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CONTEXT: Patients with Turner Syndrome often present with short stature and ovarian insufficiency. The optimal method of pubertal induction to maximize adult height (AH) is unknown. OBJECTIVE: To identify variables related to pubertal induction that are associated with growth and AH. DESIGN & SETTING: Retrospective cohort analysis of patients attending a specialized Turner Syndrome clinic at a quaternary children's hospital. PATIENTS: Patients with Turner Syndrome (n=107) who attended the clinic between 2015 and 2021. Of these, 51 received estradiol for pubertal induction. MAIN OUTCOME MEASURES: Change in height standard deviation score (ΔHeightSDS) during pubertal induction, and AH. METHODS: Age at pubertal induction, bone age delay, midparental height (MPH), growth hormone treatment, and karyotype were assessed as predictors of AH and ΔHeightSDS. Associations between karyotype and comorbidities were also assessed. RESULTS: AH was predicted by MPH (0.8cm/cm, P=0.0001) and bone age delay (-1.84 cm/year, P= 0.006). ΔHeightSDS was predicted by growth hormone dose (0.09 SDS/mg/m2/week; P=0.017), bone age delay (-1.37 SDS/year; P=0.003), and age at pubertal induction (0.44 SDS/year; P=0.001). There was an interaction between bone age delay and pubertal induction age (P=0.013), with the combination of younger age at pubertal induction and a less-delayed bone age associated with a lower ΔHeightSDS. Karyotype did not influence AH or ΔHeightSDS, but did affect rates of other comorbidities. CONCLUSIONS: Decisions around timing of pubertal induction in patients with Turner Syndrome should be tailored to the individual. The current approach to estrogen supplementation needs to be refined in order to facilitate pubertal induction in a physiological manner without compromising height.
RESUMO
BACKGROUND AND PURPOSE: Accurate delivery of radiotherapy is critical to achieve optimal treatment outcomes. Interfraction translational IGRT is now standard, and intrafraction motion management is becoming accessible. Some platforms can report both translational and rotational movements in real time. This study aims to quantify the dosimetric impact of observed intrafraction rotation of the prostate measured using monitoring software. MATERIALS AND METHODS: A dose grid resampling algorithm was used to model the dosimetric impact of prostate rotations for 20 patients on a SBRT prostate clinical trial. Translations were corrected before and during treatment, but rotations were not. Real time rotation data were acquired using KIM and a cumulative histogram analysis performed. Prostate volumes were rotated by the range of observed angles and used to calculate DVH data. RESULTS: The pitch axis had a higher range of observed rotations resulting in only 7 patients spending at least 90% of the beam on time across all fractions within rotation angles resulting in PTV D95% ≥36â¯Gy in this axis. The yaw and roll axes saw 17 and 15 patients respectively achieving this criterion. All but one of 20 patients exceeded CTV D98% ≥36â¯Gy for all observed rotation angles. CONCLUSIONS: Current CTV-PTV margins do not result in compromised CTV dose coverage due to inter and intrafraction prostate rotations in the absence of other uncertainties. Reduced PTV dosing is due to the extremely conformal treatment delivery but is unlikely to be clinically deleterious. Prostate standard IGRT should continue to focus on correcting any observed translational movements. Margin reduction could be explored in conjunction with other uncertainties.
