Total skin electron beam therapy (TSEBT) is a powerful treatment for cutaneous T-cell lymphoma (C... more Total skin electron beam therapy (TSEBT) is a powerful treatment for cutaneous T-cell lymphoma (CTCL). Based on the occurrence of relapses with low radiation doses, doses of 30-36Gy are commonly used but most patients still eventually relapse and repeat treatment courses are limited due to the cumulative toxicity. Complete response (CR) rates are about 60-90% for T2-4 stages with a 5-year relapse-free survival of 10-25% for stages IB-III. To evaluate prospectively the efficacy of low-dose TSEBT (10Gy) in terms of complete cutaneous response rate, overall response rate and response duration in CTCL. Ten patients with stage IB-IV mycosis fungoides (MF) were treated in an open-label manner with four fractions of TSEBT 1Gy weekly to a total skin dose of 10Gy. Treatment responses were assessed at 1 and 3months after treatment and subsequently at least every 6months for a total period of 2years or to disease relapse or progression. Patients achieved an overall response rate of 90%. The rate of CR or very good partial response (VGPR; <1% skin affected with patches/plaques) was 70%. The median response duration was 5·2months (range 83-469days) for CR and VGPR. Adverse effects were generally mild to moderate in severity. Low-dose TSEBT (10Gy) gave a satisfactory response rate and was well tolerated in patients with MF stage IB-IV. Future studies should determine if the combination of low-dose TSEBT with other agents could increase the rate of CR and response duration.
The value of performing post-therapy routine surveillance imaging in patients with Hodgkin lympho... more The value of performing post-therapy routine surveillance imaging in patients with Hodgkin lymphoma is controversial. This study evaluates the utility of positron emission tomography/computed tomography using 2-[18F]fluoro-2-deoxyglucose for this purpose and in situations with suspected lymphoma relapse. We conducted a multicenter retrospective study. Patients with newly diagnosed Hodgkin lymphoma achieving at least a partial remission on first-line therapy were eligible if they received positron emission tomography/computed tomography surveillance during follow-up. Two types of imaging surveillance were analyzed: "routine" when patients showed no signs of relapse at referral to positron emission tomography/computed tomography, and "clinically indicated" when recurrence was suspected. A total of 211 routine and 88 clinically indicated positron emission tomography/computed tomography studies were performed in 161 patients. In ten of 22 patients with recurrence of ...
To evaluate against Monte-Carlo the performance of various dose calculations algorithms regarding... more To evaluate against Monte-Carlo the performance of various dose calculations algorithms regarding lung tumour coverage in stereotactic body radiotherapy (SBRT) conditions. Dose distributions in virtual lung phantoms have been calculated using four commercial Treatment Planning System (TPS) algorithms and one Monte Carlo (MC) system (EGSnrc). We compared the performance of the algorithms in calculating the target dose for different degrees of lung inflation. The phantoms had a cubic 'body' and 'lung' and a central 2-cm diameter spherical 'tumour' (the body and tumour have unit density). The lung tissue was assigned five densities (rho(lung)): 0.01, 0.1, 0.2, 0.4 and 1g/cm(3). Four-field treatment plans were calculated with 6- and 18 MV narrow beams for each value of rho(lung). We considered the Pencil Beam Convolution (PBC(Ecl)) and the Analytical Anisotropic Algorithm (AAA(Ecl)) from Varian Eclipse and the Pencil Beam Convolution (PBC(OMP)) and the Collapsed Cone Convolution (CCC(OMP)) algorithms from Oncentra MasterPlan. When changing rho(lung) from 0.4 to 0.1g/cm(3), the MC median target dose decreased from 89.2% to 74.9% for 6 MV and from 83.3% to 61.6% for 18 MV (of dose maximum in the homogenous case at both energies), while for both PB algorithms the median target dose was virtually independent of lung density. Both PB algorithms overestimated the target dose, the overestimation increasing as rho(lung) decreased. Concerning target dose, the AAA(Ecl) and CCC(OMP) algorithms appear to be adequate alternatives to MC.
This study aimed at quantifying the breathing variations among lung cancer patients over full cou... more This study aimed at quantifying the breathing variations among lung cancer patients over full courses of fractionated radiotherapy. The intention was to relate these variations to the margins assigned to lung tumours, to account for respiratory motion, in fractionated radiotherapy. Eleven lung cancer patients were included in the study. The patients' chest wall motions were monitored as a surrogate measure for breathing motion during each fraction of radiotherapy by use of an external optical marker. The exhale level variations were evaluated with respect to exhale points and fraction-baseline, defined for intra- and interfraction variations respectively. The breathing amplitude was evaluated as breathing cycle amplitudes and fraction-max-amplitudes defined for intra- and interfraction breathing, respectively. The breathing variations over a full treatment course, including both intra- and interfraction variations, were 15.2mm (median over the patient population), range 5.5-26.7mm, with the variations in exhale level as the major contributing factor. The median interfraction span in exhale level was 14.8mm, whereas the median fraction-max-amplitude was 6.1mm (median of patient individual SD 1.4). The median intrafraction span in exhale level was 1.6mm, and the median breathing cycle amplitude was 4.0mm (median of patient individual SD 1.4). The variations in externally measured exhale levels are larger than variations in breathing amplitude. The interfraction variations in exhale level are in general are up to 10 times larger than intrafraction variations. Margins to account for respiratory motion cannot safely be based on one planning session, especially not if relying on measuring external marker motion. Margins for lung tumours should include interfraction variations in breathing.
Adjuvant radiotherapy after breast-conserving surgery for breast cancer implies a risk of late ca... more Adjuvant radiotherapy after breast-conserving surgery for breast cancer implies a risk of late cardiac and pulmonary toxicity. This is the first study to evaluate cardiopulmonary dose sparing of breathing adapted radiotherapy (BART) using free breathing gating, and to compare this respiratory technique with voluntary breath-hold. 17 patients were CT-scanned during non-coached breathing manoeuvre including free breathing (FB), end-inspiration gating (IG), end-expiration gating (EG), deep inspiration breath-hold (DIBH) and end-expiration breath-hold (EBH). The Varian Real-time Position Management system (RPM) was used to monitor respiratory movement and to gate the scanner. For each breathing phase, a population based internal margin (IM) was estimated based on average chest wall excursion, and incorporated into an individually optimised three-field mono-isocentric wide tangential photon field treatment plan for each scan. The target included the remaining breast, internal mammary nodes and periclavicular nodes. The mean anteroposterior chest wall excursion during FB was 2.5mm. For IG and EG, the mean excursions within gating windows were 1.1 and 0.7 mm, respectively, whereas for DIBH and EBH the excursions were 4.1 and 2.6mm, respectively. For patients with left-sided cancer, the median heart volume receiving more than 50% of the prescription dose was reduced from 19.2% for FB to 2.8% for IG and 1.9% for DIBH, and the median left anterior descending (LAD) coronary artery volume was reduced from 88.9% to 22.4% for IG and 3.6% for DIBH. Simultaneously, the median ipsilateral relative lung volume irradiated to >50% of the prescribed target dose for both right- and left-sided cancers was reduced from 45.6% for FB to 29.5% for IG and 27.7% for DIBH. For EBH and EG, both the irradiated heart, LAD and lung volumes increased compared to FB. This is the first study to demonstrate the dosimetric benefits of free breathing gated breast cancer radiotherapy. IG compared favourably with DIBH, substantially reducing cardiac doses simultaneous with significant pulmonary tissue sparing.
Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology, 2014
To analyze the recurrence pattern in relation to target volumes and (18)F-fluorodeoxyglucose (FDG... more To analyze the recurrence pattern in relation to target volumes and (18)F-fluorodeoxyglucose (FDG) uptake on positron emission tomography in head and neck squamous cell carcinoma (HNSCC) patients treated with definitive chemoradiation. 520 patients received radiotherapy for HNSCC from 2005 to 2009. Among 100 patients achieving complete clinical response and a later recurrence, 39 patients with 48 loco-regional failures had a recurrence CT scan before any salvage therapy. The estimated point of origin of each recurrence was transferred to the planning CT by deformable image co-registration. The recurrence position was then related to the delineated target volumes and iso-SUV-contours relative to the maximum standard uptake value (SUV). We defined the recurrence density as the total number of recurrences in a sub-volume divided by the sum of that volume for all patients. 54% (95% CI 37-69%) of recurrences originated inside the FDG-positive volume and 96% (95% CI 86-99%) in the high do...
Adjuvant radiotherapy of breast cancer using wide tangential photon fields implies a risk of late... more Adjuvant radiotherapy of breast cancer using wide tangential photon fields implies a risk of late cardiac and pulmonary toxicity. This CT-study evaluates the detailed potential dosimetric consequences of applying breathing adapted radiotherapy (BART), and the feasibility of a monitored voluntary breath-hold technique for right-sided as well as for left-sided tumours. After breast-conserving surgery, 16 patients were CT-scanned in distinct respiratory phases using the varian real-time position management system for the monitoring of respiratory anterioposterior chest wall excursion. Each patient underwent three scans: during free breathing (FB), voluntary expiration breath-hold (EBH) and voluntary deep inspiration breath-hold (DIBH). For each scan, an optimised treatment plan was designed with conformal tangential fields encompassing the clinical target volume (CTV) of the breast and ipsilateral internal mammary nodes, and an anterior supraclavicular field. Breath-hold was well accepted by the patients, with a median duration of 24 s for both EBH and DIBH. The mean anterioposterior chest wall excursions were 2.5, 2.6 and 4.1 mm during FB, EBH and DIBH, respectively. During EBH, the mean front chest wall position was 2.7 mm posterior to its mid-FB position, and during DIBH 12.6 mm anterior to its mid-FB position. For right-sided tumours, the median ipsilateral relative lung volume receiving >50% of the prescribed CTV dose was 39, 49 and 32% for FB, EBH and DIBH, respectively. For left-sided tumours, the corresponding percentages were 37, 46 and 31%. The median heart volume receiving >50% of the prescription dose was reduced from 8% for FB to 1% for DIBH, and the median left anterior descending coronary artery volume was reduced from 54 to 5%. Irradiated cardiac volumes can consistently be reduced for left-sided breast cancers using DIBH for wide tangential treatment fields. Additionally, substantial dose reductions in the lung are observed for both right- and left-sided tumours.
Total skin electron beam therapy (TSEBT) is a powerful treatment for cutaneous T-cell lymphoma (C... more Total skin electron beam therapy (TSEBT) is a powerful treatment for cutaneous T-cell lymphoma (CTCL). Based on the occurrence of relapses with low radiation doses, doses of 30-36Gy are commonly used but most patients still eventually relapse and repeat treatment courses are limited due to the cumulative toxicity. Complete response (CR) rates are about 60-90% for T2-4 stages with a 5-year relapse-free survival of 10-25% for stages IB-III. To evaluate prospectively the efficacy of low-dose TSEBT (10Gy) in terms of complete cutaneous response rate, overall response rate and response duration in CTCL. Ten patients with stage IB-IV mycosis fungoides (MF) were treated in an open-label manner with four fractions of TSEBT 1Gy weekly to a total skin dose of 10Gy. Treatment responses were assessed at 1 and 3months after treatment and subsequently at least every 6months for a total period of 2years or to disease relapse or progression. Patients achieved an overall response rate of 90%. The rate of CR or very good partial response (VGPR; <1% skin affected with patches/plaques) was 70%. The median response duration was 5·2months (range 83-469days) for CR and VGPR. Adverse effects were generally mild to moderate in severity. Low-dose TSEBT (10Gy) gave a satisfactory response rate and was well tolerated in patients with MF stage IB-IV. Future studies should determine if the combination of low-dose TSEBT with other agents could increase the rate of CR and response duration.
The value of performing post-therapy routine surveillance imaging in patients with Hodgkin lympho... more The value of performing post-therapy routine surveillance imaging in patients with Hodgkin lymphoma is controversial. This study evaluates the utility of positron emission tomography/computed tomography using 2-[18F]fluoro-2-deoxyglucose for this purpose and in situations with suspected lymphoma relapse. We conducted a multicenter retrospective study. Patients with newly diagnosed Hodgkin lymphoma achieving at least a partial remission on first-line therapy were eligible if they received positron emission tomography/computed tomography surveillance during follow-up. Two types of imaging surveillance were analyzed: "routine" when patients showed no signs of relapse at referral to positron emission tomography/computed tomography, and "clinically indicated" when recurrence was suspected. A total of 211 routine and 88 clinically indicated positron emission tomography/computed tomography studies were performed in 161 patients. In ten of 22 patients with recurrence of ...
To evaluate against Monte-Carlo the performance of various dose calculations algorithms regarding... more To evaluate against Monte-Carlo the performance of various dose calculations algorithms regarding lung tumour coverage in stereotactic body radiotherapy (SBRT) conditions. Dose distributions in virtual lung phantoms have been calculated using four commercial Treatment Planning System (TPS) algorithms and one Monte Carlo (MC) system (EGSnrc). We compared the performance of the algorithms in calculating the target dose for different degrees of lung inflation. The phantoms had a cubic 'body' and 'lung' and a central 2-cm diameter spherical 'tumour' (the body and tumour have unit density). The lung tissue was assigned five densities (rho(lung)): 0.01, 0.1, 0.2, 0.4 and 1g/cm(3). Four-field treatment plans were calculated with 6- and 18 MV narrow beams for each value of rho(lung). We considered the Pencil Beam Convolution (PBC(Ecl)) and the Analytical Anisotropic Algorithm (AAA(Ecl)) from Varian Eclipse and the Pencil Beam Convolution (PBC(OMP)) and the Collapsed Cone Convolution (CCC(OMP)) algorithms from Oncentra MasterPlan. When changing rho(lung) from 0.4 to 0.1g/cm(3), the MC median target dose decreased from 89.2% to 74.9% for 6 MV and from 83.3% to 61.6% for 18 MV (of dose maximum in the homogenous case at both energies), while for both PB algorithms the median target dose was virtually independent of lung density. Both PB algorithms overestimated the target dose, the overestimation increasing as rho(lung) decreased. Concerning target dose, the AAA(Ecl) and CCC(OMP) algorithms appear to be adequate alternatives to MC.
This study aimed at quantifying the breathing variations among lung cancer patients over full cou... more This study aimed at quantifying the breathing variations among lung cancer patients over full courses of fractionated radiotherapy. The intention was to relate these variations to the margins assigned to lung tumours, to account for respiratory motion, in fractionated radiotherapy. Eleven lung cancer patients were included in the study. The patients' chest wall motions were monitored as a surrogate measure for breathing motion during each fraction of radiotherapy by use of an external optical marker. The exhale level variations were evaluated with respect to exhale points and fraction-baseline, defined for intra- and interfraction variations respectively. The breathing amplitude was evaluated as breathing cycle amplitudes and fraction-max-amplitudes defined for intra- and interfraction breathing, respectively. The breathing variations over a full treatment course, including both intra- and interfraction variations, were 15.2mm (median over the patient population), range 5.5-26.7mm, with the variations in exhale level as the major contributing factor. The median interfraction span in exhale level was 14.8mm, whereas the median fraction-max-amplitude was 6.1mm (median of patient individual SD 1.4). The median intrafraction span in exhale level was 1.6mm, and the median breathing cycle amplitude was 4.0mm (median of patient individual SD 1.4). The variations in externally measured exhale levels are larger than variations in breathing amplitude. The interfraction variations in exhale level are in general are up to 10 times larger than intrafraction variations. Margins to account for respiratory motion cannot safely be based on one planning session, especially not if relying on measuring external marker motion. Margins for lung tumours should include interfraction variations in breathing.
Adjuvant radiotherapy after breast-conserving surgery for breast cancer implies a risk of late ca... more Adjuvant radiotherapy after breast-conserving surgery for breast cancer implies a risk of late cardiac and pulmonary toxicity. This is the first study to evaluate cardiopulmonary dose sparing of breathing adapted radiotherapy (BART) using free breathing gating, and to compare this respiratory technique with voluntary breath-hold. 17 patients were CT-scanned during non-coached breathing manoeuvre including free breathing (FB), end-inspiration gating (IG), end-expiration gating (EG), deep inspiration breath-hold (DIBH) and end-expiration breath-hold (EBH). The Varian Real-time Position Management system (RPM) was used to monitor respiratory movement and to gate the scanner. For each breathing phase, a population based internal margin (IM) was estimated based on average chest wall excursion, and incorporated into an individually optimised three-field mono-isocentric wide tangential photon field treatment plan for each scan. The target included the remaining breast, internal mammary nodes and periclavicular nodes. The mean anteroposterior chest wall excursion during FB was 2.5mm. For IG and EG, the mean excursions within gating windows were 1.1 and 0.7 mm, respectively, whereas for DIBH and EBH the excursions were 4.1 and 2.6mm, respectively. For patients with left-sided cancer, the median heart volume receiving more than 50% of the prescription dose was reduced from 19.2% for FB to 2.8% for IG and 1.9% for DIBH, and the median left anterior descending (LAD) coronary artery volume was reduced from 88.9% to 22.4% for IG and 3.6% for DIBH. Simultaneously, the median ipsilateral relative lung volume irradiated to >50% of the prescribed target dose for both right- and left-sided cancers was reduced from 45.6% for FB to 29.5% for IG and 27.7% for DIBH. For EBH and EG, both the irradiated heart, LAD and lung volumes increased compared to FB. This is the first study to demonstrate the dosimetric benefits of free breathing gated breast cancer radiotherapy. IG compared favourably with DIBH, substantially reducing cardiac doses simultaneous with significant pulmonary tissue sparing.
Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology, 2014
To analyze the recurrence pattern in relation to target volumes and (18)F-fluorodeoxyglucose (FDG... more To analyze the recurrence pattern in relation to target volumes and (18)F-fluorodeoxyglucose (FDG) uptake on positron emission tomography in head and neck squamous cell carcinoma (HNSCC) patients treated with definitive chemoradiation. 520 patients received radiotherapy for HNSCC from 2005 to 2009. Among 100 patients achieving complete clinical response and a later recurrence, 39 patients with 48 loco-regional failures had a recurrence CT scan before any salvage therapy. The estimated point of origin of each recurrence was transferred to the planning CT by deformable image co-registration. The recurrence position was then related to the delineated target volumes and iso-SUV-contours relative to the maximum standard uptake value (SUV). We defined the recurrence density as the total number of recurrences in a sub-volume divided by the sum of that volume for all patients. 54% (95% CI 37-69%) of recurrences originated inside the FDG-positive volume and 96% (95% CI 86-99%) in the high do...
Adjuvant radiotherapy of breast cancer using wide tangential photon fields implies a risk of late... more Adjuvant radiotherapy of breast cancer using wide tangential photon fields implies a risk of late cardiac and pulmonary toxicity. This CT-study evaluates the detailed potential dosimetric consequences of applying breathing adapted radiotherapy (BART), and the feasibility of a monitored voluntary breath-hold technique for right-sided as well as for left-sided tumours. After breast-conserving surgery, 16 patients were CT-scanned in distinct respiratory phases using the varian real-time position management system for the monitoring of respiratory anterioposterior chest wall excursion. Each patient underwent three scans: during free breathing (FB), voluntary expiration breath-hold (EBH) and voluntary deep inspiration breath-hold (DIBH). For each scan, an optimised treatment plan was designed with conformal tangential fields encompassing the clinical target volume (CTV) of the breast and ipsilateral internal mammary nodes, and an anterior supraclavicular field. Breath-hold was well accepted by the patients, with a median duration of 24 s for both EBH and DIBH. The mean anterioposterior chest wall excursions were 2.5, 2.6 and 4.1 mm during FB, EBH and DIBH, respectively. During EBH, the mean front chest wall position was 2.7 mm posterior to its mid-FB position, and during DIBH 12.6 mm anterior to its mid-FB position. For right-sided tumours, the median ipsilateral relative lung volume receiving >50% of the prescribed CTV dose was 39, 49 and 32% for FB, EBH and DIBH, respectively. For left-sided tumours, the corresponding percentages were 37, 46 and 31%. The median heart volume receiving >50% of the prescription dose was reduced from 8% for FB to 1% for DIBH, and the median left anterior descending coronary artery volume was reduced from 54 to 5%. Irradiated cardiac volumes can consistently be reduced for left-sided breast cancers using DIBH for wide tangential treatment fields. Additionally, substantial dose reductions in the lung are observed for both right- and left-sided tumours.
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Papers by Lena Specht