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Sienna J, Kahalley LS, Mabbott D, Grosshans D, Santiago AT, Paulino ADC, Merchant TE, Manzar GS, Dama H, Hodgson DC, Chintagumpala M, Okcu MF, Whitehead WE, Laperriere N, Ramaswamy V, Bartels U, Tabori U, Bennett JM, Das A, Craig T, Tsang DS. Proton Therapy Mediates Dose Reductions to Brain Structures Associated With Cognition in Children With Medulloblastoma. Int J Radiat Oncol Biol Phys 2024; 119:200-207. [PMID: 38040059 PMCID: PMC11023754 DOI: 10.1016/j.ijrobp.2023.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 10/27/2023] [Accepted: 11/19/2023] [Indexed: 12/03/2023]
Abstract
PURPOSE Emerging evidence suggests proton radiation therapy may offer cognitive sparing advantages over photon radiation therapy, yet dosimetry has not been compared previously. The purpose of this study was to examine dosimetric correlates of cognitive outcomes in children with medulloblastoma treated with proton versus photon radiation therapy. METHODS AND MATERIALS In this retrospective, bi-institutional study, dosimetric and cognitive data from 75 patients (39 photon and 36 proton) were analyzed. Doses to brain structures were compared between treatment modalities. Linear mixed-effects models were used to create models of global IQ and cognitive domain scores. RESULTS The mean dose and dose to 40% of the brain (D40) were 2.7 and 4.1 Gy less among proton-treated patients compared with photon-treated patients (P = .03 and .007, respectively). Mean doses to the left and right hippocampi were 11.2 Gy lower among proton-treated patients (P < .001 for both). Mean doses to the left and right temporal lobes were 6.9 and 7.1 Gy lower with proton treatment, respectively (P < .001 for both). Models of cognition found statistically significant associations between higher mean brain dose and reduced verbal comprehension, increased right temporal lobe D40 with reduced perceptual reasoning, and greater left temporal mean dose with reduced working memory. Higher brain D40 was associated with reduced processing speed and global IQ scores. CONCLUSIONS Proton therapy reduces doses to normal brain structures compared with photon treatment. This leads to reduced cognitive decline after radiation therapy across multiple intellectual endpoints. Proton therapy should be offered to children receiving radiation for medulloblastoma.
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Affiliation(s)
- Julianna Sienna
- Juravinski Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada.
| | - Lisa S Kahalley
- Division of Psychology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Donald Mabbott
- Department of Psychology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - David Grosshans
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Anna Theresa Santiago
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | | | - Thomas E Merchant
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Gohar S Manzar
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hitesh Dama
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - David C Hodgson
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Murali Chintagumpala
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Mehmet Fatih Okcu
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - William E Whitehead
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Normand Laperriere
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Vijay Ramaswamy
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ute Bartels
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Uri Tabori
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Julie M Bennett
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Anirban Das
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Tim Craig
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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Sekely A, Zakzanis KK, Mabbott D, Tsang DS, Kongkham P, Zadeh G, Edelstein K. Long-term neurocognitive and psychological outcomes in meningioma survivors: Individual changes over time and radiation dosimetry. Neurooncol Pract 2024; 11:157-170. [PMID: 38496914 PMCID: PMC10940838 DOI: 10.1093/nop/npad072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024] Open
Abstract
Background This study investigates long-term changes in neurocognitive performance and psychological symptoms in meningioma survivors and associations with radiation dose to circumscribed brain regions. Methods We undertook a retrospective study of meningioma survivors who underwent longitudinal clinical neurocognitive assessments. Change in neurocognitive performance or psychological symptoms was assessed using reliable change indices. Radiation dosimetry, if prescribed, was evaluated based on treatment-planning computerized tomography co-registered with contrast-enhanced 3D T1-weighted magnetic resonance imaging. Mixed effects analyses were used to explore whether incidental radiation to brain regions outside the tumor influences neurocognitive and psychological outcomes. Results Most (range = 41%-93%) survivors demonstrated stable-albeit often below average-neurocognitive and psychological trajectories, although some also exhibited improvements (range = 0%-31%) or declines (range = 0%-36%) over time. Higher radiation dose to the parietal-occipital region (partial R2 = 0.462) and cerebellum (partial R2 = 0.276) was independently associated with slower visuomotor processing speed. Higher dose to the hippocampi was associated with increases in depression (partial R2 = 0.367) and trait anxiety (partial R2 = 0.236). Conclusions Meningioma survivors experience neurocognitive deficits and psychological symptoms many years after diagnosis, and a proportion of them decline over time. This study offers proof of concept that incidental radiation to brain regions beyond the tumor site may contribute to these sequelae. Future investigations should include radiation dosimetry when examining risk factors that contribute to the quality of survivorship in this growing population.
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Affiliation(s)
- Angela Sekely
- Graduate Department of Psychological Clinical Science, University of Toronto, Toronto, Ontario, Canada
- Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Konstantine K Zakzanis
- Graduate Department of Psychological Clinical Science, University of Toronto, Toronto, Ontario, Canada
- Department of Psychology, University of Toronto, Toronto, Ontario, Canada
| | - Donald Mabbott
- Department of Psychology, University of Toronto, Toronto, Ontario, Canada
- Department of Psychology, Neurosciences, and Mental Health Program, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paul Kongkham
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Gelareh Zadeh
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Kim Edelstein
- Graduate Department of Psychological Clinical Science, University of Toronto, Toronto, Ontario, Canada
- Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
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Jabbour SK, Kumar R, Anderson B, Chino JP, Jethwa KR, McDowell L, Lo AC, Owen D, Pollom EL, Tree AC, Tsang DS, Yom SS. Combinatorial Approaches for Chemotherapies and Targeted Therapies With Radiation: United Efforts to Innovate in Patient Care. Int J Radiat Oncol Biol Phys 2024; 118:1240-1261. [PMID: 38216094 DOI: 10.1016/j.ijrobp.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 01/05/2024] [Indexed: 01/14/2024]
Abstract
Combinatorial therapies consisting of radiation therapy (RT) with systemic therapies, particularly chemotherapy and targeted therapies, have moved the needle to augment disease control across nearly all disease sites for locally advanced disease. Evaluating these important combinations to incorporate more potent therapies with RT will aid our understanding of toxicity and efficacy for patients. This article discusses multiple disease sites and includes a compilation of contributions from expert Red Journal editors from each disease site. Leveraging improved systemic control with novel agents, we must continue efforts to study novel treatment combinations with RT.
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Affiliation(s)
- Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Jersey.
| | - Ritesh Kumar
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Jersey
| | - Bethany Anderson
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Junzo P Chino
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Krishan R Jethwa
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Lachlan McDowell
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Australia
| | - Andrea C Lo
- Department of Radiation Oncology, BC Cancer Vancouver Centre, Vancouver, British Columbia, Canada
| | - Dawn Owen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Erqi L Pollom
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Alison C Tree
- Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Sue S Yom
- Department of Radiation Oncology, University of California San Francisco, California
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Ritchie T, Awrey S, Maganti M, Chahin R, Velec M, Hodgson DC, Dama H, Ahmed S, Winter JD, Laperriere N, Tsang DS. Paediatric radiation therapy without anaesthesia - Are the children moving? Radiother Oncol 2024; 193:110120. [PMID: 38311029 DOI: 10.1016/j.radonc.2024.110120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/16/2024] [Accepted: 01/24/2024] [Indexed: 02/06/2024]
Abstract
PURPOSE Children who require radiation therapy (RT) should ideally be treated awake, without anaesthesia, if possible. Audiovisual distraction is a known method to facilitate awake treatment, but its effectiveness at keeping children from moving during treatment is not known. The aim of this study was to evaluate intrafraction movement of children receiving RT while awake. METHODS In this prospective study, we measured the intrafraction movement of children undergoing treatment with fractionated RT, using pre- and post-RT cone beam CT (CBCT) with image matching on bony anatomy. Study CBCTs were acquired at first fraction, weekly during RT, and at last fraction. The primary endpoint was the magnitude of vector change between the pre- and post-RT scans. Our hypothesis was that 90 % of CBCT acquisitions would have minimal movement, defined as <3 mm for head-and-neck (HN) treatments and <5 mm for non-HN treatments. RESULTS A total of 65 children were enrolled and had evaluable data across 302 treatments with CBCT acquisitions. Median age was 11 years (range, 2-18; 1st and 3rd quartiles 7 and 14 years, respectively). Minimal movement was observed in 99.4 % of HN treatments and 97.2 % of non-HN treatments. The study hypothesis of >90 % of evaluations having minimal movement was met. Children who were age >11 years moved less at initial evaluation but tended to move more as a course of radiation progressed, as compared to children who were younger. CONCLUSION Children receiving RT with audiovisual distraction while awake had small magnitudes of observed intrafraction movement, with minimal movement in >97 % of observed RT fractions. This study validates methods of anaesthesia avoidance using audiovisual distraction for selected children.
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Affiliation(s)
- Tatiana Ritchie
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Ave, Toronto, ON, M5G 2M9, Canada
| | - Susan Awrey
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Ave, Toronto, ON, M5G 2M9, Canada
| | - Manjula Maganti
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, 610, University Ave, Toronto, ON, M5G 2M9, Canada
| | - Rehab Chahin
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Ave, Toronto, ON, M5G 2M9, Canada
| | - Michael Velec
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Ave, Toronto, ON, M5G 2M9, Canada
| | - David C Hodgson
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Ave, Toronto, ON, M5G 2M9, Canada
| | - Hitesh Dama
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Ave, Toronto, ON, M5G 2M9, Canada
| | - Sameera Ahmed
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Ave, Toronto, ON, M5G 2M9, Canada
| | - Jeff D Winter
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Ave, Toronto, ON, M5G 2M9, Canada
| | - Normand Laperriere
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Ave, Toronto, ON, M5G 2M9, Canada
| | - Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Ave, Toronto, ON, M5G 2M9, Canada.
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Tsang DS, Tsui G, Santiago AT, Keller H, Purdie T, Mcintosh C, Bauman G, La Macchia N, Parent A, Dama H, Ahmed S, Laperriere N, Millar BA, Liu V, Hodgson DC. A Prospective Study of Machine Learning-Assisted Radiation Therapy Planning for Patients Receiving 54 Gy to the Brain. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00334-1. [PMID: 38432285 DOI: 10.1016/j.ijrobp.2024.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 01/11/2024] [Accepted: 02/10/2024] [Indexed: 03/05/2024]
Abstract
PURPOSE The capacity for machine learning (ML) to facilitate radiation therapy (RT) planning for primary brain tumors has not been described. We evaluated ML-assisted RT planning with regard to clinical acceptability, dosimetric outcomes, and planning efficiency for adults and children with primary brain tumors. METHODS AND MATERIALS In this prospective study, children and adults receiving 54 Gy fractionated RT for a primary brain tumor were enrolled. For each patient, one ML-assisted RT plan was created and compared with 1 or 2 plans created using standard ("manual") planning procedures. Plans were evaluated by the treating oncologist, who was blinded to the method of plan creation. The primary endpoint was the proportion of ML plans that were clinically acceptable for treatment. Secondary endpoints included the frequency with which ML plans were selected as preferable for treatment, and dosimetric differences between ML and manual plans. RESULTS A total of 116 manual plans and 61 ML plans were evaluated across 61 patients. Ninety-four percent of ML plans and 93% of manual plans were judged to be clinically acceptable (P = 1.0). Overall, the quality of ML plans was similar to manual plans. ML plans comprised 34.5% of all plans evaluated and were selected for treatment in 36.1% of cases (P = .82). Similar tumor target coverage was achieved between both planning methods. Normal brain (brain minus planning target volume) received an average of 1 Gy less mean dose with ML plans (compared with manual plans, P < .001). ML plans required an average of 45.8 minutes less time to create, compared with manual plans (P < .001). CONCLUSIONS ML-assisted automated planning creates high-quality plans for patients with brain tumors, including children. Plans created with ML assistance delivered slightly less dose to normal brain tissues and can be designed in less time.
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Affiliation(s)
- Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
| | - Grace Tsui
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Anna T Santiago
- Department of Biostatistics, University Health Network, Toronto, Ontario, Canada
| | - Harald Keller
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Thomas Purdie
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Techna Institute, University Health Network, Toronto, Ontario, Canada
| | - Chris Mcintosh
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Techna Institute, University Health Network, Toronto, Ontario, Canada
| | - Glenn Bauman
- London Regional Cancer Program, London, Ontario, Canada
| | - Nancy La Macchia
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Amy Parent
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Hitesh Dama
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Sameera Ahmed
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Normand Laperriere
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Barbara-Ann Millar
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Valerie Liu
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - David C Hodgson
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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Schaub SK, Oh J, Menghini AM, Taylor MR, Blau MH, Murphy B, Lo A, Chapple A, Rosenberg AR, Ermoian RP, Tsang DS. Little patients, big impacts: a narrative review of palliative and emergent radiotherapy for pediatric cancers. Ann Palliat Med 2024; 13:355-372. [PMID: 38247450 DOI: 10.21037/apm-23-505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 12/11/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND AND OBJECTIVE The use of radiotherapy (RT) in the palliative and emergent settings for pediatric cancers is an under-utilized resource. Our objective was to provide an evidence-based review of the data to increase awareness of the benefit for this population along with providing guidance on pediatric specific treatment considerations for palliative care physicians, pediatric oncologists, and radiation oncologists. METHODS A narrative review was performed querying PubMed, MEDLINE, ClinicalTrials.gov databases, and supplemented with review articles, survey studies, current and recent clinical trials. When limited data existed, well-designed retrospective and prospective studies in the adult setting were evaluated and expert opinion was provided from pediatric oncologists. KEY CONTENT AND FINDINGS Pediatric specific treatment considerations include the use of anesthesia, impact of treatment on the developing child, and logistical challenges of RT. Treatment modality and dose selection are driven by histology and symptomatic site of pain, where we discuss detailed recommendations for hematologic, central nervous system, and solid tumors. For palliative RT, an underlying principle of searching for the lowest effective dose to balance response rate with minimal acute and late treatment related morbidity and logistical hardships is of paramount importance when caring for a pediatric patient. Lastly, we outline how to effectively communicate this option to patients and their caregivers. CONCLUSIONS Palliative RT can be of valuable benefit in most settings for patients with pediatric cancer. There is an unmet need for prospective data to inform on dose-fractionation along with patient and caregiver reported outcomes.
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Affiliation(s)
- Stephanie K Schaub
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Justin Oh
- British Columbia Cancer Agency, Vancouver, Canada
| | - Anthony M Menghini
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Mallory R Taylor
- Division of Hematology/Oncology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA; Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Molly H Blau
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Blair Murphy
- Department of Radiation Medicine, Oregon Health & Sciences University, Portland, OR, USA
| | - Andrea Lo
- British Columbia Cancer Agency, Vancouver, Canada
| | - Alayne Chapple
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Abby R Rosenberg
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Pediatric Palliative Care, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Ralph P Ermoian
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
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Anthes VB, Schwartz M, Cusimano M, Radovanovic I, Kulkarni AV, Laperriere N, Payne D, Heaton R, van Prooijen M, Das S, Tsang DS. Effect of Cobalt-60 Treatment Dose Rate on Arteriovenous Malformation Obliteration After Stereotactic Radiosurgery With Gamma Knife. Neurosurgery 2024; 94:575-583. [PMID: 37796152 DOI: 10.1227/neu.0000000000002701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 08/02/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Stereotactic radiosurgery (SRS) marginal dose is associated with successful obliteration of cerebral arteriovenous malformations (AVM). SRS dose rate-how old the cobalt-60 sources are-is known to influence outcomes for some neurological conditions and benign tumors. The objective of this study was to determine the association between cobalt-60 treatment dose rate and cerebral AVM obliteration in patients treated with SRS. METHODS We performed a retrospective cohort study of 361 patients undergoing 411 AVM-directed SRS treatments between 2005 and 2019 at a single institution. Lesion characteristics, SRS details, obliteration dates, and post-treatment toxicities were recorded. Univariate and multivariate regression analyses of AVM outcomes regarding SRS dose rate (range 1.3-3.7 Gy, mean = 2.4 Gy, median = 2.5 Gy) were performed. RESULTS At 10 years post-SRS, 68% of AVMs were obliterated on follow-up imaging. Dose rates >2.9 Gy/min were found to be significantly associated with AVM obliteration compared with those <2.1 Gy/min ( P = .034). AVM size, biologically effective dose, and SRS marginal dose were also associated with obliteration, with obliteration more likely for smaller lesions, higher biologically effective dose, and higher marginal dose. Higher dose rates were not associated with the development of post-SRS radiological or symptomatic edema, although larger AVM volume was associated with both types of edema. CONCLUSION Patients with cerebral AVMs treated with higher SRS dose rates (from newer cobalt-60 sources) experience higher incidences of obliteration without a significant change in the risk of post-treatment edema.
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Affiliation(s)
- Victoria B Anthes
- Radiation Medicine Program, Princess Margaret Cancer Centre and Toronto Western Hospital, University Health Network, Toronto , Ontario , Canada
| | - Michael Schwartz
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto , Ontario , Canada
| | - Michael Cusimano
- Division of Neurosurgery, St. Michael's Hospital, Unity Health Toronto, Toronto , Ontario , Canada
| | - Ivan Radovanovic
- Division of Neurosurgery, University Health Network, Toronto , Ontario , Canada
| | - Abhaya V Kulkarni
- Division of Neurosurgery, The Hospital for Sick Children, Toronto , Ontario , Canada
| | - Normand Laperriere
- Radiation Medicine Program, Princess Margaret Cancer Centre and Toronto Western Hospital, University Health Network, Toronto , Ontario , Canada
| | - David Payne
- Radiation Medicine Program, Princess Margaret Cancer Centre and Toronto Western Hospital, University Health Network, Toronto , Ontario , Canada
| | - Robert Heaton
- Radiation Medicine Program, Princess Margaret Cancer Centre and Toronto Western Hospital, University Health Network, Toronto , Ontario , Canada
| | - Monique van Prooijen
- Radiation Medicine Program, Princess Margaret Cancer Centre and Toronto Western Hospital, University Health Network, Toronto , Ontario , Canada
| | - Sunit Das
- Division of Neurosurgery, St. Michael's Hospital, Unity Health Toronto, Toronto , Ontario , Canada
| | - Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre and Toronto Western Hospital, University Health Network, Toronto , Ontario , Canada
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Dhoot AS, Ahmed Y, Tsang DS, Micieli JA. Rapid Onset Bitemporal Hemianopia as the Presenting Sign of Metastatic Adenocarcinoma of the Lung. J Neuroophthalmol 2024; 44:e184-e186. [PMID: 36542546 DOI: 10.1097/wno.0000000000001756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Arjan S Dhoot
- Faculty of Medicine (ASD), University of Toronto, Toronto, Canada; Institute of Biomedical Engineering (ASD), Faculty of Applied Science and Engineering, University of Toronto, Toronto, Canada; Department of Family Medicine (YA), Dalhousie University, Halifax, Canada; Radiation Medicine Program (DST), Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; and Department of Ophthalmology and Vision Sciences (JAM), University of Toronto, Toronto, Canada
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Das A, Fernandez NR, Levine A, Bianchi V, Stengs LK, Chung J, Negm L, Dimayacyac JR, Chang Y, Nobre L, Ercan AB, Sanchez-Ramirez S, Sudhaman S, Edwards M, Larouche V, Samuel D, Van Damme A, Gass D, Ziegler DS, Bielack SS, Koschmann C, Zelcer S, Yalon-Oren M, Campino GA, Sarosiek T, Nichols KE, Loret De Mola R, Bielamowicz K, Sabel M, Frojd CA, Wood MD, Glover JM, Lee YY, Vanan M, Adamski JK, Perreault S, Chamdine O, Hjort MA, Zapotocky M, Carceller F, Wright E, Fedorakova I, Lossos A, Tanaka R, Osborn M, Blumenthal DT, Aronson M, Bartels U, Huang A, Ramaswamy V, Malkin D, Shlien A, Villani A, Dirks PB, Pugh TJ, Getz G, Maruvka YE, Tsang DS, Ertl-Wagner B, Hawkins C, Bouffet E, Morgenstern DA, Tabori U. Combined Immunotherapy Improves Outcome for Replication-Repair-Deficient (RRD) High-Grade Glioma Failing Anti-PD-1 Monotherapy: A Report from the International RRD Consortium. Cancer Discov 2024; 14:258-273. [PMID: 37823831 PMCID: PMC10850948 DOI: 10.1158/2159-8290.cd-23-0559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/28/2023] [Accepted: 10/10/2023] [Indexed: 10/13/2023]
Abstract
Immune checkpoint inhibition (ICI) is effective for replication-repair-deficient, high-grade gliomas (RRD-HGG). The clinical/biological impact of immune-directed approaches after failing ICI monotherapy is unknown. We performed an international study on 75 patients treated with anti-PD-1; 20 are progression free (median follow-up, 3.7 years). After second progression/recurrence (n = 55), continuing ICI-based salvage prolonged survival to 11.6 months (n = 38; P < 0.001), particularly for those with extreme mutation burden (P = 0.03). Delayed, sustained responses were observed, associated with changes in mutational spectra and the immune microenvironment. Response to reirradiation was explained by an absence of deleterious postradiation indel signatures (ID8). CTLA4 expression increased over time, and subsequent CTLA4 inhibition resulted in response/stable disease in 75%. RAS-MAPK-pathway inhibition led to the reinvigoration of peripheral immune and radiologic responses. Local (flare) and systemic immune adverse events were frequent (biallelic mismatch-repair deficiency > Lynch syndrome). We provide a mechanistic rationale for the sustained benefit in RRD-HGG from immune-directed/synergistic salvage therapies. Future approaches need to be tailored to patient and tumor biology. SIGNIFICANCE Hypermutant RRD-HGG are susceptible to checkpoint inhibitors beyond initial progression, leading to improved survival when reirradiation and synergistic immune/targeted agents are added. This is driven by their unique biological and immune properties, which evolve over time. Future research should focus on combinatorial regimens that increase patient survival while limiting immune toxicity. This article is featured in Selected Articles from This Issue, p. 201.
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Affiliation(s)
- Anirban Das
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
- Department of Paediatric Haematology and Oncology, Tata Medical Center, Kolkata, India
- Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Nicholas R. Fernandez
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
| | - Adrian Levine
- Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, Canada
- Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Vanessa Bianchi
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
| | - Lucie K. Stengs
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
| | - Jiil Chung
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
| | - Logine Negm
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
| | - Jose Rafael Dimayacyac
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
| | - Yuan Chang
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
| | - Liana Nobre
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
| | - Ayse B. Ercan
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Santiago Sanchez-Ramirez
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
| | - Sumedha Sudhaman
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
| | - Melissa Edwards
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
| | - Valerie Larouche
- Pediatric Haematology/Oncology Department, CHU de Québec-Université Laval, Quebec City, Canada
| | - David Samuel
- Department of Paediatric Oncology, Valley Children's Hospital, Madera, California
| | - An Van Damme
- Department of Paediatric Haematology and Oncology, Saint Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - David Gass
- Atrium Health/Levine Children's Hospital, Charlotte, North Carolina
| | - David S. Ziegler
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, Australia
- School of Clinical Medicine, UNSW Sydney, Sydney, Australia
| | - Stefan S. Bielack
- Department of Pediatric Oncology, Hematology and Immunology, Center for Childhood, Adolescent, and Women's Medicine, Stuttgart Cancer Center, Klinikum Stuttgart, Stuttgart, Germany
| | - Carl Koschmann
- Pediatric Hematology/Oncology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Shayna Zelcer
- Department of Pediatrics, London Health Sciences Centre, London, Canada
| | - Michal Yalon-Oren
- Department of Paediatric Haematology-Oncology, Sheba Medical Centre, Ramat Gan, Israel
| | - Gadi Abede Campino
- Department of Paediatric Haematology-Oncology, Sheba Medical Centre, Ramat Gan, Israel
| | | | - Kim E. Nichols
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | | | - Kevin Bielamowicz
- Department of Pediatrics, Section of Pediatric Hematology/Oncology, The University of Arkansas for Medical Sciences/Arkansas Children's Hospital, Little Rock, Arkansas
| | - Magnus Sabel
- Department of Paediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg & Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Charlotta A. Frojd
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Matthew D. Wood
- Neuropathology, Oregon Health & Science University Department of Pathology, Portland, Oregon
| | - Jason M. Glover
- Department of Pediatric Hematology/Oncology, Randall Children's Hospital, Portland, Oregon
| | - Yi-Yen Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Magimairajan Vanan
- Pediatric Hematology-Oncology, CancerCare Manitoba, Winnipeg, Canada
- CancerCare Manitoba Research Institute, Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada
| | - Jenny K. Adamski
- Neuro-oncology Division, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Sebastien Perreault
- Neurosciences Department, Child Neurology Division, CHU Sainte-Justine, Montreal, Canada
| | - Omar Chamdine
- Pediatric Hematology Oncology, King Fahad Specialist Hospital Dammam, Eastern Province, Saudi Arabia
| | - Magnus Aasved Hjort
- Department of Paediatric Haematology and Oncology, St. Olav's University Hospital, Trondheim, Norway
| | - Michal Zapotocky
- Department of Paediatric Haematology and Oncology, Second Faculty of Medicine, University Hospital Motol, Charles University, Prague, Czech Republic
| | - Fernando Carceller
- Paediatric and Adolescent Neuro-Oncology and Drug Development, The Royal Marsden NHS Foundation Trust & Division of Clinical Studies, The Institute of Cancer Research, London, United Kingdom
| | - Erin Wright
- Division of Neuro-Oncology, Akron Children's Hospital, Akron, Ohio
| | - Ivana Fedorakova
- Clinic of Pediatric Oncology and Hematology, University Children's Hospital, Banská Bystrica, Slovakia
| | - Alexander Lossos
- Department of Oncology, Leslie and Michael Gaffin Centre for Neuro-Oncology, Hadassah-Hebrew University Medical Centre, Jerusalem, Israel
| | - Ryuma Tanaka
- Division of Hematology/Oncology/Blood and Marrow Transplantation, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael Osborn
- Women's and Children's Hospital, North Adelaide, Australia
| | - Deborah T. Blumenthal
- Neuro-Oncology Service, Tel-Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Melyssa Aronson
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Canada
| | - Ute Bartels
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Annie Huang
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
| | - Vijay Ramaswamy
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
| | - David Malkin
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Canada
| | - Adam Shlien
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Anita Villani
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Peter B. Dirks
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
- Division of Neurosurgery, The Hospital for Sick Children, Toronto, Canada
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Canada
| | - Trevor J. Pugh
- Ontario Institute for Cancer Research, Princess Margaret Cancer Centre, Toronto, Canada
| | - Gad Getz
- Broad Institute of Harvard and MIT, Cambridge, Massachusetts
| | | | - Derek S. Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Birgit Ertl-Wagner
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Canada
| | - Cynthia Hawkins
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
- Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, Canada
- Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Eric Bouffet
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Daniel A. Morgenstern
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Uri Tabori
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Canada
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10
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Ajithkumar T, Avanzo M, Yorke E, Tsang DS, Milano MT, Olch AJ, Merchant TE, Dieckmann K, Mahajan A, Fuji H, Paulino AC, Timmermann B, Marks LB, Bentzen SM, Jackson A, Constine LS. PENTEC Organ-Specific Report: Brain and Brain Stem Necrosis After Reirradiation for Recurrent Childhood Primary Central Nervous System Tumors: A PENTEC Comprehensive Review. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00001-4. [PMID: 38300187 DOI: 10.1016/j.ijrobp.2023.12.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 12/19/2023] [Accepted: 12/26/2023] [Indexed: 02/02/2024]
Abstract
PURPOSE Reirradiation is increasingly used in children and adolescents/young adults (AYA) with recurrent primary central nervous system tumors. The Pediatric Normal Tissue Effects in the Clinic (PENTEC) reirradiation task force aimed to quantify risks of brain and brain stem necrosis after reirradiation. METHODS AND MATERIALS A systematic literature search using the PubMed and Cochrane databases for peer-reviewed articles from 1975 to 2021 identified 92 studies on reirradiation for recurrent tumors in children/AYA. Seventeen studies representing 449 patients who reported brain and brain stem necrosis after reirradiation contained sufficient data for analysis. While all 17 studies described techniques and doses used for reirradiation, they lacked essential details on clinically significant dose-volume metrics necessary for dose-response modeling on late effects. We, therefore, estimated incidences of necrosis with an exact 95% CI and qualitatively described data. Results from multiple studies were pooled by taking the weighted average of the reported crude rates from individual studies. RESULTS Treated cancers included ependymoma (n = 279 patients; 7 studies), medulloblastoma (n = 98 patients; 6 studies), any CNS tumors (n = 62 patients; 3 studies), and supratentorial high-grade gliomas (n = 10 patients; 1 study). The median interval between initial and reirradiation was 2.3 years (range, 1.2-4.75 years). The median cumulative prescription dose in equivalent dose in 2-Gy fractions (EQD22; assuming α/β value = 2 Gy) was 103.8 Gy (range, 55.8-141.3 Gy). Among 449 reirradiated children/AYA, 22 (4.9%; 95% CI, 3.1%-7.3%) developed brain necrosis and 14 (3.1%; 95% CI, 1.7%-5.2%) developed brain stem necrosis with a weighted median follow-up of 1.6 years (range, 0.5-7.4 years). The median cumulative prescription EQD22 was 111.4 Gy (range, 55.8-141.3 Gy) for development of any necrosis, 107.7 Gy (range, 55.8-141.3 Gy) for brain necrosis, and 112.1 Gy (range, 100.2-117 Gy) for brain stem necrosis. The median latent period between reirradiation and the development of necrosis was 5.7 months (range, 4.3-24 months). Though there were more events among children/AYA undergoing hypofractionated versus conventionally fractionated reirradiation, the differences were not statistically significant (P = .46). CONCLUSIONS Existing reports suggest that in children/AYA with recurrent brain tumors, reirradiation with a total EQD22 of about 112 Gy is associated with an approximate 5% to 7% incidence of brain/brain stem necrosis after a median follow-up of 1.6 years (with the initial course of radiation therapy being given with conventional prescription doses of ≤2 Gy per fraction and the second course with variable fractionations). We recommend a uniform approach for reporting dosimetric endpoints to derive robust predictive models of late toxicities following reirradiation.
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Affiliation(s)
- Thankamma Ajithkumar
- Department of Oncology, Cambridge University Hospitals, Cambridge, United Kingdom.
| | - Michele Avanzo
- Division of Medical Physics, Centro di Riferimento Oncologico Aviano IRCCS, Aviano, Italy
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Derek S Tsang
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Arthur J Olch
- Department of Radiation Oncology and Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Thomas E Merchant
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Karin Dieckmann
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Hiroshi Fuji
- National Center for Child Health and Development, Tokyo, Japan
| | - Arnold C Paulino
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Beate Timmermann
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen, West German Cancer Center, Essen, Germany
| | - Lawrence B Marks
- Department of Radiation Oncology and Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Soren M Bentzen
- Division of Biostatistics and Bioinformatics, Department of Radiation Oncology, and University of Maryland Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Louis S Constine
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York; Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
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11
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Berrington de González A, Gibson TM, Lee C, Albert PS, Griffin KT, Kitahara CM, Liu D, Mille MM, Shin J, Bajaj BV, Flood TE, Gallotto SL, Paganetti H, Ahmed SK, Eaton BR, Indelicato DJ, Milgrom SA, Palmer JD, Baliga S, Poppe MM, Tsang DS, Wong K, Yock TI. The Pediatric Proton and Photon Therapy Comparison Cohort: Study Design for a Multicenter Retrospective Cohort to Investigate Subsequent Cancers After Pediatric Radiation Therapy. Adv Radiat Oncol 2023; 8:101273. [PMID: 38047226 PMCID: PMC10692298 DOI: 10.1016/j.adro.2023.101273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 05/08/2023] [Indexed: 12/05/2023] Open
Abstract
Purpose The physical properties of protons lower doses to surrounding normal tissues compared with photons, potentially reducing acute and long-term adverse effects, including subsequent cancers. The magnitude of benefit is uncertain, however, and currently based largely on modeling studies. Despite the paucity of directly comparative data, the number of proton centers and patients are expanding exponentially. Direct studies of the potential risks and benefits are needed in children, who have the highest risk of radiation-related subsequent cancers. The Pediatric Proton and Photon Therapy Comparison Cohort aims to meet this need. Methods and Materials We are developing a record-linkage cohort of 10,000 proton and 10,000 photon therapy patients treated from 2007 to 2022 in the United States and Canada for pediatric central nervous system tumors, sarcomas, Hodgkin lymphoma, or neuroblastoma, the pediatric tumors most frequently treated with protons. Exposure assessment will be based on state-of-the-art dosimetry facilitated by collection of electronic radiation records for all eligible patients. Subsequent cancers and mortality will be ascertained by linkage to state and provincial cancer registries in the United States and Canada, respectively. The primary analysis will examine subsequent cancer risk after proton therapy compared with photon therapy, adjusting for potential confounders and accounting for competing risks. Results For the primary aim comparing overall subsequent cancer rates between proton and photon therapy, we estimated that with 10,000 patients in each treatment group there would be 80% power to detect a relative risk of 0.8 assuming a cumulative incidence of subsequent cancers of 2.5% by 15 years after diagnosis. To date, 9 institutions have joined the cohort and initiated data collection; additional centers will be added in the coming year(s). Conclusions Our findings will affect clinical practice for pediatric patients with cancer by providing the first large-scale systematic comparison of the risk of subsequent cancers from proton compared with photon therapy.
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Affiliation(s)
| | - Todd M. Gibson
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Choonsik Lee
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Paul S. Albert
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Keith T. Griffin
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Cari Meinhold Kitahara
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Danping Liu
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Matthew M. Mille
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Jungwook Shin
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Benjamin V.M. Bajaj
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Tristin E. Flood
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Sara L. Gallotto
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Safia K. Ahmed
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Bree R. Eaton
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Daniel J. Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Sarah A. Milgrom
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Joshua D. Palmer
- Department of Radiation Oncology, James Cancer Hospital at the Ohio State University Wexner Medical Center and Nationwide Children's Hospital, Columbus, Ohio
| | - Sujith Baliga
- Department of Radiation Oncology, James Cancer Hospital at the Ohio State University Wexner Medical Center and Nationwide Children's Hospital, Columbus, Ohio
| | - Matthew M. Poppe
- Department of Radiation Oncology, University of Utah–Huntsman Cancer Institute, Salt Lake City, Utah
| | - Derek S. Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Kenneth Wong
- Radiation Oncology Program, Children's Hospital Los Angeles, Los Angeles, California
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Torunn I. Yock
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
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12
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Wang JZ, Nassiri F, Landry AP, Patil V, Rebchuk A, Merali ZA, Gui C, Lee G, Rogers L, Sinha J, Patel Z, Zuccato JA, Voisin MR, Munoz D, Spears J, Cusimano MD, Das S, Makarenko S, Yip S, Gao A, Laperriere N, Tsang DS, Zadeh G. Fractionated radiotherapy for surgically resected intracranial meningiomas: A multicentre retrospective cohort study. Radiother Oncol 2023; 188:109861. [PMID: 37619659 DOI: 10.1016/j.radonc.2023.109861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 08/03/2023] [Accepted: 08/14/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Aside from surgical resection, the only standard of care treatment modality for meningiomas is radiotherapy (RT). Despite this, few studies have focused on identifying clinical covariates associated with failure of fractionated RT following surgical resection (fRT), and the timing of fRT following surgery still remains controversial (adjuvant versus salvage fRT). We assessed the outcomes of the largest, multi-institutional cohort of surgically resected meningiomas treated with subsequent adjuvant and salvage fRT to identify factors associated with local freedom from recurrence (LFFR) over 3-10 years post-fRT and to determine the optimal timing of fRT. METHODS Patients with intracranial meningiomas who underwent surgery and fRT between 1997 and 2018 were included. Primary endpoints were radiographic recurrence/progression and time to progression from the completion of fRT. RESULTS 404 meningiomas were included for analysis. Of these, 167 (41.3%) recurred post-fRT. Clinical covariates independently associated with worse PFS post-fRT included receipt of previous RT to the meningioma, having a WHO grade 3 meningioma or recurrent meningioma, the meningioma having a higher MIB1-index or brain invasion on pathology, and older patient age at diagnosis. Subgroup analysis identified higher MIB1-index as a histological factor associated with poorer LFFR in WHO grade 2 meningiomas. 179 patients underwent adjuvant RT shortly after surgery whereas 225 patients had delayed, salvage fRT after recurrence/progression. Following propensity score matching, patients that underwent adjuvant fRT had improved LFFR post-fRT compared to those that received salvage fRT. CONCLUSION There is a paucity of clinical factors that can predict a meningioma's response to fRT following surgery. Adjuvant fRT may be associated with improved PFS post-fRT compared to salvage fRT. Molecular biomarkers of RT-responsiveness are needed to better inform fRT treatment decisions.
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Affiliation(s)
- Justin Z Wang
- MacFeeters Hamilton Neuro-Oncology Program, Princess Margaret Cancer Centre, University Health Network and University of Toronto, ON, Canada; Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Farshad Nassiri
- MacFeeters Hamilton Neuro-Oncology Program, Princess Margaret Cancer Centre, University Health Network and University of Toronto, ON, Canada; Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Alexander P Landry
- MacFeeters Hamilton Neuro-Oncology Program, Princess Margaret Cancer Centre, University Health Network and University of Toronto, ON, Canada; Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Vikas Patil
- MacFeeters Hamilton Neuro-Oncology Program, Princess Margaret Cancer Centre, University Health Network and University of Toronto, ON, Canada; Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Alexander Rebchuk
- Division of Neurosurgery, Vancouver General Hospital, Vancouver, BC, Canada
| | - Zamir A Merali
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Chloe Gui
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Grace Lee
- MacFeeters Hamilton Neuro-Oncology Program, Princess Margaret Cancer Centre, University Health Network and University of Toronto, ON, Canada; Temerty Faculty of Medicine, The University of Toronto, Toronto, ON, Canada
| | - Lauren Rogers
- MacFeeters Hamilton Neuro-Oncology Program, Princess Margaret Cancer Centre, University Health Network and University of Toronto, ON, Canada; Faculty of Arts & Science, Queen's University, Kingston, ON, Canada
| | - Jessica Sinha
- MacFeeters Hamilton Neuro-Oncology Program, Princess Margaret Cancer Centre, University Health Network and University of Toronto, ON, Canada
| | - Zeel Patel
- MacFeeters Hamilton Neuro-Oncology Program, Princess Margaret Cancer Centre, University Health Network and University of Toronto, ON, Canada
| | - Jeffrey A Zuccato
- MacFeeters Hamilton Neuro-Oncology Program, Princess Margaret Cancer Centre, University Health Network and University of Toronto, ON, Canada; Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Mathew R Voisin
- MacFeeters Hamilton Neuro-Oncology Program, Princess Margaret Cancer Centre, University Health Network and University of Toronto, ON, Canada; Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - David Munoz
- Department of Pathology, St. Michael's Hospital, Toronto, ON, Canada
| | - Julian Spears
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Michael D Cusimano
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Sunit Das
- Keenan Chair in Surgery, Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Serge Makarenko
- Division of Neurosurgery, Vancouver General Hospital, Vancouver, BC, Canada
| | - Stephen Yip
- Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, BC, Canada
| | - Andrew Gao
- Laboratory Medicine Program, University Health Network, Toronto, ON, Canada
| | - Normand Laperriere
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Gelareh Zadeh
- MacFeeters Hamilton Neuro-Oncology Program, Princess Margaret Cancer Centre, University Health Network and University of Toronto, ON, Canada; Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.
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Murphy B, Jackson A, Bass JK, Tsang DS, Ronckers CM, Kremer L, Baliga S, Olch A, Zureick AH, Jee KW, Constine LS, Yock TI. Modeling the Risk of Hearing Loss From Radiation Therapy in Childhood Cancer Survivors: A PENTEC Comprehensive Review. Int J Radiat Oncol Biol Phys 2023:S0360-3016(23)07779-9. [PMID: 37855793 DOI: 10.1016/j.ijrobp.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 07/28/2023] [Accepted: 08/06/2023] [Indexed: 10/20/2023]
Abstract
PURPOSE The Pediatric Normal Tissue Effects in the Clinic (PENTEC) hearing loss (HL) task force reviewed investigations on cochlear radiation dose-response relationships and risk factors for developing HL. Evidence-based dose-response data are quantified to guide treatment planning. METHODS AND MATERIALS A systematic review of the literature was performed to correlate HL with cochlear dosimetry. HL was considered present if a threshold exceeded 20 dB at any frequency. Radiation dose, ototoxic chemotherapy exposure, hearing profile including frequency spectra, interval to HL, and age at radiation therapy (RT) were analyzed. RESULTS Literature was systematically reviewed from 1970 to 2021. This resulted in 739 abstracts; 19 met inclusion for meta-analysis, and 4 included data amenable to statistical modeling. These 4 studies included 457 cochleas at risk in patients treated with RT without chemotherapy, and 398 cochlea treated with chemotherapy. The incidence and severity of cochlear HL from RT exposure alone is related to dose and age. Risk of HL was <5% in cochlea receiving a mean dose ≤35 Gy but increased to 30% at 50 Gy. HL risk ranged from 25% to 40% in children under the age of 5 years at diagnosis, declining to 10% in older children for any radiation dose. Probability of similar severe HL occurred at doses 18.3 Gy higher for children <3 versus >3 years of age. High-frequency HL was most common, with average onset occurring 3.6 years (range, 0.4-13.2 years) after RT. Exposure to platinum-based chemotherapies added to the rates of HL at a given cochlear dose level, with 300 mg/m2 shifting the dose response by 7 Gy. CONCLUSIONS In children treated with RT alone, risk of HL was low for cochlear dose <35 Gy and rose when dose exceeded 35 Gy without clear RT dose dependence. High-frequency HL was most prevalent, but all frequencies were affected. Children younger than 5 years were at highest risk of developing HL, although independent effects of dose and age were not fully elucidated. Future reports with more granular data are needed to better delineate time to onset of HL and the effects of chemoradiotherapy.
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Affiliation(s)
- Blair Murphy
- Department of Radiation Medicine, Oregon Health & Science University, Doernbecher Children's Hospital, Portland, Oregon.
| | - Andrew Jackson
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Johnnie K Bass
- Rehabilitation Services, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Cecile M Ronckers
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands; Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands; Division of Childhood Cancer Epidemiology, Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center Mainz, Mainz, Germany
| | - Leontien Kremer
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands; Emma Children's Hospital, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Sujith Baliga
- Ohio State University Medical Center, Columbus, Ohio
| | - Arthur Olch
- University of Southern California, Children's Hospital of Los Angeles, Los Angeles, California
| | | | | | - Louis S Constine
- Departments of Radiation Oncology and Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Torunn I Yock
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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14
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Jablonska PA, Parent A, La Macchia N, Chan HH, Filleti M, Ramotar M, Cho YB, Braganza M, Badzynski A, Laperriere N, Conrad T, Tsang DS, Shultz D, Santiago A, Irish JC, Millar BA, Tadic T, Berlin A. A total inverse planning paradigm: Prospective clinical trial evaluating the performance of a novel MR-based 3D-printed head immobilization device. Clin Transl Radiat Oncol 2023; 42:100663. [PMID: 37587925 PMCID: PMC10425893 DOI: 10.1016/j.ctro.2023.100663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/25/2023] [Accepted: 07/20/2023] [Indexed: 08/18/2023] Open
Abstract
Background and purpose Brain radiotherapy (cnsRT) requires reproducible positioning and immobilization, attained through redundant dedicated imaging studies and a bespoke moulding session to create a thermoplastic mask (T-mask). Innovative approaches may improve the value of care. We prospectively deployed and assessed the performance of a patient-specific 3D-printed mask (3Dp-mask), generated solely from MR imaging, to replicate a reproducible positioning and tolerable immobilization for patients undergoing cnsRT. Material and methods Patients undergoing LINAC-based cnsRT (primary tumors or resected metastases) were enrolled into two arms: control (T-mask) and investigational (3Dp-mask). For the latter, an in-house designed 3Dp-mask was generated from MR images to recreate the head positioning during MR acquisition and allow coupling with the LINAC tabletop. Differences in inter-fraction motion were compared between both arms. Tolerability was assessed using patient-reported questionnaires at various time points. Results Between January 2020 - July 2022, forty patients were enrolled (20 per arm). All participants completed the prescribed cnsRT and study evaluations. Average 3Dp-mask design and printing completion time was 36 h:50 min (range 12 h:56 min - 42 h:01 min). Inter-fraction motion analyses showed three-axis displacements comparable to the acceptable tolerance for the current standard-of-care. No differences in patient-reported tolerability were seen at baseline. During the last week of cnsRT, 3Dp-mask resulted in significantly lower facial and cervical discomfort and patients subjectively reported less pressure and confinement sensation when compared to the T-mask. No adverse events were observed. Conclusion The proposed total inverse planning paradigm using a 3D-printed immobilization device is feasible and renders comparable inter-fraction performance while offering a better patient experience, potentially improving cnsRT workflows and its cost-effectiveness.
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Affiliation(s)
- Paola Anna Jablonska
- Department of Radiation Oncology, University of Toronto, 149 College Street, Unit 504, Toronto, Ontario M5T 1P5, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 700 University Avenue, 7th Floor, Toronto, Ontario M5G 1Z5, Canada
- Department of Radiation Oncology, Clinica Universidad de Navarra, 31008 Pamplona, Spain
| | - Amy Parent
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 700 University Avenue, 7th Floor, Toronto, Ontario M5G 1Z5, Canada
| | - Nancy La Macchia
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 700 University Avenue, 7th Floor, Toronto, Ontario M5G 1Z5, Canada
| | - Harley H.L. Chan
- Guided Therapeutics (GTx) Program, Techna Institute, University Health Network, University of Toronto, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Matthew Filleti
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 700 University Avenue, 7th Floor, Toronto, Ontario M5G 1Z5, Canada
| | - Matthew Ramotar
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 700 University Avenue, 7th Floor, Toronto, Ontario M5G 1Z5, Canada
| | - Young-Bin Cho
- Department of Radiation Oncology, University of Toronto, 149 College Street, Unit 504, Toronto, Ontario M5T 1P5, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 700 University Avenue, 7th Floor, Toronto, Ontario M5G 1Z5, Canada
- Department of Radiation Oncology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Maria Braganza
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 700 University Avenue, 7th Floor, Toronto, Ontario M5G 1Z5, Canada
| | - Adam Badzynski
- Cancer Digital Intelligence Program, Princess Margaret Cancer Centre, University Health Network, 700 University Avenue, 7th Floor, Toronto, Ontario M5G 1Z5, Canada
| | - Normand Laperriere
- Department of Radiation Oncology, University of Toronto, 149 College Street, Unit 504, Toronto, Ontario M5T 1P5, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 700 University Avenue, 7th Floor, Toronto, Ontario M5G 1Z5, Canada
| | - Tatiana Conrad
- Department of Radiation Oncology, University of Toronto, 149 College Street, Unit 504, Toronto, Ontario M5T 1P5, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 700 University Avenue, 7th Floor, Toronto, Ontario M5G 1Z5, Canada
| | - Derek S. Tsang
- Department of Radiation Oncology, University of Toronto, 149 College Street, Unit 504, Toronto, Ontario M5T 1P5, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 700 University Avenue, 7th Floor, Toronto, Ontario M5G 1Z5, Canada
| | - David Shultz
- Department of Radiation Oncology, University of Toronto, 149 College Street, Unit 504, Toronto, Ontario M5T 1P5, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 700 University Avenue, 7th Floor, Toronto, Ontario M5G 1Z5, Canada
| | - Anna Santiago
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 700 University Avenue, 7th Floor, Toronto, Ontario M5G 1Z5, Canada
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, Ontario M5G 2M9, Canada
| | - Jonathan C. Irish
- Guided Therapeutics (GTx) Program, Techna Institute, University Health Network, University of Toronto, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
- Department of Otolaryngology – Head and Neck Surgery/Surgical Oncology, Princess Margaret Cancer Centre/University Health Network, 610 University Avenue, Toronto, Ontario M5G 2M9, Canada
| | - Barbara-Ann Millar
- Department of Radiation Oncology, University of Toronto, 149 College Street, Unit 504, Toronto, Ontario M5T 1P5, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 700 University Avenue, 7th Floor, Toronto, Ontario M5G 1Z5, Canada
| | - Tony Tadic
- Department of Radiation Oncology, University of Toronto, 149 College Street, Unit 504, Toronto, Ontario M5T 1P5, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 700 University Avenue, 7th Floor, Toronto, Ontario M5G 1Z5, Canada
- Guided Therapeutics (GTx) Program, Techna Institute, University Health Network, University of Toronto, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Alejandro Berlin
- Department of Radiation Oncology, University of Toronto, 149 College Street, Unit 504, Toronto, Ontario M5T 1P5, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 700 University Avenue, 7th Floor, Toronto, Ontario M5G 1Z5, Canada
- Guided Therapeutics (GTx) Program, Techna Institute, University Health Network, University of Toronto, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
- Cancer Digital Intelligence Program, Princess Margaret Cancer Centre, University Health Network, 700 University Avenue, 7th Floor, Toronto, Ontario M5G 1Z5, Canada
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15
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Wang JZ, Landry AP, Nassiri F, Merali ZA, Patel Z, Lee G, Rogers L, Zuccato JA, Voisin MR, Munoz D, Tsang DS, Laperriere N, Zadeh G. Outcomes and predictors of response to fractionated radiotherapy as primary treatment for intracranial meningiomas. Clin Transl Radiat Oncol 2023; 41:100631. [PMID: 37168253 PMCID: PMC10165177 DOI: 10.1016/j.ctro.2023.100631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 05/13/2023] Open
Abstract
Background Surgery is the primary treatment for most meningiomas. However, primary fractionated radiotherapy (fRT) remains an option for patients with larger meningiomas in challenging anatomic locations or patients at prohibitively high surgical risk. Outcome prediction for these patients is uncertain and cannot be guided by histopathology without available tumor tissue from surgery. Therefore, we aimed to assess the clinical factors that contribute to treatment failure in a large cohort of meningiomas consecutively treated with fRT as primary therapy, with the goal of identifying predictors of response. Methods Patients treated with primary fRT for intracranial meningiomas from 1998 to 2017 were reviewed. Those who received primary surgical resection, radiosurgery, previous fRT, or had <6 months of clinical follow-up were excluded. We applied logistic regression and Cox regression modeling to ascertain key predictors of treatment failure, progression-free survival (PFS), and adverse events (AE) following fRT. Results Our cohort included 137 meningiomas, 21 of which progressed after fRT (median PFS 3.45 years). Progressive meningiomas had a larger median gross tumor volume (GTV) compared to those that remained stable (19.1 cm3 vs 9.6 cm3, p = 2.86 × 10-2). GTV > 11.27 cm3 was independently predictive of progression and larger GTV was associated with higher risk of significant (grades 3/4) AE following fRT. Cavernous sinus and optic nerve sheath meningiomas had overall excellent outcomes post-fRT. Conclusions We present a large cohort of meningiomas treated with primary fRT and find GTV and anatomic location to be key predictors of outcome, adding to the complex treatment considerations for this heterogeneous disease.
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Affiliation(s)
- Justin Z. Wang
- MacFeeters Hamilton Neuro-Oncology Program, Princess Margaret Cancer Centre, University Health Network and University of Toronto, ON, Canada
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Alexander P. Landry
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Farshad Nassiri
- MacFeeters Hamilton Neuro-Oncology Program, Princess Margaret Cancer Centre, University Health Network and University of Toronto, ON, Canada
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Zamir A. Merali
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Zeel Patel
- Temerty Faculty of Medicine, The University of Toronto, Toronto, ON, Canada
| | - Grace Lee
- Temerty Faculty of Medicine, The University of Toronto, Toronto, ON, Canada
| | - Lauren Rogers
- Faculty of Arts & Science, Queen’s University, Kingston, ON, Canada
| | - Jeffrey A. Zuccato
- MacFeeters Hamilton Neuro-Oncology Program, Princess Margaret Cancer Centre, University Health Network and University of Toronto, ON, Canada
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Mathew R. Voisin
- MacFeeters Hamilton Neuro-Oncology Program, Princess Margaret Cancer Centre, University Health Network and University of Toronto, ON, Canada
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - David Munoz
- Division of Pathology, St. Michael’s Hospital, Toronto, ON, Canada
| | - Derek S. Tsang
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Normand Laperriere
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Gelareh Zadeh
- MacFeeters Hamilton Neuro-Oncology Program, Princess Margaret Cancer Centre, University Health Network and University of Toronto, ON, Canada
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Corresponding author at: Division of Neurosurgery, University of Toronto, MacFeeters Hamilton Neuro-Oncology Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
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16
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Dutra MP, Rodrigues CM, Peretz-Soroka H, Ribeiro M, Shultz D, Hodgson D, Tsang DS, Gupta AA. Radiation-induced sarcomas following childhood cancer - A Canadian Sarcoma Research and Clinical Collaboration Study (CanSaRCC). Cancer Rep (Hoboken) 2023:e1834. [PMID: 37178052 DOI: 10.1002/cnr2.1834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/19/2023] [Accepted: 04/29/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Radiation-induced sarcoma (RIS) is a late toxicity of radiation therapy (RT) usually associated with poor prognosis. Due to ongoing improvements in childhood cancer treatment and patient outcomes, RIS may become more prevalent notwithstanding evolving indications for RT. Due to limited reported studies, we sought to review our experience with RIS in survivors of pediatric cancer. METHODOLOGY Data were collected on RIS patients following treatment for childhood cancer (initial diagnosis <18 years) identified in the CanSaRCC database. Additionally, details on the protocol guidance at time of treatment were compared with current guidelines for the same disease. RESULTS Among 12 RIS identified, median age at initial diagnosis was 3.5 years (range 0.16-14) and the latency from RT to RIS diagnosis was 24.5 (range 5.4-46.2) years. Initial diagnoses included neuroblastoma, rhabdomyosarcoma, Ewing sarcoma, Wilms tumor, retinoblastoma and Hodgkin's Lymphoma. RIS histologies included osteosarcoma and soft tissue sarcomas. In comparison to protocols followed at time of diagnosis to current ones (2022), 7/12 (58%) patients would have required RT. RIS treatment included chemotherapy, radiation and surgery in 3/11 (27%), 10/11 (90%), and 7/11 (63%) patients, respectively. With a median follow-up time of 4.7 years from diagnosis of RIS, 8 (66%) patients were alive and 4 (33%) had died of progressive RIS. CONCLUSION RIS is a serious late effect of radiotherapy in childhood cancer; however, radiation remains an integral component of primary tumor management and requires participation from a specialized multi-disciplinary team, aiming to mitigate RIS and other potential late effects.
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Affiliation(s)
- Marina Parisi Dutra
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Caroline Mary Rodrigues
- Division of Medical Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hagit Peretz-Soroka
- Canadian Sarcoma Research and Clinical Collaboration, CanSaRCC, Toronto, Ontario, Canada
| | - Mauricio Ribeiro
- Division of Medical Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - David Shultz
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - David Hodgson
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Derek S Tsang
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Abha A Gupta
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Medical Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
- Canadian Sarcoma Research and Clinical Collaboration, CanSaRCC, Toronto, Ontario, Canada
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17
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Coltin H, Pequeno P, Liu N, Tsang DS, Gupta S, Taylor MD, Bouffet E, Nathan PC, Ramaswamy V. The Burden of Surviving Childhood Medulloblastoma: A Population-Based, Matched Cohort Study in Ontario, Canada. J Clin Oncol 2023; 41:2372-2381. [PMID: 36696605 PMCID: PMC10150896 DOI: 10.1200/jco.22.02466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/05/2022] [Accepted: 12/20/2022] [Indexed: 01/26/2023] Open
Abstract
PURPOSE Survivors of childhood medulloblastoma suffer from substantial late effects. We characterized these sequelae using real-world health services data in a population-based cohort of medulloblastoma survivors. METHODS All 5-year medulloblastoma survivors diagnosed age < 18 years between 1987 and 2015 in Ontario, Canada, were identified and matched 1:5 with population controls. Index date was 5 years from latest pediatric cancer event. Linkage to provincial administrative health data allowed for comparison of cumulative incidences of several adverse outcomes. RESULTS Two hundred thirty survivors, 81.3% of whom had received craniospinal irradiation, were matched with 1,150 controls. The 10-year postindex cumulative incidence of all-cause mortality was 7.9% (95% CI, 3.9 to 11.8) in survivors versus 0.6% (95% CI, 0.1 to 1.1) in controls (hazard ratio [HR], 21.5; 95% CI, 9.8 to 54.0). The cumulative incidence of stroke was higher in survivors (4.8%; 95% CI, 2.2 to 9.0) compared with controls (0.1; 95% CI, 0.01 to 0.7; HR, 45.6; 95% CI, 12.8 to 289.8). Hearing loss requiring an amplification device was present in 24.9% (95% CI, 18.8 to 31.4) of survivors versus 0.3% (95% CI, 0.1 to 1.0) of controls (HR, 96.3; 95% CI, 39.7 to 317.3). Disability support prescription claims were submitted by 44.5% (95% CI, 37.1 to 51.6) of survivors versus 5.5% (95% CI, 4.2 to 7.1) of controls (HR, 10.0; 95% CI, 7.3 to 13.6). Female survivors were significantly less likely to deliver a liveborn child compared with controls (HR, 0.2; 95% CI, 0.1 to 0.7). CONCLUSION Survivors of medulloblastoma have significant long-term medical sequelae, increased all-cause mortality, and are frequently dependent on disability supports. Efforts to reduce the toxicity of current therapy, specifically incorporating molecularly informed risk stratification to spare low- and intermediate-risk survivors the toxicity of treatment, are urgently needed. These findings should prompt a re-evaluation of our current treatment approaches where research focused on late-effect interventions should be prioritized.
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Affiliation(s)
- Hallie Coltin
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
- Programme in Developmental and Stem Cell Biology, Arthur and Sonia Labatt Brain Tumour Research Centre, Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Pediatric Hematology-Oncology, Charles-Bruneau Cancer Center, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | | | - Ning Liu
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Derek S. Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Sumit Gupta
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Pediatric Hematology-Oncology, Charles-Bruneau Cancer Center, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - Michael D. Taylor
- Programme in Developmental and Stem Cell Biology, Arthur and Sonia Labatt Brain Tumour Research Centre, Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eric Bouffet
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paul C. Nathan
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Vijay Ramaswamy
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
- Programme in Developmental and Stem Cell Biology, Arthur and Sonia Labatt Brain Tumour Research Centre, Hospital for Sick Children, Toronto, Ontario, Canada
- Departments of Medical Biophysics and Paediatrics, University of Toronto, Toronto, Ontario, Canada
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van Prooijen M, Chau L, Tsui G, Kelly V, Holwell M, Tadic T, Tsang DS, Krema H, Laperriere N. Simple and effective immobilization for radiation treatment of choroidal melanoma. Med Dosim 2023:S0958-3947(23)00023-7. [PMID: 37120386 DOI: 10.1016/j.meddos.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 03/03/2023] [Accepted: 03/11/2023] [Indexed: 05/01/2023]
Abstract
At our institution, patients diagnosed with choroidal melanoma requiring external beam radiation therapy are treated with two 6 MV volumetric-modulated arcs delivering 50 Gy over 5 daily fractions. The patient is immobilized using an Orfit head and neck mask and is directed to look at a light emitting diode (LED) during CT simulation and treatment to minimize eye movement. Patient positioning is checked with cone beam computed tomography (CBCT) daily. Translational and rotational displacements greater than 1 mm or 1° off the planned isocenter position are corrected using a Hexapod couch. The aim of this study is to verify that the mask system provides adequate immobilization and to verify our 2-mm planning target volume (PTV) margins are sufficient. Residual displacements provided by pretreatment verification and post-treatment CBCT data sets were used to assess the impact of patient mobility during treatment on the reconstructed delivered dose to the target and organs at risk. The PTV margin calculated using van Herk's method1 was used to assess patient motion plus other factors that affect treatment position, such as kV-MV isocenter coincidence. Patient position variations were small and were shown to not cause significant dose variations between the planned and reconstructed dose to the target and organs at risk. The PTV margin analysis showed patient translational motion alone required a PTV margin of 1 mm. Given other factors that affect treatment delivery accuracy, a 2-mm PTV margin was shown to be sufficient for treatment of 95% of our patients with 100% of dose delivered to the GTV. The mask immobilization with LED focus is robust and we showed a 2-mm PTV margin is adequate with this technique.
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Affiliation(s)
- Monique van Prooijen
- Department of Medical Physics, Princess Margaret Cancer Centre, Toronto, ON, M5G 1Z5, Canada.
| | - Lily Chau
- Department of Radiation Therapy, Princess Margaret Cancer Centre, Toronto, ON, M5G 2M9, Canada
| | - Grace Tsui
- Department of Radiation Therapy, Princess Margaret Cancer Centre, Toronto, ON, M5G 2M9, Canada
| | - Valerie Kelly
- Department of Radiation Therapy, Princess Margaret Cancer Centre, Toronto, ON, M5G 2M9, Canada
| | - Michael Holwell
- Department of Radiation Therapy, Princess Margaret Cancer Centre, Toronto, ON, M5G 2M9, Canada
| | - Tony Tadic
- Department of Medical Physics, University of Toronto, Princess Margaret Cancer Centre, Toronto, ON, M5G 1Z5, Canada; Department of Radiation Oncology, University of Toronto, Princess Margaret Cancer Centre, Toronto, ON, M5G 1Z5, Canada
| | - Derek S Tsang
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, ON, M5G 1Z5, Canada
| | - Hatem Krema
- Department of Ocular Oncology, Princess Margaret Cancer Centre/ UHN, University of Toronto, Toronto, ON, M5G 2M9, Canada
| | - Normand Laperriere
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, ON, M5G 1Z5, Canada
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Foo JC, Yaman Bajin I, Marushchak O, McKeown T, Bouffet E, Tsang DS, Laperriere N, Dirks P, Drake J, Ertl-Wagner B, Bartels U. Time to dismiss boost? Outcomes of children with localized and metastatic germinoma. J Neurooncol 2023; 162:443-448. [PMID: 37039951 DOI: 10.1007/s11060-023-04307-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/01/2023] [Indexed: 04/12/2023]
Abstract
PURPOSE To determine long-term outcomes of a cohort of children with germinoma treated with chemotherapy and radiation therapy without primary tumor boost even in the absence of complete response to chemotherapy METHODS: This retrospective study analyzed the outcome of patients with germinoma consecutively diagnosed and treated at a tertiary care center from January 2000 to December 2021. MRIs were reviewed by two radiologists, blinded to patient data. Tumor location at diagnosis, tumor response to chemotherapy and at completion of radiation therapy and site of relapse were assessed. Tumor response was assessed radiologically by determining the tumor size and response on diffusion-weighted imaging, in addition to biochemical, cytological parameters and neurological status. RESULTS Of 46 pediatric germinoma patients, 29 children (14 male; median age 12.8 years) received no primary tumor boost. Median follow-up was 63 months (range 9-187 months). Twenty-five children had localized disease and tumor location was suprasellar (n = 11), pineal (n = 10), bifocal (n = 3) and basal ganglia (n = 1) while 4 children had metastatic disease at presentation. All patients completed multi-agent chemotherapy followed by either ventricular irradiation (VI) (23.4 Gy) (n = 23), whole brain (WBI) (23.4 Gy) (n = 5) or craniospinal radiation (CSI) (23.4 Gy) (n = 1). Two children, who had localized disease at presentation and received VI after chemotherapy, relapsed 9 months and 32 months after completion of treatment respectively. No patient had a local relapse. Location of relapse was distant, outside (n = 1) and out- and inside (n = 1) the irradiation field. Five-year progression free survival (PFS) was 91% and overall survival (OS) was 100%. CONCLUSIONS In this case series, excellent 5-year PFS and OS rates were achieved with chemotherapy followed by radiation therapy of 23.4 Gy delivered without primary tumor boost. No local relapse was observed despite omitting primary tumor boost in patients with localized and metastatic germinoma.
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Affiliation(s)
- Jen Chun Foo
- Division of Paediatric Haematology-Oncology, Department of Paediatrics, Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Inci Yaman Bajin
- Division of Paediatric Haematology-Oncology, Department of Paediatrics, Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Oksana Marushchak
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada
| | - Tara McKeown
- Division of Paediatric Haematology-Oncology, Department of Paediatrics, Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Eric Bouffet
- Division of Paediatric Haematology-Oncology, Department of Paediatrics, Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Derek S Tsang
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Norman Laperriere
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Peter Dirks
- Division of Neuro-Surgery, Department of Surgery, Hospital for Sick Children, Toronto, Canada
| | - James Drake
- Division of Neuro-Surgery, Department of Surgery, Hospital for Sick Children, Toronto, Canada
| | - Birgit Ertl-Wagner
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Ute Bartels
- Division of Paediatric Haematology-Oncology, Department of Paediatrics, Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada.
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20
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Sherwood M, Climans S, Ramos R, Laperriere NJ, Gao AF, Millar BA, Shultz DB, Tsang DS, Mason WP. Review of 20 years of adult medulloblastoma treatment: Chemotherapy prescription trends and survival. Neurooncol Pract 2023; 10:186-194. [PMID: 36970168 PMCID: PMC10037945 DOI: 10.1093/nop/npac074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background The historic standard of care for adult medulloblastoma has been considered surgery and radiation, while chemotherapy is increasingly being prescribed. This study reviewed 20-year chemotherapy trends at a high-volume center, as well as overall and progression free-survival. Methods Adults with medulloblastoma treated at an academic center from January 1, 1999 to -December 31, 2020 were reviewed. Patient baseline data were summarized and Kaplan-Meier estimators were used for survival. Results Forty-nine patients were included; median age was 30 years and male: female ratio was 2:1. Desmoplastic and classical histologies were most common. Of all patients, 23 (47%) were high risk and 7 (14%) metastatic at diagnosis. Only 10 (20%) received initial chemotherapy, of which 70% were high risk and 30% metastatic, with most treated from 2010 to 2020. Forty percent of initial chemotherapy patients received salvage chemotherapy for recurrence or metastases (of all patients, 49% required salvage). Initial chemotherapy regimens were mainly cisplatin/lomustine/vincristine, and at recurrence cisplatin/etoposide. Median overall survival was 8.6 years (95% CI 7.5-∞), with 1-, 5-, and 10-year survival at 95.8%, 72%, and 46.7%. Median overall survival for those who did not receive initial chemotherapy was 12.4 years and 7.4 years for those who did (P-value .2). Conclusions Twenty years of adult medulloblastoma treatment was reviewed. Initial chemotherapy patients, most of whom were high risk, trended towards worse survival, but this was nonsignificant. The ideal timing and choice of chemotherapy for adult medulloblastoma is unknown-challenges of administering chemotherapy following photon craniospinal irradiation may have prevented it from becoming routine.
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Affiliation(s)
- Marissa Sherwood
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario M5T 1P5, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network (UHN), Toronto, Ontario M5G 2M9, Canada
| | - Seth Climans
- Department of Medicine, Divisions of Neurology and Department of Medical Oncology and Hematology, University of Toronto, Toronto, Ontario M5G 2C1, Canada
| | - Ronald Ramos
- Department of Medicine, Divisions of Neurology and Department of Medical Oncology and Hematology, University of Toronto, Toronto, Ontario M5G 2C1, Canada
| | - Normand J Laperriere
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario M5T 1P5, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network (UHN), Toronto, Ontario M5G 2M9, Canada
| | - Andrew F Gao
- Laboratory Medicine Program, University Health Network (UHN), Toronto, Ontario M5G 2C4, Canada
| | - Barbara-Ann Millar
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario M5T 1P5, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network (UHN), Toronto, Ontario M5G 2M9, Canada
| | - David B Shultz
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario M5T 1P5, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network (UHN), Toronto, Ontario M5G 2M9, Canada
| | - Derek S Tsang
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario M5T 1P5, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network (UHN), Toronto, Ontario M5G 2M9, Canada
| | - Warren P Mason
- Department of Medicine, Divisions of Neurology and Department of Medical Oncology and Hematology, University of Toronto, Toronto, Ontario M5G 2C1, Canada
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21
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Erker C, Mynarek M, Bailey S, Mazewski CM, Baroni L, Massimino M, Hukin J, Aguilera D, Cappellano AM, Ramaswamy V, Lassaletta A, Perreault S, Kline CN, Rajagopal R, Michaiel G, Zapotocky M, Santa-Maria Lopez V, La Madrid AM, Cacciotti C, Sandler ES, Hoffman LM, Klawinski D, Khan S, Salloum R, Hoppmann AL, Larouche V, Dorris K, Toledano H, Gilheeney SW, Abdelbaki MS, Wilson B, Tsang DS, Knipstein J, Oren MY, Shah S, Murray JC, Ginn KF, Wang ZJ, Fleischhack G, Obrecht D, Tonn S, Harrod VL, Matheson K, Crooks B, Strother DR, Cohen KJ, Hansford JR, Mueller S, Margol A, Gajjar A, Dhall G, Finlay JL, Northcott PA, Rutkowski S, Clifford SC, Robinson G, Bouffet E, Lafay-Cousin L. Outcomes of Infants and Young Children With Relapsed Medulloblastoma After Initial Craniospinal Irradiation-Sparing Approaches: An International Cohort Study. J Clin Oncol 2023; 41:1921-1932. [PMID: 36548930 DOI: 10.1200/jco.21.02968] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 07/18/2022] [Accepted: 10/28/2022] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Infant and young childhood medulloblastoma (iMB) is usually treated without craniospinal irradiation (CSI) to avoid neurocognitive late effects. Unfortunately, many children relapse. The purpose of this study was to assess salvage strategies and prognostic features of patients with iMB who relapse after CSI-sparing therapy. METHODS We assembled a large international cohort of 380 patients with relapsed iMB, age younger than 6 years, and initially treated without CSI. Univariable and multivariable Cox models of postrelapse survival (PRS) were conducted for those treated with curative intent using propensity score analyses to account for confounding factors. RESULTS The 3-year PRS, for 294 patients treated with curative intent, was 52.4% (95% CI, 46.4 to 58.3) with a median time to relapse from diagnosis of 11 months. Molecular subgrouping was available for 150 patients treated with curative intent, and 3-year PRS for sonic hedgehog (SHH), group 4, and group 3 were 60%, 84%, and 18% (P = .0187), respectively. In multivariable analysis, localized relapse (P = .0073), SHH molecular subgroup (P = .0103), CSI use after relapse (P = .0161), and age ≥ 36 months at initial diagnosis (P = .0494) were associated with improved survival. Most patients (73%) received salvage CSI, and although salvage chemotherapy was not significant in multivariable analysis, its use might be beneficial for a subset of children receiving salvage CSI < 35 Gy (P = .007). CONCLUSION A substantial proportion of patients with relapsed iMB are salvaged after initial CSI-sparing approaches. Patients with SHH subgroup, localized relapse, older age at initial diagnosis, and those receiving salvage CSI show improved PRS. Future prospective studies should investigate optimal CSI doses and the role of salvage chemotherapy in this population.
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Affiliation(s)
- Craig Erker
- Division of Hematology/Oncology, Department of Paediatrics, IWK Health Centre and Dalhousie University, Halifax, NS, Canada
| | - Martin Mynarek
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Mildred Scheel Cancer Career Center HaTriCS4, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Simon Bailey
- Wolfson Childhood Cancer Research Centre, Newcastle University Centre for Cancer, Newcastle-upon-Tyne, United Kingdom
| | | | - Lorena Baroni
- Hospital of Pediatrics SAMIC Prof. Dr Juan P. Garrahan, Buenos Aires, Argentina
| | - Maura Massimino
- Fondazione Istituto Di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori, Milan, Italy
| | - Juliette Hukin
- Divisions of Neurology and Hematology, Oncology/ Bone Marrow Transplant, Department of Pediatrics, British Columbia Children's Hospital and University of British Columbia, Vancouver, BC, Canada
| | - Dolly Aguilera
- Children's Healthcare of Atlanta & Emory University, Atlanta, GA
| | - Andrea M Cappellano
- Division of Pediatric Oncology/BMT, Instituto de Oncologia Pediátrica-GRAACC-UNIFESP, São Paulo, Brazil
| | - Vijay Ramaswamy
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Alvaro Lassaletta
- Department of Pediatric Hematology and Oncology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Sébastien Perreault
- Centre Hospitalier Universitaire Sainte, Justine, Université de Montreal, Montreal, QC, Canada
| | - Cassie N Kline
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Revathi Rajagopal
- Division of Hematology-Oncology, Department of Pediatrics, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - George Michaiel
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Keck School of Medicine of University of Southern California, Los Angeles, CA
| | - Michal Zapotocky
- Department of Paediatric Haematology and Oncology, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | | | | | - Chantel Cacciotti
- Division of Pediatric Hematology/Oncology, Western University, London, ON, Canada
- Dana Farber/Boston Children's Cancer and Blood Disorder Center, Boston, MA
| | - Eric S Sandler
- Nemours Children's Health, Wolfson's Children's Hospital & University of Florida, Jacksonville, FL
| | - Lindsey M Hoffman
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, AZ
| | - Darren Klawinski
- Nemours Children's Health, Wolfson's Children's Hospital & University of Florida, Jacksonville, FL
| | - Sara Khan
- Monash Children's Cancer Centre, Monash Children's Hospital. Monash Health. Center for Cancer Research, Hudson Institute of Medical Research, and Department of Molecular and Translational Science, School of Medicine, Nursing and Health Science, Monash University, Melbourne, Australia
- Division of Hematology, Oncology & Bone Marrow Transplant, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Ralph Salloum
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Anna L Hoppmann
- Department of Pediatrics, Division of Hematology-Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Valérie Larouche
- Department of Pediatrics, Centre Mère-enfant Soleil du CHU de Québec, CRCHU de Québec, Université Laval, Quebec City, QC, Canada
| | - Kathleen Dorris
- Children's Hospital of Colorado & University of Colorado School of Medicine, Denver, CO
| | - Helen Toledano
- Schneider Children's Medical Center of Israel, Petah Tikva, and Sackler faculty of Medicine, Tel Aviv University, Israel
| | - Stephen W Gilheeney
- Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Mohamed S Abdelbaki
- Division of Hematology, Oncology and Blood and Marrow Transplant, Nationwide Children's Hospital and The Ohio State University, Columbus, OH
- Division of Pediatric Hematology, Oncology, and Bone Marrow Transplant, Washington University School of Medicine in St Louis, St Louis, MO
| | - Beverly Wilson
- Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
| | - Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Jeffrey Knipstein
- Division of Pediatric Hematology/Oncology/BMT, Medical College of Wisconsin, Milwaukee, WI
| | - Michal Yalon Oren
- Pediatric Hemato-Oncology Department, Sheba Medical Center at Tel HaShomer, Ramat Gan, Israel
| | - Shafqat Shah
- The University of Texas Health Science Center, Department of Pediatric Hematology-Oncology, San Antonio, TX
| | - Jeffrey C Murray
- Division of Pediatric Hematology/Oncology, Cook Children's Medical Center, Fort Worth, TX
| | - Kevin F Ginn
- Division of Pediatric Hematology and Oncology, Children's Mercy Hospital, Kansas City, MO
| | - Zhihong J Wang
- Division of Hematology and Oncology, Children's Hospital of Richmond and Virginia Commonwealth University, Richmond, VA
| | - Gudrun Fleischhack
- Pediatric Hematology and Oncology, Pediatrics III, University Hospital of Essen, Essen, Germany
| | - Denise Obrecht
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Svenja Tonn
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Virginia L Harrod
- Departments of Pediatric Hematology and Oncology, Dell Children's Medical Center of Central Texas and University of Texas, Austin, TX
| | - Kara Matheson
- Research Methods Unit, Nova Scotia Health Authority, Halifax, NS, Canada
| | - Bruce Crooks
- Division of Haematology/Oncology, Department of Paediatrics, IWK Health Centre and Dalhousie University, Halifax, NS, Canada
| | - Douglas R Strother
- Section of Pediatric Hematology and Bone Marrow Transplantation, Alberta Children's Hospital, Calgary, AB, Canada
| | - Kenneth J Cohen
- Pediatric Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Jordan R Hansford
- Children's Cancer Centre, Royal Children's Hospital; Murdoch Children's Research Institute; University of Melbourne, Melbourne, Australia
| | - Sabine Mueller
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Ashley Margol
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Keck School of Medicine of University of Southern California, Los Angeles, CA
| | - Amar Gajjar
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Girish Dhall
- Division of Hematology, Oncology & Bone Marrow Transplant, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Jonathan L Finlay
- Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Paul A Northcott
- Department of Developmental Neurobiology, St Jude Children's Research Hospital, Memphis, TN
| | - Stefan Rutkowski
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Steven C Clifford
- Wolfson Childhood Cancer Research Centre, Newcastle University Centre for Cancer, Newcastle-upon-Tyne, United Kingdom
| | - Giles Robinson
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Eric Bouffet
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Lucie Lafay-Cousin
- Section of Pediatric Hematology and Bone Marrow Transplantation, Alberta Children's Hospital, Calgary, AB, Canada
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22
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Petruccelli M, Parent A, Holwell M, Dama H, Tsui G, Liu ZA, Tsang DS. Estimating Potential Benefits to Neurocognition with Proton Therapy in Adults with Brain Tumors. Int J Part Ther 2023; 9:261-268. [PMID: 37169009 PMCID: PMC10166017 DOI: 10.14338/ijpt-22-00024.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 01/17/2023] [Indexed: 03/18/2023] Open
Abstract
Abstract
Purpose
Photon radiation therapy (RT) is important in the treatment of many brain tumors but can negatively affect neurocognition. Proton therapy (PT) can reduce doses to normal brain structures. We compared photon and proton plans to estimate the potential benefit in cognition if the patient were treated with PT.
Materials and Methods
We analyzed 23 adult patients with proton and photon plans for the treatment of a primary brain tumor. Cognitive outcomes were predicted using converted equivalent dose (EQD2) with an α/β ratio of 3 to left temporal lobe and normal brain tissue. Risks of cognitive decline on 2 specific tests, the Controlled Oral Word Association Test (COWAT [letter S], a test of verbal fluency) and the Wechler Adult Intelligence Scale (WAIS-IV Coding Test, a test of processing speed) were derived from a previously published model.
Results
Dose reductions to left temporal lobe and normal brain tissue translated into lower estimated probabilities of impairment in specific neurocognitive test scores after PT. With a mean dose reduction from 1490 to 1092 cGy in EQD2 to the left temporal lobe (P < .001), there was reduction in probability of impairment in the COWAT (Letter S) test from 6.8% to 5.4%. Similar results were seen with the normal brain (750 to 451 cGy in EQD2, P < .001), with reduction in probability of impairment in the WAIS-IV Coding test from 5% to 4.1%. Other structures experiencing dose reduction with PT included each cochlea, posterior fossa, each temporal lobe, and each hippocampus.
Conclusion
We confirmed an association between PT and lower doses to brain substructures, which is expected to result in a modest decrease in probability of impairment in neurocognitive test scoring. These findings should be confirmed in prospective cohorts of patients treated with PT.
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Affiliation(s)
- Mariana Petruccelli
- 1 Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Amy Parent
- 1 Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Michael Holwell
- 1 Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Hitesh Dama
- 1 Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Grace Tsui
- 1 Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Zhihui Amy Liu
- 2 Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Derek S. Tsang
- 1 Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
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23
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Fong CH, Heaton R, Liu ZA, Li K, van Prooijen M, Cho Y, Shultz DB, Tsang DS. Dosimetric evaluation of adult and paediatric brain tumours planned using mask-based cobalt-60 fractionated stereotactic radiotherapy compared to linear accelerator-based volumetric modulated arc therapy. J Med Radiat Sci 2023; 70:64-71. [PMID: 36181359 PMCID: PMC9977670 DOI: 10.1002/jmrs.615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 08/10/2022] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION We conducted a study to evaluate the dosimetric feasibility of mask-based cobalt-60 fractionated stereotactic radiotherapy (mcfSRT) with the Leksell Gamma Knife® Icon™ device. METHODS Eleven patients with intracranial tumours were selected for this dosimetry study. These patients, previously treated with volumetric arc therapy (VMAT), were re-planned using mcfSRT. Target volume coverage, conformity/gradient indices, doses to organs at risk and treatment times were compared between the mcfSRT and VMAT plans. Two-sided paired Wilcoxon signed-rank test was used to compare differences between the two plans. RESULTS The V95 for PTV was similar between fractionated mcfSRT and VMAT (P = 0.47). The conformity index and gradient indices were 0.9 and 3.3, respectively, for mcfSRT compared to 0.7 and 4.2, respectively, for VMAT (P < 0.001 and 0.004, respectively). The radiation exposure to normal brain was lower for mcfSRT across V10, V25 and V50 compared with VMAT (P = 0.007, <0.001 and <0.001, respectively). The median D0.1cc for optic nerve and chiasm as well as the median D50 to the hippocampi were lower for mcfSRT compared to VMAT. Median beam-on time for mcfSRT was 9.7 min per fraction, compared to 0.9 min for VMAT (P = 0.002). CONCLUSION mcfSRT plans achieve equivalent target volume coverage, improved conformity and gradient indices, and reduced radiation doses to organs at risk as compared with VMAT plans. These results suggest superior dosimetric parameters for mcfSRT plans and can form the basis for future prospective studies.
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Affiliation(s)
- Chin Heng Fong
- Radiation Medicine ProgramPrincess Margaret Cancer Centre, University Health NetworkTorontoOntarioCanada
| | - Robert Heaton
- Radiation Medicine ProgramPrincess Margaret Cancer Centre, University Health NetworkTorontoOntarioCanada
| | - Zhihui Amy Liu
- Department of BiostatisticsPrincess Margaret Cancer Centre, University Health NetworkTorontoOntarioCanada
| | - Kecheng Li
- Department of Statistics and Actuarial ScienceUniversity of WaterlooWaterlooOntarioCanada
| | - Monique van Prooijen
- Radiation Medicine ProgramPrincess Margaret Cancer Centre, University Health NetworkTorontoOntarioCanada
| | - Young‐Bin Cho
- Radiation Medicine ProgramPrincess Margaret Cancer Centre, University Health NetworkTorontoOntarioCanada
| | - David B. Shultz
- Radiation Medicine ProgramPrincess Margaret Cancer Centre, University Health NetworkTorontoOntarioCanada
| | - Derek S. Tsang
- Radiation Medicine ProgramPrincess Margaret Cancer Centre, University Health NetworkTorontoOntarioCanada
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24
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Young S, Phaterpekar K, Tsang DS, Boldt G, Bauman GS. Clinical outcomes of medulloblastoma patients treated with proton radiotherapy: a systematic review. Adv Radiat Oncol 2023; 8:101189. [PMID: 37008255 PMCID: PMC10051027 DOI: 10.1016/j.adro.2023.101189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 01/27/2023] [Indexed: 02/10/2023] Open
Abstract
Purpose The aim of this study was to comprehensively review all studies examining clinical outcomes of craniospinal irradiation with proton radiotherapy for medulloblastoma (MB) to determine whether theoretical dosimetric advantages have translated into superior clinical outcomes (including survival and toxicities) compared with traditional photon-based techniques. Methods and Materials We performed a systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles reporting on clinical outcomes of pediatric and/or adult patients with MB treated with proton radiotherapy were included. Evidence quality was assessed using a modified Newcastle Ottawa scale and GRADE score. Results Thirty-five studies were included, with a total of 2059 patients reported (representing an estimated 630-654 unique patients). None of the studies were randomized, 12 were comparative, 9 were prospective, 3 were mixed, and 22 were retrospective. Average mean/median follow-up was 5.0 years (range, 4 weeks to 12.6 years). The majority of studies (n = 19) reported on treatment with passive scatter proton beams exclusively. Average study quality was 6.0 out of 9 (median, 6; standard deviation, 1.6). Nine studies scored ≥8 out of 9 on the modified Newcastle Ottawa Scale; an overall "moderate" GRADE score was assigned. Well-designed comparative cohort studies with adequate follow-up demonstrate superior neurocognitive outcomes, lower incidence of hypothyroidism (23% vs 69%), sex hormone deficiency (3% vs 19%), greater heights, and reduced acute toxicities in patients treated with protons compared to photons. Overall survival (up to 10 years), progression-free survival (up to 10 years), brain stem injury, and other endocrine outcomes were similar to those reported for photon radiation. There was insufficient evidence to make conclusions on endpoints of quality of life, ototoxicity, secondary malignancy, alopecia, scoliosis, cavernomas, and cerebral vasculopathy. Conclusions Moderate-grade evidence supports proton radiotherapy as a preferred treatment for craniospinal irradiation of MB based on equivalent disease control and comparable-to-improved toxicity versus photon beam radiation therapy.
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25
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Sekely A, Bernstein LJ, Campbell KL, Mason WP, Laperriere N, Kalidindi N, Or R, Ramos R, Climans SA, Pond GR, Ann Millar B, Shultz D, Tsang DS, Zadeh G, Edelstein K. Neurocognitive impairment, neurobehavioral symptoms, fatigue, sleep disturbance, and depressive symptoms in patients with newly diagnosed glioblastoma. Neurooncol Pract 2023; 10:89-96. [PMID: 36659968 PMCID: PMC9837779 DOI: 10.1093/nop/npac068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background In addition to poor survival rates, individuals with glioblastoma (GBM) are at risk of neurocognitive impairment due to multiple factors. This study aimed to characterize neurocognitive impairment, neurobehavioral symptoms, fatigue, sleep disturbance, and depressive symptoms in newly diagnosed GBM patients; and to examine whether neurobehavioral symptoms, fatigue, sleep, and depressive symptoms influence neurocognitive performance. Methods This study was part of a prospective, inception cohort, single-arm exercise intervention in which GBM patients underwent a neuropsychological assessment shortly after diagnosis (median 4 weeks; ie, baseline) and 3, 6, 12, and 18 months later, or until tumor progression. Here, we present baseline data. Forty-five GBM patients (mean age = 55 years) completed objective neurocognitive tests, and self-report measures of neurobehavioral symptoms, fatigue, sleep disturbance, and depressive symptoms. Results Compared to normative samples, GBM patients scored significantly lower on all neurocognitive tests, with 34 (76%) patients exhibiting neurocognitive impairment. Specifically, 53% exhibited impairment in memory retention, 51% in executive function, 42% in immediate recall, 41% in verbal fluency, and 24% in attention. There were high rates of clinically elevated sleep disturbance (70%), fatigue (57%), depressive symptoms (16%), and neurobehavioral symptoms (27%). A multivariate regression analysis revealed that depressive symptoms are significantly associated with neurocognitive impairment. Conclusions GBM patients are vulnerable to adverse outcomes including neurocognitive impairment, neurobehavioral symptoms, fatigue, sleep disturbance, and depressive symptoms shortly after diagnosis, prior to completing chemoradiation. Those with increased depressive symptoms are more likely to demonstrate neurocognitive impairment, highlighting the need for early identification and treatment of depression in this population.
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Affiliation(s)
- Angela Sekely
- Graduate Department of Psychological Clinical Science, University of Toronto, Toronto, Ontario, Canada
- Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Lori J Bernstein
- Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Kristin L Campbell
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Warren P Mason
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Normand Laperriere
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Navya Kalidindi
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Rosemarylin Or
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Ronald Ramos
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Seth A Climans
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Gregory R Pond
- Juravinski Hospital and Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Barbara Ann Millar
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - David Shultz
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gelareh Zadeh
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Kim Edelstein
- Graduate Department of Psychological Clinical Science, University of Toronto, Toronto, Ontario, Canada
- Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
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Hopewell JW, Moore J, Villafuerte CJ, Paddick I, Jones B, Hill MA, Tsang DS. Improving the Accuracy of Biologically Effective Dose Estimates, from a Previously Published Study, After Radiosurgery for Acoustic Neuromas. World Neurosurg 2022; 172:e130-e143. [PMID: 36587897 DOI: 10.1016/j.wneu.2022.12.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/27/2022] [Accepted: 12/28/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To recalculate biological effective dose values (BED) for radio-surgical treatments of acoustic neuroma from a previous study. BEDs values were previously overestimated by only using beam-on times in calculations, so excluding the important beam-off-times (when deoxyribonucleic acid repair continues) which contribute to the overall treatment time. Simple BED estimations using a mono-exponential approximation may not always be appropriate but if used should include overall treatment time. METHODS Time intervals between isocenters were estimated. These were especially important for the Gamma Knife Model 4C cases since manual changes significantly increase overall treatment times. Individual treatment parameters, such as iso-center number, beam-on-time, and beam-off-time, were then used to calculate BED values using a more appropriate bi-exponential model that includes fast and slow components of DNA damage repair over a wider time range. RESULTS The revised BED estimates differed significantly from previously published values. The overestimates of BED, obtained using beam-on-time only, varied from 0%-40.3%. BED subclasses, each with a BED range of 5 Gy2.47, indicated that revised values were consistently reduced when compared with originally quoted values, especially for 4C compared with Perfexion cases. Furthermore, subdivision of 4C cases by collimator number further emphasized the impact of scheduled gap times on BED. Further analysis demonstrated important limitations of the mono-exponential model. Target volume was a major confounding factor in the interpretation of the results of this study. CONCLUSIONS BED values should be estimated by including beam-on and beam-off times. Suggestions are provided for more accurate BED estimations in future studies.
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Affiliation(s)
- John W Hopewell
- Green Templeton College, University of Oxford, Oxford, UK; Department of Oncology, University of Oxford, Oxford, UK.
| | - Joshua Moore
- School of Mathematics, Cardiff University, Cardiff, UK
| | | | - Ian Paddick
- Queen Square Gamma Knife Centre, National Hospital for Neurology and Neurosurgery, London, UK
| | - Bleddyn Jones
- Green Templeton College, University of Oxford, Oxford, UK; Department of Oncology, University of Oxford, Oxford, UK
| | - Mark A Hill
- Department of Oncology, University of Oxford, Oxford, UK
| | - Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
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Safavi AH, Freeman C, Cheng S, Patel S, Mitera G, Kundapur V, Rutledge R, Tsang DS. Proton Therapy in Canada: Toward Universal Access and Health Equity With a Publicly Funded Facility. Int J Radiat Oncol Biol Phys 2022; 116:394-403. [PMID: 36565727 DOI: 10.1016/j.ijrobp.2022.12.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 11/17/2022] [Accepted: 12/11/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Amir H Safavi
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | | | - Sylvia Cheng
- BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Samir Patel
- Division of Radiation Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Gunita Mitera
- Canadian Association of Provincial Cancer Agencies, Toronto, Ontario, Canada
| | - Vijayananda Kundapur
- Saskatchewan Cancer Agency, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Rob Rutledge
- Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Derek S Tsang
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
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Lim-Fat MJ, Macdonald M, Lapointe S, Climans SA, Cacciotti C, Chahal M, Perreault S, Tsang DS, Gao A, Yip S, Keith J, Bennett J, Ramaswamy V, Detsky J, Tabori U, Das S, Hawkins C. Molecular testing for adolescent and young adult central nervous system tumors: A Canadian guideline. Front Oncol 2022; 12:960509. [PMID: 36249063 PMCID: PMC9559579 DOI: 10.3389/fonc.2022.960509] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 08/19/2022] [Indexed: 11/25/2022] Open
Abstract
The 2021 World Health Organization (WHO) classification of CNS tumors incorporates molecular signatures with histology and has highlighted differences across pediatric vs adult-type CNS tumors. However, adolescent and young adults (AYA; aged 15–39), can suffer from tumors across this spectrum and is a recognized orphan population that requires multidisciplinary, specialized care, and often through a transition phase. To advocate for a uniform testing strategy in AYAs, pediatric and adult specialists from neuro-oncology, radiation oncology, neuropathology, and neurosurgery helped develop this review and testing framework through the Canadian AYA Neuro-Oncology Consortium. We propose a comprehensive approach to molecular testing in this unique population, based on the recent tumor classification and within the clinical framework of the provincial health care systems in Canada.
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Affiliation(s)
- Mary Jane Lim-Fat
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- *Correspondence: Mary Jane Lim-Fat,
| | - Maria Macdonald
- Department of Oncology, London Health Sciences Centre, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Sarah Lapointe
- Division of Neurology, Department of Medicine, Centre Hospitalier de l'Universite de Montreal, Montreal, QC, Canada
| | - Seth Andrew Climans
- Department of Oncology, London Health Sciences Centre, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Chantel Cacciotti
- Department of Paediatrics, Division of Pediatric Hematology/Oncology, London Health Sciences Centre, London, ON, Canada
| | - Manik Chahal
- Department of Medical Oncology, BC Cancer Vancouver Centre, Vancouver, BC, Canada
| | - Sebastien Perreault
- Department of Pediatrics, Division of Child Neurology, CHU Sainte-Justine, Montreal, QC, Canada
| | - Derek S. Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Andrew Gao
- Department of Laboratory Medicine and Pathobiology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Stephen Yip
- Department of Pathology & Laboratory Medicine, Faculty of Medicine, University of British Columbia, BC, Canada
| | - Julia Keith
- Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada
| | - Julie Bennett
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto ON, Canada
| | - Vijay Ramaswamy
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto ON, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada
| | - Uri Tabori
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto ON, Canada
| | - Sunit Das
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Cynthia Hawkins
- Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto ON, Canada
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Huo M, Tsang DS. In Reply: Importance of Cobalt-60 Dose Rate and Biologically Effective Dose on Local Control for Intracranial Meningiomas Treated With Stereotactic Radiosurgery. Neurosurgery 2022; 91:e133-e134. [PMID: 36053084 DOI: 10.1227/neu.0000000000002138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 06/12/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- Michael Huo
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Australia
| | - Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
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Mak DY, Siddiqui Z, Liu ZA, Dama H, MacDonald SM, Wu S, Murphy ES, Hall MD, Malkov V, Onar-Thomas A, Ahmed S, Dhall G, Tsang DS. Photon versus proton whole ventricular radiotherapy for non-germinomatous germ cell tumors: A report from the Children's Oncology Group. Pediatr Blood Cancer 2022; 69:e29697. [PMID: 35373903 PMCID: PMC9329212 DOI: 10.1002/pbc.29697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/08/2022] [Accepted: 03/15/2022] [Indexed: 11/07/2022]
Abstract
PURPOSE To determine if proton therapy reduces doses to cranial organs at risk (OARs) as compared to photon therapy in children with non-germinomatous germ cell tumors (NGGCT) receiving whole ventricular radiotherapy (WVRT). METHODS AND MATERIALS Dosimetric data for patients with NGGCT prospectively enrolled in stratum 1 of the Children's Oncology Group study ACNS1123 who received 30.6 Gy WVRT were compared. Target segmentation was standardized using a contouring atlas. Doses to cranial OARs were compared between proton and photon treatments. Clinically relevant dose-volume parameters that were analyzed included mean dose and dose to 40% of the OAR volume (D40). RESULTS Mean and D40 doses to the supratentorial brain, cerebellum, and bilateral temporal, parietal, and frontal lobes were statistically significantly lower amongst proton-treated patients, as compared to photon-treated patients. In a subgroup analysis of patients uniformly treated with a 3-mm planning target volume, patients who received proton therapy continued to have statistically significantly lower doses to brain OARs. CONCLUSIONS Children treated with proton therapy for WVRT had lower doses to normal brain structures, when compared to those treated with photon therapy. Proton therapy should be considered for patients receiving WVRT for NGGCT.
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Affiliation(s)
- David Y. Mak
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario
| | - Zain Siddiqui
- Division of Radiation Oncology, Cancer Center of Southeastern Ontario, Kingston, Ontario
| | - Zhihui Amy Liu
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario
| | - Hitesh Dama
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario
| | - Shannon M. MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Shengjie Wu
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Erin S. Murphy
- Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Center, Cleveland, Ohio
| | - Matthew D. Hall
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Victor Malkov
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario
| | - Arzu Onar-Thomas
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Sameera Ahmed
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario
| | - Girish Dhall
- Division of Hematology, Oncology and Blood & Marrow Transplantation, Children's of Alabama, University of Alabama at Birmingham, Birmingham, Alabama
| | - Derek S. Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario
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Raswoli M, Tsang DS, Zadeh G, Gao AF, Shultz DB. Malignant Mimics of Trigeminal Schwannoma. Adv Radiat Oncol 2022; 8:101056. [PMID: 36176356 PMCID: PMC9513213 DOI: 10.1016/j.adro.2022.101056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 08/11/2022] [Indexed: 11/25/2022] Open
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Tsang DS, Khandwala MM, Liu ZA, Richard N, Shen G, Sekely A, Bernstein LJ, Simpson R, Mason W, Chung C, de Moraes FY, Murray L, Shultz D, Laperriere N, Millar BA, Edelstein K. Neurocognitive performance in adults treated with radiation for a primary brain tumour. Adv Radiat Oncol 2022; 7:101028. [DOI: 10.1016/j.adro.2022.101028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 07/05/2022] [Indexed: 10/31/2022] Open
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Rodrigues C, Peretz Soroka H, Pierro A, Baertschiger RM, Cypel M, Donahoe L, Tsang DS, Cho J, De Perrot M, Waddell TK, Gupta AA. Extra-Pleural Pneumonectomy (EPP) in Children and Adults with Locally Advanced Sarcoma: A CanSaRCC Study. Curr Oncol 2022; 29:4260-4266. [PMID: 35735449 PMCID: PMC9221731 DOI: 10.3390/curroncol29060340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/06/2022] [Accepted: 06/09/2022] [Indexed: 12/03/2022] Open
Abstract
Simple Summary Extra-pleural pneumonectomy (EPP) involves the removal of the parietal and visceral pleura, ipsilateral lungs, pericardium, and hemi diaphragm. In patients with advanced sarcoma in the pleura, EPP is often the only option for local control. The aim of our study was to review our institutional experience with EPP. Of ten patients in our study, five were alive without disease at last follow-up after multi-modality therapy including EPP. Two patients had local recurrence and died of progressive disease. One patient died of brain metastasis, one patient died of radiation induced sarcoma, and one patient died of surgical complications. Our results suggest that EPP is a feasible option for patients when used in combination with chemotherapy and radiation. Moreover, high-volume cancer centers should discuss the use of EPP during tumor board discussion. Abstract Sarcoma can present as locally advanced disease involving pleura for which extra-pleural pneumonectomy (EPP) may be the only surgical option to ensure adequate local control. Data were collected on patients who underwent EPP between January 2009 and August 2021 at Princess Margret Hospital and SickKids (Toronto) using the CanSaRCC (Canadian Sarcoma Research and Clinical Collaboration). Ten patients with locally advanced sarcoma involving the pleura, aged 4 to 59 years (median 19.5 years) underwent EPP. Nine (90%) received pre-operative chemotherapy and eight (80%) achieved an R0 resection. Hemithoracic radiation was administered preoperatively (n = 6, 60%) or postoperatively (n = 4, 40%). Five (50%) patients were alive without disease at last follow-up (median 34.2 months) and time from EPP to last FU was median 29.2 months (range 2.2–87.5). Two patients (20%) had local recurrence, 4.3 and 5.8 months from EPP, and both died from progressive disease, 13.1 and 8.2 months from EPP, respectively. One patient died from brain metastasis (17 months), one died from radiation associated osteosarcoma (66 months), and one died from surgical complications (heart failure from constrictive pericarditis). EPP offers a feasible and life-prolonging surgical consideration for patients with locally advanced sarcoma involving the pleura in combination with chemotherapy and radiation. Consequently, EPP should be considered during multi-disciplinary tumor board discussions at high-volume centers.
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Affiliation(s)
- Caroline Rodrigues
- Division of Medical Oncology, Canadian Sarcoma Research and Clinical Collaboration (CanSaRCC), Princess Margaret Cancer Centre—University Health Network, Toronto, ON M5G 2C1, Canada; (C.R.); (H.P.S.)
| | - Hagit Peretz Soroka
- Division of Medical Oncology, Canadian Sarcoma Research and Clinical Collaboration (CanSaRCC), Princess Margaret Cancer Centre—University Health Network, Toronto, ON M5G 2C1, Canada; (C.R.); (H.P.S.)
| | - Agostino Pierro
- Division of General Surgery, Hospital for Sick Children, University of Toronto, Toronto, ON M5G 1X8, Canada; (A.P.); (R.M.B.)
| | - Reto M. Baertschiger
- Division of General Surgery, Hospital for Sick Children, University of Toronto, Toronto, ON M5G 1X8, Canada; (A.P.); (R.M.B.)
| | - Marcelo Cypel
- Division of Thoracic Surgery, Toronto General Hospital—University Health Network, University of Toronto, Toronto, ON M5G 2C1, Canada; (M.C.); (L.D.); (M.D.P.); (T.K.W.)
| | - Laura Donahoe
- Division of Thoracic Surgery, Toronto General Hospital—University Health Network, University of Toronto, Toronto, ON M5G 2C1, Canada; (M.C.); (L.D.); (M.D.P.); (T.K.W.)
| | - Derek S. Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON M5G 2C1, Canada; (D.S.T.); (J.C.)
| | - John Cho
- Radiation Medicine Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON M5G 2C1, Canada; (D.S.T.); (J.C.)
| | - Marc De Perrot
- Division of Thoracic Surgery, Toronto General Hospital—University Health Network, University of Toronto, Toronto, ON M5G 2C1, Canada; (M.C.); (L.D.); (M.D.P.); (T.K.W.)
| | - Thomas K. Waddell
- Division of Thoracic Surgery, Toronto General Hospital—University Health Network, University of Toronto, Toronto, ON M5G 2C1, Canada; (M.C.); (L.D.); (M.D.P.); (T.K.W.)
| | - Abha A. Gupta
- Division of Medical Oncology, Canadian Sarcoma Research and Clinical Collaboration (CanSaRCC), Princess Margaret Cancer Centre—University Health Network, Toronto, ON M5G 2C1, Canada; (C.R.); (H.P.S.)
- Division of Hematology/Oncology, Hospital for Sick Children, University of Toronto, Toronto, ON M5G 1X8, Canada
- Correspondence: ; Tel.: +1-416-946-2252; Fax: +1-416-946-6546
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Coltin H, Pequeno P, Liu N, Tsang DS, Taylor MD, Bouffet E, Nathan PC, Ramaswamy V. MEDB-07. Long-term medical and functional outcomes of medulloblastoma survivors: a population-based, matched cohort study. Neuro Oncol 2022. [PMCID: PMC9164684 DOI: 10.1093/neuonc/noac079.382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND: Most medulloblastoma survivors suffer from late treatment-related sequelae. There are no population-based studies examining such late effects in a dedicated cohort of medulloblastoma survivors. METHODS: Using a provincial pediatric cancer registry, all 5+ year medulloblastoma survivors diagnosed between 1987-2015 in Ontario, Canada were identified and matched to cancer-free population controls based on age, sex, and geographical location. Cases were followed from the index date (five years from latest of diagnosis, or relapse or subsequent malignancy prior to age 18 years) until December 31, 2020 or censorship (death, or relapse or new cancer after age 18 years). Clinical data were linked to administrative health databases to estimate cumulative incidences and cause-specific hazard ratios (HR) of mortality, hospitalizations, strokes, hearing loss requiring a hearing aid, and receipt of homecare services between cohorts, accounting for matching and competing risks. RESULTS: We identified 230 cases [65.7% female; median diagnostic age: 7y, interquartile range (IQR) 4-10; median attained age: 24y, IQR 18-31] and 1150 controls. One hundred eighty-seven (81.3%) received craniospinal irradiation. Ten-year survival probability after index was 92.4% in cases and 99.4% in controls (HR 21.5, 95% CI 9.8-54.0). Cases were at higher risk for hospitalizations (HR 3.4, 95% CI 2.7-4.3), stroke (HR 45.6, 95% CI 12.8-289.8), hearing loss (HR 96.3, 95% CI 39.7-317.3), and requiring homecare services (HR 7.9, 95% CI 5.8-10.9). By 10 years after index, 4.8% (95% CI 2.2-9.0) of survivors had experienced a stroke compared to 0.1% (95% CI 0.01-0.7) of controls. CONCLUSIONS: Survivors of childhood medulloblastoma experienced an increased risk of mortality and serious morbidity compared to population controls. Consideration for mitigation strategies or early interventions in preventing neurovascular sequelae and hearing loss is warranted, as are dedicated supports for survivors.
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Affiliation(s)
- Hallie Coltin
- Division of Haematology/Oncology, Hospital for Sick Children , Toronto, Ontario , Canada
- Programme in Developmental and Stem Cell Biology, Arthur and Sonia Labatt Brain Tumour Research Centre, Hospital for Sick Children , Toronto, Ontario , Canada
| | | | - Ning Liu
- ICES , Toronto, Ontario , Canada
| | - Derek S Tsang
- Division of Haematology/Oncology, Hospital for Sick Children , Toronto, Ontario , Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network , Toronto, Ontario , Canada
| | - Michael D Taylor
- Programme in Developmental and Stem Cell Biology, Arthur and Sonia Labatt Brain Tumour Research Centre, Hospital for Sick Children , Toronto, Ontario , Canada
- Division of Neurosurgery, Hospital for Sick Children , Toronto, Ontario , Canada
| | - Eric Bouffet
- Division of Haematology/Oncology, Hospital for Sick Children , Toronto, Ontario , Canada
| | - Paul C Nathan
- Division of Haematology/Oncology, Hospital for Sick Children , Toronto, Ontario , Canada
- ICES , Toronto, Ontario , Canada
| | - Vijay Ramaswamy
- Division of Haematology/Oncology, Hospital for Sick Children , Toronto, Ontario , Canada
- Programme in Developmental and Stem Cell Biology, Arthur and Sonia Labatt Brain Tumour Research Centre, Hospital for Sick Children , Toronto, Ontario , Canada
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Coltin H, Pequeno P, Liu N, Tsang DS, Taylor MD, Bouffet E, Ramaswamy V, Nathan PC. Long-term medical and functional outcomes of ependymoma survivors: A population-based, matched cohort study. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.10054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10054 Background: Ependymoma is the third most common pediatric central nervous system tumour. Treatment approaches are intensive and may include surgery, radiation, and chemotherapy. There are no longitudinal population-based cohort studies evaluating the long-term medical and functional outcomes of survivors of childhood ependymoma. Methods: Using a provincial pediatric cancer registry, all 5+ year ependymoma survivors diagnosed between 1987-2015 in Ontario, Canada were identified and matched to cancer-free population controls based on age, sex, and geographical location. Cases were followed from the index date (5 years from latest of diagnosis, or relapse/subsequent malignancy prior to age 18 years) until December 31, 2020 or censorship (death, or relapse/ new cancer after age 18 years). Clinical data were linked to administrative health databases to estimate the cumulative incidences and cause-specific hazard ratios (HR) of mortality, hospitalizations, strokes, hearing loss requiring a hearing aid, receipt of homecare services, and subsequent malignant neoplasms (SMNs) between cohorts, accounting for matching and competing risks. Results: Of 166 ependymoma diagnoses in the study period, 70 (42.2%) were excluded, most commonly due to early death prior to the index date. Ninety-six cases were matched to 480 controls (Table). The 10-year survival probability after the index date was 92.8% in cases and 99.6% in controls (HR 9.3, 95% CI 2.3-45.2, p=0.002). Compared to controls, cases were at higher risk of hospitalization (HR 3.2, 95% CI 2.2-4.6, p<0.0001), stroke (HR 33.3, 95% CI 5.7-629.1, p<0.0001), and receiving homecare services (HR 4.1, 95% CI 2.5-6.5, p<0.0001). Cases were at high risk of hospitalizations, strokes, hearing loss, and SMNs, with cumulative incidences of 64.7% (95% CI 46.6-78.0), 9.7% (95% CI 3.4-19.9), 13.5% (95% CI 5.3-25.5), and 12.8% (95% CI 4.7-24.9) at 20-years post index date, respectively. Conclusions: As survival of pediatric ependymoma improves, establishing the burden of late morbidity is critical. Dedicated screening programs for late sensory and neurovascular sequelae are warranted, as are interventions during and following treatment to mitigate the risk of developing such complications. [Table: see text]
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Affiliation(s)
- Hallie Coltin
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | | | | | - Derek S. Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | | | - Eric Bouffet
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | - Paul C. Nathan
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
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Coltin H, Pequeno P, Liu N, Tsang DS, Taylor MD, Bouffet E, Nathan PC, Ramaswamy V. Long-term medical and functional outcomes of medulloblastoma survivors: A population-based, matched cohort study. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.10053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10053 Background: Most medulloblastoma survivors suffer from late treatment-related sequelae. There are no population-based studies examining such late effects in a dedicated cohort of medulloblastoma survivors. Methods: Using a provincial pediatric cancer registry, all 5+ year medulloblastoma survivors diagnosed between 1987-2015 at <18 years of age in Ontario, Canada were identified and matched to cancer-free population controls based on age, sex, and geographical location. Cases were followed from the index date (five years from latest of diagnosis, or relapse/subsequent malignancy prior to age 18 years) until December 31, 2020 or censorship (death, or relapse/new cancer after age 18 years). Clinical data were linked to administrative health databases to estimate the cumulative incidences and cause-specific hazard ratios (HR) of mortality, hospitalizations, strokes, hearing loss requiring a hearing aid, and receipt of homecare services between cohorts, accounting for matching and competing risks. We evaluated demographic, disease, and treatment predictors of mortality using Cox proportional hazards models. Results: Of 389 medulloblastoma diagnoses in the study period, 159 (40.9%) were excluded, most commonly due to early death prior to the index date. Two hundred thirty cases were matched to 1150 controls (Table). Ten-year survival probability after index was 92.4% in cases and 99.4% in controls (HR 21.5, 95% CI 9.8-54.0). Cases were at higher risk for hospitalizations (HR 3.4, 95% CI 2.7-4.3), stroke (HR 45.6, 95% CI 12.8-289.8), hearing loss (HR 96.3, 95% CI 39.7-317.3), and requiring homecare services (HR 7.9, 95% CI 5.8-10.9). By 10 years after index, 4.8% (95% CI 2.2-9.0) of survivors had experienced a stroke compared to 0.1% (95% CI 0.01-0.7) of controls. None of the candidate predictors were significantly associated with mortality on univariate analyses. Conclusions: Survivors of childhood medulloblastoma experienced an increased risk of mortality and serious morbidity compared to population controls. Consideration for mitigation strategies or early interventions for preventing neurovascular sequelae and hearing loss is warranted, as is dedicated supports for survivors. [Table: see text]
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Affiliation(s)
- Hallie Coltin
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | | | | | - Derek S. Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | | | - Eric Bouffet
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Paul C. Nathan
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
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Sekely A, Tsang DS, Mabbott D, Kongkham P, Zadeh G, Zakzanis KK, Edelstein K. Radiation dose to circumscribed brain regions and neurocognitive function in patients with meningioma. Neurooncol Pract 2022; 9:208-218. [PMID: 35601975 PMCID: PMC9113401 DOI: 10.1093/nop/npac011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Although radiation (RT) is standard treatment for many brain tumors, it may contribute to neurocognitive decline. The objective of this study was to investigate associations between RT dose to circumscribed brain regions and specific neurocognitive domains in patients with meningioma. Methods We undertook a retrospective study of 40 patients with meningioma who received RT and underwent an in-depth clinical neurocognitive assessment. Radiation dosimetry characteristics were delineated based on treatment planning computerized tomography co-registered with contrast-enhanced 3D T1-weighted magnetic resonance imaging. Principal components analysis was applied to organize neurocognitive test scores into factors, and multivariate multiple linear regression models were undertaken to examine if RT dose to circumscribed brain regions is associated with specific neurocognitive outcomes. Results Radiation dose to brain regions was associated with neurocognitive functions across a number of domains. High dose to the parietal-occipital region was associated with slower visuomotor processing speed (mean dose, β = -1.100, P = .017; dose to 50% of the region [D50], β = -0.697, P = .049). In contrast, high dose to the dorsal frontal region was associated with faster visuomotor processing speed (mean dose, β = 0.001, P = .036). Conclusions These findings suggest that RT delivered to brain regions (ie, parietal-occipital areas) may contribute to poor neurocognitive outcomes. Given that modern radiotherapy techniques allow for precise targeting of dose delivered to brain regions, prospective trials examining relations between dose and neurocognitive functions are warranted to confirm these preliminary results.
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Affiliation(s)
- Angela Sekely
- Graduate Department of Psychological Clinical Science, University of Toronto, Toronto, Ontario, Canada,Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada,Corresponding Author: Angela Sekely, MA, Graduate Department of Psychological Clinical Science, University of Toronto, 1265 Military Trail SY171, Scarborough, ON M1C 1A4, Canada; Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, ON, Canada ()
| | - Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada,Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Donald Mabbott
- Department of Psychology, University of Toronto, Toronto, Ontario, Canada,Department of Psychology, Neurosciences, and Mental Health Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paul Kongkham
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada,Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Gelareh Zadeh
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Konstantine K Zakzanis
- Graduate Department of Psychological Clinical Science, University of Toronto, Toronto, Ontario, Canada,Department of Psychology, University of Toronto, Toronto, Ontario, Canada
| | - Kim Edelstein
- Graduate Department of Psychological Clinical Science, University of Toronto, Toronto, Ontario, Canada,Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
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Sekely A, Zakzanis KK, Mabbott D, Tsang DS, Kongkham P, Zadeh G, Edelstein K. Long-term neurocognitive, psychological, and return to work outcomes in meningioma patients. Support Care Cancer 2022; 30:3893-3902. [PMID: 35041087 DOI: 10.1007/s00520-022-06838-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 01/13/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION This study aimed to investigate long-term neurocognitive, psychological, and return to work (RTW) outcomes in meningioma patients, and to explore whether neurocognitive and psychological factors influence RTW outcomes in this population. METHODS In this retrospective study, 61 meningioma patients completed in-depth clinical neuropsychological assessments. Of these participants, 42 were of working-age and had RTW information available following neuropsychological assessment. Seventy-one percent and 80% of patients received radiation and surgery, respectively, with 49% receiving both radiation and surgery. Associations between demographic, medical, neurocognitive, psychological, and RTW data were analyzed using multivariable logistic regression analyses. RESULTS In our sample, 68% of patients exhibited global neurocognitive impairment, with the largest effect sizes found on tests of visual memory (d = 0.73), executive function (d = 0.61), and attention (d = 0.54). Twenty-seven percent exhibited moderate to severe levels of depressive symptoms. In addition, 23% and 30% exhibited clinically significant state and trait anxiety, respectively. Forty-eight percent of patients were unable to RTW. Younger age, faster visuomotor processing speed, and, unexpectedly, higher trait anxiety scores were associated with an increased likelihood of returning to work. CONCLUSIONS Meningioma patients are at risk of experiencing neurocognitive deficits, psychological symptoms, and difficulties returning to work. Our results suggest that neurocognitive and psychological factors contribute to RTW status in meningioma patients. Prospective research studies are necessary to increase our understanding of the complexity of functional disability in this growing population.
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Affiliation(s)
- Angela Sekely
- Graduate Department of Psychological Clinical Science, University of Toronto, Toronto, ON, Canada. .,Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, ON, Canada.
| | - Konstantine K Zakzanis
- Graduate Department of Psychological Clinical Science, University of Toronto, Toronto, ON, Canada.,Department of Psychology, University of Toronto, Toronto, ON, Canada
| | - Donald Mabbott
- Department of Psychology, University of Toronto, Toronto, ON, Canada.,Department of Psychology, Neurosciences, and Mental Health Program, The Hospital for Sick Children, Toronto, ON, Canada
| | - Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Paul Kongkham
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, Toronto, ON, Canada
| | - Gelareh Zadeh
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, Toronto, ON, Canada
| | - Kim Edelstein
- Graduate Department of Psychological Clinical Science, University of Toronto, Toronto, ON, Canada.,Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
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Das A, Sudhaman S, Morgenstern D, Coblentz A, Chung J, Stone SC, Alsafwani N, Liu ZA, Karsaneh OAA, Soleimani S, Ladany H, Chen D, Zatzman M, Cabric V, Nobre L, Bianchi V, Edwards M, Sambira Nahum LC, Ercan AB, Nabbi A, Constantini S, Dvir R, Yalon-Oren M, Campino GA, Caspi S, Larouche V, Reddy A, Osborn M, Mason G, Lindhorst S, Bronsema A, Magimairajan V, Opocher E, De Mola RL, Sabel M, Frojd C, Sumerauer D, Samuel D, Cole K, Chiaravalli S, Massimino M, Tomboc P, Ziegler DS, George B, Van Damme A, Hijiya N, Gass D, McGee RB, Mordechai O, Bowers DC, Laetsch TW, Lossos A, Blumenthal DT, Sarosiek T, Yen LY, Knipstein J, Bendel A, Hoffman LM, Luna-Fineman S, Zimmermann S, Scheers I, Nichols KE, Zapotocky M, Hansford JR, Maris JM, Dirks P, Taylor MD, Kulkarni AV, Shroff M, Tsang DS, Villani A, Xu W, Aronson M, Durno C, Shlien A, Malkin D, Getz G, Maruvka YE, Ohashi PS, Hawkins C, Pugh TJ, Bouffet E, Tabori U. Genomic predictors of response to PD-1 inhibition in children with germline DNA replication repair deficiency. Nat Med 2022; 28:125-135. [PMID: 34992263 PMCID: PMC8799468 DOI: 10.1038/s41591-021-01581-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 10/15/2021] [Indexed: 02/08/2023]
Abstract
Cancers arising from germline DNA mismatch repair deficiency or polymerase proofreading deficiency (MMRD and PPD) in children harbour the highest mutational and microsatellite insertion–deletion (MS-indel) burden in humans. MMRD and PPD cancers are commonly lethal due to the inherent resistance to chemo-irradiation. Although immune checkpoint inhibitors (ICIs) have failed to benefit children in previous studies, we hypothesized that hypermutation caused by MMRD and PPD will improve outcomes following ICI treatment in these patients. Using an international consortium registry study, we report on the ICI treatment of 45 progressive or recurrent tumors from 38 patients. Durable objective responses were observed in most patients, culminating in a 3 year survival of 41.4%. High mutation burden predicted response for ultra-hypermutant cancers (>100 mutations per Mb) enriched for combined MMRD + PPD, while MS-indels predicted response in MMRD tumors with lower mutation burden (10–100 mutations per Mb). Furthermore, both mechanisms were associated with increased immune infiltration even in ‘immunologically cold’ tumors such as gliomas, contributing to the favorable response. Pseudo-progression (flare) was common and was associated with immune activation in the tumor microenvironment and systemically. Furthermore, patients with flare who continued ICI treatment achieved durable responses. This study demonstrates improved survival for patients with tumors not previously known to respond to ICI treatment, including central nervous system and synchronous cancers, and identifies the dual roles of mutation burden and MS-indels in predicting sustained response to immunotherapy. Hypermutation and microsatellite burden determine responses and long-term survival following PD-1 blockade in children and young adults with refractory cancers resulting from germline DNA replication repair deficiency.
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Affiliation(s)
- Anirban Das
- Division of Haematology Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Ontario, Canada.,The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatric Haematology/ Oncology, Tata Medical Centre, Kolkata, India
| | - Sumedha Sudhaman
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Ontario, Canada.,The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Daniel Morgenstern
- Division of Haematology Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Ailish Coblentz
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jiil Chung
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Ontario, Canada.,The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Ontario, Canada.,Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Simone C Stone
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Noor Alsafwani
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Department of Pathology, College of Medicine, Imam Abdulrahman Bin Faisal University (IAU), Dammam, Saudi Arabia
| | - Zhihui Amy Liu
- Department of Biostatistics, Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Ola Abu Al Karsaneh
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Department of Basic Medical Sciences, Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Shirin Soleimani
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Hagay Ladany
- Biotechnology and Food Engineering, Technion - Israel Institute of Technology, Tel-Aviv, Israel
| | - David Chen
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Matthew Zatzman
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Vanja Cabric
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Liana Nobre
- Division of Haematology Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Ontario, Canada.,The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Vanessa Bianchi
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Ontario, Canada.,The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Melissa Edwards
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Ontario, Canada.,The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lauren C Sambira Nahum
- Division of Haematology Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ayse B Ercan
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Ontario, Canada.,The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Ontario, Canada.,Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Arash Nabbi
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Shlomi Constantini
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel-Aviv, Israel
| | - Rina Dvir
- Department of Pediatric Hematology-Oncology, Tel-Aviv Sourasky Medical Centre, Tel-Aviv, Israel
| | - Michal Yalon-Oren
- Department of Pediatric Hematology-Oncology, Sheba Medical Centre, Ramat Gan, Israel
| | - Gadi Abebe Campino
- Department of Pediatric Hematology-Oncology, Sheba Medical Centre, Ramat Gan, Israel
| | - Shani Caspi
- Department of Pediatric Hematology-Oncology, Sheba Medical Centre, Ramat Gan, Israel
| | - Valerie Larouche
- Department of Paediatric Haematology/Oncology, Centre Hospitalier de Quebec-Universite Laval, Quebec City, Quebec, Canada
| | - Alyssa Reddy
- Departments of Neurology and Pediatrics, University of California, San Francisco, CA, USA
| | - Michael Osborn
- Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Gary Mason
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Scott Lindhorst
- Neuro-Oncology, Department of Neurosurgery, and Department of Medicine, Division of Hematology/Medical Oncology, Medical University of South Carolina, Charleston, SC, USA
| | - Annika Bronsema
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Vanan Magimairajan
- Department of Paediatric Haematology-Oncology, Cancer Care Manitoba, Research Institute in Oncology and Haematology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Enrico Opocher
- Paediatric Haematology, Oncology and Stem Cell Transplant Division, Padua University Hospital, Padua, Italy
| | - Rebecca Loret De Mola
- Pediatric Hematology-Oncology, Helen DeVos Children's Hospital, Grand Rapids, MI, USA
| | - Magnus Sabel
- Department of Paediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.,Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Charlotta Frojd
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - David Sumerauer
- Department of Paediatric Haematology and Oncology, Second Faculty of Medicine, Motol University Hospital, Charles University, Prague, Czech Republic
| | - David Samuel
- Department of Pediatric Oncology, Valley Children's Hospital, Madera, CA, USA
| | - Kristina Cole
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelpha, PA, USA
| | - Stefano Chiaravalli
- Paediatric Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Maura Massimino
- Paediatric Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Patrick Tomboc
- Department of Pediatrics, J.W. Ruby Memorial Hospital - West Virginia University, Morgantown, WV, USA
| | - David S Ziegler
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, New South Wales, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Ben George
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - An Van Damme
- Department of Paediatric Haematology and Oncology, Saint Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - Nobuko Hijiya
- Division of Pediatric Hematology/Oncology/Stem Cell Transplantation, Columbia University Irving Medical Centre, New York, NY, USA
| | - David Gass
- Atrium Health Levine Children's Hospital, Charlotte, NC, USA
| | - Rose B McGee
- Cancer Predisposition Division, Oncology Department, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Oz Mordechai
- Department of Pediatric Hematology Oncology, Rambam Health Care Campus, Haifa, Israel
| | - Daniel C Bowers
- Department of Pediatrics, The University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Theodore W Laetsch
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelpha, PA, USA
| | - Alexander Lossos
- Department of Oncology, Leslie and Michael Gaffin Center for Neuro-Oncology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Deborah T Blumenthal
- Neuro-Oncology Service, Tel-Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | | | - Lee Yi Yen
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jeffrey Knipstein
- Division of Pediatric Hematology/ Oncology/ BMT, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Anne Bendel
- Department of Pediatric Hematology-Oncology, Children's Hospitals and Clinics of Minnesota, St Paul, MN, USA
| | | | - Sandra Luna-Fineman
- Department of Pediatrics, Anschutz Medical Campus, Children's Hospital of Colorado, Aurora, CO, USA
| | - Stefanie Zimmermann
- Paediatric Haematology and Oncology, University Hospital Frankfurt, Frankfurt, Germany
| | - Isabelle Scheers
- Paediatric Gastroenterology, Hepatology and Nutrition Unit, Cliniques Universitaires St Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Kim E Nichols
- Cancer Predisposition Division, Oncology Department, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Michal Zapotocky
- Department of Paediatric Haematology and Oncology, Second Faculty of Medicine, Motol University Hospital, Charles University, Prague, Czech Republic
| | - Jordan R Hansford
- Children's Cancer Centre, Royal Children's Hospital, Murdoch Children's Research Institute, University of Melbourne, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - John M Maris
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelpha, PA, USA
| | - Peter Dirks
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada.,Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michael D Taylor
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada.,Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Abhaya V Kulkarni
- Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Manohar Shroff
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Anita Villani
- Division of Haematology Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Wei Xu
- Department of Biostatistics, Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Melyssa Aronson
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Carol Durno
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Adam Shlien
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - David Malkin
- Division of Haematology Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Gad Getz
- Massachusetts General Hospital Cancer Center and Department of Pathology, Charlestown, MA, USA.,Broad Institute of Harvard and MIT, Cambridge, MA, USA
| | - Yosef E Maruvka
- Biotechnology and Food Engineering, Technion - Israel Institute of Technology, Tel-Aviv, Israel
| | - Pamela S Ohashi
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Department of Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Cynthia Hawkins
- Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Program in Cell Biology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Trevor J Pugh
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Eric Bouffet
- Division of Haematology Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Uri Tabori
- Division of Haematology Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada. .,Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Ontario, Canada. .,The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Ontario, Canada. .,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada. .,Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.
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Tsang DS, Tsui G, McIntosh C, Purdie T, Bauman G, Dama H, Laperriere N, Millar BA, Shultz DB, Ahmed S, Khandwala M, Hodgson DC. A pilot study of machine-learning based automated planning for primary brain tumours. Radiat Oncol 2022; 17:3. [PMID: 34991634 PMCID: PMC8734345 DOI: 10.1186/s13014-021-01967-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 12/15/2021] [Indexed: 11/10/2022] Open
Abstract
Purpose High-quality radiotherapy (RT) planning for children and young adults with primary brain tumours is essential to minimize the risk of late treatment effects. The feasibility of using automated machine-learning (ML) to aid RT planning in this population has not previously been studied. Methods and materials We developed a ML model that identifies learned relationships between image features and expected dose in a training set of 95 patients with a primary brain tumour treated with focal radiotherapy to a dose of 54 Gy in 30 fractions. This ML method was then used to create predicted dose distributions for 15 previously-treated brain tumour patients across two institutions, as a testing set. Dosimetry to target volumes and organs-at-risk (OARs) were compared between the clinically-delivered (human-generated) plans versus the ML plans. Results The ML method was able to create deliverable plans in all 15 patients in the testing set. All ML plans were generated within 30 min of initiating planning. Planning target volume coverage with 95% of the prescription dose was attained in all plans. OAR doses were similar across most structures evaluated; mean doses to brain and left temporal lobe were lower in ML plans than manual plans (mean difference to left temporal, – 2.3 Gy, p = 0.006; mean differences to brain, – 1.3 Gy, p = 0.017), whereas mean doses to right cochlea and lenses were higher in ML plans (+ 1.6–2.2 Gy, p < 0.05 for each). Conclusions Use of an automated ML method to aid RT planning for children and young adults with primary brain tumours is dosimetrically feasible and can be successfully used to create high-quality 54 Gy RT plans. Further evaluation after clinical implementation is planned. Supplementary Information The online version contains supplementary material available at 10.1186/s13014-021-01967-3.
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Affiliation(s)
- Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - Grace Tsui
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - Chris McIntosh
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - Thomas Purdie
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - Glenn Bauman
- London Regional Cancer Program, London, ON, Canada
| | - Hitesh Dama
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - Normand Laperriere
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - Barbara-Ann Millar
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - David B Shultz
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - Sameera Ahmed
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - Mohammad Khandwala
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - David C Hodgson
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, ON, M5G 2M9, Canada.
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Rios JD, Velummailum R, Bennett J, Nobre L, Tsang DS, Bouffet E, Hawkins C, Tabori U, Denburg A, Pechlivanoglou P. Clinical and economic impact of molecular testing for BRAF fusion in pediatric low-grade Glioma. BMC Pediatr 2022; 22:13. [PMID: 34980048 PMCID: PMC8722113 DOI: 10.1186/s12887-021-03069-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 12/07/2021] [Indexed: 11/10/2022] Open
Abstract
Background Treatment personalization via tumor molecular testing holds promise for improving outcomes for patients with pediatric low-grade glioma (PLGG). We evaluate the health economic impact of employing tumor molecular testing to guide treatment for patients diagnosed with PLGG, particularly the avoidance of radiation therapy (RT) for patients with BRAF-fusion. Methods We performed a model-based cost-utility analysis comparing two strategies: molecular testing to determine BRAF fusion status at diagnosis against no molecular testing. We developed a microsimulation to model the lifetime health and cost outcomes (in quality-adjusted life years (QALYs) and 2018 CAD, respectively) for a simulated cohort of 100,000 patients newly diagnosed with PLGG after their initial surgery. Results The life expectancy after diagnosis for individuals who did not receive molecular testing was 39.01 (95% Confidence Intervals (CI): 32.94;44.38) years and 40.08 (95% CI: 33.19;45.76) years for those who received testing. Our findings indicate that patients who received molecular testing at diagnosis experienced a 0.38 (95% CI: 0.08;0.77) gain in QALYs and $1384 (95% CI: $-3486; $1204) reduction in costs over their lifetime. Cost and QALY benefits were driven primarily by the avoidance of long-term adverse events (stroke, secondary neoplasms) associated with unnecessary use of radiation. Conclusions We demonstrate the clinical benefit and cost-effectiveness of molecular testing in guiding the decision to provide RT in PLGG. While our results do not consider the impact of targeted therapies, this work is an example of the value of simulation modeling in assessing the long-term costs and benefits of precision oncology interventions for childhood cancer, which can aid decision-making about health system reimbursement. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-021-03069-1.
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Affiliation(s)
- Juan David Rios
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, 11th Floor - L4 East, Toronto, ON, M5G 0A4, Canada
| | - Russanthy Velummailum
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, 11th Floor - L4 East, Toronto, ON, M5G 0A4, Canada
| | - Julie Bennett
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Liana Nobre
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Derek S Tsang
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Eric Bouffet
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Cynthia Hawkins
- Department of Pathology, Hospital for Sick Children, Toronto, ON, Canada
| | - Uri Tabori
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Avram Denburg
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, 11th Floor - L4 East, Toronto, ON, M5G 0A4, Canada.,Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Petros Pechlivanoglou
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, 11th Floor - L4 East, Toronto, ON, M5G 0A4, Canada. .,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
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Huo M, Rose M, van Prooijen M, Cusimano MD, Laperriere N, Heaton R, Gentili F, Payne D, Shultz DB, Kongkham P, Kalia SK, Schwartz M, Bernstein M, Spears J, Zadeh G, Hodaie M, Tsang DS. Importance of Cobalt-60 Dose Rate and Biologically Effective Dose on Local Control for Intracranial Meningiomas Treated With Stereotactic Radiosurgery. Neurosurgery 2022; 90:140-147. [PMID: 34982881 DOI: 10.1227/neu.0000000000001755] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 08/24/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Radiosurgery dose rate and biologically effective dose (BED) are associated with outcomes after stereotactic radiosurgery (SRS) for functional neurosurgical conditions and some benign tumors. It is not known if these factors affect the efficacy of SRS for meningioma. OBJECTIVE To determine the association between cobalt-60 dose rate and BED on outcomes in patients with meningioma treated with SRS. METHODS A single-institution cohort of 336 patients treated between 2005 and 2018 with cobalt-based SRS for 414 separate meningioma lesions was assembled. BED was calculated using an SRS-specific monoexponential model accounting for treatment time per lesion, assuming α/β = 2.47 Gy. Cumulative incidences of local failure (LF) were reported after considering the competing risk of death, on a per-lesion basis. Multivariable analysis of LF was performed using a proportional hazards model. RESULTS The most common SRS dose was 12 Gy (n = 227); 140 lesions received 14 Gy. Five-year LF was 15.6% (95% confidence interval 10.4-21.9) and 4.3% (1.4-9.8) in patients who had a dose rate of <2.95 and ≥2.95 Gy/min, respectively (P = .0375). Among 354 grade I or unresected lesions treated with SRS, BED >50 Gy2.47 was associated with a lower incidence of LF (P = .0030). Each 1 Gy/min increase in dose rate was associated with an adjusted hazard ratio of 0.53 (95% confidence interval, 0.29-0.97, P = .041) for LF. Prescription dose >12 Gy was not associated with a lower incidence of LF. CONCLUSION Patients with meningiomas treated with lower dose rates experienced a higher incidence of LF than those treated with higher dose rates.
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Affiliation(s)
- Michael Huo
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Melanie Rose
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Monique van Prooijen
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Michael D Cusimano
- Division of Neurosurgery, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Normand Laperriere
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Robert Heaton
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Fred Gentili
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - David Payne
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - David B Shultz
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Paul Kongkham
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Suneil K Kalia
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Michael Schwartz
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Mark Bernstein
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Julian Spears
- Division of Neurosurgery, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Gelareh Zadeh
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Mojgan Hodaie
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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43
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Zuccato JA, Algan O, Nair VJ, Gunter T, Glenn CA, Dunn IF, Fung KM, Shultz DB, Zadeh G, Laperriere N, Tsang DS. Resection and radiotherapy for intracranial ependymoma: a multiinstitutional 50-year experience. J Neurosurg 2021; 137:1-8. [PMID: 34952512 DOI: 10.3171/2021.9.jns211299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 09/30/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Maximal safe resection is the standard-of-care treatment for adults with intracranial ependymoma. The value of adjuvant radiotherapy remains unclear as these tumors are rare and current data are limited to a few retrospective cohort studies. In this study, the authors assembled a cohort of patients across multiple international institutions to assess the utility of adjuvant radiotherapy in this patient population. METHODS Adults with intracranial ependymoma managed surgically at the University Health Network in Toronto, Canada, the University of Oklahoma Health Sciences Center in Oklahoma City, Oklahoma, and The Ottawa Hospital in Ottawa, Canada, were included in this study. The primary end points were progression-free survival (PFS) and overall survival (OS). Clinicopathological variables were assessed in univariate and multivariate Cox proportional hazard models for prognostic significance of PFS and OS. RESULTS A total of 122 patients diagnosed between 1968 and 2019 were identified for inclusion. The majority of patients had grade II ependymomas on histopathology (78%) that were infratentorially located (71%), underwent gross-total (GTR) or near-total resection (NTR; 55%), and were treated with adjuvant radiotherapy (67%). A volumetric analysis of the extent of resection in 49 patients with available tumor volume data supported the accuracy of the categorical GTR, NTR, and subtotal resection (STR) groups utilized. Independent statistically significant predictors of poorer PFS in the multivariate analysis included STR or biopsy (vs GTR/NTR; HR 5.4, 95% confidence interval [CI] 2.4-11.0, p < 0.0001) and not receiving adjuvant radiotherapy; cranial (HR 0.5, 95% CI 0.2-1.1) and craniospinal (HR 0.2, 95% CI 0.04-0.5) adjuvant radiotherapy regimens improved PFS (p = 0.0147). Predictors of poorer OS in the multivariate analysis were grade III histopathology (vs grade II: HR 5.7, 95% CI 1.6-20.2, p = 0.0064) and undergoing a biopsy/STR (vs GTR/NTR: HR 9.8, 95% CI 3.2-30.1, p = 0.0001). CONCLUSIONS The results of this 50-year experience in treating adult intracranial ependymomas confirm an important role for maximal safe resection (ideally GTR or NTR) and demonstrate that adjuvant radiotherapy improves PFS. This work will guide future studies as testing for molecular ependymoma alterations become incorporated into routine clinical practice.
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Affiliation(s)
- Jeffrey A Zuccato
- 1Division of Neurosurgery, University Health Network, University of Toronto, Ontario, Canada
| | - Ozer Algan
- 2Department of Radiation Oncology, Peggy and Charles Stephenson Oklahoma Cancer Center
| | - Vimoj J Nair
- 3Department of Radiation Oncology, The Ottawa Hospital, University of Ottawa, Ontario, Canada; and
| | - Tyler Gunter
- 2Department of Radiation Oncology, Peggy and Charles Stephenson Oklahoma Cancer Center
| | | | | | - Kar-Ming Fung
- 5Department of Pathology, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - David B Shultz
- 6Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Gelareh Zadeh
- 1Division of Neurosurgery, University Health Network, University of Toronto, Ontario, Canada
| | - Normand Laperriere
- 6Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Derek S Tsang
- 6Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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Keilty D, Khandwala M, Liu ZA, Papaioannou V, Bouffet E, Hodgson D, Yee R, Cushing S, Laperriere N, Ahmed S, Mabbott D, Ramaswamy V, Tabori U, Huang A, Bartels U, Tsang DS. Hearing Loss After Radiation and Chemotherapy for CNS and Head-and-Neck Tumors in Children. J Clin Oncol 2021; 39:3813-3821. [PMID: 34570616 DOI: 10.1200/jco.21.00899] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Hearing loss (HL) is a serious secondary effect of treatment for CNS and head-and-neck tumors in children. The goal of this study was to evaluate incidence and risk factors for HL in patients with multiple ototoxic exposures. PATIENTS AND METHODS We evaluated 340 ears from 171 patients with CNS or head-and-neck tumors treated with radiation, with or without chemotherapy, who had longitudinal audiologic evaluation. International Society of Pediatric Oncology-Boston grades were assigned to 2,420 hearing assessments. Multivariable weighted ordinal logistic regression was fitted to evaluate the effect of clinicopathologic features on HL. RESULTS Mean cochlea dose (odds ratio [OR] 1.04 per Gy, P < .001), time since radiotherapy (RT; OR 1.21 per year, P < .001), cisplatin dose (OR 1.48 per 100 mg/m2, P < .001), and carboplatin dose (OR 1.41 per 1,000 mg/m2, P = .002) were associated with increasing International Society of Pediatric Oncology-Boston grade of HL. There was no synergistic effect of RT and cisplatin (interaction term, P = .53) or RT and carboplatin (interaction term, P = .85). Cumulative incidence of high-frequency HL (> 4 kHz) was 50% or greater at 5 years after RT if mean cochlea dose was > 30 Gy, while incidence of HL across all frequencies continued to increase beyond 5 years after RT. CONCLUSION Children treated with radiation and chemotherapy experience a high incidence of HL over time, with associations found between more severe HL and cisplatin or carboplatin dose as well as mean cochlea dose. Mean cochlea dose of ≤ 30 Gy is proposed as a goal to reduce the risk of HL; a lower threshold (20-25 Gy) may be considered in patients receiving platinum chemotherapy to reduce cumulative HL burden.
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Affiliation(s)
- Dana Keilty
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Mohammad Khandwala
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Zhihui Amy Liu
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Vicky Papaioannou
- Department of Communication Disorders, Hospital for Sick Children, Toronto, ON, Canada
| | - Eric Bouffet
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, ON, Canada
| | - David Hodgson
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Ryan Yee
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Sharon Cushing
- Department of Otolaryngology-Head and Neck Surgery, Hospital for Sick Children, Toronto, ON, Canada
| | - Normand Laperriere
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Sameera Ahmed
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Donald Mabbott
- Department of Psychology, Hospital for Sick Children, Toronto, ON, Canada
| | - Vijay Ramaswamy
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, ON, Canada
| | - Uri Tabori
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, ON, Canada
| | - Annie Huang
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, ON, Canada
| | - Ute Bartels
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, ON, Canada
| | - Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
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45
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Nguyen MTB, Farahvash A, Dickson BC, Lee JM, Cusimano MD, Tsang DS, Micieli JA. Sinonasal Chondrosarcoma Presenting With Isolated Severe Vision Loss. J Neuroophthalmol 2021; 41:e752-e755. [PMID: 33136664 DOI: 10.1097/wno.0000000000001130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
ABSTRACT A 24-year-old man presented with a 2-month history of progressive, painless vision loss in the right eye, with no history of headache, nasal congestion, rhinorrhea, or epistaxis. His visual acuity was counting fingers at 1 ft in the right eye and 20 of 20 in the left eye with a right relative afferent pupillary defect and mild temporal optic disc pallor. MRI of the brain and orbits showed a mass involving bilateral ethmoid and sphenoid sinuses and right nasal cavity. He underwent urgent extended endoscopic endonasal transsphenoidal approach for resection of the sinonasal skull base tumor and photon radiation therapy. Pathology revealed a well-differentiated cartilaginous neoplasm with focal areas of entrapped native bone, consistent with a chondrosarcoma WHO grade I/III. At 6-month follow-up after surgery, he had a visual acuity of 20/40 in the right eye and 20/20 in the left eye. Malignant tumors from the sinonasal area should be kept in the differential diagnosis for compressive optic neuropathies and may present with vision loss even in the absence of nasal or sinus symptoms.
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Affiliation(s)
- Michael T B Nguyen
- Department of Ophthalmology and Vision Sciences (MTBN, JAM), University of Toronto, Toronto, Ontario, Canada ; Faculty of Medicine (AF), University of Toronto, Toronto, Ontario, Canada ; Department of Pathology and Laboratory Medicine (BCD), Mount Sinai Hospital; Department of Laboratory Medicine and Pathobiology (BCD), University of Toronto, Toronto, Ontario, Canada ; Department of Otolaryngology-Head and Neck Surgery (JML), St. Michael's Hospital, Toronto, Ontario, Canada ; Department of Otolaryngology-Head and Neck Surgery (JML), University of Toronto, Toronto, Ontario, Canada ; Division of Neurosurgery (MDC), Department of Surgery, St. Michael's Hospital, Toronto, Ontario, Canada ; Department of Surgery (MDC), University of Toronto, Toronto, Ontario, Canada ; Radiation Medicine Program (DST), Princess Margaret Cancer Centre, University Health Network; Department of Radiation Oncology (DST), University of Toronto, Toronto, Ontario, Canada ; Division of Neurology (JAM), Department of Medicine, University of Toronto, Toronto, Ontario, Canada; and Department of Ophthalmology (JAM), St. Michael's Hospital, Toronto, Ontario, Canada
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Jooya A, Simons ME, Tsang DS. Stereotactic Body Radiotherapy (SBRT) for an Extracranial Arteriovenous Malformation of the Pelvis. Cureus 2021; 13:e18750. [PMID: 34790496 PMCID: PMC8589004 DOI: 10.7759/cureus.18750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2021] [Indexed: 11/05/2022] Open
Abstract
Extracranial arteriovenous malformations (AVMs) are rare pathological, benign conditions that are characterized by aberrantly connected arteries and veins without normal intervening capillary vasculature. Although stereotactic radiosurgery is an established, efficacious, safe treatment for intracranial AVMs, there is no known published data on the use of stereotactic body radiotherapy (SBRT) for the treatment of abdominopelvic AVMs. One patient with an extracranial AVM in the pelvis that was only partially responsive to embolization was treated with SBRT to a dose of 21 Gy, delivered in three fractions over six calendar days. At presentation, the patient was non-ambulatory due to neuropathic pain from a sciatic impingement of the AVM. The patient underwent two prior catheter-based embolization procedures that had achieved partial obliteration, but with the persistence of neuropathic pain and symptoms. After SBRT to the pelvic AVM, the patient had marked improvement in pain over 10 months and was able to ambulate again. Follow-up angiography and CT demonstrated the obliteration of previously visualized AVM. We describe the first known report of pelvic AVM successfully treated with a combination of embolization and SBRT. Three-fraction SBRT to a total dose of 21 Gy appears to be safe and effective for extracranial AVMs arising in the pelvis. This strategy may be considered for patients with pelvic AVMs that are refractory to standard interventional therapies. However, these findings should be validated in larger cohorts.
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Affiliation(s)
- Alborz Jooya
- Radiation Oncology, The Ottawa Hospital, Ottawa, CAN
| | | | - Derek S Tsang
- Radiation Oncology, Princess Margaret Cancer Center, Toronto, CAN
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Mak DY, Laperriere N, Ramaswamy V, Bouffet E, Murray JC, McNall-Knapp RY, Bielamowicz K, Paulino AC, Zaky W, McGovern SL, Okcu MF, Tabori U, Dirks PB, Taylor MD, Tsang DS, Bavle A. 60: Re-Evaluating Surgery and Re-Irradiation for Locally Recurrent Pediatric Ependymoma – A Multi-Institutional Study. Radiother Oncol 2021. [DOI: 10.1016/s0167-8140(21)08938-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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48
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Liu ZA, Papaioannou V, Bouffet E, Hodgson D, Keilty D, Khandwala M, Yee R, Laperriere N, Ahmed S, Mabbott D, Cushing SL, Ramaswamy V, Tabori U, Huang A, Bartels U, Tsang DS. 41: Hearing Loss After Radiation and Chemotherapy for Central Nervous System and Head and Neck Tumours in Children. Radiother Oncol 2021. [DOI: 10.1016/s0167-8140(21)08919-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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49
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Affiliation(s)
- Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Fiona Schulte
- Division of Psychosocial Oncology, Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Seravalli E, Kroon PS, Buatti JM, Hall MD, Mandeville HC, Marcus KJ, Onal C, Ozyar E, Paulino AC, Paulsen F, Saunders D, Tsang DS, Wolden SL, Janssens GO. The potential role of MR-guided adaptive radiotherapy in pediatric oncology: Results from a SIOPE-COG survey. Clin Transl Radiat Oncol 2021; 29:71-78. [PMID: 34159265 PMCID: PMC8202186 DOI: 10.1016/j.ctro.2021.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/22/2021] [Accepted: 05/24/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND AND PURPOSE Magnetic resonance guided radiotherapy (MRgRT) has been successfully implemented for several routine clinical applications in adult patients. The purpose of this study is to map the potential benefit of MRgRT on toxicity reduction and outcome in pediatric patients treated with curative intent for primary and metastatic sites. MATERIALS AND METHODS Between May and August 2020, a survey was distributed among SIOPE- and COG-affiliated radiotherapy departments, treating at least 25 pediatrics patients annually and being (candidate) users of a MRgRT system. The survey consisted of a table with 45 rows (clinical scenarios for primary (n = 28) and metastatic (n = 17) tumors) and 7 columns (toxicity reduction, outcome improvement, PTV margin reduction, target volume daily adaptation, online re-planning, intrafraction motion compensation and on-board functional imaging) and the option to answer by 'yes/no' . Afterwards, the Dutch national radiotherapy cohort was used to estimate the percentage of pediatric treatments that may benefit from MRgRT. RESULTS The survey was completed by 12/17 (71% response rate) institutions meeting the survey inclusion criteria. Responders indicated an 'expected benefit' from MRgRT for toxicity/outcome in 7% (for thoracic lymphomas and abdominal rhabdomyosarcomas)/0% and 18% (for mediastinal lymph nodes, lymph nodes located in the liver/splenic hilum, and liver metastases)/0% of the considered scenarios for the primary and metastatic tumor sites, respectively, and a 'possible benefit' was estimated in 64%/46% and 47%/59% of the scenarios. When translating the survey outcome into a clinical perspective a toxicity/outcome benefit, either expected or possible, was anticipated for 55%/24% of primary sites and 62%/38% of the metastatic sites. CONCLUSION Although the benefit of MRgRT in pediatric radiation oncology is estimated to be modest, the potential role for reducing toxicity and improving clinical outcomes warrants further investigation. This fits best within the context of prospective studies or registration trials.
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Affiliation(s)
- Enrica Seravalli
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Petra S. Kroon
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - John M. Buatti
- Departments of Radiation Oncology, University of Iowa, Iowa City, USA
| | - Matthew D. Hall
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL, USA
| | - Henry C. Mandeville
- Department of Radiotherapy, The Royal Marsden Hospital and Institute of Cancer Research, Sutton, United Kingdom
| | - Karen J. Marcus
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA, USA
| | - Cem Onal
- Department of Radiation Oncology, Baskent University, Ankara, Turkey
| | - Enis Ozyar
- Department of Radiation Oncology, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Arnold C. Paulino
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, USA
| | - Frank Paulsen
- Department of Radiation Oncology, University Hospital Tuebingen, Tuebingen, Germany
| | | | - Derek S. Tsang
- Radiation Medicine Program, University Health Network – Princess Margaret Cancer Centre, Toronto, Canada
| | - Suzanne L. Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, NY, USA
| | - Geert O. Janssens
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
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