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Constine LS, Marks LB, Milano MT, Ronckers CM, Jackson A, Hudson MM, Marcus KJ, Hodgson DC, Hua CH, Howell RM, Marples B, Yorke E, Olch A, Bentzen SM. A User's Guide and Summary of Pediatric Normal Tissue Effects in the Clinic (PENTEC): Radiation Dose-Volume Response for Adverse Effects After Childhood Cancer Therapy and Future Directions. Int J Radiat Oncol Biol Phys 2024; 119:321-337. [PMID: 37999712 DOI: 10.1016/j.ijrobp.2023.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/01/2023] [Accepted: 09/06/2023] [Indexed: 11/25/2023]
Abstract
Pediatric Normal Tissue Effects in the Clinic (PENTEC) is an international multidisciplinary effort that aims to summarize normal-tissue toxicity risks based on published dose-volume data from studies of children and adolescents treated with radiation therapy (RT) for cancer. With recognition that children are uniquely vulnerable to treatment-related toxic effects, our mission and challenge was to assemble our group of physicians (radiation and pediatric oncologists, subspecialists), physicists with clinical and modeling expertise, epidemiologists, and other scientists to develop evidence-based radiation dosimetric guidelines, as affected by developmental status and other factors (eg, other cancer therapies and host factors). These quantitative toxicity risk estimates could serve to inform RT planning and thereby improve outcomes. Tandem goals included the description of relevant medical physics issues specific to pediatric RT and the proposal of dose-volume outcome reporting standards to inform future studies. We created 19 organ-specific task forces and methodology to unravel the wealth of data from heterogeneous published studies. This report provides a high-level summary of PENTEC's genesis, methods, key findings, and associated concepts that affected our work and an explanation of how our findings may be interpreted and applied in the clinic. We acknowledge our predecessors in these efforts, and we pay homage to the children whose lives informed us and to future generations who we hope will benefit from this additional step in our path forward.
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Affiliation(s)
- Louis S Constine
- Departments of Radiation Oncology and; Pediatrics, University of Rochester Medical Center, Wilmot Cancer Institute, Rochester, New York.
| | - Lawrence B Marks
- Department of Radiation Oncology and Lineberger Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Cécile M Ronckers
- Division of Childhood Cancer Epidemiology (EpiKiK) and the German Childhood Cancer Registry (DKKR), Johannes Gutenberg University of Mainz, Germany
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Melissa M Hudson
- Department of Oncology, Division of Cancer Survivorship, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Karen J Marcus
- Department of Radiation Oncology, Dana Farber/ Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - David C Hodgson
- Department of Radiation Oncology, University of Toronto, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Chia-Ho Hua
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Rebecca M Howell
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | | | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Arthur Olch
- Department of Radiation Oncology, University of Southern California and Children's Hospital of Los Angeles, Los Angeles, California
| | - Soren M Bentzen
- Department of Epidemiology and Public Health, University of Maryland, Baltimore, Maryland
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Bentzen SM, Vogelius IR, Hodgson D, Howell R, Jackson A, Hua CH, Olch AJ, Ronckers C, Kremer L, Milano M, Marks LB, Constine LS. Radiation Dose-Volume-Response Relationships for Adverse Events in Childhood Cancer Survivors: Introduction to the Scientific Issues in PENTEC. Int J Radiat Oncol Biol Phys 2024; 119:338-353. [PMID: 38760115 DOI: 10.1016/j.ijrobp.2023.11.028] [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: 07/21/2023] [Revised: 11/01/2023] [Accepted: 11/16/2023] [Indexed: 05/19/2024]
Abstract
At its very core, radiation oncology involves a trade-off between the benefits and risks of exposing tumors and normal tissue to relatively high doses of ionizing radiation. This trade-off is particularly critical in childhood cancer survivors (CCS), in whom both benefits and risks can be hugely consequential due to the long life expectancy if the primary cancer is controlled. Estimating the normal tissue-related risks of a specific radiation therapy plan in an individual patient relies on predictive mathematical modeling of empirical data on adverse events. The Pediatric Normal-Tissue Effects in the Clinic (PENTEC) collaborative network was formed to summarize and, when possible, to synthesize dose-volume-response relationships for a range of adverse events incident in CCS based on the literature. Normal-tissue clinical radiation biology in children is particularly challenging for many reasons: (1) Childhood malignancies are relatively uncommon-constituting approximately 1% of new incident cancers in the United States-and biologically heterogeneous, leading to many small series in the literature and large variability within and between series. This creates challenges in synthesizing data across series. (2) CCS are at an elevated risk for a range of adverse health events that are not specific to radiation therapy. Thus, excess relative or absolute risk compared with a reference population becomes the appropriate metric. (3) Various study designs and quantities to express risk are found in the literature, and these are summarized. (4) Adverse effects in CCS often occur 30, 50, or more years after therapy. This limits the information content of series with even very extended follow-up, and lifetime risk estimates are typically extrapolations that become dependent on the mathematical model used. (5) The long latent period means that retrospective dosimetry is required, as individual computed tomography-based radiation therapy plans gradually became available after 1980. (6) Many individual patient-level factors affect outcomes, including age at exposure, attained age, lifestyle exposures, health behaviors, other treatment modalities, dose, fractionation, and dose distribution. (7) Prospective databases with individual patient-level data and radiation dosimetry are being built and will facilitate advances in dose-volume-response modeling. We discuss these challenges and attempts to overcome them in the setting of PENTEC.
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Affiliation(s)
- Søren M Bentzen
- Department of Epidemiology and Public Health, Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, Maryland.
| | - Ivan R Vogelius
- Department of Oncology, Rigshospitalet, University of Copenhagen, Denmark
| | - David Hodgson
- Department of Radiation Oncology, Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rebecca Howell
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Chia-Ho Hua
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Arthur J Olch
- Department of Radiation Oncology, University of Southern California Keck School of Medicine and Children's Hospital Los Angeles, Los Angeles, California
| | - Cecile Ronckers
- Division of Childhood Cancer Epidemiology, Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Leontien Kremer
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Michael Milano
- Department of Radiation Oncology, James P. Wilmot Cancer Institute, University of Rochester, Rochester, New York
| | - Lawrence B Marks
- Department of Radiation Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Louis S Constine
- Department of Radiation Oncology, James P. Wilmot Cancer Institute, University of Rochester, Rochester, New York
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Specht L. Reappraisal of the role of radiation therapy in lymphoma treatment. Hematol Oncol 2023; 41 Suppl 1:75-81. [PMID: 37294967 DOI: 10.1002/hon.3151] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 03/28/2023] [Indexed: 06/11/2023]
Abstract
Radiation therapy (RT) for lymphomas has improved dramatically with modern imaging and treatment techniques, encompassing only the necessary volume with minimal doses to normal structures. Prescribed radiation doses are reduced, and fractionation schedules are under revision. With effective systemic treatment only initial macroscopic disease is irradiated. With no or less effective systemic treatment, possible microscopic disease is also included. Risks of long-term side effects of RT have diminished dramatically and should be weighed against risks from more systemic treatment or increased risk of relapse. Lymphoma patients are often elderly, they tolerate modern limited RT very well. Lymphomas refractory to systemic treatments often remain radioresponsive, and brief, mild RT may offer effective palliation. New roles for RT are emerging with immune therapies. RT for "bridging," keeping the lymphoma under control while waiting for immune therapy, is well established. Enhancement of the immune response to lymphomas, so-called "priming," is being intensively researched.
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Affiliation(s)
- Lena Specht
- Department of Oncology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Illidge T, Mikhaeel NG, Specht L, Yahalom J. Lymphoma: advances in imaging and radiotherapy - introductory editorial. Br J Radiol 2021; 94:20219005. [PMID: 34677091 DOI: 10.1259/bjr.20219005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Tim Illidge
- Manchester NIHR Biomedical Research Centre, University of Manchester, Christie Hospital, Manchester, United Kingdom
| | - N George Mikhaeel
- Guy's & St Thomas' NHS Foundation Trust and King's College University, London, United Kingdom
| | - Lena Specht
- Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Joachim Yahalom
- Memorial Sloan Kettering Cancer Center, New York, United States
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