Acute toxicity of postoperative IMRT and chemotherapy for endometrial cancer

Purpose The aim of this study was to determine the acute toxicity of postoperative intensity-modulated radiotherapy (IMRT) with and without chemotherapy in patients with endometrial cancer. Materials and methods A total of 19 patients with stages IB–IVB endometrial cancer who underwent surgery and postoperative IMRT were reviewed. The treatment planning goal was to cover the tissue at risk and minimize the dose to the bladder, bowel, and bone marrow. Median dose was 50.4 Gy (range 49.6–51.2 Gy). Altogether, 14 patients underwent chemotherapy; most were given carboplatin and paclitaxel. Toxicity was scored according to the Common Terminology Criteria for Adverse Events version 3.0 (CTCAE). Results The prescribed radiation treatment was completed in all patients. The prescribed cycles of chemotherapy were completed in all 14 patients, except one who received five of six cycles limited by prolonged thrombocytopenia. Chemotherapy was delayed in two patients (14%). Three patients required growth factor support during chemotherapy, and one patient required a blood transfusion. Acute grades 3–4 hematological toxicity occurred in 9 of the 14 patients (64%) who underwent chemotherapy. None experienced acute grade 3 or 4 genitourinary or gastrointestinal toxicity. Conclusion Adjuvant IMRT and chemotherapy following surgery in patients with endometrial cancer is well tolerated and did not lead to treatment modification in most patients.     

Rectal wall MRI radiomics in prostate cancer patients: prediction of and correlation with early rectal toxicity

Purpose: To investigate MRI radiomic analysis to assess IMRT associated rectal wall changes and also for predicting radiotherapy induced rectal toxicity.

Material and methods: At first, a machine learning radiomic analysis was applied on T2-weighted (T2W) and apparent diffusion coefficient (ADC) rectal wall MR images of prostate cancer patients’ pre- and post-IMRT to predict rectal toxicity. Next, Wilcoxon singed ranked test was performed to find radiomic features with significant changes pre- and post-IMRT. A logistic regression classifier was used to find correlation between features with significant changes and radiation toxicity. Area under the curve (AUC) of receiver operating characteristic (ROC) curve was used in two levels of study for finding performances.

Results: AUC_mean, 0.68?±?0.086 and 0.61?±?0.065 were obtained for pre- and post-IMRT T2 radiomic models, respectively. For ADC radiomic models, AUC_mean was 0.58?±?0.034 for pre-IMRT and was 0.56?±?0.038 for post-IMRT. Wilcoxon-signed rank test revealed that 9 T2 radiomic features vary significantly post-IMRT. The AUC of logistic-regression was in the range of 0.46–0.58 for single significant features and was 0.81 when all significant features were combined.

Conclusions: Pre-IMRT MR image radiomic features could predict rectal toxicity in prostate cancer patients. Radiotherapy associated complications may be assessed by studying the changes in the MR radiomic features.     

Hyaluronic acid gel injection in rectovaginal septum reduced incidence of rectal bleeding in brachytherapy for gynecological malignancies

PurposeThe purpose of this study was to report our initial clinical results of hyaluronic acid gel injection (HGI) in the rectovaginal septum (RVS) to reduce the incidence of rectal bleeding in vaginal brachytherapy for gynecologic malignancies.Methods and MaterialsSince 2008, CT based image-guided adaptive brachytherapy (IGABT) was initiated, and since 2015, HGI in the RVS was introduced in our institution. Vaginal cylinder with or without tandem or additional interstitial needles were applied for patients with gynecologic malignancies. Rectum dosimetric parameters and incidence of late rectum bleeding were compared between patients with and without HGI in the RVS.ResultsBetween May 2008 and October 2017, 83 patients with gynecologic malignancies were treated with IGABT involving vaginal cylinder. Eleven patients who were treated for palliative intention were excluded, and 72 patients were subjected to the analysis. Of the total 72 patients 46 were with uterine cervical cancer, 19 uterine corpus cancer, five vaginal cancer, one vulvar cancer, and one ovarian cancer. Fifteen and 57 patients were irradiated with and without HGI in the RVS, respectively. With a median follow-up period of 57.7 (4.7–123.1) months, 30 (41.7%) patients suffered from radiation-related rectal bleeding. Patients with HGI in the RVS had a statistically significant lower incidence of rectal bleeding compared with those without it (13.3% vs. 49.1%, p = 0.01).ConclusionsHGI in the RVS reduced the incidence of late rectal bleeding for patients with gynecologic malignancies treated by vaginal cylinder and was not associated with HGI-procedure-related adverse events.     

左侧乳腺癌根治术后调强放疗中剂量累加的研究

目的 通过形变配准及刚性配准进行左侧乳腺癌放疗中靶区及危及器官剂量累加的研究,探讨二者受量的变化规律。方法 回顾分析16例女性左侧乳腺癌根治术后患者,靶区包括锁上淋巴结引流区加胸壁,均采用6 MV X射线调强放疗（IMRT）。所有患者均接受定位、二程CT扫描,在定位图像（CT1）上制定放疗计划为Plan1,在二程定位图像（CT2）上制定放疗计划为Plan2。利用Velocity软件将Plan2的剂量进行刚性、形变配准到CT1剂量累加后获得Plan-rigid、Plan-deform。比较4个计划中靶区及危及器官的剂量学差异。结果 CT2比CT1的CTV体积平均缩小6.64%;形变后靶区剂量均匀性指数（HI）提高23.05%,而形变后心脏、左、右肺戴斯相似系数（DSC）均低于形变前（0.94±0.01 vs.0.89±0.05、0.96±0.01 vs.0.91±0.03、0.96±0.01 vs.0.92±0.03）,且差异均有统计学意义（Z=-3.208、-3.533、-3.535,P<0.05）;心脏及左肺各剂量-体积指标在Plan2、Plan-rigid、Plan-deform与Plan1的组间差异均无统计学意义（P>0.05）;在Plan-rigid组各剂量-体积指标均高于Plan-deform组。结论 靶区及危及器官体积、剂量-体积指标变化较小的左乳癌根治术后患者在进行放疗剂量累加时,推荐使用刚性配准,且初次调强计划的剂量-体积指标可基本反映双肺及心脏的受量情况。     

直肠癌静态调强与容积旋转调强放疗计划的剂量学对比研究

目的 对比研究直肠癌术后患者应用静态调强放疗(IMRT)和容积旋转调强放疗(VMAT)的计划质量、治疗效率和剂量精度,为临床治疗技术的选择提供参考依据.方法 选择10例直肠癌术后调强放疗患者,行CT模拟定位并勾画靶区及危及器官,在同一计划系统上给予相同处方剂量和目标优化条件,分别设计5野IMRT计划和双弧VMAT计划.比较两种计划的靶区(PTV/CTV)受量、适形指数(CI)、均匀指数(HI)、危及器官(OAR)的受量、机器跳数、治疗计划执行时间,以及剂量验证通过率.结果 两种治疗计划均能满足临床剂量要求,VMAT计划的靶区剂量覆盖率略低于IMRT计划.VMAT和IMRT计划的HI分别为0.095和0.101,差异无统计学意义(t=2.61, P>0.05);而IMRT计划的CI(0.737)优于VMAT计划(0.614)(t=4.94, P<0.05),考虑为VMAT计划优化过程中对周围正常组织低剂量区受量限制过于严格,从而造成计划的适形度受到影响.VMAT计划中正常组织如膀胱、股骨头的低剂量区较之IMRT计划均有不同程度增加.VMAT和IMRT计划的平均机器跳数(MUs)分别为599和515(t=4.72, P<0.05),相应的治疗时间分别为201和304 s(t=5.83, P<0.05).使用Delta⁴对两种计划进行验证,γ通过率(选用3%/3 mm标准)分别为VMAT 93.13%和IMRT 96.00%(t=3.75, P<0.05).结论 直肠癌VMAT和IMRT 计划均可满足临床要求,VMAT计划可以显著降低治疗时间,提高治疗效率,但其疗效还需进一步临床评估.     

Changes in insurance coverage for cancer patients receiving brachytherapy before and after enactment of the Affordable Care Act

Purpose

The Patient Protection and Affordable Care Act called for expansion of Medicaid in 2014. As some states elected to expand Medicaid and others did not, the goal of this study was to determine the effect of Medicaid expansion on the insurance status at cancer diagnosis of brachytherapy patients.

上胸段食管癌调强放射治疗中淋巴结意外照射的剂量学研究

目的比较上胸段食管癌容积旋转调强放射治疗(VMAT)与5野的静态调强放射治疗(5F-IMRT)在淋巴结意外照射中的剂量学差异,评估两种方式在上胸段食管癌放射治疗中的剂量学特点。方法选取20例典型的上胸段食管癌患者,在进行靶区勾画时,肿瘤区(GTV)、临床靶区(CTV)不包含所有淋巴结,而将淋巴结单独勾画作为正常组织。对这20例患者分别制定两套计划,即VMAT与5F-IMRT,主要的计划评估参数为靶区的适形指数(CI)、均匀指数(HI),以及接受相应处方剂量水平照射体积百分比V95、V110;危及器官(OAR)评估包括肺的Dmean、V5、V20、V30,心脏的Dmean、V25,脊髓的Dmax,机器调数(MU)。同时评估各个淋巴结的等效均衡剂量(EUD)与接受40 Gy照射剂量的体积百分比V40。结果5F-IMRT计划在V95%上具有较高的计划靶区(PTV)剂量覆盖率(t=-9.4,P<0.05),VMAT计划的适形指数(CI)优于5F-IMRT(t=-5.3,P<0.05);5F-IMRT计划较VMAT计划降低平均肺V510.9%(t=-7.8,P<0.05),降低平均脊髓Dmax 9%(t=-10.2,P<0.05);VMAT计划较5F-IMRT计划降低平均MU 18.6%(t=-6.2,P<0.05);5F-IMRT计划在所有上胸段淋巴结区域的平均EUD值为32.3~61.5 Gy,较VMAT计划(32.5~61.1 Gy)提高4.7%,平均V40提高2.4%。各个上胸段淋巴结区域除左气管支气管淋巴结(106tbL)外的意外照射剂量,与PTV的体积大小充分相关(R=0.716~0.933,P<0.05)。结论5F-IMRT的放射治疗计划在上胸段食管癌淋巴结意外照射中更具剂量学优势,且肿瘤靶区较大的患者淋巴结区域具有更高的辐射剂量。     

Comparative analysis of rectal dose parameters in image-guided high-dose-rate brachytherapy for cervical cancer with and without a rectal retractor

PurposeThe objective of this study was to determine if use of a rectal retractor (RR) in high-dose-rate intracavitary brachytherapy for cervical cancer reduces rectal dose parameters.Methods and MaterialsWe reviewed data obtained from patients treated with intracavitary brachytherapy for cervical cancer with and without an RR. Treatment plans for each brachytherapy fraction were separated into two groups; R group with use of an RR and P group with use of vaginal packing. Dose–volume parameters for high-risk clinical target volume (HR-CTV), rectum, sigmoid, small bowel, and vaginal surface were collected for each fraction. Rectal D_2cc and International Commission on Radiation Units & Measurements (ICRU) rectal point doses were compared between groups using Student's t tests. Predictors of higher rectal D_2cc were determined by univariate and multivariate regression analyses.ResultsFour hundred sixty-three brachytherapy fractions from 114 patients were used for analysis, 377 fractions with a RR (R group) and 86 with vaginal packing only (P group). Both groups were similar except for slightly higher mean HR-CTV and mean bladder volume in P group. Both mean ICRU rectal point dose (241.1 vs. 269.9 cGy, p = 0.006) and rectal D_2cc (240.6 vs. 283.6 cGy, p < 0.001) were significantly higher in P group. Point A dose, HR-CTV, stage, and use of an RR were significant predictors of rectal D_2cc on multivariate analysis.ConclusionsOur data show that use of an RR leads to lower rectal dose parameters compared with vaginal packing. Further study is needed to determine if this will lead to less long-term toxicity.     

不同淋巴结转移状况的鼻咽癌调强放疗中腮腺和肿瘤靶区体积退缩与受照剂量的相关性

目的 探讨鼻咽癌调强放疗中,不同淋巴结转移状况的腮腺和肿瘤靶区体积退缩与受照剂量的相关性,以便确定再次计划最佳时间。方法 选择30例接受调强放疗的鼻咽癌患者,根据颈部淋巴结直径大小将患者分为3组,分别是淋巴结阴性组(A组),淋巴结≤3 cm阳性组(B组),淋巴结>3 cm阳性组(C组)。初始定位CT命名为CT₀,每位患者在同一体位下每周重新扫描一次CT,即患者第5、10、15、20、25和32次治疗前行日常验证扫描图像获得CT₁、CT₂、CT₃、CT₄、CT₅、CT₆。结果 CT₀显示3组腮腺初始体积大小差异无统计学意义(P>0.05)。与A组相比,B组在CT₄以后腮腺体积开始缩小,差异有统计学意义(t=2.12~2.46,P<0.05);C组CT₂以后体积差异具有统计学意义(t=2.19~3.25,P<0.05)。各组内分次体积与初始体积CT₀相比,A组、B组在CT₃以后体积开始缩小,差异有统计学意义(t=2.16~4.11,P<0.05);C组在CT₂以后就有差异(t=2.37~5.20,P<0.05);C组CT₄与CT₂比较,差异也具有统计学意义(t=2.16、3.34,P<0.05)。结论 出于保护腮腺的考虑,淋巴结较大的患者有必要提前修改计划,建议在第10次放疗重新计划,可能在第20次放疗需要再次计划;淋巴结阴性或者很小的患者建议在第15次修改计划。     

Clinical utility and value contribution of an MRI-positive line marker for image-guided brachytherapy in gynecologic malignancies

PurposeThe purpose of this study was to investigate the utility of a novel MRI-positive line marker, composed of C4:S (cobalt chloride–based contrast agent) encapsulated in high-density polyethylene tubing, in permitting dosimetry and treatment planning directly on MRI.Methods and MaterialsWe evaluated the clinical feasibility of the C4:S line markers in nine sequential brachytherapy procedures for gynecologic malignancies, including six tandem-and-ovoid and three interstitial cases. We then quantified the internal resource utilization of an intraoperative MRI-guided procedural episode via time-driven activity-based costing, identifying opportunities for cost-containment with use of the C4:S line markers.ResultsThe C4:S line markers demonstrated the strongest positive signal visibility on 3D constructive interference in steady state (CISS)/FIESTA-C followed by T1-weighted sequences, permitting accurate delineation of the applicator lumen and thus the source path. These images may be fused along with traditional T2-weighted sequences for optimal tumor and anatomy contouring, followed by treatment planning directly on MRI. By eliminating postoperative CT for fusion and applicator registration from the procedural episode, use of the C4:S line markers could decrease workflow time and lower total delivery costs per procedure.ConclusionsThis analysis supports the clinical utility and value contribution of the C4:S line markers, which permit accurate MRI-based dosimetry and treatment planning, thereby eliminating the need for postoperative CT for fusion and applicator registration.     

应用锥形束CT对宫颈癌及子宫内膜癌术后放疗位置误差的研究

目的 通过对宫颈癌及子宫内膜癌术后放射治疗患者位置误差的分析,确定临床靶区（CTV）外扩计划靶区（PTV）边界值的大小。方法 选取26例宫颈癌及子宫内膜癌术后放疗患者通过千伏级锥形束CT（kV-CBCT）采集初次治疗前和以后每周的CT影像,与治疗计划采用的CT影像进行比对,记录各方向位置误差值并计算PTV外扩边界值M_PTV。 结果 宫颈癌及子宫内膜癌术后患者放疗时各方向均存在位置误差,患者在左右、头脚和前后方向误差分别为（0.21±3.23）、（0.55±3.51）和（0.08±2.76）mm,头脚方向的系统误差最大,左右方向次之、前后方向最小。各方向位置误差无明显差异。靶区在左右、头脚和前后方向依次需外扩5.44、7.26和5.68 mm。 结论 建议在进行宫颈癌及子宫内膜癌术后放疗时外扩PTV间距依次为左右方向5.5 mm、头脚方向7.5 mm、前后方向6 mm。     

局部进展期直肠癌新辅助调强放化疗中盆腔骨髓剂量体积参数与急性血液学不良反应的关系

目的探索直肠癌新辅助调强放化疗患者骨盆骨髓剂量体积参数(Vx)与急性血液学不良反应(HT)的相关性, 为降低放疗相关的血液不良反应风险, 优化放疗计划提供临床数据。方法回顾性分析2017年10月至2019年5月在贵州医科大学附属肿瘤医院行新辅助同步放化疗(CCRT)的41例局部进展期直肠癌(LARC)患者。所有患者均行5野调强放疗(IMRT), 计划靶区(PTV)的处方剂量为45～50.4 Gy/25～28次。放疗期间同步卡培他滨或5-氟尿嘧啶(5-FU)化疗。根据通用不良反应标准5.0 (NCI-CTC.V 5.0)评估放疗期间的急性HT。采用logistic回归分析评估骨盆(髋骨、骶骨、股骨)骨髓低剂量受照体积Vx与急性HT的关系, 采用广义相加模型(GAM)和分段回归分析进一步确定两者之间的非线性关系和阈值效应。结果多因素logistic回归分析显示, 骨盆骨髓低剂量(V5、V10)受照总体积(TV)、髋骨骨髓受照体积(CV)与≥2度白细胞降低存在显著相关性(P<0.05)。骶骨骨髓低剂量(V5、V10)受照体积(SV)与≥2度白细胞降低存在显著负相关(P<0.05)...     

Use of a rectal spacer with low-dose-rate brachytherapy for treatment of prostate cancer in previously irradiated patients: Initial experience and short-term results

BackgroundSalvage brachytherapy in patients with prior pelvic radiation carries a risk of rectal injury. Herein, we report our initial experience using a hydrogel spacer between the prostate and the rectum during salvage brachytherapy.Methods and MaterialsA total of 11 patients with prostate cancer and prior radiotherapy (5 prostate brachytherapy, 2 prostate external beam radiation therapy [EBRT], and 4 rectal cancer EBRT) received ¹²⁵I brachytherapy after attempted placement of 10 cc of a diluted hydrogel spacer between the prostate and rectum.ResultsSpacing was achieved in 8 of the 11 (73%) patients but was not possible in 3 (1 prior brachytherapy and 2 prior EBRT) owing to fibrosis and adhesions. For the 8 patients in whom spacing was accomplished, the median space between the prostate and rectum was 10.9 mm (prior EBRT) vs. 7.7 mm (prior brachytherapy), p = 0.048. Median followup was 15.7 months. One patient developed a prostato-rectal fistula requiring a diverting colostomy. The 16-month estimate of late Grade 3 or 4 gastrointestinal or genitourinary toxicity was 26%. One patient developed lymph node–positive recurrence. The 16-month prostate-specific antigen failure-free survival rate was 89%. Compared with baseline, Expanded Prostate Cancer Index Composite for Clinical Practice urinary quality of life (QoL) was significantly worse at 3 and 6 months but not significantly worse by 1 year. There were no significant changes throughout the study period in bowel or sexual QoL.ConclusionHydrogel spacer placements may be feasible in most patients with prior pelvic radiation. Further followup is needed to determine whether spacer placement will produce long-term improvements in toxicity or QoL.     

Normal limits for left ventricular ejection fraction and volumes estimated with gated myocardial perfusion imaging in patients with normal exercise test results: Influence of tracer, gender, and acquisition camera

BACKGROUND: Myocardial imaging with tracers such as technetium-99m sestamibi or thallium-201 is extensively used as a means of measuring myocardial perfusion. With gated acquisition, these tracers can also be used as a means of measuring left ventricular ejection fraction (EF) and end diastolic and end systolic volumes (EDV and ESV, respectively). The objective of this study was to determine the normal range of EF, EDV, and ESV and to evaluate differences caused by either the tracer used, the gender of the patient, or the acquisition camera used. METHODS AND RESULTS: A total of 1513 consecutive patients (mean age, 60+/-12 years [SD]) who had normal results on Bruce exercise tests had either Tc-99m sestamibi (n = 884) or Tl-201 (n = 629) injected at peak stress. Although all patients were referred for the evaluation of chest pain or dyspnea and many had cardiac risk factors, all had normal exercise capacity corrected for age, no electrocardiographic signs of ischemia, normal results on perfusion scans, and normal wall motion determined by means of quantitated gated single photon emission computed tomography (QGS). Scans were acquired on 1 of 3 different cameras. The mean EF for all patients who had gated Tc-99m sestamibi scans was 63% +/- 9%, not different from patients who had gated Tl-201 scans (63% +/- 9%). However, when the gender of the patient was considered, the mean EF for women was 66% +/- 8% with Tc-99m sestamibi (n = 519), higher than the mean EF for men (58% +/- 8%, n = 365, P<.0001). Similarly, the mean EF for women studied with Tl-201 (67% +/- 8%, n = 326) was higher than that of men (59% +/- 7%, n = 303,P<.0001). Patients with diabetes mellitus (n = 153) had a slightly reduced EF (62% +/- 10%, P<.001). In a subset of 240 patients, 140 patients studied with Tc-99m sestamibi and 100 studied with Tl-201, the EDV and ESV for women (n = 124) was estimated by means of QGS to be lower (57 +/- 17 mL and 19 +/- 11 mL, respectively) than those for men (74 +/- 22 mL-and 29 +/- 13 mL, respectively; n = 116; P<.001 for each comparison). No clinically significant differences in EF or volumes were noted based on tracers used or acquisition camera. For patients with normal results on exercise treadmill tests and perfusion imaging, the lower limit of normal for EF with gated perfusion imaging with QGS was 50% for women and 43% for men. For EDV and ESV, the upper limit of normal was 91 mL and 40 mL, respectively, for women and 119 mL and 55 mL, respectively, for men. CONCLUSIONS: No significant differences related to either tracer or acquisition camera used were noted for EF, suggesting equivalency for clinical trials for patients with normal results on exercise tests. However, EF, EDV, and ESV determined by means of gated perfusion imaging need to be corrected for gender.     

乳腺癌改良根治术患者血清CYFRA21 1、TK1及CA15 3水平变化及其与术后复发的相关性研究

目的探讨乳腺癌改良根治术患者血清细胞角蛋白19片段（cytokeratin 19 fragment,CYFRA21-1）、胸苷激酶1（thymidine kinase 1,TK1）及癌抗原15-3（cancer antigen 15-3,CA15-3）水平变化及其与术后复发的相关性。方法选取2015年1月—2017年8月成都医学院第一附属医院行乳腺癌改良根治术患者125例作为乳腺癌组,选取同期体检的年龄、性别匹配的健康体检者125例作为对照组,检测乳腺癌组改良根治术前后及对照组血清CYFRA21-1、TK1及CA15-3水平,根据乳腺癌术后有无复发分复发组和未复发组,比较2组患者血清CYFRA21-1、TK1及CA15-3水平。结果乳腺癌TNM-Ⅰ期患者CYFRA21-1、TK1、CA15-3水平低于TNM Ⅱ期、Ⅲa期患者（P＜0.05）;TNM Ⅱ期低于Ⅲa期患者,差异有统计学意义（P＜0.05）;乳腺癌组术后CYFRA21-1、TK1、CA15-3水平低于术前（P＜0.05）,乳腺癌组手术前后CYFRA21-1、TK1、CA15-3水平均高于对照组,差异有统计学意义（P＜0.05）;截止随访时间29例复发,复发率23.2%。复发组血清CYFRA21 1、TK1、CA15-3水平显著高于未复发组,差异有统计学意义（P＜0.05）,Logistic回归分析显示,血清CYFRA21-1、TK1、CA15-3水平与术后复发存在关联性（P＜0.05）;ROC曲线分析显示,CYFRA21-1、TK1、CA15-3联合预测乳腺癌术后复发的特异度、敏感度高于单一指标检测。结论乳腺癌改良根治术后血清CYFRA21-1、TK1、CA15-3水平与术后复发有关。