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Hülpüsch C, Neumann AU, Reiger M, Fischer JC, de Tomassi A, Hammel G, Gülzow C, Fleming M, Dapper H, Mayinger M, Vogel M, Ertl C, Combs SE, Traidl-Hoffmann C, Borm KJ. Association of Skin Microbiome Dynamics With Radiodermatitis in Patients With Breast Cancer. JAMA Oncol 2024; 10:516-521. [PMID: 38300584 PMCID: PMC10835615 DOI: 10.1001/jamaoncol.2023.6533] [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: 06/17/2023] [Accepted: 09/18/2023] [Indexed: 02/02/2024]
Abstract
Importance The interindividual differences in severity of acute radiation dermatitis are not well understood. To date, the pathomechanism and interplay of microbiome and radiodermatitis before and during treatment remain largely unknown. Objective To assess the association of skin microbiome baseline composition and dynamics with severity of radiodermatitis in patients undergoing adjuvant radiotherapy for breast cancer. Design, Setting, and Participants A longitudinal prospective pilot observational study was conducted between January 2017 and January 2019. Sequencing results were received in March 2021, and the data were analyzed from August 2021 to March 2023. This study was performed at an urban academic university cancer center. A total of 21 female patients with breast cancer after surgery were consecutively approached, of which 1 patient withdrew consent before the study started. Exposure Adjuvant radiotherapy for breast cancer for 7 weeks. Main Outcomes and Measures The main outcome was the association of baseline skin microbiome composition and its dynamics with the severity of radiodermatitis. A total of 360 skin microbiome samples from patients were analyzed, taken before, during, and after radiotherapy, from both the treated and contralateral healthy sides. The skin microbiome samples were analyzed using 16S (V1-V3) amplicon sequencing and quantitative polymerase chain reaction bacterial enumeration. Results Twenty female patients with breast cancer after surgery who underwent radiotherapy enrolled in the study had a median (range) age of 61 (37-81) years. The median (range) body mass index of the patients was 24.2 (17.6-38.4). The 16S sequencing revealed that low (<5%) relative abundance of commensal skin bacteria (Staphylococcus epidermidis, Staphylococcus hominis, Cutibacterium acnes) at baseline composition was associated with the development of severe radiodermatitis with an accuracy of 100% (sensitivity and specificity of 100%, P < .001). Furthermore, in patients with severe radiodermatitis, quantitative polymerase chain reaction bacterial enumeration revealed a general non-species-specific overgrowth of skin bacterial load before the onset of severe symptoms. Subsequently, the abundance of commensal bacteria increased in severe radiodermatitis, coinciding with a decline in total bacterial load. Conclusions and Relevance The findings of this observational study indicated a potential mechanism associated with the skin microbiome for the pathogenesis of severe radiodermatitis, which may be a useful biomarker for personalized prevention of radiodermatitis in patients undergoing adjuvant radiotherapy for breast cancer.
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Affiliation(s)
- Claudia Hülpüsch
- Environmental Medicine, Faculty of Medicine, University of Augsburg, Augsburg, Germany
- Chair of Environmental Medicine, Technical University Munich, Munich, Germany
- CK CARE, Christine Kühne Center for Allergy Research and Education, Davos, Switzerland
| | - Avidan Uriel Neumann
- Environmental Medicine, Faculty of Medicine, University of Augsburg, Augsburg, Germany
- CK CARE, Christine Kühne Center for Allergy Research and Education, Davos, Switzerland
- Institute of Environmental Medicine, Helmholtz Munich, Augsburg, Germany
| | - Matthias Reiger
- Environmental Medicine, Faculty of Medicine, University of Augsburg, Augsburg, Germany
- Chair of Environmental Medicine, Technical University Munich, Munich, Germany
- Institute of Environmental Medicine, Helmholtz Munich, Augsburg, Germany
| | - Julius Clemens Fischer
- Department of Radiation Oncology, School of Medicine and Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Amedeo de Tomassi
- Environmental Medicine, Faculty of Medicine, University of Augsburg, Augsburg, Germany
| | - Gertrud Hammel
- Environmental Medicine, Faculty of Medicine, University of Augsburg, Augsburg, Germany
- Institute of Environmental Medicine, Helmholtz Munich, Augsburg, Germany
| | - Carina Gülzow
- Environmental Medicine, Faculty of Medicine, University of Augsburg, Augsburg, Germany
- Chair of Environmental Medicine, Technical University Munich, Munich, Germany
- CK CARE, Christine Kühne Center for Allergy Research and Education, Davos, Switzerland
| | - Megan Fleming
- Chair of Environmental Medicine, Technical University Munich, Munich, Germany
| | - Hendrik Dapper
- Department of Radiation Oncology, School of Medicine and Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael Mayinger
- Department of Radiation Oncology, School of Medicine and Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Marco Vogel
- Department of Radiation Oncology, School of Medicine and Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Christina Ertl
- Department of Radiation Oncology, School of Medicine and Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Stephanie Elisabeth Combs
- Department of Radiation Oncology, School of Medicine and Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Germany Institute of Innovative Radiotherapy (iRT), Department of Radiation Sciences, Helmholtz Munich, Oberschleißheim, Germany
- German Consortium for Translational Cancer Research (DKTK), Partner Site Munich, Munich, Germany
| | - Claudia Traidl-Hoffmann
- Environmental Medicine, Faculty of Medicine, University of Augsburg, Augsburg, Germany
- Chair of Environmental Medicine, Technical University Munich, Munich, Germany
- CK CARE, Christine Kühne Center for Allergy Research and Education, Davos, Switzerland
- Institute of Environmental Medicine, Helmholtz Munich, Augsburg, Germany
| | - Kai Joachim Borm
- Department of Radiation Oncology, School of Medicine and Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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Dapper H, Dantes M, Herschbach P, Algül H, Heinemann V. Relevance of tumor boards for the inclusion of patients in oncological clinical trials. J Cancer Res Clin Oncol 2023; 149:7601-7608. [PMID: 36995407 PMCID: PMC10374816 DOI: 10.1007/s00432-022-04559-0] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 12/23/2022] [Indexed: 03/31/2023]
Abstract
INTRODUCTION Major national and international oncological societies generally recommend treating a significant proportion of oncological patients in clinical trials to improve therapy strategies for cancer patients. At cancer centers, the recommendation about the appropriate therapy for the individual tumor patient is usually made in interdisciplinary case discussions in multidisciplinary tumor boards (MDT). In this study, we examined the impact of MDTs for the inclusion of patients in therapy trials. METHODOLOGY A prospective, explorative study of the Comprehensive Cancer Center Munich (CCCM) was conducted at both university hospitals in 2019. In the first phase, various MDTs' case discussions about oncological situations and their decisions regarding possible therapy trials were recorded in a structured manner. In the second phase, the actual inclusion rates of patients in therapy trials and reasons for non-inclusion were examined. Finally, the data of the respective university hospitals were anonymized, pooled and analyzed. RESULTS A total of 1797 case discussions were reviewed. Therapy recommendations were made in 1527 case presentations. 38 (2.5%) of 1527 patients were already included in a therapy trial at the time of case presentation. The MDTs recommended inclusion of an additional 107 cases (7%), for a therapy trial. Of these patients, 41 were finally enrolled in a therapy trial which resulted in a total recruitment rate of 5.2%. Despite MDTs' recommendations, 66 patients were not included in a therapy trial. The main reason for non-inclusion was insufficient inclusion or existing exclusion criteria (n = 18, 28%). In 48% of all cases (n = 31), the reason for non-inclusion could not be determined. CONCLUSION The potential of MDTs as an instrument for the inclusion of patients in therapy trials is high. To increase the enrollment of patients in oncological therapy trials, structural measures such as the central use of trial administration and MTB software in addition to standardized tumor board discussions must be established to ensure a seamless flow of information about actual recruiting trials and the current status of trial participation of patients.
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Affiliation(s)
- Hendrik Dapper
- Comprehensive Cancer Center Munich, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Maurice Dantes
- Department of Radiation Oncology, Comprehensive Cancer Center Munich, University Hospital Munich, LMU Munich, Munich, Germany
| | - Peter Herschbach
- Comprehensive Cancer Center Munich, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Hana Algül
- Department of Internal Medicine II, Comprehensive Cancer Center Munich, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Volker Heinemann
- Department of Medicine III, Comprehensive Cancer Center Munich, University Hospital Munich, LMU Munich, Munich, Germany
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3
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Linde P, Klein M, Lang F, Wegen S, Petersen C, Dapper H, Fan J, Celik E, Marnitz S, Baues C. Teaching in radiation oncology: now and 2025-results of a focus group with medical students. Strahlenther Onkol 2023; 199:360-369. [PMID: 36063205 PMCID: PMC9443630 DOI: 10.1007/s00066-022-01997-0] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 07/31/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE In Germany, the new Licensing Regulations for Physicians 2025 (Ärztliche Approbationsordnung, ÄApprO) define a binding legal framework on the basis of which medical faculties modernize their curricula. Since 2015, the National Competence Based Learning Objectives Catalogue for Medicine 2.0 (Nationaler Kompetenzbasierter Lernzielkatalog 2.0., NKLM) formulates competencies and learning objectives to be achieved in the course of studies as curriculum orientation for the medical faculties. In addition, about 80% of the areas of a new core curriculum are to be made compulsory. A needs analysis in the target group of students has not yet taken place for the subject of radiation therapy (RT) or radiation oncology (RO). This study therefore surveys the experiences and requirements of students regarding medical education in RT. METHODS Qualitative single-center study using a semistructured in-depth focus group with 11 medical students (20-26 years; 6 female, 5 male) was conducted. Brainstorming sessions were conducted in small groups and individually; oral contributions were recorded, transcribed, and analyzed using qualitative content analysis according to Mayring. Results were compared with the content of the future curriculum and reviewed for congruence with current expert recommendations of the German Society of Radiation Oncology (Deutsche Gesellschaft für Radioonkologie, DEGRO). RESULTS The plans to develop a longitudinal and practice-oriented curriculum was positively received by students. Specifically, students wanted to introduce the basics of RT as an early link to practice in preclinical teaching units. The necessary acquisition of communicative skills should also be taught by lecturers in RO. Methodologically, regular digital survey tools for self-monitoring, discussion rooms, and problem-based learning were named. In the perception of students, the subject appears underrepresented in relation to its relevance in the multimodal therapy of oncological diseases. CONCLUSION Results of the needs analysis for the subject of RT are consistent with ÄApprO, NKLM, and DEGRO. Moreover, they complement them and should be considered in the curriculum development of Masterplan Medical Education 2020 (Masterplan Medizinstudium 2020). The results contribute to high-quality and target-group-oriented medical training in the subject of RT, increased visibility, and thus early bonding of future physicians to RO in Germany.
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Affiliation(s)
- Philipp Linde
- Department of Radiation Oncology, Cyberknife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
| | - Marie Klein
- Department of Radiation Oncology, Cyberknife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Frauke Lang
- Department of Radiation Oncology, Cyberknife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Simone Wegen
- Department of Radiation Oncology, Cyberknife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Cordula Petersen
- Department of Radiotherapy and Radiation Oncology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Hendrik Dapper
- Department of Radiotherapy and Radiation Oncology, Public Hospital of Bielefeld, University Medical Center East Westphalia-Lippe, Teutoburger Str. 50, 33604, Bielefeld, Germany
| | - Jiaqi Fan
- Department of Radiation Oncology, Cyberknife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Eren Celik
- Department of Radiation Oncology, Cyberknife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Simone Marnitz
- Department of Radiation Oncology, Cyberknife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Christian Baues
- Department of Radiation Oncology, Cyberknife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
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Dapper H, Diehl C, Knebel C, Mogler C, Borm K, Dobiasch S, Combs SE, Peeken JC. Outcome of patients with soft tissue sarcomas of the extremities and trunk treated by (neo)adjuvant intensity modulated radiation therapy with curative intent. Radiat Oncol 2023; 18:44. [PMID: 36869396 PMCID: PMC9985237 DOI: 10.1186/s13014-023-02238-z] [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: 09/08/2022] [Accepted: 02/25/2023] [Indexed: 03/05/2023] Open
Abstract
BACKGROUND Soft tissue sarcomas (STS) are a relatively rare group of malignant tumors. Currently, there is very little published clinical data, especially in the context of curative multimodal therapy with image-guided, conformal, intensity-modulated radiotherapy. METHODS Patients who received preoperative or postoperative intensity-modulated radiotherapy for STS of the extremities or trunk with curative intent were included in this single centre retrospective analysis. A Kaplan-Meier analysis was performed to evaluate survival endpoints. Multivariable proportional hazard models were used to investigate the association between survival endpoints and tumour-, patient-, and treatment-specific characteristics. RESULTS 86 patients were included in the analysis. The most common histological subtypes were undifferentiated pleomorphic high-grade sarcoma (UPS) (27) and liposarcoma (22). More than two third of the patients received preoperative radiation therapy (72%). During the follow-up period, 39 patients (45%) suffered from some type of relapse, mainly remote (31%). The two-years overall survival rate was 88%. The median DFS was 48 months and the median DMFS was 51 months. Female gender (HR 0.460 (0.217; 0.973)) and histology of liposarcomas compared to UPS proved to be significantly more favorable in terms of DFS (HR 0.327 (0.126; 0.852)). CONCLUSION Conformal, intensity-modulated radiotherapy is an effective treatment modality in the preoperative or postoperative management of STS. Especially for the prevention of distant metastases, the establishment of modern systemic therapies or multimodal therapy approaches is necessary.
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Affiliation(s)
- Hendrik Dapper
- Department of Radiotherapy and Radiation Oncology, Public Hospital of Bielefeld, University Medical Center East Westphalia-Lippe, Bielefeld, Germany. .,Department of Radiation Oncology, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany.
| | - Christian Diehl
- Department of Radiation Oncology, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany
| | - Carolin Knebel
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany
| | - Carolin Mogler
- Institute of Pathology, Klinikum Rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Kai Borm
- Department of Radiation Oncology, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany
| | - Sophie Dobiasch
- Department of Radiation Oncology, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany.,Deutsches Konsortium Für Translationale Krebsforschung (DKTK), Partner Site , Munich, Germany.,Institute for Radiation Medicine (IRM), Helmholtz Zentrum München, Ingolstädter Landstr. 1, Neuherberg, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany.,Deutsches Konsortium Für Translationale Krebsforschung (DKTK), Partner Site , Munich, Germany.,Institute for Radiation Medicine (IRM), Helmholtz Zentrum München, Ingolstädter Landstr. 1, Neuherberg, Germany
| | - Jan C Peeken
- Department of Radiation Oncology, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany.,Deutsches Konsortium Für Translationale Krebsforschung (DKTK), Partner Site , Munich, Germany.,Institute for Radiation Medicine (IRM), Helmholtz Zentrum München, Ingolstädter Landstr. 1, Neuherberg, Germany
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5
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Sauter C, Peeken JC, Borm K, Diehl C, Münch S, Combs SE, Dapper H. Quality of life in patients treated with radiochemotherapy for primary diagnosis of anal cancer. Sci Rep 2022; 12:4416. [PMID: 35292732 PMCID: PMC8924204 DOI: 10.1038/s41598-022-08525-1] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 03/04/2022] [Indexed: 11/12/2022] Open
Abstract
Anal cancer and the related treatment are generally known to affect patients’ quality of life. The aim of this study was to assess self-reported quality of life (QoL) of anal cancer patients after combined radiation and chemotherapy, and to identify patient-, disease-, and therapy-related factors associated with QoL. A total of 94 patients treated with definitive chemoradiation for anal cancer at our institution in the period from 2004 to 2018 were identified from our database. QoL was assessed in the remaining 52 patients using the EORTC QLQ-C30 questionnaire (cancer-specific QoL) and the newly developed anal cancer module QLQ-ANL27 (site-specific QoL). Differences in QoL between anal cancer patients and a German age and sex adjusted reference population were examined. The median follow-up was 71 months (range, 7–176). In the cancer-specific QoL module, the anal cancer cohort presented with significantly lower scores in role (− 12.2 points), emotional (− 6.6 points), and social functioning (− 6.8 points), but higher scores in diarrhea (+ 36.3 points) and constipation (+ 13.3 points) than the German reference population. There were no significant differences in disease- or therapy-related factors, but age greater than 70 years and a follow-up time greater than 71 months had a negative impact on global QoL. As for the site-specific QoL, patients with a tumor relapse showed significantly higher symptom scores than patients with a complete clinical remission in all scales except of micturition frequency. Compared to 3D conformal radiotherapy, IMRT treatment seemed to improve non-stoma bowel function (+ 23.3 points), female sexual functioning (+ 24.2 points), and came along with less scores in the symptom scales pain (− 35.9 points), toilet proximity (− 28.6 points), and cleanliness (− 26.2 points). Most of the functional scores of anal cancer patients were lower compared to the general German population, but did not seem to affect the general QoL. Fatigue, physical, and role functioning had the strongest impact on global QoL causing psychological symptoms as important as physical.
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Affiliation(s)
- Christina Sauter
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Jan C Peeken
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany.,Institute for Radiation Medicine (IRM), Helmholtz Zentrum München, Ingolstädter Landstr. 1, Neuherberg, Germany
| | - Kai Borm
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Christian Diehl
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Stefan Münch
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany.,Institute for Radiation Medicine (IRM), Helmholtz Zentrum München, Ingolstädter Landstr. 1, Neuherberg, Germany
| | - Hendrik Dapper
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
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Dapper H, Belka C, Bock F, Budach V, Budach W, Christiansen H, Debus J, Distel L, Dunst J, Eckert F, Eich H, Eicheler W, Engenhart-Cabillic R, Fietkau R, Fleischmann DF, Frerker B, Giordano FA, Grosu AL, Herfarth K, Hildebrandt G, Kaul D, Kölbl O, Krause M, Krug D, Martin D, Matuschek C, Medenwald D, Nicolay NH, Niewald M, Oertel M, Petersen C, Pohl F, Raabe A, Rödel C, Rübe C, Schmalz C, Schmeel LC, Steinmann D, Stüben G, Thamm R, Vordermark D, Vorwerk H, Wiegel T, Zips D, Combs SE. Integration of radiation oncology teaching in medical studies by German medical faculties due to the new licensing regulations : An overview and recommendations of the consortium academic radiation oncology of the German Society for Radiation Oncology (DEGRO). Strahlenther Onkol 2021; 198:1-11. [PMID: 34786605 PMCID: PMC8594460 DOI: 10.1007/s00066-021-01861-7] [Citation(s) in RCA: 3] [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: 09/01/2021] [Accepted: 09/19/2021] [Indexed: 11/30/2022]
Abstract
The new Medical Licensing Regulations 2025 (Ärztliche Approbationsordnung, ÄApprO) will soon be passed by the Federal Council (Bundesrat) and will be implemented step by step by the individual faculties in the coming months. The further development of medical studies essentially involves an orientation from fact-based to competence-based learning and focuses on practical, longitudinal and interdisciplinary training. Radiation oncology and radiation therapy are important components of therapeutic oncology and are of great importance for public health, both clinically and epidemiologically, and therefore should be given appropriate attention in medical education. This report is based on a recent survey on the current state of radiation therapy teaching at university hospitals in Germany as well as the contents of the National Competence Based Learning Objectives Catalogue for Medicine 2.0 (Nationaler Kompetenzbasierter Lernzielkatalog Medizin 2.0, NKLM) and the closely related Subject Catalogue (Gegenstandskatalog, GK) of the Institute for Medical and Pharmaceutical Examination Questions (Institut für Medizinische und Pharmazeutische Prüfungsfragen, IMPP). The current recommendations of the German Society for Radiation Oncology (Deutsche Gesellschaft für Radioonkologie, DEGRO) regarding topics, scope and rationale for the establishment of radiation oncology teaching at the respective faculties are also included.
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Affiliation(s)
- H Dapper
- Department of Radiation Oncology, Technical University of Munich, Munich, Germany. .,German Cancer Consortium (DKTK) Partner Site (DKTK), Munich, Germany.
| | - C Belka
- Department of Radiation Oncology, LMU University Hospital, Munich, Germany.,German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany
| | - F Bock
- Department of Radiation Oncology, Rostock University Medical Center, Rostock, Germany
| | - V Budach
- Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - W Budach
- Department of Radiation Oncology, Medical Faculty, Heinrich Heine University, Duesseldorf, Germany
| | - H Christiansen
- Department of Radiation Oncology, Hannover Medical School (MHH), Hannover, Germany
| | - J Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center, Heidelberg, Germany
| | - L Distel
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
| | - J Dunst
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - F Eckert
- Department of Radiation Oncology, University of Tübingen, Tübingen, Germany.,German Cancer Consortium (DKTK) Partner Site (DKTK), Tübingen, Germany
| | - H Eich
- Department of Radiation Oncology, University of Münster, Münster, Germany
| | - W Eicheler
- OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
| | - R Engenhart-Cabillic
- Department of Radiotherapy and Radiation Oncology, University of Marburg, Marburg, Germany
| | - R Fietkau
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
| | - D F Fleischmann
- Department of Radiation Oncology, LMU University Hospital, Munich, Germany.,German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany
| | - B Frerker
- Department of Radiation Oncology, Rostock University Medical Center, Rostock, Germany
| | - F A Giordano
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Bonn, Germany
| | - A L Grosu
- Department of Radiation Oncology, University Medical Center Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK) Partner Site (DKTK), Freiburg, Germany
| | - K Herfarth
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center, Heidelberg, Germany
| | - G Hildebrandt
- Department of Radiation Oncology, Rostock University Medical Center, Rostock, Germany
| | - D Kaul
- Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Partner Site Berlin, German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany
| | - O Kölbl
- Department of Radiotherapy, University of Regensburg, Regensburg, Germany
| | - M Krause
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden and Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,Partner Site Dresden, German Cancer Research Center (DKFZ), National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,Heidelberg and German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Dresden, Germany
| | - D Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - D Martin
- Department of Radiotherapy and Oncology, University Hospital, Goethe University, Frankfurt, Germany.,German Cancer Consortium (DKTK) Partner Site (DKTK), Frankfurt, Germany
| | - C Matuschek
- Department of Radiation Oncology, Medical Faculty, Heinrich Heine University, Duesseldorf, Germany
| | - D Medenwald
- Deptartment of Radiation Oncology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - N H Nicolay
- Department of Radiation Oncology, University Medical Center Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK) Partner Site (DKTK), Freiburg, Germany
| | - M Niewald
- Department of Radiotherapy and Radiooncology, Saarland University Medical Center, Homburg, Germany
| | - M Oertel
- Department of Radiation Oncology, University of Münster, Münster, Germany
| | - C Petersen
- Department of Radiotherapy and Radio-Oncology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - F Pohl
- Department of Radiotherapy, University of Regensburg, Regensburg, Germany
| | - A Raabe
- Department of Radiotherapy and Radio-Oncology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - C Rödel
- Department of Radiotherapy and Oncology, University Hospital, Goethe University, Frankfurt, Germany.,German Cancer Consortium (DKTK) Partner Site (DKTK), Frankfurt, Germany
| | - C Rübe
- Department of Radiotherapy and Radiooncology, Saarland University Medical Center, Homburg, Germany
| | - C Schmalz
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - L C Schmeel
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Bonn, Germany
| | - D Steinmann
- Department of Radiation Oncology, Hannover Medical School (MHH), Hannover, Germany
| | - G Stüben
- Department of Radiation Oncology, University of Augsburg, Augsburg, Germany
| | - R Thamm
- Department of Radiation Oncology and Radiotherapy, University Hospital Ulm, Ulm, Germany
| | - D Vordermark
- Deptartment of Radiation Oncology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - H Vorwerk
- Department of Radiotherapy and Radiation Oncology, University of Marburg, Marburg, Germany
| | - T Wiegel
- Department of Radiation Oncology and Radiotherapy, University Hospital Ulm, Ulm, Germany
| | - D Zips
- Department of Radiation Oncology, University of Tübingen, Tübingen, Germany.,German Cancer Consortium (DKTK) Partner Site (DKTK), Tübingen, Germany
| | - S E Combs
- Department of Radiation Oncology, Technical University of Munich, Munich, Germany.,Institute of Radiation Medicine, Department of Radiation Sciences, Helmholtz Zentrum München, Munich, Germany.,German Cancer Consortium (DKTK) Partner Site (DKTK), Munich, Germany
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7
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Peeken JC, Asadpour R, Specht K, Chen EY, Klymenko O, Akinkuoroye V, Hippe DS, Spraker MB, Schaub SK, Dapper H, Knebel C, Mayr NA, Gersing AS, Woodruff HC, Lambin P, Nyflot MJ, Combs SE. MRI-based delta-radiomics predicts pathologic complete response in high-grade soft-tissue sarcoma patients treated with neoadjuvant therapy. Radiother Oncol 2021; 164:73-82. [PMID: 34506832 DOI: 10.1016/j.radonc.2021.08.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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: 04/26/2021] [Revised: 08/15/2021] [Accepted: 08/27/2021] [Indexed: 02/09/2023]
Abstract
PURPOSE In high-grade soft-tissue sarcomas (STS) the standard of care encompasses multimodal therapy regimens. While there is a growing body of evidence for prognostic pretreatment radiomic models, we hypothesized that temporal changes in radiomic features following neoadjuvant treatment ("delta-radiomics") may be able to predict the pathological complete response (pCR). METHODS MRI scans (T1-weighted with fat-saturation and contrast-enhancement (T1FSGd) and T2-weighted with fat-saturation (T2FS)) of patients with STS of the extremities and trunk treated with neoadjuvant therapy were gathered from two independent institutions (training: 103, external testing: 53 patients). pCR was defined as <5% viable cells. After segmentation and preprocessing, 105 radiomic features were extracted. Delta-radiomic features were calculated by subtraction of features derived from MRI scans obtained before and after neoadjuvant therapy. After feature reduction, machine learning modeling was performed in 100 iterations of 3-fold nested cross-validation. Delta-radiomic models were compared with single timepoint models in the testing cohort. RESULTS The combined delta-radiomic models achieved the best area under the receiver operating characteristic curve (AUC) of 0.75. Pre-therapeutic tumor volume was the best conventional predictor (AUC 0.70). The T2FS-based delta-radiomic model had the most balanced classification performance with a balanced accuracy of 0.69. Delta-radiomic models achieved better reproducibility than single timepoint radiomic models, RECIST or the peri-therapeutic volume change. Delta-radiomic models were significantly associated with survival in multivariate Cox regression. CONCLUSION This exploratory analysis demonstrated that MRI-based delta-radiomics improves prediction of pCR over tumor volume and RECIST. Delta-radiomics may one day function as a biomarker for personalized treatment adaptations.
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Affiliation(s)
- Jan C Peeken
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Germany; Institute of Radiation Medicine (IRM), Department of Radiation Sciences (DRS), Helmholtz Zentrum, München, Germany; Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Germany; Department of Radiation Oncology, University of Washington, Seattle, United States; Department of Precision Medicine, GROW - School for Oncology and Developmental Biology, Maastricht University, The Netherlands.
| | - Rebecca Asadpour
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Germany
| | - Katja Specht
- Institute of Pathology, Technical University of Munich, Germany
| | - Eleanor Y Chen
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, United States
| | - Olena Klymenko
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Germany
| | - Victor Akinkuoroye
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Germany
| | - Daniel S Hippe
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, United States
| | - Matthew B Spraker
- Department of Radiation Oncology, Washington University in St. Louis, United States
| | - Stephanie K Schaub
- Department of Radiation Oncology, University of Washington, Seattle, United States
| | - Hendrik Dapper
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Germany
| | - Carolin Knebel
- Department of Orthopedics and Sports Orthopedics, Klinikum rechts der Isar, Technical University of Munich (TUM), Germany
| | - Nina A Mayr
- Department of Radiation Oncology, University of Washington, Seattle, United States
| | - Alexandra S Gersing
- Department of Radiology, Klinikum rechts der Isar, Technical University of Munich (TUM), Germany
| | - Henry C Woodruff
- Department of Precision Medicine, GROW - School for Oncology and Developmental Biology, Maastricht University, The Netherlands; Department of Radiology and Nuclear Imaging, GROW- School for Oncology and Developmental Biology, Maastricht University Medical Centre, The Netherlands
| | - Philippe Lambin
- Department of Precision Medicine, GROW - School for Oncology and Developmental Biology, Maastricht University, The Netherlands; Department of Radiology and Nuclear Imaging, GROW- School for Oncology and Developmental Biology, Maastricht University Medical Centre, The Netherlands
| | - Matthew J Nyflot
- Department of Radiation Oncology, University of Washington, Seattle, United States; Department of Radiology, University of Washington, Seattle, United States
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Germany; Institute of Radiation Medicine (IRM), Department of Radiation Sciences (DRS), Helmholtz Zentrum, München, Germany; Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Germany
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8
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Borm KJ, Junker Y, Düsberg M, Devečka M, Münch S, Dapper H, Oechsner M, Combs SE. Impact of CBCT frequency on target coverage and dose to the organs at risk in adjuvant breast cancer radiotherapy. Sci Rep 2021; 11:17378. [PMID: 34462489 PMCID: PMC8405651 DOI: 10.1038/s41598-021-96836-0] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 08/17/2021] [Indexed: 11/16/2022] Open
Abstract
The current study aims to assess the effect of cone beam computed tomography (CBCT) frequency during adjuvant breast cancer radiotherapy with simultaneous integrated boost (SIB) on target volume coverage and dose to the organs at risk (OAR). 50 breast cancer patients receiving either non-hypofractionated or hypofractionated radiotherapy after lumpectomy including a SIB to the tumor bed were selected for this study. All patients were treated in volumetric modulated arc therapy (VMAT) technique and underwent daily CBCT imaging. In order to estimate the delivered dose during the treatment, the applied fraction doses were recalculated on daily CBCT scans and accumulated using deformable image registration. Based on a total of 2440 dose recalculations, dose coverage in the clinical target volumes (CTV) and OAR was compared depending on the CBCT frequency. The estimated delivered dose (V95%) for breast-CTV and SIB-CTV was significantly lower than the planned dose distribution, irrespective of the CBCT-frequency. Between daily CBCT and CBCT on alternate days, no significant dose differences were found regarding V95% for both, breast-CTV and SIB-CTV. Dose distribution in the OAR was similar for both imaging protocols. Weekly CBCT though led to a significant decrease in dose coverage compared to daily CBCT and a small but significant dose increase in most OAR. Daily CBCT imaging might not be necessary to ensure adequate dose coverage in the target volumes while efficiently sparing the OAR during adjuvant breast cancer radiotherapy with SIB.
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Affiliation(s)
- Kai J Borm
- Department of Radiation Oncology, Klinikum Rechts Der Isar, Medical School, Technical University Munich, Ismaningerstraße 22, 81675, Munich, Germany.
| | - Yannis Junker
- Department of Radiation Oncology, Klinikum Rechts Der Isar, Medical School, Technical University Munich, Ismaningerstraße 22, 81675, Munich, Germany
| | - Mathias Düsberg
- Department of Radiation Oncology, Klinikum Rechts Der Isar, Medical School, Technical University Munich, Ismaningerstraße 22, 81675, Munich, Germany
| | - Michal Devečka
- Department of Radiation Oncology, Klinikum Rechts Der Isar, Medical School, Technical University Munich, Ismaningerstraße 22, 81675, Munich, Germany
| | - Stefan Münch
- Department of Radiation Oncology, Klinikum Rechts Der Isar, Medical School, Technical University Munich, Ismaningerstraße 22, 81675, Munich, Germany
| | - Hendrik Dapper
- Department of Radiation Oncology, Klinikum Rechts Der Isar, Medical School, Technical University Munich, Ismaningerstraße 22, 81675, Munich, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Klinikum Rechts Der Isar, Medical School, Technical University Munich, Ismaningerstraße 22, 81675, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum Rechts Der Isar, Medical School, Technical University Munich, Ismaningerstraße 22, 81675, Munich, Germany.,Deutsches Konsortium Für Translationale Krebsforschung (DKTK)-Partner Site Munich, Munich, Germany.,Institute of Radiation Medicine, Helmholtzzentrum München, Munich, Germany
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9
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Navarro F, Dapper H, Asadpour R, Knebel C, Spraker MB, Schwarze V, Schaub SK, Mayr NA, Specht K, Woodruff HC, Lambin P, Gersing AS, Nyflot MJ, Menze BH, Combs SE, Peeken JC. Development and External Validation of Deep-Learning-Based Tumor Grading Models in Soft-Tissue Sarcoma Patients Using MR Imaging. Cancers (Basel) 2021; 13:2866. [PMID: 34201251 PMCID: PMC8227009 DOI: 10.3390/cancers13122866] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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: 04/26/2021] [Revised: 05/27/2021] [Accepted: 06/02/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In patients with soft-tissue sarcomas, tumor grading constitutes a decisive factor to determine the best treatment decision. Tumor grading is obtained by pathological work-up after focal biopsies. Deep learning (DL)-based imaging analysis may pose an alternative way to characterize STS tissue. In this work, we sought to non-invasively differentiate tumor grading into low-grade (G1) and high-grade (G2/G3) STS using DL techniques based on MR-imaging. METHODS Contrast-enhanced T1-weighted fat-saturated (T1FSGd) MRI sequences and fat-saturated T2-weighted (T2FS) sequences were collected from two independent retrospective cohorts (training: 148 patients, testing: 158 patients). Tumor grading was determined following the French Federation of Cancer Centers Sarcoma Group in pre-therapeutic biopsies. DL models were developed using transfer learning based on the DenseNet 161 architecture. RESULTS The T1FSGd and T2FS-based DL models achieved area under the receiver operator characteristic curve (AUC) values of 0.75 and 0.76 on the test cohort, respectively. T1FSGd achieved the best F1-score of all models (0.90). The T2FS-based DL model was able to significantly risk-stratify for overall survival. Attention maps revealed relevant features within the tumor volume and in border regions. CONCLUSIONS MRI-based DL models are capable of predicting tumor grading with good reproducibility in external validation.
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Affiliation(s)
- Fernando Navarro
- Department of Radiation Oncology, Klinikum Rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675 Munich, Germany; (F.N.); (H.D.); (R.A.); (S.E.C.)
- Department of Informatics, Technical University of Munich (TUM), Boltzmannstr. 3, 85748 Garching, Germany;
- TranslaTUM—Central Institute for Translational Cancer Research, Einsteinstraße 25, 81675 Munich, Germany
| | - Hendrik Dapper
- Department of Radiation Oncology, Klinikum Rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675 Munich, Germany; (F.N.); (H.D.); (R.A.); (S.E.C.)
| | - Rebecca Asadpour
- Department of Radiation Oncology, Klinikum Rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675 Munich, Germany; (F.N.); (H.D.); (R.A.); (S.E.C.)
| | - Carolin Knebel
- Department of Orthopedics and Sports Orthopedics, Klinikum Rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675 Munich, Germany;
| | - Matthew B. Spraker
- Department of Radiation Oncology, Washington University in St. Louis, 4511 Forest Park Ave, St. Louis, MO 63108, USA;
| | - Vincent Schwarze
- Department of Radiology, Grosshadern Campus, Ludwig-Maximilians-University Munich, Marchioninistraße 15, 81377 Munich, Germany; (V.S.); (A.S.G.)
| | - Stephanie K. Schaub
- Department of Radiation Oncology, University of Washington, 1959 NE Pacific St, 356043, Seattle, WA 98195, USA; (S.K.S.); (N.A.M.); (M.J.N.)
| | - Nina A. Mayr
- Department of Radiation Oncology, University of Washington, 1959 NE Pacific St, 356043, Seattle, WA 98195, USA; (S.K.S.); (N.A.M.); (M.J.N.)
| | - Katja Specht
- Department of Pathology, Technical University of Munich (TUM), Trogerstr. 18, 81675 Munich, Germany;
| | - Henry C. Woodruff
- Department of Precision Medicine, GROW—School for Oncology and Developmental Biology, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands; (H.C.W.); (P.L.)
- Department of Radiology and Nuclear Imaging, GROW—School for Oncology and Developmental Biology, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Philippe Lambin
- Department of Precision Medicine, GROW—School for Oncology and Developmental Biology, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands; (H.C.W.); (P.L.)
- Department of Radiology and Nuclear Imaging, GROW—School for Oncology and Developmental Biology, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Alexandra S. Gersing
- Department of Radiology, Grosshadern Campus, Ludwig-Maximilians-University Munich, Marchioninistraße 15, 81377 Munich, Germany; (V.S.); (A.S.G.)
- Department of Radiology, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675 Munich, Germany
| | - Matthew J. Nyflot
- Department of Radiation Oncology, University of Washington, 1959 NE Pacific St, 356043, Seattle, WA 98195, USA; (S.K.S.); (N.A.M.); (M.J.N.)
- Department of Radiology, University of Washington, 4245 Roosevelt Way NE, Seattle, WA 98105, USA
| | - Bjoern H. Menze
- Department of Informatics, Technical University of Munich (TUM), Boltzmannstr. 3, 85748 Garching, Germany;
- Department for Quantitative Biomedicine, University of Zurich, Winterthurerstrasse 190, CH-8057 Zurich, Switzerland
| | - Stephanie E. Combs
- Department of Radiation Oncology, Klinikum Rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675 Munich, Germany; (F.N.); (H.D.); (R.A.); (S.E.C.)
- Department for Quantitative Biomedicine, University of Zurich, Winterthurerstrasse 190, CH-8057 Zurich, Switzerland
- Institute of Radiation Medicine (IRM), Department of Radiation Sciences (DRS), Ingolstaedter Landstr. 1, 85764 Munich, Germany
| | - Jan C. Peeken
- Department of Radiation Oncology, Klinikum Rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675 Munich, Germany; (F.N.); (H.D.); (R.A.); (S.E.C.)
- Department of Radiology and Nuclear Imaging, GROW—School for Oncology and Developmental Biology, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
- Institute of Radiation Medicine (IRM), Department of Radiation Sciences (DRS), Ingolstaedter Landstr. 1, 85764 Munich, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site, 85764 Munich, Germany
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10
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Peeken JC, Neumann J, Asadpour R, Leonhardt Y, Moreira JR, Hippe DS, Klymenko O, Foreman SC, von Schacky CE, Spraker MB, Schaub SK, Dapper H, Knebel C, Mayr NA, Woodruff HC, Lambin P, Nyflot MJ, Gersing AS, Combs SE. Prognostic Assessment in High-Grade Soft-Tissue Sarcoma Patients: A Comparison of Semantic Image Analysis and Radiomics. Cancers (Basel) 2021; 13:1929. [PMID: 33923697 PMCID: PMC8073388 DOI: 10.3390/cancers13081929] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 03/01/2021] [Revised: 04/13/2021] [Accepted: 04/13/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND In patients with soft-tissue sarcomas of the extremities, the treatment decision is currently regularly based on tumor grading and size. The imaging-based analysis may pose an alternative way to stratify patients' risk. In this work, we compared the value of MRI-based radiomics with expert-derived semantic imaging features for the prediction of overall survival (OS). METHODS Fat-saturated T2-weighted sequences (T2FS) and contrast-enhanced T1-weighted fat-saturated (T1FSGd) sequences were collected from two independent retrospective cohorts (training: 108 patients; testing: 71 patients). After preprocessing, 105 radiomic features were extracted. Semantic imaging features were determined by three independent radiologists. Three machine learning techniques (elastic net regression (ENR), least absolute shrinkage and selection operator, and random survival forest) were compared to predict OS. RESULTS ENR models achieved the best predictive performance. Histologies and clinical staging differed significantly between both cohorts. The semantic prognostic model achieved a predictive performance with a C-index of 0.58 within the test set. This was worse compared to a clinical staging system (C-index: 0.61) and the radiomic models (C-indices: T1FSGd: 0.64, T2FS: 0.63). Both radiomic models achieved significant patient stratification. CONCLUSIONS T2FS and T1FSGd-based radiomic models outperformed semantic imaging features for prognostic assessment.
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Affiliation(s)
- Jan C. Peeken
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675 Munich, Germany; (R.A.); (O.K.); (H.D.); (S.E.C.)
- Institute of Radiation Medicine (IRM), Department of Radiation Sciences (DRS), Helmholtz Zentrum München, 85764 München, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Germany
- Department of Precision Medicine, GROW—School for Oncology and Developmental Biology, Maastricht University, 6200 MD Maastricht, The Netherlands; (H.C.W.); (P.L.)
| | - Jan Neumann
- Department of Radiology, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany; (J.N.); (Y.L.); (J.R.M.); (S.C.F.); (C.E.v.S.); (A.S.G.)
| | - Rebecca Asadpour
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675 Munich, Germany; (R.A.); (O.K.); (H.D.); (S.E.C.)
| | - Yannik Leonhardt
- Department of Radiology, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany; (J.N.); (Y.L.); (J.R.M.); (S.C.F.); (C.E.v.S.); (A.S.G.)
| | - Joao R. Moreira
- Department of Radiology, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany; (J.N.); (Y.L.); (J.R.M.); (S.C.F.); (C.E.v.S.); (A.S.G.)
| | - Daniel S. Hippe
- Department of Radiation Oncology, University of Washington, Seattle, WA 98195, USA; (D.S.H.); (S.K.S.); (N.A.M.); (M.J.N.)
| | - Olena Klymenko
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675 Munich, Germany; (R.A.); (O.K.); (H.D.); (S.E.C.)
| | - Sarah C. Foreman
- Department of Radiology, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany; (J.N.); (Y.L.); (J.R.M.); (S.C.F.); (C.E.v.S.); (A.S.G.)
| | - Claudio E. von Schacky
- Department of Radiology, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany; (J.N.); (Y.L.); (J.R.M.); (S.C.F.); (C.E.v.S.); (A.S.G.)
| | - Matthew B. Spraker
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO 63110, USA;
| | - Stephanie K. Schaub
- Department of Radiation Oncology, University of Washington, Seattle, WA 98195, USA; (D.S.H.); (S.K.S.); (N.A.M.); (M.J.N.)
| | - Hendrik Dapper
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675 Munich, Germany; (R.A.); (O.K.); (H.D.); (S.E.C.)
| | - Carolin Knebel
- Department of Orthopedics and Sports Orthopedics, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany;
| | - Nina A. Mayr
- Department of Radiation Oncology, University of Washington, Seattle, WA 98195, USA; (D.S.H.); (S.K.S.); (N.A.M.); (M.J.N.)
| | - Henry C. Woodruff
- Department of Precision Medicine, GROW—School for Oncology and Developmental Biology, Maastricht University, 6200 MD Maastricht, The Netherlands; (H.C.W.); (P.L.)
- Department of Radiology and Nuclear Imaging, GROW—School for Oncology and Developmental Biology, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands
| | - Philippe Lambin
- Department of Precision Medicine, GROW—School for Oncology and Developmental Biology, Maastricht University, 6200 MD Maastricht, The Netherlands; (H.C.W.); (P.L.)
- Department of Radiology and Nuclear Imaging, GROW—School for Oncology and Developmental Biology, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands
| | - Matthew J. Nyflot
- Department of Radiation Oncology, University of Washington, Seattle, WA 98195, USA; (D.S.H.); (S.K.S.); (N.A.M.); (M.J.N.)
- Department of Radiology, University of Washington, Seattle, WA 98195, USA
| | - Alexandra S. Gersing
- Department of Radiology, Klinikum rechts der Isar, Technical University of Munich (TUM), 81675 Munich, Germany; (J.N.); (Y.L.); (J.R.M.); (S.C.F.); (C.E.v.S.); (A.S.G.)
| | - Stephanie E. Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Ismaninger Straße 22, 81675 Munich, Germany; (R.A.); (O.K.); (H.D.); (S.E.C.)
- Institute of Radiation Medicine (IRM), Department of Radiation Sciences (DRS), Helmholtz Zentrum München, 85764 München, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Germany
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11
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Dapper H, Wijnen-Meijer M, Rathfelder S, Mosene K, von Kirchbauer I, Bernhardt D, Berberat PO, Combs SE. Radiation oncology as part of medical education-current status and possible digital future prospects. Strahlenther Onkol 2020; 197:528-536. [PMID: 33230568 PMCID: PMC7682521 DOI: 10.1007/s00066-020-01712-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 08/10/2020] [Accepted: 11/02/2020] [Indexed: 11/29/2022]
Abstract
Purpose Education as part of medical education is currently changing rapidly. Not least because of the corona crisis, more and more digital teaching formats and innovative teaching concepts such as the flipped classroom model are finding their way into teaching. We analyzed the acceptance and effectiveness of traditional teaching methods as well as the interest in innovative e‑learning methods among medical students in the field of radiation oncology at the medical school of the Technical University of Munich. Methods We carried out an online-based survey as well as a knowledge test on all students from two terms who had completed the seminar series of radiation oncology. The survey comprised seven questions on the frequency of participation, acceptance, and judgment of the effectiveness in terms of learning and on a potential use of e‑learning methods using a six-point Likert scale. The test consisted of 10 multiple-choice questions. Results Traditional teaching methods are largely accepted by students and most students consider the current learning format to be effective in terms of the teaching effect in the field of radiation oncology. However, only about 50% of all knowledge questions were answered correctly. The possible use of e‑learning methods was judged critically or desired in roughly equal parts among the students. Conclusion Traditional seminars enjoy a high level of acceptance among students. Effectiveness with regard to the internalization of content taught, however, should be increased. After all, the future seems to lie in the integration of e‑learning in the form of educational videos and practical seminars.
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Affiliation(s)
- Hendrik Dapper
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Marjo Wijnen-Meijer
- School of Medicine, TUM Medical Education Center, Technical University Munich, Nigerstraße 3, 81675, Munich, Germany
| | - Salome Rathfelder
- DRF Stiftung Luftrettung gAG, Rita-Maiburg-Straße 2, 70794, Filderstadt, Germany
| | - Katharina Mosene
- School of Medicine, TUM Medical Education Center, Technical University Munich, Nigerstraße 3, 81675, Munich, Germany
| | - Isabelle von Kirchbauer
- School of Medicine, TUM Medical Education Center, Technical University Munich, Nigerstraße 3, 81675, Munich, Germany
| | - Denise Bernhardt
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Pascal O Berberat
- School of Medicine, TUM Medical Education Center, Technical University Munich, Nigerstraße 3, 81675, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany.,Institute for Radiation Medicine (IRM), Helmholtz Zentrum München (HMGU), Ingolstädter Landstr. 1, Neuherberg, Germany.,Partner Site Munich, Deutsches Konsortium für Translationale Krebsforschung (DKTK), Munich, Germany
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12
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Dapper H, Sauter C, Münch S, Combs S. Differences In Quality Of Live In Patients With Anal Cancer Treated With Either Intensity-Modulated Or 3D-Conformal Radiation Therapy. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.1954] [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: 10/23/2022]
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13
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Sauter AP, Kössinger A, Beck S, Deniffel D, Dapper H, Combs SE, Rummeny EJ, Pfeiffer D. Dual-energy CT parameters in correlation to MRI-based apparent diffusion coefficient: evaluation in rectal cancer after radiochemotherapy. Acta Radiol Open 2020; 9:2058460120945316. [PMID: 32995044 PMCID: PMC7503032 DOI: 10.1177/2058460120945316] [Citation(s) in RCA: 4] [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: 05/11/2020] [Accepted: 07/03/2020] [Indexed: 01/04/2023] Open
Abstract
Background Rectal cancer (RC) is a frequent malignancy for which magnetic resonance imaging (MRI) is the most common and accurate imaging. Iodine concentration (IC) can be quantified with spectral dual-layer computed tomography CT (DL-CT), which could improve imaging of RC, especially for evaluation of response to radiochemotherapy (RCT). Purpose To compare a DL-CT system to MRI as the non-invasive imaging gold standard for imaging of RC to evaluate the possibility of a response evaluation with DL-CT. Material and Methods Eleven patients who received DL-CT as well as MRI before and after RCT of RC were retrospectively included into this study. For each examination, a region of interest (ROI) was placed within the tumor. For MRI, the mean apparent diffusion coefficient (ADC) was assessed. For DL-CT, IC, z-effective, and Hounsfield Units (HU) were measured. IC, z-effective, and HU were normalized to the aorta. ADC was correlated to absolute and relative normalized IC, z-effective, and HU with Spearman’s ρ. Differences before and after treatment were tested with Wilcoxon signed-rank test. Results HU, IC, and Z-effective values in DL-CT images decreased significantly after RCT (P<0.01 for each comparison). The mean ADC increased significantly after RCT. Spearman’s ρ of the absolute IC difference and the absolute ADC (both before and after RCT) is high and significant (ρ = 0.73; P = 0.01), whereas the ρ-value for z-effective (ρ = 0.56) or HU (ρ = 0.45) to ADC was lower and non-significant. Conclusion Response evaluation of RC after RCT could be possible with DL-CT via the measurement of IC.
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Affiliation(s)
- Andreas P Sauter
- Department of Diagnostic and Interventional Radiology, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Antonia Kössinger
- Department of Diagnostic and Interventional Radiology, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Stefanie Beck
- Department of Diagnostic and Interventional Radiology, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Dominik Deniffel
- Department of Diagnostic and Interventional Radiology, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Hendrik Dapper
- Department of Radiation Oncology, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany.,Department of Radiation Sciences (DRS), Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Neuherberg, Germany.,Deutsches Konsortium für Translationale Krebsforschung (dktk), Partner Site Munich, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany.,Department of Radiation Sciences (DRS), Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Neuherberg, Germany.,Deutsches Konsortium für Translationale Krebsforschung (dktk), Partner Site Munich, Munich, Germany
| | - Ernst J Rummeny
- Department of Diagnostic and Interventional Radiology, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Daniela Pfeiffer
- Department of Diagnostic and Interventional Radiology, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
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Münch S, Marr L, Feuerecker B, Dapper H, Braren R, Combs SE, Duma MN. Impact of 18F-FDG-PET/CT on the identification of regional lymph node metastases and delineation of the primary tumor in esophageal squamous cell carcinoma patients. Strahlenther Onkol 2020; 196:787-794. [PMID: 32430661 PMCID: PMC7449992 DOI: 10.1007/s00066-020-01630-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 02/23/2020] [Accepted: 04/28/2020] [Indexed: 12/27/2022]
Abstract
Purpose In patients undergoing chemoradiation for esophageal squamous cell carcinoma (ESCC), the extent of elective nodal irradiation (ENI) is still discussed controversially. This study aimed to analyze patterns of lymph node metastases and their correlation with the primary tumor using 18F‑fludeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) scans. Methods 102 ESCC patients with pre-treatment FDG-PET/CT scans were evaluated retrospectively. After exclusion of patients with low FDG uptake and patients without FDG-PET-positive lymph node metastases (LNM), 76 patients were included in the final analysis. All LNM were assigned to 16 pre-defined anatomical regions and classified according to their position relative to the primary tumor (above, at the same height, or below the primary tumor). In addition, the longitudinal distance to the primary tumor was measured for all LNM above or below the primary tumor. The craniocaudal extent (i.e., length) of the primary tumor was measured using FDG-PET imaging (LPET) and also based on all other available clinical and imaging data (endoscopy, computed tomography, biopsy results) except FDG-PET (LCT/EUS). Results Significantly more LNM were identified with 18F‑FDG-PET/CT (177 LNM) compared to CT alone (131 LNM, p < 0.001). The most common sites of LNM were paraesophageal (63% of patients, 37% of LNM) and paratracheal (33% of patients, 20% of LNM), while less than 5% of patients had supraclavicular, subaortic, diaphragmatic, or hilar LNM. With regard to the primary tumor, 51% of LNM were at the same height, while 25% and 24% of lymph node metastases were above and below the primary tumor, respectively. For thirty-three LNM (19%), the distance to the primary tumor was larger than 4 cm. No significant difference was seen between LCT/EUS (median 6 cm) and LPET (median 6 cm, p = 0.846) Conclusion 18F‑FDG-PET can help to identify subclinical lymph node metastases which are located outside of recommended radiation fields. PET-based involved-field irradiation might be the ideal compromise between small treatment volumes and decreasing the risk of undertreatment of subclinical metastatic lymph nodes and should be further evaluated.
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Affiliation(s)
- Stefan Münch
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany. .,Partner Site Munich, German Cancer Consortium (DKTK), Munich, Germany.
| | - Lisa Marr
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Benedikt Feuerecker
- Department of Nuclear Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Hendrik Dapper
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Rickmer Braren
- Institute of Radiology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany.,Partner Site Munich, German Cancer Consortium (DKTK), Munich, Germany.,Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Oberschleißheim, Germany
| | - Marciana-Nona Duma
- Department of Radiation Oncology, Universitätsklinikum Jena, Friedrich-Schiller-Universität Jena, Bachstraße 18, 07743, Jena, Germany
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15
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Jesinghaus M, Boxberg M, Wilhelm D, Münch S, Dapper H, Quante M, Schlag C, Lange S, Budczies J, Konukiewitz B, Mollenhauer M, Schlitter AM, Becker KF, Feith M, Friess H, Steiger K, Combs SE, Weichert W. Post-neoadjuvant cellular dissociation grading based on tumour budding and cell nest size is associated with therapy response and survival in oesophageal squamous cell carcinoma. Br J Cancer 2019; 121:1050-1057. [PMID: 31690830 PMCID: PMC6964693 DOI: 10.1038/s41416-019-0623-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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: 06/11/2019] [Revised: 10/08/2019] [Accepted: 10/17/2019] [Indexed: 11/25/2022] Open
Abstract
Background Cellular Dissociation Grade (CDG) composed of tumour budding and cell nest size has been shown to independently predict prognosis in pre-therapeutic biopsies and primary resections of oesophageal squamous cell carcinoma (ESCC). Here, we aimed to evaluate the prognostic impact of CDG in ESCC after neoadjuvant therapy. Methods We evaluated cell nest size and tumour budding activity in 122 post-neoadjuvant ESCC resections, correlated the results with tumour regression groups and patient survival and compared the results with data from primary resected cases as well as pre-therapeutic biopsies. Results CDG remained stable when results from pre-therapeutic biopsies and post-therapeutic resections from the same patient were compared. CDG was associated with therapy response and a strong predictor of overall, disease-specific (DSS) and disease-free (DFS) survival in univariate analysis and—besides metastasis—remained the only significant survival predictor for DSS and DFS in multivariate analysis. Multivariate DFS hazard ratios reached 3.3 for CDG-G2 and 4.9 for CDG-G3 neoplasms compared with CDG-G1 carcinomas (p = 0.016). Conclusions CDG is the only morphology-based grading algorithm published to date, which in concert with regression grading, is able to contribute relevant prognostic information in the post-neoadjuvant setting of ESCC.
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Affiliation(s)
- Moritz Jesinghaus
- Institute of Pathology, Technical University Munich, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Institute for Translational Cancer Research, Munich, Germany
| | - Melanie Boxberg
- Institute of Pathology, Technical University Munich, Munich, Germany
| | - Dirk Wilhelm
- Department of Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Stefan Münch
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany.,Department of Radiation Therapy, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Hendrik Dapper
- Department of Radiation Therapy, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Michael Quante
- II Medizinische Klinik, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Christoph Schlag
- II Medizinische Klinik, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Sebastian Lange
- II Medizinische Klinik, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Jan Budczies
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - Björn Konukiewitz
- Institute of Pathology, Technical University Munich, Munich, Germany
| | | | | | | | - Marcus Feith
- Department of Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Katja Steiger
- Institute of Pathology, Technical University Munich, Munich, Germany
| | - Stephanie E Combs
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany.,Department of Radiation Therapy, Klinikum rechts der Isar, Technical University Munich, Munich, Germany.,Institute of Innovative Radiotherapy (iRT), Helmholtz Center Munich, Munich, Germany
| | - Wilko Weichert
- Institute of Pathology, Technical University Munich, Munich, Germany. .,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany.
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Peeken JC, Spraker MB, Knebel C, Dapper H, Pfeiffer D, Devecka M, Thamer A, Shouman MA, Ott A, von Eisenhart-Rothe R, Nüsslin F, Mayr NA, Nyflot MJ, Combs SE. Tumor grading of soft tissue sarcomas using MRI-based radiomics. EBioMedicine 2019; 48:332-340. [PMID: 31522983 PMCID: PMC6838361 DOI: 10.1016/j.ebiom.2019.08.059] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [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: 05/14/2019] [Revised: 08/13/2019] [Accepted: 08/24/2019] [Indexed: 12/13/2022] Open
Abstract
Background Treatment decisions for multimodal therapy in soft tissue sarcoma (STS) patients greatly depend on the differentiation between low-grade and high-grade tumors. We developed MRI-based radiomics grading models for the differentiation between low-grade (G1) and high-grade (G2/G3) STS. Methods The study was registered at ClinicalTrials.gov (number NCT03798795). Contrast-enhanced T1-weighted fat saturated (T1FSGd), fat-saturated T2-weighted (T2FS) MRI sequences, and tumor grading following the French Federation of Cancer Centers Sarcoma Group obtained from pre-therapeutic biopsies were gathered from two independent retrospective patient cohorts. Volumes of interest were manually segmented. After preprocessing, 1394 radiomics features were extracted from each sequence. Features unstable in 21 independent multiple-segmentations were excluded. Least absolute shrinkage and selection operator models were developed using nested cross-validation on a training patient cohort (122 patients). The influence of ComBatHarmonization was assessed for correction of batch effects. Findings Three radiomic models based on T2FS, T1FSGd and a combined model achieved predictive performances with an area under the receiver operator characteristic curve (AUC) of 0.78, 0.69, and 0.76 on the independent validation set (103 patients), respectively. The T2FS-based model showed the best reproducibility. The radiomics model involving T1FSGd-based features achieved significant patient stratification. Combining the T2FS radiomic model into a nomogram with clinical staging improved prognostic performance and the clinical net benefit above clinical staging alone. Interpretation MRI-based radiomics tumor grading models effectively classify low-grade and high-grade soft tissue sarcomas. Fund The authors received support by the medical faculty of the Technical University of Munich and the German Cancer Consortium.
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Affiliation(s)
- Jan C Peeken
- Department of Radiation Oncology, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich (TUM), Ismaninger Straße 22, 81675 Munich, Germany; Institute of Radiation Medicine (IRM), Department of Radiation Sciences (DRS), Helmholtz Zentrum München, Ingolstaedter Landstrasse 1, 85764 Neuherberg, Germany; Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Germany.
| | - Matthew B Spraker
- Department of Radiation Oncology, University of Washington, 1959 NE Pacific St, Box 356043, Seattle, WA 98195, United States of America
| | - Carolin Knebel
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich (TUM), Ismaninger Straße 22, 81675 München, Germany
| | - Hendrik Dapper
- Department of Radiation Oncology, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich (TUM), Ismaninger Straße 22, 81675 Munich, Germany
| | - Daniela Pfeiffer
- Department of Radiology, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich (TUM), Ismaninger Straße 22, 81675 Munich, Germany
| | - Michal Devecka
- Department of Radiation Oncology, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich (TUM), Ismaninger Straße 22, 81675 Munich, Germany
| | - Ahmed Thamer
- Department of Radiation Oncology, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich (TUM), Ismaninger Straße 22, 81675 Munich, Germany
| | - Mohamed A Shouman
- Department of Radiation Oncology, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich (TUM), Ismaninger Straße 22, 81675 Munich, Germany
| | - Armin Ott
- Institute of Medical Informatics, Statistics and Epidemiology, Technical University of Munich (TUM), Ismaninger Straße 22, 81675 Munich, Germany
| | - Rüdiger von Eisenhart-Rothe
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich (TUM), Ismaninger Straße 22, 81675 München, Germany
| | - Fridtjof Nüsslin
- Department of Radiation Oncology, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich (TUM), Ismaninger Straße 22, 81675 Munich, Germany
| | - Nina A Mayr
- Department of Radiation Oncology, University of Washington, 1959 NE Pacific St, Box 356043, Seattle, WA 98195, United States of America
| | - Matthew J Nyflot
- Department of Radiation Oncology, University of Washington, 1959 NE Pacific St, Box 356043, Seattle, WA 98195, United States of America; Department of Radiology, University of Washington, Seattle, WA, United States of America
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich (TUM), Ismaninger Straße 22, 81675 Munich, Germany; Institute of Radiation Medicine (IRM), Department of Radiation Sciences (DRS), Helmholtz Zentrum München, Ingolstaedter Landstrasse 1, 85764 Neuherberg, Germany; Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Germany
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Dapper H, Schiller K, Münch S, Peeken J, Borm K, Weber W, Combs S. Patterns of Inguinal Lymph Node Involvement in Anal Cancer - a Detailed PET-Imaging Based Analysis. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.06.2139] [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: 11/29/2022]
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18
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Peeken J, Spraker M, Pfeiffer D, Dapper H, Knebel C, Thamer A, Shouman M, Ott A, von Eisenhart-Rothe R, Nuesslin F, Mayr N, Nyflot M, Combs S. MRI-Based Radiomic Models Predict Tumor Grading in Soft-Tissue Sarcoma Patients. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.06.2189] [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: 10/26/2022]
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Mayinger M, Borm KJ, Dreher C, Dapper H, Duma MN, Oechsner M, Kampfer S, Combs SE, Habermehl D. Incidental dose distribution to locoregional lymph nodes of breast cancer patients undergoing adjuvant radiotherapy with tomotherapy - is it time to adjust current contouring guidelines to the radiation technique? Radiat Oncol 2019; 14:135. [PMID: 31370876 PMCID: PMC6676557 DOI: 10.1186/s13014-019-1328-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 12/17/2018] [Accepted: 06/26/2019] [Indexed: 11/10/2022] Open
Abstract
Purpose/objective(s) Along with breast-conserving surgery (BCS), adjuvant radiotherapy (RT) of patients with early breast cancer plays a crucial role in the oncologic treatment concept. Conventionally, irradiation is carried out with the aid of tangentially arranged fields. However, more modern and more complex radiation techniques such as IMRT (intensity-modulated radio therapy) are used more frequently, as they improve dose conformity and homogeneity and, in some cases, achieve better protection of adjacent risk factors. The use of this technique has implications for the incidental- and thus unintended- irradiation of adjacent loco regional lymph drainage in axillary lymph node levels I-III and internal mammary lymph nodes (IMLNs). A comparison of a homogeneous “real-life” patient collective, treated with helical tomotherapy (TT), patients treated with 3D conformal RT conventional tangentially arranged fields (3DCRT) and deep inspiration breath hold (3DCRT-DIBH), was conducted. Materials/methods This study included 90 treatment plans after BCS, irradiated in our clinic from January 2012 to August 2016 with TT (n = 30) and 3D-CRT (n = 30), 3DCRT DIBH (n = 30). PTVs were contoured at different time points by different radiation oncologists (> 7). TT was performed with a total dose of 50.4 Gy and a single dose of 1.8 Gy with a simultaneous integrated boost (SIB) to the tumor cavity (TT group). Patients irradiated with 3DCRT/3DCRT DIBH received 50 Gy à 2 Gy and a sequential boost. Contouring of lymph drainage routes was performed retrospectively according to RTOG guidelines. Results Average doses (DMean) in axillary lymph node Level I/Level II/Level III were 31.6 Gy/8.43 Gy/2.38 Gy for TT, 24.0 Gy/11.2 Gy/3.97 Gy for 3DCRT and 24.7 Gy/13.3 Gy/5.59 Gy for 3DCRT-DIBH patients. Internal mammary lymph nodes (IMLNs) Dmean were 27.8 Gy (TT), 13.5 Gy (3DCRT), and 18.7 Gy (3DCRT-DIBH). Comparing TT to 3DCRT-DIBH dose varied significantly in all axillary lymph node levels and the IMLNs. Comparing TT to 3DCRT significant dose difference in Level I and IMLNs was observed. Conclusion Dose applied to locoregional lymph drainage pathways varies comparing tomotherapy plans to conventional tangentially arranged fields. Studies are warranted whether dose variations influence loco-regional spread and must have implications for target volume definition guidelines.
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Affiliation(s)
- Michael Mayinger
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, D-81675, Munich, Germany. .,Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland.
| | - Kai Joachim Borm
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, D-81675, Munich, Germany
| | - Constantin Dreher
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, D-81675, Munich, Germany
| | - Hendrik Dapper
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, D-81675, Munich, Germany
| | - Marciana-Nona Duma
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, D-81675, Munich, Germany.,Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, D-85764, Oberschleißheim, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, D-81675, Munich, Germany
| | - Severin Kampfer
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, D-81675, Munich, Germany
| | - Stephanie Elisabeth Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, D-81675, Munich, Germany.,Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, D-85764, Oberschleißheim, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | - Daniel Habermehl
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, D-81675, Munich, Germany.,Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, D-85764, Oberschleißheim, Germany
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20
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Dapper H, Schiller K, Münch S, Peeken JC, Borm K, Weber W, Combs SE. Have we achieved adequate recommendations for target volume definitions in anal cancer? A PET imaging based patterns of failure analysis in the context of established contouring guidelines. BMC Cancer 2019; 19:742. [PMID: 31357959 PMCID: PMC6664500 DOI: 10.1186/s12885-019-5970-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [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: 03/27/2019] [Accepted: 07/22/2019] [Indexed: 11/10/2022] Open
Abstract
Background There are different contouring guidelines for the clinical target volume (CTV) in anal cancer (AC) which vary concerning recommendations for radiation margins in different anatomical regions, especially on inguinal site. PET imaging has become more important in primary staging of AC as a very sensitive method to detect lymph node (LN) metastases. Using PET imaging, we evaluated patterns of LN spread, and examined the differences of the respective contouring guidelines on the basis of our results. Methods We carried out a retrospective study of thirty-seven AC patients treated with chemoradiation (CRT) who underwent FDG-PET imaging for primary staging in our department between 2011 and 2018. Patients showing PET positive LN were included in this analysis. Using a color code, LN metastases of all patients were delineated on a template with “standard anatomy” and were divided indicating whether their location was in- or out-field of the standard CTV as recommended by the Radiation Therapy Oncology Group (RTOG), the Australasian Gastrointestinal Trials Group (AGITG) or the British National Guidance (BNG). Furthermore, a detailed analysis of the location of LN of the inguinal region was performed. Results Twenty-two out of thirty-seven AC patients with pre-treatment PET imaging had PET positive LN metastases, accumulating to a total of 154 LN. The most commonly affected anatomical region was inguinal (49 LN, 32%). All para-rectal, external/internal iliac, and pre-sacral LN were covered by the recommended CTVs of the three different guidelines. Of forty-nine involved inguinal LN, fourteen (29%), seven (14%) and five (10%) were situated outside of the recommended CTVs by RTOG, AGITG and BNG. Inguinal LN could be located up to 5.7 cm inferiorly to the femoral saphenous junction and 2.8 cm medial or laterally to the big femoral vessels. Conclusion Pelvis-related, various recommendations are largely consistent, and all LN are covered by the recommended CTVs. LN “misses” appear generally cranially (common iliac or para-aortic) or caudally (inguinal) to the recommended CTVs. The established guidelines differ significantly, particular regarding the inguinal region. Based on our results, we presented our suggestions for CTV definition of the inguinal region. LN involvement of a larger number of patients should be investigated to enable final recommendations.
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Affiliation(s)
- Hendrik Dapper
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Kilian Schiller
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Stefan Münch
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | - Jan C Peeken
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.,Institute for innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstr. 1, Neuherberg, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | - Kai Borm
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Wolfgang Weber
- Department of Nuclear Medicine, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.,Institute for innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstr. 1, Neuherberg, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
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Münch S, Pigorsch SU, Devečka M, Dapper H, Feith M, Friess H, Weichert W, Jesinghaus M, Braren R, Combs SE, Habermehl D. Neoadjuvant versus definitive chemoradiation in patients with squamous cell carcinoma of the esophagus. Radiat Oncol 2019; 14:66. [PMID: 30992022 PMCID: PMC6469104 DOI: 10.1186/s13014-019-1270-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 10/19/2018] [Accepted: 04/05/2019] [Indexed: 01/24/2023] Open
Abstract
Background Multimodal treatment with neoadjuvant chemoradiation followed by surgery (nCRT + S) is the treatment of choice for patients with locally advanced or node-positive esophageal squamous cell carcinoma (E-SCC). Those who are unsuitable or who decline surgery can be treated with definitive chemoradiation (dCRT). This study compares the oncologic outcome of nCRT + S and dCRT in E-SCC patients. Methods Between 2011 and 2017, 95 patients with E-SCC were scheduled for dCRT or nCRT+ S with IMRT at our department. Patients undergoing dCRT received at least 50 Gy and those undergoing nCRT + S received at least 41.4 Gy. All patients received simultaneous chemotherapy with either carboplatin and paclitaxel or cisplatin and 5-fluoruracil. We retrospectively compared baseline characteristics and oncologic outcome including overall survival (OS), progression-free survival (PFS) and site of failure between both treatment groups. Results Patients undergoing dCRT were less likely to have clinically suspected lymph node metastases (85% vs. 100%, p = 0.019) than patients undergoing nCRT + S and had more proximally located tumors (median distance from dental arch to cranial tumor border 20 cm vs. 26 cm, p < 0.001). After a median follow up of 25.6 months for surviving patients, no significant differences for OS and PFS were noticed comparing nCRT + S and dCRT. However, the rate of local tumor recurrence was significantly higher in patients treated with dCRT than in those treated with nCRT + S (38% vs. 10%, p = 0.002). Within a multivariate Cox regression model, age, tumor location, and tumor grading were the only independent parameters affecting OS and PFS. In addition to that, proximal tumor location was the only parameter independently associated with an increased risk for local treatment failure. Conclusion In E-SCC patients treated with either dCRT or nCRT + S, a higher rate of local tumor recurrence was seen in patients treated with dCRT than in patients treated with nCRT + S. There was at least a trend towards an improved OS and PFS in patients undergoing nCRT + S. However, this should be interpreted with caution, because proximal tumor location was the only parameter independently affecting the risk of local tumor recurrence.
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Affiliation(s)
- Stefan Münch
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany. .,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany.
| | - Steffi U Pigorsch
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Michal Devečka
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Hendrik Dapper
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Marcus Feith
- Department of Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Wilko Weichert
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany.,Institute of Pathology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Moritz Jesinghaus
- Institute of Pathology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Rickmer Braren
- Institute of Radiology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany.,Helmholtz Zentrum München, Institute of Radiation Medicine (IRM), Ingolstädter Landstraße 1, 85764, Oberschleißheim, Germany
| | - Daniel Habermehl
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
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22
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Dapper H, Schiller K, Münch S, Peeken J, Borm K, Weber W, Combs S. OC-0386 A PET-based patterns of failure analysis in the context of contouring guidelines in anal cancer. Radiother Oncol 2019. [DOI: 10.1016/s0167-8140(19)30806-0] [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: 11/17/2022]
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23
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Peeken JC, Knie C, Kessel KA, Habermehl D, Kampfer S, Dapper H, Devecka M, von Eisenhart-Rothe R, Specht K, Weichert W, Wörtler K, Knebel C, Wilkens JJ, Combs SE. Neoadjuvant image-guided helical intensity modulated radiotherapy of extremity sarcomas - a single center experience. Radiat Oncol 2019; 14:2. [PMID: 30626408 PMCID: PMC6327451 DOI: 10.1186/s13014-019-1207-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [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: 07/13/2018] [Accepted: 01/02/2019] [Indexed: 11/10/2022] Open
Abstract
Background Advanced radiotherapy (RT) techniques allow normal tissue to be spared in patients with extremity soft tissue sarcoma (STS). This work aims to evaluate toxicity and outcome after neoadjuvant image-guided radiotherapy (IGRT) as helical intensity modulated radiotherapy (IMRT) with reduced margins based on MRI-based target definition in patients with STS. Methods Between 2010 to 2014, 41 patients with extremity STS were treated with IGRT delivered as helical IMRT on a tomotherapy machine. The tumor site was in the upper extremity in 6 patients (15%) and lower extremity in 35 patients (85%). Reduced margins of 2.5 cm in longitudinal direction and 1.0 cm in axial direction were used to expand the MRI-defined gross tumor volume, including peritumoral edema, to the clinical target volume. An additional margin of 5 mm was added to receive the planning target volume. The full total dose of 50 Gy in 2 Gy fractions was sucessfully applied in 40 patients. Two patients received chemotherapy instead of surgery due to systemic progression. All patients were included into a strict follow-up program and were seen interdisciplinarily by the Departments of Orthopaedic Surgery and Radiation Oncology. Results Thirty eight patients that received total RT total dose and subsequent resection were analyzed for outcome. After a median follow-up of 38.5 months cumulative OS, local PFS and systemic PFS at 2 years were determined at 78.2, 85.2 and 54.5%, respectively. Two of 6 local recurrences were proximal marginal misses. Negative resection margins were achieved in 84% of patients. The rate of major wound complications was comparable to previous IMRT studies with 36.8%. RT was overall tolerable with low toxicity rates. Conclusions IMRT-IGRT offers neoadjuvant treatment for extremity STS with reduced safety margins and thus low toxicity rates. Wound complication rates were comparable to previously reported frequencies. Two reported marginal misses suggest a word of caution for reduction of longitudinal safety margins. Electronic supplementary material The online version of this article (10.1186/s13014-019-1207-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jan C Peeken
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany. .,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany.
| | - Christoph Knie
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Kerstin A Kessel
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany.,Department of Radiation Sciences (DRS), Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, Neuherberg, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | - Daniel Habermehl
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Severin Kampfer
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Hendrik Dapper
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Michal Devecka
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Rüdiger von Eisenhart-Rothe
- Department of Orthopaedic Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Katja Specht
- Department of Pathology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | - Wilko Weichert
- Department of Pathology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | - Klaus Wörtler
- Department of Radiology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Carolin Knebel
- Department of Orthopaedic Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Jan J Wilkens
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany.,Department of Radiation Sciences (DRS), Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, Neuherberg, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany.,Department of Radiation Sciences (DRS), Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, Neuherberg, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
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Dapper H, Rodríguez I, Münch S, Peeken JC, Borm K, Combs SE, Habermehl D. Impact of VMAT-IMRT compared to 3D conformal radiotherapy on anal sphincter dose distribution in neoadjuvant chemoradiation of rectal cancer. Radiat Oncol 2018; 13:237. [PMID: 30509284 PMCID: PMC6276230 DOI: 10.1186/s13014-018-1187-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [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: 08/29/2018] [Accepted: 11/19/2018] [Indexed: 12/13/2022] Open
Abstract
Background Neoadjuvant radio- or chemoradiation (nIRT) therapy is the standard treatment for loco-regional advanced rectal cancer patients of the lower or middle third. Currently, intensity modulated radiation therapy (IMRT) is not the recommended radiation technique even though IMRT has advantages compared to 3D-radiation regarding dose sparing to organs at risk like small bowel and urinary bladder. So far, the benefit of IMRT concerning the anal sphincter complex is not examined. With this study we intended to evaluate the dose distribution on the anal sphincters of rectal cancer patients treated with IMRT in comparison with 3D-techniques. Methods We selected 16 patients for the IMRT-group and 16 patients for the 3D-group with rectal cancer of the middle third who were treated in our institute. All patients received 45 Gy in a chemoradiation protocol. Patients in both groups were matched regarding stage, primary tumor distance to the anal verge and size of the tumor. We delineated the internal and external anal sphincters, the addition of both sphincters and the levator ani muscle in all patients. Subsequently, we evaluated and compared dose parameters of the different sphincters in both groups and analysed the configuration of the isodoses in the area of the caudal radiation field, respectively. Results Most of the relevant dose parameters of the caudal sphincters (Dmean, Dmedian, V10–V40) were significantly reduced in the IMRT-group compared to the 3D-group. Accordingly, the isodoses at the caudal edge of the target volume in the IMRT group demonstrated a steep dose fall. The levator ani muscle always was included into the planned target volumes and received the full dose in both groups. Conclusions The modern VMAT-IMRT can significantly reduce the dose to the anal sphincters for rectal cancer patients of the middle third who were treated with conventional chemoradiation therapy.
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Affiliation(s)
- Hendrik Dapper
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Iván Rodríguez
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Stefan Münch
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Pettenkoferstr. 8a, 80336, Munich, Germany
| | - Jan C Peeken
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Kai Borm
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.,Institut für innovative Radiotherapie (iRT), Helmholtz Zentrum München, Ingolstädter Landstr. 1, 85764, Neuherberg, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Pettenkoferstr. 8a, 80336, Munich, Germany
| | - Daniel Habermehl
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
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25
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Dapper H, Oechsner M, Hirche C, Münch S, Sauter C, Borm K, Peeken JC, Combs SE, Habermehl D. Dosimetric comparison of different radiation techniques (IMRT vs. 3-dimensional) of the "true" (deep) ano-inguinal lymphatic drainage of anal cancer patients. Radiat Oncol 2018; 13:227. [PMID: 30466454 PMCID: PMC6249729 DOI: 10.1186/s13014-018-1174-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 07/18/2018] [Accepted: 11/06/2018] [Indexed: 12/25/2022] Open
Abstract
Introduction The ano-inguinal lymphatic drainage (AILD) is located in the subcutaneous adipose tissue of the proximal medial thigh. Currently, there are no recommendations for an inclusion of the ‘true’ AILD in the clinical target volume (CTV) of definitive chemoradiation for anal cancer patients. To estimate the relevance of inguinal recurrence, we compared the incidental dose to the AILD in anal cancer (AC) patients who were treated either with Volumetric Arc Therapy – Intensity Modulated Radiation Therapy (VMAT-IMRT) or conventional 3D-radiation technique. Methods One VMAT-IMRT-plans and one 3D-plans were calculated on the same target volumes and identical dose prescription in ten patients. We defined the volume of the AILD on the planning CT-scans based on the information of new fluorescence methods. Furthermore, we defined several anatomical subvolumes of interest inside the AILD. We examined and compared absolute and relative dosimetric parameters of the AILD and different anatomical subunits. Results The Dmean of the AILD was 40 Gy in the 3D-group and 38 Gy in the IMRT-group. Dmean and Dmedian as well as the V30Gy of the AILD and all subvolumes of the caudal AILD were significant higher using 3D-RT compared to IMRT. Even though the absolute differences were small, in the caudal aspect of the ano-inguinal lymphatic drainage the V30Gy could be more than 10% less with VMAT-IMRT. Conclusions 3D-RT was slightly superior to IMRT in terms of dose coverage of the AILD. However, the absolute differences were very small. Some relevant caudal parts of the AILD received an insufficient dose for treating potential micrometastases. Particularly in high-risk situations, this may lead to inguinal recurrence and therefore the true deep AILD should be included into the target volume in high risk patients.
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Affiliation(s)
- Hendrik Dapper
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Markus Oechsner
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Christoph Hirche
- Department for Hand-, Plastic and Reconstructive Surgery, Burn Centre, BG-Trauma Centre Ludwigshafen/Rhine, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Stefan Münch
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Christina Sauter
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Kai Borm
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Jan C Peeken
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.,Institute for innovative Radiotherapie (iRT), Helmholtz Zentrum München, Ingolstädter Landstr. 1, Neuherberg, Germany.,Deutsches Konsortium für translationale Krebsforschung (DKTK), Partner SiTe Munich, Munich, Germany
| | - Daniel Habermehl
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.,Institute for innovative Radiotherapie (iRT), Helmholtz Zentrum München, Ingolstädter Landstr. 1, Neuherberg, Germany
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26
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Dapper H, Oechsner M, Münch S, Borm K, Peeken J, Mayinger M, Combs SE, Habermehl D. Dosimetric analysis and comparison of reduced longitudinal cranial margins of VMAT-IMRT of rectal cancer. Radiat Oncol 2018; 13:169. [PMID: 30189877 PMCID: PMC6127934 DOI: 10.1186/s13014-018-1120-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 07/18/2018] [Accepted: 08/29/2018] [Indexed: 12/18/2022] Open
Abstract
Background The cranial border of the target volume (TV) in rectal cancer patients treated with neoadjuvant chemoradiation (nCRT) is mostly defined at the level of L5/S1. However, current studies have shown that relapse cranially of the target volume after neoadjuvant nCRT and surgery is very rare. A reduction of cranial TV margins could be reasonable to reduce toxicity to the organs at risk (OAR). In this study we compared the dose distribution to the OAR for different cranial longitudinal margins using a dose-volume histogram (DVH) analysis. Methods Ten patients with loco regional advanced rectal cancer were analysed retrospectively. All patients were planned for Volumetric Arc Therapy Radiation Therapy (VMAT). Next to the original PTV (PTV0), three new planning target volumes (PTV) were defined for each patient: The PTV0 reduced by 1 cm, 2 cm and 3 cm on cranial extension. For each PTV a treatment plan with a total dose of 50.4 Gy with daily doses of 1.8 Gy was calculated. Dose to the OAR were evaluated and compared. Results For the bone marrow, the small bowel and the peritoneal space all clinically relevant relative dose parameters (V10-V50) as well as the Dmedian could be significantly reduced with every cranial target volume reduction of 1 cm. For V10 of the peritoneal space the dose could be nearly halved with a 3 cm shortened TV. After TV reduction of 3 cm also for the urinary bladder a significant dose reduction of the Dmedian could be achieved. Conclusions Considering the very low recurrence rates in the TME and IMRT era, the distribution patterns of these relapses as well as the relevant side effects of nCRT, we would agree with existing recommendations of reduction of the cranial target volume in nCRT treated rectal cancer patients.
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Affiliation(s)
- Hendrik Dapper
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Markus Oechsner
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Stefan Münch
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | - Kai Borm
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Jan Peeken
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Michael Mayinger
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.,Institute for innovative Radiotherapie (iRT), Helmholtz Zentrum München, Ingolstädter Landstr. 1, Neuherberg, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany
| | - Daniel Habermehl
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany
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27
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Münch S, Pigorsch SU, Devečka M, Dapper H, Weichert W, Friess H, Braren R, Combs SE, Habermehl D. Comparison of definite chemoradiation therapy with carboplatin/paclitaxel or cisplatin/5-fluoruracil in patients with squamous cell carcinoma of the esophagus. Radiat Oncol 2018; 13:139. [PMID: 30068371 PMCID: PMC6090949 DOI: 10.1186/s13014-018-1085-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [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: 02/28/2018] [Accepted: 07/24/2018] [Indexed: 11/15/2022] Open
Abstract
Background While neoadjuvant chemoradiation therapy (nCRT) with subsequent surgery is the treatment of choice for patients with locally advanced or node-positive squamous cell carcinoma of the esophagus (SCC) suitable for surgery, patients who are unsuitable for surgery or who refuse surgery should be treated with definite chemoradiation therapy (dCRT). Purpose of this study was to compare toxicity and oncologic outcome of dCRT with either cisplatin and 5-fluoruracil (CDDP/5FU) or carboplatin and paclitaxel (Carb/TAX) in patients with SCC. Methods Twenty-two patients who received dCRT with carboplatin (AUC2, weekly) and paclitaxel (50 mg per square meter of body-surface area, weekly) were retrospectively compared to 25 patients who were scheduled for dCRT with cisplatin (20 mg/m2/d) and 5-fluoruracil (500 mg/m2/d) on day 1–5 and day 29–33. For the per-protocol (PP) analysis, PP treatment was defined as complete radiation therapy with at least 54Gy and at least three complete cycles of Carb/TAX or complete radiation therapy with at least 54Gy and at least one complete cycle of CDDP/5FU. While patients who were scheduled for dCRT with Carb/TAX received a significantly higher total radiation dose (median dose 59.4Gy vs. 54Gy, p < 0.001) than patients who were scheduled for dCRT with CDDP/5FU, no significant differences were seen for other parameters (age, sex, TNM-stage, grading and tumor extension). Results Forty-seven patients (25 patients treated with CDDP/5FU and 22 patients treated with Carb/TAX) were evaluated for the intention-to-treat (ITT) analysis and 41 of 47 patients (23 patients treated with CDDP/5FU and 18 patients treated with Carb/TAX) were evaluated for the PP analysis. Severe myelotoxicity (≥ III°) was seen in 52% (CDDP/5FU) and 55% of patients (Carb/TAX), respectively (p = 1.000). In the univariate binary logistic regression analysis, patients age was the only factor associated with an increased risk of ≥ III° myelotoxicity (hazard ratio 1.145, 95% CI 1.035; 1.266; p = 0.009). Regarding treatment efficiency, no significant differences were seen for overall survival (OS) and freedom from relapse (FFR) between both treatment groups. Conclusion Myelotoxicity and oncologic outcome under dCRT were not different for patients with SCC of the esophagus treated with either CDDP/5FU or Carb/TAX. The putative equivalence of dCRT with Carb/TAX in this setting should be further investigated in prospective trials. However, our data reveal that the risk of significant myelotoxicity increases with patient age and therefore other chemotherapy regimens might be evaluated in elderly patients.
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Affiliation(s)
- Stefan Münch
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, D-81675, Munich, Germany. .,German Cancer Consortium (DKTK) Partner Site Munich, Munich, Germany.
| | - Steffi U Pigorsch
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, D-81675, Munich, Germany.,German Cancer Consortium (DKTK) Partner Site Munich, Munich, Germany
| | - Michal Devečka
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, D-81675, Munich, Germany
| | - Hendrik Dapper
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, D-81675, Munich, Germany
| | - Wilko Weichert
- German Cancer Consortium (DKTK) Partner Site Munich, Munich, Germany.,Institute of Pathology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, D-81675, Munich, Germany
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, D-81675, Munich, Germany
| | - Rickmer Braren
- Institute of Radiology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, D-81675, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, D-81675, Munich, Germany.,German Cancer Consortium (DKTK) Partner Site Munich, Munich, Germany.,Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, D-85764, Munich, Germany
| | - Daniel Habermehl
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, D-81675, Munich, Germany
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Dapper H, Habl G, Hirche C, Münch S, Oechsner M, Mayinger M, Sauter C, Combs SE, Habermehl D. Dosimetric quantification of the incidental irradiation of the 'true' (deep) ano-inguinal lymphatic drainage of anal cancer patients not described in conventional contouring guidelines. Acta Oncol 2018; 57:825-830. [PMID: 29297232 DOI: 10.1080/0284186x.2017.1415459] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [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
INTRODUCTION The ano-inguinal lymphatic drainage (AILD) is located in the subcutaneous adipose tissue of the proximal medial thigh. Findings from fluorescence methods give us new information about anatomical conditions of the AILD. Current contouring guidelines do not advise the inclusion of the 'true' AILD into the clinical target volume (CTV). Aim of this work was the retrospective analysis of the incidental dose to the AILD in an anal cancer (AC) patient cohort who underwent definitive chemoradiation (CRT) therapy with Volumetric Arc Therapy - Intensity Modulated Radiation Therapy (VMAT-IMRT). METHODS VMAT-IMRT plans of 15 AC patients were analyzed. Based on findings from new fluorescence methods we created a new volume, the expected AILD. The examined dosimetric parameters were the minimal, maximal and mean dose and V10-V50 that were delivered to the AILD, respectively. RESULTS The median volume of AILD was 1047 cm³. Mean Dmin, Dmax and Dmean were 7.5 Gy, 58.9 Gy and 40.8 Gy for AILD. The clinical relevant dose of 30.0 Gray covered in mean 76% of the volume of the AILD, respectively. CONCLUSIONS Only 76% of the AILD-volume received at least an expected required treatment dose of 30 Gy incidentally. Concerning the low number of loco-regional relapses in AC patients after definitive CRT one has to balance increased side effects against a rigid oncological-anatomical interpretation of the local lymphatic drainage by including the AILD into the standard CTV.
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Affiliation(s)
- Hendrik Dapper
- Department of Radiation Oncology, Klinikum Rechts der Isar, TU München, Munich, Germany
| | - Gregor Habl
- Department of Radiation Oncology, Klinikum Rechts der Isar, TU München, Munich, Germany
| | - Christoph Hirche
- Department for Hand-, Plastic and Rekonstructive Surgery, Burn Centre BG-Trauma Centre Ludwigshafen/RhineBG – Klinik Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Stefan Münch
- Department of Radiation Oncology, Klinikum Rechts der Isar, TU München, Munich, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Klinikum Rechts der Isar, TU München, Munich, Germany
| | - Michael Mayinger
- Department of Radiation Oncology, Klinikum Rechts der Isar, TU München, Munich, Germany
| | - Christina Sauter
- Department of Radiation Oncology, Klinikum Rechts der Isar, TU München, Munich, Germany
| | - Stephanie E. Combs
- Department of Radiation Oncology, Klinikum Rechts der Isar, TU München, Munich, Germany
- Institute for Innovative Radiotherapie (iRT), Helmholtz Zentrum München, Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Munich, Germany
| | - Daniel Habermehl
- Department of Radiation Oncology, Klinikum Rechts der Isar, TU München, Munich, Germany
- Institute for Innovative Radiotherapie (iRT), Helmholtz Zentrum München, Neuherberg, Germany
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Dapper H, Habl G, Mayinger M, Oechsner M, Combs S, Habermehl D. OC-0375: Dosimetric quantification of the „true“ ano-inguinal lymphatic drainage of anal cancer patients. Radiother Oncol 2017. [DOI: 10.1016/s0167-8140(17)30817-4] [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: 10/19/2022]
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