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Response to “Helical Tomotherapy for Simultaneous Multitarget Radiotherapy for Pulmonary Metastasis.” (Int J Radiat Oncol Biol Phys 2009;75:703–710)
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I. J. Radiation Oncology d Biology d Physics MARIA GIULIA ZAMPINO, M.D. ELENA MAGNI, M.D. MARIA CRISTINA LEONARDI, M.D. FABRIZIO LUCA, M.D. European Institute of Oncology Department of Medicine Milan, Italy doi:10.1016/j.ijrobp.2009.11.045
1. Mutahir AT, Hashmi AF. Capecitabine initially concomitant to radiotherapy then perioperatively administered in locally advanced rectal cancer. In reply to MG Zampino et al. Int J Radiat Oncol Biol Phys 2009;75:421–427. 2. Zampino MG, Magni E, Leonardi MC, et al. Capecitabine initially concomitant to radiotherapy then perioperatively administered in locally advanced rectal cancer. Int J Radiat Oncol Biol Phys 2009;75:421–427. 3. Kim DY, Jung KH, Kim TH, et al. Comparison of 5-fluorouracil/leucovorin and capecitabine into chemoradiotherapy regimens for locally advanced rectal cancer. Int J Radiat Oncol Biol Phys 2007;67:378–384. 4. Kim JC, Kim TW, Kim JU, et al. Preoperative concurrent radiotherapy with capecitabine before total mesorectal excision in locally advanced rectal cancer. Int J Radiat Oncol Biol Phys 2005;63:346–353. 5. Bullard KM, Trudel JL, Baxter NN, Rothenberger DA. Primary perineal wound closure after preoperative radiotherapy and abdominoperineal resection has a high incidence of wound failure. Dis Colon Rectum 2005;48(3):438–443. 6. Christian CK, Kwaan MR, Betensky RA, et al. Risk factors for perineal wound complications following abdominoperineal resection ha s a high incidence of wound failure. Dis Colon Rectum 2005;48:438–443. 7. Vauthey JN, Palavecino M, Curley S, et al. Right hepatic trisectionectomy for hepatobiliary disease: Results and an appraisal of its current role. Ann Surg 2008;248(1):138–140. 8. Khorana AA, Connolly GC. Assessing risk of venous thromboembolism in the patient with cancer. JCO 2009;27:4839–4847. 9. Mannaerts GHH, Schijven MP, Hendrikx A, et al. Urologic and sexual morbidity following multimodality treatment for locally advanced primary and locally recurrent rectal cancer. Eur J Surg Oncol 2001;27:265–272. 10. Das IJ, Lanciano RM, Movsas B, et al. Efficacy of a belly board device with CT-simulation in reducing small bowel volume with pelvic irradiation fields. Int J Radiat Oncol Biol Phys 1997;39:67–76.
RESPONSE TO ‘‘HELICAL TOMOTHERAPY FOR SIMULTANEOUS MULTITARGET RADIOTHERAPY FOR PULMONARY METASTASIS.’’ (INT J RADIAT ONCOL BIOL PHYS 2009;75:703–710) To the Editor: We read the study of Kim and colleagues (1) with great interest. This report has a potential merit to widen the role of radiotherapy from local therapy to regional or nearly systemic radiotherapy. On the other hand, the risk assessment for each organ should be cautiously undertaken before their tactics are applied. They treated several organs at the same time (2). For lung, they tried to decrease the risk of pulmonary toxicity by reducing the MLD (25 Gy) and V25 (\35%) in favorable groups according to Miller et al. (3). However, this guideline should be applied mainly in 2-Gy daily fractions, and 40–50 Gy of prescribed dose in 10 fractions within 2 weeks with stereotactic body radiation therapy (SBRT) required more severe constraints. For example, Baisden et al. reported a constraint for helical tomotherapy SBRT V20 \ 10% (or \15% in a minor protocol deviation) from the results of the Radiation Therapy Oncology Group 0236 protocol (4). Then, Park et al. reported their early computed tomography finding in a similar patient group (2005–2007): 52% of radiation pneumonitis and 20% of steroid requirement (5). Inasmuch as there is a discrepancy in toxicity between conventional 2-Gy fractionation and SBRT, they should follow up longer to assess the toxicity or initiate a Phase I study for dose escalation. Short life expectancy would cover toxicities; however, dose– response (including pneumonia) correlation data will be fruitful for future understanding because few data are shown about planning target volume in their articles. HIDEYA YAMAZAKI, M.D. Kyoto Prefectural University of Medicine Kyoto, Japan
Volume 76, Number 4, 2010 doi:10.1016/j.ijrobp.2009.11.047 1. Kim JY, Kay CS, Kim YS, et al. Helical tomotherapy for simultaneous multitarget radiotherapy for pulmonary metastasis. Int J Radiat Oncol Biol Phys 2009;75:703–710. 2. Jang JW, Kay CS, You CR, et al. Simultaneous multitarget irradiation using helical tomotherapy for advanced hepatocellular carcinoma with multiple extrahepatic metastases. Int J Radiat Oncol Biol Phys 2009;74:412–418. 3. Miller KL, Shafman TD, Marks LB. A practical approach to pulmonary risk assessment in the radiotherapy of lung cancer. Semin Radiat Oncol 2004;14:298–307. 4. Baisden JM, Romney DA, Reish AG, et al. Dose as a function of lung volume and planned treatment volume in helical tomotherapy intensitymodulated radiation therapy-based stereotactic body radiation therapy for small lung tumors. Int J Radiat Oncol Biol Phys 2007;68:1229–1237. 5. Park HJ, Kim KJ, Park SH, et al. Early CT findings of tomotherapyinduced radiation pneumonitis after treatment of lung malignancy. Am J Roentgenol 2009;193:W209–W213.
IN REPLY TO DR. YAMAZAKI To the Editor: In Dr. Yamazaki’s letter, he pointed to the limitation of our study (1), that is, jumping constraint application from conventional to stereotactic body radiation therapy (SBRT), and he took the Radiation Therapy Oncology Group 0236 protocol (2) as an example. However, the dose schedules were different in the studies. The fractional dose and total dose were 5 Gy and 50 Gy with 10 fractions in our study and 20 Gy and 60 Gy with 3 fractions in Radiation Therapy Oncology Group 0236, respectively. The biologic isoeffective dose can be differently predicted in regard to different dose schedules. The prediction of isoeffective dose is appropriate in a certain dose range (3) or inappropriate in another dose schedule such as radiosurgery (4). Milano et al. recently reported the recommendations consisting of the fractional dose from 5 Gy to 7 Gy in 10 fractions with SBRT, at least 700–1000 mL of lung not involved with gross disease and V20 of 25– 30% for safe hypofractionated SBRT in lung tumor (5), but they did not comment about the patients’ pulmonary condition. Our group has published two articles regarding tomotherapy in pulmonary metastases, as Dr. Yamazaki commented. The discrepancy in Grade II radiation pneumonitis appeared in those studies. The rate of medical treatment requirement for radiation pneumonitis was 20% (5/25) in one study (6) and 9.6% (3/31) in another study (1). In the study of Park et al., they excluded patients who had central lung tumor or mediastinal lymph node involvement because it was difficult to differentiate radiation pneumonitis from obstructive pneumonitis, and they included the patients with extrapulmonary metastases (6). But Kim et al. included central lung tumor and excluded synchronous extrapulmonary metastasis (1). However, because the number of patients was too small and the follow-up period was short, we agree that we should follow up longer to assess the toxicities, including decreased pulmonary function due to radiation fibrosis as a late complication (7), or develop our study through a clinical trial. In that clinical trial, not too long survival after treatment in multiple metastases may be the limitation. CHUL-SEUNG KAY, M.D. Department of Radiation Oncology Incheon St. Mary’s Hospital Catholic University of Korea College of Medicine Inchon, Korea doi:10.1016/j.ijrobp.2009.12.008 1. Kim JY, Kay CS, Kim YS, et al. Helical tomotherapy for simultaneous multitarget radiotherapy for pulmonary metastasis. Int J Radiat Oncol Biol Phys 2009;75:703–710. 2. Baisden JM, Romney DA, Reish AG, et al. Doses as a function of lung volume and planned treatment volume in helical tomotherapy intensity modulated radiation therapy based stereotactic body radiation therapy for small lung tumors. Int J Radiat Oncol Biol Phys 2007;68:1229–1237. 3. Brenner DJ. The linear quadratic model is an appropriate methodology for determining isoeffective dose at large doses per fraction. Semin Radiat Oncol 2008;18:234–239. 4. Kirkpatrick JP, Meyer JJ, Mark LB. The linear quadratic model is inappropriate to model high dose per fraction effects in radiosurgery. Semin Radiat Oncol 2008;18:240–243. 5. Milano MT, Constine LS, Okunieff P. Normal tissue toxicity after small field hypofractionated stereotactic radiation. Radiat Oncol 2008;3:36.
I. J. Radiation Oncology d Biology d Physics MARIA GIULIA ZAMPINO, M.D. ELENA MAGNI, M.D. MARIA CRISTINA LEONARDI, M.D. FABRIZIO LUCA, M.D. European Institute of Oncology Department of Medicine Milan, Italy doi:10.1016/j.ijrobp.2009.11.045
1. Mutahir AT, Hashmi AF. Capecitabine initially concomitant to radiotherapy then perioperatively administered in locally advanced rectal cancer. In reply to MG Zampino et al. Int J Radiat Oncol Biol Phys 2009;75:421–427. 2. Zampino MG, Magni E, Leonardi MC, et al. Capecitabine initially concomitant to radiotherapy then perioperatively administered in locally advanced rectal cancer. Int J Radiat Oncol Biol Phys 2009;75:421–427. 3. Kim DY, Jung KH, Kim TH, et al. Comparison of 5-fluorouracil/leucovorin and capecitabine into chemoradiotherapy regimens for locally advanced rectal cancer. Int J Radiat Oncol Biol Phys 2007;67:378–384. 4. Kim JC, Kim TW, Kim JU, et al. Preoperative concurrent radiotherapy with capecitabine before total mesorectal excision in locally advanced rectal cancer. Int J Radiat Oncol Biol Phys 2005;63:346–353. 5. Bullard KM, Trudel JL, Baxter NN, Rothenberger DA. Primary perineal wound closure after preoperative radiotherapy and abdominoperineal resection has a high incidence of wound failure. Dis Colon Rectum 2005;48(3):438–443. 6. Christian CK, Kwaan MR, Betensky RA, et al. Risk factors for perineal wound complications following abdominoperineal resection ha s a high incidence of wound failure. Dis Colon Rectum 2005;48:438–443. 7. Vauthey JN, Palavecino M, Curley S, et al. Right hepatic trisectionectomy for hepatobiliary disease: Results and an appraisal of its current role. Ann Surg 2008;248(1):138–140. 8. Khorana AA, Connolly GC. Assessing risk of venous thromboembolism in the patient with cancer. JCO 2009;27:4839–4847. 9. Mannaerts GHH, Schijven MP, Hendrikx A, et al. Urologic and sexual morbidity following multimodality treatment for locally advanced primary and locally recurrent rectal cancer. Eur J Surg Oncol 2001;27:265–272. 10. Das IJ, Lanciano RM, Movsas B, et al. Efficacy of a belly board device with CT-simulation in reducing small bowel volume with pelvic irradiation fields. Int J Radiat Oncol Biol Phys 1997;39:67–76.
RESPONSE TO ‘‘HELICAL TOMOTHERAPY FOR SIMULTANEOUS MULTITARGET RADIOTHERAPY FOR PULMONARY METASTASIS.’’ (INT J RADIAT ONCOL BIOL PHYS 2009;75:703–710) To the Editor: We read the study of Kim and colleagues (1) with great interest. This report has a potential merit to widen the role of radiotherapy from local therapy to regional or nearly systemic radiotherapy. On the other hand, the risk assessment for each organ should be cautiously undertaken before their tactics are applied. They treated several organs at the same time (2). For lung, they tried to decrease the risk of pulmonary toxicity by reducing the MLD (25 Gy) and V25 (\35%) in favorable groups according to Miller et al. (3). However, this guideline should be applied mainly in 2-Gy daily fractions, and 40–50 Gy of prescribed dose in 10 fractions within 2 weeks with stereotactic body radiation therapy (SBRT) required more severe constraints. For example, Baisden et al. reported a constraint for helical tomotherapy SBRT V20 \ 10% (or \15% in a minor protocol deviation) from the results of the Radiation Therapy Oncology Group 0236 protocol (4). Then, Park et al. reported their early computed tomography finding in a similar patient group (2005–2007): 52% of radiation pneumonitis and 20% of steroid requirement (5). Inasmuch as there is a discrepancy in toxicity between conventional 2-Gy fractionation and SBRT, they should follow up longer to assess the toxicity or initiate a Phase I study for dose escalation. Short life expectancy would cover toxicities; however, dose– response (including pneumonia) correlation data will be fruitful for future understanding because few data are shown about planning target volume in their articles. HIDEYA YAMAZAKI, M.D. Kyoto Prefectural University of Medicine Kyoto, Japan
Volume 76, Number 4, 2010 doi:10.1016/j.ijrobp.2009.11.047 1. Kim JY, Kay CS, Kim YS, et al. Helical tomotherapy for simultaneous multitarget radiotherapy for pulmonary metastasis. Int J Radiat Oncol Biol Phys 2009;75:703–710. 2. Jang JW, Kay CS, You CR, et al. Simultaneous multitarget irradiation using helical tomotherapy for advanced hepatocellular carcinoma with multiple extrahepatic metastases. Int J Radiat Oncol Biol Phys 2009;74:412–418. 3. Miller KL, Shafman TD, Marks LB. A practical approach to pulmonary risk assessment in the radiotherapy of lung cancer. Semin Radiat Oncol 2004;14:298–307. 4. Baisden JM, Romney DA, Reish AG, et al. Dose as a function of lung volume and planned treatment volume in helical tomotherapy intensitymodulated radiation therapy-based stereotactic body radiation therapy for small lung tumors. Int J Radiat Oncol Biol Phys 2007;68:1229–1237. 5. Park HJ, Kim KJ, Park SH, et al. Early CT findings of tomotherapyinduced radiation pneumonitis after treatment of lung malignancy. Am J Roentgenol 2009;193:W209–W213.
IN REPLY TO DR. YAMAZAKI To the Editor: In Dr. Yamazaki’s letter, he pointed to the limitation of our study (1), that is, jumping constraint application from conventional to stereotactic body radiation therapy (SBRT), and he took the Radiation Therapy Oncology Group 0236 protocol (2) as an example. However, the dose schedules were different in the studies. The fractional dose and total dose were 5 Gy and 50 Gy with 10 fractions in our study and 20 Gy and 60 Gy with 3 fractions in Radiation Therapy Oncology Group 0236, respectively. The biologic isoeffective dose can be differently predicted in regard to different dose schedules. The prediction of isoeffective dose is appropriate in a certain dose range (3) or inappropriate in another dose schedule such as radiosurgery (4). Milano et al. recently reported the recommendations consisting of the fractional dose from 5 Gy to 7 Gy in 10 fractions with SBRT, at least 700–1000 mL of lung not involved with gross disease and V20 of 25– 30% for safe hypofractionated SBRT in lung tumor (5), but they did not comment about the patients’ pulmonary condition. Our group has published two articles regarding tomotherapy in pulmonary metastases, as Dr. Yamazaki commented. The discrepancy in Grade II radiation pneumonitis appeared in those studies. The rate of medical treatment requirement for radiation pneumonitis was 20% (5/25) in one study (6) and 9.6% (3/31) in another study (1). In the study of Park et al., they excluded patients who had central lung tumor or mediastinal lymph node involvement because it was difficult to differentiate radiation pneumonitis from obstructive pneumonitis, and they included the patients with extrapulmonary metastases (6). But Kim et al. included central lung tumor and excluded synchronous extrapulmonary metastasis (1). However, because the number of patients was too small and the follow-up period was short, we agree that we should follow up longer to assess the toxicities, including decreased pulmonary function due to radiation fibrosis as a late complication (7), or develop our study through a clinical trial. In that clinical trial, not too long survival after treatment in multiple metastases may be the limitation. CHUL-SEUNG KAY, M.D. Department of Radiation Oncology Incheon St. Mary’s Hospital Catholic University of Korea College of Medicine Inchon, Korea doi:10.1016/j.ijrobp.2009.12.008 1. Kim JY, Kay CS, Kim YS, et al. Helical tomotherapy for simultaneous multitarget radiotherapy for pulmonary metastasis. Int J Radiat Oncol Biol Phys 2009;75:703–710. 2. Baisden JM, Romney DA, Reish AG, et al. Doses as a function of lung volume and planned treatment volume in helical tomotherapy intensity modulated radiation therapy based stereotactic body radiation therapy for small lung tumors. Int J Radiat Oncol Biol Phys 2007;68:1229–1237. 3. Brenner DJ. The linear quadratic model is an appropriate methodology for determining isoeffective dose at large doses per fraction. Semin Radiat Oncol 2008;18:234–239. 4. Kirkpatrick JP, Meyer JJ, Mark LB. The linear quadratic model is inappropriate to model high dose per fraction effects in radiosurgery. Semin Radiat Oncol 2008;18:240–243. 5. Milano MT, Constine LS, Okunieff P. Normal tissue toxicity after small field hypofractionated stereotactic radiation. Radiat Oncol 2008;3:36.