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Dive into the research topics where Antonio L. Damato is active.

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Featured researches published by Antonio L. Damato.


Practical radiation oncology | 2014

The role of postoperative radiation therapy for endometrial cancer: Executive summary of an American society for radiation oncology evidence-based guideline

Ann H. Klopp; Benjamin D. Smith; Kaled M. Alektiar; Alvin R. Cabrera; Antonio L. Damato; Beth Erickson; Gini F. Fleming; David K. Gaffney; Kathryn M. Greven; Karen H. Lu; David Miller; David Moore; Daniel G. Petereit; Tracey E. Schefter; William Small; Catheryn M. Yashar; Akila N. Viswanathan

PURPOSE To present evidence-based guidelines for adjuvant radiation in the treatment of endometrial cancer. METHODS AND MATERIALS Key clinical questions to be addressed in this evidence-based guideline on endometrial cancer were identified. A comprehensive literature review was performed to identify studies that included no adjuvant therapy, or pelvic radiation or vaginal brachytherapy with or without systemic chemotherapy. Outcomes included local control, survival rates, and overall assessment of quality of life. RESULTS Patients with grade 1 or 2 cancers with either no invasion or <50% myometrial invasion (MI), especially when no other high risk features are present, can be safely observed after hysterectomy. Vaginal cuff brachytherapy is as effective as pelvic radiation therapy at preventing vaginal recurrence for patients with grade 1 or 2 cancers with ≥50% MI or grade 3 tumors with <50% MI. Patients with grade 3 cancer with ≥50% MI or cervical stroma invasion may benefit from pelvic radiation to reduce the risk of pelvic recurrence. There is limited evidence for a benefit to vaginal cuff brachytherapy following pelvic radiation. Multimodality treatment is recommended for patients with positive nodes or involved uterine serosa, ovaries or fallopian tubes, vagina, bladder, or rectum. CONCLUSIONS External beam and vaginal brachytherapy remain integral aspects of adjuvant therapy for endometrial cancer.


Magnetic Resonance Imaging | 2012

3-T MR-guided brachytherapy for gynecologic malignancies.

Tina Kapur; Jan Egger; Antonio L. Damato; Ehud J. Schmidt; Akila N. Viswanathan

Gynecologic malignancies are a leading cause of death in women worldwide. Standard treatment for many primary and recurrent gynecologic cancer cases includes external-beam radiation followed by brachytherapy. Magnetic resonance (MR) imaging is beneficial in diagnostic evaluation, in mapping the tumor location to tailor radiation dose and in monitoring the tumor response to treatment. Initial studies of MR guidance in gynecologic brachytherapy demonstrate the ability to optimize tumor coverage and reduce radiation dose to normal tissues, resulting in improved outcomes for patients. In this article, we describe a methodology to aid applicator placement and treatment planning for 3 Tesla (3-T) MR-guided brachytherapy that was developed specifically for gynecologic cancers. This methodology has been used in 18 cases from September 2011 to May 2012 in the Advanced Multimodality Image Guided Operating (AMIGO) suite at Brigham and Womens Hospital. AMIGO comprises state-of-the-art tools for MR imaging, image analysis and treatment planning. An MR sequence using three-dimensional (3D)-balanced steady-state free precession in a 3-T MR scanner was identified as the best sequence for catheter identification with ballooning artifact at the tip. 3D treatment planning was performed using MR images. Items in development include software designed to support virtual needle trajectory planning that uses probabilistic bias correction, graph-based segmentation and image registration algorithms. The results demonstrate that 3-T MR image guidance has a role in gynecologic brachytherapy. These novel developments have the potential to improve targeted treatment to the tumor while sparing the normal tissues.


Brachytherapy | 2013

Clinical outcomes of high-dose-rate interstitial gynecologic brachytherapy using real-time CT guidance

Larissa J. Lee; Antonio L. Damato; Akila N. Viswanathan

PURPOSE To evaluate clinical outcomes of CT-guided high-dose-rate (HDR) interstitial brachytherapy for primary and recurrent gynecologic cancer. METHODS AND MATERIALS Records were reviewed for 68 women (34 with primary disease and 34 with recurrence) treated with CT-guided HDR interstitial brachytherapy between May 2005 and September 2011. Interstitial application was performed under general anesthesia using an iterative approach of catheter insertion and adjustment with serial image acquisition by CT in a dedicated brachytherapy suite. The median fractional brachytherapy dose was 3.9Gy delivered twice daily in seven fractions. The median cumulative dose in equivalent 2-Gy fractions was 74.8Gy. Actuarial survival estimates were calculated using the Kaplan-Meier method, and toxicity was reported by Common Toxicity Criteria. RESULTS Primary disease sites were endometrial (34), cervical (17), vaginal (11), ovarian (3), and vulvar (3). Median age was 61.5 years, and tumor size at diagnosis was 3.4cm. Median D90 and V100 were 73.6Gy and 87.5%, respectively; median D2cc for bladder, rectum, and sigmoid were 67.1, 64.6, and 53.7Gy, respectively. With a median followup of 17 months, actuarial rates of local control, progression-free survival, and overall survival at 2 years for all patients were 86%, 60%, and 64%, respectively. There were 9 grade 3 late toxicities (six gastrointestinal and three vulvovaginal). CONCLUSIONS HDR interstitial brachytherapy with CT-guided catheter placement results in acceptable local control, toxicity, and survival rates for women with primary or recurrent gynecologic cancer. Durable pelvic control may be achieved in most patients with this specialized brachytherapy technique.


International Journal of Radiation Oncology Biology Physics | 2012

Duodenal and other gastrointestinal toxicity in cervical and endometrial cancer treated with extended-field intensity modulated radiation therapy to paraaortic lymph nodes.

Philip D. Poorvu; Cheryl A. Sadow; Kanokpis Townamchai; Antonio L. Damato; Akila N. Viswanathan

PURPOSE To characterize the rates of acute and late duodenal and other gastrointestinal (GI) toxicities among patients treated for cervical and endometrial cancers with extended-field intensity modulated radiation therapy (EF-IMRT) to the paraaortic nodes and to analyze dose-volume relationships of GI toxicities. METHODS AND MATERIALS Fifty-three patients with endometrial or cervical cancer underwent EF-IMRT to the paraaortic nodes, of whom 46 met the inclusion criteria for GI toxicity and 45 for duodenal toxicity analysis. The median prescribed dose to the paraaortic nodes was 54 Gy (range, 41.4-65 Gy). The 4 duodenal segments, whole duodenum, small bowel loops, peritoneum, and peritoneum plus retroperitoneal segments of colon were contoured retrospectively, and dosimetric analysis was performed to identify dose-volume relationships to grade ≥3 acute (<90 day) and late (≥90 day) GI toxicity. RESULTS Only 3/46 patients (6.5%) experienced acute grade ≥3 GI toxicity and 3/46 patients (6.5%) experienced late grade ≥3 GI toxicity. The median dose administered to these 6 patients was 50.4 Gy. One of 12 patients who received 63 to 65 Gy at the level of the renal hilum experienced grade 3 GI toxicity. Dosimetric analysis of patients with and without toxicity revealed no differences between the mean absolute or fractional volumes at any 5-Gy interval between 5 Gy and the maximum dose. None of the patients experienced duodenal toxicity. CONCLUSIONS Treatment of paraaortic nodes with IMRT is associated with low rates of GI toxicities and no duodenal-specific toxicity, including patients treated with concurrent chemotherapy. This technique may allow sufficient dose sparing of the bowel to enable safe dose escalation to at least 65 Gy.


Gynecologic Oncology | 2013

Vaginal brachytherapy for early stage uterine papillary serous and clear cell endometrial cancer

Kanokpis Townamchai; Ross S. Berkowitz; Mandar S. Bhagwat; Antonio L. Damato; Scott Friesen; Larissa J. Lee; Ursula A. Matulonis; Desmond A. O'Farrell; Akila N. Viswanathan

OBJECTIVE To report clinical outcomes following adjuvant high-dose-rate (HDR) vaginal brachytherapy (VB) for early-stage uterine papillary serous (UPSC) and clear cell (CC) endometrial cancer. METHODS A retrospective study of Stage I and II papillary serous and clear cell endometrial cancer treated with post-operative HDR VB between October 2005 and May 2012 was performed. A total of 37 patients were identified, 26 with UPSC, 9 with CC and 2 with mixed UPSC/CC. After total hysterectomy and bilateral salpingo-oophorectomy, VB was administered without external-beam radiation with a dose of 24 Gy in 6 fractions prescribed to the vaginal surface. Chemotherapy was given to 30 patients (75%). RESULTS The median follow up time was 24.8 months (range, 2.0 to 71.5 months). Four patients relapsed, 2 with UPSC and 2 with CC. The initial site of relapse was concurrent vagina, pelvic/para-aortic nodes and abdominal wall (1), pelvic/para-aortic nodes (1) and para-aortic nodes alone (2). The 2-year vaginal-control rate was 96.8%. The pelvic-control rate including vaginal and nodal relapse was 93.5%. The 2-year disease-free and overall survival rates were 89.3% and 100%, respectively. CONCLUSION HDR VB as the sole adjuvant treatment modality for early-stage UPSC/CC is associated with a low rate of vaginal relapse and excellent survival outcomes. This novel low-dose regimen for VB is safe and effective.


Gynecologic Oncology | 2013

Clinical outcomes following 3D image-guided brachytherapy for vaginal recurrence of endometrial cancer ☆

Larissa J. Lee; Antonio L. Damato; Akila N. Viswanathan

PURPOSE To evaluate clinical outcomes for women with recurrent endometrial cancer treated with 3D image-guided brachytherapy METHODS AND MATERIALS 44 women, of whom 13 had received prior RT, received salvage RT for vaginal recurrence from 9/03 to 8/11. HDR or LDR interstitial brachytherapy was performed under MR or CT guidance in 35 patients (80%); 9 (20%) had CT-guided HDR cylinder brachytherapy. The median cumulative dose in EQD2 was 75.5 Gy. Actuarial estimates of local failure (LF), disease-free (DFS) and overall survival (OS) were calculated by Kaplan-Meier. RESULTS Histologic subtypes were endometrioid (EAC, 33), papillary serous/clear cell (UPSC/CC, 5) and carcinosarcoma (CS, 6). The 2-year DFS/OS rates were 75%/89% for EAC and 11%/24% for UPSC/CC/CS (both p<0.01). On MVA, high tumor grade was associated with recurrence (HR 3.2 for grade 2, 9.6 for grade 3, p<0.01). The LF rate at 2 years was 4% for patients without versus 39% for those with prior RT (p=0.1). Patients who had prior RT received lower cumulative doses at recurrence (66.5 Gy vs. 74.4 Gy, p<0.01). The 2-year DFS/OS rates with and without prior RT were 26%/55% and 72%/80% (both p=0.1). Four patients (9%) experienced grade 3 late toxicity, including 3 of 13 (23%) in the re-irradiation setting and 1 of 31 (3%) with no prior radiotherapy. DISCUSSION 3D image-guided brachytherapy results in excellent local control for women with recurrent endometrial cancer, particularly with cumulative EQD2 doses greater than 70 Gy. Successful salvage of vaginal recurrence is related to tumor grade and histologic subtype.


Medical Physics | 2014

A system to use electromagnetic tracking for the quality assurance of brachytherapy catheter digitization

Antonio L. Damato; Akila N. Viswanathan; Sarah M. Don; Jorgen L. Hansen; Robert A. Cormack

PURPOSE To investigate the use of a system using electromagnetic tracking (EMT), post-processing and an error-detection algorithm for detecting errors and resolving uncertainties in high-dose-rate brachytherapy catheter digitization for treatment planning. METHODS EMT was used to localize 15 catheters inserted into a phantom using a stepwise acquisition technique. Five distinct acquisition experiments were performed. Noise associated with the acquisition was calculated. The dwell location configuration was extracted from the EMT data. A CT scan of the phantom was performed, and five distinct catheter digitization sessions were performed. No a priori registration of the CT scan coordinate system with the EMT coordinate system was performed. CT-based digitization was automatically extracted from the brachytherapy plan DICOM files (CT), and rigid registration was performed between EMT and CT dwell positions. EMT registration error was characterized in terms of the mean and maximum distance between corresponding EMT and CT dwell positions per catheter. An algorithm for error detection and identification was presented. Three types of errors were systematically simulated: swap of two catheter numbers, partial swap of catheter number identification for parts of the catheters (mix), and catheter-tip shift. Error-detection sensitivity (number of simulated scenarios correctly identified as containing an error/number of simulated scenarios containing an error) and specificity (number of scenarios correctly identified as not containing errors/number of correct scenarios) were calculated. Catheter identification sensitivity (number of catheters correctly identified as erroneous across all scenarios/number of erroneous catheters across all scenarios) and specificity (number of catheters correctly identified as correct across all scenarios/number of correct catheters across all scenarios) were calculated. The mean detected and identified shift was calculated. RESULTS The maximum noise ±1 standard deviation associated with the EMT acquisitions was 1.0 ± 0.1 mm, and the mean noise was 0.6 ± 0.1 mm. Registration of all the EMT and CT dwell positions was associated with a mean catheter error of 0.6 ± 0.2 mm, a maximum catheter error of 0.9 ± 0.4 mm, a mean dwell error of 1.0 ± 0.3 mm, and a maximum dwell error of 1.3 ± 0.7 mm. Error detection and catheter identification sensitivity and specificity of 100% were observed for swap, mix and shift (≥2.6 mm for error detection; ≥2.7 mm for catheter identification) errors. A mean detected shift of 1.8 ± 0.4 mm and a mean identified shift of 1.9 ± 0.4 mm were observed. CONCLUSIONS Registration of the EMT dwell positions to the CT dwell positions was possible with a residual mean error per catheter of 0.6 ± 0.2 mm and a maximum error for any dwell of 1.3 ± 0.7 mm. These low residual registration errors show that quality assurance of the general characteristics of the catheters and of possible errors affecting one specific dwell position is possible. The sensitivity and specificity of the catheter digitization verification algorithm was 100% for swap and mix errors and for shifts ≥2.6 mm. On average, shifts ≥1.8 mm were detected, and shifts ≥1.9 mm were detected and identified.


Brachytherapy | 2014

Characterization of implant displacement and deformation in gynecologic interstitial brachytherapy

Antonio L. Damato; Robert A. Cormack; Akila N. Viswanathan

PURPOSE To determine the uncertainties in implant position during multifraction gynecologic interstitial brachytherapy, we analyzed the interfraction displacements and deformations of gynecologic interstitial implants. METHODS AND MATERIALS Fourteen gynecologic patients treated with multifraction high-dose-rate interstitial brachytherapy received two CT scans each at the time of implantation and 48-72 h later. Rigid fusions on the pubic symphysis were performed. This analysis included catheter shifts in the cranial (CR), caudal (CA), anterior, posterior, left, and right directions; template shifts; the change in the catheter length measured along the path from catheter tip to catheter connector (offset); the change in relative distances between catheters (deformations); and changes in rectum and bladder D2cc and tumor D90. RESULTS Of the 198 catheters analyzed, the number of catheter shifts (%) and mean ± standard deviation were 43% CA (5.0 ± 2.0 mm), 22% CR (7.9 ± 4.0 mm), 14% anterior (6.3 ± 2.1 mm), 48% posterior (8.7 ± 3.1 mm), 7% left (4.8 ± 0.4 mm), and 9% right (5.4 ± 0.9 mm). Catheter offsets were 3% CA (7.2 ± 6.3 mm) and 11% CR (6.1 ± 2.6 mm). Template shifts were 43% CA (5.2 ± 1.6 mm) and 14% CR (6.6 ± 4.0 mm). Deformations were 10 shrinkages (4.7 ± 0.9 mm) and 32 expansions (4.7 ± 0.5 mm). Dosimetric changes were 5.2% ± 10.8% for rectum D2cc, -1.1% ± 18.5% for bladder D2cc, and -5.1% ± 6.7% for tumor D90. CONCLUSIONS On average, less than 1 cm displacements and deformations of the implant occurred over the course of treatment. Proper quality assurance methodologies should be in place to detect shifts that can potentially result in inadvertent insertion into normal tissue.


Brachytherapy | 2015

Redesign of process map to increase efficiency: Reducing procedure time in cervical cancer brachytherapy

Antonio L. Damato; Larissa J. Lee; Mandar S. Bhagwat; Ivan Buzurovic; Robert A. Cormack; Susan Finucane; Jorgen L. Hansen; Desmond A. O'Farrell; Alecia Offiong; Una Randall; Scott Friesen; Akila N. Viswanathan

PURPOSE To increase intraprocedural efficiency in the use of clinical resources and to decrease planning time for cervical cancer brachytherapy treatments through redesign of the procedures process map. METHODS AND MATERIALS A multidisciplinary team identified all tasks and associated resources involved in cervical cancer brachytherapy in our institution and arranged them in a process map. A redesign of the treatment planning component of the process map was conducted with the goal of minimizing planning time. Planning time was measured on 20 consecutive insertions, of which 10 were performed with standard procedures and 10 with the redesigned process map, and results were compared. Statistical significance (p < 0.05) was measured with a two-tailed t test. RESULTS Twelve tasks involved in cervical cancer brachytherapy treatments were identified. The process map showed that in standard procedures, the treatment planning tasks were performed sequentially. The process map was redesigned to specify that contouring and some planning tasks are performed concomitantly. Some quality assurance tasks were reorganized to minimize adverse effects of a possible error on procedure time. Test dry runs followed by live implementation confirmed the applicability of the new process map to clinical conditions. A 29% reduction in planning time (p < 0.01) was observed with the introduction of the redesigned process map. CONCLUSIONS A process map for cervical cancer brachytherapy was generated. The treatment planning component of the process map was redesigned, resulting in a 29% decrease in planning time and a streamlining of the quality assurance process.


Journal of Clinical Oncology | 2013

Novel Use of a Hydrogel Spacer Permits Reirradiation in Otherwise Incurable Recurrent Gynecologic Cancers

Akila N. Viswanathan; Antonio L. Damato; Paul L. Nguyen

Introduction Each year in the United States, there are approximately 80,000 new cases of gynecologic cancer and 25,000 deaths resulting from the disease. Uterine cancer comprises 47,000 cases and cervical cancer approximately 12,000. Up to 40% of patients with these cancers (specifically locally advanced cervical, vaginal, vulvar, or high-risk uterine cancers) receive radiation with the intent of cure at the time of diagnosis. Fewer than 5% of women treated with pelvic radiation or vaginal brachytherapy for early-stage uterine cancer suffer a vaginal or pelvic relapse, whereas up to 20% of those treated with chemoradiotherapy for locally advanced cervical cancer may relapse in the irradiated field. Image-guided brachytherapy in patients with locally advanced cervical cancer has significantly improved toxicity and local recurrence (LR) rates, reducing the LR rate to approximately 10%. Nonetheless, an estimated 2,000 patients with gynecologic cancer experience LR in an irradiated field in the United States each year, representing a significant cause of morbidity and mortality. In the absence of other sites of disease (ie, distant metastases), successful removal of the locally recurrent tumor may result in a long disease-free interval or cure. However, surgical resection often requires a pelvic exenteration, a procedure with high morbidity and low salvage rates. In addition, local infiltration of the tumor, fibrosis from previous radiation and proximity of normal tissue structures may make the tumor unresectable. Reirradiation strategies have been limited as a result of the high risk of fatal morbidity with standard techniques. Recurrent disease in the pelvis after radiation is often incurable because of the low tolerance of normal tissues to reirradiation. As a result of improvements in the delivery and technical accuracy of radiation with the assistance of three-dimensional imaging used for treatment planning, reirradiation has recently been attempted. Specifically, in gynecologic cancer, recurrent lesions in the vagina, cervix, or low pelvis may be amenable to internal irradiation with highly conformal image-guided interstitial brachytherapy. The dose received by the normal tissues with reirradiation remains a primary concern. Herein we describe a novel approach, using a hydrogel spacer to separate the normal tissues from the tumor, which allows dose escalation to curative levels not otherwise permissible because of toxic adverse effects. Polymer hydrogel temporary spacer material (Duraseal; Covidien, Mansfield, MA) is designed to hold its shape for 4 weeks in vivo before hydrolysis and resorption. This hydrogel safely separates normal tissues, including the rectum and small bowel, from the tumor, resulting in significantly lower radiation doses to previously irradiated normal tissue. Previous studies have evaluated the use of a hydrogel spacer to reduce rectal dose in recurrent prostate cancer. No adverse events have been reported in the literature.

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Robert A. Cormack

Brigham and Women's Hospital

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Larissa J. Lee

Brigham and Women's Hospital

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Ivan Buzurovic

Brigham and Women's Hospital

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Mandar S. Bhagwat

Brigham and Women's Hospital

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Phillip M. Devlin

Brigham and Women's Hospital

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Scott Friesen

Brigham and Women's Hospital

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Desmond A. O'Farrell

Brigham and Women's Hospital

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Jorgen L. Hansen

Brigham and Women's Hospital

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Ehud J. Schmidt

Brigham and Women's Hospital

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