On the feasibility of automatically selecting similar patients in highly individualized radiotherapy dose reconstruction for historic data of pediatric cancer survivors

Purpose: The aim of this study is to establish the first step toward a novel and highly individualized three-dimensional (3D) dose distribution reconstruction method, based on CT scans and organ delineations of recently treated patients. Specifically, the feasibility of automatically selecting the CT scan of a recently treated childhood cancer patient who is similar to a given historically treated child who suffered from Wilms' tumor is assessed.Methods: A cohort of 37 recently treated children between 2- and 6-yr old are considered. Five potential notions of ground-truth similarity are proposed, each focusing on different anatomical aspects. These notions are automatically computed from CT scans of the abdomen and 3D organ delineations (liver, spleen, spinal cord, external body contour). The first is based on deformable image registration, the second on the Dice similarity coefficient, the third on the Hausdorff distance, the fourth on pairwise organ distances, and the last is computed by means of the overlap volume histogram. The relationship between typically available features of historically treated patients and the proposed ground-truth notions of similarity is studied by adopting state-of-the-art machine learning techniques, including random forest. Also, the feasibility of automatically selecting the most similar patient is assessed by comparing ground-truth rankings of similarity with predicted rankings.Results: Similarities (mainly) based on the external abdomen shape and on the pairwise organ distances are highly correlated (Pearson rp ≥ 0.70) and are successfully modeled with random forests based on historically recorded features (pseudo-R2 ≥ 0.69). In contrast, similarities based on the shape of internal organs cannot be modeled. For the similarities that random forest can reliably model, an estimation of feature relevance indicates that abdominal diameters and weight are the most important. Experiments on automatically selecting similar patients lead to coarse, yet quite robust results: the most similar patient is retrieved only 22% of the times, however, the error in worst-case scenarios is limited, with the fourth most similar patient being retrieved.Conclusions: Results demonstrate that automatically selecting similar patients is feasible when focusing on the shape of the external abdomen and on the position of internal organs. Moreover, whereas the common practice in phantom-based dose reconstruction is to select a representative phantom using age, height, and weight as discriminant factors for any treatment scenario, our analysis on abdominal tumor treatment for children shows that the most relevant features are weight and the anterior-posterior and left-right abdominal diameters

Diaphragm and abdominal organ motion during radiotherapy:a comprehensive multicenter study in 189 children

Background: For accurate thoracic and abdominal radiotherapy, inter- and intrafractional geometrical uncertainties need to be considered to enable accurate margin sizes. We aim to quantify interfractional diaphragm and abdominal organ position variations, and intrafractional diaphragm motion in a large multicenter cohort of pediatric cancer patients (&lt; 18 years). We investigated the correlation of interfractional position variations and intrafractional motion with age, and with general anesthesia (GA). Methods: In 189 children (mean age 8.1; range 0.4–17.9 years) from six institutes, interfractional position variation of both hemidiaphragms, spleen, liver, left and right kidneys was quantified using a two-step registration. CBCTs were registered to the reference CT relative to the bony anatomy, followed by organ registration. We calculated the group mean, systematic and random errors (standard deviations Σ and σ, respectively) in cranial-caudal (CC), left-right and anterior-posterior directions. Intrafractional right hemidiaphragm motion was quantified using CBCTs on which the breathing amplitude, defined as the difference between end-inspiration and end-expiration peaks, was assessed (N = 79). We investigated correlations with age (Spearman’s ρ), and differences in motion between patients treated with and without GA (N = 75; all &lt; 5.5 years). Results: Interfractional group means were largest in CC direction and varied widely between patients, with largest variations in the right hemidiaphragm (range -13.0–17.5 mm). Interfractional group mean of the left kidney showed a borderline significant correlation with age (p = 0.047; ρ = 0.17). Intrafractional right hemidiaphragm motion in patients ≥ 5.5 years (mean 10.3 mm) was significantly larger compared to patients &lt; 5.5 years treated without GA (mean 8.3 mm) (p = 0.02), with smaller Σ and σ values. We found a significant correlation between breathing amplitude and age (p &lt; 0.001; ρ = 0.43). Interfractional right hemidiaphragm position variations were significantly smaller in patients &lt; 5.5 years treated with GA than without GA (p = 0.004), but intrafractional motion showed no significant difference. Conclusion: In this large multicenter cohort of children undergoing thoracic and abdominal radiotherapy, we found that interfractional position variation does not depend on age, but the use of GA in patients &lt; 5.5 years showed smaller systematic and random errors. Furthermore, our results showed that breathing amplitude increases with age. Moreover, variations between patients advocate the need for a patient-specific margin approach.</p

Relating anatomical variations and patient features with dose-reconstruction accuracy of a 3D dose-reconstruction approach using CT scans of recently-treated children

Purpose Reconstructing 3D dose distributions for pre-1990 pediatric 2D radiotherapy plans is challenging, but key to research on late adverse effects. We studied the relation between dosimetric accuracy, anatomical variation, and other patient features of a 3D dose-reconstruction approach using CT scans of recently-treated patients, rather than phantoms. Materials and methods CT-scans of 22 Wilms’ tumor patients (age:2.5-5.3yrs; n boys/girls:11/11) treated between 2004 and 2015 were included. Two clinical plans as applied to a 4-year-old boy and girl with a left-sided Wilms’ tumor served as references. Each plan was applied to the CT scans of the other 21 patients, adjusted to correct for anatomical differences as visible in digitally-reconstructed-radiographs, and the resulting dose was calculated. Deviations in reconstructed dose, with respect to the reference dose, in organs-at-risk (spinal cord, right kidney, liver, and spleen) were characterized by the mean dose error normalized by the prescribed dose (DEmean). Deviations in organs’ location relative to a reference point (\Delta O_loc) and in organs’ shape captured by the Dice coefficient (DC) were calculated. We estimated the Pearson’s correlation between DEmean, on the one hand, and O­loc, DC, gender, age, height, and weight, on the other hand. Results Average(range) DEmean values were: spinal cord:3(0-8)%; right kidney:6(0-20)%; liver:9(0-20)%; and spleen:23(0-80)%. DC and DEmean in the right kidney were moderately negatively correlated (r2=0.41). DEmean in the liver was uncorrelated with any o

Radiation-associated adverse events after childhood cancer

With improved survival rates, childhood cancer survivors are confronted with treatment-related adverse events, especially when radiation therapy was involved. After the introduction (Chapter 1), the Chapters 2 and 3 present the EKZ/AMC childhood cancer survivor cohort and the methodology of using the equivalent dose in 2-Gy fractions (EQD2), which is considered a novel approach in epidemiological studies on late effects. In four cohort studies adverse events are analyzed in relation to the EQD2, also considering other treatment-related risk factors. Chapter 4 focuses on one diagnosis and evaluated late effects in long-term Wilms’ tumor survivors, as such a subcohort of the EKZ/AMC cohort. In Chapter 5 the dose-effect relationships for adverse events after cranial radiation therapy were analyzed. This study included the complete cohort, thus comprising a wide variety of diagnoses. This was also the case in Chapter 6, in which cerebrovascular events including stroke and TIA (i.e. transient ischemic accident) have been studied. Chapter 7 presents the study on valvular abnormalities detected by echocardiography in childhood cancer survivors treated with potentially cardiotoxic therapy. Chapter 8 includes the protocol of the Cochrane Systematic Review on breast cancer in female survivors who had received radiotherapy involving the chest for their primary malignancy. The actual review is currently in progress. The thesis concludes with a summary and general discussion in chapter 9

Gene expression analysis of glycosylation-related genes by real-time polymerase chain reaction.

Glycan molecules covalently linked to proteins or lipids control vital properties of cells, such as signaling, adherence, and migration through the body. The biosynthesis of such glycans depends on the concerted action of many endoplasmic reticulum and Golgi enzymes, a process that is tightly ordered and regulated. To understand the function of glycoconjugates in cellular interactions, it is crucial to investigate the regulation of expression of the genes encoding the "glycosylation-related" genes, encompassing large families of glycosyltransferases, glycosidases, and sulfotransferases. This chapter describes an easy, flexible, and reliable method of quantitative real-time polymerase chain reaction to measure the expression levels of 80 human glycosylation-related genes that primarily encode common enzymes involved in N- and O-linked protein glycosylation and/or glycolipids. Designing and including additional primer sets to detect more genes can easily extend the system. In order to allow the normalization of gene expression data obtained by real-time polymerase chain reaction within different cells, tissues, or under different experimental conditions, a protocol is included to detect genes suitable for use as endogenous reference genes

Activation of human endothelial cells by tumor necrosis factor-α results in profound changes in the expression of glycosylation-related genes

The endothelium plays a central role in the logistics of the immune system by allowing the selective transmigration of leukocytes, as well as the maintenance of the circulation and coagulation homeostasis. Evidence is increasing that the carbohydrate composition of the endothelial cell surface is critical for the cells to exert their physiological function. The major aim of this study is to unravel the mechanisms underlying the expression of carbohydrate structures by endothelial cells, which are involved in leukocyte adhesion and migration. Using quantitative real-time PCR, the expression profile of a selected group of 74 glycosylation-related genes has been determined in human umbilical vein endothelial cells (HUVEC) and human foreskin microvascular endothelial cells (FMVEC) under control and TNFα-induced conditions. The set of genes comprised 59 glycosyltransferases, 6 mannosidases and 9 sulfotransferases. In parallel, the overall cell surface glycan profile has been assessed by the use of glycan-specific lectins and monoclonal antibodies. The results demonstrate that HUVEC and FMVEC differ substantially in the expression of glycosylation-related genes and, accordingly, also in the presence of different glycan epitopes on the cell membrane. Induction of an inflamed phenotype of the cells by treatment with TNFα differentially modulates a set of these genes in HUVEC and FMVEC resulting in a change in the cell membrane associated glycans that are of importance in inflammation-related endothelial cell-surface processes