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Knap MM, Khan S, Khalil AA, Møller DS, Hoffmann L. Outcome of conventional radiotherapy in small centrally located tumours or lymph nodes: minimal toxicity, remarkable survival but challenging loco-regional control. Acta Oncol 2023; 62:1433-1439. [PMID: 37707506 DOI: 10.1080/0284186x.2023.2257872] [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: 05/22/2023] [Accepted: 09/04/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND In peripheral lung tumours, stereotactic body radiotherapy (SBRT) is superior to conventional RT. SBRT has also shown high loco-regional control (LC) in centrally located tumours, but there is a high risk of severe toxicity. The STRICTSTARLung trial (NCT05354596) examines if risk-adapted SBRT for central tumours is feasible. In this study, we examined overall survival (OS), Disease-free survival (DSF), LC, and toxicity in patients with central tumours that could have been candidates for SBRT but received conventional RT. MATERIAL AND METHODS Retrospectively, we evaluated 49 lung cancer patients that between 2008 and 2021 received RT (60-70Gy in 2 Gy fractions) for a solitary tumour or lymph node with a diameter <5cm located <2cm from the bronchial tree, oesophagus, aorta or heart. All tumours were pathologically verified; 30 were primary lung tumours (T1b-T4) and 19 were solitary lymph nodes (T0N1-N2). Chemotherapy was administered as concomitant (29) or sequential (4). OS and LC were analysed using Kaplan Meier. Cox proportional hazards model for OS and disease-free survival (DFS) was performed including tumour volume, histology, sex, T- vs N-site and chemotherapy. Toxicity was scored. RESULTS In 42 patients, the tumour was located <1 cm to mediastinum. Median follow-up time was 44 months (range: 7-123). The median OS was 51 months. OS at 1-, 3- and 5-year was 88% (SE:5), 59% (SE:7) and 50% (SE:8). Loco-regional recurrences occurred in 16 patients resulting in 1-, and 3-year LC rates of 77% (SE:6) and 64% (SE:8). The majority occurred within 3 years after RT. Only stage showed significant impact on OS and DFS. No patients experienced grade 4-5 toxicity. Seven patients developed grade 3 toxicity (5 oesophageal stenosis, 2 pneumonitis). CONCLUSION Conventional RT for patients with small central lung tumours or solitary lymph nodes is feasible. Median OS was 51 months, and toxicity was low with no grade 4-5 events.
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Affiliation(s)
- M M Knap
- Department of Oncology, Aarhus University Hospital, Aarhus N, Denmark
| | - S Khan
- Department of Respiratory Diseases and Allergology, Aarhus University Hospital, Aarhus N, Denmark
| | - A A Khalil
- Department of Oncology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - D S Møller
- Department of Oncology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - L Hoffmann
- Department of Oncology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
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Hoffmann L, Ehmsen ML, Hansen J, Hansen R, Knap MM, Mortensen HR, Poulsen PR, Ravkilde T, Rose HK, Schmidt HH, Worm ES, Møller DS. Repeated deep-inspiration breath-hold CT scans at planning underestimate the actual motion between breath-holds at treatment for lung cancer and lymphoma patients. Radiother Oncol 2023; 188:109887. [PMID: 37659663 DOI: 10.1016/j.radonc.2023.109887] [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: 06/25/2023] [Revised: 08/04/2023] [Accepted: 08/23/2023] [Indexed: 09/04/2023]
Abstract
PURPOSE/OBJECTIVE Deep-inspiration breath-hold (DIBH) during radiotherapy may reduce dose to the lungs and heart compared to treatment in free breathing. However, intra-fractional target shifts between several breath-holds may decrease target coverage. We compared target shifts between four DIBHs at the planning-CT session with those measured on CBCT-scans obtained pre- and post-DIBH treatments. MATERIAL/METHODS Twenty-nine lung cancer and nine lymphoma patients were treated in DIBH. An external gating block was used as surrogate for the DIBH-level with a window of 2 mm. Four DIBH CT-scans were acquired: one for planning (CTDIBH3) and three additional (CTDIBH1,2,4) to assess the intra-DIBH target shifts at scanning by registration to CTDIBH3. During treatment, pre-treatment (CBCTpre) and post-treatment (CBCTpost) scans were acquired. For each pair of CBCTpre/post, the target intra-DIBH shift was determined. For lung cancer, tumour (GTV-Tlung) and lymph nodes (GTV-Nlung) were analysed separately. Group mean (GM), systematic and random errors, and GM for the absolute maximum shifts (GMmax) were calculated for the shifts between CTDIBH1,2,3,4 and between CBCTpre/post. RESULTS For GTV-Tlung, GMmax was larger at CBCT than CT in all directions. GMmax in cranio-caudal direction was 3.3 mm (CT)and 6.1 mm (CBCT). The standard deviations of the shifts in the left-right and cranio-caudal directions were larger at CBCT than CT. For GTV-Nlung and CTVlymphoma, no difference was found in GMmax or SD. CONCLUSION Intra-DIBH shifts at planning-CT session are generally smaller than intra-DIBH shifts observed at CBCTpre/post and therefore underestimate the intra-fractional DIBH uncertainty during treatment. Lung tumours show larger intra-fractional variations than lymph nodes and lymphoma targets.
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Affiliation(s)
- Lone Hoffmann
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - M L Ehmsen
- Danish Center for Proton Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - J Hansen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - R Hansen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - M M Knap
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - H R Mortensen
- Danish Center for Proton Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - P R Poulsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Danish Center for Proton Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - T Ravkilde
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - H K Rose
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - H H Schmidt
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - E S Worm
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - D S Møller
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Khalil AA, Knap MM, Møller DS, Nyeng TB, Kjeldsen R, Hoffmann L. Local control after stereotactic body radiotherapy of centrally located lung tumours. Acta Oncol 2021; 60:1069-1073. [PMID: 33988493 DOI: 10.1080/0284186x.2021.1914345] [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] [Indexed: 10/21/2022]
Affiliation(s)
- A. A. Khalil
- Department of Oncology, Aarhus University Hospital, Aarhus N, Denmark
| | - M. M. Knap
- Department of Oncology, Aarhus University Hospital, Aarhus N, Denmark
| | - D. S. Møller
- Department of Medical Physics, Aarhus University Hospital, Aarhus N, Denmark
| | - T. B. Nyeng
- Department of Medical Physics, Aarhus University Hospital, Aarhus N, Denmark
| | - R. Kjeldsen
- Department of Oncology, Aalborg University Hospital, Aarhus N, Denmark
| | - L. Hoffmann
- Department of Medical Physics, Aarhus University Hospital, Aarhus N, Denmark
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Hoffmann L, Knap MM, Alber M, Møller DS. Optimal beam angle selection and knowledge-based planning significantly reduces radiotherapy dose to organs at risk for lung cancer patients. Acta Oncol 2021; 60:293-299. [PMID: 33306422 DOI: 10.1080/0284186x.2020.1856409] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 12/25/2022]
Abstract
BACKGROUND Lung cancer patients struggle with high toxicity rates. This study investigates if IMRT plans with individually set beam angles or uni-lateral VMAT plans results in dose reduction to OARs. We investigate if introduction of a RapidPlan model leads to reduced dose to OARs. Finally, the model is validated prospectively. MATERIAL AND METHODS Seventy-four consecutive lung cancer patients treated with IMRT were included. For all patients, new IMRT plans were made by an experienced dose planner re-tuning beam angles aiming for minimized dose to the lungs and heart. Additionally, VMAT plans were made. The IMRT plans were selected as input for a RapidPlan model, which was used to generate 74 new IMRT plans. The new IMRT plans were used as input for a second RapidPlan model. This model was clinically implemented and used for generation of clinical treatment plans. Dosimetric parameters were compared using a Wilcoxon signed rank test or a 1-sided student's t-test. p < .05 was considered significant. RESULTS IMRT plans significantly reduced mean doses to lungs (MLD) and heart (MHD) by 1.6 Gy and 1.7 Gy in mean compared to VMAT plans. MLD was significantly (p < .001) reduced from 10.8 Gy to 9.4 Gy by using the second RapidPlan model. MHD was significantly (p < .001) reduced from 4.9 Gy to 3.9 Gy. The model was validated in prospectively collected treatment plans showing significantly lower MLD after the implementation of the second RapidPlan model. CONCLUSION Introduction of RapidPlan and beam angles selected based on the target and OARs position reduces dose to OARs.
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Affiliation(s)
- L. Hoffmann
- Department of Oncology, Section for Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - M. M. Knap
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - M. Alber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - D. S. Møller
- Department of Oncology, Section for Medical Physics, Aarhus University Hospital, Aarhus, Denmark
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Kandi M, Hoffmann L, Sloth Moeller D, Schmidt HH, Knap MM, Khalil AA. Local failure after radical radiotherapy of non-small cell lung cancer in relation to the planning FDG-PET/CT. Acta Oncol 2018; 57:813-819. [PMID: 29205088 DOI: 10.1080/0284186x.2017.1409436] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Local recurrence (rec) in lung cancer is associated with poor survival. This study examined whether the pattern of failure is associated with the most PET avid volume in the planning-FDG-PET/CT scan (p-PET/CT). METHODS 162 consecutive inoperable NSCLC patients (pts) receiving radiotherapy between January 2012 and April 2014 were reviewed. Radiotherapy was delivered in 2 Gy/fraction (5f/week) to a total dose of 60-66 Gy. Pts were followed with CT scans every third month. Patients with local rec as first event were analyzed. For the primary tumor (T) the overlap-fraction (OF) between 50% of SUVpeak on p-PET/CT and the volume of T-rec was calculated: OF = (SUVp50∩T-rec)/min(SUVp50, T-rec). Similarly for the GTV on the p-CT: OF = (GTV∩T-rec)/min(GTV, T-rec). OF was based on a rigid registration between p-PET/CT and rec-CT with PET guided delineation of T- rec. For lymph nodes (LN), the correlation between the location of treated-LN and the location of recurrence-LN was evaluated. RESULTS 67 patients developed local rec. 51 pts had rec in T-site, 45 pts in LN-site. Due to anatomical changes, reliable registration between p-CT and rec-CT was only obtained in 26 pts with T-rec. The median OFSUVp50 was 52, 8% [range 26; 100%] and the median OFGTV was 80.5% [19.7; 100%]. Eleven pts had higher OFSUVp50 than OFGTV. LN-rec predominantly occurred in the station 2R (32%), 4R (46%), 7 (46%) and right hilum (36%). Pts with malignant LNs in station 4R or 7 on p-CT had a high risk of rec in these stations; 4R (55%) and 7 (83%). CONCLUSIONS This study indicates that the most PET active volume on p-PET-CT is a driver for rec at T-site. LN-recurrences predominantly appear in station 2R, 4R, 7 and right hilum. Additional confirmatory studies regarding lymph node mapping and selective lymph node irradiation is needed.
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Affiliation(s)
- M. Kandi
- Department of Oncology, Aarhus University Hospital, Aarhus C, Denmark
| | - L. Hoffmann
- Department of Medical Physics, Aarhus University Hospital, Aarhus C, Denmark
| | - D. Sloth Moeller
- Department of Medical Physics, Aarhus University Hospital, Aarhus C, Denmark
| | - H. H. Schmidt
- Department of Oncology, Aarhus University Hospital, Aarhus C, Denmark
| | - M. M. Knap
- Department of Oncology, Aarhus University Hospital, Aarhus C, Denmark
| | - A. A. Khalil
- Department of Oncology, Aarhus University Hospital, Aarhus C, Denmark
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Abstract
Dose volume histogram points (DVHPs) frequently serve as dose constraints in radiotherapy treatment planning. An experiment was designed to investigate the reliability of DVHP inference from clinical data for multiple cohort sizes and complication incidence rates. The experimental background was radiation pneumonitis in non-small cell lung cancer and the DVHP inference method was based on logistic regression. From 102 NSCLC real-life dose distributions and a postulated DVHP model, an 'ideal' cohort was generated where the most predictive model was equal to the postulated model. A bootstrap and a Cohort Replication Monte Carlo (CoRepMC) approach were applied to create 1000 equally sized populations each. The cohorts were then analyzed to establish inference frequency distributions. This was applied to nine scenarios for cohort sizes of 102 (1), 500 (2) to 2000 (3) patients (by sampling with replacement) and three postulated DVHP models. The Bootstrap was repeated for a 'non-ideal' cohort, where the most predictive model did not coincide with the postulated model. The Bootstrap produced chaotic results for all models of cohort size 1 for both the ideal and non-ideal cohorts. For cohort size 2 and 3, the distributions for all populations were more concentrated around the postulated DVHP. For the CoRepMC, the inference frequency increased with cohort size and incidence rate. Correct inference rates >[Formula: see text] were only achieved by cohorts with more than 500 patients. Both Bootstrap and CoRepMC indicate that inference of the correct or approximate DVHP for typical cohort sizes is highly uncertain. CoRepMC results were less spurious than Bootstrap results, demonstrating the large influence that randomness in dose-response has on the statistical analysis.
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Affiliation(s)
- C M Lutz
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
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Abstract
The aim of this study was to evaluate the value of pelvic lymph node dissection (PLND) performed as a separate procedure in a consecutive Danish bladder cancer cohort and also to analyse if the number of lymph nodes excised had an impact on outcome. From 1992 to 1998, 339 cystectomy candidates were retrospectively reviewed. Based on a preoperative PLND, 248 patients (10% N+) underwent radical cystectomy and 91 (87% N+) underwent radio- or chemotherapy. The median follow-up was 6.3 years. PLND was able to separate N+ from N0 patients with a false-negative rate of 3% compared with the following cystectomy. Lymph node-positive patients treated with cystectomy (n=24) all died from their bladder cancer. Therefore, accurate pathological N classification before the treatment decision seems worthwhile. The median number of lymph nodes excised was six and the number of lymph nodes had an independent prognostic impact on survival. This underlines the need for guidelines for surgical lymphadenectomy and the pathological assessment of lymph nodes in bladder cancer.
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Affiliation(s)
- M M Knap
- Department of Urology, Aarhus University Hospital, Denmark.
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Offersen BV, Knap MM, Marcussen N, Horsman MR, Hamilton-Dutoit S, Overgaard J. Intense inflammation in bladder carcinoma is associated with angiogenesis and indicates good prognosis. Br J Cancer 2002; 87:1422-30. [PMID: 12454772 PMCID: PMC2376289 DOI: 10.1038/sj.bjc.6600615] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2002] [Revised: 08/22/2002] [Accepted: 09/04/2002] [Indexed: 12/18/2022] Open
Abstract
The aim of this study was to investigate the prognostic influence of microvessel density using the hot spot method in 107 patients diagnosed with transitional cell carcinoma of the bladder. In each case, inflammation was found in the invasive carcinoma, therefore we classified the degree of inflammation as minimal, moderate or intense. Microvessel density was then reevaluated in each tumour in areas corresponding to these three categories. Median microvessel density irrespective of degree of inflammation was 71. Areas of minimal, moderate and intense inflammation were found in 48, 92 and 32 tumours. Microvessel density increased significantly with increasing degree of inflammation. Disease-specific survival was improved if areas of intense inflammation were present in the carcinoma (P=0.004). High microvessel density, irrespective of the degree of inflammation, was associated with a significantly better disease-specific survival (P=0.01). Multivariate analysis using death of disease as endpoint demonstrated an independent prognostic value of N-classification (N0, hazard ratio (HR)=1 vs N1, HR=2.89 (range, 1.52-5.52) vs N2, HR=3.61 (range, 1.84-7.08)), and intense inflammation, HR=0.48 (range, 0.24-0.96). Malignancy grade, T classification and microvessel density were not independent significant markers of poor outcome. In conclusion, inflammation was significantly correlated to microvessel density, and areas of intense inflammation were an independent marker of good prognosis.
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Affiliation(s)
- B V Offersen
- Department of Experimental Clinical Oncology, Danish Cancer Society, Aarhus University Hospital, Noerrebrogade 44, bldg 5, DK-8000 Aarhus C, Denmark.
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