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Colaco RJ, Nichols RC, Huh S, Getman N, Ho MW, Li Z, Morris CG, Mendenhall WM, Mendenhall NP, Hoppe BS. Protons offer reduced bone marrow, small bowel, and urinary bladder exposure for patients receiving neoadjuvant radiotherapy for resectable rectal cancer. J Gastrointest Oncol 2014; 5:3-8. [PMID: 24490037 DOI: 10.3978/j.issn.2078-6891.2013.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 06/25/2013] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND To assess the potential benefit of proton therapy (PT) over photon therapy, we compared 3-dimensional conformal radiotherapy (3DCRT), intensity-modulated radiotherapy (IMRT), and PT plans in patients undergoing neoadjuvant chemoradiation for resectable rectal cancer at our institution. METHODS Eight consecutive patients with resectable (T2-T3) rectal cancers underwent 3DCRT, IMRT, and 3-dimensional conformal PT treatment planning. Initial target volumes (PTV1) were contoured using the Radiation Therapy Oncology Group anorectal atlas guidelines. Boost target volumes (PTV2) consisted of the gross rectal tumor plus a uniform 2-cm expansion. Plans delivered 45 Gray (Gy) or Cobalt Gray Equivalent (CGE) to the PTV1 and a 5.4-Gy (CGE) boost to the PTV2. Ninety-five percent of the PTVs received 100% of the target dose and 100% of the PTVs received 95% of the target dose. Standard normal-tissue constraints were utilized. Wilcoxon paired t-tests were performed to compare various dosimetric points between the 3 plans for each patient. RESULTS All plans met all normal-tissue constraints and were isoeffective in terms of PTV coverage. The proton plans offered significantly reduced median normal-tissue exposure over the 3DCRT and IMRT plans with respect to pelvic bone marrow at the V5Gy, V10Gy, V15Gy, and V20Gy levels and the small bowel space at the V10Gy and V20Gy levels. The proton plans also offered significantly reduced median normal-tissue exposure over the 3DCRT plans with respect to the small bowel at the V30Gy and V40Gy levels and the urinary bladder at the V40Gy level. CONCLUSIONS By reducing bone marrow exposure, PT may reduce the acute hematologic toxicity of neoadjuvant chemoradiation and increase the likelihood of uninterrupted chemotherapy delivery. Bone marrow sparing may also facilitate the delivery of salvage chemotherapy for patients who subsequently develop hematogenous metastasis. Reduced small bowel exposure using PT may also reduce toxicity and possibly facilitate the use of more-aggressive chemotherapy with radiotherapy.
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Affiliation(s)
- Rovel J Colaco
- University of Florida Proton Therapy Institute, Jacksonville, Florida, USA
| | | | - Soon Huh
- University of Florida Proton Therapy Institute, Jacksonville, Florida, USA
| | - Nataliya Getman
- University of Florida Proton Therapy Institute, Jacksonville, Florida, USA
| | - Meng Wei Ho
- University of Florida Proton Therapy Institute, Jacksonville, Florida, USA
| | - Zuofeng Li
- University of Florida Proton Therapy Institute, Jacksonville, Florida, USA
| | | | | | - Nancy P Mendenhall
- University of Florida Proton Therapy Institute, Jacksonville, Florida, USA
| | - Bradford S Hoppe
- University of Florida Proton Therapy Institute, Jacksonville, Florida, USA
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Proton radiotherapy for pediatric sarcoma. Cancers (Basel) 2014; 6:112-27. [PMID: 24424260 PMCID: PMC3980591 DOI: 10.3390/cancers6010112] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 12/17/2013] [Accepted: 12/18/2013] [Indexed: 11/16/2022] Open
Abstract
Pediatric sarcomas represent a distinct group of pathologies, with approximately 900 new cases per year in the United States alone. Radiotherapy plays an integral role in the local control of these tumors, which often arise adjacent to critical structures and growing organs. The physical properties of proton beam radiotherapy provide a distinct advantage over standard photon radiation by eliminating excess dose deposited beyond the target volume, thereby reducing both the dose of radiation delivered to non-target structures as well as the total radiation dose delivered to a patient. Dosimetric studies comparing proton plans to IMRT and 3D conformal radiation have demonstrated the superiority of protons in numerous pediatric malignancies and data on long-term clinical outcomes and toxicity is emerging. In this article, we review the existing clinical and dosimetric data regarding the use of proton beam radiation in malignant bone and soft tissue sarcomas.
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Oshiro Y, Mizumoto M, Okumura T, Sugahara S, Fukushima T, Ishikawa H, Nakao T, Hashimoto T, Tsuboi K, Ohkawa H, Kaneko M, Sakurai H. Clinical results of proton beam therapy for advanced neuroblastoma. Radiat Oncol 2013; 8:142. [PMID: 23758770 PMCID: PMC3693889 DOI: 10.1186/1748-717x-8-142] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 06/01/2013] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To evaluate the efficacy of proton beam therapy (PBT) for pediatric patients with advanced neuroblastoma. METHODS PBT was conducted at 21 sites in 14 patients with neuroblastoma from 1984 to 2010. Most patients were difficult to treat with photon radiotherapy. Two and 6 patients were classified into stages 3 and 4, respectively, and 6 patients had recurrent disease. Seven of the 8 patients who received PBT as the initial treatment were classified as the high risk group. Twelve patients had gross residual disease before PBT and 2 had undergone intraoperative radiotherapy before PBT. Five patients received PBT for multiple sites, including remote metastases. Photon radiotherapy was used in combination with PBT for 3 patients. The PBT doses ranged from 19.8 to 45.5 GyE (median: 30.6 GyE). RESULTS Seven patients are alive with no evidence of disease, 1 is alive with disease progression, and 6 died due to the tumor. Recurrence in the treatment field was not observed and the 3-year locoregional control rate was 82%. Severe acute radiotoxicity was not observed, but 1 patient had narrowing of the aorta and asymptomatic vertebral compression fracture at 28 years after PBT, and hair loss was prolonged in one patient. CONCLUSION PBT may be a better alternative to photon radiotherapy for children with advanced neuroblastoma, and may be conducted safely for patients with neuroblastoma that is difficult to manage using photon beams.
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Fogliata A, Scorsetti M, Navarria P, Catalano M, Clivio A, Cozzi L, Lobefalo F, Nicolini G, Palumbo V, Pellegrini C, Reggiori G, Roggio A, Vanetti E, Alongi F, Pentimalli S, Mancosu P. Dosimetric comparison between VMAT with different dose calculation algorithms and protons for soft-tissue sarcoma radiotherapy. Acta Oncol 2013; 52:545-52. [PMID: 22671576 DOI: 10.3109/0284186x.2012.689853] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND To appraise the potential of volumetric modulated arc therapy (VMAT, RapidArc) and proton beams to simultaneously achieve target coverage and enhanced sparing of bone tissue in the treatment of soft-tissue sarcoma with adequate target coverage. MATERIAL AND METHODS Ten patients presenting with soft-tissue sarcoma of the leg were collected for the study. Dose was prescribed to 66.5 Gy in 25 fractions to the planning target volume (PTV) while significant maximum dose to the bone was constrained to 50 Gy. Plans were optimised according to the RapidArc technique with 6 MV photon beams or for intensity modulated protons. RapidArc photon plans were computed with: 1) AAA; 2) Acuros XB as dose to medium; and 3) Acuros XB as dose to water. RESULTS All plans acceptably met the criteria of target coverage (V95% >90-95%) and bone sparing (D(1 cm3) <50 Gy). Significantly higher PTV dose homogeneity was found for proton plans. Near-to-maximum dose to bone was similar for RapidArc and protons, while volume receiving medium/low dose levels was minimised with protons. Similar results were obtained for the remaining normal tissue. Dose distributions calculated with the dose to water option resulted ~5% higher than corresponding ones computed as dose to medium. CONCLUSION High plan quality was demonstrated for both VMAT and proton techniques when applied to soft-tissue sarcoma.
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Affiliation(s)
- Antonella Fogliata
- Oncology Institute of Southern Switzerland, Medical Physics Unit,
Bellinzona, Switzerland
| | - Marta Scorsetti
- IRCCS Istituto Clinico Humanitas, Radiation Oncology,
Rozzano, Milan, Italy
| | - Piera Navarria
- IRCCS Istituto Clinico Humanitas, Radiation Oncology,
Rozzano, Milan, Italy
| | - Maddalena Catalano
- IRCCS Istituto Clinico Humanitas, Radiation Oncology,
Rozzano, Milan, Italy
| | - Alessandro Clivio
- Oncology Institute of Southern Switzerland, Medical Physics Unit,
Bellinzona, Switzerland
| | - Luca Cozzi
- Oncology Institute of Southern Switzerland, Medical Physics Unit,
Bellinzona, Switzerland
| | - Francesca Lobefalo
- IRCCS Istituto Clinico Humanitas, Radiation Oncology,
Rozzano, Milan, Italy
| | - Giorgia Nicolini
- Oncology Institute of Southern Switzerland, Medical Physics Unit,
Bellinzona, Switzerland
| | - Valentina Palumbo
- IRCCS Istituto Clinico Humanitas, Radiation Oncology,
Rozzano, Milan, Italy
| | - Chiara Pellegrini
- IRCCS Istituto Clinico Humanitas, Radiation Oncology,
Rozzano, Milan, Italy
| | - Giacomo Reggiori
- IRCCS Istituto Clinico Humanitas, Radiation Oncology,
Rozzano, Milan, Italy
| | - Antonella Roggio
- IRCCS Istituto Clinico Humanitas, Radiation Oncology,
Rozzano, Milan, Italy
| | - Eugenio Vanetti
- Oncology Institute of Southern Switzerland, Medical Physics Unit,
Bellinzona, Switzerland
| | - Filippo Alongi
- IRCCS Istituto Clinico Humanitas, Radiation Oncology,
Rozzano, Milan, Italy
| | - Sara Pentimalli
- IRCCS Istituto Clinico Humanitas, Radiation Oncology,
Rozzano, Milan, Italy
| | - Pietro Mancosu
- IRCCS Istituto Clinico Humanitas, Radiation Oncology,
Rozzano, Milan, Italy
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Yock TI, Caruso PA. Risk of second cancers after photon and proton radiotherapy: a review of the data. HEALTH PHYSICS 2012; 103:577-585. [PMID: 23032887 DOI: 10.1097/hp.0b013e3182609ba4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Control rates for pediatric and adult malignancies are now approximately 80 and 60%, respectively, due to dramatic improvements in surgery, chemotherapy, and radiotherapy. However, radiotherapy is responsible for many of the adverse late effects of treatment, which is now well documented in the literature. The most serious and life threatening side effect of radiotherapy that affects both children and adults is radiation-induced second primary cancers.
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Affiliation(s)
- Torunn I Yock
- Massachusetts General Hospital, Department of Radiation Oncology, 100 Blossom Street, COX LL, Boston, MA 02114-2617, USA.
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Combs SE, Kessel KA, Herfarth K, Jensen A, Oertel S, Blattmann C, Ecker S, Hoess A, Martin E, Witt O, Jäkel O, Kulozik AE, Debus J. Treatment of pediatric patients and young adults with particle therapy at the Heidelberg Ion Therapy Center (HIT): establishment of workflow and initial clinical data. Radiat Oncol 2012; 7:170. [PMID: 23072718 PMCID: PMC3504515 DOI: 10.1186/1748-717x-7-170] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 10/13/2012] [Indexed: 12/30/2022] Open
Abstract
Background To report on establishment of workflow and clinical results of particle therapy at the Heidelberg Ion Therapy Center. Materials and methods We treated 36 pediatric patients (aged 21 or younger) with particle therapy at HIT. Median age was 12 years (range 2-21 years), five patients (14%) were younger than 5 years of age. Indications included pilocytic astrocytoma, parameningeal and orbital rhabdomyosarcoma, skull base and cervical chordoma, osteosarcoma and adenoid-cystic carcinoma (ACC), as well as one patient with an angiofibroma of the nasopharynx. For the treatment of small children, an anesthesia unit at HIT was established in cooperation with the Department of Anesthesiology. Results Treatment concepts depended on tumor type, staging, age of the patient, as well as availability of specific study protocols. In all patients, particle radiotherapy was well tolerated and no interruptions due to toxicity had to be undertaken. During follow-up, only mild toxicites were observed. Only one patient died of tumor progression: Carbon ion radiotherapy was performed as an individual treatment approach in a child with a skull base recurrence of the previously irradiated rhabdomyosarcoma. Besides this patient, tumor recurrence was observed in two additional patients. Conclusion Clinical protocols have been generated to evaluate the real potential of particle therapy, also with respect to carbon ions in distinct pediatric patient populations. The strong cooperation between the pediatric department and the department of radiation oncology enable an interdisciplinary treatment and stream-lined workflow and acceptance of the treatment for the patients and their parents.
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Affiliation(s)
- Stephanie E Combs
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, Heidelberg, 69120, Germany.
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Terezakis SA, Wharam MD. Radiotherapy for rhabdomyosarcoma: indications and outcome. Clin Oncol (R Coll Radiol) 2012; 25:27-35. [PMID: 22990007 DOI: 10.1016/j.clon.2012.07.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Revised: 04/19/2012] [Accepted: 05/17/2012] [Indexed: 11/25/2022]
Abstract
Rhabdomyosarcoma is the most common soft tissue sarcoma of childhood. Improvements in the clinical outcomes of rhabdomyosarcoma have been secondary to the intensification and refinement of treatment investigated by the Intergroup Rhabdomyosarcoma Study Group. Advances in diagnostic imaging techniques have led to improvements in staging and contribute to precision in radiation field design. Radiation treatment has been integrated into the primary treatment of most patients with rhabdomyosarcoma. Each treatment site has special considerations with regards to prognosis, outcomes and potential morbidities that affect the choice of local therapy. Advanced radiotherapy techniques using conformal treatment with intensity-modulated radiotherapy and proton therapy are particularly advantageous for the treatment of sites close to critical structures, such as the head and neck and genitourinary system. Active investigation is underway to develop strategies to reduce the radiation dose and volume in an effort to minimise late toxicity and improve the therapeutic ratio.
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Affiliation(s)
- S A Terezakis
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Abstract
The increasing efficacy of pediatric cancer therapy over the past four decades has produced many long-term survivors that now struggle with serious treatment related morbidities affecting their quality of life. Radiation therapy is responsible for a significant proportion of these late effects, but a relatively new and emerging modality, proton radiotherapy hold great promise to drastically reduce these treatment related late effects in long term survivors by sparing dose to normal tissues. Dosimetric studies of proton radiotherapy compared with best available photon based treatment show significant dose sparing to developing normal tissues. Furthermore, clinical data are now emerging that begin to quantify the benefit in decreased late treatment effects while maintaining excellent cancer control rates.
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Affiliation(s)
- Shane E Cotter
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA 02115, USA
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Rombi B, DeLaney TF, MacDonald SM, Huang MS, Ebb DH, Liebsch NJ, Raskin KA, Yeap BY, Marcus KJ, Tarbell NJ, Yock TI. Proton Radiotherapy for Pediatric Ewing's Sarcoma: Initial Clinical Outcomes. Int J Radiat Oncol Biol Phys 2012; 82:1142-8. [DOI: 10.1016/j.ijrobp.2011.03.038] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2010] [Revised: 03/17/2011] [Accepted: 03/23/2011] [Indexed: 01/28/2023]
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Dosimetric comparison of combined intensity-modulated radiotherapy (IMRT) and proton therapy versus IMRT alone for pelvic and para-aortic radiotherapy in gynecologic malignancies. Int J Radiat Oncol Biol Phys 2011; 82:e477-84. [PMID: 22177626 DOI: 10.1016/j.ijrobp.2011.07.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Revised: 05/18/2011] [Accepted: 07/12/2011] [Indexed: 10/14/2022]
Abstract
PURPOSE To perform a dosimetric comparison of intensity-modulated radiotherapy (IMRT), passive scattering proton therapy (PSPT), and intensity-modulated proton therapy (IMPT) to the para-aortic (PA) nodal region in women with locally advanced gynecologic malignancies. METHODS AND MATERIALS The CT treatment planning scans of 10 consecutive patients treated with IMRT to the pelvis and PA nodes were identified. The clinical target volume was defined by the primary tumor for patients with cervical cancer and by the vagina and paravaginal tissues for patients with endometrial cancer, in addition to the regional lymph nodes. The IMRT, PSPT, and IMPT plans were generated using the Eclipse Treatment Planning System and were analyzed for various dosimetric endpoints. Two groups of treatment plans including proton radiotherapy were created: IMRT to pelvic nodes with PSPT to PA nodes (PSPT/IMRT), and IMRT to pelvic nodes with IMPT to PA nodes (IMPT/IMRT). The IMRT and proton RT plans were optimized to deliver 50.4 Gy or Gy (relative biologic effectiveness [RBE)), respectively. Dose-volume histograms were analyzed for all of the organs at risk. The paired t test was used for all statistical comparison. RESULTS The small-bowel V(20), V(30), V(35), andV(40) were reduced in PSPT/IMRT by 11%, 18%, 27%, and 43%, respectively (p < 0.01). Treatment with IMPT/IMRT demonstrated a 32% decrease in the small-bowel V(20). Treatment with PSPT/IMRT showed statistically significant reductions in the body V(5-20); IMPT/IMRT showed reductions in the body V(5-15). The dose received by half of both kidneys was reduced by PSPT/IMRT and by IMPT/IMRT. All plans maintained excellent coverage of the planning target volume. CONCLUSIONS Compared with IMRT alone, PSPT/IMRT and IMPT/IMRT had a statistically significant decrease in dose to the small and large bowel and kidneys, while maintaining excellent planning target volume coverage. Further studies should be done to correlate the clinical significance of these findings.
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Terezakis SA, Heron DE, Lavigne RF, Diehn M, Loo BW. What the Diagnostic Radiologist Needs to Know about Radiation Oncology. Radiology 2011; 261:30-44. [DOI: 10.1148/radiol.11101688] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Huh WW, Fitzgerald N, Mahajan A, Sturgis EM, Beverly Raney R, Anderson PM. Pediatric sarcomas and related tumors of the head and neck. Cancer Treat Rev 2011; 37:431-9. [DOI: 10.1016/j.ctrv.2011.04.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Revised: 04/12/2011] [Accepted: 04/18/2011] [Indexed: 01/07/2023]
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Liu H, Chang JY. Proton therapy in clinical practice. CHINESE JOURNAL OF CANCER 2011; 30:315-26. [PMID: 21527064 PMCID: PMC4013396 DOI: 10.5732/cjc.010.10529] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Revised: 12/16/2010] [Accepted: 03/23/2011] [Indexed: 11/17/2022]
Abstract
Radiation dose escalation and acceleration improves local control but also increases toxicity. Proton radiation is an emerging therapy for localized cancers that is being sought with increasing frequency by patients. Compared with photon therapy, proton therapy spares more critical structures due to its unique physics. The physical properties of a proton beam make it ideal for clinical applications. By modulating the Bragg peak of protons in energy and time, a conformal radiation dose with or without intensity modulation can be delivered to the target while sparing the surrounding normal tissues. Thus, proton therapy is ideal when organ preservation is a priority. However, protons are more sensitive to organ motion and anatomy changes compared with photons. In this article, we review practical issues of proton therapy, describe its image-guided treatment planning and delivery, discuss clinical outcome for cancer patients, and suggest challenges and the future development of proton therapy.
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Affiliation(s)
- Hui Liu
- Sun Yat-sen University Cancer Center, Guangzhou, Guangdong 510060, P. R. China;
| | - Joe Y. Chang
- Radiation Oncology Department, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
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Nichols RC, Huh SN, Henderson RH, Mendenhall NP, Flampouri S, Li Z, D'Agostino HJ, Cury JD, Pham DC, Hoppe BS. Proton radiation therapy offers reduced normal lung and bone marrow exposure for patients receiving dose-escalated radiation therapy for unresectable stage iii non-small-cell lung cancer: a dosimetric study. Clin Lung Cancer 2011; 12:252-7. [PMID: 21726825 DOI: 10.1016/j.cllc.2011.03.027] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2010] [Revised: 01/18/2011] [Accepted: 01/24/2011] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The purpose of this study was to determine the potential benefit of proton radiation therapy over photon radiation therapy in patients with unresectable stage III non-small-cell lung cancer. MATERIALS AND METHODS Optimized 3-dimensional conformal photon (3DCRT), intensity-modulated radiation therapy (IMRT) and proton therapy (PT) plans were generated for 8 consecutive patients with unresectable stage III non-small-cell lung cancer using the same target goals and normal tissue constraints. The radiation exposure to non-targeted normal structures, including lung, bone marrow, esophagus, heart, and spinal cord, were compared. Photon doses are expressed in gray (Gy). Proton doses are expressed in cobalt gray equivalents (CGE). RESULTS In all patients, 3DCRT, IMRT, and PT plans, achieved the dose goals for the target volumes. Compared with the 3DCRT plans, proton plans offered a median 29% reduction in normal lung V(20) Gy (CGE), a median 33% reduction in mean lung dose (MLD), and a median 30% reduction in the volume of bone marrow receiving a dose of 10 Gy (CGE). Compared with the IMRT plans, the proton plans offered a median 26% reduction in normal lung V(20) Gy (CGE), a median 31% reduction in MLD, and a median 27% reduction in the volume of bone marrow receiving a dose of 10 Gy (CGE). CONCLUSION By reducing the volumes of normal structures irradiated, protons can potentially improve the therapeutic index for patients with unresectable stage III non-small-cell lung cancer receiving combined radiation therapy and chemotherapy.
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Affiliation(s)
- R Charles Nichols
- University of Florida Proton Therapy Institute, University of Florida College of Medicine, Jacksonville, USA.
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Proton radiotherapy for parameningeal rhabdomyosarcoma: clinical outcomes and late effects. Int J Radiat Oncol Biol Phys 2011; 82:635-42. [PMID: 21377294 DOI: 10.1016/j.ijrobp.2010.11.048] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Revised: 11/09/2010] [Accepted: 11/22/2010] [Indexed: 11/23/2022]
Abstract
PURPOSE To report the clinical outcome and late side effect profile of proton radiotherapy in the treatment of children with parameningeal rhabdomyosarcoma (PM-RMS). METHODS AND MATERIALS Seventeen consecutive children with PM-RMS were treated with proton radiotherapy at Massachusetts General Hospital between 1996 and 2005. We reviewed the medical records of all patients and asked referring physicians to report specific side effects of interest. RESULTS Median patient age at diagnosis was 3.4 years (range, 0.4-17.6). Embryonal (n = 11), alveolar (n = 4), and undifferentiated (n = 2) histologies were represented. Ten patients (59%) had intracranial extension. Median prescribed dose was 50.4 cobalt gray equivalents (GyRBE) (range, 50.4-56.0 GyRBE) delivered in 1.8-2.0-GyRBE daily fractions. Median follow-up was 5.0 years for survivors. The 5-year failure-free survival estimate was 59% (95% confidence interval, 33-79%), and overall survival estimate was 64% (95% confidence interval, 37-82%). Among the 7 patients who failed, sites of first recurrence were local only (n = 2), regional only (n = 2), distant only (n = 2), and local and distant (n = 1). Late effects related to proton radiotherapy in the 10 recurrence-free patients (median follow-up, 5 years) include failure to maintain height velocity (n = 3), endocrinopathies (n = 2), mild facial hypoplasia (n = 7), failure of permanent tooth eruption (n = 3), dental caries (n = 5), and chronic nasal/sinus congestion (n = 2). CONCLUSIONS Proton radiotherapy for patients with PM-RMS yields tumor control and survival comparable to that in historical controls with similar poor prognostic factors. Furthermore, rates of late effects from proton radiotherapy compare favorably to published reports of photon-treated cohorts.
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Hill-Kayser CE, Both S, Tochner Z. Proton Therapy: Ever Shifting Sands and the Opportunities and Obligations within. Front Oncol 2011; 1:24. [PMID: 22655235 PMCID: PMC3355860 DOI: 10.3389/fonc.2011.00024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 08/11/2011] [Indexed: 12/25/2022] Open
Abstract
Proton therapy is associated with significant benefit in terms of normal tissue sparing and potential radiation dose escalation for many patients with malignant diseases. Due to recognition of these qualities, the availability of this technology is increasing rapidly, both through increased availability of large centers, and with the possibility of smaller, lower cost proton therapy centers. Such expansion is associated with increased opportunity to provide this beneficial technology to larger numbers of patients; however, the importance of careful treatment planning and delivery, deliberate patient selection, rigorous scientific investigation including comparison to other technologies when possible, and mindfulness of ethical issues and cost effectiveness must not be forgotten. The obligation to move forward responsibly rests on the shoulders of radiation oncologists around the world. In this article, we discuss current use of proton therapy worldwide, as well as many of the factors that must be taken into account during rapid expansion of this exciting technology.
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Affiliation(s)
- Christine E Hill-Kayser
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania Philadelphia, PA, USA
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Cotter SE, Herrup DA, Friedmann A, Macdonald SM, Pieretti RV, Robinson G, Adams J, Tarbell NJ, Yock TI. Proton radiotherapy for pediatric bladder/prostate rhabdomyosarcoma: clinical outcomes and dosimetry compared to intensity-modulated radiation therapy. Int J Radiat Oncol Biol Phys 2010; 81:1367-73. [PMID: 20934266 DOI: 10.1016/j.ijrobp.2010.07.1989] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2010] [Revised: 07/06/2010] [Accepted: 07/30/2010] [Indexed: 11/30/2022]
Abstract
PURPOSE In this study, we report the clinical outcomes of 7 children with bladder/prostate rhabdomyosarcoma (RMS) treated with proton radiation and compare proton treatment plans with matched intensity-modulated radiation therapy (IMRT) plans, with an emphasis on dose savings to reproductive and skeletal structures. METHODS AND MATERIALS Follow-up consisted of scheduled clinic appointments at our institution or direct communication with the treating physicians for referred patients. Each proton radiotherapy plan used for treatment was directly compared to an IMRT plan generated for the study. Clinical target volumes and normal tissue volumes were held constant to facilitate dosimetric comparisons. Each plan was optimized for target coverage and normal tissue sparing. RESULTS Seven male patients were treated with proton radiotherapy for bladder/prostate RMS at the Massachusetts General Hospital between 2002 and 2008. Median age at treatment was 30 months (11-70 months). Median follow-up was 27 months (10-90 months). Four patients underwent a gross total resection prior to radiation, and all patients received concurrent chemotherapy. Radiation doses ranged from 36 cobalt Gray equivalent (CGE) to 50.4 CGE. Five of 7 patients were without evidence of disease and with intact bladders at study completion. Target volume dosimetry was equivalent between the two modalities for all 7 patients. Proton radiotherapy led to a significant decrease in mean organ dose to the bladder (25.1 CGE vs. 33.2 Gy; p=0.03), testes (0.0 CGE vs. 0.6 Gy; p=0.016), femoral heads (1.6 CGE vs. 10.6 Gy; p=0.016), growth plates (21.7 CGE vs. 32.4 Gy; p=0.016), and pelvic bones (8.8 CGE vs. 13.5 Gy; p=0.016) compared to IMRT. CONCLUSIONS This study provides evidence of significant dose savings to normal structures with proton radiotherapy compared to IMRT and is well tolerated in this patient population. The long-term impact of these reduced doses can be tested in future studies incorporating extended follow-up, objective outcome measures, and quality-of-life analyses.
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Affiliation(s)
- Shane E Cotter
- Harvard Radiation Oncology Program, Boston, Massachusetts 02114, USA
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70
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Abstract
Pediatric caregivers and parents are eager to know the role of proton beam therapy (PBT) in the treatment of children with brain and solid tumors and other diseases for which radiation therapy is indicated. Although the number of children treated with PBT for the most common pediatric tumors is relatively small and outcome data are clearly lacking, modeling radiation dose, volume, and outcomes based on photon benchmark data and clinical experience suggest an advantage for PBT and an opportunity to reduce or eliminate many of the early and late effects of radiation therapy. As the number of centers available to treat children increases, it is incumbent on those with access to this modality to optimize other critical aspects of radiotherapy and cancer care and follow-up that are requisite to achieving disease control and high-quality survivorship. Even though the focus of pediatric radiation oncology is weighted toward side effect reduction, there is an opportunity for dose escalation or biologically optimized radiotherapy in a number of diseases or settings in which high-dose irradiation is considered unapproachable. Justification for PBT in pediatric patients should be realized once the costs of treating acute symptoms, growth hormone deficiency, orthopedic deformities, and secondary malignancies are studied and reduced.
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71
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Abstract
Proton beam therapy provides the opportunity for more localized delivery of ionizing radiation with the potential for improved normal tissue avoidance to reduce treatment related morbidity and to allow for dose escalation to improve disease control and survival without increased toxicity. However, a systematic review of published peer-reviewed literature reported previously and updated here is devoid of any clinical data demonstrating benefit in terms of survival, tumor control, or toxicity in comparison with best conventional treatment for any of the tumors so far treated including skull base and ocular tumors, prostate cancer and childhood malignancies. The current lack of evidence for benefit of protons should provide a stimulus for continued research. Well designed in silico clinical trials using validated normal tissue complication probability-models are important to predict the magnitude of benefit for individual tumor sites but the future use of protons should be guided by clear evidence of benefit demonstrated in well-designed prospective studies, away from commercial influence, and this is likely to require international collaboration. Any complex and expensive technology, including proton therapy, should not be employed on the basis of belief alone and requires testing to avoid inappropriate use of potential detriment to future patients.
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72
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Abstract
Proton beam radiation therapy (PBRT) has unique physical properties (e.g., Bragg Peak) that limit the amount of normal tissue irradiated in the head and neck region while maximizing the radiation delivered to the tumor. Radiation therapy is commonly used in both the primary and adjuvant setting for many head and neck malignancies. Limiting the unnecessary radiation to normal tissues within the head and neck region can result in a profound improvement in quality of life during and after treatment. Although PBRT was initially developed in the 1950s, recent technological advances have permitted the development of hospital-based facilities for proton delivery. PBRT has been shown to improve outcomes for patients with sinonasal tumors, chordomas, chondrosarcomas, ocular, and periocular malignancies. Further development of intensity-modulated proton therapy will permit comprehensive treatment for head and neck tumors.
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74
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Matuszak MM, Yan D, Grills I, Martinez A. Clinical applications of volumetric modulated arc therapy. Int J Radiat Oncol Biol Phys 2010; 77:608-16. [PMID: 20100639 DOI: 10.1016/j.ijrobp.2009.08.032] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2009] [Revised: 08/04/2009] [Accepted: 08/17/2009] [Indexed: 01/30/2023]
Abstract
PURPOSE To present treatment planning case studies for several treatment sites for which volumetric modulated arc therapy (VMAT) could have a positive impact; and to share an initial clinical experience with VMAT for stereotactic body radiotherapy (SBRT). METHODS AND MATERIALS Four case studies are presented to show the potential benefit of VMAT compared with conformal and intensity-modulated radiotherapy (IMRT) techniques in pediatric cancer, bone marrow-sparing whole-abdominopelvic irradiation (WAPI), and SBRT of the lung and spine. Details of clinical implementation of VMAT for SBRT are presented. The VMAT plans are compared with conventional techniques in terms of dosimetric quality and delivery efficiency. RESULTS Volumetric modulated arc therapy reduced the treatment time of spine SBRT by 37% and improved isodose conformality. Conformal and VMAT techniques for lung SBRT had similar dosimetric quality, but VMAT had improved target coverage and took 59% less time to deliver, although monitor units were increased by 5%. In a complex pediatric pelvic example, VMAT reduced treatment time by 78% and monitor units by 25% compared with IMRT. A double-isocenter VMAT technique for WAPI can spare bone marrow while maintaining good delivery efficiency. CONCLUSIONS Volumetric modulated arc therapy is a new technology that may benefit different patient populations, including pediatric cancer patients and those undergoing concurrent chemotherapy and WAPI. Volumetric modulated arc therapy has been used and shown to be beneficial for significantly improving delivery efficiency of lung and spine SBRT.
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Affiliation(s)
- Martha M Matuszak
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI 48073-6769, USA
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75
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Abstract
Radiation therapy is an important component of treatment of many pediatric central nervous system tumors. The radiation treatment target is determined by tumor histology, extent of disease, anticipated pattern of spread, and expected pattern of failure. Children cured of their tumors live to experience the long-term sequelae of radiation treatment, including developmental, neurocognitive, neuroendocrine, and hearing late effects. The development of more conformal radiation techniques has decreased inadvertent radiation dose to normal tissues and should decrease long-term treatment sequelae that are the result of normal tissue radiation. Intensity-modulated radiation therapy improves treatment conformity and decreases high dose to nearby normal tissues; however, it delivers a larger volume of low- and intermediate-dose radiation. Proton radiation eliminates exit dose to normal tissues, thereby eliminating approximately 50% of unnecessary radiation to normal tissues. The long-term clinical benefits of proton radiation in the pediatric population are just beginning to be reported in the literature.
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Affiliation(s)
- Karen E Hoffman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Leseur J, Carrie C, Le Prisé E, Bernier V, Beneyton V, Mahé M, Supiot S. Radiothérapie conformationnelle par modulation d’intensité des tumeurs pédiatriques. Cancer Radiother 2009; 13:536-42. [DOI: 10.1016/j.canrad.2009.07.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2009] [Revised: 06/23/2009] [Accepted: 07/06/2009] [Indexed: 01/16/2023]
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