1
|
Draeger E, Roberts K, Decker RD, Bahar N, Wilson LD, Contessa J, Husain Z, Williams BB, Flood AB, Swartz HM, Carlson DJ. In Vivo Verification of Electron Paramagnetic Resonance Biodosimetry Using Patients Undergoing Radiation Therapy Treatment. Int J Radiat Oncol Biol Phys 2024; 119:292-301. [PMID: 38072322 DOI: 10.1016/j.ijrobp.2023.11.029] [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: 08/14/2023] [Revised: 09/28/2023] [Accepted: 11/19/2023] [Indexed: 01/06/2024]
Abstract
PURPOSE Electron paramagnetic resonance (EPR) biodosimetry, used to triage large numbers of individuals incidentally exposed to unknown doses of ionizing radiation, is based on detecting a stable physical response in the body that is subject to quantifiable variation after exposure. In vivo measurement is essential to fully characterize the radiation response relevant to a living tooth measured in situ. The purpose of this study was to verify EPR spectroscopy in vivo by estimating the radiation dose received in participants' teeth. METHODS AND MATERIALS A continuous wave L-band spectrometer was used for EPR measurements. Participants included healthy volunteers and patients undergoing head and neck and total body irradiation treatments. Healthy volunteers completed 1 measurement each, and patients underwent measurement before starting treatment and between subsequent fractions. Optically stimulated luminescent dosimeters and diodes were used to determine the dose delivered to the teeth to validate EPR measurements. RESULTS Seventy measurements were acquired from 4 total body irradiation and 6 head and neck patients over 15 months. Patient data showed a linear increase of EPR signal with delivered dose across the dose range tested. A linear least-squares weighted fit of the data gave a statistically significant correlation between EPR signal and absorbed dose (P < .0001). The standard error of inverse prediction (SEIP), used to assess the usefulness of fits, was 1.92 Gy for the dose range most relevant for immediate triage (≤7 Gy). Correcting for natural background radiation based on patient age reduced the SEIP to 1.51 Gy. CONCLUSIONS This study demonstrated the feasibility of using spectroscopic measurements from radiation therapy patients to validate in vivo EPR biodosimetry. The data illustrated a statistically significant correlation between the magnitude of EPR signals and absorbed dose. The SEIP of 1.51 Gy, obtained under clinical conditions, indicates the potential value of this technique in response to large radiation events.
Collapse
Affiliation(s)
- Emily Draeger
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut.
| | - Kenneth Roberts
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Roy D Decker
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Nina Bahar
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Lynn D Wilson
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Joseph Contessa
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Zain Husain
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Benjamin B Williams
- Department of Radiology & EPR Center, Geisel Medical School at Dartmouth, Hanover, New Hampshire
| | - Ann Barry Flood
- Department of Radiology & EPR Center, Geisel Medical School at Dartmouth, Hanover, New Hampshire
| | - Harold M Swartz
- Department of Radiology & EPR Center, Geisel Medical School at Dartmouth, Hanover, New Hampshire
| | - David J Carlson
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut.
| |
Collapse
|
2
|
Osapoetra LO, Dasgupta A, DiCenzo D, Fatima K, Quiaoit K, Saifuddin M, Karam I, Poon I, Husain Z, Tran WT, Sannachi L, Czarnota GJ. Quantitative US Delta Radiomics to Predict Radiation Response in Individuals with Head and Neck Squamous Cell Carcinoma. Radiol Imaging Cancer 2024; 6:e230029. [PMID: 38391311 PMCID: PMC10988345 DOI: 10.1148/rycan.230029] [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: 03/21/2023] [Revised: 11/24/2023] [Accepted: 01/17/2024] [Indexed: 02/24/2024]
Abstract
Purpose To investigate the role of quantitative US (QUS) radiomics data obtained after the 1st week of radiation therapy (RT) in predicting treatment response in individuals with head and neck squamous cell carcinoma (HNSCC). Materials and Methods This prospective study included 55 participants (21 with complete response [median age, 65 years {IQR: 47-80 years}, 20 male, one female; and 34 with incomplete response [median age, 59 years {IQR: 39-79 years}, 33 male, one female) with bulky node-positive HNSCC treated with curative-intent RT from January 2015 to October 2019. All participants received 70 Gy of radiation in 33-35 fractions over 6-7 weeks. US radiofrequency data from metastatic lymph nodes were acquired prior to and after 1 week of RT. QUS analysis resulted in five spectral maps from which mean values were extracted. We applied a gray-level co-occurrence matrix technique for textural analysis, leading to 20 QUS texture and 80 texture-derivative parameters. The response 3 months after RT was used as the end point. Model building and evaluation utilized nested leave-one-out cross-validation. Results Five delta (Δ) parameters had statistically significant differences (P < .05). The support vector machines classifier achieved a sensitivity of 71% (15 of 21), a specificity of 76% (26 of 34), a balanced accuracy of 74%, and an area under the receiver operating characteristic curve of 0.77 on the test set. For all the classifiers, the performance improved after the 1st week of treatment. Conclusion A QUS Δ-radiomics model using data obtained after the 1st week of RT from individuals with HNSCC predicted response 3 months after treatment completion with reasonable accuracy. Keywords: Computer-Aided Diagnosis (CAD), Ultrasound, Radiation Therapy/Oncology, Head/Neck, Radiomics, Quantitative US, Radiotherapy, Head and Neck Squamous Cell Carcinoma, Machine Learning Clinicaltrials.gov registration no. NCT03908684 Supplemental material is available for this article. © RSNA, 2024.
Collapse
Affiliation(s)
| | | | - Daniel DiCenzo
- From the Departments of Radiation Oncology (L.O.O., A.D., I.K., I.P.,
Z.H., W.T.T., G.J.C.), Medical Oncology (W.T.T.), and Medicine (W.T.T.),
Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON, Canada M4N
3M5; Departments of Radiation Oncology (L.O.O., A.D., I.K., I.P., Z.H., W.T.T.,
G.J.C.) and Medical Biophysics (G.J.C.), University of Toronto, Toronto, Canada;
and Departments of Physical Sciences (L.O.O., A.D., D.D., K.F., K.Q., M.S.,
L.S., G.J.C.) and Evaluative Clinical Sciences (W.T.T.), Sunnybrook Research
Institute, Toronto, Canada
| | - Kashuf Fatima
- From the Departments of Radiation Oncology (L.O.O., A.D., I.K., I.P.,
Z.H., W.T.T., G.J.C.), Medical Oncology (W.T.T.), and Medicine (W.T.T.),
Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON, Canada M4N
3M5; Departments of Radiation Oncology (L.O.O., A.D., I.K., I.P., Z.H., W.T.T.,
G.J.C.) and Medical Biophysics (G.J.C.), University of Toronto, Toronto, Canada;
and Departments of Physical Sciences (L.O.O., A.D., D.D., K.F., K.Q., M.S.,
L.S., G.J.C.) and Evaluative Clinical Sciences (W.T.T.), Sunnybrook Research
Institute, Toronto, Canada
| | - Karina Quiaoit
- From the Departments of Radiation Oncology (L.O.O., A.D., I.K., I.P.,
Z.H., W.T.T., G.J.C.), Medical Oncology (W.T.T.), and Medicine (W.T.T.),
Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON, Canada M4N
3M5; Departments of Radiation Oncology (L.O.O., A.D., I.K., I.P., Z.H., W.T.T.,
G.J.C.) and Medical Biophysics (G.J.C.), University of Toronto, Toronto, Canada;
and Departments of Physical Sciences (L.O.O., A.D., D.D., K.F., K.Q., M.S.,
L.S., G.J.C.) and Evaluative Clinical Sciences (W.T.T.), Sunnybrook Research
Institute, Toronto, Canada
| | - Murtuza Saifuddin
- From the Departments of Radiation Oncology (L.O.O., A.D., I.K., I.P.,
Z.H., W.T.T., G.J.C.), Medical Oncology (W.T.T.), and Medicine (W.T.T.),
Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON, Canada M4N
3M5; Departments of Radiation Oncology (L.O.O., A.D., I.K., I.P., Z.H., W.T.T.,
G.J.C.) and Medical Biophysics (G.J.C.), University of Toronto, Toronto, Canada;
and Departments of Physical Sciences (L.O.O., A.D., D.D., K.F., K.Q., M.S.,
L.S., G.J.C.) and Evaluative Clinical Sciences (W.T.T.), Sunnybrook Research
Institute, Toronto, Canada
| | - Irene Karam
- From the Departments of Radiation Oncology (L.O.O., A.D., I.K., I.P.,
Z.H., W.T.T., G.J.C.), Medical Oncology (W.T.T.), and Medicine (W.T.T.),
Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON, Canada M4N
3M5; Departments of Radiation Oncology (L.O.O., A.D., I.K., I.P., Z.H., W.T.T.,
G.J.C.) and Medical Biophysics (G.J.C.), University of Toronto, Toronto, Canada;
and Departments of Physical Sciences (L.O.O., A.D., D.D., K.F., K.Q., M.S.,
L.S., G.J.C.) and Evaluative Clinical Sciences (W.T.T.), Sunnybrook Research
Institute, Toronto, Canada
| | - Ian Poon
- From the Departments of Radiation Oncology (L.O.O., A.D., I.K., I.P.,
Z.H., W.T.T., G.J.C.), Medical Oncology (W.T.T.), and Medicine (W.T.T.),
Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON, Canada M4N
3M5; Departments of Radiation Oncology (L.O.O., A.D., I.K., I.P., Z.H., W.T.T.,
G.J.C.) and Medical Biophysics (G.J.C.), University of Toronto, Toronto, Canada;
and Departments of Physical Sciences (L.O.O., A.D., D.D., K.F., K.Q., M.S.,
L.S., G.J.C.) and Evaluative Clinical Sciences (W.T.T.), Sunnybrook Research
Institute, Toronto, Canada
| | - Zain Husain
- From the Departments of Radiation Oncology (L.O.O., A.D., I.K., I.P.,
Z.H., W.T.T., G.J.C.), Medical Oncology (W.T.T.), and Medicine (W.T.T.),
Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON, Canada M4N
3M5; Departments of Radiation Oncology (L.O.O., A.D., I.K., I.P., Z.H., W.T.T.,
G.J.C.) and Medical Biophysics (G.J.C.), University of Toronto, Toronto, Canada;
and Departments of Physical Sciences (L.O.O., A.D., D.D., K.F., K.Q., M.S.,
L.S., G.J.C.) and Evaluative Clinical Sciences (W.T.T.), Sunnybrook Research
Institute, Toronto, Canada
| | - William T. Tran
- From the Departments of Radiation Oncology (L.O.O., A.D., I.K., I.P.,
Z.H., W.T.T., G.J.C.), Medical Oncology (W.T.T.), and Medicine (W.T.T.),
Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON, Canada M4N
3M5; Departments of Radiation Oncology (L.O.O., A.D., I.K., I.P., Z.H., W.T.T.,
G.J.C.) and Medical Biophysics (G.J.C.), University of Toronto, Toronto, Canada;
and Departments of Physical Sciences (L.O.O., A.D., D.D., K.F., K.Q., M.S.,
L.S., G.J.C.) and Evaluative Clinical Sciences (W.T.T.), Sunnybrook Research
Institute, Toronto, Canada
| | - Lakshmanan Sannachi
- From the Departments of Radiation Oncology (L.O.O., A.D., I.K., I.P.,
Z.H., W.T.T., G.J.C.), Medical Oncology (W.T.T.), and Medicine (W.T.T.),
Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON, Canada M4N
3M5; Departments of Radiation Oncology (L.O.O., A.D., I.K., I.P., Z.H., W.T.T.,
G.J.C.) and Medical Biophysics (G.J.C.), University of Toronto, Toronto, Canada;
and Departments of Physical Sciences (L.O.O., A.D., D.D., K.F., K.Q., M.S.,
L.S., G.J.C.) and Evaluative Clinical Sciences (W.T.T.), Sunnybrook Research
Institute, Toronto, Canada
| | - Gregory J. Czarnota
- From the Departments of Radiation Oncology (L.O.O., A.D., I.K., I.P.,
Z.H., W.T.T., G.J.C.), Medical Oncology (W.T.T.), and Medicine (W.T.T.),
Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON, Canada M4N
3M5; Departments of Radiation Oncology (L.O.O., A.D., I.K., I.P., Z.H., W.T.T.,
G.J.C.) and Medical Biophysics (G.J.C.), University of Toronto, Toronto, Canada;
and Departments of Physical Sciences (L.O.O., A.D., D.D., K.F., K.Q., M.S.,
L.S., G.J.C.) and Evaluative Clinical Sciences (W.T.T.), Sunnybrook Research
Institute, Toronto, Canada
| |
Collapse
|
3
|
Weiss Y, Chin L, Younus E, Guo K, Dydula C, Hupman A, Lau A, Husain Z, Bayley A, Higgins K, Enepekides D, Eskander A, Ho L, Poon I, Karam I. Cine MRI-based analysis of intrafractional motion in radiation treatment planning of head and neck cancer patients. Radiother Oncol 2023; 186:109790. [PMID: 37414256 DOI: 10.1016/j.radonc.2023.109790] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 06/27/2023] [Accepted: 06/30/2023] [Indexed: 07/08/2023]
Abstract
PURPOSE/OBJECTIVE(S) To investigate intrafraction motion of (HN) target volumes and to determine patient-specific planning target volume (PTV) margins. MATERIALS/METHODS MR-cine imaging was performed for radiation treatment planning in HN cancer patients treated with definitive EBRT (n = 62) or SBRT (n = 4) on a 1.5 T MRI between 2017-2019. Dynamic MRI scans (sagittal orientation, 2 × 82 × 7 mm3 resolution), ranging from 3-5 min and 900-1500 images, were acquired. The position of the maximum tumor displacement along each direction in the anterior/posterior (A/P) and superior/inferior (S/I) position was recorded and analyzed to determine average PTV margins. RESULTS Primary tumor sites (n = 66) were oropharynx (n = 39), larynx (n = 24) and hypopharynx (n = 3). PTV margins for A/P/S/I positions were 4.1/4.4/5.0/6.2 mm and 4.9/4.3/6.7/7.7 mm for oropharyngeal and laryngeal/hypopharyngeal cancers when accounting for all motion. V100 for PTV was calculated and compared to the original plans. The mean drop in PTV coverage was in most cases under 5%. For a subset of patients with 3 mm plans available, V100 for PTV had more substantial decreases in coverage averaging 8.2% - and 14.3% for oropharyngeal and laryngeal/hypopharynx plans, respectively. CONCLUSION The use of MR-cine in treatment planning allows for quantification of tumor motion during swallow and resting periods and should be accounted for during treatment planning. With motion considered, the derived margins may exceed the commonly used 3-5 mm PTV margins. Quantification and analysis of tumor and patient-specific PTV margins is a step towards real-time MRI guidance adaptive radiotherapy.
Collapse
Affiliation(s)
- Yonatan Weiss
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Lee Chin
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Eyesha Younus
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Kaiming Guo
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Christopher Dydula
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Allan Hupman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Angus Lau
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Zain Husain
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Andrew Bayley
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Kevin Higgins
- Department of Otolaryngology - Head and Neck Surgery, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Danny Enepekides
- Department of Otolaryngology - Head and Neck Surgery, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Antoine Eskander
- Department of Otolaryngology - Head and Neck Surgery, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Ling Ho
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Ian Poon
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Irene Karam
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.
| |
Collapse
|
4
|
Yan M, Holden L, Detsky J, Tseng CL, Soliman H, Myrehaug S, Husain Z, Das S, Yeboah C, Lipsman N, Ruschin M, Sahgal A. Conventionally fully fractionated Gamma Knife Icon re-irradiation of primary recurrent intracranial tumors: the first report indicating feasibility and safety. J Neurosurg 2023; 138:674-682. [PMID: 35986735 DOI: 10.3171/2022.6.jns22998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 06/17/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE With the incorporation of real-time image guidance on the Gamma Knife system allowing for mask-based immobilization (Gamma Knife Icon [GKI]), conventionally fully fractionated (1.8-3.0 Gy/day) GKI radiation can now be delivered to take advantage of an inherently minimal margin for delivery uncertainty, sharp dose falloff, and inhomogeneous dose distribution. This case series details the authors' preliminary experience in re-irradiating 7 complex primary intracranial tumors, which were considered to have been previously maximally radiated and situated adjacent to critical organs at risk. METHODS The authors retrospectively reviewed all patients who received fractionated re-irradiation using GKI at the Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada, between 2016 and 2021. Patients with brain metastases, and those who received radiotherapy courses in 5 or fewer fractions, were excluded. All radiotherapy doses were converted to the equivalent total dose in 2-Gy fractions (EQD2), with the assumption of an α/β ratio of 2 for late normal tissue toxicity and 10 for the tumor. RESULTS A total of 7 patients were included in this case series. Three patients had recurrent meningiomas, as well as 1 patient each with ependymoma, intracranial sarcoma, pituitary macroadenoma, and papillary pineal tumor. Six patients had undergone prior linear accelerator-based conventional fractionated radiotherapy and 1 patient had undergone prior proton therapy. Patients were re-irradiated with a median (range) total dose of 50.4 (30-63.4) Gy delivered in a median (range) of 28 (10-38) fractions with GKI. The median (range) target volume was 6.58 (0.2-46.3) cm3. The median (range) cumulative mean EQD2 administered to the tumor was 121.1 (107.9-181.3) Gy, and the median (range) maximum point EQD2 administered to the brainstem, optic nerves, and optic chiasm were 91.6 (74.0-111.5) Gy, 58.9 (6.3-102.9) Gy, and 59.9 (36.7-127.3) Gy, respectively. At a median (range) follow-up of 15 (6-42) months, 6 of 7 patients were alive with 4 having locally controlled disease. Only 3 patients experienced treatment-related toxicities, which were self-limited. CONCLUSIONS Fractionated radiotherapy using GKI may be a safe and effective method for the re-irradiation of complex progressive primary intracranial tumors, where the aim is to minimize the potential for serious late effects.
Collapse
Affiliation(s)
- Michael Yan
- 1Department of Radiation Oncology, Sunnybrook Health Sciences Centre
| | - Lori Holden
- 1Department of Radiation Oncology, Sunnybrook Health Sciences Centre
| | - Jay Detsky
- 1Department of Radiation Oncology, Sunnybrook Health Sciences Centre
| | - Chia-Lin Tseng
- 1Department of Radiation Oncology, Sunnybrook Health Sciences Centre
| | - Hany Soliman
- 1Department of Radiation Oncology, Sunnybrook Health Sciences Centre
| | - Sten Myrehaug
- 1Department of Radiation Oncology, Sunnybrook Health Sciences Centre
| | - Zain Husain
- 1Department of Radiation Oncology, Sunnybrook Health Sciences Centre
| | - Sunit Das
- 2Division of Neurosurgery, St. Michael's Hospital
| | - Collins Yeboah
- 3Department of Medical Physics, Sunnybrook Health Sciences Centre; and
| | - Nir Lipsman
- 4Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Mark Ruschin
- 3Department of Medical Physics, Sunnybrook Health Sciences Centre; and
| | - Arjun Sahgal
- 1Department of Radiation Oncology, Sunnybrook Health Sciences Centre
| |
Collapse
|
5
|
Stewart J, Sahgal A, Zadeh MM, Moazen B, Jabehdar Maralani P, Breen S, Lau A, Binda S, Keller B, Husain Z, Myrehaug S, Detsky J, Soliman H, Tseng CL, Ruschin M. Empirical planning target volume modeling for high precision MRI guided intracranial radiotherapy. Clin Transl Radiat Oncol 2023; 39:100582. [PMID: 36699195 PMCID: PMC9869418 DOI: 10.1016/j.ctro.2023.100582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
Purpose Magnetic resonance image-guided radiotherapy for intracranial indications is a promising advance; however, uncertainties remain for both target localization after translation-only MR setup and intrafraction motion. This investigation quantified these uncertainties and developed a population-based planning target volume (PTV) model to explore target and organ-at-risk (OAR) volumetric coverage tradeoffs. Methods Sixty-six patients, 49 with a primary brain tumor and 17 with a post-surgical resection cavity, treated on a 1.5T-based MR-linac across 1329 fractions were included. At each fraction, patients were setup by translation-only fusion of the online T1 MRI to the planning image. Each fusion was independently repeated offline accounting for rotations. The six degree-of-freedom difference between fusions was applied to transform the planning CTV at each fraction (CTVfx). A PTV model parameterized by volumetric CTVfx coverage, proportion of fractions, and proportion of patients was developed. Intrafraction motion was quantified in a 412 fraction subset as the fusion difference between post- and pre-irradiation T1 MRIs. Results For the left-right/anterior-posterior/superior-inferior axes, mean ± SD of the rotational fusion differences were 0.1 ± 0.8/0.1 ± 0.8/-0.2 ± 0.9°. Covering 98 % of the CTVfx in 95 % of fractions in 95 % of patients required a 3 mm PTV margin. Margin reduction decreased PTV-OAR overlap; for example, the proportion of optic chiasm overlapped by the PTV was reduced up to 23.5 % by margin reduction from 4 mm to 3 mm. Conclusions An evidence-based PTV model was developed for brain cancer patients treated on the MR-linac. Informed by this model, we have clinically adopted a 3 mm PTV margin for conventionally fractionated intracranial patients.
Collapse
Affiliation(s)
- James Stewart
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Mahtab M. Zadeh
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Bahareh Moazen
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Pejman Jabehdar Maralani
- Department of Medical Imaging, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Stephen Breen
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
- Department of Medical Physics, Sunnybrook Odette Cancer Centre, Toronto, Canada
| | - Angus Lau
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Shawn Binda
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
| | - Brian Keller
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
- Department of Medical Physics, Sunnybrook Odette Cancer Centre, Toronto, Canada
| | - Zain Husain
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
- Department of Medical Physics, Sunnybrook Odette Cancer Centre, Toronto, Canada
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Corresponding author at: Department of Medical Physics, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada.
| |
Collapse
|
6
|
Oglesby RT, Lam WW, Ruschin M, Holden L, Sarfehnia A, Yeboah C, Sahgal A, Soliman H, Detsky J, Tseng CL, Myrehaug S, Husain Z, Lau AZ, Stanisz GJ, Chugh BP. Skull phantom-based methodology to validate MRI co-registration accuracy for Gamma Knife radiosurgery. Med Phys 2022; 49:7071-7084. [PMID: 35842918 DOI: 10.1002/mp.15851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/09/2022] [Accepted: 06/28/2022] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Target localization, for stereotactic radiosurgery (SRS) treatment with Gamma Knife, has become increasingly reliant on the co-registration between the planning MRI and the stereotactic cone-beam computed tomography (CBCT). Validating image registration between modalities would be particularly beneficial when considering the emergence of novel functional and metabolic MRI pulse sequences for target delineation. This study aimed to develop a phantom-based methodology to quantitatively compare the co-registration accuracy of the standard clinical imaging protocol to a representative MRI sequence that was likely to fail co-registration. The comparative methodology presented in this study may serve as a useful tool to evaluate the clinical translatability of novel MRI sequences. METHODS A realistic human skull phantom with fiducial marker columns was designed and manufactured to fit into a typical MRI head coil and the Gamma Knife patient positioning system. A series of "optimized" 3D MRI sequences-T1 -weighted Dixon, T1 -weighted fast field echo (FFE), and T2 -weighted fluid-attenuated inversion recovery (FLAIR)-were acquired and co-registered to the CBCT. The same sequences were "compromised" by reconstructing without geometric distortion correction and re-collecting with lower signal-to-noise-ratio (SNR) to simulate a novel MRI sequence with poor co-registration accuracy. Image similarity metrics-structural similarity (SSIM) index, mean squared error (MSE), and peak SNR (PSNR)-were used to quantitatively compare the co-registration of the optimized and compromised MR images. RESULTS The ground truth fiducial positions were compared to positions measured from each optimized image volume revealing a maximum median geometric uncertainty of 0.39 mm (LR), 0.92 mm (AP), and 0.13 mm (SI) between the CT and CBCT, 0.60 mm (LR), 0.36 mm (AP), and 0.07 mm (SI) between the CT and T1 -weighted Dixon, 0.42 mm (LR), 0.23 mm (AP), and 0.08 mm (SI) between the CT and T1 -weighted FFE, and 0.45 mm (LR), 0.19 mm (AP), and 1.04 mm (SI) between the CT and T2 -weighted FLAIR. Qualitatively, pairs of optimized and compromised image slices were compared using a fusion image where separable colors were used to differentiate between images. Quantitatively, MSE was the most predictive and SSIM the second most predictive metric for evaluating co-registration similarity. A clinically relevant threshold of MSE, SSIM, and/or PSNR may be defined beyond which point an MRI sequence should be rejected for target delineation based on its dissimilarity to an optimized sequence co-registration. All dissimilarity thresholds calculated using correlation coefficients with in-plane geometric uncertainty would need to be defined on a sequence-by-sequence basis and validated with patient data. CONCLUSION This study utilized a realistic skull phantom and image similarity metrics to develop a methodology capable of quantitatively assessing whether a modern research-based MRI sequence can be co-registered to the Gamma Knife CBCT with equal or less than equal accuracy when compared to a clinically accepted protocol.
Collapse
Affiliation(s)
- Ryan T Oglesby
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Wilfred W Lam
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Mark Ruschin
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Lori Holden
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Arman Sarfehnia
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Department of Physics, Ryerson University, Toronto, Ontario, Canada
| | - Collins Yeboah
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Hany Soliman
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Jay Detsky
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Chia-Lin Tseng
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Sten Myrehaug
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Zain Husain
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Angus Z Lau
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Greg J Stanisz
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Neurosurgery and Paediatric Neurosurgery, Medical University of Lublin, Lublin, Poland.,Department of Physics, Ryerson University, Toronto, Ontario, Canada
| | - Brige P Chugh
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Department of Physics, Ryerson University, Toronto, Ontario, Canada
| |
Collapse
|
7
|
Mehrabian H, Chan RW, Sahgal A, Chen H, Theriault A, Lam WW, Myrehaug S, Tseng CL, Husain Z, Detsky J, Soliman H, Stanisz GJ. Chemical Exchange Saturation Transfer MRI for Differentiating Radiation Necrosis From Tumor Progression in Brain Metastasis-Application in a Clinical Setting. J Magn Reson Imaging 2022; 57:1713-1725. [PMID: 36219521 DOI: 10.1002/jmri.28440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/07/2022] [Accepted: 09/08/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND High radiation doses of stereotactic radiosurgery (SRS) for brain metastases (BM) can increase the likelihood of radiation necrosis (RN). Advanced MRI sequences can improve the differentiation between RN and tumor progression (TP). PURPOSE To use saturation transfer MRI methods including chemical exchange saturation transfer (CEST) and magnetization transfer (MT) to distinguish RN from TP. STUDY TYPE Prospective cohort study. SUBJECTS Seventy patients (median age 60; 73% females) with BM (75 lesions) post-SRS. FIELD STRENGTH/SEQUENCE 3-T, CEST imaging using low/high-power (saturation B1 = 0.52 and 2.0 μT), quantitative MT imaging using B1 = 1.5, 3.0, and 5.0 μT, WAter Saturation Shift Referencing (WASSR), WAter Shift And B1 (WASABI), T1 , and T2 mapping. All used gradient echoes except T2 mapping (gradient and spin echo). ASSESSMENT Voxel-wise metrics included: magnetization transfer ratio (MTR); apparent exchange-dependent relaxation (AREX); MTR asymmetry; normalized MT exchange rate and pool size product; direct water saturation peak width; and the observed T1 and T2 . Regions of interests (ROIs) were manually contoured on the post-Gd T1 w. The mean (of median ROI values) was compared between groups. Clinical outcomes were determined by clinical and radiologic follow-up or histopathology. STATISTICAL TESTS t-Test, univariable and multivariable logistic regression, receiver operating characteristic, and area under the curve (AUC) with sensitivity/specificity values with the optimal cut point using the Youden index, Akaike information criterion (AIC), Cohen's d. P < 0.05 with Bonferroni correction was considered significant. RESULTS Seven metrics showed significant differences between RN and TP. The high-power MTR showed the highest AUC of 0.88, followed by low-power MTR (AUC = 0.87). The combination of low-power CEST scans improved the separation compared to individual parameters (with an AIC of 70.3 for low-power MTR/AREX). Cohen's d effect size showed that the MTR provided the largest effect sizes among all metrics. DATA CONCLUSION Significant differences between RN and TP were observed based on saturation transfer MRI. EVIDENCE LEVEL 3 Technical Efficacy: Stage 2.
Collapse
Affiliation(s)
- Hatef Mehrabian
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Rachel W Chan
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Aimee Theriault
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Wilfred W Lam
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Zain Husain
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Greg J Stanisz
- Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, Lublin, Poland
| |
Collapse
|
8
|
Jabehdar Maralani P, Chen H, Moazen B, Mojtahed Zadeh M, Salehi F, Chan A, Zeng LK, Abugharib A, Tseng CL, Husain Z, Myrehaug S, Soliman H, Detsky J, Heyn C, Ruschin M, Larouche J, Sahgal A. Proposing a quantitative MRI-based linear measurement framework for response assessment following stereotactic body radiation therapy in patients with spinal metastasis. J Neurooncol 2022; 160:265-272. [PMID: 36203028 DOI: 10.1007/s11060-022-04152-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 09/28/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE To provide evidence towards a quantitative response assessment framework incorporating MRI-based linear measurements for spinal metastasis that predicts outcome following stereotactic body radiation therapy (SBRT). METHODS Adult patients with de novo spinal metastases treated with SBRT between 2008 and 2018 were retrospectively assessed. The metastatic lesions involving the pedicles, articular processes, lamina, transverse process, spinous process and vertebral body at leach level were measured separately using linear measurements on pre- and all post-SBRT MRIs. The outcome was segment-specific progression (SSP) using SPINO guidelines which was dated to the first clinical documentation of progression, or the date of the associated MRI if imaging was the reason for progression. Random forest analysis for variable selection and recursive partitioning analysis for SSP probability prediction were used. RESULTS Five Hundred Ninety-three spinal levels (323 patients) from 4081 MRIs were evaluated. The appearance of new T1 hypointensity and increase in Bilsky grade had an odds ratio (OR) of 33.5 and 15.5 for SSP, respectively. Compared to baseline, an increase of > 3 mm in any lesion dimension, combined with a 1.67-fold increase in area, had an OR of 4.6 for SSP. The sensitivity, specificity, positive predictive value, negative predictive value, balanced accuracy and area under the curve of the training model were 96.7%, 89.6%, 28.6%, 99.8%, 93.2% and 0.905 and of the test model were 91.3%, 89.3%, 27.1% 99.6%, 90.3% and 0.933, respectively. CONCLUSION With further refinement and validation in prospective multicentre studies, MRI-based linear measurements can help predict response assessment in SBRT-treated spinal metastases.
Collapse
Affiliation(s)
- Pejman Jabehdar Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, AG270c, Toronto, ON, M4N 3M5, Canada.
| | - Hanbo Chen
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Bahareh Moazen
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, AG270c, Toronto, ON, M4N 3M5, Canada
| | - Mahtab Mojtahed Zadeh
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, AG270c, Toronto, ON, M4N 3M5, Canada
| | - Fateme Salehi
- Department of Radiology, McMaster University, Hamilton, Canada
| | - Aimee Chan
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, AG270c, Toronto, ON, M4N 3M5, Canada
| | - Liang K Zeng
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Ahmed Abugharib
- Department of Clinical Oncology, Sohag University Hospital, Sohag, Egypt
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Zain Husain
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Chinthaka Heyn
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, AG270c, Toronto, ON, M4N 3M5, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Jeremie Larouche
- Division of Orthopedic Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| |
Collapse
|
9
|
Palhares D, Chen H, Wang M, Myrehaug S, Detsky J, Tseng CLE, Husain Z, Lim-fat MJ, Lipsman N, Das S, Keith J, Sahgal A, Soliman H. 43: Predictive Factors for Survival and Radiation Necrosis in Patients with Recurrent High-Grade Glioma Treated with Re-Irradiation. Radiother Oncol 2022. [DOI: 10.1016/s0167-8140(22)04322-5] [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: 11/15/2022]
|
10
|
Hudson JM, Stewart J, Zeng KL, Chen H, Ruschin M, Soliman H, Myrehaug S, Husain Z, Sahgal A, Detsky J. 2: Impact of MGMT Promoter Methylation Status on Tumour Dynamics During Weekly Adaptive Radiotherapy for Glioblastoma. Radiother Oncol 2022. [DOI: 10.1016/s0167-8140(22)04281-5] [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: 11/25/2022]
|
11
|
Zeng KL, Abugharib A, Soliman H, Myrehaug S, Husain Z, Detsky J, Ruschin M, Karotki A, Atenafu E, Maralani P, Sahgal A, Tseng CL. 83: Dose-Escalated Two-Fraction Spine Stereotactic Body Radiotherapy: 28 GY Versus 24 GY in 2 Daily Fractions. Radiother Oncol 2022. [DOI: 10.1016/s0167-8140(22)04362-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
12
|
Palhares D, Zeng KL, Myrehaug S, Tseng CL(E, Detsky J, Husain Z, Heyn C(C, Maralani P, da Costa L, Larouche J, Sahgal A, Soliman H. 77: Outcomes of 30GY in 4 Fractions for Spine Stereotactic Body Radiotherapy. Radiother Oncol 2022. [DOI: 10.1016/s0167-8140(22)04356-0] [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: 11/28/2022]
|
13
|
Yan M, Holden L, Wang M, Soliman H, Myrehaug S, Tseng CL, Detsky J, Ruschin M, Tjong M, Atenafu EG, Das S, Lipsman N, Heyn C, Sahgal A, Husain Z. Gamma knife icon based hypofractionated stereotactic radiosurgery (GKI-HSRS) for brain metastases: impact of dose and volume. J Neurooncol 2022; 159:705-712. [PMID: 35999435 DOI: 10.1007/s11060-022-04115-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 08/09/2022] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Gamma Knife Icon-based hypofractionated stereotactic radiosurgery (GKI-HSRS) is a novel technical paradigm in the treatment of brain metastases that allows for both the dosimetric benefits of the GKI stereotactic radiosurgery (SRS) platform as well as the biologic benefits of fractionation. We report mature local control and adverse radiation effect (ARE) outcomes following 5 fraction GKI-HSRS for intact brain metastases. METHODS Patients with intact brain metastases treated with 5-fraction GKI-HSRS were retrospectively reviewed. Survival, local control, and adverse radiation effect rates were determined. Univariable and multivariable regression (MVA) were performed on potential predictive factors. RESULTS Two hundred and ninety-nine metastases in 146 patients were identified. The median clinical follow-up was 10.7 months (range 0.5-47.6). The median total dose and prescription isodose was 27.5 Gy (range, 20-27.5) in 5 daily fractions and 52% (range, 45-93), respectively. The median overall survival (OS) was 12.7 months, and the 1-year local failure rate was 15.2%. MVA identified a total dose of 27.5 Gy vs. ≤ 25 Gy (hazard ratio [HR] 0.59, p = 0.042), and prior chemotherapy exposure (HR 1.99, p = 0.015), as significant predictors of LC. The 1-year ARE rate was 10.8% and the symptomatic ARE rate was 1.8%. MVA identified a gross tumor volume of ≥ 4.5 cc (HR 7.29, p < 0.001) as a significant predictor of symptomatic ARE. CONCLUSION Moderate total doses in 5 daily fractions of GKI-HSRS were associated with high rates of LC and a low incidence of symptomatic ARE.
Collapse
Affiliation(s)
- Michael Yan
- Department of Radiation Oncology, Odette Cancer Center, University of Toronto, Toronto, Canada
| | - Lori Holden
- Department of Radiation Oncology, Odette Cancer Center, University of Toronto, Toronto, Canada
| | - Michael Wang
- Department of Radiation Oncology, Odette Cancer Center, University of Toronto, Toronto, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Center, University of Toronto, Toronto, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Center, University of Toronto, Toronto, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Center, University of Toronto, Toronto, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Center, University of Toronto, Toronto, Canada
| | - Mark Ruschin
- Department of Medical Physics, Odette Cancer Center, University of Toronto, Toronto, Canada
| | - Michael Tjong
- Department of Radiation Oncology, Odette Cancer Center, University of Toronto, Toronto, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, Princess Margaret Cancer Center, University of Toronto, Toronto, Canada
| | - Sunit Das
- Department of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Nir Lipsman
- Department of Neurosurgery, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
| | - Chinthaka Heyn
- Department of Radiology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Center, University of Toronto, Toronto, Canada
| | - Zain Husain
- Department of Radiation Oncology, Odette Cancer Center, University of Toronto, Toronto, Canada. .,Sunnybrook Health Sciences Center, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
| |
Collapse
|
14
|
Hudson JM, Stewart J, Zeng KL, Chen H, Ruschin M, Soliman H, Tseng CL, Myrehaug S, Husain Z, Sahgal A, Detsky J. LOCL-16 IMPACT OF MGMT PROMOTER METHYLATION STATUS ON TUMOR DYNAMICS DURING WEEKLY ADAPTIVE RADIOTHERAPY FOR GLIOBLASTOMA. Neurooncol Adv 2022. [PMCID: PMC9354172 DOI: 10.1093/noajnl/vdac078.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
PURPOSE
Adaptive MRI-guided radiotherapy (RT) on a 1.5T-MR-Linac using reduced clinical target volumes (CTV) of 5mm instead of the 15mm standard for glioblastoma (GBM) is currently being evaluated on the UNITED clinical trial (NCT04726397). We explored the morphological changes that occur during adaptive RT with concurrent temozolomide between tumors with MGMT promotor methylation (MGMT-m) vs. unmethylation (MGMT-um).
METHODS
Thirty patients with IDH-wildtype GBMs were treated with 60Gy in 30 (n=12) or 40Gy in 15 fractions (n=18) (Fx). The CTV included a 5mm expansion on the gross tumor volume (GTV) +/- FLAIR hyperintense areas-at-risk and a 3mm planning target volume. Planning was performed on a pre-treatment reference MRI (FxRef) followed by weekly on-line adaptive re-planning at Fx1, Fx6, etc. acquired on the MR-Linac. Interim fractions were image-guided by pre-beam-on onboard MRI. The GTV/CTVs were quantified by their absolute volumes, volumes relative to the FxRef and the maximum linear distance from the edges of the reference contour to the weekly adapted contours (migration distance, dmig). MGMT promoter methylation status was explored as a fixed effect in a linear mixed statistical model.
RESULTS
Weekly median changes in GTV relative to FxRef in MGMT-um tumors (n=12) were 10.3%, 9.2%, 10.6%, 14.5%, 18.0% and 17.3%, respectively, while for MGMT-m (n=18) were 3.4%, 0.0%, -8.6%, -11.3%, -11.3% and -5.6% (p=0.021). Between FxRef and Fx1, the GTV increased by over 10% in 58% of MGMT-um tumors vs. 33% of MGMT-m tumors. Similar significant trends were observed with the CTVs. MGMT-um tumors had significantly larger dmig compared to tumors with MGMT-m (median 9.6mm vs. 5.8mm, respectively (p=0.018)).
CONCLUSIONS
MGMT-um GBM exhibited significant changes in morphology and migration distance between the time of treatment planning to the first treatment fraction, as well as throughout a course of RT. In this population, our results support a greater frequency of imaging and plan adaptation when applying personalized reduced CTV margins.
Collapse
Affiliation(s)
- John M Hudson
- Department of Radiation Oncology, University of Toronto , Toronto , Canada
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto , Canada
| | - James Stewart
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto , Canada
| | - K Liang Zeng
- Department of Radiation Oncology, University of Toronto , Toronto , Canada
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto , Canada
| | - Hanbo Chen
- Department of Radiation Oncology, University of Toronto , Toronto , Canada
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto , Canada
| | - Mark Ruschin
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto , Canada
| | - Hany Soliman
- Department of Radiation Oncology, University of Toronto , Toronto , Canada
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto , Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, University of Toronto , Toronto , Canada
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto , Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, University of Toronto , Toronto , Canada
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto , Canada
| | - Zain Husain
- Department of Radiation Oncology, University of Toronto , Toronto , Canada
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto , Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, University of Toronto , Toronto , Canada
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto , Canada
| | - Jay Detsky
- Department of Radiation Oncology, University of Toronto , Toronto , Canada
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto , Canada
| |
Collapse
|
15
|
Forner D, Mok F, Verma N, Karam I, Goldstein D, Higgins K, Enepekides D, Nadler A, Pugash R, Husain Z, Chan K, Smoragiewicz M, Cohen L, Hazey JW, Fung EC, Kang SY, Seim NB, Simpson C, Eskander A. Placement technique impacts gastrostomy tube-related complications amongst head and neck cancer patients. Oral Oncol 2022; 130:105903. [DOI: 10.1016/j.oraloncology.2022.105903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 04/17/2022] [Accepted: 05/04/2022] [Indexed: 11/16/2022]
|
16
|
Id Said B, Chen H, Jerzak KJ, Warner E, Myrehaug S, Tseng CL, Detsky J, Husain Z, Sahgal A, Soliman H. Trastuzumab emtansine increases the risk of stereotactic radiosurgery-induced radionecrosis in HER2 + breast cancer. J Neurooncol 2022; 159:177-183. [PMID: 35715667 DOI: 10.1007/s11060-022-04055-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 06/01/2022] [Indexed: 12/22/2022]
Abstract
INTRODUCTION In this study, we investigate factors associated with radionecrosis (RN) in HER2 + (human epidermal growth factor receptor 2) patients with brain metastases (BrM) treated with stereotactic radiosurgery (SRS). METHODS Patients with HER2 + breast cancer BrM treated with SRS (2010-2020) were identified from an institutional database. The incidence of RN was determined per treated BrM according to serial imaging and/or histology. Factors associated with RN such as age, RT dose, BrM volume, and initiation of Trastuzumab Emtansine (T-DM1) were investigated with univariate and multivariable analyses (MVA). RESULTS 67 HER2 + patients with 223 BrM were identified. 21 patients (31.3%) were treated with T-DM1 post-SRS, including 14 patients (20.9%) who received T-DM1 within 12 months of SRS. The median follow-up was 15.6 (interquartile range (IQR) 5.4-35.3) months. The overall probability of RN post-SRS was 21.6% (95% confidence interval (CI) 2.7-10.7), and the 1 and 2 year risk was 6.7% (95% CI 2.7-10.7) and 15.2% (95% CI 9.2-21.3). MVA identified T-DM1 treatment post-SRS (hazard ratio (HR) 2.5, 95% CI 1.2-5.3, p = 0.02) and equivalent dose in 2 Gy fractions (EQD2) > 90 Gy2 (HR 2.4, 95% CI 1.1-5.1, p = 0.02) as predictors of RN. Patients treated with T-DM1 and SRS had a 29.9% (95% CI 15.3-44.6%) probability of RN, with a 25.2% (95% CI 12.8-37.6%) risk at 1- and 2 years post-T-DM1. The majority of RN were symptomatic (71%), with a median time to RN of 4.8 months. CONCLUSION T-DM1 exposure post-SRS was associated with a higher risk of RN among patients with HER2 + BrM.
Collapse
Affiliation(s)
- Badr Id Said
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, 2075 Bayview Ave., T2 181, Toronto, ON, M4N 3M5, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, 2075 Bayview Ave., T2 181, Toronto, ON, M4N 3M5, Canada
| | - Katarzyna J Jerzak
- Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, Toronto, ON, Canada
| | - Ellen Warner
- Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, Toronto, ON, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, 2075 Bayview Ave., T2 181, Toronto, ON, M4N 3M5, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, 2075 Bayview Ave., T2 181, Toronto, ON, M4N 3M5, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, 2075 Bayview Ave., T2 181, Toronto, ON, M4N 3M5, Canada
| | - Zain Husain
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, 2075 Bayview Ave., T2 181, Toronto, ON, M4N 3M5, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, 2075 Bayview Ave., T2 181, Toronto, ON, M4N 3M5, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Science Centre, 2075 Bayview Ave., T2 181, Toronto, ON, M4N 3M5, Canada.
| |
Collapse
|
17
|
Dickstein DR, Lehrer EJ, Hsieh K, Hotca A, Jones BM, Powers A, Sharma S, Liu J, Gupta V, Mell L, Husain Z, Kirke D, Misiukiewicz K, Posner M, Genden E, Bakst RL. Management of Older Adults with Locally Advanced Head and Neck Cancer. Cancers (Basel) 2022; 14:cancers14112809. [PMID: 35681789 PMCID: PMC9179912 DOI: 10.3390/cancers14112809] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 05/29/2022] [Accepted: 06/01/2022] [Indexed: 02/01/2023] Open
Abstract
Simple Summary Approximately one third of patients with head and neck cancer are older adults. The number of older adults with head and neck cancer continues to rise especially as life expectancy increases. However, this population remains significantly underrepresented in clinical trials. Due to this, there is no clear consensus regarding the optimal treatment for older adults with head and neck cancer. In general, older adults are a complex cohort due to variations in functional and performance status, medical comorbidities, and medication management. Treatment for head and neck cancer involves surgery, radiation therapy, systemic therapy, or a combination. These treatments are highly demanding. Additionally, they are associated with toxicity which can be especially difficult for older adults to tolerate. This may lead to treatment interruptions and compromised outcomes. In order to understand the optimal treatment for older adults with head and neck cancer, novel predictive scores are being developed. Additionally, ongoing clinical trials are investigating less intensive treatments for older adults. This review provides an overview of current clinical data, treatment considerations, and future areas of investigation for older adults with head and neck cancer. Abstract Thirty percent of patients with head and neck squamous cell carcinoma (HNSCC) are at least 70 years of age. This number continues to rise as life expectancy continues to increase. Still, older adults with HNSCC remain underrepresented in clinical trials, resulting in ambiguity on optimal management. Older adults are a complex patient population, often requiring increased support due to issues relating to functional and performance status, medical comorbidities, and medication management. Furthermore, in older adults with HNSCC, many of these conditions are independently associated with increased toxicity and worse outcomes. Toxicity in the older adult remains difficult to predict and to understand, and as treatment decisions are based on treatment tolerability, it is essential to understand the toxicities and how to minimize them. Novel predictive scores are being developed specifically for older adults with HNSCC to understand toxicity and to assist in personalized treatment decisions. There are clinical trials presently underway that are investigating shortened radiation courses and novel, less toxic systemic treatments in this population. In the forthcoming sections, we provide a detailed overview of the clinical data, treatment paradigms, and considerations in this population. This review provides a comprehensive overview of existing clinical data and clinical considerations in the older adult head and neck cancer population. Additionally, we provide a detailed overview of pertinent current and ongoing clinical trials, as well as future areas for investigation.
Collapse
Affiliation(s)
- Daniel R. Dickstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.R.D.); (E.J.L.); (K.H.); (A.H.); (B.M.J.); (S.S.); (J.L.); (V.G.)
| | - Eric J. Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.R.D.); (E.J.L.); (K.H.); (A.H.); (B.M.J.); (S.S.); (J.L.); (V.G.)
| | - Kristin Hsieh
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.R.D.); (E.J.L.); (K.H.); (A.H.); (B.M.J.); (S.S.); (J.L.); (V.G.)
| | - Alexandra Hotca
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.R.D.); (E.J.L.); (K.H.); (A.H.); (B.M.J.); (S.S.); (J.L.); (V.G.)
| | - Brianna M. Jones
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.R.D.); (E.J.L.); (K.H.); (A.H.); (B.M.J.); (S.S.); (J.L.); (V.G.)
| | - Ann Powers
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (A.P.); (D.K.); (E.G.)
| | - Sonam Sharma
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.R.D.); (E.J.L.); (K.H.); (A.H.); (B.M.J.); (S.S.); (J.L.); (V.G.)
| | - Jerry Liu
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.R.D.); (E.J.L.); (K.H.); (A.H.); (B.M.J.); (S.S.); (J.L.); (V.G.)
| | - Vishal Gupta
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.R.D.); (E.J.L.); (K.H.); (A.H.); (B.M.J.); (S.S.); (J.L.); (V.G.)
| | - Loren Mell
- Department of Radiation Oncology, University of San Diego, La Jolla, CA 92110, USA;
| | - Zain Husain
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5S 1A1, Canada;
| | - Diana Kirke
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (A.P.); (D.K.); (E.G.)
| | - Krzysztof Misiukiewicz
- Department of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (K.M.); (M.P.)
| | - Marshall Posner
- Department of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (K.M.); (M.P.)
| | - Eric Genden
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (A.P.); (D.K.); (E.G.)
| | - Richard L. Bakst
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.R.D.); (E.J.L.); (K.H.); (A.H.); (B.M.J.); (S.S.); (J.L.); (V.G.)
- Correspondence:
| |
Collapse
|
18
|
Holden L, Yan M, Sahgal A, Husain Z. The Impact of Dose on Treatment Outcomes in Patients Treated for Brain Metastases With a Hypofractionated Technique on Gamma Knife. J Med Imaging Radiat Sci 2022. [DOI: 10.1016/j.jmir.2022.04.017] [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: 10/18/2022]
|
19
|
Galapin M, Chin L, Erler D, Bayley A, Husain Z, Karam I, Poon I. Building a Head and Neck SBRT Program on a Strong Foundation: Harmonizing IGRT Practice. J Med Imaging Radiat Sci 2022. [DOI: 10.1016/j.jmir.2022.04.015] [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: 10/18/2022]
|
20
|
Palma DA, Prisman E, Berthelet E, Tran E, Hamilton S, Wu J, Eskander A, Higgins K, Karam I, Poon I, Husain Z, Enepekides D, Hier M, Sultanem K, Richardson K, Mlynarek A, Johnson-Obaseki S, Odell M, Bayley A, Dowthwaite S, Jackson JE, Dzienis M, O'Neil J, Chandarana S, Banerjee R, Hart R, Chung J, Tenenholtz T, Krishnan S, Le H, Yoo J, Mendez A, Winquist E, Kuruvilla S, Stewart P, Warner A, Mitchell S, Chen J, Parker C, Wehrli B, Kwan K, Theurer J, Sathya J, Hammond JA, Read N, Venkatesan V, MacNeil SD, Fung K, Nichols AC. Assessment of Toxic Effects and Survival in Treatment Deescalation With Radiotherapy vs Transoral Surgery for HPV-Associated Oropharyngeal Squamous Cell Carcinoma: The ORATOR2 Phase 2 Randomized Clinical Trial. JAMA Oncol 2022; 8:1-7. [PMID: 35482348 PMCID: PMC9052108 DOI: 10.1001/jamaoncol.2022.0615] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The optimal approach for treatment deescalation in human papillomavirus (HPV)-related oropharyngeal squamous cell carcinomas (OPSCCs) is unknown. Objective To assess a primary radiotherapy (RT) approach vs a primary transoral surgical (TOS) approach in treatment deescalation for HPV-related OPSCC. Design, Setting, and Participants This international, multicenter, open-label parallel-group phase 2 randomized clinical trial was conducted at 9 tertiary academic cancer centers in Canada and Australia and enrolled patients with T1-T2N0-2 p16-positive OPSCC between February 13, 2018, and November 17, 2020. Patients had up to 3 years of follow-up. Interventions Primary RT (consisting of 60 Gy of RT with concurrent weekly cisplatin in node-positive patients) vs TOS and neck dissection (ND) (with adjuvant reduced-dose RT depending on pathologic findings). Main Outcomes and Measures The primary end point was overall survival (OS) compared with a historical control. Secondary end points included progression-free survival (PFS), quality of life, and toxic effects. Results Overall, 61 patients were randomized (30 [49.2%] in the RT arm and 31 [50.8%] in the TOS and ND arm; median [IQR] age, 61.9 [57.2-67.9] years; 8 women [13.6%] and 51 men [86.4%]; 31 [50.8%] never smoked). The trial began in February 2018, and accrual was halted in November 2020 because of excessive toxic effects in the TOS and ND arm. Median follow-up was 17 months (IQR, 15-20 months). For the OS end point, there were 3 death events, all in the TOS and ND arm, including the 2 treatment-related deaths (0.7 and 4.3 months after randomization, respectively) and 1 of myocardial infarction at 8.5 months. There were 4 events for the PFS end point, also all in the TOS and ND arm, which included the 3 mortality events and 1 local recurrence. Thus, the OS and PFS data remained immature. Grade 2 to 5 toxic effects occurred in 20 patients (67%) in the RT arm and 22 (71%) in the TOS and ND arm. Mean (SD) MD Anderson Dysphagia Inventory scores at 1 year were similar between arms (85.7 [15.6] and 84.7 [14.5], respectively). Conclusions and Relevance In this randomized clinical trial, TOS was associated with an unacceptable risk of grade 5 toxic effects, but patients in both trial arms achieved good swallowing outcomes at 1 year. Long-term follow-up is required to assess OS and PFS outcomes. Trial Registration Clinicaltrials.gov Identifier: NCT03210103.
Collapse
Affiliation(s)
- David A Palma
- Division of Radiation Oncology, Department of Oncology, Western University, London, Ontario, Canada
| | - Eitan Prisman
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric Berthelet
- Division of Radiation Oncology, Department of Oncology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric Tran
- Division of Radiation Oncology, Department of Oncology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sarah Hamilton
- Division of Radiation Oncology, Department of Oncology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jonn Wu
- Division of Radiation Oncology, Department of Oncology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Antoine Eskander
- Department of Otolaryngology-Head and Neck Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kevin Higgins
- Department of Otolaryngology-Head and Neck Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Irene Karam
- Department of Radiation Oncology, Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ian Poon
- Department of Radiation Oncology, Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Zain Husain
- Department of Radiation Oncology, Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Danny Enepekides
- Department of Otolaryngology-Head and Neck Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Michael Hier
- Department of Otolaryngology-Head and Neck Surgery, McGill University, Montreal, Quebec, Canada
| | - Khalil Sultanem
- Department of Radiation Oncology, McGill University, Montreal, Quebec, Canada
| | - Keith Richardson
- Department of Otolaryngology-Head and Neck Surgery, McGill University, Montreal, Quebec, Canada
| | - Alex Mlynarek
- Department of Otolaryngology-Head and Neck Surgery, McGill University, Montreal, Quebec, Canada
| | | | - Michael Odell
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Andrew Bayley
- Department of Radiation Oncology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Samuel Dowthwaite
- Department of Otolaryngology-Head and Neck Surgery, Gold Coast University Hospital, Southport, Queensland, Australia
| | - James E Jackson
- Icon Cancer Centre, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Marcin Dzienis
- Department of Medical Oncology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - John O'Neil
- Icon Cancer Centre, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Shamir Chandarana
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Robyn Banerjee
- Division of Radiation Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Robert Hart
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Jeffson Chung
- Department of Otolaryngology-Head and Neck Surgery, West Virginia University, Morgantown
| | - Todd Tenenholtz
- Department of Radiation Oncology, West Virginia University, Morgantown
| | - Suren Krishnan
- Department of Otolaryngology-Head and Neck Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Hien Le
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - John Yoo
- Department of Otolaryngology-Head and Neck Surgery, Western University, London, Ontario, Canada
| | - Adrian Mendez
- Department of Otolaryngology-Head and Neck Surgery, Western University, London, Ontario, Canada
| | - Eric Winquist
- Division of Medical Oncology, Department of Oncology, Western University, London, Ontario, Canada
| | - Sara Kuruvilla
- Division of Medical Oncology, Department of Oncology, Western University, London, Ontario, Canada
| | - Paul Stewart
- Division of Medical Oncology, Department of Oncology, Western University, London, Ontario, Canada
| | - Andrew Warner
- Division of Radiation Oncology, Department of Oncology, Western University, London, Ontario, Canada
| | - Sylvia Mitchell
- Division of Radiation Oncology, Department of Oncology, Western University, London, Ontario, Canada
| | - Jeff Chen
- Division of Radiation Oncology, Department of Oncology, Western University, London, Ontario, Canada
| | - Christina Parker
- Department of Audiology, London Health Sciences Centre, London, Ontario, Canada
| | - Bret Wehrli
- Department of Pathology, Western University, London, Ontario, Canada
| | - Keith Kwan
- Department of Pathology, Western University, London, Ontario, Canada
| | - Julie Theurer
- School of Communication Sciences and Disorders, Western University, London, Ontario, Canada
| | - Jinka Sathya
- Division of Radiation Oncology, Department of Oncology, Western University, London, Ontario, Canada
| | - J Alex Hammond
- Division of Radiation Oncology, Department of Oncology, Western University, London, Ontario, Canada
| | - Nancy Read
- Division of Radiation Oncology, Department of Oncology, Western University, London, Ontario, Canada
| | - Varagur Venkatesan
- Division of Radiation Oncology, Department of Oncology, Western University, London, Ontario, Canada
| | - S Danielle MacNeil
- Department of Otolaryngology-Head and Neck Surgery, Western University, London, Ontario, Canada
| | - Kevin Fung
- Department of Otolaryngology-Head and Neck Surgery, Western University, London, Ontario, Canada
| | - Anthony C Nichols
- Department of Otolaryngology-Head and Neck Surgery, Western University, London, Ontario, Canada
| |
Collapse
|
21
|
Noel CW, Du Y(J, Baran E, Forner D, Husain Z, Higgins KM, Karam I, Chan KKW, Hallet J, Wright F, Coburn NG, Eskander A, Gotlib Conn L. Enhancing Outpatient Symptom Management in Patients With Head and Neck Cancer: A Qualitative Analysis. JAMA Otolaryngol Head Neck Surg 2022; 148:333-341. [PMID: 35238872 PMCID: PMC8895314 DOI: 10.1001/jamaoto.2021.4555] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
IMPORTANCE Patients with head and neck cancer manage a variety of symptoms at home on an outpatient basis. Clinician review alone often leaves patient symptoms undetected and untreated. Standardized symptom assessment using patient-reported outcomes (PROs) has been shown in randomized clinical trials to improve symptom detection and overall survival, although translation into real-world settings remains a challenge. OBJECTIVE To better understand how patients with head and neck cancer cope with cancer-related symptoms and to examine their perspectives on standardized symptom assessment. DESIGN, PARTICIPANTS, AND SETTING This was a qualitative analysis using semistructured interviews of patients with head and neck cancer and their caregivers from November 2, 2020, to April 16, 2021, at a regional tertiary center in Canada. Purposive sampling was used to recruit a varied group of participants (cancer subsite, treatment received, sociodemographic factors). Drawing on the Supportive Care Framework, a thematic approach was used to analyze the data. Data analysis was performed from November 2, 2020, to August 2, 2021. MAIN OUTCOMES AND MEASURES Patient perception of ambulatory symptom management and standardized symptom assessment. RESULTS Among 20 participants (median [range] age, 59.5 [33-74] years; 9 [45%] female; 13 [65%] White individuals), 4 themes were identified: (1) timely physical symptom management, (2) information as a tool for symptom management, (3) barriers to psychosocial support, and (4) external factors magnifying symptom burden. Participants' perceptions of standardized symptom assessment varied. Some individuals described the symptom monitoring process as facilitating self-reflection and symptom detection. Others felt disempowered by the process, particularly when symptom scores were inconsistently reviewed or acted on. CONCLUSIONS AND RELEVANCE This qualitative analysis provides a novel description of head and neck cancer symptom management from the patient perspective. The 4 identified themes and accompanying recommendations serve as guides for enhanced symptom monitoring.
Collapse
Affiliation(s)
- Christopher W. Noel
- Department of Otolaryngology−Head and Neck Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada,ICES, Toronto, Ontario, Canada
| | - Yue (Jennifer) Du
- Department of Otolaryngology−Head and Neck Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Elif Baran
- Department of Otolaryngology−Head and Neck Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - David Forner
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada,Division of Otolaryngology−Head and Neck Surgery, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Zain Husain
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kevin M. Higgins
- Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Irene Karam
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kelvin K. W. Chan
- Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Julie Hallet
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada,ICES, Toronto, Ontario, Canada,Evaluative Clinical Sciences, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Frances Wright
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada,Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Natalie G. Coburn
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada,ICES, Toronto, Ontario, Canada,Evaluative Clinical Sciences, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada,Ontario Health Cancer Care, Toronto, Ontario, Canada
| | - Antoine Eskander
- Department of Otolaryngology−Head and Neck Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada,ICES, Toronto, Ontario, Canada,Evaluative Clinical Sciences, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Lesley Gotlib Conn
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada,Evaluative Clinical Sciences, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| |
Collapse
|
22
|
Abugharib A, Zeng KL, Tseng CL, Soliman H, Myrehaug S, Husain Z, Maralani PJ, Larouche J, Cheung P, Emmenegger U, Atenafu EG, Sahgal A, Detsky JS. Spine Stereotactic Body Radiotherapy for Prostate Cancer Metastases and the Impact of Hormone Sensitivity Status on Local Control. Neurosurgery 2022; 90:743-749. [PMID: 35343467 DOI: 10.1227/neu.0000000000001909] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 12/15/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Stereotactic body radiotherapy (SBRT) is used to deliver ablative dose of radiation to spinal metastases. OBJECTIVE To report the first dedicated series of spine SBRT specific to prostate cancer (PCa) metastases with outcomes reported according to hormone sensitivity status. METHODS A prospective database was reviewed identifying patients with PCa treated with spine SBRT. This included those with hormone-sensitive PCa (HSPC) and castrate-resistant PCa (CRPC). The primary end point was MRI-based local control (LC). RESULTS A total of 183 spine segments in 93 patients were identified; 146 segments had no prior radiation and 37 had been previously radiated; 27 segments were postoperative. The median follow-up was 31 months. At the time of SBRT, 50 patients had HSPC and the remaining 43 had CRPC. The most common fractionation scheme was 24-28 Gy in 2 SBRT fractions (76%). LC rates at 1 and 2 years were 99% and 95% and 94% and 78% for the HSPC and CRPC cohorts, respectively. For patients treated with de novo SBRT, a higher risk of local failure was observed in patients with CRPC (P = .0425). The 1-year and 2-year overall survival rates were significantly longer at 98% and 95% in the HSPC cohort compared with 79% and 65% in the CRPC cohort (P = .0005). The cumulative risk of vertebral compression fracture at 2 years was 10%. CONCLUSION Favorable LC rates were observed after spine SBRT for PCa metastases; strategies to improve long-term LC in patients with CRPC require further investigation.
Collapse
Affiliation(s)
- Ahmed Abugharib
- Department of Clinical Oncology, Sohag University Hospital, Sohag University, Sohag, Egypt.,Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - K Liang Zeng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Zain Husain
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Pejman Jabehdar Maralani
- Department of Medical Imaging, Neuroradiology Division, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jeremie Larouche
- Department of Surgery, Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Patrick Cheung
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Urban Emmenegger
- Division of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jay S Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
23
|
Davies JC, Husain Z, Day TA, Graboyes EM, Eskander A. Perioperative Mortality Risk in Patients Undergoing Transoral Robotic Surgery for T1-T2 Oropharyngeal Squamous Cell Carcinoma: A National Cancer Database Study. Front Oncol 2022; 11:808465. [PMID: 35071012 PMCID: PMC8770260 DOI: 10.3389/fonc.2021.808465] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/13/2021] [Indexed: 12/14/2022] Open
Abstract
The National Cancer Database is a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society. The American College of Surgeons and the Commission on Cancer have not verified and are not responsible for the analytic or statistical methods used or for the conclusions drawn from these data by the investigators.
Collapse
Affiliation(s)
- Joel C Davies
- Department of Otolaryngology-Head and Neck Surgery, Sinai Health System, University of Toronto, Toronto, ON, Canada
| | - Zain Husain
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Science Center, Odette Cancer Center, University of Toronto, Toronto, ON, Canada
| | - Terry A Day
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston, SC, United States
| | - Evan M Graboyes
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston, SC, United States.,Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, United States
| | - Antoine Eskander
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Science Center, Odette Cancer Center, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
24
|
Geraghty BJ, Dasgupta A, Sandhu M, Malik N, Maralani PJ, Detsky J, Tseng CL, Soliman H, Myrehaug S, Husain Z, Perry J, Lau A, Sahgal A, Czarnota GJ. Predicting survival in patients with glioblastoma using MRI radiomic features extracted from radiation planning volumes. J Neurooncol 2022; 156:579-588. [PMID: 34981301 DOI: 10.1007/s11060-021-03939-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 12/27/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Quantitative image analysis using pre-operative magnetic resonance imaging (MRI) has been able to predict survival in patients with glioblastoma (GBM). The study explored the role of postoperative radiation (RT) planning MRI-based radiomics to predict the outcomes, with features extracted from the gross tumor volume (GTV) and clinical target volume (CTV). METHODS Patients with IDH-wildtype GBM treated with adjuvant RT having MRI as a part of RT planning process were included in the study. 546 features were extracted from each GTV and CTV. A LASSO Cox model was applied, and internal validation was performed using leave-one-out cross-validation with overall survival as endpoint. Cross-validated time-dependent area under curve (AUC) was constructed to test the efficacy of the radiomics model, and clinical features were used to generate a combined model. Analysis was done for the entire group and in individual surgical groups-gross total excision (GTR), subtotal resection (STR), and biopsy. RESULTS 235 patients were included in the study with 57, 118, and 60 in the GTR, STR, and biopsy subgroup, respectively. Using the radiomics model, binary risk groups were feasible in the entire cohort (p < 0.01) and biopsy group (p = 0.04), but not in the other two surgical groups individually. The integrated AUC (iAUC) was 0.613 for radiomics-based classification in the biopsy subgroup, which improved to 0.632 with the inclusion of clinical features. CONCLUSION Imaging features extracted from the GTV and CTV regions can lead to risk-stratification of GBM undergoing biopsy, while the utility in other individual subgroups needs to be further explored.
Collapse
Affiliation(s)
- Benjamin J Geraghty
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada.,Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Archya Dasgupta
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada.,Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Michael Sandhu
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada.,Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Nauman Malik
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Pejman Jabehdar Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada.,Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada.,Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada.,Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada.,Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Zain Husain
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada.,Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - James Perry
- Department of Neurology, Sunnybrook Health Sciences Centre, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Angus Lau
- Physical Sciences, Sunnybrook Research Institute, Toronto, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada.,Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Gregory J Czarnota
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada. .,Department of Radiation Oncology, University of Toronto, Toronto, Canada. .,Physical Sciences, Sunnybrook Research Institute, Toronto, Canada. .,Department of Medical Biophysics, University of Toronto, Toronto, Canada.
| |
Collapse
|
25
|
Tan H, Stewart J, Ruschin M, Wang MH, Myrehaug S, Tseng CL, Detsky J, Husain Z, Chen H, Sahgal A, Soliman H. Inter-fraction dynamics during post-operative 5 fraction cavity hypofractionated stereotactic radiotherapy with a MR LINAC: a prospective serial imaging study. J Neurooncol 2022; 156:569-577. [PMID: 34981300 DOI: 10.1007/s11060-021-03938-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 12/27/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE/OBJECTIVE(S) This study examined changes in the clinical target volume (CTV) and associated clinical implications on a magnetic resonance imaging linear accelerator (MR LINAC) during hypofractionated stereotactic radiotherapy (HSRT) to resected brain metastases. In addition, the suitability of using T2/FLAIR (T2f) sequence to define CTV was explored by assessing contouring variability between gadolinium-enhanced T1 (T1c) and T2f sequences. MATERIALS/METHODS Fifteen patients treated to either 27.5 or 30 Gy with five fraction HSRT were imaged with T1c and T2f sequences during treatment; T1c was acquired at planning (FxSim), and fraction 3 (Fx3), and T2f was acquired at FxSim and all five fractions. The CTV were contoured on all acquired images. Inter-fraction cavity dynamics and CTV contouring variability were quantified using absolute volume, Dice similarity coefficient (DSC), and Hausdorff distance (HD) metrics. RESULTS The median CTV on T1c and T2f sequences at FxSim were 12.0cm3 (range, 1.2-30.1) and 10.2cm3 (range, 2.9-27.9), respectively. At Fx3, the median CTV decreased in both sequences to 9.3cm3 (range, 3.7-25.9) and 8.6cm3 (range, 3.3-22.5), translating to a median % relative reduction of - 11.4% on T1c (p = 0.009) and - 8.4% on T2f (p = 0.032). We observed a median % relative reduction in CTV between T1c and T2f at FxSim of - 6.0% (p = 0.040). The mean DSC was 0.85 ± 0.10, and the mean HD was 5.3 ± 2.7 mm when comparing CTV on T1c and T2f at FxSim. CONCLUSION Statistically significant reductions in cavity CTV was observed during HSRT, supporting the use of MR image guided radiation therapy and treatment adaptation to mitigate toxicity. Significant CTV contouring variability was seen between T1c and T2f sequences. Trial registration NCT04075305 - August 30, 2019.
Collapse
Affiliation(s)
- Hendrick Tan
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- GenesisCare, Perth, WA, Australia
| | - James Stewart
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
- Department of Medical Physics, Sunnybrook Odette Cancer Centre, Toronto, Canada
| | - Michael H Wang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Zain Husain
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
- Department of Radiation Oncology, University of Toronto, Toronto, Canada.
| |
Collapse
|
26
|
Wang MH, Kim A, Ruschin M, Tan H, Soliman H, Myrehaug S, Detsky J, Husain Z, Atenafu EG, Keller B, Sahgal A, Tseng CL. Comparison of Prospectively Generated Glioma Treatment Plans Clinically Delivered on Magnetic Resonance Imaging (MRI)-Linear Accelerator (MR-Linac) Versus Conventional Linac: Predicted and Measured Skin Dose. Technol Cancer Res Treat 2022; 21:15330338221124695. [PMID: 36071647 PMCID: PMC9459463 DOI: 10.1177/15330338221124695] [Citation(s) in RCA: 4] [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] [Indexed: 11/17/2022] Open
Abstract
Introduction: Magnetic resonance imaging-linear accelerator
radiotherapy is an innovative technology that requires special consideration for
secondary electron interactions within the magnetic field, which can alter dose
deposition at air–tissue interfaces. As part of ongoing quality assurance and
quality improvement of new radiotherapy technologies, the purpose of this study
was to evaluate skin dose modelled from the treatment planning systems of a
magnetic resonance imaging-linear accelerator and a conventional linear
accelerator, and then correlate with in vivo measurements of delivered skin dose
from each linear accelerator. Methods: In this prospective cohort
study, 37 consecutive glioma patients had treatment planning completed and
approved prior to radiotherapy initiation using commercial treatment planning
systems: a Monte Carlo-based algorithm for magnetic resonance imaging-linear
accelerator or a convolution-based algorithm for conventional linear
accelerator. In vivo skin dose was measured using an optically stimulated
luminescent dosimeter. Results: Monte Carlo-based magnetic
resonance imaging-linear accelerator plans and convolution-based conventional
linear accelerator plans had similar dosimetric parameters for target volumes
and organs-at-risk. However, magnetic resonance imaging-linear accelerator plans
had 1.52 Gy higher mean dose to air cavities (P < .0001) and
1.10 Gy higher mean dose to skin (P < .0001). In vivo skin
dose was 14.5% greater for magnetic resonance imaging-linear accelerator
treatments (P = .0027), and was more accurately predicted by
Monte Carlo-based calculation (ρ = 0.95,
P < .0001) versus convolution-based
(ρ = 0.80, P = .0096).
Conclusion: This is the first prospective dosimetric comparison
of glioma patients clinically treated on both magnetic resonance imaging-linear
accelerator and conventional linear accelerator. Our findings suggest that skin
doses were significantly greater with magnetic resonance imaging-linear
accelerator plans but correlated better with in vivo measurements of actual skin
dose from delivered treatments. Future magnetic resonance imaging-linear
accelerator planning processes are being designed to account for skin dosimetry
and treatment delivery.
Collapse
Affiliation(s)
- Michael H Wang
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, 7938University of Toronto, Toronto, Ontario, Canada
| | - Anthony Kim
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, 7938University of Toronto, Toronto, Ontario, Canada.,Department of Medical Physics, Sunnybrook Odette Cancer Centre, 7938University of Toronto, Toronto, Ontario, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, 7938University of Toronto, Toronto, Ontario, Canada.,Department of Medical Physics, Sunnybrook Odette Cancer Centre, 7938University of Toronto, Toronto, Ontario, Canada
| | - Hendrick Tan
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, 7938University of Toronto, Toronto, Ontario, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, 7938University of Toronto, Toronto, Ontario, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, 7938University of Toronto, Toronto, Ontario, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, 7938University of Toronto, Toronto, Ontario, Canada
| | - Zain Husain
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, 7938University of Toronto, Toronto, Ontario, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, 7989University Health Network, 7938University of Toronto, Toronto, Ontario, Canada
| | - Brian Keller
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, 7938University of Toronto, Toronto, Ontario, Canada.,Department of Medical Physics, Sunnybrook Odette Cancer Centre, 7938University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, 7938University of Toronto, Toronto, Ontario, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, 7938University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
27
|
Kim MS, Malik NH, Chen H, Poon I, Husain Z, Eskander A, Boldt G, Louie AV, Karam I. Stereotactic radiotherapy as planned boost after definitive radiotherapy for head and neck cancers: Systematic review. Head Neck 2021; 44:770-782. [PMID: 34927313 DOI: 10.1002/hed.26948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/02/2021] [Accepted: 12/02/2021] [Indexed: 12/08/2022] Open
Abstract
Management of locoregionally advanced head and neck cancers (HNCs) remains a challenge. Some groups have attempted to use stereotactic radiotherapy (SBRT) to deliver "boost" treatment following conventional radiotherapy to improve local control (LC) and overall survival (OS), while aiming for acceptable toxicities. Medline, EMBASE, and Cochrane Library databases were queried for SBRT as curative-intent planned boost in HNC after conventional radiotherapy. Individual studies were reviewed from inception until January 2021, extracting patient, treatment, and outcome data. Nine studies met inclusion criteria, representing 454 unique patients treated with curative intent across multiple head and neck sites with conventional radiotherapy. At 3 years, median LC was 92% (90%-98%), and median OS was 80% (75%-91%). Seven treatment-related grade 5 toxicities (1.5%) were reported. Despite acceptable LC and OS rates, there were severe treatment-related late toxicities. As such, SBRT boost should only be used in investigational settings until more data is available.
Collapse
Affiliation(s)
- Michael S Kim
- Department of Radiation Oncology, Nova Scotia Cancer Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Nauman H Malik
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ian Poon
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Zain Husain
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Antoine Eskander
- Department of Otolaryngology-Head and Neck Surgery, Sunnybrook Health Sciences Centre, Odette Cancer Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Gabriel Boldt
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Alexander V Louie
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Irene Karam
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
28
|
Noel CW, Forner D, Chepeha DB, Baran E, Chan KKW, Parmar A, Husain Z, Karam I, Hallet J, Coburn NG, Eskander A. The Edmonton Symptom Assessment System: A narrative review of a standardized symptom assessment tool in head and neck oncology. Oral Oncol 2021; 123:105595. [PMID: 34775181 DOI: 10.1016/j.oraloncology.2021.105595] [Citation(s) in RCA: 6] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 10/01/2021] [Accepted: 10/19/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Symptom burden is common in head and neck cancer patients though it frequently remains undetected and untreated. The Edmonton Symptom Assessment System - revised version (ESAS-r) is a generic symptom scale deployed in many outpatient settings worldwide. The ESAS-r is meant to improve symptom detection and management. We sought to review the ESAS-r and its psychometric properties in a head and neck oncology population. METHODS Narrative Review. RESULTS Over the past 30 years, the ESAS-r has emerged as one of the most used symptom scales for cancer patients. Its psychometric properties in a heterogenous cancer population are well supported, proving to be reliable and valid in a variety of settings. The linking of ESAS-r scores with Ontario administrative health data has led to a detailed assessment of validity in head and neck cancer. The ESAS-r can discriminate between high and low levels of symptom burden and is responsive to change over time in this patient population. ESAS-r scores have also been shown to be a strong predictor of future emergency department use and unplanned hospitalization in head and neck cancer patients. CONCLUSIONS The ESAS-r is reliable and valid in the head and neck cancer population and may serve as a useful clinical endpoint in research studies.
Collapse
Affiliation(s)
- Christopher W Noel
- Department of Otolaryngology - Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada
| | - David Forner
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada; Division of Otolaryngology Head & Neck Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Douglas B Chepeha
- Department of Otolaryngology - Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada; Department of Otolaryngology Head & Neck Surgery/Surgical Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Elif Baran
- Department of Otolaryngology - Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Kelvin K W Chan
- Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Ambica Parmar
- Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Zain Husain
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Irene Karam
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Julie Hallet
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada; Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Natalie G Coburn
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada; Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Antoine Eskander
- Department of Otolaryngology - Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada; Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Otolaryngology - Head & Neck Surgery, Sunnybrook Health Sciences Centre and Michael Garron Hospital, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
29
|
Malik N, Geraghty B, Dasgupta A, Maralani PJ, Sandhu M, Detsky J, Tseng CL, Soliman H, Myrehaug S, Husain Z, Perry J, Lau A, Sahgal A, Czarnota GJ. MRI radiomics to differentiate between low grade glioma and glioblastoma peritumoral region. J Neurooncol 2021; 155:181-191. [PMID: 34694564 DOI: 10.1007/s11060-021-03866-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 10/05/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The peritumoral region (PTR) of glioblastoma (GBM) appears as a T2W-hyperintensity and is composed of microscopic tumor and edema. Infiltrative low grade glioma (LGG) comprises tumor cells that seem similar to GBM PTR on MRI. The work here explored if a radiomics-based approach can distinguish between the two groups (tumor and edema versus tumor alone). METHODS Patients with GBM and LGG imaged using a 1.5 T MRI were included in the study. Image data from cases of GBM PTR, and LGG were manually segmented guided by T2W hyperintensity. A set of 91 first-order and texture features were determined from each of T1W-contrast, and T2W-FLAIR, diffusion-weighted imaging sequences. Applying filtration techniques, a total of 3822 features were obtained. Different feature reduction techniques were employed, and a subsequent model was constructed using four machine learning classifiers. Leave-one-out cross-validation was used to assess classifier performance. RESULTS The analysis included 42 GBM and 36 LGG. The best performance was obtained using AdaBoost classifier using all the features with a sensitivity, specificity, accuracy, and area of curve (AUC) of 91%, 86%, 89%, and 0.96, respectively. Amongst the feature selection techniques, the recursive feature elimination technique had the best results, with an AUC ranging from 0.87 to 0.92. Evaluation with the F-test resulted in the most consistent feature selection with 3 T1W-contrast texture features chosen in over 90% of instances. CONCLUSIONS Quantitative analysis of conventional MRI sequences can effectively demarcate GBM PTR from LGG, which is otherwise indistinguishable on visual estimation.
Collapse
Affiliation(s)
- Nauman Malik
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, T2, Toronto, ON, M4N3M5, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Benjamin Geraghty
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, T2, Toronto, ON, M4N3M5, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada.,Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Archya Dasgupta
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, T2, Toronto, ON, M4N3M5, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada.,Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Pejman Jabehdar Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Michael Sandhu
- Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, T2, Toronto, ON, M4N3M5, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada.,Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, T2, Toronto, ON, M4N3M5, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada.,Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, T2, Toronto, ON, M4N3M5, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada.,Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, T2, Toronto, ON, M4N3M5, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada.,Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Zain Husain
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, T2, Toronto, ON, M4N3M5, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada.,Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - James Perry
- Department of Neurology, Sunnybrook Health Sciences Centre, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Angus Lau
- Physical Sciences, Sunnybrook Research Institute, Toronto, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, T2, Toronto, ON, M4N3M5, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada.,Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Gregory J Czarnota
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, T2, Toronto, ON, M4N3M5, Canada. .,Department of Radiation Oncology, University of Toronto, Toronto, Canada. .,Physical Sciences, Sunnybrook Research Institute, Toronto, Canada. .,Department of Medical Biophysics, University of Toronto, Toronto, Canada.
| |
Collapse
|
30
|
Jabehdar Maralani P, Tseng CL, Baharjoo H, Wong E, Kapadia A, Dasgupta A, Howard P, Chan AKM, Atenafu EG, Lu H, Tyrrell P, Das S, Payabvash S, Detsky J, Husain Z, Myrehaug S, Soliman H, Chen H, Heyn C, Symons S, Sahgal A. The Initial Step Towards Establishing a Quantitative, Magnetic Resonance Imaging-Based Framework for Response Assessment of Spinal Metastases After Stereotactic Body Radiation Therapy. Neurosurgery 2021; 89:884-891. [PMID: 34392364 PMCID: PMC8645191 DOI: 10.1093/neuros/nyab310] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 01/11/2021] [Accepted: 06/09/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND There are no established threshold values regarding the degree of growth on imaging when assessing response of spinal metastases treated with stereotactic body radiation therapy (SBRT). OBJECTIVE To determine a magnetic resonance imaging-based minimum detectable difference (MDD) in gross tumor volume (GTV) and its association with 1-yr radiation site-specific (RSS) progression-free survival (PFS). METHODS GTVs at baseline and first 2 post-SBRT scans (Post1 and Post2, respectively) for 142 spinal segments were contoured, and percentage volume change between scans calculated. One-year RSS PFS was acquired from medical records. The MDD was determined. The MDD was compared against optimal thresholds of GTV changes associated with 1-yr RSS PFS using Youden's J index, and receiver operating characteristic curves between timepoints compared to determine which timeframe had the best association. RESULTS A total of 17 of the 142 segments demonstrated progression. The MDD was 10.9%. Baseline-Post2 demonstrated the best performance (area under the curve [AUC] 0.90). Only Baseline-Post2 had an optimal threshold > MDD at 14.7%. Due to large distribution of GTVs, volumes were split into tertiles. Small tumors (GTV < 2 cc) had optimal thresholds of 42.0%, 71.3%, and 37.2% at Baseline-Post1 (AUC 0.81), Baseline-Post2 (AUC 0.89), and Post1-Post2 (AUC 0.77), respectively. Medium tumors (2 ≤ GTV ≤ 8.3 cc) all demonstrated optimal thresholds < MDD, with AUCs ranging from 0.65 to 0.84. Large tumors (GTV > 8.3 cc) had 2 timepoints where optimal thresholds > MDD: Baseline-Post2 (13.3%; AUC 0.97) and Post1-Post2 (11.8%; AUC 0.66). Baseline-Post2 had the best association with RSS PFS for all tertiles. CONCLUSION Given a MDD of 10.9%, for small GTVs, larger (>37%) changes were required before local failure could be determined, compared to 11% to 13% for medium/large tumors.
Collapse
Affiliation(s)
| | - Chia-Lin Tseng
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | | | - Erin Wong
- Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Anish Kapadia
- Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Archya Dasgupta
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Peter Howard
- Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Aimee K M Chan
- Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, Toronto, Canada
| | - Hua Lu
- Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Pascal Tyrrell
- Department of Medical Imaging, University of Toronto, Toronto, Canada
- Department of Statistical Sciences, University of Toronto, Toronto, Canada
- Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Sunit Das
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Canada
| | | | - Jay Detsky
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Zain Husain
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Hany Soliman
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Chris Heyn
- Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Sean Symons
- Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| |
Collapse
|
31
|
Said BI, Chen H, Jerzak K, Myrehaug S, Tseng CL, Detsky J, Husain Z, Sahgal A, Soliman H. 158: T-DM1 Increases the Risk of SRS-Induced Radiation Necrosis in HER2 + Breast Cancer. Radiother Oncol 2021. [DOI: 10.1016/s0167-8140(21)08873-3] [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: 11/16/2022]
|
32
|
Abugharib A, Karam I, Husain Z, Chin L, Bayley A, Poon I. 156: Stereotactic Body Radiotherapy (SBRT) for the Palliation of Unirradiated Mucosal Head and Neck Tumours. Radiother Oncol 2021. [DOI: 10.1016/s0167-8140(21)08871-x] [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]
|
33
|
Myrehaug S, Hudson J, Soliman H, Ruschin M, Tseng CL, Detsky J, Husain Z, Keith J, Atenafu EG, Maralani P, Heyn C, Das S, Lipsman N, Sahgal A. Hypofractionated Stereotactic Radiation Therapy for Intact Brain Metastases in 5 Daily Fractions: Effect of Dose on Treatment Response. Int J Radiat Oncol Biol Phys 2021; 112:342-350. [PMID: 34537313 DOI: 10.1016/j.ijrobp.2021.09.003] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/13/2021] [Accepted: 09/01/2021] [Indexed: 01/09/2023]
Abstract
PURPOSE Multileaf collimator (MLC) linear accelerator (Linac)-based hypofractionated stereotactic radiation therapy (HSRT) is increasingly used not only for large brain metastases or those adjacent to critical structures but also for those metastases that would otherwise be considered for single-fraction radiosurgery (SRS). However, data on outcomes in general are limited, and there is a lack of understanding regarding optimal dosing. Our aim was to report mature image-based outcomes for MLC-Linac HSRT with a focus on clinical and dosimetric factors associated with local failure (LF). METHODS AND MATERIALS A total of 220 patients with 334 brain metastases treated with HSRT were identified. All patients were treated using a 5-fraction daily regimen and were followed with clinical evaluation and volumetric magnetic resonance imaging every 2 to 3 months. Overall survival and progression-free survival were calculated using the Kaplan-Meier method, with LF determined using Fine and Gray's competing risk method. Predictive factors were identified using Cox regression multivariate analysis. RESULTS Median follow-up was 10.8 months. Median size of treated metastasis was 1.9 cm; 60% of metastases were <2 cm in size. The median total dose was 30 Gy in 5 fractions; 36% of the cohort received <30 Gy. The median time to LF and 12-month cumulative incidence of LF was 8.5 months and 23.8%, respectively. Median time to death and 12-month overall survival rates were 11.8 months and 48.2%, respectively. Fifty-two metastases (15.6%) had an adverse radiation effect, of which 32 (9.5%) were symptomatic necrosis. Multivariable analysis identified worse LF in patients who received a total dose of <30 Gy (hazard ratio, 1.62; P = .03), with LF at 6 and 12 months of 13% and 33% for patients treated with <30 Gy versus 5% and 19% for patients treated with >30 Gy. Exploratory analysis demonstrated a dose-response effect observed in all histologic types, including among breast cancer subtypes. CONCLUSION Optimal local control is achieved with HSRT of ≥30 Gy in 5 daily fractions, independent of tumor volume and histology, with an acceptable risk of radiation necrosis.
Collapse
Affiliation(s)
- Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada.
| | - John Hudson
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Mark Ruschin
- Department of Medical Physics, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Zain Husain
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Julia Keith
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, Ontario, Canada
| | - Pejman Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Chris Heyn
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Sunit Das
- Department of Neurosurgery, St. Michaels Hospital, Ontario, Canada
| | - Nir Lipsman
- Department of Neurosurgery, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Ontario, Canada
| |
Collapse
|
34
|
Noel CW, Sutradhar R, Zhao H, Delibasic V, Forner D, Irish JC, Kim J, Husain Z, Mahar A, Karam I, Enepekides DJ, Chan KKW, Singh S, Hallet J, Coburn NG, Eskander A. Reply to K. Yokoyama et al. J Clin Oncol 2021; 39:2417-2419. [PMID: 33950700 DOI: 10.1200/jco.21.00688] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Christopher W Noel
- Christopher W. Noel, MD, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Rinku Sutradhar, PhD, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Haoyu Zhao, MPH, and Victoria Delibasic, BHSc, ICES, Toronto, ON, Canada; David Forner, MD, MSc, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, NS, Canada; Jonathan C. Irish, MD, MSc, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; John Kim, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; Zain Husain, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Alyson Mahar, PhD, Department of Community Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada; Irene Karam, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Danny J. Enepekides, MD, MPH, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Kelvin K. W. Chan, MD, MSc, PhD, and Simron Singh,MD, MPH, Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Julie Hallet, MD, MSc, and Natalie G. Coburn, MD, MPH, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; and Antoine Eskander, MD, ScM, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Rinku Sutradhar
- Christopher W. Noel, MD, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Rinku Sutradhar, PhD, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Haoyu Zhao, MPH, and Victoria Delibasic, BHSc, ICES, Toronto, ON, Canada; David Forner, MD, MSc, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, NS, Canada; Jonathan C. Irish, MD, MSc, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; John Kim, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; Zain Husain, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Alyson Mahar, PhD, Department of Community Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada; Irene Karam, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Danny J. Enepekides, MD, MPH, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Kelvin K. W. Chan, MD, MSc, PhD, and Simron Singh,MD, MPH, Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Julie Hallet, MD, MSc, and Natalie G. Coburn, MD, MPH, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; and Antoine Eskander, MD, ScM, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Haoyu Zhao
- Christopher W. Noel, MD, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Rinku Sutradhar, PhD, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Haoyu Zhao, MPH, and Victoria Delibasic, BHSc, ICES, Toronto, ON, Canada; David Forner, MD, MSc, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, NS, Canada; Jonathan C. Irish, MD, MSc, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; John Kim, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; Zain Husain, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Alyson Mahar, PhD, Department of Community Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada; Irene Karam, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Danny J. Enepekides, MD, MPH, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Kelvin K. W. Chan, MD, MSc, PhD, and Simron Singh,MD, MPH, Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Julie Hallet, MD, MSc, and Natalie G. Coburn, MD, MPH, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; and Antoine Eskander, MD, ScM, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Victoria Delibasic
- Christopher W. Noel, MD, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Rinku Sutradhar, PhD, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Haoyu Zhao, MPH, and Victoria Delibasic, BHSc, ICES, Toronto, ON, Canada; David Forner, MD, MSc, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, NS, Canada; Jonathan C. Irish, MD, MSc, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; John Kim, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; Zain Husain, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Alyson Mahar, PhD, Department of Community Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada; Irene Karam, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Danny J. Enepekides, MD, MPH, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Kelvin K. W. Chan, MD, MSc, PhD, and Simron Singh,MD, MPH, Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Julie Hallet, MD, MSc, and Natalie G. Coburn, MD, MPH, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; and Antoine Eskander, MD, ScM, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - David Forner
- Christopher W. Noel, MD, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Rinku Sutradhar, PhD, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Haoyu Zhao, MPH, and Victoria Delibasic, BHSc, ICES, Toronto, ON, Canada; David Forner, MD, MSc, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, NS, Canada; Jonathan C. Irish, MD, MSc, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; John Kim, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; Zain Husain, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Alyson Mahar, PhD, Department of Community Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada; Irene Karam, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Danny J. Enepekides, MD, MPH, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Kelvin K. W. Chan, MD, MSc, PhD, and Simron Singh,MD, MPH, Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Julie Hallet, MD, MSc, and Natalie G. Coburn, MD, MPH, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; and Antoine Eskander, MD, ScM, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jonathan C Irish
- Christopher W. Noel, MD, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Rinku Sutradhar, PhD, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Haoyu Zhao, MPH, and Victoria Delibasic, BHSc, ICES, Toronto, ON, Canada; David Forner, MD, MSc, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, NS, Canada; Jonathan C. Irish, MD, MSc, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; John Kim, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; Zain Husain, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Alyson Mahar, PhD, Department of Community Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada; Irene Karam, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Danny J. Enepekides, MD, MPH, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Kelvin K. W. Chan, MD, MSc, PhD, and Simron Singh,MD, MPH, Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Julie Hallet, MD, MSc, and Natalie G. Coburn, MD, MPH, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; and Antoine Eskander, MD, ScM, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - John Kim
- Christopher W. Noel, MD, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Rinku Sutradhar, PhD, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Haoyu Zhao, MPH, and Victoria Delibasic, BHSc, ICES, Toronto, ON, Canada; David Forner, MD, MSc, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, NS, Canada; Jonathan C. Irish, MD, MSc, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; John Kim, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; Zain Husain, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Alyson Mahar, PhD, Department of Community Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada; Irene Karam, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Danny J. Enepekides, MD, MPH, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Kelvin K. W. Chan, MD, MSc, PhD, and Simron Singh,MD, MPH, Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Julie Hallet, MD, MSc, and Natalie G. Coburn, MD, MPH, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; and Antoine Eskander, MD, ScM, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Zain Husain
- Christopher W. Noel, MD, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Rinku Sutradhar, PhD, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Haoyu Zhao, MPH, and Victoria Delibasic, BHSc, ICES, Toronto, ON, Canada; David Forner, MD, MSc, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, NS, Canada; Jonathan C. Irish, MD, MSc, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; John Kim, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; Zain Husain, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Alyson Mahar, PhD, Department of Community Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada; Irene Karam, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Danny J. Enepekides, MD, MPH, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Kelvin K. W. Chan, MD, MSc, PhD, and Simron Singh,MD, MPH, Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Julie Hallet, MD, MSc, and Natalie G. Coburn, MD, MPH, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; and Antoine Eskander, MD, ScM, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Alyson Mahar
- Christopher W. Noel, MD, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Rinku Sutradhar, PhD, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Haoyu Zhao, MPH, and Victoria Delibasic, BHSc, ICES, Toronto, ON, Canada; David Forner, MD, MSc, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, NS, Canada; Jonathan C. Irish, MD, MSc, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; John Kim, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; Zain Husain, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Alyson Mahar, PhD, Department of Community Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada; Irene Karam, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Danny J. Enepekides, MD, MPH, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Kelvin K. W. Chan, MD, MSc, PhD, and Simron Singh,MD, MPH, Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Julie Hallet, MD, MSc, and Natalie G. Coburn, MD, MPH, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; and Antoine Eskander, MD, ScM, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Irene Karam
- Christopher W. Noel, MD, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Rinku Sutradhar, PhD, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Haoyu Zhao, MPH, and Victoria Delibasic, BHSc, ICES, Toronto, ON, Canada; David Forner, MD, MSc, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, NS, Canada; Jonathan C. Irish, MD, MSc, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; John Kim, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; Zain Husain, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Alyson Mahar, PhD, Department of Community Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada; Irene Karam, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Danny J. Enepekides, MD, MPH, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Kelvin K. W. Chan, MD, MSc, PhD, and Simron Singh,MD, MPH, Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Julie Hallet, MD, MSc, and Natalie G. Coburn, MD, MPH, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; and Antoine Eskander, MD, ScM, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Danny J Enepekides
- Christopher W. Noel, MD, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Rinku Sutradhar, PhD, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Haoyu Zhao, MPH, and Victoria Delibasic, BHSc, ICES, Toronto, ON, Canada; David Forner, MD, MSc, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, NS, Canada; Jonathan C. Irish, MD, MSc, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; John Kim, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; Zain Husain, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Alyson Mahar, PhD, Department of Community Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada; Irene Karam, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Danny J. Enepekides, MD, MPH, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Kelvin K. W. Chan, MD, MSc, PhD, and Simron Singh,MD, MPH, Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Julie Hallet, MD, MSc, and Natalie G. Coburn, MD, MPH, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; and Antoine Eskander, MD, ScM, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Kelvin K W Chan
- Christopher W. Noel, MD, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Rinku Sutradhar, PhD, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Haoyu Zhao, MPH, and Victoria Delibasic, BHSc, ICES, Toronto, ON, Canada; David Forner, MD, MSc, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, NS, Canada; Jonathan C. Irish, MD, MSc, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; John Kim, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; Zain Husain, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Alyson Mahar, PhD, Department of Community Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada; Irene Karam, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Danny J. Enepekides, MD, MPH, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Kelvin K. W. Chan, MD, MSc, PhD, and Simron Singh,MD, MPH, Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Julie Hallet, MD, MSc, and Natalie G. Coburn, MD, MPH, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; and Antoine Eskander, MD, ScM, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Simron Singh
- Christopher W. Noel, MD, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Rinku Sutradhar, PhD, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Haoyu Zhao, MPH, and Victoria Delibasic, BHSc, ICES, Toronto, ON, Canada; David Forner, MD, MSc, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, NS, Canada; Jonathan C. Irish, MD, MSc, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; John Kim, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; Zain Husain, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Alyson Mahar, PhD, Department of Community Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada; Irene Karam, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Danny J. Enepekides, MD, MPH, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Kelvin K. W. Chan, MD, MSc, PhD, and Simron Singh,MD, MPH, Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Julie Hallet, MD, MSc, and Natalie G. Coburn, MD, MPH, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; and Antoine Eskander, MD, ScM, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Julie Hallet
- Christopher W. Noel, MD, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Rinku Sutradhar, PhD, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Haoyu Zhao, MPH, and Victoria Delibasic, BHSc, ICES, Toronto, ON, Canada; David Forner, MD, MSc, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, NS, Canada; Jonathan C. Irish, MD, MSc, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; John Kim, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; Zain Husain, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Alyson Mahar, PhD, Department of Community Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada; Irene Karam, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Danny J. Enepekides, MD, MPH, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Kelvin K. W. Chan, MD, MSc, PhD, and Simron Singh,MD, MPH, Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Julie Hallet, MD, MSc, and Natalie G. Coburn, MD, MPH, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; and Antoine Eskander, MD, ScM, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Natalie G Coburn
- Christopher W. Noel, MD, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Rinku Sutradhar, PhD, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Haoyu Zhao, MPH, and Victoria Delibasic, BHSc, ICES, Toronto, ON, Canada; David Forner, MD, MSc, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, NS, Canada; Jonathan C. Irish, MD, MSc, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; John Kim, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; Zain Husain, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Alyson Mahar, PhD, Department of Community Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada; Irene Karam, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Danny J. Enepekides, MD, MPH, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Kelvin K. W. Chan, MD, MSc, PhD, and Simron Singh,MD, MPH, Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Julie Hallet, MD, MSc, and Natalie G. Coburn, MD, MPH, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; and Antoine Eskander, MD, ScM, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Antoine Eskander
- Christopher W. Noel, MD, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Rinku Sutradhar, PhD, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada; Haoyu Zhao, MPH, and Victoria Delibasic, BHSc, ICES, Toronto, ON, Canada; David Forner, MD, MSc, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, NS, Canada; Jonathan C. Irish, MD, MSc, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; John Kim, MD, Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; Zain Husain, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Alyson Mahar, PhD, Department of Community Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada; Irene Karam, MD, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Danny J. Enepekides, MD, MPH, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Kelvin K. W. Chan, MD, MSc, PhD, and Simron Singh,MD, MPH, Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Julie Hallet, MD, MSc, and Natalie G. Coburn, MD, MPH, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; and Antoine Eskander, MD, ScM, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada, ICES, Toronto, ON, Canada, Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| |
Collapse
|
35
|
Fatima K, Dasgupta A, DiCenzo D, Kolios C, Quiaoit K, Saifuddin M, Sandhu M, Bhardwaj D, Karam I, Poon I, Husain Z, Sannachi L, Czarnota GJ. Ultrasound delta-radiomics during radiotherapy to predict recurrence in patients with head and neck squamous cell carcinoma. Clin Transl Radiat Oncol 2021; 28:62-70. [PMID: 33778174 PMCID: PMC7985224 DOI: 10.1016/j.ctro.2021.03.002] [Citation(s) in RCA: 7] [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: 12/23/2020] [Revised: 02/23/2021] [Accepted: 03/07/2021] [Indexed: 12/24/2022] Open
Abstract
PURPOSE This study investigated the use of quantitative ultrasound (QUS) obtained during radical radiotherapy (RT) as a radiomics biomarker for predicting recurrence in patients with node-positive head-neck squamous cell carcinoma (HNSCC). METHODS Fifty-one patients with HNSCC were treated with RT (70 Gy/33 fractions) (±concurrent chemotherapy) were included. QUS Data acquisition involved scanning an index neck node with a clinical ultrasound device. Radiofrequency data were collected before starting RT, and after weeks 1, and 4. From this data, 31 spectral and related-texture features were determined for each time and delta (difference) features were computed. Patients were categorized into two groups based on clinical outcomes (recurrence or non-recurrence). Three machine learning classifiers were used for the development of a radiomics model. Features were selected using a forward sequential selection method and validated using leave-one-out cross-validation. RESULTS The median follow up for the entire group was 38 months (range 7-64 months). The disease sites involved neck masses in patients with oropharynx (39), larynx (5), carcinoma unknown primary (5), and hypopharynx carcinoma (2). Concurrent chemotherapy and cetuximab were used in 41 and 1 patient(s), respectively. Recurrence was seen in 17 patients. At week 1 of RT, the support vector machine classifier resulted in the best performance, with accuracy and area under the curve (AUC) of 80% and 0.75, respectively. The accuracy and AUC improved to 82% and 0.81, respectively, at week 4 of treatment. CONCLUSION QUS Delta-radiomics can predict higher risk of recurrence with reasonable accuracy in HNSCC.Clinical trial registration: clinicaltrials.gov.in identifier NCT03908684.
Collapse
Key Words
- AAC, Average acoustic concentration
- ACE, Attenuation co-efficient estimate
- ASD, Average scatterer diameter
- AUC, Area under the curve
- Acc, Accuracy
- CON, Contrast
- COR, Correlation
- CR, Complete responders
- CT, Computed tomography
- Delta-radiomics
- EBV, Epstein-Barr virus
- ENE, Energy
- FDG-PET, 18F-fluorodeoxyglucose positron emission tomography
- FLD, Fisher’s linear discriminant
- FN, False negative
- FP, False positive
- GLCM, Grey level co-occurrence matrix
- HN, Head and neck
- HNSCC, Head and neck squamous cell carcinoma
- HOM, Homogeneity
- HPV, Human papillomavirus
- Head and neck malignancy
- IGRT, Image-guided radiation therapy
- IMRT, Intensity-modulated radiation therapy
- MBF, Mid-band fit
- MRI, Magnetic resonance imaging
- Machine learning
- NR, Non-recurrence
- PET, Positron emission tomography
- PR, Partial responders
- QUS, Quantitative ultrasound
- Quantitative ultrasound
- R, Recurrence
- RF, Radiofrequency
- RFS, Recurrence-free survival
- ROI, Region of interest
- RT, Radiotherapy
- Radiomics
- Radiotherapy squamous cell carcinoma
- Recurrence
- SAS, Spacing among scatterers
- SI, Spectral intercept
- SP, Specificity
- SS, Spectral slope
- SVM, Support vector machine
- Sn, Sensitivity
- TN, True negative
- TP, True positive
- US, Ultrasound
- kNN, k nearest neighbors
Collapse
Affiliation(s)
- Kashuf Fatima
- Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Archya Dasgupta
- Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Daniel DiCenzo
- Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | | | - Karina Quiaoit
- Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | | | - Michael Sandhu
- Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Divya Bhardwaj
- Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Irene Karam
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Ian Poon
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Zain Husain
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | | | - Gregory J. Czarnota
- Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Canada
| |
Collapse
|
36
|
Nguyen TK, Sahgal A, Detsky J, Atenafu EG, Myrehaug S, Tseng CL, Husain Z, Heyn C, Maralani P, Ruschin M, Perry J, Soliman H. Predictors of leptomeningeal disease following hypofractionated stereotactic radiotherapy for intact and resected brain metastases. Neuro Oncol 2021; 22:84-93. [PMID: 31412120 DOI: 10.1093/neuonc/noz144] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The objective was to evaluate the risk and predictors of developing leptomeningeal disease (LMD) in patients with brain metastases treated with 5-fraction hypofractionated stereotactic radiotherapy (HSRT). METHODS Patients treated with HSRT for intact brain metastases and/or surgical cavities were reviewed from a prospectively maintained database. Radiographic patterns of LMD were classified as focal classical, diffuse classical, focal nodular, and diffuse nodular. RESULTS HSRT was delivered, most commonly 30 Gy in 5 fractions, to 320 intracranial lesions (57% intact and 43% surgical cavities) in 235 patients. The median follow-up was 13.4 months (range, 0.8 to 60 mo). LMD developed in 19% of patients with a 1-year LMD rate of 12%. From the diagnosis of LMD, the median overall survival (OS) was 3.8 months (range, 2-20.8 mo). The most common LMD pattern was diffuse nodular (44%). No difference in OS was observed between LMD patterns (P = 0.203). Multivariable analysis identified surgical cavities at significantly higher risk of LMD compared with intact lesions (odds ratio [OR] = 2.30, 95% CI: 1.24, 4.29, P = 0.008). For cavities, radiosensitive tumors (OR = 2.35, 95% CI: 1.04, 5.35, P = 0.041) predicted for LMD, while, for intact metastases, patients receiving treatment with targeted agents or immunotherapy (TA/I) were at lower risk (OR = 0.178, 95% CI: 0.04, 0.79, P = 0.023). CONCLUSIONS Patients who had a brain metastasis resected were at an increased risk of LMD. OS was poor despite treatment of LMD, and no differences in OS based on the pattern of LMD was observed. Treatment with TA/I was observed to be protective against LMD and requires further study.
Collapse
Affiliation(s)
- Timothy K Nguyen
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Zain Husain
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Chris Heyn
- Department of Neuroradiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Pejman Maralani
- Department of Neuroradiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - James Perry
- Department of Medicine, Division of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
37
|
Noel CW, Sutradhar R, Zhao H, Delibasic V, Forner D, Irish JC, Kim J, Husain Z, Mahar A, Karam I, Enepekides DJ, Chan KKW, Singh S, Hallet J, Coburn NG, Eskander A. Patient-Reported Symptom Burden as a Predictor of Emergency Department Use and Unplanned Hospitalization in Head and Neck Cancer: A Longitudinal Population-Based Study. J Clin Oncol 2021; 39:675-684. [PMID: 33405964 DOI: 10.1200/jco.20.01845] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
PURPOSE To determine the association between patient-reported symptom burden and subsequent emergency department use and unplanned hospitalization (ED/Hosp) in a head and neck cancer (HNC) patient population. METHODS This was a population-based study of patients diagnosed with HNC who had completed at least one outpatient Edmonton Symptom Assessment System (ESAS) assessment between January 2007 and March 2018 in Ontario, Canada. Logistic regression models were used to determine the relationship between outpatient ESAS scores and subsequent 14-day ED/Hosp use. A generalized estimating equation approach with an exchangeable correlation structure was incorporated to account for patient-level clustering. RESULTS There were 11,761 patients identified, completing a total of 73,282 ESAS assessments and experiencing 5,203 ED/Hosp events. Six of the nine ESAS symptom scores were positively associated with ED/Hosp use, with pain, appetite, shortness of breath, and tiredness demonstrating the strongest associations. A global ESAS score was calculated by selecting the highest individual symptom score (h-ESAS). Among patients reporting a maximum h-ESAS score of 10, 15.1% had an ED/Hosp event within 14 days compared with 1.5% for those with the lowest possible score of zero. In adjusted analysis, the odds of ED/Hosp use increased with h-ESAS (1.23 per one-unit increase [95% CI, 1.22 to 1.25]). When treated as a categorical variable, patients with the maximum h-ESAS score of 10 had 9.23 (95% CI, 7.22 to 11.33) higher odds of ED/Hosp use, relative to the minimum score of zero. CONCLUSION ESAS scores are strongly associated with subsequent ED/Hosp events in patients with HNC. Clinician education around how ESAS data might inform patient care may enhance symptom detection and management.
Collapse
Affiliation(s)
- Christopher W Noel
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - Rinku Sutradhar
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | | | | | - David Forner
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jonathan C Irish
- Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Jonathan Kim
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Zain Husain
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Alyson Mahar
- Department of Community Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Irene Karam
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Danny J Enepekides
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kelvin K W Chan
- Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Simron Singh
- Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Julie Hallet
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Natalie G Coburn
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Antoine Eskander
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| |
Collapse
|
38
|
Dasgupta A, Fatima K, DiCenzo D, Bhardwaj D, Quiaoit K, Saifuddin M, Karam I, Poon I, Husain Z, Tran WT, Sannachi L, Czarnota GJ. Quantitative ultrasound radiomics in predicting recurrence for patients with node-positive head-neck squamous cell carcinoma treated with radical radiotherapy. Cancer Med 2020; 10:2579-2589. [PMID: 33314716 PMCID: PMC8026932 DOI: 10.1002/cam4.3634] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 06/25/2020] [Revised: 11/05/2020] [Accepted: 11/05/2020] [Indexed: 12/24/2022] Open
Abstract
This prospective study was conducted to investigate the role of quantitative ultrasound (QUS) radiomics in predicting recurrence for patients with node‐positive head‐neck squamous cell carcinoma (HNSCC) treated with radical radiotherapy (RT). The most prominent cervical lymph node (LN) was scanned with a clinical ultrasound device having central frequency of 6.5 MHz. Ultrasound radiofrequency data were processed to obtain 7 QUS parameters. Color‐coded parametric maps were generated based on individual QUS spectral features corresponding to each of the smaller units. A total of 31 (7 primary QUS and 24 texture) features were obtained before treatment. All patients were treated with radical RT and followed according to standard institutional practice. Recurrence (local, regional, or distant) served as an endpoint. Three different machine learning classifiers with a set of maximally three features were used for model development and tested with leave‐one‐out cross‐validation for nonrecurrence and recurrence groups. Fifty‐one patients were included, with a median follow up of 38 months (range 7–64 months). Recurrence was observed in 17 patients. The best results were obtained using a k‐nearest neighbor (KNN) classifier with a sensitivity, specificity, accuracy, and an area under curve of 76%, 71%, 75%, and 0.74, respectively. All the three features selected for the KNN model were texture features. The KNN‐model‐predicted 3‐year recurrence‐free survival was 81% and 40% in the predicted no‐recurrence and predicted‐recurrence groups, respectively. (p = 0.001). The pilot study demonstrates pretreatment QUS‐radiomics can predict the recurrence group with an accuracy of 75% in patients with node‐positive HNSCC. Clinical trial registration: clinicaltrials.gov.in identifier NCT03908684.
Collapse
Affiliation(s)
- Archya Dasgupta
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada.,Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Kashuf Fatima
- Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Daniel DiCenzo
- Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Divya Bhardwaj
- Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Karina Quiaoit
- Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | | | - Irene Karam
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Ian Poon
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Zain Husain
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - William T Tran
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada.,Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | | | - Gregory J Czarnota
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada.,Physical Sciences, Sunnybrook Research Institute, Toronto, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Canada
| |
Collapse
|
39
|
Malik NH, Kim MS, Chen H, Poon I, Husain Z, Eskander A, Boldt G, Louie AV, Karam I. Stereotactic Radiation Therapy for De Novo Head and Neck Cancers: A Systematic Review and Meta-Analysis. Adv Radiat Oncol 2020; 6:100628. [PMID: 33665492 PMCID: PMC7897759 DOI: 10.1016/j.adro.2020.11.013] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 11/12/2020] [Indexed: 12/19/2022] Open
Abstract
Purpose Stereotactic body radiation therapy (SBRT) for de novo (previously untreated) head and neck cancers (HNCs) is increasingly being used in medically unfit patients. A systematic review of SBRT was conducted for previously untreated HNCs. Methods and Materials Medline (PubMed), excerpta medica database, and Cochrane Library databases were queried from inception until July 2020. Comparative outcome data were extracted where available up to 5 years. Results from random-effect models were presented in forest plots, with between-study heterogeneity evaluated by I2 statistics and Q-tests. Results Nine studies met inclusion criteria, representing 157 patients. Local control rates at 1, 2, and 3 years were as follows: 90.7% (95% confidence interval, 80.6%-95.6%), 81.8% (67.2%-90.7%), and 73.5% (40.4%-90.5%), respectively. Overall survival at 1, 2, and 3 years was 75.9% (75.1%-76.6%), 61.1% (60.3%-61.9%), and 50.0% (48.8%-51.4%), respectively. Late grade 3 to 4 toxicity rate was 3.3% (0.2%-10.2%), and late grade 5 toxicity rate was 0.1% (0.0%-1.0%). Conclusions SBRT for de novo HNC is safe and effective in providing locoregional control, with acceptable toxicities in most subsites. This finding warrants broader validation to guide its scope.
Collapse
Affiliation(s)
- Nauman H. Malik
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Michael S. Kim
- Department of Radiation Oncology, Nova Scotia Cancer Centre, Dalhousie University, Halifax, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Ian Poon
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Zain Husain
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Antoine Eskander
- Department of Otolaryngology–Head and Neck Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Gabriel Boldt
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Alexander V. Louie
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Irene Karam
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
- Corresponding author: Irene Karam, MD
| |
Collapse
|
40
|
Noel CW, Forner D, Wu V, Enepekides D, Irish JC, Husain Z, Chan KKW, Hallet J, Coburn N, Eskander A. Predictors of surgical readmission, unplanned hospitalization and emergency department use in head and neck oncology: A systematic review. Oral Oncol 2020; 111:105039. [PMID: 33141060 DOI: 10.1016/j.oraloncology.2020.105039] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 07/21/2020] [Revised: 09/18/2020] [Accepted: 10/04/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To identify predictors of unplanned hospitalization and emergency department (ED) use among head and neck oncology patients. METHODS Peer reviewed publications were identified through a systematic search of MEDLINE, Embase and Cochrane CENTRAL. Studies describing a cohort of HNC patients that detailed predictors of unplanned hospitalization or ED use in risk-adjusted models were eligible for inclusion. The methodologic quality of included studies was assessed using the Quality In Prognostic Studies (QUIPS) tool and an adapted version of the GRADE framework. RESULTS Of the 932 articles identified, 39 studies met our inclusion criteria with 31/39 describing predictors of surgical readmission and 10/39 describing predictors of ED use or unplanned hospitalization during radiation/chemoradiation treatment. Risk factors were classified into either 'patient-related', 'cancer severity' or 'process' factors. In the subset of studies looking at readmission following surgery wound complications (10/14 studies), presence of comorbidity (16/28 studies), low socioeconomic status (8/17 studies), cancer stage (9/14 studies), and prolonged hospital stay (7/18 studies) were the variables most frequently associated with readmission on multivariable analysis. Presence of comorbidity (6/10) and chemotherapy use (4/10) were more frequently associated with ED use and unplanned hospitalization. CONCLUSIONS Several consistent predictors have been identified across a variety of studies. This work is a critical first step towards the development of readmission and ED prediction models. It also enables meaningful comparison of hospital readmission rates with risk adjustment in HNC patients.
Collapse
Affiliation(s)
- Christopher W Noel
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - David Forner
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Vincent Wu
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Danny Enepekides
- Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jonathan C Irish
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada; Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Zain Husain
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kelvin K W Chan
- Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Canadian Centre for Applied Research in Cancer Control, Toronto, Ontario, Canada
| | - Julie Hallet
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Natalie Coburn
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | - Antoine Eskander
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada.
| |
Collapse
|
41
|
Stewart J, Sahgal A, Lee Y, Soliman H, Tseng CL, Detsky J, Husain Z, Ho L, Das S, Maralani PJ, Lipsman N, Stanisz G, Perry J, Chen H, Atenafu EG, Campbell M, Lau AZ, Ruschin M, Myrehaug S. Quantitating Interfraction Target Dynamics During Concurrent Chemoradiation for Glioblastoma: A Prospective Serial Imaging Study. Int J Radiat Oncol Biol Phys 2020; 109:736-746. [PMID: 33068687 DOI: 10.1016/j.ijrobp.2020.10.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/18/2020] [Accepted: 10/05/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE Magnetic resonance image (MRI) guided radiation therapy has the potential to improve outcomes for glioblastoma by adapting to tumor changes during radiation therapy. This study quantifies interfraction dynamics (tumor size, position, and geometry) based on sequential magnetic resonance imaging scans obtained during standard 6-week chemoradiation. METHODS AND MATERIALS Sixty-one patients were prospectively imaged with gadolinium-enhanced T1 (T1c) and T2/FLAIR axial sequences at planning (Fx0), fraction 10 (Fx10), fraction 20 (Fx20), and 1 month after the final fraction of chemoradiation therapy (P1M). Gross tumor volumes (GTVs) and clinical target volumes (CTVs) were contoured at all time points. Target dynamics were quantified by absolute volume (V), volume relative to Fx0 (Vrel), and the migration distance (dmigrate; the linear displacement of the GTV or CTV relative to Fx0). Temporal changes were assessed using a linear mixed-effects model. RESULTS Median volumes at Fx0, Fx10, Fx20, and P1M for the GTV were 18.4 cm3 (range, 1.1-110.5 cm3), 14.7 cm3 (range, 0.9-115.1 cm3), 13.7 cm3 (range, 0.6-174.2 cm3), and 13.0 cm3 (range, 0.9-76.3 cm3), respectively, with corresponding median Vrel of 0.88 at Fx10, 0.77 at Fx20, and 0.71 at P1M relative to Fx0 (P < .001 for all). The GTV (CTV) migration distances were greater than 5 mm in 46% (54%) of patients at Fx10, 50% (58%) of patients at Fx20, and 52% (57%) of patients at P1M. Dynamic tumor morphologic changes were observed, with 40% of patients exhibiting a decreased GTV (Vrel ≤1) with a dmigrate >5 mm during chemoradiation therapy. CONCLUSIONS Clinically meaningful tumor dynamics were observed during chemoradiation therapy for glioblastoma, supporting evaluation of daily MRI guided radiation therapy and treatment plan adaptation.
Collapse
Affiliation(s)
- James Stewart
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Young Lee
- Department of Radiation Oncology, University of Toronto, Toronto, Canada; Department of Medical Physics, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Zain Husain
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Ling Ho
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
| | - Sunit Das
- Division of Neurosurgery and Centre for Ethics, St. Michael's Hospital, Toronto, Canada; The Arthur and Sonia Labatt Brain Tumour Research Centre, SickKids Hospital, Toronto, Canada; Division of Neurosurgery, University of Toronto, Toronto, Canada
| | - Pejman Jabehdar Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Nir Lipsman
- Division of Neurosurgery, University of Toronto, Toronto, Canada; Department of Physical Sciences, Sunnybrook Research Institute, Toronto, Canada; Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Greg Stanisz
- Department of Physical Sciences, Sunnybrook Research Institute, Toronto, Canada; Department of Medical Biophysics University of Toronto, Toronto, Canada; Department of Neurosurgery and Pediatric Neurosurgery, Medical University, Lublin, Poland
| | - James Perry
- Division of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, University Health Network, University of Toronto, Toronto, Canada
| | - Mikki Campbell
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada
| | - Angus Z Lau
- Department of Physical Sciences, Sunnybrook Research Institute, Toronto, Canada; Department of Medical Biophysics University of Toronto, Toronto, Canada
| | - Mark Ruschin
- Department of Radiation Oncology, University of Toronto, Toronto, Canada; Department of Medical Physics, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
| | - Sten Myrehaug
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada.
| |
Collapse
|
42
|
Detsky JS, Nguyen TK, Lee Y, Atenafu E, Maralani P, Husain Z, Tseng CL, Myrehaug S, Soliman H, Sahgal A. Mature Imaging-Based Outcomes Supporting Local Control for Complex Reirradiation Salvage Spine Stereotactic Body Radiotherapy. Neurosurgery 2020; 87:816-822. [PMID: 32374852 DOI: 10.1093/neuros/nyaa109] [Citation(s) in RCA: 9] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 02/16/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Upon progression after upfront radiotherapy to spinal metastases, low-dose re-irradiation conventional external beam radiation (cEBRT) provides limited clinical benefit. Spine stereotactic body radiotherapy (SBRT) allows for dose escalation in the salvage setting with the potential for improved local control. OBJECTIVE To report mature clinical and imaging-based outcomes for salvage SBRT. METHODS A retrospective review was undertaken of consecutive patients with spinal metastases treated with re-irradiation spine SBRT having failed either cEBRT (n = 60 with 1 prior course and n = 17 with 2 or more prior cEBRT courses), or prior SBRT (n = 6) to the same spinal segment. The primary outcome was local failure (LF), and secondary outcomes included overall survival (OS) and the rate of vertebral compression fracture (VCF). RESULTS A total of 43 patients with 83 spinal segments treated with salvage SBRT were reviewed. The crude risk of LF was 18%, and actuarial LF rates at 6, 12, and 24 mo were 7%, 14%, and 19%, respectively. The presence of extensive paraspinal disease (hazard ratio [HR] = 7.1, 95% CI 1.5-34) significantly predicted for LF. The median OS was 13.2 (95% CI 6.1-16.3) mo, and the presence of neurological deficits (HR = 4.7, 95% CI 1.8-12.1) and brain metastases (HR = 2.6, 95% CI 1.1-6.3) were significant prognostic factors. The crude risk of VCF was 4%, and radiation myelopathy was not observed. CONCLUSION These data support the safety and efficacy of spinal re-irradiation with SBRT including patients with prior SBRT and multiple courses of prior cEBRT.
Collapse
Affiliation(s)
- Jay S Detsky
- Department of Radiation Oncology, Odette Cancer Center, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Timothy K Nguyen
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario
| | - Young Lee
- Department of Radiation Oncology, Odette Cancer Center, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Eshetu Atenafu
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, Ontario
| | - Pejman Maralani
- Medical Imaging, Odette Cancer Center, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Zain Husain
- Department of Radiation Oncology, Odette Cancer Center, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Chia-Lin Tseng
- Department of Radiation Oncology, Odette Cancer Center, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Sten Myrehaug
- Department of Radiation Oncology, Odette Cancer Center, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Center, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Center, Sunnybrook Health Sciences Centre, Toronto, Ontario
| |
Collapse
|
43
|
Zeng KL, Husain Z, Soliman H, Myrehaug S, Tseng CL, Detsky J, Lee Y, Campbell M, Foster M, Atenafu E, Maralani P, Sahgal A. 35: Imaging-Based Local Control Rates for “Radioresistant” Spinal Metastases Following Spine Stereotactic Body Radiotherapy Using Prostate Cancer as The “Radiosensitive” Reference. Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(20)30927-0] [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: 11/16/2022]
|
44
|
Siu J, Fuller K, Nadler A, Pugash R, Cohen L, Deutsch K, Enepekides D, Karam I, Husain Z, Chan K, Singh S, Poon I, Higgins K, Xu B, Eskander A. Metastasis to gastrostomy sites from upper aerodigestive tract malignancies: a systematic review and meta-analysis. Gastrointest Endosc 2020; 91:1005-1014.e17. [PMID: 31926149 DOI: 10.1016/j.gie.2019.12.045] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 12/26/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Metastasis to the gastrostomy site in patients with upper aerodigestive tract (UADT) malignancies is a rare but devastating adverse event that has been poorly described. Our aim was to determine the overall incidence and clinicopathologic characteristics observed with development of gastrostomy site metastasis in patients with UADT cancers. METHODS This was a systematic review and meta-analysis of 6138 studies retrieved from Medline, EMBASE, CINAHL, and the Cochrane Register after being queried for studies including gastrostomy site metastasis in patients with UADT malignancies. RESULTS The final analysis included 121 studies. Pooled analysis showed an overall event rate gastrostomy site metastasis of .5% (95% confidence interval [CI], .4%-.7%). Subgroup analysis showed an event rate of .56% (95% CI, .40%-.79%) with the pull technique and .29% (95% CI, .15%-.55%) with the push technique. Clinicopathologic characteristics observed with gastrostomy site metastasis were late-stage disease (T3/T4) (57.8%), positive lymph node status (51.2%), and no evidence of systemic disease (M0) (62.8%) at initial presentation. The average time from gastrostomy placement to diagnosis of metastasis was 7.78 ± 4.9 months, average tumor size on detection was 4.65 cm (standard deviation, 2.02), and average length of survival was 7.26 months (standard deviation, 6.23). CONCLUSIONS Gastrostomy site metastasis is a rare but serious adverse event that occurs at an overall rate of .5%, particularly in patients with advanced-stage disease, and is observed with a very poor prognosis. These findings emphasize a need for clinical practice guidelines to include a regular assessment of the PEG site and highlight the importance of detection and management of gastrostomy site metastasis by the multidisciplinary care oncology team.
Collapse
Affiliation(s)
- Jennifer Siu
- Department of Otolaryngology-Head and Neck Cancer Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Kaitlin Fuller
- Gerstein Science Information Centre, University of Toronto Libraries, Toronto, Ontario, Canada
| | - Ashlie Nadler
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Robyn Pugash
- Vascular/Interventional Radiology, Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Lawrence Cohen
- Division of Gastroenterology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Konrado Deutsch
- Department of Otolaryngology-Head and Neck Cancer Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Danny Enepekides
- Department of Otolaryngology-Head and Neck Cancer Surgery, University of Toronto, Toronto, Ontario, Canada; Head & Neck Surgical Oncology, University of Toronto, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Irene Karam
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Zain Husain
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kelvin Chan
- Division of Medical Oncology, University of Toronto, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Canadian Centre for Applied Research in Cancer Control, Toronto, Canada
| | - Simron Singh
- Division of Medical Oncology, University of Toronto, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Ian Poon
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kevin Higgins
- Department of Otolaryngology-Head and Neck Cancer Surgery, University of Toronto, Toronto, Ontario, Canada; Head & Neck Surgical Oncology, University of Toronto, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Bin Xu
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Antoine Eskander
- Department of Otolaryngology-Head and Neck Cancer Surgery, University of Toronto, Toronto, Ontario, Canada; Head & Neck Surgical Oncology, University of Toronto, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Otolaryngology-Head & Neck Surgery, Surgical Oncology, Michael Garron Hospital, Toronto, Ontario, Canada; Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Science, Toronto, Ontario, Canada
| |
Collapse
|
45
|
Faruqi S, Ruschin M, Soliman H, Myrehaug S, Zeng KL, Husain Z, Atenafu E, Tseng CL, Das S, Perry J, Maralani P, Heyn C, Mainprize T, Sahgal A. Adverse Radiation Effect After Hypofractionated Stereotactic Radiosurgery in 5 Daily Fractions for Surgical Cavities and Intact Brain Metastases. Int J Radiat Oncol Biol Phys 2020; 106:772-779. [DOI: 10.1016/j.ijrobp.2019.12.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 11/05/2019] [Accepted: 12/02/2019] [Indexed: 11/25/2022]
|
46
|
Nichols AC, Lang P, Prisman E, Berthelet E, Tran E, Hamilton S, Wu J, Fung K, de Almeida JR, Bayley A, Goldstein DP, Eskander A, Husain Z, Bahig H, Christopoulous A, Hier M, Sultanem K, Richardson K, Mlynarek A, Krishnan S, Le H, Yoo J, MacNeil SD, Mendez A, Winquist E, Read N, Venkatesan V, Kuruvilla S, Warner A, Mitchell S, Corsten M, Rajaraman M, Johnson-Obaseki S, Eapen L, Odell M, Chandarana S, Banerjee R, Dort J, Matthews TW, Hart R, Kerr P, Dowthwaite S, Gupta M, Zhang H, Wright J, Parker C, Wehrli B, Kwan K, Theurer J, Palma DA. Treatment de-escalation for HPV-associated oropharyngeal squamous cell carcinoma with radiotherapy vs. trans-oral surgery (ORATOR2): study protocol for a randomized phase II trial. BMC Cancer 2020; 20:125. [PMID: 32059705 PMCID: PMC7023689 DOI: 10.1186/s12885-020-6607-z] [Citation(s) in RCA: 40] [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: 12/20/2019] [Accepted: 02/06/2020] [Indexed: 11/28/2022] Open
Abstract
Background Patients with human papillomavirus-positive (HPV+) oropharyngeal squamous cell carcinoma (OPC) have substantially better treatment response and overall survival (OS) than patients with HPV-negative disease. Treatment options for HPV+ OPC can involve either a primary radiotherapy (RT) approach (± concomitant chemotherapy) or a primary surgical approach (± adjuvant radiation) with transoral surgery (TOS). These two treatment paradigms have different spectrums of toxicity. The goals of this study are to assess the OS of two de-escalation approaches (primary radiotherapy and primary TOS) compared to historical control, and to compare survival, toxicity and quality of life (QOL) profiles between the two approaches. Methods This is a multicenter phase II study randomizing one hundred and forty patients with T1–2 N0–2 HPV+ OPC in a 1:1 ratio between de-escalated primary radiotherapy (60 Gy) ± concomitant chemotherapy and TOS ± de-escalated adjuvant radiotherapy (50–60 Gy based on risk factors). Patients will be stratified based on smoking status (< 10 vs. ≥ 10 pack-years). The primary endpoint is OS of each arm compared to historical control; we hypothesize that a 2-year OS of 85% or greater will be achieved. Secondary endpoints include progression free survival, QOL and toxicity. Discussion This study will provide an assessment of two de-escalation approaches to the treatment of HPV+ OPC on oncologic outcomes, QOL and toxicity. Results will inform the design of future definitive phase III trials. Trial Registration Clinicaltrials.gov identifier: NCT03210103. Date of registration: July 6, 2017, Current version: 1.3 on March 15, 2019.
Collapse
Affiliation(s)
- Anthony C Nichols
- Department of Otolaryngology - Head and Neck Surgery, Western University, London, ON, Canada
| | - Pencilla Lang
- Department of Radiation Oncology, London Health Sciences Centre, Western University, 800 Commissioners Rd. E, London, Ontario, N6A 5W9, Canada
| | - Eitan Prisman
- Division of Otolaryngology - Head and Neck Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Eric Berthelet
- Department of Radiation Oncology, University of British Columbia, Vancouver, BC, Canada
| | - Eric Tran
- Department of Radiation Oncology, University of British Columbia, Vancouver, BC, Canada
| | - Sarah Hamilton
- Department of Radiation Oncology, University of British Columbia, Vancouver, BC, Canada
| | - Jonn Wu
- Department of Radiation Oncology, University of British Columbia, Vancouver, BC, Canada
| | - Kevin Fung
- Department of Otolaryngology - Head and Neck Surgery, Western University, London, ON, Canada
| | - John R de Almeida
- Department of Otolaryngology - Head and Neck Surgery, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Andrew Bayley
- Department of Radiation Oncology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - David P Goldstein
- Department of Otolaryngology - Head and Neck Surgery, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Antoine Eskander
- Department of Otolaryngology - Head and Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Zain Husain
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Houda Bahig
- Department of Radiation Oncology, CHUM, Université de Montréal, Montreal, QC, Canada
| | - Apostolos Christopoulous
- Department of Otorhinolaryngology - Head and Neck Surgery, CHUM, Université de Montréal, Montreal, QC, Canada
| | - Michael Hier
- Department of Otolaryngology - Head and Neck Surgery, McGill University, Montreal, QC, Canada
| | - Khalil Sultanem
- Department of Radiation Oncology, McGill University, Montreal, QC, Canada
| | - Keith Richardson
- Department of Otolaryngology - Head and Neck Surgery, McGill University, Montreal, QC, Canada
| | - Alex Mlynarek
- Department of Otolaryngology - Head and Neck Surgery, McGill University, Montreal, QC, Canada
| | - Suren Krishnan
- Department of Otolaryngology - Head and Neck Surgery, Royal Adelaide Hospital, Adelaide, Australia
| | - Hien Le
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, Australia
| | - John Yoo
- Department of Otolaryngology - Head and Neck Surgery, Western University, London, ON, Canada
| | - S Danielle MacNeil
- Department of Otolaryngology - Head and Neck Surgery, Western University, London, ON, Canada
| | - Adrian Mendez
- Department of Otolaryngology - Head and Neck Surgery, Western University, London, ON, Canada
| | - Eric Winquist
- Department of Medical Oncology, Western University, London, ON, Canada
| | - Nancy Read
- Department of Radiation Oncology, London Health Sciences Centre, Western University, 800 Commissioners Rd. E, London, Ontario, N6A 5W9, Canada
| | - Varagur Venkatesan
- Department of Radiation Oncology, London Health Sciences Centre, Western University, 800 Commissioners Rd. E, London, Ontario, N6A 5W9, Canada
| | - Sara Kuruvilla
- Department of Medical Oncology, Western University, London, ON, Canada
| | - Andrew Warner
- Department of Radiation Oncology, London Health Sciences Centre, Western University, 800 Commissioners Rd. E, London, Ontario, N6A 5W9, Canada
| | - Sylvia Mitchell
- Department of Radiation Oncology, London Health Sciences Centre, Western University, 800 Commissioners Rd. E, London, Ontario, N6A 5W9, Canada
| | - Martin Corsten
- Division of Otolaryngology - Head and Neck Surgery, Dalhousie University, Halifax, NS, Canada
| | - Murali Rajaraman
- Division of Otolaryngology - Head and Neck Surgery, Dalhousie University, Halifax, NS, Canada
| | | | - Libni Eapen
- Department of Radiation Oncology, University of Ottawa, Ottawa, ON, Canada
| | - Michael Odell
- Department of Otolaryngology - Head and Neck Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Shamir Chandarana
- Section of Otolaryngology - Head and Neck Surgery, University of Calgary, Calgary, AB, Canada
| | - Robyn Banerjee
- Department of Radiation Oncology, University of Calgary, Calgary, AB, Canada
| | - Joseph Dort
- Section of Otolaryngology - Head and Neck Surgery, University of Calgary, Calgary, AB, Canada
| | - T Wayne Matthews
- Section of Otolaryngology - Head and Neck Surgery, University of Calgary, Calgary, AB, Canada
| | - Robert Hart
- Section of Otolaryngology - Head and Neck Surgery, University of Calgary, Calgary, AB, Canada
| | - Paul Kerr
- Department of Otolaryngology, University of Manitoba, Winnipeg, MB, Canada
| | - Samuel Dowthwaite
- Department of Otolaryngology - Head and Neck Surgery, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Michael Gupta
- Division of Otolaryngology - Head and Neck Surgery, McMaster University, Hamilton, ON, Canada
| | - Han Zhang
- Division of Otolaryngology - Head and Neck Surgery, McMaster University, Hamilton, ON, Canada
| | - Jim Wright
- Department of Radiation Oncology, McMaster University, Hamilton, ON, Canada
| | - Christina Parker
- Department of Audiology, London Health Sciences Centre, London, ON, Canada
| | - Bret Wehrli
- Department of Pathology, Western University, London, ON, Canada
| | - Keith Kwan
- Department of Pathology, Western University, London, ON, Canada
| | - Julie Theurer
- School of Communication Sciences and Disorders, Western University, London, ON, Canada
| | - David A Palma
- Department of Radiation Oncology, London Health Sciences Centre, Western University, 800 Commissioners Rd. E, London, Ontario, N6A 5W9, Canada.
| |
Collapse
|
47
|
Tom MC, Joshi N, Vicini F, Chang AJ, Hong TS, Showalter TN, Chao ST, Wolden S, Wu AJ, Martin D, Husain Z, Badiyan SN, Kolar M, Sherertz T, Mourtada F, Cohen GN, Shah C. The American Brachytherapy Society consensus statement on intraoperative radiation therapy. Brachytherapy 2019; 18:242-257. [PMID: 31084904 DOI: 10.1016/j.brachy.2019.01.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [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: 12/29/2018] [Accepted: 01/30/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE Although radiation therapy has traditionally been delivered with external beam or brachytherapy, intraoperative radiation therapy (IORT) represents an alternative that may shorten the course of therapy, reduce toxicities, and improve patient satisfaction while potentially lowering the cost of care. At this time, there are limited evidence-based guidelines to assist clinicians with patient selection for IORT. As such, the American Brachytherapy Society presents a consensus statement on the use of IORT. METHODS Physicians and physicists with expertise in intraoperative radiation created a site-directed guideline for appropriate patient selection and utilization of IORT. RESULTS Several IORT techniques exist including radionuclide-based high-dose-rate, low-dose-rate, electron, and low-energy electronic. In breast cancer, IORT as monotherapy should only be used on prospective studies. IORT can be considered in the treatment of sarcomas with close/positive margins or recurrent sarcomas. IORT can be considered in conjunction with external beam radiotherapy for retroperitoneal sarcomas. IORT can be considered for colorectal malignancies with concern for positive margins and in the setting of recurrent gynecologic cancers. For thoracic, head and neck, and central nervous system malignancies, utilization of IORT should be evaluated on a case-by-case basis. CONCLUSIONS The present guidelines provide clinicians with a summary of current data regarding IORT by treatment site and guidelines for the appropriate patient selection and safe utilization of the technique. High-dose-rate, low-dose-rate brachytherapy methods are appropriate when IORT is to be delivered as are electron and low-energy based on the clinical scenario.
Collapse
Affiliation(s)
- Martin C Tom
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, OH
| | - Nikhil Joshi
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, OH
| | - Frank Vicini
- 21st Century Oncology, Michigan Healthcare Professionals, Farmington Hills, MI
| | | | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA
| | - Samuel T Chao
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, OH
| | - Suzanne Wolden
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Abraham J Wu
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Douglas Martin
- Department of Radiation Oncology, Ohio State University, Columbus, OH
| | - Zain Husain
- Department of Therapeutic Radiology, Yale University, New Haven, CT
| | - Shahed N Badiyan
- Department of Radiation Oncology, Washington University, St. Louis, MO
| | - Matthew Kolar
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, OH
| | - Tracy Sherertz
- Department of Radiation Oncology, Kaiser Capitol Hill, Seattle, WA
| | - Firas Mourtada
- Helen F. Graham Cancer Center & Research Institute, Christiana Care Health System, Newark, DE
| | - Gilad N Cohen
- Department Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, OH.
| |
Collapse
|
48
|
Zhan KY, Puram SV, Li MM, Silverman DA, Agrawal AA, Ozer E, Old MO, Carrau RL, Rocco JW, Higgins KM, Enepekides DJ, Husain Z, Kang SY, Eskander A. National treatment trends in human papillomavirus–positive oropharyngeal squamous cell carcinoma. Cancer 2019; 126:1295-1305. [DOI: 10.1002/cncr.32654] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/13/2019] [Accepted: 11/15/2019] [Indexed: 12/24/2022]
Affiliation(s)
- Kevin Y. Zhan
- Division of Head and Neck Oncology, Department of Otolaryngology–Head and Neck Surgery James Cancer Center and Solove Research Institute, Ohio State University Columbus Ohio
| | - Sidharth V. Puram
- Division of Head and Neck Oncology, Department of Otolaryngology–Head and Neck Surgery James Cancer Center and Solove Research Institute, Ohio State University Columbus Ohio
| | - Michael M. Li
- Division of Head and Neck Oncology, Department of Otolaryngology–Head and Neck Surgery James Cancer Center and Solove Research Institute, Ohio State University Columbus Ohio
| | - Dustin A. Silverman
- Division of Head and Neck Oncology, Department of Otolaryngology–Head and Neck Surgery James Cancer Center and Solove Research Institute, Ohio State University Columbus Ohio
| | - Amit A. Agrawal
- Division of Head and Neck Oncology, Department of Otolaryngology–Head and Neck Surgery James Cancer Center and Solove Research Institute, Ohio State University Columbus Ohio
| | - Enver Ozer
- Division of Head and Neck Oncology, Department of Otolaryngology–Head and Neck Surgery James Cancer Center and Solove Research Institute, Ohio State University Columbus Ohio
| | - Matthew O. Old
- Division of Head and Neck Oncology, Department of Otolaryngology–Head and Neck Surgery James Cancer Center and Solove Research Institute, Ohio State University Columbus Ohio
| | - Ricardo L. Carrau
- Division of Head and Neck Oncology, Department of Otolaryngology–Head and Neck Surgery James Cancer Center and Solove Research Institute, Ohio State University Columbus Ohio
| | - James W. Rocco
- Division of Head and Neck Oncology, Department of Otolaryngology–Head and Neck Surgery James Cancer Center and Solove Research Institute, Ohio State University Columbus Ohio
| | - Kevin M. Higgins
- Department of Otolaryngology–Head and Neck Surgery Sunnybrook Health Sciences Centre University of Toronto Toronto Ontario Canada
| | - Danny J. Enepekides
- Department of Otolaryngology–Head and Neck Surgery Sunnybrook Health Sciences Centre University of Toronto Toronto Ontario Canada
| | - Zain Husain
- Department of Radiation Oncology Sunnybrook Health Sciences Centre and Odette Cancer Centre University of Toronto Toronto Ontario Canada
| | - Stephen Y. Kang
- Division of Head and Neck Oncology, Department of Otolaryngology–Head and Neck Surgery James Cancer Center and Solove Research Institute, Ohio State University Columbus Ohio
| | - Antoine Eskander
- Department of Otolaryngology–Head and Neck Surgery Sunnybrook Health Sciences Centre University of Toronto Toronto Ontario Canada
- Institute of Health Policy, Management, and Evaluation University of Toronto Toronto Ontario Canada
| |
Collapse
|
49
|
Miccio JA, Verma V, Kelly J, Kann BH, An Y, Park HS, Eskander A, Burtness B, Husain Z. Impact of contralateral lymph nodal involvement and extranodal extension on survival of surgically managed HPV-positive oropharyngeal cancer staged with the AJCC eighth edition. Oral Oncol 2019; 99:104447. [DOI: 10.1016/j.oraloncology.2019.104447] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/08/2019] [Accepted: 10/09/2019] [Indexed: 10/25/2022]
|
50
|
Hellyer J, Padda S, Vali S, Das A, Sikora H, Husain Z, Kumar A, Abbasi T, Wakelee H. P1.15-02 Role of mTOR Inhibitor Everolimus in the Treatment of Metastatic Thymic Epithelial Tumors. J Thorac Oncol 2019. [DOI: 10.1016/j.jtho.2019.08.1215] [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: 10/25/2022]
|