1
|
Nguyen P, Indelicato DJ, Esterman A, Paulino AC, Ermoian RP, Laack NN, Perkins SM, Mangona V, Mihalcik S, Lee J, Hill-Kayser C, Kwok Y, Chang JHC, Perentesis JP, MacEwan I, Le H, Yock TI. Acute Toxicities of Proton Craniospinal Irradiation in Pediatric Medulloblastoma: A Pediatric Proton/Photon Consortium Registry (PPCR) Study. Int J Part Ther 2025; 16:100747. [PMID: 40336980 PMCID: PMC12056773 DOI: 10.1016/j.ijpt.2025.100747] [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: 07/17/2024] [Revised: 03/21/2025] [Accepted: 04/09/2025] [Indexed: 05/09/2025] Open
Abstract
Purpose Medulloblastoma is one of the most common malignant brain tumors in children, and 75% of patients achieve long-term survival. There are limited studies reporting acute toxicity for pediatric patients receiving proton therapy for craniospinal irradiation (CSI) in medulloblastoma, and these are limited by their retrospective nature, modest cohort sizes, and lack of a comparator group. Materials and Methods We analyzed data from the Pediatric Proton/Photon Consortium Registry. Patients with a diagnosis of medulloblastoma, receiving CSI with doses of either 23.4 Gy or 36 to 39.6 Gy, and with toxicity data at baseline and completion of treatment, were identified for inclusion. Results A total of 272 patients were included for analysis. All patients received proton therapy. The median age of patients was 8 years (range 3-22 years), and 67.6% were male. Most patients were of good performance status with eastern cooperative oncology group (ECOG) 0 or 1, 36.8% and 31.6%, respectively. In total, 68.8% of patients had classic medulloblastoma; 76.8% had M0 disease; and 62.9% of patients had standard-risk disease.Acute toxicities were reported as grade 1 or higher. The most common toxicities occurring during treatment were skin (90.3%), gastrointestinal (71.6%), hematological (54.9%), and mouth (32.0%). Toxicity rates were lower than in the published literature. All patients completed treatment. Conclusion Our findings suggest that proton CSI has an acceptable degree of acute toxicity in the treatment of pediatric medulloblastoma. Future studies would benefit from toxicity grading, toxicity timing, and a photon comparator group.
Collapse
Affiliation(s)
| | - Daniel J. Indelicato
- University of Florida Health Proton Therapy Institute, Jacksonville, Florida, USA
| | | | | | | | | | | | | | - Stephen Mihalcik
- Northwestern Medicine Chicago Proton Center, Warrenville, Illinois, USA
| | - Jae Lee
- ProCure New Jersey, Somerset, New Jersesy, USA
| | | | - Young Kwok
- Maryland Proton Treatment Center, Baltimore, Maryland, USA
| | | | | | | | - Hien Le
- Royal Adelaide Hospital, Adelaide, Australia
| | - Torunn I. Yock
- Massachusetts General Hospital, Boston, Massachusetts, USA
| |
Collapse
|
2
|
Diaz LS, Agrup M, Askild A, Embring A, Engellau J, Kristensen IF, Flejmer A, Fröjd C, Nilsson MP, Svärd AM, Walfridsson A, Blomstrand M. Acute side effects of proton and photon radiotherapy for medulloblastoma: a retrospective national multicenter study. J Neurooncol 2025:10.1007/s11060-025-05016-x. [PMID: 40232619 DOI: 10.1007/s11060-025-05016-x] [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: 02/17/2025] [Accepted: 03/17/2025] [Indexed: 04/16/2025]
Abstract
PURPOSE A comparison of acute toxicity between photon and proton radiotherapy (RT) for children undergoing treatment for medulloblastoma. METHODS This retrospective multi-institutional cohort study included 96 children < 18 years treated for medulloblastoma in Sweden during 2008-2020. Patients treated with protons (n = 37) and photons (n = 59) were compared regarding acute side effects and radiation dose to intracerebral organs at risk (OARs). Data was collected from a prospectively maintained national database and was supplemented from a retrospective review of medical records. Acute symptoms were graded according to CTCAE (Common Terminology Criteria for Adverse Events), maximum grade occurring during RT and within 2 months after RT. Hematological toxicity was evaluated according to maximum grade and percentual reduction during RT. RESULTS No significant differences in incidence or severity of acute symptoms were observed between proton-RT and photon-RT; grade ≥ 2 fatigue (5.4 vs. 10.2%), headache (2.7 vs. 3.4%), nausea (43.2 vs. 42.4%), dermatitis (5.4 vs. 15.3%), gastrointestinal toxicity (0 vs. 0%), weight loss (10.8 vs. 8.5%). Median percentual reduction (0% vs. -11,25%) in hemoglobin was significantly smaller during proton-RT (p < 0.001). No difference was observed for leucocytes, neutrophiles, or platelets. Absorbed mean dose to intracranial OARs was significantly lower with proton-RT. CONCLUSION This is one of the largest studies comparing acute side effects of proton-RT and photon-RT including only paediatric medulloblastoma patients. Proton-RT was safe and well tolerated regarding acute side effects. Absorbed dose to intracranial OARs was significantly lower with proton-RT. Further investigations of long-term side effects and cognitive evaluation is needed to show that this will translate into true clinical value for patients.
Collapse
Affiliation(s)
- Linn Söderlund Diaz
- Department of Oncology, Sahlgrenska University Hospital, Blå Stråket 2, Gothenburg, 413 46, Sweden.
| | - Måns Agrup
- Department of Oncology, Linköping University Hospital, Linköping, Sweden
| | - Anna Askild
- Department of Oncology, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - Anna Embring
- Department of Oncology, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - Jacob Engellau
- Department of Radiation Oncology, Skåne University Hospital, Lund, Sweden
| | | | - Anna Flejmer
- Department of Radiation Oncology, Uppsala University Hospital, Uppsala, Sweden
| | - Charlotta Fröjd
- Department of Oncology, Sahlgrenska University Hospital, Blå Stråket 2, Gothenburg, 413 46, Sweden
| | - Martin P Nilsson
- Department of Radiation Oncology, Skåne University Hospital, Lund, Sweden
| | - Anna Maja Svärd
- Department of Oncology, Umeå University Hospital, Umeå, Sweden
| | | | - Malin Blomstrand
- Department of Oncology, Sahlgrenska University Hospital, Blå Stråket 2, Gothenburg, 413 46, Sweden
- Sahlgrenska Academy, Institute of Clincial Sciences, Department of Oncology, Gothenburg, Sweden
| |
Collapse
|
3
|
Khalili BF, Walbert T, Horbinski C, Dixit K, Gururangan K, Thio H, Tate MC, Stupp R, Lukas RV, Templer JW. Levetiracetam and valproic acid in glioma: antiseizure and potential antineoplastic effects. Future Oncol 2025; 21:483-491. [PMID: 39786974 PMCID: PMC11812422 DOI: 10.1080/14796694.2025.2450215] [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: 09/03/2024] [Accepted: 01/03/2025] [Indexed: 01/12/2025] Open
Abstract
Seizures are a frequent complication in glioma. Incidence of brain tumor-related epilepsy (BTRE) in high-grade glioma (HGG) is an estimated > 25% and in low-grade glioma (LGG) is approximately 72%. Two first-line antiseizure medications (ASMs) for BTRE include levetiracetam (LEV) and valproic acid (VPA). Use of VPA has decreased because of a broader side effect profile, potential interaction with chemotherapeutic drugs, and availability of newer generation agents. In refractory BTRE, LEV and VPA may be prescribed together to enhance seizure control. VPA and LEV have gained attention for their purported antineoplastic effects and synergistic role with temozolomide. VPA is suggested to modulate anticancer activity in vitro through multiple mechanisms. In addition, retrospective studies indicate increased overall survival in patients with epileptogenic HGGs who are managed with LEV or VPA rather than other ASMs. However, these studies have numerous limitations. It is also reported that patients with glioma and a seizure history have a longer survival. This extended survival, if one exists, may be only observed in certain gliomas with corresponding patient characteristics. We provide a brief overview of the management of BTRE, VPA and LEV as anticonvulsants and antineoplastics, and the factors that may be associated with survival in epileptogenic glioma.
Collapse
Affiliation(s)
| | - Tobias Walbert
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
- Department of Neurology, Wayne State University, Detroit, MI, USA
| | - Craig Horbinski
- Department of Pathology, Northwestern University, Chicago, IL, USA
- Department of Neurological Surgery, Northwestern University, Chicago, IL, USA
- Lou & Jean Malnati Brain Tumor Institute, Northwestern University, Chicago, IL, USA
| | - Karan Dixit
- Lou & Jean Malnati Brain Tumor Institute, Northwestern University, Chicago, IL, USA
- Department of Neurology, Northwestern University, Chicago, IL, USA
| | - Kapil Gururangan
- Department of Neurology, Northwestern University, Chicago, IL, USA
| | - Helen Thio
- Department of Neurology, Northwestern University, Chicago, IL, USA
| | - Matthew C. Tate
- Department of Neurological Surgery, Northwestern University, Chicago, IL, USA
- Lou & Jean Malnati Brain Tumor Institute, Northwestern University, Chicago, IL, USA
| | - Roger Stupp
- Department of Neurological Surgery, Northwestern University, Chicago, IL, USA
- Lou & Jean Malnati Brain Tumor Institute, Northwestern University, Chicago, IL, USA
- Department of Neurology, Northwestern University, Chicago, IL, USA
- Section of Hematology & Oncology, Northwestern University, Chicago, IL, USA
| | - Rimas V. Lukas
- Lou & Jean Malnati Brain Tumor Institute, Northwestern University, Chicago, IL, USA
- Department of Neurology, Northwestern University, Chicago, IL, USA
| | - Jessica W. Templer
- Lou & Jean Malnati Brain Tumor Institute, Northwestern University, Chicago, IL, USA
- Department of Neurology, Northwestern University, Chicago, IL, USA
| |
Collapse
|
4
|
Schafer ES, Rushing T, Crews KR, Annesley C, Colace SI, Kaiser N, Pommert L, Ramsey LB, Sabnis HS, Wong K, Chang BH, Cooper TM, Shah NN, Rheingold SR, Place AE, Chi YY, Bhojwani D, Wayne AS, Bernhardt MB. Optimizing early phase clinical trial washout periods: a report from the Therapeutic Advances in Childhood Leukemia and Lymphoma consortium. J Natl Cancer Inst 2024; 116:1721-1729. [PMID: 38964343 PMCID: PMC11542989 DOI: 10.1093/jnci/djae165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 05/30/2024] [Accepted: 06/26/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND The National Cancer Institute (NCI) issued a 2021 memorandum adopting the American Society of Clinical Oncology (ASCO) and Friends of Cancer Research (Friends) task force recommendations to broaden clinical study eligibility criteria. They recommended that washout periods be eliminated for most prior cancer therapy and when required to utilize evidence- and/or rationale-based criteria. The Therapeutic Advances in Childhood Leukemia and Lymphoma (TACL) consortium responded to this guidance. METHODS A TACL task force reviewed the consortium's research portfolio, the relevant literature and guidance documents from ASCO-Friends, NCI, and US Food and Drug Administration to make expert consensus and evidence-based recommendations for modernizing, broadening, and codifying TACL-study washout periods while ensuring consistency with pediatric ethics, and federal regulations. TACL's screening log was reviewed to estimate the impact that updated washout periods would have on patient inclusivity and recruitment. RESULTS Over a 19-year period, 42 (14.6% of all screened ineligible patients [n = 287]) patients were identified as excluded from TACL early phase studies exclusively because of not meeting washout criteria. An additional 6 (2.1%) did not meet washout and at least 1 other exclusion criterion. A new TACL washout guidance document was developed and then adopted for use. Where washout criteria were not eliminated, rationale- and/or evidenced-based criteria were established with citation. CONCLUSION In an effort to reduce unnecessary exclusion from clinical trials, TACL created rationale- and/or evidenced-based washout period standards largely following guidance from the NCI and ASCO-Friends recommendations. These new, expanded eligibility criteria are expected to increase access to TACL clinical trials while maintaining safety and scientific excellence.
Collapse
Affiliation(s)
- Eric S Schafer
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Cancer and Hematology Center, Texas Children’s Hospital, Houston, TX, USA
| | - Teresa Rushing
- Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Kristine R Crews
- Department of Pharmacy and Pharmaceutical Sciences, St Jude Children’s Research Hospital, Memphis, TN, USA
| | - Colleen Annesley
- Seattle Children’s Hospital Cancer and Blood Disorders Service, University of Washington School of Medicine, Seattle, WA, USA
| | - Susan I Colace
- Division of Hematology, Oncology and Blood and Marrow Transplant, Nationwide Children’s Hospital, Columbus, OH, USA
- Department of Pediatrics, the Ohio State University College of Medicine, Columbus, OH, USA
| | - Nicole Kaiser
- Center for Cancer and Blood Disorders, Children’s Hospital Colorado, Aurora, CO, USA
| | - Lauren Pommert
- Division of Oncology, Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Laura B Ramsey
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children’s Mercy Kansas City, Department of Pediatrics, University of Missouri, Kansas City, MO, USA
| | - Himalee S Sabnis
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA, USA
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Kenneth Wong
- Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Los Angeles, CA, USA
- University of Southern California Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Bill H Chang
- Division of Pediatric Hematology Oncology, Oregon Health and Science University, Portland, OR, USA
| | - Todd M Cooper
- Seattle Children’s Hospital Cancer and Blood Disorders Service, University of Washington School of Medicine, Seattle, WA, USA
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Susan R Rheingold
- Division of Oncology and Center for Childhood Cancer Research, Children’s Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew E Place
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Yueh-Yun Chi
- Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Los Angeles, CA, USA
- University of Southern California Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Deepa Bhojwani
- Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Los Angeles, CA, USA
- University of Southern California Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Alan S Wayne
- Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Los Angeles, CA, USA
- University of Southern California Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - M Brooke Bernhardt
- Department of Pharmacy and Pharmaceutical Sciences, St Jude Children’s Research Hospital, Memphis, TN, USA
| |
Collapse
|
5
|
Li Z, Lin Z, Liu H, Xiao R, Lin C, Zhu W, Luo J, Xu S, Chi F, He H. Treatment Continuity and Bone Marrow Suppression in Whole-Brain and Whole-Spinal Cord Radiotherapy for Medulloblastoma Patients. Clin Med Insights Oncol 2024; 18:11795549241286431. [PMID: 39371257 PMCID: PMC11456176 DOI: 10.1177/11795549241286431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 09/06/2024] [Indexed: 10/08/2024] Open
Abstract
Background This study investigated the factors influencing treatment continuity and bone marrow suppression in whole-brain and whole-spinal cord radiotherapy for medulloblastoma, providing a clinical reference for mitigating the impact of hematological suppression on radiotherapy continuity. Methods A retrospective analysis was conducted on patients with medulloblastoma who underwent craniospinal irradiation (CSI) radiotherapy at our hospital between August 2019 and December 2023. According to the inclusion and exclusion criteria, a total of 87 patients were enrolled. The bone marrow suppression status, clinical data, and radiotherapy dose data of the enrolled patients were recorded, and correlation analyses were performed. Based on the correlation results, further group comparisons were subsequently conducted. Results Overall, 22.99% (20 out of 87) of the patients experienced treatment interruption (median duration, 6.5 [5, 8] days), typically during the 12th (7.5, 14.75) radiotherapy session. Treatment continuity was weakly correlated with age and treatment modality, and the timing of interruptions was weakly correlated with dosage and treatment modality. Bone marrow suppression severity was weakly correlated with age, body mass index (BMI), and treatment modality. Treatment modality and age were found to be independent predictors of treatment continuity and the degree of bone marrow suppression, respectively. Subgroup comparisons revealed differences in the severity of bone marrow suppression, grade of hematological toxicity, and timing of interruption depending on the treatment modality, dosage, and sex (P < .05). Conclusions Timely monitoring of hematological changes, especially in the middle and posterior segments after radiotherapy, is crucial. Treatment with helical tomotherapy, male sex, younger age, and lower BMI during radiotherapy are indicators of greater clinical attention.
Collapse
Affiliation(s)
| | | | | | - Runnan Xiao
- Department of Radiotherapy, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Chuyan Lin
- Department of Radiotherapy, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Wenlong Zhu
- Department of Radiotherapy, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jiaxiu Luo
- Department of Radiotherapy, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Senku Xu
- Department of Radiotherapy, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Feng Chi
- Department of Radiotherapy, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Huilang He
- Department of Radiotherapy, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
| |
Collapse
|
6
|
Turcas A, Homorozeanu B, Gheara C, Balan C, Cosnarovici R, Diaconu O, Fekete Z, Mihut E, Olteanu D, Pruteanu P, Tipcu A, Turcas A, Cernea D, Leucuta D, Achimas-Cadariu P. Dynamics and predictors of hematologic toxicity during cranio-spinal irradiation. Rep Pract Oncol Radiother 2024; 29:362-372. [PMID: 39144265 PMCID: PMC11321791 DOI: 10.5603/rpor.101094] [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: 11/17/2023] [Accepted: 05/31/2024] [Indexed: 08/16/2024] Open
Abstract
Background Craniospinal irradiation (CSI) is a complex radiotherapy (RT) technique required for treating specific brain tumors and some hematologic malignancies. With large volumes of hematogenous bone marrow (BM) being irradiated, CSI could cause acute hematologic toxicity, leading to treatment interruptions or severe complications. We report on the dynamics and dose/volume predictors of hematologic toxicity during CSI. Materials and methods Pediatric patients (≤ 18years) undergoing CSI in a tertiary cancer center were included. Medical records were retrospectively reviewed for clinical data and blood parameters were collected at baseline and weekly, until four weeks after the end of RT. The BM substructures were contoured, and dose-volume parameters were extracted. We used Wilcoxon rank-sum test to compare quantitative data, Chi square test for qualitative data and receiver operating characteristics (ROC) curves for dose/volume thresholds. Results Fifty-one patients were included. Severe toxicities (grade 3-4) were recorded as follows: 2% anemia, 8% thrombocytopenia, 25% leukopenia, 24% neutropenia. Ninety-eight percent of patients had lymphopenia (grade 1-4) at some point. Twenty-nine percent required granulocyte-colony stimulating factor, 50% had an infection and 8% required a blood transfusion. Dmean > 3.6 Gy and V15 Gy > 10.6% for Pelvic Bones were associated with a higher risk of developing any ≥ G3 toxicities. Dmean > 30-35 Gy to the thoracic and lumbar spine was predictive for G3-4 anemia and thrombocytopenia, and Cervical Spine Dmean > 30 Gy was associated with ≥ G3 neutropenia. Conclusion CSI was well tolerated, without life-threatening complications in our cohort, but hematologic toxicity was frequent, with severity increasing with higher mean doses delivered to the hematogenous BM and larger volumes of BM receiving 30-35 Gy.
Collapse
Affiliation(s)
- Andrada Turcas
- Radiotherapy Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
- Oncology Department, The University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
| | - Bianca Homorozeanu
- Radiotherapy Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
- Oncology Department, The University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
| | - Cristina Gheara
- Radiotherapy Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
- Faculty of Physics, “Babes-Bolyai” University, Cluj-Napoca, Romania
| | - Cristina Balan
- Radiotherapy Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
- Faculty of Physics, “Babes-Bolyai” University, Cluj-Napoca, Romania
| | - Rodica Cosnarovici
- Paediatric Oncology Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
| | - Oana Diaconu
- Radiotherapy Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
- Faculty of Physics, “Babes-Bolyai” University, Cluj-Napoca, Romania
| | - Zsolt Fekete
- Radiotherapy Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
- Oncology Department, The University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
| | - Emilia Mihut
- Paediatric Oncology Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
| | - Diana Olteanu
- Paediatric Oncology Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
| | - Paula Pruteanu
- Paediatric Oncology Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
| | - Alexandru Tipcu
- Radiotherapy Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
- Oncology Department, The University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
| | - Adrian Turcas
- Oncology Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
| | - Dana Cernea
- Radiotherapy Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
| | - Daniel Leucuta
- Department of Medical Informatics and Biostatistics, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
| | - Patriciu Achimas-Cadariu
- Oncology Department, The University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
- Surgical Oncology Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
| |
Collapse
|
7
|
Ma J, Li Y, Yu H, Zhang J, Zhang Y, Verma V, Chen H, Qin X, Zhai X, Shang S, Shangguan J, Wang R, Tian C, Wang F, Yu J, Chen D. The Role of Thoracic Vertebral Body Dosimetry in Minimizing Acute Hematologic Toxicities of Patients With Non-Small Cell Lung Cancer Receiving Lung Radiation Therapy and Immunotherapy. Int J Radiat Oncol Biol Phys 2024; 119:78-89. [PMID: 38040058 DOI: 10.1016/j.ijrobp.2023.11.037] [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: 05/09/2023] [Revised: 10/31/2023] [Accepted: 11/19/2023] [Indexed: 12/03/2023]
Abstract
PURPOSE Hematologic toxicities (HTs) are among the most common toxicities of combined immunotherapy and radiation therapy (RT). It remains essential to prevent RT-induced HTs because they can cause treatment discontinuation (influencing antitumoral effects) and because lymphopenia might dampen the effects of immunotherapy. To date, there are no studies examining the effect of thoracic vertebral body (TVB) RT dose on HTs in patients with non-small cell lung cancer receiving combined lung RT and programmed cell death (ligand) 1 immunotherapy. METHODS AND MATERIALS For standardization, all doses were reported as 2-Gy equivalents (EQD2). Mirroring publications before the immunotherapy era, TVB volumes referred to T1-T10, and specific dosimetric parameters (DmeanEQD2, V5EQD2-V60EQD2) were analyzed. Logistic regression estimated associations between grade ≥3 HTs (HT3+) and dosimetric/clinical parameters. Normal tissue complication probability (NTCP) models were constructed by logistic regression analysis modeling for HT3+. Receiver operating characteristic (ROC) analysis delineated TVB dosimetric thresholds, the stratification of which was able to evaluate post-RT absolute lymphocyte count and immunotherapy responses. Areas under the curve (AUCs) for NTCP models were corroborated by bootstrapping (optimism-corrected) methodology. RESULTS In 132 patients, there were 26 (19.7%) instances of HT3+. On multivariate analysis, DmeanEQD2 and V5EQD2 to V20EQD2 were associated with HT3+ (P < .05 for all). The NTCP models illustrated a 50% probability of HT3+ at a DmeanEQD2 = 39.8 Gy, V5EQD2 = 87.4%, V10EQD2 = 77.0%, and V20EQD2 = 68.4%. ROC analysis delineated optimal thresholds of HT3+ with DmeanEQD2 ± 30.2 Gy, V5EQD2 ± 69.1%, V10EQD2 ± 64.6%, and V20EQD2 ± 53.5%. Patients treated with values above those cutoffs had over double the risk of HT3+, with significant differences in post-RT absolute lymphocyte count and immunotherapy responses (P < .05 for all). AUCs for each individual parameter ranged from 0.743 to 0.798, and combining all 4 aforementioned cutoffs into a ROC curve resulted in a qualitatively higher AUC (0.836). CONCLUSIONS This hypothesis-generating work suggests that TVB dosimetry may equate with HT3+ in patients with non-small cell lung cancer undergoing combined lung RT/immunotherapy. Applying TVB dose constraints in this population could reduce HT3+ and avoid dampening of immunotherapy responses, but prospective validation is required.
Collapse
Affiliation(s)
- Jiachun Ma
- Department of Radiation Oncology and Shandong Provincial Key Laboratory of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China; Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, China.
| | - Yan Li
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Hongxuan Yu
- Department of Radiation Oncology and Shandong Provincial Key Laboratory of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China; Shandong University Cancer Center, Jinan, China
| | - Jingxin Zhang
- Department of Radiation Oncology and Shandong Provincial Key Laboratory of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China; Shandong University Cancer Center, Jinan, China
| | - Yanyan Zhang
- Department of Radiation Oncology and Shandong Provincial Key Laboratory of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Vivek Verma
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hao Chen
- Clinical Epidemiology Unit, Clinical Research Center of Shandong University, Qilu Hospital of Shandong University, Jinan, China
| | - Xiaohang Qin
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - Xiaoqian Zhai
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Shijie Shang
- Department of Radiation Oncology and Shandong Provincial Key Laboratory of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China; Shandong University Cancer Center, Jinan, China
| | - Jian Shangguan
- Department of Radiation Oncology and Shandong Provincial Key Laboratory of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Ruiyang Wang
- Department of Radiation Oncology and Shandong Provincial Key Laboratory of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Chen Tian
- Department of Radiation Oncology and Shandong Provincial Key Laboratory of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Fei Wang
- Department of Radiation Oncology and Shandong Provincial Key Laboratory of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Jinming Yu
- Department of Radiation Oncology and Shandong Provincial Key Laboratory of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China; Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Dawei Chen
- Department of Radiation Oncology and Shandong Provincial Key Laboratory of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China.
| |
Collapse
|
8
|
Li Q, Yang W, Liu H, Yao J, Wang Q, Lin D, Shi J. Analysis of related factors of CRA in lung cancer patients with different serum iron levels: A retrospective cohort study. Cancer Med 2024; 13:e7147. [PMID: 38562035 PMCID: PMC10985406 DOI: 10.1002/cam4.7147] [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: 10/10/2023] [Revised: 03/14/2024] [Accepted: 03/17/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Serum iron, an essential component of hemoglobin (Hb) synthesis in vivo, is a crucial parameter for evaluating the body's iron storage and metabolism capacity. Iron deficiency leads to reduced Hb synthesis in red blood cells and smaller red blood cell volume, ultimately resulting in iron-deficiency anemia. Although serum iron cannot independently evaluate iron storage or metabolism ability, it can reflect iron concentration in vivo and serve as a good predictor of iron-deficiency anemia. Therefore, exploring the influence of different serum iron levels on anemia and diagnosing and treating iron deficiency in the early stages is of great significance for patients with lung cancer. AIM This study aims to explore the related factors of cancer-related anemia (CRA) in lung cancer and construct a nomogram prediction model to evaluate the risk of CRA in patients with different serum iron levels. METHODS A single-center retrospective cohort study was conducted, including 1610 patients with lung cancer, of whom 1040 had CRA. The relationship between CRA and its influencing factors was analyzed using multiple linear regression models. Lung cancer patients were divided into two groups according to their serum iron levels: decreased serum iron and normal serum iron. Each group was randomly divided into a training cohort and a validation cohort at a ratio of 7:3. The influencing factors were screened by univariate and multivariate logistic regression analyses, and nomogram models were constructed. The area under the receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA) were used to evaluate the models. RESULTS CRA in lung cancer is mainly related to surgery, chemotherapy, Karnofsky Performance Status (KPS) score, serum iron, C-reactive protein (CRP), albumin, and total cholesterol (p < 0.05). CRA in lung cancer patients with decreased serum iron is primarily associated with albumin, age, and cancer staging, while CRA in lung cancer patients with normal serum iron is mainly related to CRP, albumin, total cholesterol, and cancer staging. The area under the ROC curve of the training cohort and validation cohort for the prediction model of lung cancer patients with decreased serum iron was 0.758 and 0.760, respectively. Similarly, the area under the ROC curve of the training cohort and validation cohort for the prediction model of lung cancer patients with normal serum iron was 0.715 and 0.730, respectively. The calibration curves of both prediction models were around the ideal 45° line, suggesting good discrimination and calibration. DCA showed that the nomograms had good clinical utility. CONCLUSION Both models have good reliability and validity and have significant clinical value. They can help doctors better assess the risk of developing CRA in lung cancer patients. CRP is a risk factor for CRA in lung cancer patients with normal serum iron but not in patients with decreased serum iron. Therefore, whether CRP and the inflammatory state represented by CRP will further aggravate the decrease in serum iron levels, thus contributing to anemia, warrants further study.
Collapse
Affiliation(s)
- Quan‐yao Li
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine Affiliated to Shanghai University of Traditional Chinese MedicineShanghaiChina
| | - Wen‐xiao Yang
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine Affiliated to Shanghai University of Traditional Chinese MedicineShanghaiChina
| | - Hui Liu
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine Affiliated to Shanghai University of Traditional Chinese MedicineShanghaiChina
| | - Jia‐lin Yao
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine Affiliated to Shanghai University of Traditional Chinese MedicineShanghaiChina
| | - Qin Wang
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine Affiliated to Shanghai University of Traditional Chinese MedicineShanghaiChina
| | - Dan Lin
- Yueyang Hospital of Integrated Traditional Chinese and Western Medicine Affiliated to Shanghai University of Traditional Chinese MedicineShanghaiChina
| | - Jun Shi
- Department of Traditional Chinese MedicineShanghai Fourth People's Hospital Affiliated to Tongji University of MedicineShanghaiChina
| |
Collapse
|
9
|
Perlow HK, Matsui JK, Ewing A, Cadieux C, Dibs K, Upadhyay R, Blakaj DM, Beyer SJ, Thomas EM, Grecula JC, Raval RR, Palmer JD. Volumetric Modulated Arc Therapy Craniospinal Irradiation Utilizing a Vertebral Body Sparing Approach: An Alternative Approach to Improve Access and Minimize Toxicity. Adv Radiat Oncol 2024; 9:101424. [PMID: 38379893 PMCID: PMC10877680 DOI: 10.1016/j.adro.2023.101424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 10/24/2023] [Indexed: 02/22/2024] Open
Abstract
Introduction Craniospinal irradiation (CSI) is indicated for adult patients diagnosed with leptomeningeal disease (LMD). Proton-based vertebral body sparing (VBS) CSI has been explored with pediatric patients to minimize hematologic toxicity; however, utilization of VBS in an adult population is limited. A recent phase II trial has shown efficacy of proton-based CSI to treat non-small cell lung and breast cancer with LMD. We hypothesize that VBS CSI using volumetric modulated arc therapy (VMAT) could also effectively reduce dose to vertebral bodies and surrounding organs at risk, minimizing toxicity for adult patients with LMD and comparing favorably to proton-based CSI. Methods and Materials Consecutive patients with LMD received VMAT VBS CSI, 30 Gy in 10 fractions, as a part of a prospective registry. Full VMAT arcs for the brain fields matched to 2 spine isocenters for the upper and lower spine were created using limited posterior arcs. To further decrease the vertebral body dose, an avoid entry and exit contour was created. Acute toxicity data were collected using Common Terminology Criteria for Adverse Events v5. Results Ten adult patients were treated in this cohort. One patient experienced grade 2 neutropenia with the remaining 9 experiencing grade 1 hematologic toxicity. Three patients experienced grade 2 gastrointestinal toxicity with the remaining 7 experiencing grade 1 nausea. No patient experienced grade 3+ toxicities in this cohort. One patient experienced a 5-day delay in systemic therapy initiation due to neutropenia; otherwise, all patients planned for systemic therapy started without delay. Conclusions In this study, VMAT VBS CSI led to acceptable toxicity compared with patients treated with proton CSI on a phase 2 clinical trial. Given its promising early results, future prospective evaluation of the technique is warranted.
Collapse
Affiliation(s)
- Haley K. Perlow
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | - Ashlee Ewing
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Catherine Cadieux
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Khaled Dibs
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Rituraj Upadhyay
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Dukagjin M. Blakaj
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sasha J. Beyer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Evan M. Thomas
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - John C. Grecula
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Raju R. Raval
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Joshua D. Palmer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| |
Collapse
|
10
|
Joseph A, Akinsete A, Adeneye S, Balogun O, Awofeso O, Oladipo A, Ajose A, Elhamamsi I, Merrell K, Ngwa W, Puthoff D, Shour AR, Onitilo A. Feasibility and Safety of Implementing Volumetric Arc Therapy (VMAT) for Pediatric Craniospinal Irradiation in a Low-Middle-Income Region: The Nigerian Experience. Adv Radiat Oncol 2024; 9:101325. [PMID: 38405304 PMCID: PMC10885594 DOI: 10.1016/j.adro.2023.101325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/19/2023] [Indexed: 02/27/2024] Open
Abstract
Purpose Volumetric modulated arc therapy (VMAT) is a relatively new treatment technique in sub-Saharan Africa. Although craniospinal irradiation (CSI) in the pediatric population has been practiced in Nigeria for many years, the use of VMAT to deliver this treatment is previously undocumented. We reviewed the first set of patients to undergo CSI at a cancer center in Nigeria, detailing the treatment technique, the progress experienced, dose statistics achieved, treatment toxicities, and cancer outcomes to date. Methods and Materials This was a prospective case series of 5 children with histologically diagnosed cancers requiring CSI whose parents consented to the study. They were recruited at evaluation and followed through the process of their therapy. Toxicity was monitored at weekly review appointments using the Common Terminology Criteria for Adverse Events version 5.0. Follow-up of the children will continue in the long-term effects clinic. Results Five patients with a median age of 6 were recruited. Diagnoses were intracranial germ cell tumor (n = 2), medulloblastoma (n = 1), pineoblastoma (n = 1), and ependymoma (n = 1). For all patients, a dose of 36.0 Gy in 1.8 Gy daily fractions was prescribed to the entire neuraxis. A subsequent boost of 18 Gy (n = 4) to 19.8 Gy (n = 1) in 10 daily fractions to the primary tumor bed (n = 2) and posterior fossa (n = 2) was delivered. Four patients had chemotherapy before, during, or after radiation therapy. No patient experienced grade 3 or greater toxicity. Conclusions Our results indicate great progress has been made in the delivery of CSI in Nigeria, demonstrating tolerable acute side effects using VMAT. This series suggests the feasibility of implementing VMAT technology in low- or middle-income countries. Additional follow-up will be needed to determine whether survival rates and chronic toxicity rates are similar to those reported in the literature.
Collapse
Affiliation(s)
- Adedayo Joseph
- NSIA-LUTH Cancer Center, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Adeseye Akinsete
- Department of Pediatrics, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Samuel Adeneye
- NSIA-LUTH Cancer Center, Lagos University Teaching Hospital, Lagos, Nigeria
- Department of Radiation Biology, Radiotherapy and Radiodiagnosis, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Onyinye Balogun
- Department of Radiation Oncology, Weill Cornell Medicine, New York, New York
| | - Opeyemi Awofeso
- Psychosocial Oncology & Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Aishat Oladipo
- NSIA-LUTH Cancer Center, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Azeezat Ajose
- NSIA-LUTH Cancer Center, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Ibrahim Elhamamsi
- NSIA-LUTH Cancer Center, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Kenneth Merrell
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Wilfred Ngwa
- Sidney Kimmel Comprehensive Cancer Center, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - David Puthoff
- Office of Research and Sponsored Programs, Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, Wisconsin
| | - Abdul R. Shour
- Cancer Care and Research Center, Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, Wisconsin
| | - Adedayo Onitilo
- Cancer Care and Research Center, Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, Wisconsin
- Department of Oncology, Cancer Care and Research Center, Marshfield Clinic Health System, Marshfield, Wisconsin
| |
Collapse
|
11
|
Hu L, Zhai A, Chen Q, Puri V, Chen CC, Yu F, Fox J, Wolden S, Yang J, Simone CB, Lin H. Proton pencil beam scanning craniospinal irradiation (CSI) with a single posterior brain beam: Dosimetry and efficiency. Med Dosim 2023; 49:25-29. [PMID: 38040549 PMCID: PMC11934868 DOI: 10.1016/j.meddos.2023.10.010] [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: 09/08/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 12/03/2023]
Abstract
This study explores the feasibility and potential dosimetric and time efficiency benefit of proton Pencil Beam Scanning (PBS) craniospinal irradiation with a single posterior-anterior (SPA) brain field. The SPA approach was compared to our current clinical protocol using Bilateral Posterior Oblique brain fields (BPO). Ten consecutive patients were simulated in the head-first supine position on a long BOS frame and scanned using 3 mm CT slice thickness. A customized thermoplastic mask immobilized the patient's head, neck, and shoulders. A vac-lock was used to secure the legs. PBS proton plans were robustly optimized with 3mm setup errors and 3.5% range uncertainties in the Eclipse V15.6 treatment planning system (n = 12 scenarios). In order to achieve a smooth gradient dose match at the junction area, at least 5 cm overlap region was maintained between the segments and 5 mm uncertainty along the cranial-cauda direction was applied to each segment independently as additional robust optimization scenarios. The brain doses were planned by SPA or BPO fields. All spine segments were planned with a single PA field. Dosimetric differences between the BPO and SPA approaches were compared, and the treatment efficiency was analyzed according to timestamps of beam delivery. Results: The maximum brain dose increases to 111.1 ± 2.1% for SPA vs. 109.0 ± 1.7% for BPO (p < 0.01). The dose homogeneity index (D5/D95) in brain CTV was comparable between techniques (1.037 ± 0.010 for SPA and 1.033 ± 0.008 for BPO). Lens received lower maximum doses by 2.88 ± 1.58 Gy (RBE) (left) and 2.23 ± 1.37 Gy (RBE) (right) in the SPA plans (p < 0.01). No significant cochlea dose change was observed. SPA reduced the treatment time by more than 4 minutes on average and ranged from 2 to 10 minutes, depending on the beam waiting and allocation time. SPA is dosimetrically comparable to BPO, with reduced lens doses at the cost of slightly higher dose inhomogeneity and hot spots. Implementation of SPA is feasible and can help to improve the treatment efficiency of PBS CSI treatment.
Collapse
Affiliation(s)
- Lei Hu
- New York Proton Center, New York, NY, USA; Department of Radiation Oncology, Inova Schar Cancer Institute, FairFax, VA, USA.
| | - Anna Zhai
- New York Proton Center, New York, NY, USA
| | - Qing Chen
- New York Proton Center, New York, NY, USA
| | | | - Chin-Cheng Chen
- New York Proton Center, New York, NY, USA; St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Francis Yu
- New York Proton Center, New York, NY, USA
| | - Jana Fox
- Department of Radiation Oncology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Suzanne Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jonathan Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Charles B Simone
- New York Proton Center, New York, NY, USA; Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Haibo Lin
- New York Proton Center, New York, NY, USA; Department of Radiation Oncology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA; Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| |
Collapse
|
12
|
Ziemann C, Cremers F, Motisi L, Albers D, MacPherson M, Rades D. Novel hybrid treatment planning approach for irradiation a pediatric craniospinal axis. Med Dosim 2023; 49:93-101. [PMID: 37798155 DOI: 10.1016/j.meddos.2023.08.011] [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: 03/22/2023] [Revised: 07/19/2023] [Accepted: 08/26/2023] [Indexed: 10/07/2023]
Abstract
This study presents a new treatment planning approach merging 3D-CRT and VMAT fields into a hybrid treatment plan (HybTP), in order to achieve an optimum dose coverage of the planning target volume (PTV) and protection of OAR. Craniospinal axis irradiation (CSI) treated with 3D conformal radiotherapy (3D-CRT) is associated with high doses to the heart and eye lenses but provides better sparing of lungs and kidneys compared to volumetric modulated arc therapy (VMAT). VMAT treatment spares eye lenses and the heart, but lungs and kidneys are not as effective as 3D-CRT. Thus, a combination of both techniques (HybTP) may be optimal in sparing all these organs at risk (OAR). The results of HybTP are compared with helical tomotherapy (HT), intensity modulated radio therapy (IMRT), VMAT, and 3D-CRT plans. Hybrid, HT, VMAT, IMRT, and 3D-CRT treatment plans for a male child (age 6 years) with medulloblastoma were created and compared. A total dose of 35.2 Gy (PTV) with a dose per fraction of 1.6 Gy was prescribed. The following dose acceptance criteria were defined: The plans were compared regarding dose homogeneity index (HI) and conformity index (CI), PTV coverage, (particularly at cribriform plate) and doses at OARs. Best conformity was achieved with HT (CI = 0.98) followed by VMAT (CI = 0.96), IMRT (CI = 0.91), HybTP (CI = 0.86), and 3D-CRT (CI = 0.83). The homogeneity index varied marginally. For both HT and IMRT the HI was 0.07, and for 3D-CRT, VMAT and HybTP the HI was between 0.13 and 0.15. The cribriform plate was sufficiently covered by HybTP, VMAT, and 3D-CRT. The dose acceptance criteria for OARs were met by HT and HybTP. VMAT did not meet the criteria for lung (Dmean = right 10.4 Gy/left 10.2 Gy), 3D-CRT did not meet the criteria for eye lenses (Dmax = right 32.3 Gy/left 33.1), and heart (V25≈44%) and IMRT did not meet the criteria for lung (Dmean = right 11.1 Gy/left 11.2 Gy) and eye lenses (Dmax = right 12.2 Gy/left 13.1). HybTP meets all defined acceptance criteria and has proved to be a reasonable alternative for CSI. With HybTP that combines VMAT at the brain and heart with 3D-CRT posterior spinal fields (to spare lungs and kidneys), both appropriate coverage of the PTV and sparing of OAR can be achieved.
Collapse
Affiliation(s)
- Christian Ziemann
- Department of Radiotherapy, University Medical Center Schleswig Holstein/Campus Luebeck, Luebeck, Germany.
| | - Florian Cremers
- Department of Radiotherapy, University Medical Center Schleswig Holstein/Campus Luebeck, Luebeck, Germany
| | - Laura Motisi
- Department of Radiation Oncology, University Hospital Zürich, Zürich, Suisse
| | - Dirk Albers
- Department of Radiotherapy and Radiation Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Miller MacPherson
- University of Ottawa, The Ottawa Hospital, Department of Radiology, Radiation Oncology, and Medical Physics, Ottawa, Canada
| | - Dirk Rades
- Department of Radiotherapy, University Medical Center Schleswig Holstein/Campus Luebeck, Luebeck, Germany
| |
Collapse
|
13
|
Chen J, Fu Z, Zhu Y. Comparison of Acute Hematological Adverse Reactions Induced by Craniospinal Irradiation With Intensity-Modulated Radiotherapy and Conventional Radiotherapy. Clin Med Insights Oncol 2023; 17:11795549231185474. [PMID: 37476536 PMCID: PMC10354821 DOI: 10.1177/11795549231185474] [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: 02/06/2023] [Accepted: 06/13/2023] [Indexed: 07/22/2023] Open
Abstract
Background With the update of equipment, the hospital base of this study began to adopt craniospinal irradiation (CSI) intensity-modulated radiotherapy (IMRT) in May 2018 to replace the traditional CSI conventional radiotherapy (CRT) technology. The purpose of this study was designed to compare the differences in acute hematological adverse reactions induced by CSI-IMRT and CSI-CRT. Methods The clinical data and hematological data of 102 patients with central nervous system malignant tumors who underwent CSI treatment at the 900th Hospital of Joint Logistics Support Force of PLA from January 2008 to August 2022 were analyzed retrospectively. The patients included 63 men and 39 women, aged 3 to 56 years old. On the basis of the radiotherapy technique used, the patients were divided into the CSI-IMRT group (38 cases) and CSI-CRT group (64 cases). Acute hematological adverse reactions during radiotherapy were compared between the two groups according to the Common Terminology Criteria for Adverse Events version 4.0. The Mann-Whitney U test was used to compare the measurement data, and the χ2 test was used to compare the count data. Results No significant difference was found between the CSI-IMRT group and the CSI-CRT group in terms of sex, histopathological type, tumor location, spinal cord invasion, surgery, and the Eastern Cooperative Oncology Group score (χ2 = 0.004 to 6.213; all P > .05). No significant difference was found in onset time of myelosuppression (11 days (interquartile range [IQR]: 7 to 14; minimum [min] to maximum [max]: 0 to 26) vs 8 days (IQR: 7 to 15; min to max: 3 to 29)) and nadir time of myelosuppression (21 days (IQR: 18 to 25; min to max: 12 to 35) vs 22 days (IQR: 15 to 25; min to max: 12 to 36)) between the CSI-IMRT group and the CSI-CRT group (Z = -0.856, -0.248; all P > .05). There were no significant differences in the incidence of decreased white blood cell counts (WBC), platelet counts, and hemoglobin concentration between the CSI-IMRT group and the CSI-CRT group, 86.8% (33/38) vs 78.1% (50/64), 57.9% (22/38) vs 42.2% (27/64), 57.9% (22/38) vs 53.1% (34/64); χ2 = 1.195, 2.357, 0.219; all P > .05. There were no significant differences in the incidence of decreased WBC, platelet counts, and hemoglobin concentration (severe myelosuppression) in grades III and IV, 23.7% (9/38) vs 21.9% (14/64), 7.9% (3/38) vs 3.1% (2/64), 5.3% (2/38) vs 9.4% (6/64); χ2 = 0.045, 1.164, 0.558; all P > .05. Conclusions There was no significant difference in the incidence of myelosuppression and severe myelosuppression (grade III or above) induced by CSI-IMRT and CSI-CRT. CSI-IMRT is worthy of further clinical application.
Collapse
Affiliation(s)
| | | | - Yunyun Zhu
- Zhu Yunyun, Department of Oncology Radiotherapy, The 900th Hospital of Joint Logistics Support Force of PLA, Fuzhou General Hospital, Clinical Medical College, Fujian Medical University, Fuzhou General Teaching Hospital and Fujian University of Traditional Chinese Medicine, Fuzhou 350025, China.
| |
Collapse
|
14
|
Vázquez M, Bachmann N, Pica A, Bolsi A, De Angelis C, Lomax AJ, Weber DC. Early outcome after craniospinal irradiation with pencil beam scanning proton therapy for children, adolescents and young adults with brain tumors. Pediatr Blood Cancer 2023; 70:e30087. [PMID: 36377685 DOI: 10.1002/pbc.30087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/21/2022] [Accepted: 10/12/2022] [Indexed: 11/16/2022]
Abstract
Central nervous system (CNS) tumors are the most common solid malignancies in children and adolescents and young adults (C-AYAs). Craniospinal irradiation (CSI) is an essential treatment component for some malignancies, but it can also lead to important toxicity. Pencil beam scanning proton therapy (PBSPT) allows for a minimization of dose delivered to organs at risk and, thus, potentially reduced acute and late toxicity. This study aims to report the clinical outcomes and toxicity rates after CSI for C-AYAs treated with PBSPT. Seventy-one C-AYAs (median age: 7.4 years) with CNS tumors were treated with CSI between 2004 and 2021. Medulloblastoma (n = 42: 59%) and ependymoma (n = 8; 11%) were the most common histologies. Median prescribed total PBSPT dose was 54 GyRBE (range: 18-60.4), and median prescribed craniospinal dose was 24 GyRBE (range: 18-36.8). Acute and late toxicities were coded according to Common Terminology Criteria for Adverse Events. After a median follow-up of 24.5 months, the estimated 2-year local control, distant control, and overall survival were 86.3%, 80.5%, and 84.7%, respectively. Late grade ≥3 toxicity-free rate was 92.6% at 2 years. Recurrent and metastatic tumors were associated with worse outcome. In conclusion, excellent tumor control with low toxicity rates was observed in C-AYAs with brain tumors treated with CSI using PBSPT.
Collapse
Affiliation(s)
- Miriam Vázquez
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Villigen, Switzerland
| | - Nicolas Bachmann
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Villigen, Switzerland.,Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alessia Pica
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Villigen, Switzerland
| | - Alessandra Bolsi
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Villigen, Switzerland
| | - Claudio De Angelis
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Villigen, Switzerland
| | - Antony J Lomax
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Villigen, Switzerland
| | - Damien C Weber
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Villigen, Switzerland.,Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Radiation Oncology, University Hospital of Zürich, Zürich, Switzerland
| |
Collapse
|
15
|
Ruggi A, Melchionda F, Sardi I, Pavone R, Meneghello L, Kitanovski L, Zaletel LZ, Farace P, Zucchelli M, Scagnet M, Toni F, Righetto R, Cianchetti M, Prete A, Greto D, Cammelli S, Morganti AG, Rombi B. Toxicity and Clinical Results after Proton Therapy for Pediatric Medulloblastoma: A Multi-Centric Retrospective Study. Cancers (Basel) 2022; 14:2747. [PMID: 35681727 PMCID: PMC9179586 DOI: 10.3390/cancers14112747] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 05/28/2022] [Accepted: 05/30/2022] [Indexed: 02/04/2023] Open
Abstract
Medulloblastoma is the most common malignant brain tumor in children. Even if current treatment dramatically improves the prognosis, survivors often develop long-term treatment-related sequelae. The current radiotherapy standard for medulloblastoma is craniospinal irradiation with a boost to the primary tumor site and to any metastatic sites. Proton therapy (PT) has similar efficacy compared to traditional photon-based radiotherapy but might achieve lower toxicity rates. We report on our multi-centric experience with 43 children with medulloblastoma (median age at diagnosis 8.7 years, IQR 6.6, M/F 23/20; 26 high-risk, 14 standard-risk, 3 ex-infant), who received active scanning PT between 2015 and 2021, with a focus on PT-related acute-subacute toxicity, as well as some preliminary data on late toxicity. Most acute toxicities were mild and manageable with supportive therapy. Hematological toxicity was limited, even among HR patients who underwent hematopoietic stem-cell transplantation before PT. Preliminary data on late sequelae were also encouraging, although a longer follow-up is needed.
Collapse
Affiliation(s)
- Alessandro Ruggi
- Specialty School of Paediatrics-Alma Mater Studiorum, Università di Bologna, 40138 Bologna, Italy;
| | - Fraia Melchionda
- Pediatric Onco-Hematology, IRCCS Sant’Orsola SSD, University Hospital of Bologna, 40138 Bologna, Italy; (F.M.); (A.P.)
| | - Iacopo Sardi
- Neuro-Oncology Unit, Department of Pediatric Oncology, Meyer Children’s Hospital, 50139 Florence, Italy; (I.S.); (R.P.)
| | - Rossana Pavone
- Neuro-Oncology Unit, Department of Pediatric Oncology, Meyer Children’s Hospital, 50139 Florence, Italy; (I.S.); (R.P.)
| | - Linda Meneghello
- Pediatric Onco-Hematology Service, Pediatric Unit, Santa Chiara Hospital, 38123 Trento, Italy;
| | - Lidija Kitanovski
- Department of Oncology and Haematology, University Children’s Hospital, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia;
| | | | - Paolo Farace
- Proton Therapy Unit, Santa Chiara Hospital, Azienda Provinciale per i Servizi Sanitari (APSS), 38123 Trento, Italy; (P.F.); (R.R.); (M.C.)
| | - Mino Zucchelli
- Pediatric Neurosurgery, Institute of Neurological Science, IRCCS Bellaria Hospital, 40139 Bologna, Italy;
| | - Mirko Scagnet
- Department of Neurosurgery, Meyer Children’s Hospital, 50139 Florence, Italy;
| | - Francesco Toni
- Neuroradiology Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy;
| | - Roberto Righetto
- Proton Therapy Unit, Santa Chiara Hospital, Azienda Provinciale per i Servizi Sanitari (APSS), 38123 Trento, Italy; (P.F.); (R.R.); (M.C.)
| | - Marco Cianchetti
- Proton Therapy Unit, Santa Chiara Hospital, Azienda Provinciale per i Servizi Sanitari (APSS), 38123 Trento, Italy; (P.F.); (R.R.); (M.C.)
| | - Arcangelo Prete
- Pediatric Onco-Hematology, IRCCS Sant’Orsola SSD, University Hospital of Bologna, 40138 Bologna, Italy; (F.M.); (A.P.)
| | - Daniela Greto
- Azienda Ospedaliero-Universitaria Careggi, 50134 Florence, Italy;
| | - Silvia Cammelli
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (S.C.); (A.G.M.)
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy
| | - Alessio Giuseppe Morganti
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (S.C.); (A.G.M.)
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy
| | - Barbara Rombi
- Proton Therapy Unit, Santa Chiara Hospital, Azienda Provinciale per i Servizi Sanitari (APSS), 38123 Trento, Italy; (P.F.); (R.R.); (M.C.)
| |
Collapse
|
16
|
Chou B, Hopper A, Elster J, Crawford JR, McConnell K, Chang A, Mundt AJ, MacEwan I. Volumetric de-escalation and improved acute toxicity with proton craniospinal irradiation using a vertebral body-sparing technique. Pediatr Blood Cancer 2022; 69:e29489. [PMID: 34866330 DOI: 10.1002/pbc.29489] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 08/30/2021] [Accepted: 10/26/2021] [Indexed: 11/06/2022]
Abstract
PURPOSE In growing children, craniospinal irradiation (CSI) has historically treated the entire vertebral body (VB) to avoid potential long-term spinal abnormalities. Vertebral body-sparing proton craniospinal irradiation (VBSpCSI) is a technique that spares the majority of the VB from significant irradiation, and long-term safety outcomes have been reported previously. This retrospective study reviews the acute toxicity profile of children treated with VBSpCSI in a cohort comparison with photon-based craniospinal radiotherapy (3DCRT). METHODS Thirty-eight pediatric CSI patients treated between 2008 and 2018 were retrospectively evaluated for treatment-related toxicity. Acute toxicity outcomes and acute hematologic profiles were compared according to treatment modality, either VBSpCSI or 3DCRT. Statistical analysis was performed using Fisher's exact test for toxicity. RESULTS Twenty-five patients received VBSpCSI and 13 patients received photon CSI. Mean patient age at treatment was 7.5 years (range 2-16). The cohorts were well matched with respect to gender, age, and CSI dose. Patients receiving VBSpCSI had lower rates of grade 2+ gastrointestinal (GI) toxicity (24% vs. 76.5%, p = .005), grade 2+ nausea (24% vs. 61.5%, p = .035), and any-grade esophagitis (0% vs. 38%, p = .0026). Patients treated with VBSpCSI had lower red blood cell transfusion rates (21.7% vs. 60%, p = .049) and grade 4+ lymphopenia (33.3% vs. 77.8%, p = .046). CONCLUSIONS VBSpCSI in children is a volumetric de-escalation from traditional volumes, which irradiate the entire VB to full or intermediate doses. In our study, VBSpCSI was associated with lower rates of acute GI and hematologic toxicities. Long-term growth outcomes and disease control outcomes are needed for this technique.
Collapse
Affiliation(s)
- Brian Chou
- Department of Radiation Oncology, Loyola University Medical Center, Maywood, Illinois, USA
| | - Austin Hopper
- Department of Radiation Medicine and Applied Sciences, University of California - San Diego, San Diego, California, USA
| | - Jennifer Elster
- Department of Pediatric Hematology and Oncology, University of California - San Diego, San Diego, California, USA
| | - John R Crawford
- Department of Neurosciences and Pediatrics, University of California - San Diego and Rady Children's Hospital, San Diego, California, USA
| | - Kristen McConnell
- Department of Radiation Medicine and Applied Sciences, University of California - San Diego, San Diego, California, USA
| | - Andrew Chang
- California Protons Cancer Therapy Center, San Diego, California, USA
| | - Arno J Mundt
- Department of Radiation Medicine and Applied Sciences, University of California - San Diego, San Diego, California, USA
| | - Iain MacEwan
- Department of Radiation Medicine and Applied Sciences, University of California - San Diego, San Diego, California, USA
| |
Collapse
|
17
|
Acute Hematological Toxicity during Cranio-Spinal Proton Therapy in Pediatric Brain Embryonal Tumors. Cancers (Basel) 2022; 14:cancers14071653. [PMID: 35406425 PMCID: PMC8997073 DOI: 10.3390/cancers14071653] [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: 02/06/2022] [Revised: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Embryonal tumors represent a heterogeneous entity of brain tumors that need a multidisciplinary treatment including cranio-spinal irradiation (CSI), with a known impact on the acute toxicity. Proton therapy (PT) boasts a reduction in acute hematological toxicity. METHODS We retrospectively examined 20 pediatric patients affected by high-risk medulloblastoma and other rare embryonal brain tumors subjected to CSI with PT from September 2016 to April 2020. Before CSI, all patients received induction chemotherapy, and three patients additionally received two high-dose courses with thiotepa, followed by an autologous haemopoietic stem cell transplantation. We recorded the total white blood cell count, absolute neutrophil count, platelets, and hemoglobin levels for all patients during PT. RESULTS Leucocytes and neutrophils decreased directly after the beginning of treatment, reaching a complete recovery at the end of treatment. Hemoglobin values remained constant over the treatment course. The median platelet value decreased until reaching a plateau around halfway through therapy, followed by a slow increase. No cases of febrile neutropenia or severe infections were reported. No treatment discontinuation due to hematological toxicity was necessary. CONCLUSIONS CSI with PT was proven to be safe in this setting of pediatric patients. Our study showed that despite all patients having undergone chemotherapy prior to irradiation, no serious hematological toxicity was reported at the end of the treatment with PT, and, therefore, no treatment was discontinued or delayed.
Collapse
|
18
|
Uemura S, Demizu Y, Hasegawa D, Fujikawa T, Inoue S, Nishimura A, Tojyo R, Nakamura S, Kozaki A, Saito A, Kishimoto K, Ishida T, Mori T, Koyama J, Kawamura A, Akasaka Y, Yoshida M, Fukumitsu N, Soejima T, Kosaka Y. The comparison of acute toxicities associated with craniospinal irradiation between photon beam therapy and proton beam therapy in children with brain tumors. Cancer Med 2022; 11:1502-1510. [PMID: 35137555 PMCID: PMC8921900 DOI: 10.1002/cam4.4553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/24/2021] [Accepted: 11/27/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction This study aimed to evaluate acute toxicities associated with irradiation between the X‐CSI (photon beam craniospinal irradiation) and P‐CSI (proton beam craniospinal irradiation) groups in children with brain tumors. Methods Sixty‐two consecutive patients who received initial craniospinal irradiation (CSI) for brain tumors in our center between January 1, 2011 and May 31, 2021, were included in the study. Acute toxicities were retrospectively evaluated during CSI using Common Terminology Criteria for Adverse Events version 5.0. Maximum grades of fatigue, headache, insomnia, nausea, vomiting, dermatitis, constipation, abdominal pain, oropharyngeal mucositis, and hematological toxicities were evaluated. Results Thirty‐six patients received X‐CSI, and 26 patients received P‐CSI. The median dose of CSI was 18.0 Gy in the X‐CSI group and 23.4 Gy (relative biological effectiveness) in the P‐CSI group (p < 0.001). The P‐CSI group had a lower incidence of more than grade 2 nausea (11.5% vs. 69.4%, p = 0.008) and vomiting (7.7% vs. 38.8%, p < 0.001), compared with the X‐CSI group. Multivariate logistic regression analysis with adjustments for potential confounding factors of doses of CSI showed that proton radiation therapy was associated with a marked reduced risk of more than grade 2 nausea and vomiting during CSI (adjusted odds ratio, 0.050; 95% confidential interval, 0.011–0.24; p < 0.001). Conclusion The present study suggests that P‐CSI reduces the acute gastrointestinal toxicities associated with irradiation.
Collapse
Affiliation(s)
- Suguru Uemura
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Yusuke Demizu
- Department of Radiation Oncology, Kobe Proton Center, Kobe, Japan
| | - Daiichiro Hasegawa
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Tomoko Fujikawa
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Shotaro Inoue
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Akihiro Nishimura
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Ryunosuke Tojyo
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Sayaka Nakamura
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Aiko Kozaki
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Atsuro Saito
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Kenji Kishimoto
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Toshiaki Ishida
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Takeshi Mori
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| | - Jyunji Koyama
- Department of Neurosurgery, Kobe Children's Hospital, Kobe, Japan
| | | | | | - Makiko Yoshida
- Department of Pathology, Kobe Children's Hospital, Kobe, Japan
| | | | | | - Yoshiyuki Kosaka
- Department of Hematology and Oncology, Kobe Children's Hospital, Kobe, Japan
| |
Collapse
|
19
|
Mell LK. Trials and tribulations of bone marrow sparing radiotherapy for cervical cancer. Radiother Oncol 2021; 167:78-80. [PMID: 34896460 DOI: 10.1016/j.radonc.2021.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 11/22/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Loren K Mell
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, United States.
| |
Collapse
|
20
|
Liu KX, Ioakeim-Ioannidou M, Susko MS, Rao AD, Yeap BY, Snijders AM, Ladra MM, Vogel J, Zaslowe-Dude C, Marcus KJ, Yock TI, Grassberger C, Braunstein SE, Haas-Kogan DA, Terezakis SA, MacDonald SM. A Multi-institutional Comparative Analysis of Proton and Photon Therapy-Induced Hematologic Toxicity in Patients With Medulloblastoma. Int J Radiat Oncol Biol Phys 2020; 109:726-735. [PMID: 33243479 DOI: 10.1016/j.ijrobp.2020.09.049] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 09/11/2020] [Accepted: 09/22/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE This multi-institutional retrospective study sought to examine the hematologic effects of craniospinal irradiation (CSI) in pediatric patients with medulloblastoma using proton or photon therapy. METHODS AND MATERIALS Clinical and treatment characteristics were recorded for 97 pediatric patients with medulloblastoma who received CSI without concurrent chemotherapy or with concurrent single-agent vincristine from 2000 to 2017. Groups of 60 and 37 patients underwent treatment with proton-based and photon-based therapy, respectively. Overall survival was determined by Kaplan-Meier curves with log-rank test. Comparisons of blood counts at each timepoint were conducted using multiple t tests with Bonferroni corrections. Univariate and multivariate analyses of time to grade ≥3 hematologic toxicity were performed with Cox regression analyses. RESULTS Median age of patients receiving proton and photon CSI was 7.5 years (range, 3.5-22.7 years) and 9.9 years (range, 3.6-19.5 years), respectively. Most patients had a diagnosis of standard risk medulloblastoma, with 86.7% and 89.2% for the proton and photon cohorts, respectively. Median total dose to involved field or whole posterior fossa was 54.0 Gy/Gy relative biological effectiveness (RBE) and median CSI dose was 23.4 Gy/Gy(RBE) (range, 18-36 Gy/Gy[RBE]) for both cohorts. Counts were significantly higher in the proton cohort compared with the photon cohort in weeks 3 to 6 of radiation therapy (RT). Although white blood cell counts did not differ between the 2 cohorts, patients receiving proton RT had significantly higher lymphocyte counts throughout the RT course. Similar results were observed when excluding patients who received vertebral body sparing proton RT or limiting to those receiving 23.4 Gy. Only photon therapy was associated with decreased time to grade ≥3 hematologic toxicity on univariate and multivariable analyses. No difference in overall survival was observed, and lymphopenia did not predict survival. CONCLUSIONS Patients who receive CSI using proton therapy experience significantly decreased hematologic toxicity compared with those receiving photon therapy.
Collapse
Affiliation(s)
- Kevin X Liu
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Myrsini Ioakeim-Ioannidou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Radiation and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Matthew S Susko
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Avani D Rao
- Department of Radiation and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Beow Y Yeap
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Antoine M Snijders
- Biological Systems and Engineering Division, Lawrence Berkeley National Laboratory, Berkeley, California
| | - Matthew M Ladra
- Department of Radiation and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jennifer Vogel
- Department of Radiation and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Cierra Zaslowe-Dude
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Karen J Marcus
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Torunn I Yock
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Clemens Grassberger
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Daphne A Haas-Kogan
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stephanie A Terezakis
- Department of Radiation and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center Johns Hopkins School of Medicine, Baltimore, Maryland; Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|
21
|
Madan R, Kumar N, Gupta A, Gupta K, Salunke P, Khosla D, Yadav BS, Kapoor R. Effect of prophylactic granulocyte-colony stimulating factor (G-CSF) on acute hematological toxicity in medulloblastoma patients during craniospinal irradiation (CSI). Clin Neurol Neurosurg 2020; 196:105975. [PMID: 32505868 DOI: 10.1016/j.clineuro.2020.105975] [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: 01/29/2020] [Revised: 02/24/2020] [Accepted: 05/26/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Haematological toxicity and treatment breaks are common during cranio-spinal irradiation (CSI) due to irradiation of large volume of bone marrow. We conducted this study to see the effect of prophylactic granulocyte colony stimulating factor (GCSF) in reducing treatment breaks. PATIENTS AND METHODS The study was conducted over a period of 15 months from August 2017 to November 2018. Histopathologically proven Medulloblastoma patients received prophylactic GCSF during CSI. Acute hematological toxicities and treatment breaks were noted and effect of age and pretreatment blood counts were analyzed by SPSS (Statistical Package for Social Sciences) version 23. RESULTS A total of 28 patients were included in the study. During CSI, hematological toxicity leading to treatment breaks was observed in 11 (39.3 %) patients, of which grade 3 and 2 toxicities were seen in ten and one patients respectively. Younger age (<10 years) at diagnosis was significantly associated with the development of hematological toxicity (p = 0.028, Chi-Square). No correlation was found with pre-treatment blood counts. CONCLUSION Prophylactic use of GCSF may be effective in preventing radiation induced hematological toxicity and treatment breaks.
Collapse
Affiliation(s)
- R Madan
- Department of Radiotherapy and Oncology, PGIMER, Chandigarh, India
| | - N Kumar
- Department of Radiotherapy and Oncology, PGIMER, Chandigarh, India.
| | - A Gupta
- Department of Radiotherapy and Oncology, PGIMER, Chandigarh, India
| | - K Gupta
- Department of Pathology, PGIMER, Chandigarh, India
| | - P Salunke
- Department of Neurosurgery, PGIMER, Chandigarh, India
| | - D Khosla
- Department of Radiotherapy and Oncology, PGIMER, Chandigarh, India
| | - B S Yadav
- Department of Radiotherapy and Oncology, PGIMER, Chandigarh, India
| | - R Kapoor
- Department of Radiotherapy and Oncology, PGIMER, Chandigarh, India
| |
Collapse
|
22
|
Wong KK, Ragab O, Tran HN, Pham A, All S, Waxer J, Olch AJ. Acute toxicity of craniospinal irradiation with volumetric-modulated arc therapy in children with solid tumors. Pediatr Blood Cancer 2018; 65:e27050. [PMID: 29630782 DOI: 10.1002/pbc.27050] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 01/30/2018] [Accepted: 02/14/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Craniospinal irradiation (CSI) is an important part of curative radiation therapy (RT) for many types of pediatric brain or solid tumors. After conventional CSI, long term survivors may experience sequelae due to unintended dose to normal tissue. Volumetric modulated arc therapy (VMAT) CSI reduces off-target doses at the cost of greater complexity and error risk, and we describe our initial experience in a group of pediatric patients with solid tumors presenting with disseminated or recurrent disease. PROCEDURE Pediatric patients with brain tumors were identified at Children's Hospital Los Angeles from 2013 to 2015. Clinical characteristics, acute toxicity, and radiotherapy data were abstracted from their medical records. We identified 19 patients who received VMAT CSI. Quality assurance was performed with a cylindrical detector array and ion chamber measurements at the arc junctions. RESULTS Patients had medulloblastoma or supratentorial primitive neuro-ectodermal tumor (n = 14, 11 high risk), germ cell tumors (two), relapsed neuroblastoma (two), and atypical teratoid/rhabdoid tumor (one). The most common acute toxicity was hematologic, including leukopenia (11% grade [Gr] 2, 26% Gr 3, and 63% Gr 4), anemia (89% Gr 2), and thrombocytopenia (16% Gr 1-2, 26% Gr 3, and 37% Gr 4). Despite leukopenia, we encountered only two Gr 3 infections (urinary tract and lung). The majority required blood products (89% red blood cells and 68% platelets). Weight loss was also common (47% Gr 1 and 26% Gr 2). CONCLUSIONS VMAT CSI, along with chemotherapy and anesthesia, is feasible with supportive care. Daily image-guided RT improves accuracy and reduces the risk of spinal cord overdose without increasing treatment time. Further research is needed to determine whether reducing doses to organs, such as thyroid, heart, or hippocampus, offsets the risk of increased volume of low-dose irradiation.
Collapse
Affiliation(s)
- Kenneth K Wong
- Department of Radiation Oncology, Keck School of Medicine of the University of Southern California, Los Angeles, California.,Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, California
| | - Omar Ragab
- Department of Radiation Oncology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Hung N Tran
- Pediatric Neuro-Oncology, Department of Pediatrics, Kaiser Permanente, Los Angeles, California
| | - Anthony Pham
- Department of Radiation Oncology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Sean All
- College of Medicine, University of Central Florida, Orlando, Florida
| | - Jonathan Waxer
- School of Medicine, Tulane University, New Orleans, Louisiana
| | - Arthur J Olch
- Department of Radiation Oncology, Keck School of Medicine of the University of Southern California, Los Angeles, California.,Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, California
| |
Collapse
|
23
|
Kauffmann G, Buerki RA, Lukas RV, Gondi V, Chmura SJ. Case Report of Bone Marrow-Sparing Proton Therapy Craniospinal Irradiation for Central Nervous System Myelomatosis. Cureus 2017; 9:e1885. [PMID: 29387514 PMCID: PMC5786350 DOI: 10.7759/cureus.1885] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Central nervous system (CNS) involvement is rare but it is an increasingly recognized complication of the multiple myeloma. The craniospinal radiotherapy is a standard treatment option, however, it may be challenging to deliver due to hematologic toxicity in the patients with multiple prior systemic therapies. We report a case of CNS myelomatosis in a patient with prior stem cell transplant multiple systemic therapies treated with bone marrow-sparing proton therapy craniospinal irradiation, with the dramatic clinical response and minimal hematologic toxicity.
Collapse
Affiliation(s)
- Greg Kauffmann
- Department of Radiation and Cellular Oncology, University of Chicago
| | | | - Rimas V Lukas
- Neuro-Oncology, Northwestern University, Feinberg School of Medicine; Chicago, Illinois
| | - Vinai Gondi
- Radiation Oncology, Northwestern Medicine Chicago Proton Center, Warrenville, Il
| | - Steven J Chmura
- Department of Radiation and Cellular Oncology, University of Chicago
| |
Collapse
|
24
|
Barney CL, Scoville N, Allan E, Ayan A, DiCostanzo D, Haglund KE, Grecula J, Williams T, Xu-Welliver M, Otterson GA, Bazan JG. Radiation Dose to the Thoracic Vertebral Bodies Is Associated With Acute Hematologic Toxicities in Patients Receiving Concurrent Chemoradiation for Lung Cancer: Results of a Single-Center Retrospective Analysis. Int J Radiat Oncol Biol Phys 2017; 100:748-755. [PMID: 29413286 DOI: 10.1016/j.ijrobp.2017.11.025] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 11/04/2017] [Accepted: 11/16/2017] [Indexed: 12/13/2022]
Abstract
PURPOSE To test the hypothesis that increasing radiation therapy (RT) dose to the thoracic vertebral bodies (TVBs) contributes to the development of hematologic toxicities (HTs) in patients with lung cancer. METHODS AND MATERIALS Cases of non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) treated with definitive chemoradiation with concurrent platinum-based doublet chemotherapy at our institution from 2007 to 2016 were identified. Mean TVB dose and the volume of TVBs receiving at least 5 to 60 Gy (V5-V60) were retrospectively recorded. Logistic regression was used to test associations between grade ≥3 HT (HT3+) and dosimetric/clinical parameters. Normal tissue complication probability was evaluated using the Lyman-Kutcher-Burman (LKB) model for HT3+, and receiver operating characteristics analysis was used to determine dosimetric cut-points. RESULTS We identified 201 patients, the majority having NSCLC (n=162, 81%) and stage III to IV disease (n=179, 89%). All patients received either cisplatin/etoposide (n=107, 53%) or carboplatin/paclitaxel (n=94, 47%). Median RT dose was 60 Gy (range, 60-70 Gy). The rate of HT3+ was 49% (n=99). Increasing mean TVB dose (per Gy) was associated with higher odds of developing HT3+ (odds ratio 1.041, 95% confidence interval 1.004-1.080, P=.032), as were increasing TVB V5 to V20. These dosimetric correlates to HT3+ persisted on multivariate analysis. Constrained optimization of the LKB model for HT3+ yielded the parameters: n=1, m=1.79, and TD50=21.4 Gy. Optimal cut-points identified were V5=65%, V10=60%, V20=50%, and mean dose=23.5 Gy. Patients with values above these cut-points had an approximately 2-fold increased risk of HT3+. CONCLUSIONS We found that mean TVB dose and low-dose parameters (V5-V20) were associated with HT3+ in chemoradiation for lung cancer. Per the LKB model, bone marrow behaves like a parallel organ (n=1), implying that mean TVB dose is a useful predictor for toxicity. These data suggest that efforts to spare dose to the TVBs may reduce rates of severe HT.
Collapse
Affiliation(s)
- Christian L Barney
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio
| | - Nicholas Scoville
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio
| | - Eric Allan
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio
| | - Ahmet Ayan
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio
| | - Dominic DiCostanzo
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio
| | - Karl E Haglund
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio
| | - John Grecula
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio
| | - Terence Williams
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio
| | - Meng Xu-Welliver
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio
| | - Gregory A Otterson
- Division of Medical Oncology, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio
| | - Jose G Bazan
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio.
| |
Collapse
|
25
|
Kumar N, Miriyala R, Thakur P, Madan R, Salunke P, Yadav B, Gupta A. Impact of acute hematological toxicity on treatment interruptions during cranio-spinal irradiation in medulloblastoma: a tertiary care institute experience. J Neurooncol 2017; 134:309-315. [PMID: 28577033 DOI: 10.1007/s11060-017-2524-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 05/29/2017] [Indexed: 11/26/2022]
Abstract
To analyze treatment interruptions due to acute hematological toxicity in patients of medulloblastoma receiving cranio-spinal irradiation (CSI). Prospectively collected data from case records of 52 patients of medulloblastoma treated between 2011 and 2014 was evaluated. Blood counts were monitored twice a week during CSI. Spinal irradiation was interrupted for patients with ≥grade 2 hematological toxicity and resumed after recovery to grade 1 level (TLC >3000; platelet count >75,000). Treatment interruptions and hematological toxicity were analyzed. Median age was 11 years. All patients received adjuvant CSI of 36 Gy, followed by boost of 18 Gy to posterior fossa, at 1.8 Gy per fraction. Concurrent chemotherapy was not given. Adjuvant chemotherapy was given after CSI for high risk patients. Spinal fields were interrupted in 73.1% of patients. Cause of first interruption was leucopenia in 92.1%, thrombocytopenia in 2.6%, and both in 5.3%. Median number of fractions at first interruption was 8, with 25% of interruptions in first week. Median duration for hematological recovery after nadir was 5 days for leucopenia and 3 days for thrombocytopenia. Half of the patients had at least 2 interruptions, and 19% subsequently developed grade 3 toxicity. On multivariate analysis, significant correlation with duration of delay was observed for pre-treatment haemoglobin, number of fractions at first interruption, grade and duration of recovery of leucopenia. Acute hematological toxicity with CSI is frequently under-reported. Patients with low pre-treatment hemoglobin, early onset leucopenia, profound leucopenia and prolonged recovery times are at a higher risk of having protracted courses of irradiation. Frequent monitoring of blood counts and timely interruption of spinal fields of irradiation at grade 2 level of hematological toxicity minimizes the risk of grade 3 and grade 4 toxicity, while reducing the interruptions in irradiation of the gross tumour bed.
Collapse
Affiliation(s)
- Narendra Kumar
- Department of Radiotherapy & Oncology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - Raviteja Miriyala
- Department of Radiotherapy & Oncology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Pragyat Thakur
- Department of Radiotherapy & Oncology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Renu Madan
- Department of Radiotherapy & Oncology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Pravin Salunke
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Budhi Yadav
- Department of Radiotherapy & Oncology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ankita Gupta
- Department of Radiotherapy & Oncology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| |
Collapse
|
26
|
Cox MC, Kusters JM, Gidding CE, Schieving JH, van Lindert EJ, Kaanders JH, Janssens GO. Acute toxicity profile of craniospinal irradiation with intensity-modulated radiation therapy in children with medulloblastoma: A prospective analysis. Radiat Oncol 2015; 10:241. [PMID: 26597178 PMCID: PMC4657242 DOI: 10.1186/s13014-015-0547-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 11/17/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To report on the acute toxicity in children with medulloblastoma undergoing intensity-modulated radiation therapy (IMRT) with daily intrafractionally modulated junctions. METHODS Newly diagnosed patients, aged 3-21, with standard-risk (SR) or high-risk (HR) medulloblastoma were eligible. A dose of 23.4 or 36.0 Gy in daily fractions of 1.8 Gy was prescribed to the craniospinal axis, followed by a boost to the primary tumor bed (54 or 55.8 Gy) and metastases (39.6-55.8 Gy), when indicated. Weekly, an intravenous bolus of vincristine was combined for patients with SR medulloblastoma and patients participating in the COG-ACNS-0332 study. Common toxicity criteria (CTC, version 2.0) focusing on skin, alopecia, voice changes, conjunctivitis, anorexia, dysphagia, gastro-intestinal symptoms, headache, fatigue and hematological changes were scored weekly during radiotherapy. RESULTS From 2010 to 2014, data from 15 consecutive patients (SR, n = 7; HR, n = 8) were collected. Within 72 h from onset of treatment, vomiting (66 %) and headache (46 %) occurred. During week 3 of treatment, a peak incidence in constipation (33 %) and abdominal pain/cramping (40 %) was observed, but only in the subgroup of patients (n = 9) receiving vincristine (constipation: 56 vs 0 %, P = .04; pain/cramping: 67 vs 0 %, P = .03). At week 6, 73 % of the patients developed faint erythema of the cranial skin with dry desquamation (40 %) or moist desquamation confined to the skin folds of the auricle (33 %). No reaction of the skin overlying the spinal target volume was observed. CONCLUSIONS Headache at onset and gastro-intestinal toxicity, especially in patients receiving weekly vincristine, were the major complaints of patients with medulloblastoma undergoing craniospinal irradiation with IMRT.
Collapse
Affiliation(s)
- Maurice C Cox
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Johannes M Kusters
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Corrie E Gidding
- Department of Pediatric Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Jolanda H Schieving
- Department of Neurology, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Erik J van Lindert
- Department of Neurosurgery, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Johannes H Kaanders
- Department of Radiation Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Geert O Janssens
- Department of Radiation Oncology, University Medical Center Utrecht and Princess Maxima Center for Pediatric Oncology, Utrecht, 3584, CX, The Netherlands.
| |
Collapse
|
27
|
Hong J, Woo HS, Kim H, Ahn HK, Sym SJ, Park J, Ahn JY, Cho EK, Shin DB, Lee JH. Anemia as a useful biomarker in patients with diffuse large B-cell lymphoma treated with R-CHOP immunochemotherapy. Cancer Sci 2014; 105:1569-75. [PMID: 25263825 PMCID: PMC4317957 DOI: 10.1111/cas.12544] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 09/15/2014] [Accepted: 09/19/2014] [Indexed: 12/27/2022] Open
Abstract
The aim of the current study is to evaluate the prognostic value of anemia, an easily estimable parameter in patients with diffuse large B-cell lymphoma treated with rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP) immunochemotherapy. A total of 157 patients with newly diagnosed diffuse large B-cell lymphoma treated with ≥1 cycle of R-CHOP were included. Hemoglobin level without red cell transfusion within 7 days of initiation of treatment was chosen as a parameter of baseline cancer-induced anemia. To investigate the clinical significance of chemotherapy-induced anemia and its recovery after completion of treatment, 87 patients in complete remission for ≥6 months from the time of the last cycle of R-CHOP were grouped and analyzed separately. Patients with a cancer-induced anemia of hemoglobin <10 g/dL showed inferior event-free and disease-free survival compared to those with hemoglobin ≥10 g/dL. This finding was observed irrespective of the status of pre-treatment bone marrow involvement. In multivariate analysis, hemoglobin <10 g/dL was found to be an international prognostic index-independent prognostic factor. Risk of relapse was significantly higher for patients who were still anemic at 6 months after R-CHOP, compared to those who achieved complete recovery from chemotherapy-induced anemia within 6 months.
Collapse
Affiliation(s)
- Junshik Hong
- Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, Korea
| | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Gilreath JA, Stenehjem DD, Rodgers GM. Diagnosis and treatment of cancer-related anemia. Am J Hematol 2014; 89:203-12. [PMID: 24532336 DOI: 10.1002/ajh.23628] [Citation(s) in RCA: 145] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 10/25/2013] [Accepted: 10/31/2013] [Indexed: 01/04/2023]
Abstract
Cancer-related anemia (CRA) is due to multiple etiologies, including chemotherapy-induced myelosuppression, blood loss, functional iron deficiency, erythropoietin deficiency due to renal disease, marrow involvement with tumor as well as other factors. The most common treatment options for CRA include iron therapy, erythropoietic-stimulating agents (ESAs), and red cell transfusion. Safety concerns as well as restrictions and reimbursement issues surrounding ESA therapy for CRA have resulted in suboptimal treatment. Similarly, many clinicians are not familiar or comfortable using intravenous iron products to treat functional iron deficiency associated with CRA. This article summarizes our approach to treating CRA and discusses commonly encountered clinical scenarios for which current clinical guidelines do not apply.
Collapse
Affiliation(s)
- Jeffrey A. Gilreath
- Department of Pharmacy; Huntsman Cancer Institute; University of Utah Hospitals and Clinics; Salt Lake City Utah
| | - David D. Stenehjem
- Department of Pharmacy; Huntsman Cancer Institute; University of Utah Hospitals and Clinics; Salt Lake City Utah
- Department of Pharmacotherapy; Pharmacotherapy Outcomes Research Center, College of Pharmacy, University of Utah; Salt Lake City Utah
| | - George M. Rodgers
- Department of Medicine; University of Utah Hospitals and Clinics; Salt Lake City Utah
- Department of Pathology; University of Utah Hospitals and Clinics; Salt Lake City Utah
| |
Collapse
|
29
|
Barney CL, Brown AP, Grosshans DR, McAleer MF, de Groot JF, Puduvalli V, Tucker SL, Crawford CN, Gilbert MR, Brown PD, Mahajan A. Technique, outcomes, and acute toxicities in adults treated with proton beam craniospinal irradiation. Neuro Oncol 2013; 16:303-9. [PMID: 24311638 DOI: 10.1093/neuonc/not155] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Proton craniospinal irradiation (p-CSI) has been proposed to reduce side effects associated with CSI. We evaluated acute toxicities and preliminary clinical outcomes in a series of adults treated with p-CSI. METHODS We reviewed medical records for 50 patients (aged 16-63 y) with malignancies of varying histologies treated consecutively with vertebral body-sparing p-CSI at MD Anderson Cancer Center from 2007 to 2011. Median CSI and total boost doses were 30.6 and 54 Gy. Forty patients received chemotherapy, varying by histology. Median follow-up was 20.1 months (range, 0.3-59). RESULTS Median doses to the thyroid gland, pituitary gland, hypothalamus, and cochleae were 0.003 Gy-relative biological effectiveness (RBE; range, 0.001-8.5), 36.1 Gy-RBE (22.5-53.0), 37.1 Gy-RBE (22.3-54.4), and 33.9 Gy-RBE (22.2-52.4), respectively. Median percent weight loss during CSI was 1.6% (range, 10% weight loss to 14% weight gain). Mild nausea/vomiting was common (grade 1 = 46%, grade 2 = 20%); however, only 5 patients experienced grade ≥2 anorexia (weight loss >5% baseline weight). Median percent baseline white blood cells, hemoglobin, and platelets at nadir were 52% (range, 13%-100%), 97% (65%-112%), and 61% (10%-270%), respectively. Four patients developed grade ≥3 cytopenias. Overall and progression-free survival rates were 96% and 82%, respectively, at 2 years and 84% and 68% at 5 years. CONCLUSIONS This large series of patients treated with p-CSI confirms low rates of acute toxicity, consistent with dosimetric models. Vertebral body-sparing p-CSI is feasible and should be considered as a way to reduce acute gastrointestinal and hematologic toxicity in adults requiring CSI.
Collapse
Affiliation(s)
- Christian L Barney
- Corresponding Author: Anita Mahajan, MD, Department of Radiation Oncology, Unit 97, MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Brown AP, Barney CL, Grosshans DR, McAleer MF, de Groot JF, Puduvalli VK, Tucker SL, Crawford CN, Khan M, Khatua S, Gilbert MR, Brown PD, Mahajan A. Proton beam craniospinal irradiation reduces acute toxicity for adults with medulloblastoma. Int J Radiat Oncol Biol Phys 2013; 86:277-84. [PMID: 23433794 DOI: 10.1016/j.ijrobp.2013.01.014] [Citation(s) in RCA: 132] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Revised: 12/31/2012] [Accepted: 01/08/2013] [Indexed: 11/25/2022]
Abstract
PURPOSE Efficacy and acute toxicity of proton craniospinal irradiation (p-CSI) were compared with conventional photon CSI (x-CSI) for adults with medulloblastoma. METHODS AND MATERIALS Forty adult medulloblastoma patients treated with x-CSI (n=21) or p-CSI (n=19) at the University of Texas MD Anderson Cancer Center from 2003 to 2011 were retrospectively reviewed. Median CSI and total doses were 30.6 and 54 Gy, respectively. The median follow-up was 57 months (range 4-103) for x-CSI patients and 26 months (range 11-63) for p-CSI. RESULTS p-CSI patients lost less weight than x-CSI patients (1.2% vs 5.8%; P=.004), and less p-CSI patients had >5% weight loss compared with x-CSI (16% vs 64%; P=.004). p-CSI patients experienced less grade 2 nausea and vomiting compared with x-CSI (26% vs 71%; P=.004). Patients treated with x-CSI were more likely to have medical management of esophagitis than p-CSI patients (57% vs 5%, P<.001). p-CSI patients had a smaller reduction in peripheral white blood cells, hemoglobin, and platelets compared with x-CSI (white blood cells 46% vs 55%, P=.04; hemoglobin 88% vs 97%, P=.009; platelets 48% vs 65%, P=.05). Mean vertebral doses were significantly associated with reductions in blood counts. CONCLUSIONS This report is the first analysis of clinical outcomes for adult medulloblastoma patients treated with p-CSI. Patients treated with p-CSI experienced less treatment-related morbidity including fewer acute gastrointestinal and hematologic toxicities.
Collapse
Affiliation(s)
- Aaron P Brown
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Management der Wirbelsäulenmetastasen, Strategien und operative Indikationen. DER ORTHOPADE 2012; 41:632-9. [DOI: 10.1007/s00132-012-1910-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
32
|
Gündüz E, Gülbaş Z. Supportive care in hemato-oncology: a review in light of the latest guidelines. Turk J Haematol 2012; 29:1-9. [PMID: 24744617 PMCID: PMC3986760 DOI: 10.5505/tjh.2012.10327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2011] [Accepted: 05/17/2011] [Indexed: 11/09/2022] Open
Abstract
Recent developments in cancer therapy have resulted in increases in treatment success rates and survival. One of thebasic goals of such therapy is improving patient quality of life. Chemotherapy protocols for solid or hematologicalmalignancies-most of which include multiple agents-negatively impact patient quality of life. Additionally, there havebeen developments in supportive care, which seeks to ameliorate or minimize the negative effects of chemotherapy.Herein we present a review and brief summarization of some of the agents used for supportive care in cancer patientsin light of the latest guidelines.
Collapse
Affiliation(s)
- Eren Gündüz
- Eskişehir Osmangazi University, School of Medicine, Department of Hematology, Eskişehir, Turkey
| | - Zafer Gülbaş
- Anadolu Health Center, Bone Marrow Transplantation Center, Kocaeli, Turkey
| |
Collapse
|
33
|
Berenson J, Pflugmacher R, Jarzem P, Zonder J, Schechtman K, Tillman JB, Bastian L, Ashraf T, Vrionis F. Balloon kyphoplasty versus non-surgical fracture management for treatment of painful vertebral body compression fractures in patients with cancer: a multicentre, randomised controlled trial. Lancet Oncol 2011; 12:225-35. [DOI: 10.1016/s1470-2045(11)70008-0] [Citation(s) in RCA: 322] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
34
|
Goethals I, Dierckx R, De Meerleer G, Gemmel F, De Neve W, Van De Wiele C. Nucl Med Commun 2003; 24:845-852. [DOI: 10.1097/00006231-200308000-00001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
|
35
|
Goethals I, Dierckx R, De Meerleer G, Gemmel F, De Neve W, Van De Wiele C. Nuclear medicine in the prediction and detection of radiation associated normal tissue damage of kidney, brain, bone marrow and salivary glands. Nucl Med Commun 2003; 24:845-52. [PMID: 12869815 DOI: 10.1097/01.mnm.0000084581.51410.46] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
36
|
Chang EL, Allen P, Wu C, Ater J, Kuttesch J, Maor MH. Acute toxicity and treatment interruption related to electron and photon craniospinal irradiation in pediatric patients treated at the University of Texas M. D. Anderson Cancer Center. Int J Radiat Oncol Biol Phys 2002; 52:1008-16. [PMID: 11958896 DOI: 10.1016/s0360-3016(01)02717-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To determine the incidence of acute toxicity and treatment interruption associated with electron and photon craniospinal irradiation (CSI) in children treated with or without chemotherapy. MATERIALS AND METHODS A retrospective study involving a computerized search of the radiotherapy database at the University of Texas M. D. Anderson Cancer Center identified a total of 79 eligible patients </=18 years old who had received electron (n = 46) or photon (n = 33) CSI from October 1980 to March 2000. Acute toxicity was graded according to the 1998 National Cancer Institute Common Toxicity Criteria. Chemotherapy sequencing was categorized as before or after CSI or no chemotherapy. The incidences of weight loss and skin toxicity were recorded and differences in treatment interruption and hematologic values with respect to modality used (electron vs. photon), age (</=6 or >6 years), and sequencing of chemotherapy were compared using chi-square tests. RESULTS The median age of the electron group was lower than that of the photon group (6.7 years and 11.7 years, respectively). The two groups were otherwise well matched in terms of median spinal dose (31.1 vs. 33.3 Gy), fraction size (1.57 vs. 1.63 Gy), and total treatment time (32.4 vs. 30.7 days). Only 2 patients in each group (photon and electron) had a treatment break (>3 days). The mean number of days interrupted was 0.94 (photon) and 1.1 (electron) (p = 0.72). The electron and photon groups were well balanced in terms of receiving pre-CSI chemotherapy (37% vs. 41%, p = 0.776). Chemotherapy given before radiotherapy vs. after or not at all was associated with an increased incidence of Grade 3-4 leukopenia (76% vs. 49%, p = 0.02), thrombocytopenia (90% vs. 10%, p = 0), and neutropenia (50% vs. 15%, p = 0.005). A younger age was associated with Grade 3-4 thrombocytopenia (29% vs. 8.7%, p = 0.034), and decreased hemoglobin (29% vs. 6.5%, p = 0.014). The incidence of leukocyte depression of Grade 3-4 toxicity was 62% in the electron group and 32% in the photon group (p = 0.018). The incidence of Grade 3-4 platelet toxicity was higher with electrons (21%) than with photons (4%), but the difference was of borderline significance (p = 0.053). The difference in Grade 1-2 weight loss was not statistically significant (86% electron vs. 55% photon groups, p = 0.53), and Grade 3-4 weight loss did not occur within the entire study group. Most patients experienced Grade 0-1 radiation dermatitis with either electrons or photons. CONCLUSION A younger patient age (</=6 years) and the sequence of chemotherapy before radiotherapy were associated with increased acute hematologic toxicity. Grade 3-4 weight loss, a surrogate for gastrointestinal toxicity, was not observed within the entire population. Despite the increased acute hematologic toxicities associated with CSI in very young children, the vast majority of patients were able to complete photon or electron CSI with minimal to no treatment interruptions. CSI with the electron technique can be used as an alternative to photon CSI in young children, and in our experience does not require the routine use of hematopoietic growth factors.
Collapse
Affiliation(s)
- Eric L Chang
- Department of Radiation Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, TX, USA.
| | | | | | | | | | | |
Collapse
|
37
|
Kortmann RD, Kühl J, Timmermann B, Mittler U, Urban C, Budach V, Richter E, Willich N, Flentje M, Berthold F, Slavc I, Wolff J, Meisner C, Wiestler O, Sörensen N, Warmuth-Metz M, Bamberg M. Postoperative neoadjuvant chemotherapy before radiotherapy as compared to immediate radiotherapy followed by maintenance chemotherapy in the treatment of medulloblastoma in childhood: results of the German prospective randomized trial HIT '91. Int J Radiat Oncol Biol Phys 2000; 46:269-79. [PMID: 10661332 DOI: 10.1016/s0360-3016(99)00369-7] [Citation(s) in RCA: 295] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE The German Society of Pediatric Hematology and Oncology (GPOH) conducted a randomized, prospective, multicenter trial (HIT '91) in order to improve the survival of children with medulloblastoma by using postoperative neoadjuvant chemotherapy before radiation therapy as opposed to maintenance chemotherapy after immediate postoperative radiotherapy. METHODS AND MATERIALS Between 1991 and 1997, 158 patients were enrolled and 137 patients randomized. Seventy-two patients were allocated to receive neoadjuvant chemotherapy before radiotherapy (arm I, investigational). Chemotherapy consisted of ifosfamide, etoposide, intravenous high-dose methotrexate, cisplatin, and cytarabine given in two cycles. In arm II (standard arm), 65 patients were assigned to receive immediate postoperative radiotherapy, with concomitant vincristine followed by 8 cycles of maintenance chemotherapy consisting of cisplatin, CCNU, and vincristine ("Philadelphia protocol"). All patients received radiotherapy to the craniospinal axis (35.2 Gy total dose, 1.6 Gy fractionated dose / 5 times per week followed by a boost to posterior fossa with 20 Gy, 2.0 Gy fractionated dose). RESULTS During chemotherapy Grade III/IV infections were predominant in arm I (40%). Peripheral neuropathy and ototoxicity were prevailing in arm II (37% and 34%, respectively). Dose modification was necessary in particular in arm II (63%). During radiotherapy acute toxicity was mild in the majority of patients and equally distributed in both arms. Myelosuppression led to a mean prolongation of treatment time of 11.5 days in arm I and 7.5 days in arm II, and interruptions in 35% of patients in arm I. Quality control of radiotherapy revealed correct treatment in more than 88% for dose prescription, more than 88% for coverage of target volume, and 98% for field matching. At a median follow-up of 30 months (range 1.4-62 months), the Kaplan-Meier estimates for relapse-free survival at 3 years for all randomized patients were 0.70+/-0.08; for patients with residual disease: 0.72+/-0.06; without residual disease: 0.68+/-0.09; M0: 0.72+/-0.04; M1: 0.65+/-0.12; and M2/3: 0.30+/-0.15. For all randomized patients without M2/3 disease: 0.65+/-0.05 (arm I) and 0.78+/-0.06 (arm II) (p < 0.03); patients between 3 and 5.9 years: 0.60+/-0.13 and 0.64+/-0.14, respectively, but patients between 6 and 18 years: 0.62+/-0.09 and 0.84+/-0.08, respectively (p < 0.03). In a univariate analysis the only negative prognostic factors were M2/3 disease (p < 0.002) and an age of less than 8 years (p < 0.03). CONCLUSIONS Maintenance chemotherapy would seem to be more effective in low-risk medulloblastoma, especially in patients older than 6 years of age. Neoadjuvant chemotherapy was accompanied by increased myelotoxicity of the subsequent radiotherapy, causing a higher rate of interruptions and an extended overall treatment time. Delayed and/or protracted radiotherapy may therefore have a negative impact on outcome. M2/3 disease was associated with a poor survival in both arms, suggesting the need for a more intensive treatment. Young age and M2/3 stage were negative prognostic factors in medulloblastoma, but residual or M1 disease was not, suggesting a new stratification system for risk subgroups. High quality of radiotherapy may be a major contributing factor for the overall outcome.
Collapse
Affiliation(s)
- R D Kortmann
- Department of Radiotherapy, University of Tuebinen, Germany.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Chow E, Danjoux CE, Pataki I, Franssen E, Jenkin RD. Effect of hemoglobin on radiotherapy response in children with medulloblastoma: should patients with a low hemoglobin be transfused? MEDICAL AND PEDIATRIC ONCOLOGY 1999; 32:395-7. [PMID: 10219347 DOI: 10.1002/(sici)1096-911x(199905)32:5<395::aid-mpo18>3.0.co;2-c] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- E Chow
- Department of Radiation Oncology, Toronto Sunnybrook Regional Cancer Centre, University of Toronto, Canada
| | | | | | | | | |
Collapse
|