Publications by authors named "Pervin Hurmuz"

32 Publications

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 Mar 4. Epub 2021 Mar 4.

From the Department of Radiation Oncology, Adana Dr Turgut Noyan Research and Treatment Center, Baskent University Faculty of Medicine, Adana Department of Radiation Oncology, Hacettepe University Faculty of Medicine, Ankara Division of Radiation Oncology, Memorial Sisli Hospital Department of Radiation Oncology, Acıbadem MAA University Maslak Hospital Department of Radiation Oncology, Istanbul Bilim University, Istanbul Division of Radiation Oncology, Iskenderun Gelisim Hospital, Hatay Department of Radiation Oncology, Acıbadem MAA University Atakent Hospital Department of Radiation Oncology, School of Medicine, Koc University, Istanbul, Turkey.

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
March 2021

Gemcitabine based trimodality treatment in patients with muscle invasive bladder cancer: May neutrophil lymphocyte and platelet lymphocyte ratios predict outcomes?

Urol Oncol 2020 Nov 11. Epub 2020 Nov 11.

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

Purpose: Cisplatin based chemoradiation has been commonly used as a definitive treatment for muscle-invasive bladder cancer (MIBC). The aim of the current study is to evaluate oncologic results and toxicity profile of bladder-sparing treatment with external beam radiotherapy (EBRT) and gemcitabine chemotherapy (ChT) in patients with MIBC.

Materials And Methods: Between April 2005 and November 2018 44 patients with nonmetastatic and N0 MIBC were treated with transurethral resection of bladder (TURB), EBRT and concurrent gemcitabine. All patients were staged using thorax-abdomen-pelvic CT and pelvic MRI. EBRT was delivered using 3D conformal technique or intensity modulated radiotherapy. Patients received 50 Gy in 25 to 28 fractions to full bladder followed by a boost dose of 10 Gy in 5 fractions to empty bladder with weekly concurrent gemcitabine of 50 mg/m. All patients were evaluated for age, gender, smoking status, neutrophil lymphocyte ratio (NLR) and platelet lymphocyte ratio (PLR) at diagnosis, presence of hydroureteronephrosis (HUN), preoperative tumor size, tumor multifocality, presence of CIS, clinical tumor stage. Acute/late genitourinary (GUS) and gastrointestinal (GIS) toxicity, recurrence status, cancer specific survival (CSS) and overall survival (OS) were evaluated. Statistical analysis was performed using SPSS v21.0. Kaplan-Meier survival estimates were calculated to describe CSS and OS. The effect of different parameters on survival was investigated using the log rank test.

Results: Median age of the patients was 72 years (interquartile [IQR]; 66-80). The median tumor size was 30 mm (IQR, 15-59 mm). Thirty-two (77%) patients had T2, 6 (14%) patients had T3, and 4 (9%) patients had T4a disease. Median NLR was 2.6 (IQR, 1.7-3.8) and median PLR was 126.47 (IQR, 77.4-184.8). Median follow-up time was 21 months (range, 6-153 months). At the first TURB performed 6 weeks after CRT, complete response, partial response, stable disease, and progression was detected in 37 (84%), 3 (7%), 1 (2%), and 3 (7%) patients, respectively. One- and 2-year OS, CSS, LRFS, and DMFS rates were 86% and 64%; 88% and 66%; 65% and 44%; 68% and 48%, respectively. In univariate analysis; prognostic factors were age and presence of HUN for OS and DMFS; age, HUN, presence of CIS, NLR, and PLR for DSS; HUN, NLR, and PLR for LRFS, respectively. In multivariate analysis, the independent predictor was the presence of HUN for OS, LRFS, and DMFS; NLR for DSS; PLR for LRFS and age for DMSF. For a subgroup of 17 patients with complete TURB and no CIS and HUN symptoms, 2-year OS, DSS, LRFS, and DMFS rates were 88%, 88%, 72%, and 79%, respectively. The treatment was well-tolerated and all patients completed the planned EBRT and ChT. No acute or late ≥ grade 3 toxicity was observed. Grade II acute GIS toxicity was detected in 3 (7%) patients and grade II acute GUS toxicity was detected in 9 (21%) patients, respectively. Grade II late GUS toxicity was observed in 2 (5%) patients.

Conclusion: Gemcitabine based trimodality treatment is well-tolerated with similar oncologic outcomes reported in the literature. Older age, presence of CIS and high NLR and PLR values seem to deteriorate DSS.
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http://dx.doi.org/10.1016/j.urolonc.2020.11.006DOI Listing
November 2020

Factors affecting post-treatment radiation-induced lung disease in patients receiving stereotactic body radiotherapy to lung.

Radiat Environ Biophys 2021 Mar 24;60(1):87-92. Epub 2020 Oct 24.

Department of Radiation Oncology, Hacettepe University Faculty of Medicine, 06100, Ankara, Turkey.

The aim of the study is to investigate factors that may cause radiation-induced lung disease (RILD) in patients undergoing stereotactic body radiotherapy (SBRT) for lung tumors. Medical records of patients treated between May 2018 and June 2019 with SBRT were retrospectively evaluated. All patients should have a diagnosis of either primary non-small cell lung cancer (NSCLC) or less than three metastases to lung from another primary. The median treatment dose was 50 Gy in 4-5 fractions. Tumor response and RILD were evaluated in thoracic computer tomography (CT) using RECIST criteria. 82 patients with 97 lung lesions were treated. The median age was 68 years (IQR = 62-76). With a median follow-up of 7.2 months (3-18 months), three patients had grade 3 radiation pneumonitis (RP). RILD was observed in 52% of cases. Patients who had RILD had a higher risk of symptomatic RP (p = 0.007). In multivariate analyses older age, previous lung radiotherapy history, and median planning treatment volume (PTV) D95 value of ≥ 48 Gy were associated with RILD. Local recurrence (LR) was observed in 5.1% of cases. There was no difference in overall survival and LR with the presence of RILD. Older age, previous lung radiotherapy history, and median PTV D95 value of ≥ 48 Gy seems to be associated with post-SBRT RILD.
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http://dx.doi.org/10.1007/s00411-020-00878-3DOI Listing
March 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 body radiotherapy in patients with early-stage non-small cell lung cancer: Does beam-on time matter?

Jpn J Clin Oncol 2020 Sep;50(10):1182-1187

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

Purpose: Stereotactic body radiotherapy (SBRT) is an effective treatment option for patients with early-stage non-small cell lung cancer (NSCLC). In this study, we evaluated the treatment results using two different SBRT techniques and the effect of beam-on time (BOT) on treatment outcomes.

Methods: Between July 2007 and January 2018, 142 patients underwent SBRT for primary NSCLC. We have delivered SBRT using either respiratory tracking system (RTS) or internal-target-volume (ITV)-based motion management techniques. The effect of age, tumor size, pretreatment tumor SUVmax value, presence of tissue diagnosis, histopathological subtype, operability status, tumor location, motion management technique, BED10 value, BOT on overall survival (OS), loco-regional control (LRC), event-free survival (EFS) and primary tumor control (PTC) were evaluated.

Results: Median age of the patients was 70 years (range, 39-91 years). Most of the patients were inoperable (90%) at the time of SBRT. Median BED10 value was 112.5 Gy. With a median follow-up of 25 months, PTC was achieved in 91.5% of the patients. Two-year estimated OS, LRC, PTC and EFS rates were 68, 63, 63 and 53%, respectively. For the entire group, OS was associated with BOT (P = 0.027), and EFS was associated with BOT (P = 0.027) and tumor size (P = 0.015). For RTS group, OS was associated with age (P = 0.016), EFS with BOT (P = 0.05) and tumor size (P = 0.024), LRC with BOT (P = 0.008) and PTC with BOT (P = 0.028). The treatment was well tolerated in general.

Conclusion: SBRT is an effective and safe treatment with high OS, LRC, EFS and PTC rates in patients with primary NSCLC. Protracted BOT might deteriorate SBRT outcomes.
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http://dx.doi.org/10.1093/jjco/hyaa093DOI Listing
September 2020

FLASH-radiotherapy: A new perspective in immunotherapy era?

Radiother Oncol 2020 04 19;145:137. Epub 2020 Jan 19.

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

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http://dx.doi.org/10.1016/j.radonc.2019.12.015DOI Listing
April 2020

Comments on "Risk factors for vertebral compression fracture after spine stereotactic body radiation therapy: Long-term results of a prospective phase 2 study".

Radiother Oncol 2020 04 18;145:127. Epub 2020 Jan 18.

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

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http://dx.doi.org/10.1016/j.radonc.2019.12.014DOI Listing
April 2020

Prognostic significance of castrate testosterone levels for patients with intermediate and high risk prostate cancer.

World J Clin Oncol 2019 Aug;10(8):283-292

Department of Radiation Oncology, Hacettepe University Faculty of Medicine, Ankara 06100, Turkey M.D.

Background: Testosterone level of < 50 ng/dL has been used to define castrate level after surgery or after androgen deprivation treatment (ADT) in metastatic prostate cancer (PC).

Aim: To evaluate the effect of two different castrate testosterone levels, < 50 and < 20 ng/dL, on biochemical relapse free survival (BRFS) in patients with non-metastatic intermediate and high risk PC receiving definitive radiotherapy (RT) and ADT.

Methods: Between April 1998 and February 2011; 173 patients with intermediate and high risk disease were treated. Radiotherapy was delivered by either three-dimensional-conformal technique to a total dose of 73.4 Gy at the ICRU reference point or intensity modulated radiotherapy technique to a total dose of 76 Gy. All the patients received 3 mo of neoadjuvant ADT followed by RT and additional 6 mo of ADT. ASTRO Phoenix definition was used to define biochemical relapse.

Results: Median follow up duration was 125 months. Ninety-six patients (56%) had castrate testosterone level < 20 ng/dL and 139 patients (80%) had castrate testosterone level < 50 ng/dL. Both values are valid at predicting BRFS. However, patients with testosterone < 20 ng/dL have significantly better BRFS compared to other groups ( = 0.003). When we compare two values, it was found that using 20 ng/dL is better than 50 ng/dL in predicting the BRFS (AUC = 0.63 0.58, respectively).

Conclusion: Castrate testosterone level of less than 20 ng/dL is associated with better BRFS and is better in predicting the BRFS. Further studies using current standard of care of high dose IMRT and longer ADT duration might support these findings.
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http://dx.doi.org/10.5306/wjco.v10.i8.283DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6717705PMC
August 2019

Integration of 68Ga-PSMA-PET/CT in Radiotherapy Planning for Prostate Cancer Patients.

Clin Nucl Med 2019 Sep;44(9):e510-e516

Departments of Radiation Oncology.

To assess the role of Gallium-labeled-prostate-specific membrane antigen PET/CT (Ga-PSMA-PET/CT) in risk group definition and radiotherapy planning in the initially planned definitive radiotherapy (RT) for prostate cancer patients.

Methods: The clinical data of 191 prostate cancer patients treated with definitive intensity-modulated RT were retrospectively analyzed. All patients were initially staged with thoracoabdominal CT and bone scintigraphy, and the second staging was performed using Ga-PSMA-PET/CT. Both stages were evaluated for the decision making of RT and any change in RT target volumes.

Results: After staging with Ga-PSMA-PET/CT, 26 patients (13.6%) had risk group changes, 16 patients (8.4%) had an increase in risk group, and 10 patients (5.2%) had a decrease in risk group. Down-staging occurred in 22 patients (11.5%), and upstaging was observed in 30 patients (15.7%). A total of 26 patients (13.6%) had nodal stage changes. After the Ga-PSMA-PET/CT scans, the number of metastatic patient increased to 17 (8.9%), with 4 of them moving from oligo- to polymetastatic disease. An additional irradiation of pelvic lymphatics and metastatic site was performed in 13 patients (6.8%) and 6 patients (3.2%), respectively. The RT was aborted in 4 patients (2.1%) because of parenchymal or distant site metastasis observed in the Ga-PSMA-PET/CT.

Conclusions: We found that Ga-PSMA-PET/CT causes considerable migration in stage, risk group, and RT field arrangements, especially in high-risk patients regardless of the GS and baseline prostate-specific antigen values alone. Ga-PSMA-PET/CT seems to have a great influence on RT decision making in prostate cancer patients.
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http://dx.doi.org/10.1097/RLU.0000000000002691DOI Listing
September 2019

Treatment outcomes of prostate cancer patients with Gleason score 8-10 treated with definitive radiotherapy : TROD 09-001 multi-institutional study.

Strahlenther Onkol 2019 Oct 29;195(10):882-893. Epub 2019 May 29.

Department of Radiation Oncology, Hacettepe University, Faculty of Medicine, 06100, Ankara, Turkey.

Purpose: To validate the clinical outcomes and prognostic factors in prostate cancer (PCa) patients with Gleason score (GS) 8-10 disease treated with external beam radiotherapy (EBRT) + androgen deprivation therapy (ADT) in the modern era.

Methods: Institutional databases of biopsy proven 641 patients with GS 8-10 PCa treated between 2000 and 2015 were collected from 11 institutions. In this multi-institutional Turkish Radiation Oncology Group study, a standard database sheet was sent to each institution for patient enrollment. The inclusion criteria were, T1-T3N0M0 disease according to AJCC (American Joint Committee on Cancer) 2010 Staging System, no prior diagnosis of malignancy, at least 70 Gy total irradiation dose to prostate ± seminal vesicles delivered with either three-dimensional conformal RT or intensity-modulated RT and patients receiving ADT.

Results: The median follow-up time was 5.9 years (range 0.4-18.2 years); 5‑year overall survival (OS), biochemical relapse-free survival (BRFS) and distant metastases-free survival (DMFS) rates were 88%, 78%, and 79%, respectively. Higher RT doses (≥78 Gy) and longer ADT duration (≥2 years) were significant predictors for improved DMFS, whereas advanced stage was a negative prognosticator for DMFS in patients with GS 9-10.

Conclusions: Our results validated the fact that oncologic outcomes after radical EBRT significantly differ in men with GS 8 versus those with GS 9-10 prostate cancer. We found that EBRT dose was important predictive factor regardless of ADT period. Patients receiving 'non-optimal treatment' (RT doses <78 Gy and ADT period <2 years) had the worst treatment outcomes.
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http://dx.doi.org/10.1007/s00066-019-01476-zDOI Listing
October 2019

In Regard to Videtic et al.

Int J Radiat Oncol Biol Phys 2019 06;104(2):466-467

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

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http://dx.doi.org/10.1016/j.ijrobp.2019.02.012DOI Listing
June 2019

In Regard to Bryant et al.

Int J Radiat Oncol Biol Phys 2019 05;104(1):224-225

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

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http://dx.doi.org/10.1016/j.ijrobp.2019.01.083DOI Listing
May 2019

Prevalence of Complementary Medicine Use in Patients With Cancer: A Turkish Comprehensive Cancer Center Experience.

J Glob Oncol 2018 09 18;4:1-6. Epub 2017 Apr 18.

Suayib Yalcin and Pervin Hurmuz, Hacettepe University School of Medicine, Ankara, Turkey; and Lacey McQuinn and Aung Naing, University of Texas MD Anderson Cancer Center, Houston, TX.

Purpose: Complementary and alternative medicine (CAM) has been popular among patients with cancer for several decades. The objectives of this study were to evaluate the prevalence of CAM use and to identify the factors affecting CAM use in a large patient cohort seen at a comprehensive cancer center in Turkey.

Patients And Methods: An investigator-designed survey was completed by volunteer patients who visited the outpatient clinic in the medical oncology department. CAM use encompassed pharmacologic agents including vitamins, dietary supplements, and herbal products or nonpharmacologic methods like prayer, meditation, hypnosis, massage, or acupuncture.

Results: Of 1,499 patients who answered the survey, 1,433 (96%) used nonpharmacologic CAM and 60 (4%) used pharmacologic CAM (pCAM). The most frequent types of CAM used were prayer (n = 1,433) followed by herbal products (n = 42). pCAM use was not significantly associated with age ( P = .63), sex ( P = .15), diagnosis ( P = .15), or income level ( P = .09). However, it was significantly associated with the level of education ( P = .0067) and employment status ( P < .001). Patients with higher education levels used more pCAM products ( P = .025). Among 60 pCAM users, six patients (10%) used pCAM for more than 2 years and 22 (36%) did not consult their physicians about their pCAM use. Only nine patients (15%) reported unpleasant adverse effects related to pCAM.

Conclusion: Although CAM use was high among our patients, prevalence of pCAM use was lower than expected. Patients with higher education levels tended to use more pCAM.
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http://dx.doi.org/10.1200/JGO.2016.008896DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6180833PMC
September 2018

In Regard to Chen et al.

Int J Radiat Oncol Biol Phys 2018 07 20;101(4):998. Epub 2018 Jun 20.

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

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http://dx.doi.org/10.1016/j.ijrobp.2018.04.079DOI Listing
July 2018

In Regard to Nantavithya et al.

Int J Radiat Oncol Biol Phys 2018 07;101(3):744-745

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

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http://dx.doi.org/10.1016/j.ijrobp.2018.03.044DOI Listing
July 2018

In Regard to Kumar et al.

Int J Radiat Oncol Biol Phys 2018 03;100(4):1079-1080

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

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http://dx.doi.org/10.1016/j.ijrobp.2017.12.009DOI Listing
March 2018

Investigating the surface dose contribution of intrafractional kV imaging in CyberKnife-based stereotactic radiosurgery.

Med Dosim 2017 Winter;42(4):304-309. Epub 2017 Jul 21.

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

CyberKnife treatment consists of hundreds of noncoplanar beams and numerous intrafractional images that can be taken during a single treatment fraction; thus, doses because of imaging should be considered in this technique. The aim of this study is to investigate the in-field and out-of-field surface doses induced from kV imaging system during stereotactic radiosurgery (SRS) treatment. The imaging-induced surface doses were measured at the center of the imaging field and within ±15-cm distance from the center in both craniocaudal and lateral directions. TLD100H thermoluminescence dosimeters and EBT2 gafchromic films were used to take the measurements at the locations of 0, ±5, ±10, and ±15 cm in the 2 orthogonal directions on abdominal region of a Rando phantom. The surface dose contributions of imaging system for the 4 most commonly used energy options of 90, 100, 110, and 120 kVp with 3 mAs options of 10, 30, and 90 mAs were measured and compared. Imaging dose values have a positive correlation with both parameters of energy and mAs. The energy options of 100, 110, and 120 kVp, in average, induced 60%, 101%, and 141% more doses per mAs than 90 kVp energy in the imaging field center. A threefold increase in mAs values, i.e., from 10 mAs to 30 mAs and from 30 mAs to 90 mAs, caused higher dose in field center with a factor of 2.53 ± 0.08 when the energy value was kept constant. The in-field dose distributions within ±10 cm in both directions showed a flat pattern with a standard deviation lower than 5%, whereas the out-of-field doses at ±15-cm distance from the field center suddenly dropped to almost half of the central doses. Although a single imaging attempt causes a very low dose compared with the therapeutic dose level, one should be aware of the cumulative surface dose increase with higher imaging number. Proper patient setup, fiducial usage, and reduction of both the mAs values and the imaging numbers should be, therefore, considered to keep the cumulative surface dose in a lower level.
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http://dx.doi.org/10.1016/j.meddos.2017.06.005DOI Listing
August 2018

Reirradiation of Pediatric Tumors Using Hypofractionated Stereotactic Radiotherapy.

Technol Cancer Res Treat 2017 04 8;16(2):195-202. Epub 2016 Jul 8.

1 Department of Radiation Oncology, School of Medicine, Hacettepe University, Ankara, Turkey.

Background: This study aimed to evaluate the efficacy and safety of hypofractionated stereotactic radiotherapy for reirradiation of recurrent pediatric tumors.

Methods And Materials: The study included 23 pediatric patients who were reirradiated using hypofractionated stereotactic radiotherapy in the radiation oncology department between January 2008 and November 2013. In total, 33 tumors were treated-27 (82%) cranial and 6 (18%) extracranial. Hypofractionated stereotactic radiotherapy was administered due to recurrent disease in 31 (94%) tumors and residual disease in 2 (6%) tumors. The median total dose was 25 Gy (range: 15-40 Gy), and the median follow-up was 20 months (range: 2-68 months).

Results: The 1-year and 2-year local control rates in the entire study population were 42% and 31%, respectively. The median local control time was 11 months (range: 0-54 months) following hypofractionated stereotactic radiotherapy. The patients with tumor response after hypofractionated stereotactic radiotherapy had significantly longer local control than the patients with post-hypofractionated stereotactic radiotherapy tumor progression (21 vs 3 months, P < .001). Tumor volume <1.58 cm was correlated (not significantly) with better local control (23 vs 7 months, P = .064).

Conclusion: Reirradiation of pediatric tumors using hypofractionated stereotactic radiotherapy is a safe and effective therapeutic approach. This treatment modality should be considered as a treatment option in selected pediatric patients.
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http://dx.doi.org/10.1177/1533034616655952DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5616030PMC
April 2017

The dosimetric impact of implants on the spinal cord dose during stereotactic body radiotherapy.

Radiat Oncol 2016 May 25;11:71. Epub 2016 May 25.

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

Background: The effects of spinal implants on dose distribution have been studied for conformal treatment plans. However, the dosimetric impact of spinal implants in stereotactic body radiotherapy (SBRT) treatments has not been studied in spatial orientation. In this study we evaluated the effect of spinal implants placed in sawbone vertebra models implanted as in vivo instrumentations.

Methods: Four different spinal implant reconstruction techniques were performed using the standard sawbone lumbar vertebrae model; 1. L2-L4 posterior instrumentation without anterior column reconstruction (PI); 2. L2-L4 anterior instrumentation, L3 corpectomy, and anterior column reconstruction with a titanium cage (AIAC); 3. L2-L4 posterior instrumentation, L3 corpectomy, and anterior column reconstruction with a titanium cage (PIAC); 4. L2-L4 anterior instrumentation, L3 corpectomy, and anterior column reconstruction with chest tubes filled with bone cement (AIABc). The target was defined as the spinous process and lamina of the lumbar (L) 3 vertebra. A thermoluminescent dosimeter (TLD, LiF:Mg,Ti) was located on the measurement point anterior to the spinal cord. The prescription dose was 8 Gy and the treatment was administered in a single fraction using a CyberKnife® (Accuray Inc., Sunnyvale, CA, USA). We performed two different treatment plans. In Plan A beam interaction with the rod was not limited. In plan B the rod was considered a structure of avoidance, and interaction between the rod and beam was prevented. TLD measurements were compared with the point dose calculated by the treatment planning system (TPS).

Results And Discussion: In plan A, the difference between TLD measurement and the dose calculated by the TPS was 1.7 %, 2.8 %, and 2.7 % for the sawbone with no implant, PI, and PIAC models, respectively. For the AIAC model the TLD dose was 13.8 % higher than the TPS dose; the difference was 18.6 % for the AIABc model. In plan B for the AIAC and AIABc models, TLD measurement was 2.5 % and 0.9 % higher than the dose calculated by the TPS, respectively.

Conclusions: Spinal implants may be present in the treatment field in patients scheduled to undergo SBRT. For the types of implants studied herein anterior rod instrumentation resulted in an increase in the spinal cord dose, whereas use of a titanium cage had a minimal effect on dose distribution. While planning SBRT in patients with spinal reconstructions, avoidance of the rod and preventing interaction between the rod and beam might be the optimal solution for preventing unexpectedly high spinal cord doses.
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http://dx.doi.org/10.1186/s13014-016-0649-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4880816PMC
May 2016

Evaluation of the effect of changes in dose rate on rat lung cells.

Technol Cancer Res Treat 2015 Jun 14;14(3):343-9. Epub 2014 Sep 14.

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

The aim of this study is to evaluate the effect of dose rate (DR) on lung tissue. The rats included in the study were randomly grouped into 3 groups: Group (G) 1 was defined as control group, and in this group rats were sham irradiated. G2 was the group receiving a single dose of 12 Gy in DR of 300 monitor unit (MU)/min. G3 was the group receiving a single dose of 12 Gy in DR of 600 MU/min. Radiotherapy (RT) was applied under general anesthesia with 6-MV photon beams to both lungs. At the 6th and 16th week of the RT, animals from each group were killed for light and electron microscopy evaluation. We evaluated the scores of each group in the 6th and the 16th week and found that in G2, there were significant increases in the perivascular fibrosis (P = .018), interstitial fibrosis (P = .002), total inflammation (P = .040), and total fibrosis (P = .003) scores. In G3, we found statistically significant increases in perivascular fibrosis (P = .001), interstitial fibrosis (P = .002), and total fibrosis scores (P = .029). There was no significant difference in the total inflammation score in G3 (P = .225). When we compare G2 and G3 in the 6th week, we found significant increase in the interstitial thickening (P = .039) and total inflammation (P = .035) scores in G3. Dose rate per fraction may have an impact on normal tissue toxicity. The prominent effect of increased DR in lung tissue is fibrosis which should be kept in mind, especially in cases where higher doses per fraction are used.
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http://dx.doi.org/10.1177/1533034614547450DOI Listing
June 2015

Impact of locoregional treatment on survival in patients presented with metastatic breast carcinoma.

Breast 2014 Dec 5;23(6):775-83. Epub 2014 Sep 5.

Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, 06100 Ankara, Turkey.

Objectives: In this study, we tried to evaluate the efficacy of locoregional treatment (LRT) in patients with metastatic breast carcinoma (MBC).

Materials And Methods: The medical records of 227 patients with MBC at initial presentation between April 1999 and January 2013 were retrospectively evaluated. The median age at diagnosis was 50 years (range, 27-83 years). Thirty-nine patients (17%) had no LRT. Among patients who had LRT, 2 (1%) had locoregional radiotherapy (RT) alone, 54 (29%) had surgery alone [mastectomy, n = 50; breast conserving surgery (BCS), n = 4] and 132 (70%) had surgery (mastectomy, n = 119; BCS, n = 13) followed by locoregional RT.

Results: The median follow-up time was 35 months (range, 4-149 months). Five-year OS and PFS rates were 44% and 20%, respectively. In both univariate and multivariate analysis LRT per se did not affect OS and PFS rates. However, the 5-year OS and PFS rates were significantly higher in patients treated with locoregional RT than the ones who were not. The corresponding rates were 56% vs. 24% for OS and 27% vs. 7% for PFS (p < 0.001). Median survival was 67 months and 37 months, respectively.

Conclusion: Our study showed that patients with MBC who received postoperative locoregional RT may have a survival advantage compared with patients who were only treated by surgery. A phase III trial testing the role of adjuvant locoregional RT may help to distinguish patients who will benefit from adjuvant RT.
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http://dx.doi.org/10.1016/j.breast.2014.08.008DOI Listing
December 2014

Assessment of uterus position as a surrogate for high-risk clinical target volume with respect to the applicator position for multiple fractions of brachytherapy in cervical cancer.

Arch Gynecol Obstet 2014 Dec 8;290(6):1201-5. Epub 2014 Jul 8.

Department of Clinical Oncology, St James's Institute of Oncology, Leeds, UK.

Aim: Hybrid magnetic resonance imaging/computerized tomography (MRI/CT) planning for high-dose-rate (HDR) brachytherapy in cervical cancer with MR/CT fusion for the first fraction followed by CT for fraction 2 and 3 is used at our center. The aim of this study is to evaluate the position of applicator intrauterine tube (IU) in relation to uterine serosa with each fraction of intracavitary high-dose-rate brachytherapy.

Methods: Position of the applicator relative to uterus was measured from tip of the applicator (IU) to the top of uterus in the plane of IU and perpendicular to IU in anterior, posterior, left and right directions at the tip of IU, mid-point of the IU and 1 cm from the surface of vaginal ring. The mean absolute difference (±95 % confidence interval) between these positions at fraction 2 and 3 was calculated with fraction one as reference.

Results: The mean absolute difference (±95 %) of the applicator relative to uterus was 2.7 ± 0.5 mm at the tip, 1.5 ± 4 mm at mid-point and 1.1 ± 0.3 mm at 1 cm from the surface of the ring.

Conclusion: This study shows that there is consistency in inter-fraction applicator position relative to uterus apart from at the tip and, therefore, in situations where high-risk clinical target volume (HRCTV) extends towards uterine fundus, MRI should be used for each fraction of brachytherapy planning to accurately define HRCTV.
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http://dx.doi.org/10.1007/s00404-014-3350-1DOI Listing
December 2014

Radiosensitization effect of vemurafenib.

Authors:
Pervin Hurmuz

J BUON 2014 Apr-Jun;19(2):579-80

Department of Radiation Oncology, 06100, Sihhiye, Ankara, Turkey.

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September 2014

Metaplastic breast carcinoma: a heterogeneous disease.

Asian Pac J Cancer Prev 2014 ;15(6):2851-6

Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey E-mail :

The aim of this study is to evaluate clinicopathologic characteristics and the multi-disciplinary treatment results of metaplastic breast cancer (MBC) patients treated in a single institute. Seventeen female patients with MBC treated in our department between June 2000 and January 2012 were identified and retrospectively evaluated. The median age at diagnosis was 46 years (range, 26-66 years). The median tumor size at diagnosis was 3.5 cm (range 1.5-12 cm). Six (35%) patients underwent breast conservation surgery and 11 (65%) mastectomy. Axillary lymph node metastasis was found in 6 (35%) patients. Twelve (71%) had triple negative tumors. Postoperative RT and systemic adjuvant treatment was given to all patients accordingly to stage and biological characteristics. Median follow-up time was 27 months (range, 12-151 months). At the time of this analysis, 14 (82%) patients were alive with no evidence of disease, and 1 (6%) was alive with disease. The 3-year OS was 91% and 5-year 80%, and DFS rates were 76% and 76%, respectively. Despite the young age of our patients with mostly high grade tumors, larger tumor size and higher rates of lymph node metastasis, the survival outcomes in our study are favorable in comparison with previously reported series.
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http://dx.doi.org/10.7314/apjcp.2014.15.6.2851DOI Listing
January 2015

A simple strategy to decrease fatal carotid blowout syndrome after stereotactic body reirradiaton for recurrent head and neck cancers.

Radiat Oncol 2013 Oct 18;8:242. Epub 2013 Oct 18.

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

Background: This study aimed to compare the therapeutic outcomes and fatal carotid blow out syndrome (CBOS) incidence rates between two different stereotactic body radiotherapy (SBRT) protocols.

Methods: The study included 75 patients with inoperable locally recurrent head and neck cancer treated with SBRT in our department between June 2007 and March 2011. The first 43 patients were treated sequentially (group I). Then our SBRT protocol was changed due to the high rate of CBOS, and the following 32 patients were treated every other day in a prospective institutional protocol (group II).

Results: Median overall survival in group I and group II was 11 months and 23 months, respectively (P = 0.006). We observed 11 cases of CBOS. Only 1 of 7 patients (14%) with CBOS survived in group I, whereas 2 of 4 patients (50%) in group II remain alive. CBOS free median overall survivals were 9 months, and 23 months in group I and group II respectively (P = 0.002). The median radiation dose received by the carotid artery in patients with CBOS was 36.5 Gy (range: 34-42.8 Gy), versus 34.7 Gy (range: 0-44 Gy) in the patients that didn't have CBOS (P = 0.15). CBOS did not occur in any of the patients with a maximum carotid artery radiation dose <34 Gy.

Conclusions: Every other day SBRT protocol for re-irradiation of recurrent head and neck cancer is promising in terms of decreasing the incidence of fatal CBOS.
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http://dx.doi.org/10.1186/1748-717X-8-242DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4016484PMC
October 2013

Robotic stereotactic radiosurgery in patients with nasal cavity and paranasal sinus tumors.

Technol Cancer Res Treat 2014 Oct 31;13(5):409-13. Epub 2013 Aug 31.

Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Sihhiye, Ankara, 06100, Turkey.

The aim of this retrospective study is to evaluate our therapeutic results in patients with paranasal sinus (PNS) or nasal cavity (NC) malignancies treated with robotic stereotactic radiosurgery (SRS). Between August 2007 and October 2008, 27 patients with PNS or NC tumors were treated in our department using SRS. Median age was 53 years (range, 27-84 years). Eleven patients were female and sixteen were male. Most common histopathology was SCC (44%). The disease involved the maxillary sinus in 15 patients (55%). SRS was applied to 6 patients (22%) for reirradiation, while the others received it as a primary treatment. Seven patients had SRS as a boost dose to external beam radiotherapy. SRS was delivered with cyberknife (Accuray Incorporated, Sunnyvale, CA, USA). The median dose to the tumor was 31 Gy (range, 15-37.5 Gy) in median 5 fractions (range, 3-5 fractions). After a median follow-up of 21.4 months (range, 3-59 months), 76% of the patients were free of local relapse. Three patients showed local progression and 3 developed distant metastases. One- and two-year survival rates for the entire group were 95.2% (SEM = 0.046) and 77.1% (SEM = 0.102), respectively. We observed brain necrosis in 2 patients, visual disorder in 2 patients, bone necrosis in 2 patients and trismus in 1 patient as a SRS related late toxicity. Robotic SRS seems to be a feasible treatment strategy for patients with PNS tumors. Further prospective studies with longer follow up times should be performed.
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http://dx.doi.org/10.7785/tcrtexpress.2013.600264DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4527521PMC
October 2014

Determination of gonad doses during robotic stereotactic radiosurgery for various tumor sites.

Med Phys 2013 Apr;40(4):041703

Hacettepe University Faculty of Medicine, Department of Radiation Oncology, Ankara 06100, Turkey.

Purpose: The authors evaluated the absorbed dose received by the gonads during robotic stereotactic radiosurgery (SRS) for the treatment of different tumor localizations.

Methods: The authors measured the gonad doses during the treatment of head and neck, thoracic, abdominal, or pelvic tumors in both RANDO phantom and actual patients. The computerized tomography images were transferred to the treatment planning system. The contours of tumor and critical organs were delineated on each slice, and treatment plans were generated. Measurements for gonad doses were taken from the geometric projection of the ovary onto the skin for female patients, and from the scrotal skin for male patients by attaching films and Thermoluminescent dosimeters (TLDs). SRS was delivered with CyberKnife (Accuray Inc., Sunnyvale, CA).

Results: The median gonadal doses with TLD and film dosimeter in actual patients were 0.19 Gy (range, 0.035-2.71 Gy) and 0.34 Gy (range, 0.066-3.18 Gy), respectively. In the RANDO phantom, the median ovarian doses with TLD and film dosimeter were 0.08 Gy (range, 0.03-0.159 Gy) and 0.05 Gy (range, 0.015-0.13 Gy), respectively. In the RANDO phantom, the median testicular doses with TLD and film dosimeter were 0.134 Gy (range 0.056-1.97 Gy) and 0.306 Gy (range, 0.065-2.25 Gy).

Conclusions: Gonad doses are below sterility threshold in robotic SRS for different tumor localizations. However, particular attention should be given to gonads during robotic SRS for pelvic tumors.
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http://dx.doi.org/10.1118/1.4794180DOI Listing
April 2013

Management of malignant pleural mesothelioma.

Authors:
Pervin Hürmüz

Thorac Cancer 2010 Jul 12;1(2):53-61. Epub 2010 Apr 12.

Department of Radiation Oncology, Trabzon Numune Education and Research Hospital, Trabzon, Turkey.

Malignant pleural mesothelioma is a rare neoplasm arising from the surface serosal cells of the pleural cavity. More than 80% of cases of malignant pleural mesothelioma have been attributed to asbestos exposure. In its natural course median survival is 4 to 12 months. If untreated most of patients die due to local complications of the disease. Surgery improves local control but is not sufficient as a single treatment modality. The recommended treatment strategy for a select group of patients is multimodal therapy that includes surgery, radiotherapy and chemotherapy.
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http://dx.doi.org/10.1111/j.1759-7714.2010.00001.xDOI Listing
July 2010