Control de calidad de la radioterapia del cáncer de cervix

Introducción - Las herramientas educativas en línea permiten una formación médica interactiva para estudiantes dispersos geográficamente. Pocos estudios tienen como objetivo primario su validación objetiva. Por sus ventajas logísticas, se utilizó un taller de delineación en línea (TDE) para homogeneizar el contorneo como control de calidad de radioterapia en el ensayo prospectivo multicéntrico europeo RAIDs (Rational molecular Assessments and Innovative Drug Selection) en cáncer de cérvix localmente avanzado (CCLA). Se realizaron dos TDE idénticos para evaluar sobre un paciente de simulacro las delineaciones de los centros RAIDs. Objetivos .- Principales: 1. Realizar una validación interobservadora de los TDE en CCLA mediante una evaluaci ón cualitativa y cuantitativa de la mejoría de delineaciones entre participantes (variabilidad interobservadora). 2. Efectuar una validación intraobservadora del TDE en CCLA mediante una evaluaci ón cualitativa y cuantitativa de la mejoría de delineaciones de cada participante (variabilidad intraobservadora). .- Secundarios: 1. Evaluar la metodología de enseñanza del TDE mediante cuestionarios de satisfacci ón. 2. Análizar las delineaciones de los participantes de los centros europeos que utilizan la resonancia magnética para planificar braquiterapia (BQT) con respecto a los que no la usan. Metodología - Se realizaron dos TDE incluyendo 46 especialistas de 14 centros de RAIDs. Se estableció una colaboración técnica con la Sociedad Europea de Oncología Radioter ápica (ESTRO). La formación se realizó por una experta en la materia, CHM. Mediante 3 presentaciones en directo en línea se presentaron la plataforma de contorneo Fellowship in Anatomical deLineation and CONtouring (FALCON) EduCaseTM, las guías de delineaci ón y los contornos de los participantes. Los participantes completaron contornos basales (C1), guía (C2) y finales (C3) para radioterapia externa (RTE) y braquiterapia (BQT) en CCLA. La variabilidad interobservadora e intraobservadora se evaluó cuantitativamente (Índice DICE) y se analizaron mediante un modelo lineal mixto. La variabilidad intraobservadora fue evaluada cualitativamente mediante el test de McNemar. Resultados - Nueve participantes enviaron contornos para RTE y BQT (C1-C3). Treinta y dos envió algún contorno. La comparación interobservadora cuantitativa de RTE mostró una mejoría significativa entre C2 y C1 para intestino, CTV ganglionar, CTV-p y GTVganglio con un detrimento significativo para GTV-ganglio (entre C3 y C1; C2), CTV-p (entre C3 y C2) e intestino (entre C3 y C2), es decir, una mejoría en general entre C2 y C1, con un detrimento significativo entre C3 y C2 en dos volúmenes blanco y un órgano de riesgo. Para BQT hubo una mejoría significativa entre C2 y C1 para vejiga, GTV, HRCTV e IR-CTV con un detrimento significativo para vejiga (entre C3 y C2), en resumen, una mejoría general entre C2 y C1, con sólo un detrimento entre C3 y C2 para la vejiga. Las comparaciones intraobservadoras cuantitativas mostraron una mejoría signi cativa de delineaciones de regiones de interés entre C2 y C1, C3 y C1 y C3 y C2 para RTE y entre C2 y C1 para BQT. Las comparaciones cualitativas intraobservadoras destacables en BQT fueron una mejoría significativa en las direcciones derecha y posterolateral derecha para los volúmenes blanco entre C2 y C1, que pasaron a ser signi cativamente peores para estas direcciones entre C3 y C1; C2. El resultado de las preguntas acerca de la organización y el contenido del TDE del cuestionario de satisfacción (escala del 1 al 5, 1=poco satisfecho, 5=muy satisfecho) para los 20 participantes que respondieron fue de media 4.36 (rango: 3.95-4.60). Los centros que empleaban resonancia magnética para la delineación en BQT tuvieron una mejoría significativa para HR-CTV con respecto a los que usaban otras técnicas (entre C2 y C1: p-value < 0.005; entre C3 y C1: p-value = 0.02). Conclusiones - Los TDE permiten formar, armonizar inicialmente la delineación y evaluar la experiencia de los centros antes de la inclusión de pacientes de una forma cómoda y eficaz en el seno de un estudio multicéntrico.Introduction - E-learning programmes allow e ective medical training for geographically dispersed participants. Few studies aim primarily to validate these programmes objectively. Considering its logistical aptitudes, an ODW using FALCON was used to homogenise delineation practice in cervical cancer as quality control among European centres participating in a multicentre prospective trial on locally advanced cervical cancer (LACC). Two identical ODW were performed, to evaluate the delineations of RAIDs centres on a ctitious patient. Aims Primary endpoints: 1. Interobserver validation of the ODW in LACC by using qualitative and quantitative assessments of the improvement of clinician contours between clinicians (interobserver variability). 2. Intraobserver validation of the ODW in LACC by assessing qualitatively and quantitatively the improvement of the clinician contours for each clinician (intraobserver variability). Secondary endpoints: 1. Evaluation of the teaching methodology of the ODW as re ected by the participant satisfaction questionnaires. 2. Analysis of clinician contouring on magnetic resonance imaging (MRI) for European centres which use MRI for brachytherapy planning versus those which do not. Methods - Two ODW included 46 clinicians from 14 RAIDs centres. A technical collaboration was established with European Society for Radiotherapy & Oncology (ESTRO). Training was performed by an expert in the eld, CHM. Through 3 live online presentations, the contouring platform FALCON EduCaseTM, the delineation guidelines and the participant contours were presented. Participants were asked to complete baseline contouring (C1), guideline contouring (C2) and nal contouring (C3) for external beam radiotherapy (EBRT) and brachytherapy (BT) for LACC. Interobserver and intraobserver variability was quantitatively evaluated (DICE index) and analysed by a linear mixed model. Intraobserver variability was qualitatively evaluated by the McNemar test. Results - Nine participants contoured for EBRT and BT for C1 - C3. Thirty-two clinicians submitted any contour. Concerning interobserver quantitative comparisons for EBRT, signi cant improvement was observed for C2 vs. C1 for bowel, nodal elective volume (CTV-node), GTV-p, uterus and vagina, at least 20 mm below GTV-p (CTV-p) and radiologically pathological lymph nodes to boost (GTV-node), versus a signi cant detriment for GTV-node (C3 vs. C1; C2), CTV-p (C3 vs. C2) and bowel (C3 vs. C2), showing overall an improvement in C2 vs. C1, versus a detriment in C3 vs. C2 for two target volumes and one organ at risk. In the BT treatment there was signi cant improvement for C2 vs. C1 for bladder, gross tumor volume (GTV), high risk CTV (HR-CTV) and intermediate risk CTV (IR-CTV), versus a signi cant detriment for bladder (C3 vs. C2), thus a general improvement in C2 vs. C1, with only a detriment in C3 vs. C2 for bladder. As for intraobserver quantitative comparisons, a signi cant improvement was observed for contouring a region of interest between C2 vs. C1, C3 vs. C1 and C3 vs. C2 for EBRT and between C2 vs. C1 for BT. Notable intraobserver qualitative comparisons were found for BT, a signi cant improvement towards the right and posterolateral right directions for target volumes in C2 vs. C1, which became signi cantly worse in these directions in C3 vs. C1 and C2. The average result of the Organisation and Content items in the satisfaction questionnaire for the 20 ODW participants who responded (scale 1-5, 1=poor, 5=excellent) was 4.36 (range 3.95-4.60). With regard to the imaging technique used for BT planning, centres using magnetic resonance imaging (MRI) did significantly better in the BT case for HR-CTV than centres using other techniques (C2 vs. C1: p-value < 0.005; C3 vs. C1: p-value = 0.02). Conclusions - ODW allow to train, initially harmonise contouring and assess the experience of centres before patient inclusion conveniently and eficiently in the context of a multicentre trial

Interim position emission tomography-computed tomography during multimodality treatment of locally advanced esophageal cancer: a scoping review.

BACKGROUND Among cancers, esophageal cancer (EC) has one of the highest incidences and mortality in Asia. As recognized in many national guidelines, functional imaging performed with position emission tomography is recommended for patients with locally advanced disease. This review evaluated evidence for the use of fluorodeoxyglucose (FDG) interim positron emission tomography (PETint) in bimodality (chemoradiation) and trimodality (chemoradiation followed by surgery) management of locally advanced esophageal cancer (LAEC), with a focus on its prognostic and predictive value. METHODS The MEDLINE database was searched from January 1, 2001, to January 1, 2022, as part of a scoping review. References of selected articles were manually checked to identify other articles meeting the inclusion criteria; only original articles were included, and reviews, guidelines, letters, editorials, and case reports were excluded. RESULTS A total of 63 articles were included in this review. PET-computed tomography (PET-CT) is recognized as having a significant role in the assessment of treatment response. Studies on the predictive PETint suggest that it has a certain value, particularly for early response. Identification of poor responders or nonresponders soon after commencement of multimodality treatment allows for treatment modification. CONCLUSIONS The scoping review indicated variable utility for the prognostic value of PETint. There is a need to improve its accuracy, which can likely be achieved through greater standardization of measurements and reporting and testing as well as combination with other promising measures of response to residual disease

A three-dimensional printed customized bolus: adapting to the shape of the outer ear

Background: The skin-sparing effect of megavoltage-photon beams in radiotherapy (RT) reduces the target coverage of superficial tumours. Consequently, a bolus is widely used to enhance the target coverage for superficial targets. This study evaluates a three-dimensional (3D)-printed customized bolus for a very irregular surface, the outer ear. Materials and methods: We fabricated a bolus using a computed tomography (CT) scanner and evaluated its efficacy. The head of an Alderson Rando phantom was scanned with a CT scanner. Two 3D boluses of 5- and 10-mm thickness were designed to fit on the surface of the ear. They were printed by the Stratasys Objet260 Connex3 using the malleable “rubber-like” photopolymer Agilus. CT simulations of the Rando phantom with and without the 3D and commercial high density boluses were performed to evaluate the dosimetric properties of the 3D bolus. The prescription dose to the outer ear was 50 Gy at 2 Gy/fraction. Results: We observed that the target coverage was slightly better with the 3D bolus of 10 mm compared with the commercial one (D98% 98.2% vs. 97.6%).The maximum dose was reduced by 6.6% with the 3D bolus and the minimum dose increased by 5.2% when comparing with the commercial bolus. In addition, the homogeneity index was better for the 3D bolus (0.041 vs. 0.073). Conclusion: We successfully fabricated a customized 3D bolus for a very irregular surface. The target coverage and dosimetric parameters were at least comparable with a commercial bolus. Thus, the use of malleable materials can be considered for the fabrication of customized boluses in cases with complex anatomy

Ethnic difference in risk of toxicity in prostate cancer patients treated with dynamic arc radiation therapy

Aims and background: The objective of this study was to assess the influence of ethnicity on toxicity in patients treated with dynamic arc radiation therapy (ART) for prostate cancer (PC). Methods: From June 2006 to May 2012, 162 cT1-T3 cN0 cM0 PC patients were treated with ART (primary diagnosis, n = 125; post-prostatectomy/brachytherapy biochemical recurrence, n = 26; adjuvant post-prostatectomy, n = 11) at 2 institutions. Forty-five patients were Latin Americans and 117 were Europeans. The dose prescribed to the prostate ranged between 68 Gy and 81 Gy. Results: The median age was 69 years (range 43-87 years). The median follow-up was 18 months (range 2-74 months). Overall, only 3 patients died, none due to a cancer-related cause. Biochemical recurrence was seen in 7 patients. The rates of acute grade 2 gastrointestinal (GI) and genitourinary (GU) toxicities were 19.7% and 17%, respectively. Only 1 patient experienced acute grade 3 GI toxicity, whereas 11 patients (6.7%) experienced acute grade 3 GU toxicity. Multivariate analysis showed that undergoing whole pelvic lymph node irradiation was associated with a higher grade of acute GI toxicity (OR: 3.46; p = 0.003). In addition, older age was marginally associated with a higher grade of acute GI toxicity (OR: 2.10; p = 0.074). Finally, ethnicity was associated with acute GU toxicity: Europeans had lowergrade toxicity (OR: 0.27; p = 0.001). Conclusions: Our findings suggest an ethnic difference in GU toxicity for PC patients treated with ART. In addition, we found that ART is associated with a very low risk of severe toxicity and a low recurrence rate

A data mining based clinical decision support system for survival in lung cancer

Background: A clinical decision support system (CDSS) has been designed to predict the outcome (overall survival) by extracting and analyzing information from routine clinical activity as a complement to clinical guidelines in lung cancer patients. Materials and methods: Prospective multicenter data from 543 consecutive (2013–2017) lung cancer patients with 1167 variables were used for development of the CDSS. Data Mining analyses were based on the XGBoost and Generalized Linear Models algorithms. The predictions from guidelines and the CDSS proposed were compared. Results: Overall, the highest (> 0.90) areas under the receiver-operating characteristics curve AUCs for predicting survival were obtained for small cell lung cancer patients. The AUCs for predicting survival using basic items included in the guidelines were mostly below 0.70 while those obtained using the CDSS were mostly above 0.70. The vast majority of comparisons between the guideline and CDSS AUCs were statistically significant (p < 0.05). For instance, using the guidelines, the AUC for predicting survival was 0.60 while the predictive power of the CDSS enhanced the AUC up to 0.84 (p = 0.0009). In terms of histology, there was only a statistically significant difference when comparing the AUCs of small cell lung cancer patients (0.96) and all lung cancer patients with longer (≥ 18 months) follow up (0.80; p < 0.001). Conclusions: The CDSS successfully showed potential for enhancing prediction of survival. The CDSS could assist physicians in formulating evidence-based management advice in patients with lung cancer, guiding an individualized discussion according to prognosis.Instituto de Salud Carlos III PI16/02104Junta de Andalucía PIN-0476-2017Ministerio de Economía y Competitividad FPAP13-1E-242

The role of radiotherapy in locally advanced pancreatic cancer

International audienceAt diagnosis, about 15% of patients with pancreatic cancer present with a resectable tumour, 50% have a metastatic tumour, and 35% a locally advanced tumour, non-metastatic but unresectable due to vascular invasion, or borderline resectable. Despite the technical progress made in the field of radiation therapy and the improvement of the efficacy of chemotherapy, the prognosis of these patients remains very poor. Recently, the role of radiation therapy in the management of pancreatic cancer has been much debated. This review aims to evaluate the role of radiation therapy for patients with locally advanced tumours

Optimizing lung cancer radiation treatment worldwide in COVID-19 outbreak

COVID-19 has spread around the planet, sending billions of people into lockdown as health services struggle to cope. By April 2020, there are over a million two hundred thousand confirmed cases and more than sixty-five thousand deaths worldwide Meanwhile in Asia, where the disease began, the spread continues, in China it seems for now to have passed its peak. Italy, Spain, France, and the US have been the countries more affected in terms of deaths. The coronavirus is more dangerous to the elderly and those with certain pre-existing medical conditions which is precisely the profile of lung cancer patients. Essential cancer services should be delivered but all steps should be taken to protect patients and the health workforce from infection with COVID-19. This presents a major challenge to radiotherapy (RT) departments worldwide in curbing the spread of COVID-19 while ensuring the continuity of services. In RT, shortening overall treatment time to reduce the number of patients present in the department is an important consideration. An international panel, including the majority of countries most affected by the COVID-19 pandemic, with expertise in the management of cancer in high-volume comprehensive centres from the largest societies of radiation oncology worldwide have come together to share their experience on COVID-19 preparedness in the context of lung cancer RT to deliver optimal care in such exceptional circumstances, based on the latest evidence. A comprehensive systematic review of the literature through a PubMed search was undertaken. Given that lung cancer is one of the most common and severe pathologies in radiation oncology departments, the following recommendations require particularly urgent consideration. The decision-making paths strongly depend on locally available resources, and a tailored approach should be used to attend lung cancer patients during this pandemic.Peer reviewe

Haematological and renal toxicity of radiation therapy in neuroblastoma paediatric patients

[Purpose] The objective of this study was to evaluate the renal and hematologic toxicity in paediatric patients with adrenal high-risk neuroblastoma who have received radiation therapy (RT) as part of radical treatment.[Material and methods] Pediatric patients diagnosed with high-risk adrenal neuroblastoma who received RT as part of the definitive treatment between January 2004 and May 2020 in a single institution were selected. Complete blood counts (CBC) and creatinine clearance (CrCl) pre-RT and post-RT were compared through the Wilcoxon signed-rank test and correlated with survival analysis by Cox regression.[Results] Forty-two children with a median age of 3 years at diagnosis and 2.8 years of follow-up were selected. A significant and acute decrease in lymphocytes was found (p = 0.002) 1 month from RT. Patients with a drop higher than 50% of the previous value experimented a significant reduction in overall survival (55 vs 10%; p = 0.031). At the end of the follow-up, a significant increase in all blood counts was observed. With respect to renal function, an acute and significant decrease in CrCl was observed tin patients younger than 4 years who received RT (p = 0.013). However, it was not clinically relevant.[Conclusion] Our data suggest that acute lymphopenia occurs after RT and could be associated with a poorer prognosis. Other blood counts are reduced after RT and all of them are in physiological range at the end of follow-up. Our cohort presented excellent renal outcomes without any case of chronic renal dysfunction.Peer reviewe

Late toxicity for prostate cancer patients treated with hypofractionated helical tomotherapy

AimThe purpose of this study is to evaluate the long term tolerability of hypofractionated helical tomotherapy (HT) in localized prostate cancer patients.BackgroundPrevious hypofractionated schedules with conventional RT were associated with excessive toxicity, likely due to inadequate sophistication of treatment delivery. There are few data about late toxicity after HT.Materials and methodsWe evaluated 38 patients with primary adenocarcinoma of the prostate. There were 9 (24%), 15 (39%), and 14 (37%) patients with high, intermediate, and low risk, respectively. Patients were treated with hypofractionated HT from May 2008 to February 2011. Hypofractionation regimens included: 68.04Gy at 2.52Gy/fraction (N=25; 66%), 70Gy at 2.5Gy/fraction (N=4; 11%) and 70.2Gy at 2.6Gy/fraction (N=9; 23%). Late genitourinary (GU) and gastrointestinal (GI) toxicity was scored using the Radiation Therapy Oncology Group scoring system.ResultsMedian age at diagnosis was 70 years (range 49–80) and median follow-up, 5.8 years. Late grade 1, 2 and 3 GI toxicity were 13%, 24%, and 2.6%, respectively. Late grade 1, 2, 3 GU toxicity were 29%, 21%, and 8%, respectively. Sexual toxicity was evaluated in 19 patients to be grade 1, 2 in 11% and grade 3 in 16%. Multivariate analysis showed that patients with higher values of rectum V50 associated with late GI toxicity (P=0.025). Patients with PSA ≤8 (P=0.048) or comorbidities (P=0.013) at diagnosis were associated with higher late GU toxicity. Additionally, PSA ≤8 also associated with moderate (grade ≥2) late GU toxicity in the multivariate analysis (P=0.028).ConclusionsHypofractionated HT can be delivered safely with limited rates of moderate and severe late toxicity. The proportion of the rectum that receives a moderate and high dose, having comorbidities, and PSA at diagnosis seem to associate with long term toxicity