rochester, Rochester, NY
- Department of Pediatrics, University of Rochester, Rochester, NY
| | - Bradford S. Hoppe
- Department of Radiation Oncology, Mayo Clinic-Jacksonville, Jacksonville, FL
| | - Choonsik Lee
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Rebecca M. Howell
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
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9
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Chounta S, Allodji R, Vakalopoulou M, Bentriou M, Do DT, De Vathaire F, Diallo I, Fresneau B, Charrier T, Zossou V, Christodoulidis S, Lemler S, Letort Le Chevalier V. Dosiomics-Based Prediction of Radiation-Induced Valvulopathy after Childhood Cancer. Cancers (Basel) 2023; 15:3107. [PMID: 37370717 DOI: 10.3390/cancers15123107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/16/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
Valvular Heart Disease (VHD) is a known late complication of radiotherapy for childhood cancer (CC), and identifying high-risk survivors correctly remains a challenge. This paper focuses on the distribution of the radiation dose absorbed by heart tissues. We propose that a dosiomics signature could provide insight into the spatial characteristics of the heart dose associated with a VHD, beyond the already-established risk induced by high doses. We analyzed data from the 7670 survivors of the French Childhood Cancer Survivors' Study (FCCSS), 3902 of whom were treated with radiotherapy. In all, 63 (1.6%) survivors that had been treated with radiotherapy experienced a VHD, and 57 of them had heterogeneous heart doses. From the heart-dose distribution of each survivor, we extracted 93 first-order and spatial dosiomics features. We trained random forest algorithms adapted for imbalanced classification and evaluated their predictive performance compared to the performance of standard mean heart dose (MHD)-based models. Sensitivity analyses were also conducted for sub-populations of survivors with spatially heterogeneous heart doses. Our results suggest that MHD and dosiomics-based models performed equally well globally in our cohort and that, when considering the sub-population having received a spatially heterogeneous dose distribution, the predictive capability of the models is significantly improved by the use of the dosiomics features. If these findings are further validated, the dosiomics signature may be incorporated into machine learning algorithms for radiation-induced VHD risk assessment and, in turn, into the personalized refinement of follow-up guidelines.
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Affiliation(s)
- Stefania Chounta
- Université Paris-Saclay, Univ. Paris-Sud, UVSQ, CESP, Cancer and Radiation Team, F-94805 Villejuif, France
- INSERM, CESP, Cancer and Radiation Team, F-94805 Villejuif, France
- Gustave Roussy, Department of Clinical Research, Cancer and Radiation Team, F-94805 Villejuif, France
- Université Paris-Saclay, CentraleSupélec, Mathématiques et Informatique pour la Complexité et les Systèmes, F-91190 Gif-sur-Yvette, France
| | - Rodrigue Allodji
- Université Paris-Saclay, Univ. Paris-Sud, UVSQ, CESP, Cancer and Radiation Team, F-94805 Villejuif, France
- INSERM, CESP, Cancer and Radiation Team, F-94805 Villejuif, France
- Gustave Roussy, Department of Clinical Research, Cancer and Radiation Team, F-94805 Villejuif, France
- Polytechnic School of Abomey-Calavi (EPAC), University of Abomey-Calavi, 01, Cotonou P.O. Box 2009, Benin
| | - Maria Vakalopoulou
- Université Paris-Saclay, CentraleSupélec, Mathématiques et Informatique pour la Complexité et les Systèmes, F-91190 Gif-sur-Yvette, France
| | - Mahmoud Bentriou
- Université Paris-Saclay, CentraleSupélec, Mathématiques et Informatique pour la Complexité et les Systèmes, F-91190 Gif-sur-Yvette, France
| | - Duyen Thi Do
- Université Paris-Saclay, Univ. Paris-Sud, UVSQ, CESP, Cancer and Radiation Team, F-94805 Villejuif, France
- INSERM, CESP, Cancer and Radiation Team, F-94805 Villejuif, France
- Gustave Roussy, Department of Clinical Research, Cancer and Radiation Team, F-94805 Villejuif, France
| | - Florent De Vathaire
- Université Paris-Saclay, Univ. Paris-Sud, UVSQ, CESP, Cancer and Radiation Team, F-94805 Villejuif, France
- INSERM, CESP, Cancer and Radiation Team, F-94805 Villejuif, France
- Gustave Roussy, Department of Clinical Research, Cancer and Radiation Team, F-94805 Villejuif, France
| | - Ibrahima Diallo
- Department of Radiation Oncology, Gustave Roussy, F-94800 Villejuif, France
- Gustave Roussy, Inserm, Radiothérapie Moléculaire et Innovation Thérapeutique, Paris-Saclay University, F-94800 Villejuif, France
| | - Brice Fresneau
- Gustave Roussy, Université Paris-Saclay, Department of Pediatric Oncology, F-94805 Villejuif, France
| | - Thibaud Charrier
- Université Paris-Saclay, Univ. Paris-Sud, UVSQ, CESP, Cancer and Radiation Team, F-94805 Villejuif, France
- INSERM, CESP, Cancer and Radiation Team, F-94805 Villejuif, France
- Gustave Roussy, Department of Clinical Research, Cancer and Radiation Team, F-94805 Villejuif, France
- Institut Curie, PSL Research University, INSERM, U900, F-92210 Saint Cloud, France
| | - Vincent Zossou
- Université Paris-Saclay, Univ. Paris-Sud, UVSQ, CESP, Cancer and Radiation Team, F-94805 Villejuif, France
- INSERM, CESP, Cancer and Radiation Team, F-94805 Villejuif, France
- Gustave Roussy, Department of Clinical Research, Cancer and Radiation Team, F-94805 Villejuif, France
- Polytechnic School of Abomey-Calavi (EPAC), University of Abomey-Calavi, 01, Cotonou P.O. Box 2009, Benin
- Institut de Formation et de Recherche en Informatique, (IFRI-UAC), Cotonou P.O. Box 2009, Benin
| | - Stergios Christodoulidis
- Université Paris-Saclay, CentraleSupélec, Mathématiques et Informatique pour la Complexité et les Systèmes, F-91190 Gif-sur-Yvette, France
| | - Sarah Lemler
- Université Paris-Saclay, CentraleSupélec, Mathématiques et Informatique pour la Complexité et les Systèmes, F-91190 Gif-sur-Yvette, France
| | - Veronique Letort Le Chevalier
- Université Paris-Saclay, CentraleSupélec, Mathématiques et Informatique pour la Complexité et les Systèmes, F-91190 Gif-sur-Yvette, France
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10
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Chounta S, Lemler S, Haddy N, Fresneau B, Mansouri I, Bentriou M, Demoor-Goldschmidt C, Diallo I, Souchard V, Do TD, Veres C, Surun A, Doz F, Llanas D, Vu-Bezin G, Rubino C, de Vathaire F, Letort V, Allodji RS. The risk of valvular heart disease in the French Childhood Cancer Survivors' Study: Contribution of dose-volume histogram parameters. Radiother Oncol 2023; 180:109479. [PMID: 36657724 DOI: 10.1016/j.radonc.2023.109479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 11/17/2022] [Accepted: 01/09/2023] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND PURPOSE Valvular Heart Disease (VHD) is a known complication of childhood cancer after radiotherapy treatment. However, the dose-volume-effect relationships have not been fully explored. MATERIALS AND METHODS We obtained individual heart Dose Volume Histograms (DVH) for survivors of the French Childhood Cancer Survivors Study (FCCSS) who had received radiotherapy. We calculated the Mean Dose to the Heart (MHD) in Gy, as well as the heart DVH parameters (Vd Gy, which represents the percentage of heart volume receiving at least d Gy), fixing the thresholds to 0.1 Gy, 5 Gy, 20 Gy, and 40 Gy. We analyzed them furtherly in the subpopulation of the cohort that was treated with a dose lower than 5 Gy (V0.1Gy|V5Gy=0%), 20 Gy (V5Gy|V20Gy=0%), and 40 Gy (V20Gy|V40Gy=0%), respectively. We investigated their role in the occurrence of a VHD in this population-based observational cohort study using the Cox proportional hazard model, adjusting for age at cancer diagnosis and chemotherapy exposure. RESULTS Median follow-up was 30.6 years. Eighty-one patients out of the 7462 (1 %) with complete data experienced a severe VHD (grade ≥ 3). The risk of VHD increased along with the MHD, and it was associated with high doses to the heart (V40Gy < 50 %, hazard ratio (HR) = 7.96, 95 % CI: 4.26-14.88 and V20Gy|V40Gy=0% >50 %, HR = 5.03, 95 % CI: [2.35-10.76]). Doses 5-20 Gy to more than 50 % (V5Gy|V20Gy=0% >50 %) of the heart induced a marginally non-significant estimated risk. We also observed a remarkable risk increase with attained age. CONCLUSIONS Our results provide new insight into the VHD risk that may impact current treatments and long-term follow-up of childhood cancer survivors.
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Affiliation(s)
- Stefania Chounta
- Université Paris-Saclay, Univ. Paris-Sud, UVSQ, CESP, Cancer and Radiation Team, Villejuif, France; INSERM, CESP, Cancer and Radiation Team, F-94805 Villejuif, France; Gustave Roussy, Department of Clinical Research, Cancer and Radiation Team, F-94805 Villejuif, France; Université Paris-Saclay, CentraleSupélec, Mathématiques et Informatique pour la Complexité et les Systèmes, 91190, Gif-sur-Yvette, France
| | - Sarah Lemler
- Université Paris-Saclay, CentraleSupélec, Mathématiques et Informatique pour la Complexité et les Systèmes, 91190, Gif-sur-Yvette, France
| | - Nadia Haddy
- Université Paris-Saclay, Univ. Paris-Sud, UVSQ, CESP, Cancer and Radiation Team, Villejuif, France; INSERM, CESP, Cancer and Radiation Team, F-94805 Villejuif, France; Gustave Roussy, Department of Clinical Research, Cancer and Radiation Team, F-94805 Villejuif, France
| | - Brice Fresneau
- Gustave Roussy, Université Paris-Saclay, Department of Pediatric oncology, Villejuif, F-94805, France
| | - Imene Mansouri
- Université Paris-Saclay, Univ. Paris-Sud, UVSQ, CESP, Cancer and Radiation Team, Villejuif, France; INSERM, CESP, Cancer and Radiation Team, F-94805 Villejuif, France; Gustave Roussy, Department of Clinical Research, Cancer and Radiation Team, F-94805 Villejuif, France; EPI-PHARE Scientific Interest Group, Saint-Denis, France; French National Agency for the Safety of Medicines and Health Products (ANSM), Saint-Denis, France
| | - Mahmoud Bentriou
- Université Paris-Saclay, CentraleSupélec, Mathématiques et Informatique pour la Complexité et les Systèmes, 91190, Gif-sur-Yvette, France
| | - Charlotte Demoor-Goldschmidt
- Université Paris-Saclay, Univ. Paris-Sud, UVSQ, CESP, Cancer and Radiation Team, Villejuif, France; INSERM, CESP, Cancer and Radiation Team, F-94805 Villejuif, France; Gustave Roussy, Department of Clinical Research, Cancer and Radiation Team, F-94805 Villejuif, France; Chu de Nantes, Pediatric Oncology, 38 Bd Jean Monnet, Nantes 44093, France
| | - Ibrahima Diallo
- Department of Radiation Oncology, Gustave Roussy, Villejuif, Paris, France; Gustave Roussy, Inserm, Radiothérapie Moléculaire et Innovation Thérapeutique, Paris-Saclay University, Villejuif, Île-de-France, France
| | - Vincent Souchard
- Université Paris-Saclay, Univ. Paris-Sud, UVSQ, CESP, Cancer and Radiation Team, Villejuif, France; INSERM, CESP, Cancer and Radiation Team, F-94805 Villejuif, France; Gustave Roussy, Department of Clinical Research, Cancer and Radiation Team, F-94805 Villejuif, France
| | - Thi-Duyen Do
- Université Paris-Saclay, Univ. Paris-Sud, UVSQ, CESP, Cancer and Radiation Team, Villejuif, France; INSERM, CESP, Cancer and Radiation Team, F-94805 Villejuif, France; Gustave Roussy, Department of Clinical Research, Cancer and Radiation Team, F-94805 Villejuif, France
| | - Cristina Veres
- Department of Radiation Oncology, Gustave Roussy, Villejuif, Paris, France; Gustave Roussy, Inserm, Radiothérapie Moléculaire et Innovation Thérapeutique, Paris-Saclay University, Villejuif, Île-de-France, France
| | - Aurore Surun
- SIREDO Oncology Center (Care, Innovation, Research for Children, Adolescents and Young Adults with Cancer), Institut Curie, Paris, France
| | - François Doz
- SIREDO Oncology Center (Care, Innovation, Research for Children, Adolescents and Young Adults with Cancer), Institut Curie, Paris, France; Université Paris Cité, Paris, France
| | - Damien Llanas
- Université Paris-Saclay, Univ. Paris-Sud, UVSQ, CESP, Cancer and Radiation Team, Villejuif, France; INSERM, CESP, Cancer and Radiation Team, F-94805 Villejuif, France; Gustave Roussy, Department of Clinical Research, Cancer and Radiation Team, F-94805 Villejuif, France
| | - Giao Vu-Bezin
- Université Paris-Saclay, Univ. Paris-Sud, UVSQ, CESP, Cancer and Radiation Team, Villejuif, France; INSERM, CESP, Cancer and Radiation Team, F-94805 Villejuif, France; Gustave Roussy, Department of Clinical Research, Cancer and Radiation Team, F-94805 Villejuif, France
| | - Carole Rubino
- Université Paris-Saclay, Univ. Paris-Sud, UVSQ, CESP, Cancer and Radiation Team, Villejuif, France; INSERM, CESP, Cancer and Radiation Team, F-94805 Villejuif, France; Gustave Roussy, Department of Clinical Research, Cancer and Radiation Team, F-94805 Villejuif, France
| | - Florent de Vathaire
- Université Paris-Saclay, Univ. Paris-Sud, UVSQ, CESP, Cancer and Radiation Team, Villejuif, France; INSERM, CESP, Cancer and Radiation Team, F-94805 Villejuif, France; Gustave Roussy, Department of Clinical Research, Cancer and Radiation Team, F-94805 Villejuif, France
| | - Véronique Letort
- Université Paris-Saclay, CentraleSupélec, Mathématiques et Informatique pour la Complexité et les Systèmes, 91190, Gif-sur-Yvette, France
| | - Rodrigue Setcheou Allodji
- Université Paris-Saclay, Univ. Paris-Sud, UVSQ, CESP, Cancer and Radiation Team, Villejuif, France; INSERM, CESP, Cancer and Radiation Team, F-94805 Villejuif, France; Gustave Roussy, Department of Clinical Research, Cancer and Radiation Team, F-94805 Villejuif, France; Polytechnic School of Abomey-Calavi (EPAC), University of Abomey-Calavi, 01 P.O. Box 2009, Cotonou, Benin.
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11
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Krittanawong C, Singh NK, Scheuring RA, Urquieta E, Bershad EM, Macaulay TR, Kaplin S, Dunn C, Kry SF, Russomano T, Shepanek M, Stowe RP, Kirkpatrick AW, Broderick TJ, Sibonga JD, Lee AG, Crucian BE. Human Health during Space Travel: State-of-the-Art Review. Cells 2022; 12:cells12010040. [PMID: 36611835 PMCID: PMC9818606 DOI: 10.3390/cells12010040] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/05/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022] Open
Abstract
The field of human space travel is in the midst of a dramatic revolution. Upcoming missions are looking to push the boundaries of space travel, with plans to travel for longer distances and durations than ever before. Both the National Aeronautics and Space Administration (NASA) and several commercial space companies (e.g., Blue Origin, SpaceX, Virgin Galactic) have already started the process of preparing for long-distance, long-duration space exploration and currently plan to explore inner solar planets (e.g., Mars) by the 2030s. With the emergence of space tourism, space travel has materialized as a potential new, exciting frontier of business, hospitality, medicine, and technology in the coming years. However, current evidence regarding human health in space is very limited, particularly pertaining to short-term and long-term space travel. This review synthesizes developments across the continuum of space health including prior studies and unpublished data from NASA related to each individual organ system, and medical screening prior to space travel. We categorized the extraterrestrial environment into exogenous (e.g., space radiation and microgravity) and endogenous processes (e.g., alteration of humans' natural circadian rhythm and mental health due to confinement, isolation, immobilization, and lack of social interaction) and their various effects on human health. The aim of this review is to explore the potential health challenges associated with space travel and how they may be overcome in order to enable new paradigms for space health, as well as the use of emerging Artificial Intelligence based (AI) technology to propel future space health research.
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Affiliation(s)
- Chayakrit Krittanawong
- Department of Medicine and Center for Space Medicine, Section of Cardiology, Baylor College of Medicine, Houston, TX 77030, USA
- Translational Research Institute for Space Health, Houston, TX 77030, USA
- Department of Cardiovascular Diseases, New York University School of Medicine, New York, NY 10016, USA
- Correspondence: or (C.K.); (B.E.C.); Tel.: +1-713-798-4951 (C.K.); +1-281-483-0123 (B.E.C.)
| | - Nitin Kumar Singh
- Biotechnology and Planetary Protection Group, Jet Propulsion Laboratory, California Institute of Technology, Pasadena, CA 91109, USA
| | | | - Emmanuel Urquieta
- Translational Research Institute for Space Health, Houston, TX 77030, USA
- Department of Emergency Medicine and Center for Space Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | - Eric M. Bershad
- Department of Neurology, Center for Space Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | | | - Scott Kaplin
- Department of Cardiovascular Diseases, New York University School of Medicine, New York, NY 10016, USA
| | - Carly Dunn
- Department of Dermatology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Stephen F. Kry
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | | | - Marc Shepanek
- Office of the Chief Health and Medical Officer, NASA, Washington, DC 20546, USA
| | | | - Andrew W. Kirkpatrick
- Department of Surgery and Critical Care Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | | | - Jean D. Sibonga
- Division of Biomedical Research and Environmental Sciences, NASA Lyndon B. Johnson Space Center, Houston, TX 77058, USA
| | - Andrew G. Lee
- Department of Ophthalmology, University of Texas Medical Branch School of Medicine, Galveston, TX 77555, USA
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX 77030, USA
- Department of Ophthalmology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Department of Ophthalmology, Texas A and M College of Medicine, College Station, TX 77807, USA
- Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
- Departments of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medicine, New York, NY 10021, USA
| | - Brian E. Crucian
- National Aeronautics and Space Administration (NASA) Johnson Space Center, Human Health and Performance Directorate, Houston, TX 77058, USA
- Correspondence: or (C.K.); (B.E.C.); Tel.: +1-713-798-4951 (C.K.); +1-281-483-0123 (B.E.C.)
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12
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Bisello S, Cilla S, Benini A, Cardano R, Nguyen NP, Deodato F, Macchia G, Buwenge M, Cammelli S, Wondemagegnehu T, Uddin AFMK, Rizzo S, Bazzocchi A, Strigari L, Morganti AG. Dose-Volume Constraints fOr oRganS At risk In Radiotherapy (CORSAIR): An "All-in-One" Multicenter-Multidisciplinary Practical Summary. Curr Oncol 2022; 29:7021-50. [PMID: 36290829 DOI: 10.3390/curroncol29100552] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/20/2022] [Accepted: 09/22/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The safe use of radiotherapy (RT) requires compliance with dose/volume constraints (DVCs) for organs at risk (OaRs). However, the available recommendations are sometimes conflicting and scattered across a number of different documents. Therefore, the aim of this work is to provide, in a single document, practical indications on DVCs for OaRs in external beam RT available in the literature. MATERIAL AND METHODS A multidisciplinary team collected bibliographic information on the anatomical definition of OaRs, on the imaging methods needed for their definition, and on DVCs in general and in specific settings (curative RT of Hodgkin's lymphomas, postoperative RT of breast tumors, curative RT of pediatric cancers, stereotactic ablative RT of ventricular arrythmia). The information provided in terms of DVCs was graded based on levels of evidence. RESULTS Over 650 papers/documents/websites were examined. The search results, together with the levels of evidence, are presented in tabular form. CONCLUSIONS A working tool, based on collected guidelines on DVCs in different settings, is provided to help in daily clinical practice of RT departments. This could be a first step for further optimizations.
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13
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Aziz-Bose R, Margossian R, Ames BL, Moss K, Ehrhardt MJ, Armenian SH, Yock TI, Nekhlyudov L, Williams D, Hudson M, Nohria A, Kenney LB. Delphi Panel Consensus Recommendations for Screening and Managing Childhood Cancer Survivors at Risk for Cardiomyopathy. JACC CardioOncol 2022; 4:354-367. [PMID: 36213355 PMCID: PMC9537072 DOI: 10.1016/j.jaccao.2022.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 04/29/2022] [Accepted: 05/06/2022] [Indexed: 11/18/2022] Open
Abstract
Background Cardiomyopathy is a leading cause of late morbidity and mortality in childhood cancer survivors (CCS). Evidence-based guidelines recommend risk-stratified screening for cardiomyopathy, but the management approach for abnormalities detected when screening asymptomatic young adult CCS is poorly defined. Objectives The aims of this study were to build upon existing guidelines by describing the expert consensus–based cardiomyopathy screening practices, management approach, and clinical rationale for the management of young adult CCS with screening-detected abnormalities and to identify areas of controversy in practice. Methods A multispecialty Delphi panel of 40 physicians with expertise in cancer survivorship completed 3 iterative rounds of semi-open-ended questionnaires regarding their approaches to the management of asymptomatic young adult CCS at risk for cardiomyopathy (screening practices, referrals, cardiac testing, laboratory studies, medications). Consensus was defined as ≥90% panelist agreement with recommendation. Results The response rate was 100% for all 3 rounds. Panelists reached consensus on the timing and frequency of echocardiographic screening for anthracycline-associated cardiomyopathy, monitoring during pregnancy, laboratory testing for modifiable cardiac risk factors, and referral to cardiology for ejection fraction ≤50% or preserved ejection fraction with diastolic dysfunction. Controversial areas (<75% agreement) included chest radiation dose threshold to merit screening, indications for advanced cardiac imaging and cardiac serum biomarkers for follow-up of abnormal echocardiographic findings, and medical management of asymptomatic left ventricular systolic dysfunction. Conclusions Expert practice is largely consistent with existing risk-based screening guidelines. Some recommendations for managing abnormalities detected on screening echocardiography remain controversial. The rationale offered by experts for divergent approaches may help guide clinical decisions in the absence of guidelines specific to young adult CCS.
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Affiliation(s)
- Rahela Aziz-Bose
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Address for correspondence: Dr Rahela Aziz-Bose, Dana-Farber Cancer Institute, SW 311, 450 Brookline Avenue, Boston, Massachusetts 02215, USA. @DrN_CancerPCP
| | - Renee Margossian
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Bethany L. Ames
- Geisel School of Medicine at Dartmouth, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Kerry Moss
- Connecticut Children’s Hospital, Hartford, Connecticut, USA
| | - Matthew J. Ehrhardt
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Saro H. Armenian
- Department of Pediatrics and Population Sciences, City of Hope, Duarte, California, USA
| | - Torunn I. Yock
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Larissa Nekhlyudov
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - David Williams
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Melissa Hudson
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Anju Nohria
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Adult Survivorship Program, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Lisa B. Kenney
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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14
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Gupta AC, Owens CA, Shrestha S, Lee C, Smith SA, Weathers RE, Netherton T, Balter PA, Kry SF, Followill DS, Griffin KT, Long JP, Armstrong GT, Howell RM. Body region-specific 3D age-scaling functions for scaling whole-body computed tomography anatomy for pediatric late effects studies. Biomed Phys Eng Express 2022; 8:10.1088/2057-1976/ac3f4e. [PMID: 34874300 PMCID: PMC9547666 DOI: 10.1088/2057-1976/ac3f4e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 12/02/2021] [Indexed: 02/03/2023]
Abstract
Purpose.Radiation epidemiology studies of childhood cancer survivors treated in the pre-computed tomography (CT) era reconstruct the patients' treatment fields on computational phantoms. For such studies, the phantoms are commonly scaled to age at the time of radiotherapy treatment because age is the generally available anthropometric parameter. Several reference size phantoms are used in such studies, but reference size phantoms are only available at discrete ages (e.g.: newborn, 1, 5, 10, 15, and Adult). When such phantoms are used for RT dose reconstructions, the nearest discrete-aged phantom is selected to represent a survivor of a specific age. In this work, we (1) conducted a feasibility study to scale reference size phantoms at discrete ages to various other ages, and (2) evaluated the dosimetric impact of using exact age-scaled phantoms as opposed to nearest age-matched phantoms at discrete ages.Methods.We have adopted the University of Florida/National Cancer Institute (UF/NCI) computational phantom library for our studies. For the feasibility study, eight male and female reference size UF/NCI phantoms (5, 10, 15, and 35 years) were downscaled to fourteen different ages which included next nearest available lower discrete ages (1, 5, 10 and 15 years) and the median ages at the time of RT for Wilms' tumor (3.9 years), craniospinal (8.0 years), and all survivors (9.1 years old) in the Childhood Cancer Survivor Study (CCSS) expansion cohort treated with RT. The downscaling was performed using our in-house age scaling functions (ASFs). To geometrically validate the scaling, Dice similarity coefficient (DSC), mean distance to agreement (MDA), and Euclidean distance (ED) were calculated between the scaled and ground-truth discrete-aged phantom (unscaled UF/NCI) for whole-body, brain, heart, liver, pancreas, and kidneys. Additionally, heights of the scaled phantoms were compared with ground-truth phantoms' height, and the Centers for Disease Control and Prevention (CDC) reported 50th percentile height. Scaled organ masses were compared with ground-truth organ masses. For the dosimetric assessment, one reference size phantom and seventeen body-size dependent 5-year-old phantoms (9 male and 8 female) of varying body mass indices (BMI) were downscaled to 3.9-year-old dimensions for two different radiation dose studies. For the first study, we simulated a 6 MV photon right-sided flank field RT plan on a reference size 5-year-old and 3.9-year-old (both of healthy BMI), keeping the field size the same in both cases. Percent of volume receiving dose ≥15 Gy (V15) and the mean dose were calculated for the pancreas, liver, and stomach. For the second study, the same treatment plan, but with patient anatomy-dependent field sizes, was simulated on seventeen body-size dependent 5- and 3.9-year-old phantoms with varying BMIs. V15, mean dose, and minimum dose received by 1% of the volume (D1), and by 95% of the volume (D95) were calculated for pancreas, liver, stomach, left kidney (contralateral), right kidney, right and left colons, gallbladder, thoracic vertebrae, and lumbar vertebrae. A non-parametric Wilcoxon rank-sum test was performed to determine if the dose to organs of exact age-scaled and nearest age-matched phantoms were significantly different (p < 0.05).Results.In the feasibility study, the best DSCs were obtained for the brain (median: 0.86) and whole-body (median: 0.91) while kidneys (median: 0.58) and pancreas (median: 0.32) showed poorer agreement. In the case of MDA and ED, whole-body, brain, and kidneys showed tighter distribution and lower median values as compared to other organs. For height comparison, the overall agreement was within 2.8% (3.9 cm) and 3.0% (3.2 cm) of ground-truth UF/NCI and CDC reported 50th percentile heights, respectively. For mass comparison, the maximum percent and absolute differences between the scaled and ground-truth organ masses were within 31.3% (29.8 g) and 211.8 g (16.4%), respectively (across all ages). In the first dosimetric study, absolute difference up to 6% and 1.3 Gy was found for V15and mean dose, respectively. In the second dosimetric study, V15and mean dose were significantly different (p < 0.05) for all studied organs except the fully in-beam organs. D1and D95were not significantly different for most organs (p > 0.05).Conclusion.We have successfully evaluated our ASFs by scaling UF/NCI computational phantoms from one age to another age, which demonstrates the feasibility of scaling any CT-based anatomy. We have found that dose to organs of exact age-scaled and nearest aged-matched phantoms are significantly different (p < 0.05) which indicates that using the exact age-scaled phantoms for retrospective dosimetric studies is a better approach.
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Affiliation(s)
- Aashish C. Gupta
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX USA,The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX USA
| | - Constance A. Owens
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX USA,The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX USA
| | - Suman Shrestha
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX USA,The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX USA
| | - Choonsik Lee
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD USA
| | - Susan A. Smith
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Rita E. Weathers
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Tucker Netherton
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Peter A. Balter
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX USA,The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX USA
| | - Stephen F. Kry
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX USA,The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX USA
| | - David S. Followill
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX USA,The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX USA
| | - Keith T. Griffin
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD USA,George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, GA USA
| | - James P. Long
- The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX USA,Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN USA
| | - Rebecca M. Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX USA,The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX USA,Address for correspondence: Rebecca M. Howell, Director, Radiation Dosimetry Services, Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, 8060 El Rio St., Unit 605, Houston, TX 77054,
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Banaei A, Hashemi B, Bakhshandeh M. Estimating cancer risks due to whole lungs low dose radiotherapy with different techniques for treating COVID-19 pneumonia. Radiat Oncol 2022; 17:10. [PMID: 35057839 PMCID: PMC8771186 DOI: 10.1186/s13014-021-01971-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 12/20/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Low dose radiotherapy (LDRT) of whole lungs with photon beams is a novel method for treating COVID-19 pneumonia. This study aimed to estimate cancer risks induced by lung LDRT for different radiotherapy delivery techniques. METHOD Four different radiotherapy techniques, including 3D-conformal with anterior and posterior fields (3D-CRT AP-PA), 3D-conformal with 8 coplanar fields (3D-CRT 8 fields), eight fields intensity-modulated radiotherapy (IMRT), and volumetric modulated arc therapy using 2 full arcs (VMAT) were planned on the CT images of 32 COVID-19 patients with the prescribed dose of 1 Gy to the lungs. Organ average and maximum doses, and PTV dose distribution indexes were compared between different techniques. The radiation-induced cancer incidence and cancer-specific mortality, and cardiac heart disease risks were estimated for the assessed techniques. RESULTS In IMRT and VMAT techniques, heart (mean and max), breast (mean, and max), and stomach (mean) doses and also maximum dose in the body were significantly lower than the 3D-CRT techniques. The calculated conformity indexes were similar in all the techniques. However, the homogeneity indexes were lower (i.e., better) in intensity-modulated techniques (P < 0.03) with no significant differences between IMRT and VMAT plans. Lung cancer incident risks for all the delivery techniques were similar (P > 0.4). Cancer incidence and mortality risks for organs located closer to lungs like breast and stomach were higher in 3D-CRT techniques than IMRT or VMAT techniques (excess solid tumor cancer incidence risks for a 30 years man: 1.94 ± 0.22% Vs. 1.68 ± 0.17%; and women: 6.66 ± 0.81% Vs. 4.60 ± 0.43%: cancer mortality risks for 30 years men: 1.63 ± 0.19% Vs. 1.45 ± 0.15%; and women: 3.63 ± 0.44% Vs. 2.94 ± 0.23%). CONCLUSION All the radiotherapy techniques had low cancer risks. However, the overall estimated risks induced by IMRT and VMAT radiotherapy techniques were lower than the 3D-CRT techniques and can be used clinically in younger patients or patients having greater concerns about radiation induced cancers.
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Affiliation(s)
- Amin Banaei
- Department of Medical Physics, Faculty of Medical Sciences, Tarbiat Modares University, Al-Ahmad and Chamran Cross, 1411713116 Tehran, Iran
| | - Bijan Hashemi
- Department of Medical Physics, Faculty of Medical Sciences, Tarbiat Modares University, Al-Ahmad and Chamran Cross, 1411713116 Tehran, Iran
| | - Mohsen Bakhshandeh
- Department of Radiology Technology, Faculty of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Smyth G, Mowat S, Chia K, Robinson K, Warren-oseni K, Welsh L, Blasiak-wal I, Mandeville H. Clinical Implementation of Robust Multi-isocentric Volumetric Modulated Arc Radiotherapy for Craniospinal Irradiation. Clin Oncol (R Coll Radiol) 2022. [DOI: 10.1016/j.clon.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 12/07/2021] [Accepted: 01/04/2022] [Indexed: 11/30/2022]
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