RESUMEN
BACKGROUND: There is a discrepancy about the metastatic rate of internal mammary lymph nodes (IMNs) between clinical and pathologic findings. We aimed to investigate the metastatic rate of IMNs and to provide recommendations on target volume delineation of IMNs for adjuvant radiotherapy in breast cancer patients. METHODS: We retrospectively analyzed data from 114 breast cancer patients treated with surgery without adjuvant radiotherapy who developed local and/or regional lymph node recurrence/metastasis at our institute from January 2015 to January 2019. Patients with widely lung or pleural metastases were excluded. We first analyzed the recurrence rate with the chest wall, the metastatic rate of internal mammary/anterior mediastinal, ipsilateral axillary and supraclavicular lymph nodes, and then investigated the distribution of the IMNs. RESULTS: Among the 114 included patients, the recurrence rate with the chest wall, metastatic rate of IMNs, IMNs/anterior mediastinal lymph nodes, ipsilateral axillary lymph nodes, and the ipsilateral supraclavicular lymph nodes was 43, 37.7, 59.6, 12.3, and 22.8%, respectively. The metastatic IMNs were mainly located from the first to the second intercostal space. However, metastatic lymph nodes could also be observed above the upper edge of the first rib. CONCLUSIONS: The metastatic rate is high in the IMNs and irradiation of the internal mammary lymphatic chain is required. It is suggested that the upper bound of the internal mammary lymphatic chain should be up to the subclavian vein with a 5-mm margin, thus connecting to the caudal border of supraclavicular clinical target volume in breast cancer patients at high risk of recurrence.
Asunto(s)
Neoplasias de la Mama/patología , Ganglios Linfáticos/patología , Irradiación Linfática/normas , Recurrencia Local de Neoplasia/patología , Planificación de la Radioterapia Asistida por Computador/métodos , Radioterapia Adyuvante/métodos , Adulto , Anciano , Axila , Neoplasias de la Mama/radioterapia , Neoplasias de la Mama/cirugía , Femenino , Humanos , Incidencia , Metástasis Linfática , Mastectomía/métodos , Mediastino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/epidemiología , Estadificación de Neoplasias , Estudios RetrospectivosRESUMEN
PURPOSE: The ongoing phase 2/3 PRODIGE 26/CONCORDE trial compares chemoradiation therapy with and without dose escalation in patients with locally advanced or unresectable esophageal cancer. The results of a benchmark case procedure are reported here to evaluate the protocol compliance of participating centers as part of quality assurance for radiation therapy. METHODS AND MATERIALS: Volume delineation, target coverage, and dose constraints to the organs at risk (OARs) were assessed on treatment plans of a common benchmark case performed by each participating center. The centers were classified in 3 categories: per protocol, minor acceptable deviation (MiD), or major unacceptable deviation (MaD). A plan was rejected if ≥4 MiDs or 1 MaD were found. RESULTS: Thirty-5 centers submitted 43 plans. Among them, 14 (32.6%) were per protocol, 19 (44.2%) presented at least 1 MiD, 2 (4.6%) presented at least 1 MaD, and 8 (18.6%) presented both MiD and MaD. Overall, 11 (25.6%) plans were rejected. Only 1 plan was rejected because gross tumor volume was not correctly delineated. The OAR delineation was respected in all cases. Dose constraints to the OARs were respected in the majority of cases except for the heart, where one-third of the plans presented a deviation. As for the target volume, 3 plans (5.8%) had a major underdosage and 1 plan (1.9%) had a major overdosage. Overall, 58% of all treatments were planned with intensity modulated radiation therapy, whereas 42% were planned with 3-dimensional chemoradiation therapy. Significantly more plans in the intensity modulated radiation therapy group were accepted compared with the 3-dimensional chemoradiation therapy group (P = .03). CONCLUSION: The high frequency of protocol deviations underlines the importance of a quality assurance program in clinical trials. Further work should assess the impact of quality assurance for radiation therapy on patient outcomes.
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Carcinoma de Células Escamosas/diagnóstico por imagen , Quimioradioterapia/normas , Neoplasias Esofágicas/diagnóstico por imagen , Órganos en Riesgo/diagnóstico por imagen , Garantía de la Calidad de Atención de Salud , Planificación de la Radioterapia Asistida por Computador/normas , Radioterapia de Intensidad Modulada/normas , Anciano , Protocolos de Quimioterapia Combinada Antineoplásica/administración & dosificación , Benchmarking , Instituciones Oncológicas/clasificación , Instituciones Oncológicas/normas , Carcinoma de Células Escamosas/patología , Carcinoma de Células Escamosas/terapia , Quimioradioterapia/métodos , Cisplatino/administración & dosificación , Esquema de Medicación , Neoplasias Esofágicas/patología , Neoplasias Esofágicas/terapia , Fluorouracilo/administración & dosificación , Francia , Adhesión a Directriz/clasificación , Adhesión a Directriz/normas , Adhesión a Directriz/estadística & datos numéricos , Corazón/efectos de la radiación , Humanos , Riñón/diagnóstico por imagen , Leucovorina/administración & dosificación , Hígado/diagnóstico por imagen , Pulmón/diagnóstico por imagen , Ganglios Linfáticos/diagnóstico por imagen , Ganglios Linfáticos/patología , Irradiación Linfática/métodos , Irradiación Linfática/normas , Masculino , Compuestos Organoplatinos/administración & dosificación , Órganos en Riesgo/efectos de la radiación , Dosificación Radioterapéutica , Planificación de la Radioterapia Asistida por Computador/clasificación , Planificación de la Radioterapia Asistida por Computador/estadística & datos numéricos , Radioterapia Conformacional/normas , Médula Espinal/diagnóstico por imagen , Carga TumoralRESUMEN
The advent of sentinel lymph node technique has led to a shift in lymph node staging, due to the emergence of new entities, namely micrometastases and isolated tumour cells. In addition, the therapeutic role of axillary lymph node dissection is more and more questioned and radiotherapy has been shown to be equivalent to complementary axillary lymph node dissection in patients without clinical node involvement. This article looks at the literature in favour of performing axillary irradiation in patients with pN1mi stage breast cancer who have undergone a mastectomy without a complementary axillary lymph node dissection, and in favour of abstention of any further treatment of the axilla in patients with pN0(i+) or pN1mi tumours who have undergone breast conserving surgery and a sentinel lymph node procedure followed by systemic treatment. The impact of regional lymph nodes irradiation in case of axillary involvement 2mm or less is also discussed.
Asunto(s)
Neoplasias de la Mama/patología , Neoplasias de la Mama/radioterapia , Irradiación Linfática , Femenino , Humanos , Irradiación Linfática/normas , Estadificación de NeoplasiasRESUMEN
PURPOSE: Recently, involved-site radiation therapy (ISRT) guidelines have been developed and published to replace the previous concept of involved-field radiation therapy for patients with lymphoma. However, these ISRT guidelines may be interpreted in different ways, posing difficulties for prospective clinical trials. This study reports survey results regarding interpretation of the ISRT guidelines. METHODS AND MATERIALS: Forty-four expert lymphoma radiation oncologists were asked to participate in a survey that included 7 different cases associated with 9 questions. The questions pertained to ISRT contouring and asked respondents to choose between 2 different answers (no "correct" answer) and a third write-in option allowed. RESULTS: Fifty-two percent of those surveyed responded to the questionnaire. Among those who responded, 72% have practiced for >10 years, 46% have treated >20 Hodgkin lymphoma cases annually, and 100% were familiar with the ISRT concept. Among the 9 questions associated with the 7 cases, 3 had concordance among the expert radiation oncologists of greater than 70%. Six of the questions had less than 70% concordance (range, 56%-67%). CONCLUSIONS: Even among expert radiation oncologists, interpretation of ISRT guidelines is variable. Further guidance for ISRT field design will be needed to reduce variability among practicing physicians.
Asunto(s)
Competencia Clínica , Consenso , Enfermedad de Hodgkin/diagnóstico por imagen , Enfermedad de Hodgkin/radioterapia , Guías de Práctica Clínica como Asunto/normas , Oncología por Radiación/normas , Diafragma , Ingle , Neoplasias de Cabeza y Cuello/diagnóstico por imagen , Neoplasias de Cabeza y Cuello/radioterapia , Encuestas de Atención de la Salud , Enfermedad de Hodgkin/patología , Humanos , Ilion , Ganglios Linfáticos/patología , Irradiación Linfática/normas , Neoplasias del Mediastino/diagnóstico por imagen , Neoplasias del Mediastino/radioterapia , Estadificación de Neoplasias , Neoplasias de la Parótida/diagnóstico por imagen , Neoplasias de la Parótida/radioterapia , RadiografíaRESUMEN
PURPOSE: The Korean Radiation Oncology Group (KROG) 08-06 study protocol allowed radiation therapy (RT) technique to include or exclude breast cancer patients from receiving radiation therapy to the internal mammary lymph node (IMN). The purpose of this study was to assess dosimetric differences between the 2 groups and potential influence on clinical outcome by a dummy run procedure. METHODS AND MATERIALS: All participating institutions were asked to produce RT plans without irradiation (Arm 1) and with irradiation to the IMN (Arm 2) for 1 breast-conservation treatment case (breast-conserving surgery [BCS]) and 1 mastectomy case (modified radical mastectomy [MRM]) whose computed tomography images were provided. We assessed interinstitutional variations in IMN delineation and evaluated the dose-volume histograms of the IMN and normal organs. A reference IMN was delineated by an expert panel group based on the study guidelines. Also, we analyzed the potential influence of actual dose variation observed in this study on patient survival. RESULTS: Although physicians intended to exclude the IMN within the RT field, the data showed almost 59.0% of the prescribed dose was delivered to the IMN in Arm 1. However, the mean doses covering the IMN in Arm 1 and Arm 2 were significantly different for both cases (P<.001). Due to the probability of overdose in Arm 1, the estimated gain in 7-year disease-free survival rate would be reduced from 10% to 7.9% for BCS cases and 7.1% for MRM cases. The radiation doses to the ipsilateral lung, heart, and coronary artery were lower in Arm 1 than in Arm 2. CONCLUSIONS: Although this dummy run study indicated that a substantial dose was delivered to the IMN, even in the nonirradiation group, the dose differences between the 2 groups were statistically significant. However, this dosimetric profile should be studied further with actual patient samples and be taken into consideration when analyzing clinical outcomes according to IMN irradiation.
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Neoplasias de la Mama/terapia , Ganglios Linfáticos/efectos de la radiación , Irradiación Linfática/normas , Garantía de la Calidad de Atención de Salud/normas , Planificación de la Radioterapia Asistida por Computador/normas , Radioterapia Conformacional/normas , Supervivencia sin Enfermedad , Femenino , Humanos , Corea (Geográfico) , Metástasis Linfática , Mastectomía , Proyectos Piloto , Dosificación Radioterapéutica , Reproducibilidad de los Resultados , Proyectos de Investigación , Sensibilidad y Especificidad , Resultado del TratamientoRESUMEN
BACKGROUND: Predicting outcome of breast cancer (BC) patients based on sentinel lymph node (SLN) status without axillary lymph node dissection (ALND) is an area of uncertainty. It influences the decision-making for regional nodal irradiation (RNI). The aim of the NORA (NOdal RAdiotherapy) survey was to examine the patterns of RNI. METHODS: A web-questionnaire, including several clinical scenarios, was distributed to 88 EORTC-affiliated centers. Responses were received between July 2013 and January 2014. RESULTS: A total of 84 responses were analyzed. While three-dimensional (3D) radiotherapy (RT) planning is carried out in 81 (96%) centers, nodal areas are delineated in only 51 (61%) centers. Only 14 (17%) centers routinely link internal mammary chain (IMC) and supraclavicular node (SCN) RT indications. In patients undergoing total mastectomy (TM) with ALND, SCN-RT is recommend by 5 (6%), 53 (63%) and 51 (61%) centers for patients with pN0(i+), pN(mi) and pN1, respectively. Extra-capsular extension (ECE) is the main factor influencing decision-making RNI after breast conserving surgery (BCS) and TM. After primary systemic therapy (PST), 49 (58%) centers take into account nodal fibrotic changes in ypN0 patients for RNI indications. In ypN0 patients with inner/central tumors, 23 (27%) centers indicate SCN-RT and IMC-RT. In ypN1 patients, SCN-RT is delivered by less than half of the centers in patients with ypN(i+) and ypN(mi). Twenty-one (25%) of the centers recommend ALN-RT in patients with ypN(mi) or 1-2N+ after ALND. Seventy-five (90%) centers state that age is not considered a limiting factor for RNI. CONCLUSION: The NORA survey is unique in evaluating the impact of SLNB/ALND status on adjuvant RNI decision-making and volumes after BCS/TM with or without PST. ALN-RT is often indicated in pN1 patients, particularly in the case of ECE. Besides the ongoing NSABP-B51/RTOG and ALLIANCE trials, NORA could help to design future specific RNI trials in the SLNB era without ALND in patients receiving or not PST.
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Neoplasias de la Mama/epidemiología , Neoplasias de la Mama/radioterapia , Irradiación Linfática/normas , Guías de Práctica Clínica como Asunto/normas , Encuestas y Cuestionarios , Neoplasias de la Mama/diagnóstico , Europa (Continente)/epidemiología , Femenino , Humanos , Irradiación Linfática/métodos , Resultado del TratamientoRESUMEN
Radiation therapy (RT) is the most effective single modality for local control of non-Hodgkin lymphoma (NHL) and is an important component of therapy for many patients. Many of the historic concepts of dose and volume have recently been challenged by the advent of modern imaging and RT planning tools. The International Lymphoma Radiation Oncology Group (ILROG) has developed these guidelines after multinational meetings and analysis of available evidence. The guidelines represent an agreed consensus view of the ILROG steering committee on the use of RT in NHL in the modern era. The roles of reduced volume and reduced doses are addressed, integrating modern imaging with 3-dimensional planning and advanced techniques of RT delivery. In the modern era, in which combined-modality treatment with systemic therapy is appropriate, the previously applied extended-field and involved-field RT techniques that targeted nodal regions have now been replaced by limiting the RT to smaller volumes based solely on detectable nodal involvement at presentation. A new concept, involved-site RT, defines the clinical target volume. For indolent NHL, often treated with RT alone, larger fields should be considered. Newer treatment techniques, including intensity modulated RT, breath holding, image guided RT, and 4-dimensional imaging, should be implemented, and their use is expected to decrease significantly the risk for normal tissue damage while still achieving the primary goal of local tumor control.
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Irradiación Linfática/métodos , Linfoma no Hodgkin/patología , Linfoma no Hodgkin/radioterapia , Dosificación Radioterapéutica , Planificación de la Radioterapia Asistida por Computador/métodos , Carga Tumoral , Adulto , Terapia Combinada/métodos , Humanos , Irradiación Linfática/normas , Linfoma no Hodgkin/tratamiento farmacológico , Órganos en Riesgo , Planificación de la Radioterapia Asistida por Computador/normasRESUMEN
Standard locoregional treatment of early-stage breast cancer currently consists of the conservative surgery and sentinel lymph node biopsy. In the event of positive sentinel node biopsy, an axillary level I-II lymphadenectomy should be carried out. However, recent publications have increasingly supported a tendency not to apply the surgical lymphadenectomy, but simultaneously, it has been developed a new role of regional radiotherapy, even if there is only 1-3 axillary lymph nodes involved. Given these new trends, radiation oncologists are facing the dilemma with regard to deciding about regional irradiation of breast cancer. For such purpose, The Spanish Group of Breast Cancer Radiation Oncology (GEORM as per its Spanish acronym) decided to reach a consensus to issue the respective guidelines for such types of cases. GEORM Managing Commission, gathering 13 members of different Spanish regional communities, issued a questionnaire including different clinical situations. These questions were set as key questions seeking responses, which were answered by 66 % out of the 75 members of the group. Following the response, the guidelines were drafted based on the replies to the mentioned questionnaire. All the respective issues were discussed by means of a virtual platform. In this article, we show the levels of consensus for different clinical situations, depending on the number of nodes involved and the type of surgical procedure performed on the axillary lymph nodes. The ongoing evolution of the oncological treatments obliges the radiation oncologists to take decisions without any existing clarifying evidence, and therefore, the consensus is necessary, which can assist in the decision-making process by the practitioners in such kinds of clinical situations.
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Neoplasias de la Mama/radioterapia , Ganglios Linfáticos/efectos de la radiación , Irradiación Linfática/normas , Guías de Práctica Clínica como Asunto/normas , Radioterapia Adyuvante/normas , Axila , Consenso , Femenino , Humanos , Metástasis Linfática/radioterapia , Encuestas y CuestionariosRESUMEN
PURPOSE: Intensity-modulated radiation therapy (IMRT) is the standard of care for head-and-neck cancer (HNC). We treated patients with HNC by delivering either a moderate hypofractionation (MHF) schedule (66 Gy at 2.2 Gy per fraction to the gross tumor [primary and nodal]) with standard dose fractionation (54-60 Gy at 1.8-2.0 Gy per fraction) to the elective neck lymphatics or a conventional dose and fractionation (CDF) schedule (70 Gy at 2.0 Gy per fraction) to the gross tumor (primary and nodal) with reduced dose to the elective neck lymphatics. We analyzed these two cohorts for treatment outcomes. METHODS AND MATERIALS: Between November 2001 and February 2009, 89 patients with primary carcinomas of the oral cavity, larynx, oropharynx, hypopharynx, and nasopharynx received definitive IMRT with or without concurrent chemotherapy. Twenty patients were treated using the MHF schedule, while 69 patients were treated with the CDF schedule. Patient characteristics and dosimetry plans were reviewed. Patterns of failure including local recurrence (LR), regional recurrence (RR), distant metastasis (DM), disease-free survival (DFS), overall survival (OS), and toxicities, including rate of feeding tube placement and percentage of weight loss, were reviewed and analyzed. RESULTS: Median follow-up was 31.2 months. Thirty-five percent of patients in the MHF cohort and 77% of patients in the CDF cohort received chemotherapy. No RR was observed in either cohort. OS, DFS, LR, and DM rates for the entire group at 2 years were 89.3%, 81.4%, 7.1%, and 9.4%, respectively. Subgroup analysis showed no significant differences in OS (p = 0.595), DFS (p = 0.863), LR (p = 0.833), or DM (p = 0.917) between these two cohorts. Similarly, no significant differences were observed in rates of feeding tube placement and percentages of weight loss. CONCLUSIONS: Similar treatment outcomes were observed for MHF and CDF cohorts. A dose of 50 Gy at 1.43 Gy per fraction may be sufficient to electively treat low-risk neck lymphatics.
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Fraccionamiento de la Dosis de Radiación , Neoplasias Laríngeas/radioterapia , Irradiación Linfática/métodos , Neoplasias de la Boca/radioterapia , Neoplasias Faríngeas/radioterapia , Radioterapia de Intensidad Modulada/métodos , Adulto , Anciano , Estudios de Cohortes , Supervivencia sin Enfermedad , Nutrición Enteral/estadística & datos numéricos , Femenino , Humanos , Neoplasias Laríngeas/tratamiento farmacológico , Neoplasias Laríngeas/mortalidad , Neoplasias Laríngeas/patología , Irradiación Linfática/efectos adversos , Irradiación Linfática/normas , Masculino , Persona de Mediana Edad , Neoplasias de la Boca/tratamiento farmacológico , Neoplasias de la Boca/mortalidad , Neoplasias de la Boca/patología , Neoplasias Faríngeas/tratamiento farmacológico , Neoplasias Faríngeas/mortalidad , Neoplasias Faríngeas/patología , Radioterapia de Intensidad Modulada/efectos adversos , Radioterapia de Intensidad Modulada/mortalidad , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenRESUMEN
PURPOSE: Cure rates of early Hodgkin lymphoma (HL) are high, and avoidance of late complications and second malignancies have become increasingly important. This comparative treatment planning study analyzes to what extent target volume reduction to involved-node (IN) and intensity-modulated (IM) radiotherapy (RT), compared with involved-field (IF) and three-dimensional (3D) RT, can reduce doses to organs at risk (OAR). METHODS AND MATERIALS: Based on 20 computed tomography (CT) datasets of patients with early unfavorable mediastinal HL, we created treatment plans for 3D-RT and IMRT for both the IF and IN according to the guidelines of the German Hodgkin Study Group (GHSG). As OAR, we defined heart, lung, breasts, and spinal cord. Dose-volume histograms (DVHs) were evaluated for planning target volumes (PTVs) and OAR. RESULTS: Average IF-PTV and IN-PTV were 1705 cm(3) and 1015 cm(3), respectively. Mean doses to the PTVs were almost identical for all plans. For IF-PTV/IN-PTV, conformity was better with IMRT and homogeneity was better with 3D-RT. Mean doses to the heart (17.94/9.19 Gy for 3D-RT and 13.76/7.42 Gy for IMRT) and spinal cord (23.93/13.78 Gy for 3D-RT and 19.16/11.55 Gy for IMRT) were reduced by IMRT, whereas mean doses to lung (10.62/8.57 Gy for 3D-RT and 12.77/9.64 Gy for IMRT) and breasts (left 4.37/3.42 Gy for 3D-RT and 6.04/4.59 Gy for IMRT, and right 2.30/1.63 Gy for 3D-RT and 5.37/3.53 Gy for IMRT) were increased. Volume exposed to high doses was smaller for IMRT, whereas volume exposed to low doses was smaller for 3D-RT. Pronounced benefits of IMRT were observed for patients with lymph nodes anterior to the heart. IN-RT achieved substantially better values than IF-RT for almost all OAR parameters, i.e., dose reduction of 20% to 50%, regardless of radiation technique. CONCLUSIONS: Reduction of target volume to IN most effectively improves OAR sparing, but is still considered investigational. For the time being, IMRT should be considered for large PTVs especially when the anterior mediastinum is involved.
Asunto(s)
Enfermedad de Hodgkin/radioterapia , Irradiación Linfática/normas , Órganos en Riesgo/efectos de la radiación , Traumatismos por Radiación/prevención & control , Planificación de la Radioterapia Asistida por Computador/normas , Radioterapia de Intensidad Modulada/normas , Algoritmos , Mama/anatomía & histología , Mama/efectos de la radiación , Femenino , Alemania , Corazón/efectos de la radiación , Enfermedad de Hodgkin/patología , Humanos , Pulmón/efectos de la radiación , Irradiación Linfática/métodos , Metástasis Linfática , Masculino , Método de Montecarlo , Tratamientos Conservadores del Órgano/métodos , Guías de Práctica Clínica como Asunto/normas , Dosificación Radioterapéutica , Planificación de la Radioterapia Asistida por Computador/métodos , Radioterapia Conformacional/métodos , Radioterapia Conformacional/normas , Radioterapia de Intensidad Modulada/métodos , Médula Espinal/efectos de la radiaciónRESUMEN
PURPOSE: We have been using intensity-modulated radiotherapy (IMRT) for selective neck irradiation. This article presents an analysis of patterns of failure and their dosimetric correlation. METHODS AND MATERIALS: Between October 2003 and January 2008, 83 patients with head-and-neck cancer were treated with IMRT. Nodal levels were contoured as per the Radiation Therapy Oncology Group (RTOG) consensus guidelines. RESULTS: There were 32 relapses with 23 local relapses (21 local relapses alone and 2 local and regional relapses, simultaneously), 9 regional relapses (including 2 simultaneous local and regional relapses), and 5 distant relapses, of which 2 patients had local relapses. At 2 and 3 years, the locoregional relapse-free survival rates were was 68.3% and 60.8%, respectively, while the overall survival rates were 84.1% and 81.7%, respectively. Subgroup analyses revealed significant differences in locoregional relapse-free survival rates for total treatment times of <53 days vs. >53 days, a volume of CTV1PTV (i.e., the volume prescribed 70 Gy) <177 cc vs. >177 cc, a V100 for CTV1PTV of <91% vs. >91%, and a minimum dose to CTV1PTV of <54 Gy vs. >54 Gy. There were no failures in the elective nodal volume, substantiating both the nodal selection criteria and the RTOG consensus guidelines for delineation of neck node levels. CONCLUSIONS: IMRT for head-neck cancer is feasible, using elective nodal selection criteria along with RTOG consensus guidelines for the radiological boundaries of levels of neck nodes.
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Neoplasias de Cabeza y Cuello/radioterapia , Irradiación Linfática/métodos , Guías de Práctica Clínica como Asunto/normas , Oncología por Radiación/normas , Radioterapia de Intensidad Modulada/métodos , Adulto , Anciano , Trastornos de Deglución/etiología , Supervivencia sin Enfermedad , Femenino , Adhesión a Directriz , Neoplasias de Cabeza y Cuello/mortalidad , Neoplasias de Cabeza y Cuello/patología , Humanos , Irradiación Linfática/efectos adversos , Irradiación Linfática/normas , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/patología , Neutropenia/etiología , Traumatismos por Radiación/complicaciones , Radioterapia de Intensidad Modulada/efectos adversos , Radioterapia de Intensidad Modulada/normas , Estomatitis/etiología , Tasa de Supervivencia , Trombocitopenia/etiología , Insuficiencia del Tratamiento , Xerostomía/etiologíaRESUMEN
PURPOSE: To compare the dosimetry of target and normal tissue when tangents with the breast tissue were applied in a subset of breast cancer patients who had undergone computed tomography (CT) planning both supine and prone. METHODS AND MATERIALS: The CT images of 20 patients who had undergone simulation in supine and prone positions were used for planning. The axillary lymph node regions (level I-III), breast tissue, tumor bed, heart, and bilateral lungs were manually contoured. Standard tangent fields were designed for the whole breast to deliver a prescribed dose of 50 Gy. Dose-volume histograms were compared between the two sets. RESULTS: In each patient, coverage of breast tissue and tumor bed was readily achieved by either technique. In either position, treatment of the nodal regions was inadequate. On average, the mean dose to the nodal regions for levels I-III was approximately 50% less in the prone as compared with the supine position. The mean ipsilateral lung volume receiving 95% of the prescribed dose was 6.3% in the supine position compared to 0.43% in the prone position. When planned supine, the mean heart volume receiving 30 Gy was 0.56% compared with 0.30% in the prone position. CONCLUSIONS: Planning in either position was found to achieve adequate coverage of the breast tissue and tumor bed for all patients. Lung was better spared prone. Coverage of axillary nodes was inadequate in either position, but further reduced in the prone vs. supine position. The choice of optimal setup should take into considerations stage and risk of nodal recurrence.
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Neoplasias de la Mama/radioterapia , Irradiación Linfática/métodos , Axila , Mama/anatomía & histología , Neoplasias de la Mama/diagnóstico por imagen , Neoplasias de la Mama/patología , Estudios de Factibilidad , Femenino , Corazón/diagnóstico por imagen , Humanos , Pulmón/diagnóstico por imagen , Ganglios Linfáticos/diagnóstico por imagen , Irradiación Linfática/normas , Tamaño de los Órganos , Posición Prona , Dosificación Radioterapéutica , Planificación de la Radioterapia Asistida por Computador/métodos , Posición Supina , Tomografía Computarizada por Rayos X , Carga TumoralRESUMEN
PURPOSE: To assess doses received by mediastinal and hilar lymph node stations (LNS) delineated according to published recommendations when "standard" two-dimensional (2D) elective fields are applied and to assess doses to critical structures when fields are designed using 2D and three-dimensional (3D) treatment planning for elective irradiation. METHODS AND MATERIALS: LNS were delineated on axial CT scans according to existing recommendations. For each case and tumor location, 2D anteroposterior-posteroanterior (AP-PA) elective fields were applied using the AP-PA CT topograms. From the 2D portal fields, 3D dose distributions were then calculated to particular LNS. Next, 3D plans were prepared for elective nodal irradiation for tumors of different lobes. Doses for critical structures were compared for 2D and 3D plans. RESULTS: LNS 1/2R, 1/2L, 3A, 3P, 5, 6, and 8 were not adequately covered in a substantial part of plans by standard 2D portals when guidelines for delineation were strictly followed. The magnitude of the lack of coverage increased with margin application. There was a trend for a higher yet probably still safe dose delivered to lung for 3D plans compared with 2D plans with a prescription dose of 45 Gy. CONCLUSIONS: 2D fields did not entirely cover LNS delineated according to the recommendations for 3D techniques. A strict adherence to these guidelines may lead to larger portals than traditionally constructed using 2D methods. Some modifications for clinical implementation are discussed.
Asunto(s)
Neoplasias Pulmonares/radioterapia , Irradiación Linfática/normas , Planificación de la Radioterapia Asistida por Computador/normas , Radioterapia Conformacional/normas , Humanos , Neoplasias Pulmonares/diagnóstico por imagen , Metástasis Linfática/diagnóstico por imagen , Metástasis Linfática/radioterapia , Mediastino , Ilustración Médica , Guías de Práctica Clínica como Asunto/normas , Radiografía , Dosificación Radioterapéutica , Carga TumoralRESUMEN
PURPOSE: Radiation therapy to the pelvic lymph nodes in high-risk prostate cancer is required on several Radiation Therapy Oncology Group (RTOG) clinical trials. Based on a prior lymph node contouring project, we have shown significant disagreement in the definition of pelvic lymph node volumes among genitourinary radiation oncology specialists involved in developing and executing current RTOG trials. MATERIALS AND METHODS: A consensus meeting was held on October 3, 2007, to reach agreement on pelvic lymph node volumes. Data were presented to address the lymph node drainage of the prostate. Extensive discussion ensued to develop clinical target volume (CTV) pelvic lymph node consensus. RESULTS: Consensus was obtained resulting in computed tomography image-based pelvic lymph node CTVs. Based on this consensus, the pelvic lymph node volumes to be irradiated include: distal common iliac, presacral lymph nodes (S(1)-S(3)), external iliac lymph nodes, internal iliac lymph nodes, and obturator lymph nodes. Lymph node CTVs include the vessels (artery and vein) and a 7-mm radial margin being careful to "carve out" bowel, bladder, bone, and muscle. Volumes begin at the L5/S1 interspace and end at the superior aspect of the pubic bone. Consensus on dose-volume histogram constraints for OARs was also attained. CONCLUSIONS: Consensus on pelvic lymph node CTVs for radiation therapy to address high-risk prostate cancer was attained and is available as web-based computed tomography images as well as a descriptive format through the RTOG. This will allow for uniformity in evaluating the benefit and risk of such treatment.
Asunto(s)
Ganglios Linfáticos/diagnóstico por imagen , Irradiación Linfática/normas , Neoplasias de la Próstata/radioterapia , Oncología por Radiación/normas , Urología/normas , Humanos , Escisión del Ganglio Linfático/normas , Masculino , Pelvis , Dosificación Radioterapéutica , Recto/diagnóstico por imagen , Tomografía Computarizada por Rayos X/normas , Vejiga Urinaria/diagnóstico por imagenRESUMEN
PURPOSE: We conducted a comparative study of clinical target volume (CTV) definition of pelvic lymph nodes by multiple genitourinary (GU) radiation oncologists looking at the levels of discrepancies amongst this group. METHODS AND MATERIALS: Pelvic computed tomography (CT) scans from 2 men were distributed to 14 Radiation Therapy Oncology Group GU radiation oncologists with instructions to define CTVs for the iliac and presacral lymph nodes. The CT data with contours were then returned for analysis. In addition, a questionnaire was completed that described the physicians' method for target volume definition. RESULTS: Significant variation in the definition of the iliac and presacral CTVs was seen among the physicians. The minimum, maximum, mean (SD) iliac volumes (mL) were 81.8, 876.6, 337.6 +/- 203 for case 1 and 60.3, 627.7, 251.8 +/- 159.3 for case 2. The volume of 100% agreement was 30.6 and 17.4 for case 1 and 2 and the volume of the union of all contours was 1,012.0 and 807.4 for case 1 and 2, respectively. The overall agreement was judged to be moderate in both cases (kappa = 0.53 (p < 0.0001) and kappa = 0.48 (p < 0.0001). There was no volume of 100% agreement for either of the two presacral volumes. These variations were confirmed in the responses to the associated questionnaire. CONCLUSIONS: Significant disagreement exists in the definition of the CTV for pelvic nodal radiation therapy among GU radiation oncology specialists. A consensus needs to be developed so as to accurately assess the merit and safety of such treatment.
Asunto(s)
Ganglios Linfáticos/diagnóstico por imagen , Irradiación Linfática/normas , Neoplasias de la Próstata/diagnóstico por imagen , Oncología por Radiación/normas , Radioterapia Conformacional/normas , Carga Tumoral , Adenocarcinoma/diagnóstico por imagen , Adenocarcinoma/patología , Adenocarcinoma/radioterapia , Consenso , Humanos , Irradiación Linfática/métodos , Masculino , Persona de Mediana Edad , Pelvis/diagnóstico por imagen , Neoplasias de la Próstata/patología , Neoplasias de la Próstata/radioterapia , Radiografía , Dosificación Radioterapéutica , Recto , Vejiga Urinaria , Urología/normasRESUMEN
Thoracic radiotherapy (RT) is an integral part of the management of small-cell lung cancer (SCLC) because its administration provides a survival benefit in patients with limited-stage disease. However, there are many areas of controversy with respect to the delivery of curative RT, and these include definition of the target to be irradiated. A current area of concern is defining what the RT portal must encompass with respect to the mediastinal lymph nodes; that is, whether one should electively treat all mediastinal nodes, or selectively include those with some clinical risk for harboring disease, or perhaps omit elective nodal irradiation altogether. The purpose of the present report is therefore to address the concepts underlying elective or selective nodal irradiation as it applies to SCLC, looking at clinical, imaging, and RT reports to help define the parameters appropriate to treating individual patients.
Asunto(s)
Carcinoma de Células Pequeñas/radioterapia , Agencias Internacionales , Neoplasias Pulmonares/radioterapia , Irradiación Linfática/métodos , Energía Nuclear , Carcinoma de Células Pequeñas/diagnóstico por imagen , Carcinoma de Células Pequeñas/patología , Ensayos Clínicos como Asunto , Humanos , Neoplasias Pulmonares/diagnóstico por imagen , Neoplasias Pulmonares/patología , Irradiación Linfática/normas , Mediastino , Estadificación de Neoplasias/métodos , Tomografía de Emisión de Positrones , Carga TumoralRESUMEN
PURPOSE: In chemoradiation for pancreatic carcinoma three-dimensional target volume definitions could maximize tolerability and therapeutic effect at the same time because toxicity correlates with treatment volume. We aimed to define guidelines for elective treatment of nodal areas based on pathologic nodal involvement to optimize treatment volume for this tumor. METHODS AND MATERIALS: Pathologic patterns of regional nodal spread in 175 patients who underwent primary pancreatoduodenectomy with > or =10 assessed nodes and literature data on para-aortic spread were the base of the definition of the target volume. Significant correlations between spread to lymphatic areas and tumor characteristics were determined using Fisher's exact test. Computed tomography scans and a Pinnacle3 (Philips, Best, The Netherlands) system were used for treatment planning. RESULTS: Among 175 resected tumors without pretreatment, 76% had regional nodal metastasis and 22% had spread to distant nodes. High-risk lymphatic areas were identified and selected for elective treatment. A standardized planning procedure was derived and tested under treatment conditions. CONCLUSIONS: Histopathologic data allowed us to develop recommendations for standardized treatment planning for ductal carcinoma of the pancreatic head. These are proposed for quality assurance in multicenter studies and routine use.
Asunto(s)
Carcinoma Ductal Pancreático/radioterapia , Irradiación Linfática/normas , Neoplasias Pancreáticas/radioterapia , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma Ductal Pancreático/secundario , Carcinoma Ductal Pancreático/cirugía , Femenino , Humanos , Escisión del Ganglio Linfático , Irradiación Linfática/métodos , Metástasis Linfática , Masculino , Persona de Mediana Edad , Neoplasias Pancreáticas/patología , Neoplasias Pancreáticas/cirugía , Pancreaticoduodenectomía , Guías de Práctica Clínica como Asunto , Dosificación Radioterapéutica , Planificación de la Radioterapia Asistida por Computador , Radioterapia Conformacional/normasRESUMEN
PURPOSE: To evaluate the impact of the quality of involved-field radiotherapy (IFRT) on clinical outcome in patients with advanced Hodgkin's lymphoma (HL) in complete remission (CR) after six to eight cycles of mechlorethamine, vincristine, procarbazine, prednisone-doxorubicin, bleomycin, and vinblastine (MOPP-ABV) chemotherapy. METHODS AND MATERIALS: A retrospective review of clinical and radiologic data, radiation charts, simulator films, and megavoltage (MV) photographs was performed. IFRT consisted of 24 Gy to all initially involved nodal areas and 16-24 Gy to all initially involved extranodal sites. Major violations were defined as no or only partial irradiation of an originally involved area, or a total dose <90% of the prescribed dose. RESULTS: Of the 739 patients who were enrolled in the trial between 1989 and 2000, 57% achieved a CR; 152 of 172 patients randomized to IFRT actually received radiotherapy; and in 135 patients, quality control was performed. The overall major violation rate was 47%, predominantly concerning target volumes. The total dose was correct in 81% of the patients. After a median follow-up of 6.5 years, there was no difference in cumulative failure rate between patients with or without major violations. There was no relationship between incidence or site of relapse and major protocol violations. CONCLUSION: In advanced-stage HL patients in complete remission after six to eight cycles of MOPP-ABV, the outcome was not influenced by violation of the radiotherapy protocol.
Asunto(s)
Enfermedad de Hodgkin/radioterapia , Control de Calidad , Protocolos de Quimioterapia Combinada Antineoplásica/administración & dosificación , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Bleomicina/administración & dosificación , Terapia Combinada , Doxorrubicina/administración & dosificación , Enfermedad de Hodgkin/tratamiento farmacológico , Enfermedad de Hodgkin/patología , Humanos , Irradiación Linfática/normas , Mecloretamina/administración & dosificación , Prednisona/administración & dosificación , Procarbazina/administración & dosificación , Dosificación Radioterapéutica , Ensayos Clínicos Controlados Aleatorios como Asunto , Inducción de Remisión , Estudios Retrospectivos , Vinblastina/administración & dosificación , Vincristina/administración & dosificaciónRESUMEN
BACKGROUND: Treatment of internal mammary lymph node (IMN) metastases remains controversial because of the difficulty in predicting involvement, potential treatment-related morbidity, and questionable efficacy. Lymphoscintigraphy with sentinel lymph node biopsy offers a means to identify occult involvement of IMN, allowing appropriate patient selection for IMN treatment. METHODS: The authors retrospectively reviewed 262 lymphoscintigraphies (LS) of 248 patients treated at the University of Florida (Gainesville, FL) between 1998 and 2002. Tumor characteristics were assessed for their value in predicting IMN drainage and their association with IMN radiation. RESULTS: Lymph flow to the IMN was documented with LS in 23 of 262 tumor specimens (9%). Flow to the IMN was not correlated with any of the five factors: tumor location, tumor size, lymphovascular invasion, pathologic lymph node status, and laterality of the involved breast (right vs. left breast). Identification of IMN flow increased from 5.7% to 10.1% with the use of a deep injection technique. IMN radiotherapy was used more frequently in patients with larger tumors (15 of 188 in Tis/T1 vs. 31 of 70 in T2-T4; P<0.0001) and positive lymph nodes (17 of 91 in lymph node-negative patients vs. 28 of 66 in lymph node-positive patients; P<0.0001). In patients with T2N0 tumors (n=32), IMN radiotherapy was used more frequently with medial tumors (5 of 11 [45%]) than with lateral tumors (4 of 21 [19%]). CONCLUSIONS: The incidence of flow to the IMN documented with the current LS technique was low compared with other LS and extended radical mastectomy series. Histopathologic information was obtained for the sentinel IMN when IMN flow was identified on the LS. In the absence of histopathologic information, treatment decisions should continue to be based on clinical factors known to be correlated with occult IMN involvement.