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Lavan NA, Smyth G, McQuaid D, Gaze MN, Stacey C, Vaidya S, Saran FH, Oelfke U, Mandeville HC. A Four-dimensional Computed Tomography Generated Internal Target Volume Approach to Paediatric High Risk Neuroblastoma to Reduce Organ at Risk and Normal Tissue Irradiation. Clin Oncol (R Coll Radiol) 2024; 36:780-789. [PMID: 39370346 DOI: 10.1016/j.clon.2024.08.009] [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: 05/20/2024] [Accepted: 08/12/2024] [Indexed: 10/08/2024]
Abstract
AIMS The magnitude of upper abdominal organ motion in children may be overestimated by current planning target volumes (PTV). A four-dimensional computed tomography (4DCT) - derived internal target volume (ITV) is frequently used in adult radiotherapy to take respiratory-related organ motion into account. In this study, the dosimetric consequences for target coverage and organs at risk from the use of an ITV approach compared to standard PTV margins in children with high-risk neuroblastoma were investigated. MATERIALS AND METHODS 14 patients, median age 4.1 years, range 1.5 - 18.9 years, (9 midline targets, 5 lateralised) each had two dual arc volumetric modulated arc therapy (VMAT) plans (14 ×1.5 Gy) generated. One used an ITV-approach; motion information derived from 4DCT (PTV_itv) with a 5mm ITV to PTV expansion, and the other a PTV margin of 10mm from CTV to PTV (PTV_standard). Differences in absolute PTV volume and organ at risk doses are described. RESULTS The ITV approach resulted in a highly significant reduction in PTV size of 38% (p<0.0001). For midline targets, an ITV approach resulted in a small but statistically significant reduction in combined mean kidney dose of 0.8Gy, p 0.01. Mean heart and lung dose were reduced by an average of 1 Gy with an ITV approach. Non-PTV integral dose from 30.4 Gy L to 27.8 Gy L using an ITV approach. CONCLUSION An ITV-approach to respiratory related organ motion management in children can significantly reduce absolute PTV volumes, maintain target coverage and reduce dose delivered to normal tissue in proximity to the target. This is an essential step to maximising the benefits of highly conformal radiotherapy techniques including VMAT for this patient group, and in the future with Proton Therapy.
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Affiliation(s)
- N A Lavan
- Department of Radiotherapy, The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, Sutton, UK.
| | - G Smyth
- Joint Department of Physics at the Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, Sutton, UK
| | - D McQuaid
- Joint Department of Physics at the Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, Sutton, UK
| | - M N Gaze
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - C Stacey
- Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, UK
| | - S Vaidya
- Department of Paediatric Oncology, The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, Sutton, UK
| | - F H Saran
- Department of Radiotherapy, The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, Sutton, UK
| | - U Oelfke
- Joint Department of Physics at the Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, Sutton, UK
| | - H C Mandeville
- Department of Radiotherapy, The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, Sutton, UK.
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Gains JE, Patel A, Chang YC, Mandeville HC, Smyth G, Stacey C, Talbot J, Wheatley K, Gaze MN. A Randomised Phase II Trial to Evaluate the Feasibility of Radiotherapy Dose Escalation, Facilitated by Intensity-Modulated Arc Radiotherapy Techniques, in High-Risk Neuroblastoma. Clin Oncol (R Coll Radiol) 2024; 36:e154-e162. [PMID: 38553363 DOI: 10.1016/j.clon.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/17/2024] [Accepted: 03/08/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND AND PURPOSE For high-risk neuroblastoma, planning target volume coverage is often compromised to respect adjacent kidney tolerance. This trial investigated whether intensity-modulated arc radiotherapy techniques (IMAT) could facilitate dose escalation better than conventional techniques. MATERIALS AND METHODS Children with high-risk abdominal neuroblastoma referred for radiotherapy to the primary tumour site and involved regional lymph nodes were randomised to receive either standard dose (21 Gy in 14 fractions) or escalated dose (36 Gy in 24 fractions) radiotherapy. Dual planning with both a conventional anterior-posterior parallel opposed pair radiotherapy technique and an IMAT technique was performed. The quality of target volume and organ-at-risk delineation, and dosimetric plans, were externally reviewed. Dosimetric parameters were used to judge the superior technique for treatment. This feasibility trial was not powered to detect improvement in outcome with dose escalation. RESULTS Between 2017 and 2020, 50 patients were randomised and dual-planned. The IMAT technique was judged more favourable in 48 patients. In all patients randomised to receive 36 Gy, IMAT would have permitted delivery of the full dose (median D50% 36.0 Gy, inter-quartile range 36.0-36.1 Gy) to the target volume, whereas dose compromise would have been required with conventional planning (median D50% 35.6 Gy, inter-quartile range 28.7-35.9 Gy). CONCLUSION IMAT facilitates safe dose escalation to 36 Gy in patients receiving radiotherapy for neuroblastoma. The value of dose escalation is now being evaluated in a current prospective phase III randomised trial.
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Affiliation(s)
- J E Gains
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - A Patel
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Yen-Ch'ing Chang
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - H C Mandeville
- Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - G Smyth
- National Radiotherapy Trials Quality Assurance Group, The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - C Stacey
- Radiotherapy Physics Group, University College London Hospitals NHS Foundation Trust, London, UK
| | - J Talbot
- Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - K Wheatley
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - M N Gaze
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK. https://twitter.com/@MarkGaze
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Taylor S, Lim P, Cantwell J, D’Souza D, Moinuddin S, Chang YC, Gaze MN, Gains J, Veiga C. Image guidance and interfractional anatomical variation in paediatric abdominal radiotherapy. Br J Radiol 2023; 96:20230058. [PMID: 37102707 PMCID: PMC10230397 DOI: 10.1259/bjr.20230058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/22/2023] [Accepted: 03/23/2023] [Indexed: 04/28/2023] Open
Abstract
OBJECTIVES To identify variables predicting interfractional anatomical variations measured with cone-beam CT (CBCT) throughout abdominal paediatric radiotherapy, and to assess the potential of surface-guided radiotherapy (SGRT) to monitor these changes. METHODS Metrics of variation in gastrointestinal (GI) gas volume and separation of the body contour and abdominal wall were calculated from 21 planning CTs and 77 weekly CBCTs for 21 abdominal neuroblastoma patients (median 4 years, range: 2 - 19 years). Age, sex, feeding tubes, and general anaesthesia (GA) were explored as predictive variables for anatomical variation. Furthermore, GI gas variation was correlated with changes in body and abdominal wall separation, as well as simulated SGRT metrics of translational and rotational corrections between CT/CBCT. RESULTS GI gas volumes varied 74 ± 54 ml across all scans, while body and abdominal wall separation varied 2.0 ± 0.7 mm and 4.1 ± 1.5 mm from planning, respectively. Patients < 3.5 years (p = 0.04) and treated under GA (p < 0.01) experienced greater GI gas variation; GA was the strongest predictor in multivariate analysis (p < 0.01). Absence of feeding tubes was linked to greater body contour variation (p = 0.03). GI gas variation correlated with body (R = 0.53) and abdominal wall (R = 0.63) changes. The strongest correlations with SGRT metrics were found for anterior-posterior translation (R = 0.65) and rotation of the left-right axis (R = -0.36). CONCLUSIONS Young age, GA, and absence of feeding tubes were linked to stronger interfractional anatomical variation and are likely indicative of patients benefiting from adaptive/robust planning pathways. Our data suggest a role for SGRT to inform the need for CBCT at each treatment fraction in this patient group. ADVANCES IN KNOWLEDGE This is the first study to suggest the potential role of SGRT for the management of internal interfractional anatomical variation in paediatric abdominal radiotherapy.
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Affiliation(s)
- Sabrina Taylor
- University College London, Centre for Medical Image Computing, London, United Kingdom
| | - Pei Lim
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Jessica Cantwell
- Radiotherapy, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Derek D’Souza
- Radiotherapy, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Syed Moinuddin
- Radiotherapy, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Yen-Ching Chang
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Mark N Gaze
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Jennifer Gains
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Catarina Veiga
- University College London, Centre for Medical Image Computing, London, United Kingdom
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4
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Boterberg T, Dunlea C, Harrabi S, Janssens G, Laprie A, Whitfield G, Gaze M. Contemporary paediatric radiation oncology. Arch Dis Child 2023; 108:332-337. [PMID: 35851293 DOI: 10.1136/archdischild-2021-323059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 07/03/2022] [Indexed: 11/03/2022]
Abstract
Treatment with ionising radiation is a valuable component of treatment schedules for a many children and young people with cancer. While some form of radiotherapy has been in use for over 100 years, a series of innovations has revolutionised paediatric radiation oncology. Mostly, high-energy X-ray photons are used, but proton beam radiotherapy is increasingly offered, especially in children and young people. This is to reduce the radiation exposure of healthy normal tissues and so the likelihood of adverse effects. Other methods of radiotherapy delivery include brachytherapy and molecular radiotherapy. The most appropriate treatment technique should be selected for every child. Advances in computers and imaging, developments in the technology of radiation delivery and a better understanding of pathology and molecular biology of cancer, coupled with parallel improvements in surgery and systemic therapy, have led to a transformation of practice in recent decades. Initially an empirical art form, radiotherapy for children has become a technically advanced, evidence-based cornerstone of increasingly personalised cancer medicine with solid scientific foundations. Late sequelae of treatment-the adverse effects once accepted as the cost of cure-have been significantly reduced in parallel with increased survival rates. The delivery of radiotherapy to children and young people requires a specialised multiprofessional team including radiation oncologists, therapeutic radiographers, play specialists and physicists among others. This article reviews the types of radiotherapy now available and outlines the pathway of the child through treatment. It aims to demonstrate to paediatricians how contemporary paediatric radiation oncology differs from past practice.
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Affiliation(s)
- Tom Boterberg
- Department of Radiotherapy, University of Ghent, Ghent, Belgium
| | - Cathy Dunlea
- Department of Radiotherapy, University College London Hospitals NHS Foundation Trust, London, UK
| | - Semi Harrabi
- Department of Radiotherapy, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Geert Janssens
- Department of Paediatric Oncology, Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Department of Radiotherapy, University Medical Centre, Utrecht, The Netherlands
| | - Anne Laprie
- Department of Radiotherapy, Institut Universitaire du Cancer Toulouse Oncopole, Toulouse, France
| | - Gillian Whitfield
- Department of Radiotherapy, Christie Hospital, Manchester, Manchester, UK
| | - Mark Gaze
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
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5
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Jazmati D, Brualla L, Littooij AS, Webber B, Dieckmann K, Janssens GO, Simon T, Gaze MN, Merta J, Serrano A, Dietzsch S, Kramer PH, Wulff J, Boterberg T, Timmermann B. Overcoming inter-observer planning variability in target volume contouring and dose planning for high-risk neuroblastoma - a European multicenter effort of the SIOPEN radiotherapy committee. Radiother Oncol 2023; 181:109464. [PMID: 36640946 DOI: 10.1016/j.radonc.2023.109464] [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: 09/03/2022] [Revised: 12/26/2022] [Accepted: 01/06/2023] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND PURPOSE To establish an international quality standard for contouring and planning for high-risk neuroblastoma within the prospective High-Risk Neuroblastoma Study 2 of SIOP-Europe-Neuroblastoma (SIOPEN HR-NBL2), which includes a randomized question on dose escalation for residual disease. MATERIALS AND METHODS Data on four patients with high-risk neuroblastoma were selected and distributed to the radiotherapy committee of the HR-NBL2 study for independent contouring and planning. Differences in contouring were analyzed using apparent and kappa-corrected agreement. Plans were analyzed regarding the dose-volume histogram metrics. Results were discussed among experts and agreement was obtained. RESULTS Substantial agreement was found for contouring of the heart (0.64), liver (0.70), left lung (0.74), and right lung (0.74). For contouring of the gastrointestinal tract (0.54), left kidney (0.60), and right kidney (0.59) moderate agreement was obtained. For target volume delineation, agreement for preoperative tumour extent was moderate (0.42), for CTV fair (0.35) and only low (0.06) for residual tumour, respectively. The dose planning strategies appeared to be relatively homogeneous among all experts. CONCLUSION Considerable variability was found for the delineation of target volumes, particularly the boost volume, whereas the contouring of the organs at risk and the planning strategy were reasonably consistent. In order to obtain reliable results from the randomized HR-NBL2 trial, standardization of target volume delineation based on adequate imaging is crucial.
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Affiliation(s)
- Danny Jazmati
- Department of Particle Therapy, University Hospital Essen, Germany; West German Proton Therapy Centre Essen (WPE), Germany; West German Cancer Center (WTZ), Germany.
| | - Lorenzo Brualla
- West German Proton Therapy Centre Essen (WPE), Germany; West German Cancer Center (WTZ), Germany; Faculty of Medicine, University of Duisburg-Essen, Germany
| | - Annemieke S Littooij
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands., the Netherlands; Princess Maxima Center for Pediatric Oncology, Utrecht, the Netherlands.
| | - Britta Webber
- Danish Centre of Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Karin Dieckmann
- Department of Radio-Oncology, Medical University of Vienna, Vienna, Austria
| | - Geert O Janssens
- Department of Radiation Oncology, University Medical Center Utrecht, and Princess Maxima Center for Pediatric Oncology, Utrecht, the Netherlands; Princess Maxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Thorsten Simon
- Pediatric Oncology and Hematology, University of Cologne, Cologne, Germany
| | - Mark N Gaze
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Julien Merta
- Department of Particle Therapy, University Hospital Essen, Germany; West German Proton Therapy Centre Essen (WPE), Germany
| | | | - Stefan Dietzsch
- Department of Radiation Oncology, University Hospital Leipzig, Leipzig, Germany
| | - Paul-Heinz Kramer
- West German Proton Therapy Centre Essen (WPE), Germany; West German Cancer Center (WTZ), Germany
| | - Jörg Wulff
- West German Proton Therapy Centre Essen (WPE), Germany; West German Cancer Center (WTZ), Germany
| | - Tom Boterberg
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Beate Timmermann
- Department of Particle Therapy, University Hospital Essen, Germany; West German Proton Therapy Centre Essen (WPE), Germany; West German Cancer Center (WTZ), Germany; German Cancer Consortium (DKTK), Germany
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6
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Smith K, Ulin K, Knopp M, Kry S, Xiao Y, Rosen M, Michalski J, Iandoli M, Laurie F, Quigley J, Reifler H, Santiago J, Briggs K, Kirby S, Schmitter K, Prior F, Saltz J, Sharma A, Bishop-Jodoin M, Moni J, Cicchetti MG, FitzGerald TJ. Quality improvements in radiation oncology clinical trials. Front Oncol 2023; 13:1015596. [PMID: 36776318 PMCID: PMC9911211 DOI: 10.3389/fonc.2023.1015596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 01/06/2023] [Indexed: 01/27/2023] Open
Abstract
Clinical trials have become the primary mechanism to validate process improvements in oncology clinical practice. Over the past two decades there have been considerable process improvements in the practice of radiation oncology within the structure of a modern department using advanced technology for patient care. Treatment planning is accomplished with volume definition including fusion of multiple series of diagnostic images into volumetric planning studies to optimize the definition of tumor and define the relationship of tumor to normal tissue. Daily treatment is validated by multiple tools of image guidance. Computer planning has been optimized and supported by the increasing use of artificial intelligence in treatment planning. Informatics technology has improved, and departments have become geographically transparent integrated through informatics bridges creating an economy of scale for the planning and execution of advanced technology radiation therapy. This serves to provide consistency in department habits and improve quality of patient care. Improvements in normal tissue sparing have further improved tolerance of treatment and allowed radiation oncologists to increase both daily and total dose to target. Radiation oncologists need to define a priori dose volume constraints to normal tissue as well as define how image guidance will be applied to each radiation treatment. These process improvements have enhanced the utility of radiation therapy in patient care and have made radiation therapy an attractive option for care in multiple primary disease settings. In this chapter we review how these changes have been applied to clinical practice and incorporated into clinical trials. We will discuss how the changes in clinical practice have improved the quality of clinical trials in radiation therapy. We will also identify what gaps remain and need to be addressed to offer further improvements in radiation oncology clinical trials and patient care.
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Affiliation(s)
- Koren Smith
- Imaging and Radiation Oncology Core-Rhode Island, Department of Radiation Oncology, UMass Chan Medical School, Lincoln, RI, United States
| | - Kenneth Ulin
- Imaging and Radiation Oncology Core-Rhode Island, Department of Radiation Oncology, UMass Chan Medical School, Lincoln, RI, United States
| | - Michael Knopp
- Imaging and Radiation Oncology Core-Ohio, Department of Radiology, The Ohio State University, Columbus, OH, United States
| | - Stephan Kry
- Imaging and Radiation Oncology Core-Houston, Division of Radiation Oncology, University of Texas, MD Anderson, Houston, TX, United States
| | - Ying Xiao
- Imaging and Radiation Oncology Core Philadelphia, Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, United States
| | - Mark Rosen
- Imaging and Radiation Oncology Core Philadelphia, Department of Radiology, University of Pennsylvania, Philadelphia, PA, United States
| | - Jeff Michalski
- Department of Radiation Oncology, Washington University, St Louis, MO, United States
| | - Matthew Iandoli
- Imaging and Radiation Oncology Core-Rhode Island, Department of Radiation Oncology, UMass Chan Medical School, Lincoln, RI, United States
| | - Fran Laurie
- Imaging and Radiation Oncology Core-Rhode Island, Department of Radiation Oncology, UMass Chan Medical School, Lincoln, RI, United States
| | - Jean Quigley
- Imaging and Radiation Oncology Core-Rhode Island, Department of Radiation Oncology, UMass Chan Medical School, Lincoln, RI, United States
| | - Heather Reifler
- Imaging and Radiation Oncology Core-Rhode Island, Department of Radiation Oncology, UMass Chan Medical School, Lincoln, RI, United States
| | - Juan Santiago
- Imaging and Radiation Oncology Core-Rhode Island, Department of Radiation Oncology, UMass Chan Medical School, Lincoln, RI, United States
| | - Kathleen Briggs
- Imaging and Radiation Oncology Core-Rhode Island, Department of Radiation Oncology, UMass Chan Medical School, Lincoln, RI, United States
| | - Shawn Kirby
- Imaging and Radiation Oncology Core-Rhode Island, Department of Radiation Oncology, UMass Chan Medical School, Lincoln, RI, United States
| | - Kate Schmitter
- Imaging and Radiation Oncology Core-Rhode Island, Department of Radiation Oncology, UMass Chan Medical School, Lincoln, RI, United States
| | - Fred Prior
- Department of Biomedical Informatics, University of Arkansas, Little Rock, AR, United States
| | - Joel Saltz
- Department of Biomedical Informatics, Stony Brook University, Stony Brook, NY, United States
| | - Ashish Sharma
- Department of Biomedical Informatics, Emory University, Atlanta, GA, United States
| | - Maryann Bishop-Jodoin
- Imaging and Radiation Oncology Core-Rhode Island, Department of Radiation Oncology, UMass Chan Medical School, Lincoln, RI, United States
| | - Janaki Moni
- Imaging and Radiation Oncology Core-Rhode Island, Department of Radiation Oncology, UMass Chan Medical School, Lincoln, RI, United States
| | - M. Giulia Cicchetti
- Imaging and Radiation Oncology Core-Rhode Island, Department of Radiation Oncology, UMass Chan Medical School, Lincoln, RI, United States
| | - Thomas J. FitzGerald
- Imaging and Radiation Oncology Core-Rhode Island, Department of Radiation Oncology, UMass Chan Medical School, Lincoln, RI, United States
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7
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Taylor S, Lim P, Ahmad R, Alhadi A, Harris W, Rompokos V, D'Souza D, Gaze M, Gains J, Veiga C. Risk of radiation-induced second malignant neoplasms from photon and proton radiotherapy in paediatric abdominal neuroblastoma. Phys Imaging Radiat Oncol 2021; 19:45-52. [PMID: 34307918 PMCID: PMC8295851 DOI: 10.1016/j.phro.2021.06.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/28/2021] [Accepted: 06/18/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND AND PURPOSE State-of-the-art radiotherapy modalities have the potential of reducing late effects of treatment in childhood cancer survivors. Our aim was to investigate the carcinogenic risk associated with 3D conformal (photon) radiation (3D-CRT), intensity modulated arc therapy (IMAT) and pencil beam scanning proton therapy (PBS-PT) in the treatment of paediatric abdominal neuroblastoma. MATERIALS AND METHODS The risk of radiation-induced second malignant neoplasm (SMN) was estimated using the concept of organ equivalent dose (OED) for eleven organs (lungs, rectum, colon, stomach, small intestine, liver, bladder, skin, central nervous system (CNS), bone, and soft tissues). The risk ratio (RR) between radiotherapy modalities and lifetime absolute risks (LAR) were reported for twenty abdominal neuroblastoma patients (median, 4y; range, 1-9y) historically treated with 3D-CRT that were also retrospectively replanned for IMAT and PBS-PT. RESULTS The risk of SMN due to primary radiation was reduced in PBS-PT against 3D-CRT and IMAT for most patients and organs. The RR across all organs ranged from 0.38 ± 0.22 (bladder) to 0.98 ± 0.04 (CNS) between PBS-PT and IMAT, and 0.12 ± 0.06 (rectum and bladder) to 1.06 ± 0.43 (bone) between PBS-PT and 3D-CRT. The LAR for most organs was within 0.01-1% (except the colon) with a cumulative risk of 21 ± 13%, 35 ± 14% and 35 ± 16% for PBS-PT, IMAT and 3D-CRT, respectively. CONCLUSIONS PBS-PT was associated with the lowest risk of radiation-induced SMN compared to IMAT and 3D-CRT in abdominal neuroblastoma treatment. Other clinical endpoints and plan robustness should also be considered for optimal plan selection.
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Affiliation(s)
- Sophie Taylor
- Centre for Medical Image Computing, Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Pei Lim
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Reem Ahmad
- Centre for Medical Image Computing, Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Ammar Alhadi
- Centre for Medical Image Computing, Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - William Harris
- Centre for Medical Image Computing, Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Vasilis Rompokos
- Radiotherapy Physics Services, University College London Hospitals NHS Foundation Trust, London, UK
| | - Derek D'Souza
- Radiotherapy Physics Services, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mark Gaze
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jennifer Gains
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Catarina Veiga
- Centre for Medical Image Computing, Department of Medical Physics and Biomedical Engineering, University College London, London, UK
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8
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FitzGerald TJ, Followill D, Laurie F, Boterberg T, Hanusik R, Kessel S, Karolczuk K, Iandoli M, Ulin K, Morano K, Bishop-Jodoin M, Kry S, Lowenstein J, Molineu A, Moni J, Cicchetti MG, Prior F, Saltz J, Sharma A, Mandeville HC, Bernier-Chastagner V, Janssens G. Quality assurance in radiation oncology. Pediatr Blood Cancer 2021; 68 Suppl 2:e28609. [PMID: 33818891 PMCID: PMC10578132 DOI: 10.1002/pbc.28609] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 07/06/2020] [Accepted: 07/08/2020] [Indexed: 11/08/2022]
Abstract
The Children's Oncology Group (COG) has a strong quality assurance (QA) program managed by the Imaging and Radiation Oncology Core (IROC). This program consists of credentialing centers and providing real-time management of each case for protocol compliant target definition and radiation delivery. In the International Society of Pediatric Oncology (SIOP), the lack of an available, reliable online data platform has been a challenge and the European Society for Paediatric Oncology (SIOPE) quality and excellence in radiotherapy and imaging for children and adolescents with cancer across Europe in clinical trials (QUARTET) program currently provides QA review for prospective clinical trials. The COG and SIOP are fully committed to a QA program that ensures uniform execution of protocol treatments and provides validity of the clinical data used for analysis.
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Affiliation(s)
| | | | - Fran Laurie
- Imaging and Radiation Oncology Core Rhode Island, Lincoln, Rhode Island
| | - Tom Boterberg
- Department of Radiation Oncology, Ghent University, Ghent, Belgium
| | - Richard Hanusik
- Imaging and Radiation Oncology Core Rhode Island, Lincoln, Rhode Island
| | - Sandra Kessel
- Imaging and Radiation Oncology Core Rhode Island, Lincoln, Rhode Island
| | - Kathryn Karolczuk
- Imaging and Radiation Oncology Core Rhode Island, Lincoln, Rhode Island
| | - Matthew Iandoli
- Imaging and Radiation Oncology Core Rhode Island, Lincoln, Rhode Island
| | - Kenneth Ulin
- Imaging and Radiation Oncology Core Rhode Island, Lincoln, Rhode Island
| | - Karen Morano
- Imaging and Radiation Oncology Core Rhode Island, Lincoln, Rhode Island
| | | | - Stephen Kry
- Imaging and Radiation Oncology Core Houston, Houston, Texas
| | | | - Andrea Molineu
- Imaging and Radiation Oncology Core Houston, Houston, Texas
| | - Janaki Moni
- Imaging and Radiation Oncology Core Rhode Island, Lincoln, Rhode Island
| | | | - Fred Prior
- Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Joel Saltz
- Department of Biomedical Informatics, Stony Brook University, Stony Brook, New York
| | - Ashish Sharma
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, Georgia
| | - Henry C Mandeville
- Children's and Young Person's Unit and Haemato-oncology Unit, The Royal Marsden NHS Foundation Trust, Surrey, UK
| | | | - Geert Janssens
- Radiation Therapy, Prinses Maxima - Center for Pediatric Oncology, Utrecht, The Netherlands
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Lim PS, Rompokos V, Bizzocchi N, Gillies C, Gosling A, Royle G, Chang YC, Gaze MN, Gains JE. Pencil Beam Scanning Proton Therapy Case Selection for Paediatric Abdominal Neuroblastoma: Effects of Tumour Location and Bowel Gas. Clin Oncol (R Coll Radiol) 2021; 33:e132-e142. [PMID: 32962907 DOI: 10.1016/j.clon.2020.08.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/28/2020] [Indexed: 12/12/2022]
Abstract
AIMS Pencil beam scanning (PBS) proton therapy is an increasingly used radiation modality for childhood malignancies due to its ability to minimise dose to surrounding organs. However, the dosimetry is extremely sensitive to anatomical and density changes. The aims of this study were to investigate if there is a dosimetric benefit or detriment with PBS for paediatric abdominal neuroblastoma, assess gastrointestinal air variability and its dosimetric consequences, plus identify if there are factors that could assist case selection for PBS referral. MATERIALS AND METHODS Twenty neuroblastoma cases were double-planned with PBS and intensity-modulated arc therapy (IMAT). Cases were divided into unilateral, midline unilateral and midline bilateral locations in relation to the kidneys. Plans were recalculated after the gastrointestinal volume was simulated as air (Hounsfield Units -700) and water (Hounsfield Units 0), then compared with nominal plans (recalculated - nominal, ΔD). Forty-three weekly cone beam computed tomography scans were analysed to quantify gastrointestinal air variability during treatment. RESULTS PBS reduced the mean dose to normal tissues at all tumour locations, particularly unilateral tumours. However, 15% had better dosimetry with IMAT, all of which were midline tumours. Increased gastrointestinal air caused significant compromises to PBS versus IMAT plans for midline tumours [median/maximum ΔD95% clinical target volume (CTV) -2.4%/-15.7% PBS versus 1.4%/0% IMAT, P = 0.003], whereas minimal impact was observed for unilateral tumours (ΔD95% CTV -0.5%/-1.9% PBS versus 0.5%/-0.5% IMAT, P = 0.008). D95% CTV was significantly decreased in PBS plans if planning target volume (PTV) ≥400 cm3 (median -4.1%, P = 0.001) or PTV extension ≥60% anterior to vertebral body (-2.1%, P = 0.002). A larger variation in gastrointestinal air was observed in patients treated under general anaesthesia (median 38.4%) versus awake (11.5%); P = 0.004. CONCLUSION In this planning study, tumours at the unilateral location consistently showed improved dose reductions to normal tissue with minimal dose degradation from increased gastrointestinal air with PBS plans. Tumour location, PTV volume and anterior extension of PTV are useful characteristics in facilitating patient selection for PBS.
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Affiliation(s)
- P S Lim
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK; Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - V Rompokos
- Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, UK
| | - N Bizzocchi
- Centre for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - C Gillies
- Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, UK
| | - A Gosling
- Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, UK
| | - G Royle
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK; Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Y-C Chang
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - M N Gaze
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - J E Gains
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK.
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10
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Zhao Q, Liu Y, Zhang Y, Meng L, Wei J, Wang B, Wang H, Xin Y, Dong L, Jiang X. Role and toxicity of radiation therapy in neuroblastoma patients: A literature review. Crit Rev Oncol Hematol 2020; 149:102924. [PMID: 32172225 DOI: 10.1016/j.critrevonc.2020.102924] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 02/13/2020] [Accepted: 03/02/2020] [Indexed: 11/16/2022] Open
Abstract
Neuroblastoma is the most common extracranial solid tumor, arising from primitive sympathetic ganglion cells, in pediatric patients. The unique features of neuroblastoma include variable clinical behaviors, such as rapid progression to death and maturation to benign ganglioneuroma, followed by regression. Radiation therapy (RT) is usually administered to both the primary tumor bed and persistent metastatic sites after induction chemotherapy for high-risk neuroblastoma. RT to the tumor bed after surgical resection contributes significantly to local disease control and prevention of local relapse, confirming the role of RT. Palliative radiotherapy for metastatic neuroblastoma is also effective and safe and mainly provides symptomatic relief. The late side effects of RT in neuroblastoma patients include growth and developmental failure, hypothyroidism, gastrointestinal dysfunction, neurocognitive defects, pulmonary and cardiac abnormalities, infertility, and secondary cancers. In this article, we reviewed the role and toxicity of RT in neuroblastoma patients.
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Affiliation(s)
- Qin Zhao
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun, 130021, China.
| | - Yang Liu
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun, 130021, China.
| | - Yuyu Zhang
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun, 130021, China.
| | - Lingbin Meng
- Department of Internal Medicine, Florida Hospital, Orlando, FL, 32803, USA.
| | - Jinlong Wei
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun, 130021, China.
| | - Bin Wang
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun, 130021, China.
| | - Huanhuan Wang
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun, 130021, China.
| | - Ying Xin
- Key Laboratory of Pathobiology, Ministry of Education, Jilin University, Changchun, 130021, China.
| | - Lihua Dong
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun, 130021, China.
| | - Xin Jiang
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun, 130021, China.
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11
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Guérin F, Rogers T, Minard-Colin V, Gaze MN, Terwisscha S, Van Noesel M, De Corti F, Guillén Burrieza G, De Salvo GL, Kelsey A, Orbach D, Ferrari A, Bergeron C, Bisogno G, Martelli H. Outcome of localized liver-bile duct rhabdomyosarcoma according to local therapy: A report from the European Paediatric Soft-Tissue Sarcoma Study Group (EpSSG)-RMS 2005 study. Pediatr Blood Cancer 2019; 66:e27725. [PMID: 30920113 DOI: 10.1002/pbc.27725] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 03/06/2019] [Accepted: 03/08/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To evaluate the impact of local therapies on the outcome of patients with liver-bile duct rhabdomyosarcoma (LBDRMS). METHODS Data of 30 patients included in the EpSSG-RMS 2005 study were analyzed. RESULTS The median age at diagnosis was 3 years (11 months-8 years). All patients had non-alveolar histology. Fifteen patients had a tumor > 5 cm and six had enlarged regional lymph nodes on imaging. Eight patients (27%) had primary surgery (1 R0). Six of them received external beam radiotherapy (EBRT). All are in first complete remission (CR1) except one (R1, EBRT+ , local relapse, death). Six patients (20%) received EBRT without surgery: one had local relapse and died. Sixteen patients (53%) underwent delayed surgery, with 12 achieving R0 margins, which were higher than those in the primary surgery group (P = 0.003). Three patients with R0 margins received EBRT; one had a metastatic relapse and died. Nine patients with R0 resection did not receive EBRT, three relapsed locally (two deaths). Four R1 patients received additional EBRT without relapses. Local relapse occurred in two among 19 patients with EBRT and three among 11 without EBRT (P = 0.326). At a median follow-up of 61 months (48-84 months), five patients died; all had a tumor size > 5 cm (P = 0.01). The five-year overall survival was 85% (95% CI, 65-94), and event-free survival was 76% (95% CI, 54-89). CONCLUSION This analysis did not show any significant difference in outcome between irradiated and nonirradiated patients. Local relapse in LBDRMS is related to initial tumor size and is often fatal.
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Affiliation(s)
- Florent Guérin
- Department of Paediatric Surgery, Bicêtre Hospital, Hôpitaux Universitaires Paris-Sud, Le Kremlin-Bicetre, France
| | - Timothy Rogers
- Department of Paediatric Surgery, University Hospitals Bristol NHS Foundation trust, Bristol, United Kingdom
| | - Véronique Minard-Colin
- Département d'Oncologie de l'Enfant et de l'Adolescent, Institut Gustave Roussy, Villejuif, France
| | - Mark N Gaze
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Sheila Terwisscha
- Department of Paediatric Surgery, Prinses Máxima Centrum voor Kinderoncologie, Utrecht, the Netherlands
| | - Max Van Noesel
- Department of Paediatric Surgery, Prinses Máxima Centrum voor Kinderoncologie, Utrecht, the Netherlands
| | - Federica De Corti
- Pediatric Surgery Unit, Department of Woman's and Child's Health, University Hospital of Padova, Padova, Italy
| | | | - Gian Luca De Salvo
- Clinical Trials and Biostatistics Unit, Istituto Oncologico Veneto IOV-IRCCS, Padova, Italy
| | - Anna Kelsey
- Department of Paediatric Histopathology, Royal Manchester Children Hospital, Manchester, United Kingdom
| | - Daniel Orbach
- SIREDO Oncology Center (Care, Innovation and Research for Children, Adolescents and Young Adults with Cancer), Institut Curie, PSL University, Paris, France
| | - Andrea Ferrari
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - Christophe Bergeron
- Institut d'Hématologie et d'Oncologie Pédiatrique, Centre Léon Bérard, Lyon, France
| | - Gianni Bisogno
- Hematology Oncology Division, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Hélène Martelli
- Department of Paediatric Surgery, Bicêtre Hospital, Hôpitaux Universitaires Paris-Sud, Le Kremlin-Bicetre, France
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12
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Lavan NA, Saran FH, Oelfke U, Mandeville HC. Adopting Advanced Radiotherapy Techniques in the Treatment of Paediatric Extracranial Malignancies: Challenges and Future Directions. Clin Oncol (R Coll Radiol) 2019; 31:50-57. [PMID: 30361128 DOI: 10.1016/j.clon.2018.08.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 08/01/2018] [Indexed: 12/25/2022]
Abstract
Geometric uncertainties in radiotherapy are conventionally addressed by defining a safety margin around the radiotherapy target. Misappropriation of such margins could result in disease recurrence from geometric miss or unnecessary irradiation of normal tissue. Numerous quantitative organ motion studies in adults have been published, but the first paediatric-specific studies were only published in recent years. In the very near future, intensity-modulated proton beam therapy and magnetic resonance-guided radiotherapy will be clinically implemented in the UK. Such techniques offer the ability to deliver radiotherapy to the pinnacle of precision and accuracy, if geometric uncertainty relating to internal organ motion and deformation can be optimally managed. The optimal margin to account for internal organ motion in children remains largely undefined. Continuing efforts to characterise motion in children and young people is necessary to optimally define safety margins and to realise the full potential of intensity-modulated radiotherapy, magnetic resonance-guided radiotherapy and intensity-modulated proton beam therapy. This overview offers a timely review of published reports on paediatric organ motion, in anticipation of the increasing application of advanced radiotherapy techniques in paediatric radiotherapy.
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Affiliation(s)
- N A Lavan
- The Institute of Cancer Research, Sutton, UK.
| | - F H Saran
- The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - U Oelfke
- Joint Department of Physics at the Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, Sutton, UK
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13
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Arumugam S, Manning-Cork NJ, Gains JE, Boterberg T, Gaze MN. The Evidence for External Beam Radiotherapy in High-Risk Neuroblastoma of Childhood: A Systematic Review. Clin Oncol (R Coll Radiol) 2018; 31:182-190. [PMID: 30509728 DOI: 10.1016/j.clon.2018.11.031] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 10/27/2018] [Indexed: 12/15/2022]
Abstract
AIMS External beam radiotherapy is widely used in various ways in the management of neuroblastoma. Despite extensive clinical experience, the precise role of radiotherapy in neuroblastoma remains unclear. The purpose of this systematic review was to survey the published literature to identify, without bias, the evidence for the clinical effectiveness of external beam radiotherapy as part of the initial multimodality treatment of high-risk neuroblastoma. We considered four areas: treatment of the tumour bed and residual primary tumour, identification of any dose-response relationship, treatment of metastatic sites, identification of any technical advances that may be beneficial. We also aimed to define uncertainties, which may be clarified in future clinical trials. MATERIALS AND METHODS Bibliographic databases were searched for neuroblastoma and radiotherapy. Reviewers assessed 1283 papers for inclusion by title and abstract, with consensus achieved through discussion. Data extraction on 57 included papers was carried out by one reviewer and checked by another. Studies were assessed for their level of evidence and risk of bias, and a descriptive analysis of data was carried out. RESULTS Fifteen papers provided some evidence that radiotherapy to the tumour bed and residual tumour may possibly be of value. However, there is a significant risk of bias and no evidence that all subgroups will benefit. There is some suggestion from six papers that dose may be important, but no hard evidence. It remains unclear whether irradiation of metastatic sites is helpful. Technical advances may be of value in radiotherapy of high-risk neuroblastoma. CONCLUSIONS There are data that show that radiotherapy is of some efficacy in the management of high-risk neuroblastoma, but there is no level one evidence that shows that it is being used in the best possible way. Prospective randomised trials are necessary to provide more evidence to guide development of optimal radiotherapy treatment schedules.
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Affiliation(s)
- S Arumugam
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - N J Manning-Cork
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - J E Gains
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - T Boterberg
- Department of Radiation Oncology, Ghent University Hospital, Gent, Belgium
| | - M N Gaze
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK.
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Long-term side effects of radiotherapy for pediatric localized neuroblastoma : results from clinical trials NB90 and NB94. Strahlenther Onkol 2015; 191:604-12. [PMID: 25896312 DOI: 10.1007/s00066-015-0837-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 03/25/2015] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Neuroblastoma (NB) is the most frequent indication for extracranial pediatric radiotherapy. As long-term survival of high-risk localized NB has greatly improved, we reviewed treatment-related late toxicities in pediatric patients who received postoperative radiotherapy (RT) for localized NB within two French prospective clinical trials: NB90 and NB94. PATIENTS AND METHODS From 1990-2000, 610 children were enrolled. Among these, 35 were treated with induction chemotherapy, surgery, and RT. The recommended RT dose was 24 Gy at ≤ 2 years, 34 Gy at > 2 years, ± a 5 Gy boost in both age groups. RESULTS The 22 patients still alive after 5 years were analyzed. The median follow-up time was 14 years (range 5-21 years). Late effects after therapy occurred in 73 % of patients (16/22), within the RT field for 50 % (11/22). The most frequent in-field effects were musculoskeletal abnormalities (n = 7) that occurred only with doses > 31 Gy/1.5 Gy fraction (p = 0.037). Other effects were endocrine in 3 patients and second malignancies in 2 patients. Four patients presented with multiple in-field late effects only with doses > 31 Gy. CONCLUSION After a median follow-up of 14 years, late effects with multimodality treatment were frequent. The most frequent effects were musculoskeletal abnormalities and the threshold for their occurrence was 31 Gy.
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15
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Treatment of high-risk neuroblastoma in children: recent clinic trial results. ACTA ACUST UNITED AC 2013. [DOI: 10.4155/cli.13.90] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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