Publications by authors named "Ezgi Oymak"

22 Publications

  • Page 1 of 1

Clinical parameters and nomograms for predicting lymph node metastasis detected with Ga-PSMA-PET/CT in prostate cancer patients candidate to definitive radiotherapy.

Prostate 2021 May 5. Epub 2021 May 5.

Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey.

Background: Defining the extent of disease spread with imaging modalities is crucial for therapeutic decision-making and definition of treatment. This study aimed to investigate whether clinical parameters and nomograms predict prostate-specific membrane antigen (PSMA)-positive lymph nodes in treatment-naïve nonmetastatic prostate cancer (PC) patients.

Materials And Methods: The clinical data of 443 PC patients (83.3% high-risk and 16.7% intermediate-risk) were retrospectively analyzed. Receiver operating characteristic (ROC) curves with areas under the curve (AUC) were generated to evaluate the accuracy of clinical parameters (prostate-specific antigen [PSA], T stage, Gleason score [GS], International Society of Urological Pathology [ISUP] grade) and nomograms (Roach formula [RF], Yale formula [YF], and a new formula [NF]) in predicting lymph node metastasis. The AUCs of the various parameters and clinical nomograms were compared using ROC and precision-recall (PR) curves.

Results: A total of 288 lymph node metastases were identified in 121 patients (27.3%) using Ga-PSMA-11-positron emission tomography (PET)/computed tomography (CT). Most PSMA-avid lymph node metastases occurred in external or internal iliac lymph nodes (142; 49.3%). Clinical T stage, PSA, GS, and ISUP grade were significantly associated with PSMA-positive lymph nodes according to univariate logistic regression analysis. The PSMA-positive lymph nodes were more frequently detected in patients with PSA >20 ng/ml, GS ≥7 or high risk disease compared to their counterparts. The clinical T stage, serum PSA level, GS, and ISUP grade showed similar accuracy in predicting PSMA-positive metastasis, with AUC values ranging from 0.675 to 0.704. The median risks for PSMA-positive lymph nodes according to the RF, YF, and NF were 31.3% (range: 12.3%-100%), 22.3% (range: 4.7%-100%), and 40.5% (range: 12.3%-100%), respectively. The AUC values generated from ROC and PR curve analyses were similar for all clinical nomograms, although the RF and YF had higher accuracy compared to NF.

Conclusion: The clinical T stage, PSA, GS, and ISUP grade are independent predictors of PSMA-positive lymph nodes. The RF and YF can be used to identify patients who can benefit from Ga-PSMA-11 PET/CT for the detection of lymph node metastasis. Together with nomograms, Ga-PSMA-11 PET/CT images help to localize PSMA-positive lymph node metastases and can thus assist in surgery and radiotherapy planning.
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http://dx.doi.org/10.1002/pros.24142DOI Listing
May 2021

Stereotactic body radiotherapy for oligoprogressive lesions in metastatic castration-resistant prostate cancer patients during abiraterone/enzalutamide treatment.

Prostate 2021 Apr 27. Epub 2021 Apr 27.

Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey.

Background: Metastasis-directed therapy (MDT) utilizing stereotactic body radiotherapy (SBRT) for oligoprogressive lesions could provide a delay in next-line systemic treatment (NEST) change while undergoing androgen receptor-targeted agents (ARTA) treatment. We evaluated prognostic factors for prostate cancer-specific survival (PCSS) and progression-free survival (PFS) to characterize patients receiving treatment with ARTA who may benefit from MDT for oligoprogressive lesions. The impact of MDT on delaying NEST and the predictive factors for NEST-free survival (NEST-FS) were also assessed.

Materials And Methods: The clinical data of 54 metastatic castration-resistant prostate cancer patients with 126 oligoprogressive lesions receiving abiraterone (1 g/day) or enzalutamide (160 mg/day) before or after systemic chemotherapy were analyzed. A median of three lesions (range: 1-5) were treated with MDT. The primary endpoints were PCSS and PFS. The secondary endpoints were time to switch to NEST and NEST-FS.

Results: The median follow-up time was 19.1 months. Univariate analysis showed that the number of oligoprogressive lesions treated with SBRT and the time between the start of ARTA treatment and oligoprogression were significant prognostic factors for PCSS, and the timing of ARTA treatment (before or after chemotherapy) and the prostate-specific antigen (PSA) response after MDT were significant prognostic factors for PFS. Multivariate analysis showed that early MDT for oligoprogressive lesions delivered less than 6 months after the beginning of ARTA and higher PSA levels after MDT were significant predictors of worse PCSS and PFS. The median total duration of ARTA treatment was 13.8 months. The median time between the start of ARTA treatment and the start of MDT for oligoprogressive lesions was 5.2 months, and MDT extended the ARTA treatment by 8.6 months on average. Thirty-two (59.3%) patients continued ARTA treatment after MDT. ARTA treatment after chemotherapy, early oligoprogression requiring MDT, and lower radiation doses for MDT were independent predictors of NEST-FS in multivariate analysis.

Conclusions: MDT for oligoprogressive lesions is effective and may provide several benefits compared to switching from ARTA treatment to NEST. Patients with early progression while on ARTAs and inadequate PSA responses after MDT have a greater risk of rapid disease progression and poor survival, which necessitates intensified treatment.
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http://dx.doi.org/10.1002/pros.24132DOI Listing
April 2021

Stereotactic radiotherapy to oligoprogressive lesions detected with Ga-PSMA-PET/CT in castration-resistant prostate cancer patients.

Eur J Nucl Med Mol Imaging 2021 Mar 10. Epub 2021 Mar 10.

Department of Radiation Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey.

Purpose: We assessed the outcomes of stereotactic body radiotherapy (SBRT) to treat oligoprogressive castration-resistant prostate cancer (CRPC) patients with ≤5 lesions using gallium prostate-specific membrane antigen-positron emission tomography (Ga-PSMA-PET/CT).

Methods: The clinical data of 67 CRPC patients with 133 lesions treated with Ga-PSMA-PET/CT-based SBRT were retrospectively analyzed. All of the patients had oligoprogressive disease during androgen-deprivation therapy (ADT). The prognostic factors for overall- (OS) and progression-free survival (PFS) and the predictive factors for switching to next-line systemic treatment (NEST) and NEST-free survival (NEST-FS) were analyzed.

Results: With a median follow-up of 17.5 months, the 2-year overall survival (OS) and PFS rates were 86.9% and 34.4%, respectively. The PSA response was observed in 49 patients (73.1%). Progression was observed in 37 patients (55.2%) at a median of 11.0 months following SBRT. A total of 45 patients (67.2%) remained on ADT after SBRT, and 22 patients (32.8%) had a NEST change at a median of 16.4 months after metastasis-directed treatment (MDT). Patients with a NEST change had higher post-SBRT PSA values and fewer PSA nadirs after MDT than their counterparts. In multivariate analysis, higher pre-SBRT PSA values were the only significant predictor for worse OS and NEST-FS, and no significant factor was found for PFS. No serious acute or late toxicities were observed.

Conclusion: This study demonstrated the feasibility of MDT using SBRT to treat oligoprogressive lesions by Ga-PSMA-PET/CT in CRPC patients is efficient and well-tolerated, prolonging the effectiveness of ADT by delaying NEST.
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http://dx.doi.org/10.1007/s00259-021-05298-zDOI Listing
March 2021

Oligometastatic Bone Disease in Castration-Sensitive Prostate Cancer Patients Treated With Stereotactic Body Radiotherapy Using 68Ga-PSMA PET/CT: TROD 09-004 Study.

Clin Nucl Med 2021 06;46(6):465-470

Department of Radiation Oncology, Hacettepe University Faculty of Medicine, Ankara.

Purpose: To evaluate the outcomes of metastasis-directed treatment (MDT) using stereotactic body radiotherapy (SBRT) for bone-only oligometastasis (OM) detected with gallium prostate-specific membrane antigen (68Ga-PSMA) PET/CT in castration-sensitive prostate cancer (PC) patients.

Methods: In this multi-institutional study, clinical data of 74 PC patients with 153 bone lesions who were undergoing MDT were retrospectively evaluated. Twenty-seven patients (36.5%) had synchronous, and 47 (63.5%) had metachronous OM. All patients had PC with 5 metastases or fewer detected by 68Ga-PSMA PET/CT and treated using SBRT with a median dose of 20 Gy. The prognostic factors for PC-specific survival (PCSS) and progression-free survival (PFS) were analyzed.

Results: The median follow-up was 27.3 months. Patients with synchronous OM were older and received higher rates of androgen deprivation therapy after SBRT compared with patients with metachronous OM. The 2-year PCSS and PFS rates were 92.0% and 72.0%, respectively. A prostate-specific antigen (PSA) decline was observed in 56 patients (75.7%), and 48 (64.9%) had a PSA response defined as at least 25% decrease of PSA after MDT. The 2-year local control rate per lesion was 95.4%. In multivariate analysis, single OM and PSA response after MDT were significant predictors for better PCSS and PFS. In-field recurrence was observed in 4 patients (6.5%) with 10 lesions at a median of 13.1 months after MDT completion. No serious late toxicity was observed.

Conclusions: We demonstrated that SBRT is an efficient and well-tolerated treatment option for PC patients with 5 bone-only oligometastases or fewer detected with 68Ga-PSMA PET/CT.
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http://dx.doi.org/10.1097/RLU.0000000000003558DOI Listing
June 2021

Role of 68-Ga-PSMA-PET/CT in pelvic radiotherapy field definitions for lymph node coverage in prostate cancer patients.

Radiother Oncol 2020 10 28;151:222-227. Epub 2020 Aug 28.

Department of Radiation Oncology, Hacettepe University, Faculty of Medicine, Ankara, Turkey.

Purpose: To evaluate the distribution of metastatic lymph nodes (LN) detected on Ga-PSMA-positron emission tomography/computed tomography (PET/CT) in treatment-naïve prostate cancer (PC) patients and to analyze the LN coverage rates of the pelvic fields defined in the GETUG trial and RTOG guidelines and a pelvic field extending superiorly from the L4/L5 interspace.

Materials And Methods: Ga-PSMA-PET/CT images obtained at diagnosis of 138 PC patients were retrospectively analyzed. The number and locations of Ga-PSMA-positive LNs were co-registered with one single-planning CT. The numbers, locations, and sizes of LNs located outside the three pelvic volumes were investigated for the entire cohort and for patients with LN metastasis in the pelvic area only.

Results: A total of 441 PSMA-PET-positive LN metastases were identified. The most frequent metastatic LNs were internal iliac LNs (25.2%). Para-aortic and presacral LNs outside the three pelvic fields were present in 20 (14.5%) and 22 patients (15.9%), respectively. The LN coverage rates according to the GETUG trial, the RTOG guidelines, and the pelvic field extending superiorly from L4/L5 were 44.2%, 52.2%, and 71, respectively, in the entire cohort and 51.7%, 61 and 83.1%, respectively, in patients with only pelvic LN metastasis. The number of metastatic LNs was a predictive factor for LNs located outside the three pelvic fields.

Conclusions: Extending the cranial margin of the pelvic field from L5/S1 to L4/L5 increases the accuracy of pelvic field irradiation in approximately 20% of patients, highlighting the importance of proximal common iliac irradiation, particularly in patients with multiple LN metastasis.
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http://dx.doi.org/10.1016/j.radonc.2020.08.021DOI Listing
October 2020

Treatment outcomes of metastasis-directed treatment using Ga-PSMA-PET/CT for oligometastatic or oligorecurrent prostate cancer: Turkish Society for Radiation Oncology group study (TROD 09-002).

Strahlenther Onkol 2020 Nov 2;196(11):1034-1043. Epub 2020 Jul 2.

Faculty of Medicine, Department of Radiation Oncology, Hacettepe University, Ankara, Turkey.

Purpose: The aim of this study was to evaluate the outcomes of Ga prostate-specific membrane antigen (Ga-PSMA) positron-emission tomography (PET)/CT-based metastasis-directed treatment (MDT) for oligometastatic prostate cancer (PC).

Methods: In this multi-institutional study, clinical data of 176 PC patients with 353 lesions receiving MDT between 2014 and 2019 were retrospectively evaluated. All patients had biopsy proven PC with ≤5 metastases detected with Ga-PSMA-PET/CT. MDT was delivered with conventional fractionation or stereotactic body radiotherapy (SBRT) techniques. CTCAE v4.0 was used for acute and RTOG/EORTC Late Radiation Morbidity Scoring Schema was used for late toxicity evaluation.

Results: At the time of MDT, 59 patients (33.5%) had synchronous and 117 patients (66.5%) had metachronous metastases. Median number of metastases was one and the MDT technique was SBRT in 73.3% patients. The 2‑year overall survival (OS) and progression-free survival (PFS) rates were 87.6% and 63.1%, respectively. With a median follow-up of 22.9 months, 9 patients had local recurrence at the irradiated site. The 2‑year local control rate at the treated oligometastatic site per patient was 93.2%. In multivariate analysis, an increased number of oligometastases and untreated primary PC were negative predictors for OS; advanced clinical tumor stage, untreated primary PC, BED3 value of ≤108 Gy, and MDT with conventional fractionation were negative predictors for PFS. No patient experienced grade ≥3 acute toxicity, but one patient had a late grade 3 toxicity of compression fracture after spinal SBRT.

Conclusion: Ga-PSMA-PET/CT-based MDT is an efficient and safe treatment for oligometastatic PC patients. Proper patient selection might improve treatment outcomes.
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http://dx.doi.org/10.1007/s00066-020-01660-6DOI Listing
November 2020

Stereotactic radiotherapy in patients with oligometastatic or oligoprogressive gynecological malignancies: a multi-institutional analysis.

Int J Gynecol Cancer 2020 06 8;30(6):865-872. Epub 2020 Apr 8.

Department of Radiation Oncology, Hacettepe Universitesi Tip Fakultesi, Ankara, Turkey.

Introduction: Data supporting stereotactic body radiotherapy for oligometastatic patients are increasing; however, the outcomes for gynecological cancer patients have yet to be fully explored. Our aim is to analyze the clinical outcomes of stereotactic body radiotherapy in the treatment of patients with recurrent or oligometastatic ovarian cancer or cervical cancer.

Methods: The clinical data of 29 patients (35 lesions) with oligometastatic cervical cancer (21 patients, 72%) and ovarian carcinoma (8 patients, 28%) who were treated with stereotactic body radiotherapy for metastatic sites were retrospectively evaluated. All patients had <5 metastases at diagnosis or during progression, and were treated with stereotactic body radiotherapy for oligometastatic disease. Patients with ≥5 metastases or with brain metastases and those who underwent re-irradiation for primary site were excluded. Age, progression time, mean biologically effective dose, and treatment response were compared for overall survival and progression-free survival.

Results: A total of 29 patients were included in the study. De novo oligometastatic disease was observed in 7 patients (24%), and 22 patients (76%) had oligoprogression. The median follow-up was 15.3 months (range 1.9-95.2). The 1 and 2 year overall survival rates were 85% and 62%, respectively, and the 1 and 2 year progression-free survival rates were 27% and 18%, respectively. The 1 and 2 year local control rates for all patients were 84% and 84%, respectively. All disease progressions were observed at a median time of 7.7 months (range 1.0-16.0) after the completion of stereotactic body radiotherapy. Patients with a complete response after stereotactic body radiotherapy for oligometastasis had a significantly higher 2 year overall survival and progression-free survival compared with their counterparts. In multivariate analysis, early progression (≤12 months) and complete response after stereotactic body radiotherapy for oligometastasis were the significant prognostic factors for improved overall survival. However, no significant factor was found for progression-free survival in the multivariable analysis. No patients experienced grade 3 or higher acute or late toxicities.

Conclusions: Patients with early detection of oligometastasis (≤12 months) and with complete response observed at the stereotactic body radiotherapy site had a better survival compared with their counterparts. Stereotactic body radiotherapy at the oligometastatic site resulted in excellent local control rates with minimal toxicity, and can potentially contribute to long-term survival.
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http://dx.doi.org/10.1136/ijgc-2019-001115DOI Listing
June 2020

Retrospective correlation of ga-psma uptake with clinical parameters in prostate cancer patients undergoing definitive radiotherapy.

Ann Nucl Med 2020 Jun 27;34(6):388-396. Epub 2020 Mar 27.

Faculty of Medicine, Department of Nuclear Medicine, Adana Dr Turgut Noyan Research and Treatment Center, Başkent University, Adana, Turkey.

Objective: The aim of the study is to investigate the correlation between the intensity of prostate-specific membrane antigen (PSMA) uptake in primary tumor and clinico-pathological characteristics of non-metastatic prostate cancer patients treated with definitive radiotherapy (RT).

Methods: Using the clinical data of 201 prostate cancer patients who were referred for  Ga-PSMA-positron emission tomography (PET/CT) for staging and RT planning, we analyzed the correlations among intermediate- or high-risk disease based on Gleason score (GS), prostate-specific antigen (PSA) level, D'Amico risk group classification, and maximum standardized uptake (SUV) of primary tumor.

Results: Primary tumor was visualized via  Ga-PSMA-PET/CT scan in 192 patients (95.5%). The median SUV of primary tumor and metastatic lymph node were 13.2 (range 3.3-83.7) and 11.4 (range 3.6-64.5), respectively. A significant moderate correlation was observed between PSA level and median tumor SUV as measured by  Ga-PSMA-PET/CT (Spearman = 0.425; p < 0.001). Patients with serum PSA > 10 ng/mL, GS > 7, D'Amico high-risk group classification, and pelvic lymph node metastasis had significantly higher tracer uptake in primary tumor than their counterparts. The median SUV of primary tumor was highest in patients with GS 9. The primary tumor detection rates of  Ga-PSMA-PET/CT were 83%, 92%, and 99% for patients with serum PSA ≤ 5.0 ng/mL (14 patients, 7%), PSA 5.1-10.0 ng/mL (45 patients, 22%), and PSA > 10 ng/mL (142 patients, 71%), respectively.

Conclusions: We demonstrated a correlation between prostate tumor characteristics and PSMA tracer uptake. Patients with serum PSA > 10 ng/mL, GS > 7, D'Amico high-risk group classification, and pelvic lymph node metastasis had significantly higher SUV than their counterparts. In addition, the primary tumor detection rate was higher in patients with serum PSA > 10 ng/mL and GS > 7.
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http://dx.doi.org/10.1007/s12149-020-01462-xDOI Listing
June 2020

The hematologic parameters in metastatic castration-resistant prostate cancer patients treated with abiraterone acetate.

Future Oncol 2019 May 12;15(13):1469-1479. Epub 2019 Apr 12.

Department of Radiation Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey.

Currently, there are no predictive markers of response to abiraterone. We calculated neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) at baseline and at 4 and 12 weeks after initiation of abiraterone, and we evaluated prostate-specific antigen (PSA) response every 4 weeks in 102 metastatic castration-resistant prostate cancer (mCRPC) patients treated with abiraterone either pre- or postchemotherapy. With a median follow-up was 24.0 months (range: 0.3-54.9), median overall survival (OS) was 20.8 months. High-NLR patients who remained high or who returned to low NLR after 4 and 12 weeks showed significantly worse OS than patients with low baseline NLR. NLR and prostate-specific antigen response to abiraterone was a significant predictor of OS and progression-free survival (PFS) in metastatic castration-resistant prostate cancer patients treated with abiraterone delivered either pre- or postchemotherapy.
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http://dx.doi.org/10.2217/fon-2018-0635DOI Listing
May 2019

Outcome of loco-regional radiotherapy in metastatic castration-resistant prostate cancer patients treated with abiraterone acetate.

Strahlenther Onkol 2019 Oct 30;195(10):872-881. Epub 2019 Jan 30.

Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey.

Purpose: To evaluate the potential benefit of curative radiotherapy (RT) to the primary tumor in metastatic castration-resistant prostate cancer (mCRPC) patients treated with abiraterone.

Materials And Methods: The clinical parameters of 106 mCRPC patients treated with abiraterone were retrospectively evaluated. Patients were either oligometastatic (≤5 metastases) at diagnosis or became oligometastatic after the systemic treatment was analyzed. Local RT to the primary tumor and pelvic lymphatics was delivered in 44 patients (41%), and 62 patients (59%) did not have RT to the primary tumor. After propensity match analysis, a total of 92 patients were analyzed.

Resultsn: Median follow-up time was 14.2 months (range: 2.3-54.9 months). Median overall survival (OS) was higher in patients treated with local RT to the primary tumor than in those treated without local RT with borderline significance (24.1 vs. 21.4 months; p = 0.08). Local RT to the prostate and pelvic lymphatics significantly diminished the local recurrence rate (16 patients, 31% vs. 2 patients, 5%; p = 0.003). In multivariate analysis, the prostate specific antigen (PSA) response ≥50% of the baseline obtained 3 weeks after abiraterone therapy was the only significant prognostic factor for better OS and progression-free survival (PFS). Patients treated with primary RT to the prostate had significantly less progression under abiraterone and a longer abiraterone period than those treated without local prostate RT.

Conclusions: Local prostate RT significantly improved OS and local control in mCRPC patients treated with abiraterone. The patients treated with primary RT had significantly less progression under abiraterone and a longer abiraterone period than those treated without local prostate RT.
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http://dx.doi.org/10.1007/s00066-019-01429-6DOI Listing
October 2019

Responding to Veiga et al. 'Long term radiological features of radiation-induced lung damage'.

Radiother Oncol 2018 12 17;129(3):611-612. Epub 2018 Jul 17.

Başkent University, Faculty of Medicine, Adana Dr Turgut Noyan Research and Treatment Center, Department of Radiation Oncology, Adana, Turkey. Electronic address:

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http://dx.doi.org/10.1016/j.radonc.2018.06.030DOI Listing
December 2018

Bilateral Choroidal Metastases from Lung Adenocarcinoma: A Case Report.

Case Rep Oncol 2016 Sep-Dec;9(3):530-536. Epub 2016 Sep 13.

Sakarya University Training and Research Hospital, Department of Medical Oncology, Sakarya, Turkey.

The most common malignancy of the eye is metastatic tumors, with choroidal metastases being the majority of them. In women, breast cancer is the most common cause of orbital metastases, and in men, it is lung cancer. Despite the fact that there are efficient treatment options for orbital metastases, the benefit of procedures to detect choroidal metastases is debatable due to the quick progression and poor prognosis of lung cancer. In choroidal metastases resulting from lung cancer, patients are usually presented with decreased sight. Defects in the field of vision, flashes of light and floating bodies generally follow. Treatment options of choroidal metastases include many methods including laser photocoagulation, cryotherapy, chemotherapy, radiotherapy, surgical resection, enucleation and photodynamic therapy. There are reports emphasizing radiotherapy as the most efficient treatment option. In this case report, we sum up the case of a male patient presenting with blurry vision in both eyes, who was subsequently detected to have bilateral choroidal metastatic tumor and was diagnosed with primary lung adenocarcinoma.
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http://dx.doi.org/10.1159/000449154DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5073677PMC
September 2016

Multifocal soft tissue Langerhans' cell histiocytosis treated with PET-CT based conformal radiotherapy.

Jpn J Radiol 2015 Sep 26;33(9):603-6. Epub 2015 Jul 26.

Division of Medical Oncology, Baskent University Faculty of Medicine, Ankara, Turkey.

Introduction: Langerhans' cell histiocytosis (LCH) is a proliferative disorder of Langerhans cells, which is seen extremely rarely in adults. Conventional imaging modalities, such as skeletal surveys and bone scans, were accepted to be standard methods for diagnosis; however, 18-fluorodeoxyglucose positron emission tomography (PET-CT) has been increasingly used.

Methods: We report on a 33-year-old female patient with disseminated LCH treated with radiotherapy and systemic chemotherapy where PET-CT has been used for defining the extent of the disease, RT planning and assessment of treatment response during follow-up.

Results: The patient was treated with 24 Gy 3-dimensional conformal radiotherapy (RT), given as 2 Gy a day, 5 days a week. The patient was also treated with systemic prednisolone 20 mg/m(2), concurrently. The chemotherapeutic regimen switched to cytosine-arabinoside with a dose of 100 mg/m(2) subcutaneously daily for 4 days, vincristine 1.5 mg/m(2) given on the 1st day and prednisolone 20 mg/m(2) for 4 cycles. After local RT with adjuvant chemotherapy, the patient was alive for 54 months and remained disease-free at last visit.

Conclusion: RT is a treatment choice in multi-system LCH as well as solitary lesions. Low-dose RT is adequate to control large masses of LCH including soft tissue and lymph nodes.
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http://dx.doi.org/10.1007/s11604-015-0466-6DOI Listing
September 2015

Prognostic value of pretreatment 18F-fluorodeoxyglucose uptake in patients with cervical cancer treated with definitive chemoradiotherapy.

Int J Gynecol Cancer 2013 Jul;23(6):1104-10

Department of Radiation Oncology, Baskent University Faculty of Medicine, Adana, Turkey.

Objective: We analyzed the correlation of F-fluorodeoxyglucose (FDG) uptake into primary tumors using the maximum standardized uptake value (SUVmax) and clinicopathological factors of disease. The impact of the pretreatment SUVmax of the primary tumor on survival was investigated.

Materials And Methods: The records of 149 patients with biopsy-proven cervical cancer treated with definitive chemoradiotherapy (ChRT) were reviewed. All patients underwent pretreatment FDG positron emission tomography with computed tomography, and posttherapy FDG positron emission tomography with computed tomography was performed within a median interval of 4.2 months (range, 3.0-11.2 months) after the completion of chemoradiotherapy.

Results: The mean SUVmax in patients with lymph node metastasis was significantly higher than that in patients without metastasis (19.7 ± 8.2 vs 16.4 ± 8.2, respectively; P = 0.01). A significant difference existed between tumor size (<4 vs ≥4 cm) and the primary tumor SUVmax (14.7 ± 6.6 vs 18.7 ± 8.5, respectively; P = 0.02). The primary tumor pretreatment SUVmax for patients with complete remission was significantly lower than that of patients with partial response or progressive disease (15.6 ± 5.7 vs 28.0 ± 9.9, respectively; P < 0.001). The relationship between primary tumor FDG uptake and survival was evaluated by the cutoff value determined by receiver operating characteristic curve analysis. The area under the curve was 0.901 (P < 0.001; 95% confidence interval, 0.848-0.954), and 15.6 was determined as the SUVmax cutoff value. The 4-year actuarial overall survival (OS) and disease-free survival for SUVmax of less than 15.6 compared with SUVmax of 15.6 or greater were 85% vs 34% (P < 0.001) and 80% vs 29%, respectively (P < 0.001). In multivariate analysis, age, SUVmax of 15.6 or greater, and lymph node metastasis were independent prognostic factors of OS, and International Federation of Gynecology and Obstetrics stage IIB or higher, SUVmax of 15.6 or greater, and lymph node metastasis were significant factors for disease-free survival.

Conclusion: The primary tumor pretreatment SUVmax is correlated with increased tumor size and lymph node involvement at diagnosis, how well the primary tumor responds to treatment, the likelihood of disease recurrence, and OS.
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http://dx.doi.org/10.1097/IGC.0b013e3182989483DOI Listing
July 2013

Isolated mediastinal lymph node false positivity of [18F]-fluorodeoxyglucose-positron emission tomography/computed tomography in patients with cervical cancer.

Int J Gynecol Cancer 2013 Feb;23(2):337-42

Department of Radiation Oncology, Faculty of Medicine, Baskent University, Ankara, Turkey.

Objective: This study aimed to evaluate the degree of mediastinal involvement in patients with cervical cancer with isolated mediastinal [F]-fluorodeoxyglucose-positron emission tomography (FDG-PET) positivity as verified by histopathologic examination.

Methods: Two hundred twenty-eight patients with newly diagnosed cervical cancer and who underwent FDG-PET imaging were analyzed. Twenty-nine patients (17%) had disseminated disease detected with PET/computed tomography (CT). Only 10 patients (4%) had increased FDG uptake in mediastinal lymph nodes alone. Of the 10 patients with mediastinal disease, 2 refused surgical mediastinal lymph node biopsy and did not receive any treatment. Patients with suspected paratracheal or subcarinal lymph node metastasis detected on PET/CT underwent mediastinoscopy, and those with hilar metastasis had video-assisted mediastinal lymphadenectomy. Treatment was delivered according to final staging based on histopathologic confirmation of mediastinal lymph node involvement.

Results: The mean (SD) maximum standardized uptake values for primary cervical tumor and mediastinal lymph nodes were 19.7 (10.3) and 7.5 (1.6), respectively. Of 8 patients who underwent mediastinal lymph node confirmation, 6 (75%) were tumor free, demonstrating granulomatous changes, and were treated curatively. No patients had residual or recurrent disease at the primary site, and all but 1 were alive without disease. Two patients with confirmed mediastinal lymph node metastasis were treated palliatively and died between 9 and 11 months after diagnosis.

Conclusions: Positron emission tomography/CT is an important tool for lymphatic staging and evaluation of distant metastases in cervical cancer. However, PET/CT should be interpreted cautiously for isolated mediastinal involvement; surgical evaluation is required for accurate staging and appropriate treatment decisions to achieve better outcomes.
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http://dx.doi.org/10.1097/IGC.0b013e31827e00ccDOI Listing
February 2013

Correlation of conventional and conformal plan parameters for predicting radiation pneumonitis in patients treated with breast cancer.

J Breast Cancer 2012 Sep 28;15(3):320-8. Epub 2012 Sep 28.

Department of Radiation Oncology, Baskent University Faculty of Medicine, Adana Research and Treatment Centre, Adana, Turkey.

Purpose: The purpose of this study is to evaluate the correlation between the conventional plan parameters and dosimetric parameters obtained from conformal radiotherapy (RT) planning, and between these parameters and radiation pneumontitis (RP) incidence.

Methods: Clinical and dosimetric data of 122 patients that were treated with mastectomy and adjuvant 3D conformal RT (39% received 2-field RT [2-FRT], and in addition, 61% received 4-field RT [4-FRT]) were retrospectively analyzed. Central lung depth (CLD), maximum lung depth (MLD), and lung length were measured by the conventional plan. Lung dose-volume histograms (DVH) were created with conformal planning, and the lung volumes receiving 5 to 50 Gy (V(5Gy) to V(50Gy)) were calculated. Minimum (D(min)), maximum (D(max)), and mean doses (D(mean)) for the ipsilateral lung and bilateral lungs were measured by DVH. Correlations between 3D dosimetric data and 2D radiographic parameters were analyzed.

Results: The conventional plan parameters did not significantly differ between 2-FRT and 4-FRT. The conformal plan D(min), D(max), and D(mean) values were higher in 4-FRT versus 2-FRT. CLD and MLD were correlated with DVH parameter V(5Gy) to V(45Gy) values for ipsilateral, as well as bilateral lungs for 2-FRT. MLD and ipsilateral D(mean) via 2-FRT planning had the strongest positive correlation (r=0.76, p<0.01). Moderate correlations existed between CLD and ipsilateral and bilateral lung V(5Gy-45Gy), and between MLD and bilateral lung V(5Gy-45Gy) values in 2-FRT. Only four patients developed symptomatic RP, 4 with 4-FRT and one with 2-FRT.

Conclusion: The conformal plan parameters were strongly correlated with dose-volume parameters for breast 2-FRT. With only 4 cases of Grade 3 RP observed, our study is limited in its ability to provide definitive guidance, however assuming that CLD is an indicator for RP, V(20Gy) could be used as a predictor for RP and for 2-FRT. A well-defined parameters are still required to predict RP in 4-FRT.
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http://dx.doi.org/10.4048/jbc.2012.15.3.320DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3468786PMC
September 2012

Primary solitary extramedullary plasmacytoma of the tongue.

Ear Nose Throat J 2012 Jul;91(7):292-5

Department of Radiation Oncology, Baskent University Faculty of Medicine, Adana Research and Treatment Centre, 01120 Adana, Turkey.

Extramedullary plasmacytomas are rare malignancies. Most cases (80%) are seen in the head and neck region, where they represent 1% of all head and neck malignancies. We report a case of an extramedullary plasmacytoma of the tongue that was treated successfully with three-dimensional conformal radiotherapy. The patient was a 50-year-old woman who was admitted to our hospital with bilateral pain and ulceration on the sides of her tongue. Findings on magnetic resonance imaging and positron-emission tomography did not demonstrate any mass within the tongue or any lymphatic or distant metastasis. A tissue biopsy identified a plasma cell neoplasm. The patient was treated with a total dose of 50 Gy delivered in 2-Gy daily fractions. After 54 months of post-treatment follow-up, she exhibited no sign of systemic myeloma or local recurrence. This case is presented not only for the rarity of the tumor type, but also for its unusual location.
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July 2012

Evaluation of field-in-field technique for total body irradiation.

Int J Radiat Oncol Biol Phys 2012 Aug 26;83(5):1641-8. Epub 2012 Jan 26.

Department of Radiation Oncology, Baskent University Faculty of Medicine, Adana, Turkey.

Purpose: To evaluate the clinical use of a field-in-field (FIF) technique for total body irradiation (TBI) using a treatment-planning system (TPS) and to verify TPS results with in vivo dose measurements using metal-oxide-semiconductor field-effect transistor (MOSFET) detectors.

Methods And Materials: Clinical and dosimetric data of 10 patients treated with TBI were assessed. Certain radiation parameters were measured using homogenous and regular phantoms at an extended distance of 380 cm, and the results were compared with data from a conventional standard distance of 100 cm. Additionally, dosimetric validation of TPS doses was performed with a Rando phantom using manual calculations. A three-dimensional computed tomography plan was generated involving 18-MV photon beams with a TPS for both open-field and FIF techniques. The midline doses were measured at the head, neck, lung, umbilicus, and pelvis for both open-field and FIF techniques.

Results: All patients received planned TBI using the FIF technique with 18-MV photon energies and 2 Gy b.i.d. on 3 consecutive days. The difference in tissue maximum ratios between the extended and conventional distances was <2%. The mean deviation of manual calculations compared with TPS data was +1.6% (range, 0.1-2.4%). A homogenous dose distribution was obtained with 18-MV photon beams using the FIF technique. The mean lung dose for the FIF technique was 79.2% (9.2 Gy; range, 8.8-9.7 Gy) of the prescribed dose. The MOSFET readings and TPS doses in the body were similar (percentage difference range, -0.5% to 2.5%) and slightly higher in the shoulder and lung (percentage difference range, 4.0-5.5%).

Conclusion: The FIF technique used for TBI provides homogenous dose distribution and is feasible, simple, and spares time compared with more-complex techniques. The TPS doses were similar to the midline doses obtained from MOSFET readings.
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http://dx.doi.org/10.1016/j.ijrobp.2011.10.045DOI Listing
August 2012

Dosimetric comparison of the field-in-field technique and tangential wedged beams for breast irradiation.

Jpn J Radiol 2012 Apr 21;30(3):218-26. Epub 2011 Dec 21.

Department of Radiation Oncology, Adana Research and Treatment Centre, Baskent University Faculty of Medicine, 01120 Adana, Turkey.

Purpose: To analyze tangential wedged beam and field-in-field (FIF) technique doses using dose-volume histograms and conformality indices for target volume and healthy tissues within the irradiated volume.

Materials And Methods: Thirty patients treated with breast-conserving surgery and postoperative whole breast radiotherapy were enrolled. Three plans were generated: a standard tangential plan with either one outer field wedge or bilateral wedges, and an FIF plan. Three indices were used: the dose homogeneity index (DHI), PTV dose improvement index (PDI(index)) and geometric conformity index (g). Also ipsilateral lung, heart and contralateral breast doses were compared for each plan.

Results: Dose homogeneity index was significantly lower for the FIF (0.117 ± 0.021) than for the single wedge (0.131 ± 0.025, p = 0.02) and double wedged plan (0.128 ± 0.025, p = 0.04), respectively. The g was significantly less in the FIF (0.70 ± 0.14) compared to the wedge plans (0.80 ± 0.17, p = 0.02 and 0.83 ± 0.16, p = 0.003). Contralateral breast doses were significantly lower in the FIF plan. The FIF plan significantly lowered MU compared to both the single wedge and bilateral wedge plans.

Conclusion: The dose distribution within the target was more homogenous, and the doses for healthy tissue were less in the FIF plan compared to the tangential wedge plans.
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http://dx.doi.org/10.1007/s11604-011-0034-7DOI Listing
April 2012

Pseudoprogression in patients with glioblastoma multiforme after concurrent radiotherapy and temozolomide.

Am J Clin Oncol 2012 Jun;35(3):284-9

Department of Radiation Oncology, Adana Medical and Research Center, Baskent University Medical Faculty, Kisla Saglik Yerleskesi, Adana, Turkey.

Background: To evaluate pathologically confirmed incidence of pseudoprogression and its impact on survival in glioblastoma multiforme (GBM) patients treated with radiotherapy and concurrent temozolomide (TMZ), followed by 6 months of TMZ maintenance therapy.

Materials And Methods: Sixty-three patients with histologic proof of GBM underwent 60 Gy (2 Gy/fr, 30 fractions) of brain radiotherapy concurrent with continuous 75 mg/m/d TMZ, followed by 6 cycles of maintenance TMZ (200 mg/m/d for 5 d, every 28 d). Response assessment was performed by magnetic resonance imaging every 2 months. All patients with radiologic doubt of early tumor progression (≤6 mo) underwent salvage surgery.

Results: All patients underwent surgical resection. Gross total, subtotal resection, and biopsy were performed in 17 (27.0%), 32 (51.6%), and 14 (21.4%) patients, respectively. Lesion enlargement on first follow-up magnetic resonance imaging evidenced in 28 (44.4%) patients. Salvage pathologies revealed pseudoprogression in 12 of 28 (42.8%) patients corresponding to an overall pseudoprogression rate of 19%. Survival analysis revealed that patients with pseudoprogression had superior overall and progression-free survival rates at both 1 and 2 years (P<0.05 for each, respectively).

Conclusions: Current results indicates the urgency of need for novel imaging techniques and/or biochemical marker(s) that can better distinguish pseudoprogression from true progression to avoid unnecessary and potentially harmful surgical interventions in almost half of the radiologically progressive GBM patients. Our additional observation which suggests better survival for patients with pseudoprogression warrants to be studied in larger patient cohorts.
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http://dx.doi.org/10.1097/COC.0b013e318210f54aDOI Listing
June 2012

Comparison of conventional and CT-based planning for intracavitary brachytherapy for cervical cancer: target volume coverage and organs at risk doses.

J Exp Clin Cancer Res 2009 Jul 1;28:95. Epub 2009 Jul 1.

Department of Radiation Oncology, Baskent University Medical Faculty, Adana, Turkey.

Background: To compare intracavitary brachytherapy (ICBT) planning methods for cervical cancer, based on either orthogonal radiographs (conventional plan) or CT sections (CT plan); the comparison focused on target volume coverage and dose volume analysis of organs at risk (OARs), by representing point doses defined by the International Commission on Radiation Units and Measurement (ICRU) and dose volume histograms (DVHs) from 3D planning.

Methods: We analyzed the dosimetric data for 62 conventional and CT-based ICBT plans. The gross tumor volume (GTV), clinical target volume (CTV) and organs at risk (OAR)s were contoured on the CT-plan. Point A and ICRU 38 rectal and bladder points were defined on reconstructed CT images.

Results: Patients were categorized on the basis of whether the >95% isodose line of the point-A prescription dose encompassed the CTV (group 1, n = 24) or not (group 2, n = 38). The mean GTV and CTV (8.1 cc and 20.6 cc) were smaller in group 1 than in group 2 (24.7 cc and 48.4 cc) (P <0.001). The mean percentage of GTV and CTV coverage with the 7 Gy isodose was 93.1% and 88.2% for all patients, and decreased with increasing tumor size and stage. The mean D2 and D5 rectum doses were 1.66 and 1.42 times higher than the corresponding ICRU point doses and the mean D2 and D5 bladder doses were 1.51 and 1.28 times higher. The differences between the ICRU dose and the D2 and D5 doses were significantly higher in group 2 than in group 1 for the bladder, but not for the rectum.

Conclusion: The CT-plan is superior to the conventional plan in target volume coverage and appropriate evaluation of OARs, as the conventional plan overestimates tumor doses and underestimates OAR doses.
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http://dx.doi.org/10.1186/1756-9966-28-95DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2711061PMC
July 2009