Radiation-Related Treatment Effects Across the Age Spectrum: Differences and Similarities or What the Old and Young Can Learn from Each Other

Radiation related effects in children and adults limit the delivery of effective radiation doses and result in long-term morbidity affecting function and quality of life. Improvements in our understanding of the etiology and biology of these effects, including the influence of clinical variables, dosimetric factors, and the underlying biologic processes has made treatment safer and more efficacious. However, the approach to studying and understanding these effects differs between children and adults. By using the pulmonary and skeletal organ systems as examples, comparisons are made across the age spectrum for radiation related effects including pneumonitis, pulmonary fibrosis, osteonecrosis and fracture. Methods for dosimetric analysis, incorporation of imaging and biology as well a length of follow-up are compared, contrasted and discussed for both organ systems in children and adults. Better understanding of each age specific approach and how it differs may improve our ability to study late effects of radiation across the age

A knowledge-guided active model method of skull segmentation on T1-weighted MR images

Skull is the anatomic landmark for patient set up of head radiation therapy. Skull is generally segmented from CT images because CT provides better definition of skull than MR imaging. In the mean time, radiation therapy is planned on MR images for soft tissue information. This study utilized a knowledge-guided active model (KAM) method to segmented skull on MR images in order to enable radiation therapy planning with MR images as the primary planning dataset. KAM utilized age-specific skull mesh models that segmented from CT images using a conditional region growing algorithm. Skull models were transformed to given MR images using an affine registration algorithm based on normalized mutual information. The transformed mesh models actively located skull boundaries by minimizing their total energy. The preliminary validation was performed on MR and CT images from five patients. The KAM segmented skulls were compared with those segmented from CT images. The average image similarity (kappa index) was 0.57. The initial validation showed that it was promising to segment skulls directly on MR images using KAM

Improvement of tomographic intensity modulated radiotherapy dose distributions using periodic shifting of arc abutment regions

Based on the study of treatment arc positioning versus target length, a method that allowed periodic shift of arc abutment regions through the course of intensity modulated radiotherapy (IMRT) was developed. In this method, two treatment plans were developed for the same tumor. The first plan contained the original target (Planning Target Volume as defined by radiation oncologist) and the second one contained a modified target. The modification of the original target consisted of simply increasing its length, adding a small extension to it, or creating a distant pseudo target. These modifications cause arc abutment regions in the second plan to be shifted relative to their positions in the first plan. Different methods of target modification were investigated because in some cases (for instance, when a critical structure might overlap with the target extension) a simple extension of the target would cause an unacceptable irradiation of the sensitive structures. The dose prescribed to the modified portion of the target varied from 10% to 100% of the original target dose. It was found that a clinically significant shift (⩾5 mm) in abutment region locations occurred when the dose prescribed to the extended portion of the target was ⩾95% of the original target dose. On the other hand, the pseudo target required only ∼10% to 20% of the original target dose to produce the same shift in arc positions. Results of the film dosimetry showed that when a single plan was used for the treatment delivery, the dose nonuniformity was 17% and 25% of the prescribed dose with 0.5 and 1 mm errors in couch indexing, respectively. The dose nonuniformity was reduced by at least half when two plans were used for IMRT delivery

Repeat nephron-sparing surgery for children with bilateral Wilms tumor

Background Renal insufficiency is a significant complication of Wilms tumor treatment in the 5% with bilateral disease. Nephron-sparing surgery (NSS) is recommended after neoadjuvant chemotherapy initially. However, the role of NSS in recurrent disease is unknown. We reviewed our experience to assess the feasibility and oncologic and functional outcomes of repeat NSS for children with recurrent disease. Methods A retrospective review was performed of all children treated at our institution for bilateral, favorable histology (FH) Wilms tumor. Patients undergoing repeat NSS for locally recurrent disease were identified. The outcomes evaluated included tumor recurrence, renal function, and patient survival. Results Since 2001, 36 children with bilateral FH Wilms tumor have been treated at our institution. Eight patients (22%) underwent repeat NSS for locally recurrent disease. Two patients had a second local recurrence and underwent a third NSS. Six patients are alive without disease (75%) with an average follow-up of 4.5 years. Two patients have died, each with blastemal-predominant histology at repeat NSS. The surviving patients have normal renal function, although two patients require medical management of hypertension. Conclusions Our experience suggests that repeat NSS for local recurrence of FH bilateral Wilms tumor is feasible and affords acceptable oncologic outcome with preservation of renal function. However, more aggressive therapy may be required for patients whose recurrence has blastemal-predominant histology, given the poor outcome for these patients in our series. © 2014 Elsevier Inc. All rights reserved

Margin status and tumor recurrence after nephron-sparing surgery for bilateral Wilms tumor

Purpose Nephron-sparing surgery (NSS) has been advocated for patients with bilateral Wilms tumor (BWT). We sought to determine whether margin status impacted local tumor recurrence. Methods A retrospective review of patients undergoing NSS for BWT from November 1999 to March 2009 at our institution in which local recurrence rates based on margin status were compared. Results Of 21 patients, five (23.8%) had positive margins. These and 2 (9.5%) with focal anaplasia received flank XRT. Seven (33%) patients developed recurrent disease, a mean of 18.0 (range 1.3-39.9) months after NSS. Recurrence rates were similar in patients with positive and negative margins (1/5 [20%] vs 6/16 [37.5%]; p = 0.47). Hypertension occurred more frequently in patients who received XRT (57.1% vs 28.6%). At a median follow-up of 28.6 months (range 5.2-142.3), 19 patients are alive, without evidence of disease; one patient (with a positive margin at initial NSS) died of metastatic anaplastic WT and another died of a brain tumor. One patient, with multiple risk factors, developed renal failure. Conclusions In our experience, local recurrence rates after NSS were not affected by surgical margin status although all patients with positive margins received XRT. These results support the aggressive use of NSS for patients with BWT. © 2013 Elsevier Inc