1
|
Phillips GS, Freret ME, Friedman DN, Trelles S, Kukoyi O, Freites-Martinez A, Unger RH, Disa JJ, Wexler LH, Tinkle CL, Mechalakos JG, Dusza SW, Beal K, Wolden SL, Lacouture ME. Assessment and Treatment Outcomes of Persistent Radiation-Induced Alopecia in Patients With Cancer. JAMA Dermatol 2021; 156:963-972. [PMID: 32756880 DOI: 10.1001/jamadermatol.2020.2127] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance Persistent radiation-induced alopecia (pRIA) and its management have not been systematically described. Objective To characterize pRIA in patients with primary central nervous system (CNS) tumors or head and neck sarcoma. Design, Setting, and Participants A retrospective cohort study of patients from January 1, 2011, to January 30, 2019, was conducted at 2 large tertiary care hospitals and comprehensive cancer centers. Seventy-one children and adults diagnosed with primary CNS tumors or head and neck sarcomas were evaluated for pRIA. Main Outcomes and Measures The clinical and trichoscopic features, scalp radiation dose-response relationship, and response to topical minoxidil were assessed using standardized clinical photographs of the scalp, trichoscopic images, and radiotherapy treatment plans. Results Of the 71 patients included (median [range] age, 27 [4-75] years; 51 female [72%]), 64 (90%) had a CNS tumor and 7 (10%) had head and neck sarcoma. Alopecia severity was grade 1 in 40 of 70 patients (56%), with localized (29 of 54 [54%]), diffuse (13 of 54 [24%]), or mixed (12 of 54 [22%]) patterns. The median (range) estimated scalp radiation dose was 39.6 (15.1-50.0) Gy; higher dose (odds ratio [OR], 1.15; 95% CI, 1.04-1.28) and proton irradiation (OR, 5.7; 95% CI, 1.05-30.8) were associated with greater alopecia severity (P < .001), and the dose at which 50% of patients were estimated to have severe (grade 2) alopecia was 36.1 Gy (95% CI, 33.7-39.6 Gy). Predominant trichoscopic features included white patches (16 of 28 [57%]); in 15 patients, hair-shaft caliber negatively correlated with scalp dose (correlation coefficient, -0.624; P = .01). The association between hair density and scalp radiation dose was not statistically significant (-0.381; P = .16). Twenty-eight of 34 patients (82%) responded to topical minoxidil, 5% (median follow-up, 61 [interquartile range, 21-105] weeks); 4 of 25 (16%) topical minoxidil recipients with clinical images improved in severity grade. Two patients responded to hair transplantation and 1 patient responded to plastic surgical reconstruction. Conclusions and Relevance Persistent radiation-induced alopecia among patients with primary CNS tumors or head and neck sarcomas represents a dose-dependent phenomenon that has distinctive clinical and trichoscopic features. The findings of this study suggest that topical minoxidil and procedural interventions may have benefit in the treatment of pRIA.
Collapse
Affiliation(s)
- Gregory S Phillips
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Morgan E Freret
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Sabrina Trelles
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Oluwaseun Kukoyi
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Azael Freites-Martinez
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Dermatology Service, Hospital Ruber Juan Bravo and Universidad Europea, Madrid, Spain
| | - Robin H Unger
- Department of Dermatology, Mount Sinai Medical Center, New York, New York
| | - Joseph J Disa
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Leonard H Wexler
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christopher L Tinkle
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - James G Mechalakos
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Stephen W Dusza
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kathryn Beal
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Suzanne L Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mario E Lacouture
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| |
Collapse
|
2
|
Scoccianti S, Simontacchi G, Greto D, Perna M, Terziani F, Talamonti C, Teriaca MA, Caramia G, Lo Russo M, Olmetto E, Delli Paoli C, Grassi R, Carfora V, Saieva C, Bonomo P, Detti B, Mangoni M, Desideri I, Francolini G, Di Cataldo V, Marrazzo L, Pallotta S, Livi L. Dosimetric Predictors of Acute and Chronic Alopecia in Primary Brain Cancer Patients Treated With Volumetric Modulated Arc Therapy. Front Oncol 2020; 10:467. [PMID: 32322558 PMCID: PMC7156544 DOI: 10.3389/fonc.2020.00467] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 03/16/2020] [Indexed: 12/18/2022] Open
Abstract
Purpose: To determine dose constraints that correlate with alopecia in patients treated with photon-based Volumetric Modulated Arc Therapy (VMAT) for primary brain tumors. Methods: During the treatment planning process, the scalp was drawn as a region of interest. Dose received by 0.1 cc (D0.1cc), mean dose (Dmean), absolute volumes receiving different doses (V16Gy, V20Gy, V25Gy, V30Gy, V35Gy, V40Gy, and V43Gy) were registered for the scalp. Alopecia was assessed according to Common Terminology Criteria for Adverse Events (CTCAE) v4.0. Receiver operating characteristics (ROC) curve analysis was used to identify parameters associated with hair-loss. Results: One-hundred and one patients were included in this observational study. At the end of radiotherapy (RT), 5 patients did not develop alopecia (Dmean scalp 3.1 Gy). The scalp of the patients with G1 (n = 11) and G2 (n = 85) alopecia received Dmean of 10.6 Gy and 11.8 Gy, respectively. At ROC analysis, V16Gy20Gy ≥ 5.2 cc were the strongest predictors of acute alopecia risk. Chronic hair-loss assessment was available for 74 patients: median time to recovery from G2 alopecia was 5, 9 months. The actuarial rate of hair regrowth was 98.1% at 18 months after the end of RT. At ROC analysis, V40Gy43Gy ≥2.2 cc were the strongest predictors of chronic G2-alopecia risk. V20Gy, V40Gy, and D0,1cc were shown to be independent variables according to correlation coefficient r. Conclusions: V20Gy and V40Gy were the strongest predictors for acute and chronic G2 hair-loss, respectively. The low-dose bath typical of VMAT corresponds to large areas of acute but transient alopecia. However, the steep dose gradient of VMAT allows to reduce the areas of the scalp that receive higher doses, minimizing the risk of permanent alopecia. The application of our dosimetric findings for the scalp may help in reducing the alopecia risk and also in estimating the probability of hair-loss during patient counseling before starting radiotherapy.
Collapse
Affiliation(s)
- Silvia Scoccianti
- Radiation Oncology Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Gabriele Simontacchi
- Radiation Oncology Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Daniela Greto
- Radiation Oncology Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Marco Perna
- Radiation Oncology Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Francesca Terziani
- Radiation Oncology Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Cinzia Talamonti
- Medical Physics Unit, Department of Experimental and Clinical Biomedical Sciences "Mario Serio," Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Maria Ausilia Teriaca
- Radiation Oncology Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Giorgio Caramia
- Radiation Oncology Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Monica Lo Russo
- Radiation Oncology Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Emanuela Olmetto
- Radiation Oncology Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Camilla Delli Paoli
- Radiation Oncology Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Roberta Grassi
- Radiation Oncology Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Vincenzo Carfora
- Radiation Oncology Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Calogero Saieva
- SC Epidemiology of Risk Factors and Lifestyles, Institute for Study, Prevention, and Oncology Network (ISPRO), Florence, Italy
| | - Pierluigi Bonomo
- Radiation Oncology Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Beatrice Detti
- Radiation Oncology Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Monica Mangoni
- Radiation Oncology Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Isacco Desideri
- Radiation Oncology Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Giulio Francolini
- Radiation Oncology Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Vanessa Di Cataldo
- Radiation Oncology Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Livia Marrazzo
- Medical Physics Unit, Department of Experimental and Clinical Biomedical Sciences "Mario Serio," Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Stefania Pallotta
- Medical Physics Unit, Department of Experimental and Clinical Biomedical Sciences "Mario Serio," Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Lorenzo Livi
- Radiation Oncology Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| |
Collapse
|
3
|
Roberge D, Parker W, Niazi TM, Olivares M. Treating the Contents and Not the Container: Dosimetric Study of Hair-sparing Whole Brain Intensity Modulated Radiation Therapy. Technol Cancer Res Treat 2016; 4:567-70. [PMID: 16173827 DOI: 10.1177/153303460500400510] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Hematogenous metastatases are the most common adult central nervous system malignancies. The standard treatment of these patients continues to include whole brain radiation. An unavoidable toxicity of this treatment is acute iatrogenic alopecia. This alopecia is a significant cause of patient distress. Our purpose was to quantify the sparing of the hair bearing skin that could be achieved by using a complex hair-sparing approach. To achieve this goal, we treat an anthropomorphic phantom with both conventional and inverse-planned intensity-modulated portals. The skin dose was evaluated through dose-volume histograms and thermo-luminescent dosimetry. The median calculated dose was reduced by 38%. The average measured dose at five surface points was reduced by 53% — from 95% of the prescription dose with the conventional plan, to 44%, with the IMRT plan. This sparing was achieved while maintaining adequate target coverage. Because of the low radiation tolerance of the hair follicle, this dose reduction is not expected, on its own, to eliminate radiation alopecia but bears promise in combination with other toxicity-sparing strategies.
Collapse
Affiliation(s)
- David Roberge
- Department of Oncology, Division of Radiation Oncology, McGill University, Montreal, Quebec, H3G 1A4, Canada.
| | | | | | | |
Collapse
|
4
|
Witek M, Vahknenko Y, Siglin J, Harrison A, Xiao Y, Lui H, Andrews D, Shi W. Dose Reduction to the Scalp with Hippocampal Sparing Is Achievable with Intensity Modulated Radiotherapy. ACTA ACUST UNITED AC 2014; 3:176-182. [PMID: 29963335 PMCID: PMC6020831 DOI: 10.4236/ijmpcero.2014.33023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
We evaluated the feasibility of combined hippocampal- and scalp-sparing intensity-modulated radiotherapy (IMRT) plans. This study included 7 patients who received conventional palliative whole brain radiation treatment (WBRT) for brain metastasis. The brain, hippocampus, and scalp were contoured and replanned with intensity modulated radiation therapy. The prescription dose was 30 Gray (Gy) in 10 fractions with hippocampus and normal structure constraints per the Radiation Therapy Oncology Group (RTOG) 0933 protocol. Further planning was done to minimize the scalp dose while maintaining the dose constraints for the hippocampus. Dose volume histograms were obtained from conventional opposed lateral fields, IMRT and compared. Planning target volume (PTV) coverage for all plans fell within the RTOG 0933 critical structure acceptable variation category. When compared to traditional opposed lateral fields, the IMRT plan with combined hippocampal- and scalp-sparing constraints was able to significantly reduce the max and mean scalp dose as well as the percentage of scalp receiving 10 and 20 Gy by 46% and 35%, respectively, while maintaining acceptable RTOG 0933 hippocampal dose variations. We conclude that acceptable PTV coverage and sparing of the scalp and hippocampus can be accomplished using a 9-field non-coplanar IMRT plan. Prospective study is warranted to understand the impact on radiation induced alopecia.
Collapse
Affiliation(s)
- Matthew Witek
- Department of Radiation Oncology, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Yelena Vahknenko
- Department of Radiation Oncology, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Joshua Siglin
- Department of Radiation Oncology, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Amy Harrison
- Department of Radiation Oncology, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Ying Xiao
- Department of Radiation Oncology, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Haison Lui
- Department of Radiation Oncology, Thomas Jefferson University Hospital, Philadelphia, USA
| | - David Andrews
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Wenyin Shi
- Department of Radiation Oncology, Thomas Jefferson University Hospital, Philadelphia, USA
| |
Collapse
|