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Mirandola A, Colombo F, Cavagnetto F, Cavallo A, Gusinu M, Molinelli S, Pignoli E, Ciocca M, Barra S, Giannelli F, Pecori E, Jereczek-Fossa BA, Orlandi E, Vennarini S. Dosimetric Comparison Between Proton and Photon Radiation Therapies for Pediatric Neuroblastoma. Int J Part Ther 2024; 12:100100. [PMID: 39022120 PMCID: PMC11252081 DOI: 10.1016/j.ijpt.2024.100100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/15/2024] [Accepted: 04/23/2024] [Indexed: 07/20/2024] Open
Abstract
Purpose The aim of this study is to determine the most beneficial radiation treatment technique for pediatric patients with thoracic and abdominal neuroblastoma (NBL), through a dosimetric comparison between photon Volumetric Modulated Arc Therapy and proton Intensity-Modulated Proton Therapy treatment plans. Materials and Methods A retrospective analysis was conducted on a multicentre case series of 19 patients with thoracic and/or abdominal NBL who underwent radiation therapy, following the recommendations of the European protocol for high-risk NBL (HR-NBL2/SIOPEN). The prescribed dose was 21.6 Gy in 12 fractions (1.8 Gy/fraction) delivered over the preoperative disease volume. The dose volume histograms were analyzed for each patient, and a Wilcoxon signed-rank test with a significance level of 0.01 was employed to assess statistical differences between the dosimetric parameters investigated. Two homogeneity indices (HI and newHI) were compared to evaluate the uniformity in dose, delivered to the adjacent vertebrae (VBs_Adj). Results Both radiation techniques conform to the protocol regarding CTV/PTV coverage for every location. Proton therapy resulted in statistically significant dose sparing for the heart and lungs in supradiaphragmatic locations and for the contralateral kidney, liver, spleen, and bowel in subdiaphragmatic locations. For both techniques, sparing the non-adjacent vertebrae (VBs_NAdj) results more challenging, although promising results were obtained. Furthermore, the dose delivered to the VBs_Adj was not statistically different, in terms of homogeneity, for the 2 radiation techniques that both met the protocol's requirements. Conclusion This dosimetric analysis highlights the potential of protons to reduce radiation dose to healthy tissue. These findings apply to all the investigated patients, regardless of primary tumor location, making proton therapy a valuable option for the treatment of neuroblastoma. However, a multidisciplinary assessment of each case is essential to ensure the selection of the most effective and suitable treatment modality.
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Affiliation(s)
- Alfredo Mirandola
- Medical Physics Unit, National Center for Oncological Hadrontherapy, Pavia, Italy
| | - Francesca Colombo
- Radiotherapy Department, National Center for Oncological Hadrontherapy, Pavia, Italy
| | | | - Anna Cavallo
- Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Marco Gusinu
- Medical Physics Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Silvia Molinelli
- Medical Physics Unit, National Center for Oncological Hadrontherapy, Pavia, Italy
| | - Emanuele Pignoli
- Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Mario Ciocca
- Medical Physics Unit, National Center for Oncological Hadrontherapy, Pavia, Italy
| | - Salvina Barra
- Radiation Oncology Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Flavio Giannelli
- Radiation Oncology Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Emilia Pecori
- Pediatric Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Barbara A. Jereczek-Fossa
- Division of Radiation Oncology, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Ester Orlandi
- Radiotherapy Department, National Center for Oncological Hadrontherapy, Pavia, Italy
- Department of Clinical, Surgical, Diagnostic and Pediatric Services, University of Pavia, Pavia, Italy
| | - Sabina Vennarini
- Pediatric Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
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Van Ommen F, le Quellenec GAT, Willemsen-Bosman ME, van Noesel MM, van den Heuvel-Eibrink MM, Seravalli E, Kroon PS, Janssens GO. MRI-based inter- and intrafraction motion analysis of the pancreatic tail and spleen as preparation for adaptive MRI-guided radiotherapy in neuroblastoma. Radiat Oncol 2023; 18:160. [PMID: 37784151 PMCID: PMC10546671 DOI: 10.1186/s13014-023-02347-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 09/06/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND In pediatric radiotherapy treatment planning of abdominal tumors, dose constraints to the pancreatic tail/spleen are applied to reduce late toxicity. In this study, an analysis of inter- and intrafraction motion of the pancreatic tail/spleen is performed to estimate the potential benefits of online MRI-guided radiotherapy (MRgRT). MATERIALS AND METHODS Ten randomly selected neuroblastoma patients (median age: 3.4 years), irradiated with intensity-modulated arc therapy at our department (prescription dose: 21.6/1.8 Gy), were retrospectively evaluated for inter- and intrafraction motion of the pancreatic tail/spleen. Three follow-up MRIs (T2- and T1-weighted ± gadolinium) were rigidly registered to a planning CT (pCT), on the vertebrae around the target volume. The pancreatic tail/spleen were delineated on all MRIs and pCT. Interfraction motion was defined as a center of gravity change between pCT and T2-weighted images in left-right (LR), anterior-posterior (AP) and cranial-caudal (CC) direction. For intrafraction motion analysis, organ position on T1-weighted ± gadolinium was compared to T2-weighted. The clinical radiation plan was used to estimate the dose received by the pancreatic tail/spleen for each position. RESULTS The median (IQR) interfraction motion was minimal in LR/AP, and largest in CC direction; pancreatic tail 2.5 mm (8.9), and spleen 0.9 mm (3.9). Intrafraction motion was smaller, but showed a similar motion pattern (pancreatic tail, CC: 0.4 mm (1.6); spleen, CC: 0.9 mm (2.8)). The differences of Dmean associated with inter- and intrafraction motions ranged from - 3.5 to 5.8 Gy for the pancreatic tail and - 1.2 to 3.0 Gy for the spleen. In 6 out of 10 patients, movements of the pancreatic tail and spleen were highlighted as potentially clinically significant because of ≥ 1 Gy dose constraint violation. CONCLUSION Inter- and intrafraction organ motion results into unexpected constrain violations in 60% of a randomly selected neuroblastoma cohort, supporting further prospective exploration of MRgRT.
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Affiliation(s)
- Fasco Van Ommen
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands.
| | - Gaelle A T le Quellenec
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
- Department of Radiation Oncology, Institut de Cancérologie de l'Ouest, Nantes, France
| | - Mirjam E Willemsen-Bosman
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
| | - Max M van Noesel
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | | | - Enrica Seravalli
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
| | - Petra S Kroon
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
| | - Geert O Janssens
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
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Pediatric radiotherapy for thoracic and abdominal targets: organ motion, reported margin sizes, and delineation variations – a systematic review. Radiother Oncol 2022; 173:134-145. [DOI: 10.1016/j.radonc.2022.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 05/09/2022] [Accepted: 05/26/2022] [Indexed: 11/21/2022]
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Laprie A, Bernier V, Padovani L, Martin V, Chargari C, Supiot S, Claude L. Guide for paediatric radiotherapy procedures. Cancer Radiother 2021; 26:356-367. [PMID: 34969622 DOI: 10.1016/j.canrad.2021.11.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
A third of children with cancer receive radiotherapy as part of their initial treatment, which represents 800 paediatric irradiations per year in France carried out in 15 specialized centres approved on the recommendations of the French national cancer institute in decreasing order of frequency, the types of cancer that require irradiation are: brain tumours, neuroblastomas, Ewing's sarcomas, Hodgkin's lymphomas, soft tissue sarcomas including rhabdomyosarcomas, and nephroblastomas. The treatment guidelines follow the recommendations of the French society for childhood cancers (SFCE) or the French and European prospective protocols. The therapeutic indications, the technical and/and ballistic choices of complex cases are frequently discussed during bimonthly paediatric radiotherapy technical web-conferences. All cancers combined, overall survival being 80%, long-term toxicity logically becomes an important concern, making the preparation of treatments complex. The irradiation methods include all the techniques currently available: 3D conformational irradiation, intensity modulation radiation therapy, irradiation under normal or hypofractionated stereotaxic conditions, brachytherapy and proton therapy. We present the update of the recommendations of the French society for radiation oncology on the indications, the technical methods of realization and the organisation and the specificities of paediatric radiation oncology.
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Affiliation(s)
- A Laprie
- Département d'oncologie radiothérapie, Institut universitaire du cancer de Toulouse-Oncopole (IUCT-oncopole), université Paul-Sabatier Toulouse III, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex 9, France.
| | - V Bernier
- Département d'oncologie radiothérapie, Institut de cancérologie de Lorraine centre Alexis-Vautrin, 6, avenue de Bourgogne, CS 30519, 54519 Vandœuvre-lès-Nancy cedex, France
| | - L Padovani
- Département de cancérologie radiothérapie, CHU, 13000 Marseille, France; Université Aix-Marseille, 13000 Marseille, France
| | - V Martin
- Département de cancérologie radiothérapie, institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif cedex, France
| | - C Chargari
- Département d'oncologie radiothérapie, institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif cedex, France; Service de santé des armées, 75000 Paris, France
| | - S Supiot
- Département de radiothérapie, Institut de cancérologie de l'Ouest (ICO) centre René-Gauducheau, 44800 Saint-Herblain, France; Université de Nantes, 44000 Nantes, France
| | - L Claude
- Département d'oncologie radiothérapie, centre Léon-Bérard, 28, rue Laennec, 69373 Lyon cedex 08, France
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5
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Taylor S, Lim P, Ahmad R, Alhadi A, Harris W, Rompokos V, D'Souza D, Gaze M, Gains J, Veiga C. Risk of radiation-induced second malignant neoplasms from photon and proton radiotherapy in paediatric abdominal neuroblastoma. Phys Imaging Radiat Oncol 2021; 19:45-52. [PMID: 34307918 PMCID: PMC8295851 DOI: 10.1016/j.phro.2021.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/28/2021] [Accepted: 06/18/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND AND PURPOSE State-of-the-art radiotherapy modalities have the potential of reducing late effects of treatment in childhood cancer survivors. Our aim was to investigate the carcinogenic risk associated with 3D conformal (photon) radiation (3D-CRT), intensity modulated arc therapy (IMAT) and pencil beam scanning proton therapy (PBS-PT) in the treatment of paediatric abdominal neuroblastoma. MATERIALS AND METHODS The risk of radiation-induced second malignant neoplasm (SMN) was estimated using the concept of organ equivalent dose (OED) for eleven organs (lungs, rectum, colon, stomach, small intestine, liver, bladder, skin, central nervous system (CNS), bone, and soft tissues). The risk ratio (RR) between radiotherapy modalities and lifetime absolute risks (LAR) were reported for twenty abdominal neuroblastoma patients (median, 4y; range, 1-9y) historically treated with 3D-CRT that were also retrospectively replanned for IMAT and PBS-PT. RESULTS The risk of SMN due to primary radiation was reduced in PBS-PT against 3D-CRT and IMAT for most patients and organs. The RR across all organs ranged from 0.38 ± 0.22 (bladder) to 0.98 ± 0.04 (CNS) between PBS-PT and IMAT, and 0.12 ± 0.06 (rectum and bladder) to 1.06 ± 0.43 (bone) between PBS-PT and 3D-CRT. The LAR for most organs was within 0.01-1% (except the colon) with a cumulative risk of 21 ± 13%, 35 ± 14% and 35 ± 16% for PBS-PT, IMAT and 3D-CRT, respectively. CONCLUSIONS PBS-PT was associated with the lowest risk of radiation-induced SMN compared to IMAT and 3D-CRT in abdominal neuroblastoma treatment. Other clinical endpoints and plan robustness should also be considered for optimal plan selection.
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Affiliation(s)
- Sophie Taylor
- Centre for Medical Image Computing, Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Pei Lim
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Reem Ahmad
- Centre for Medical Image Computing, Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Ammar Alhadi
- Centre for Medical Image Computing, Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - William Harris
- Centre for Medical Image Computing, Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Vasilis Rompokos
- Radiotherapy Physics Services, University College London Hospitals NHS Foundation Trust, London, UK
| | - Derek D'Souza
- Radiotherapy Physics Services, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mark Gaze
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jennifer Gains
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Catarina Veiga
- Centre for Medical Image Computing, Department of Medical Physics and Biomedical Engineering, University College London, London, UK
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Mizumoto M, Fuji H, Miyachi M, Soejima T, Yamamoto T, Aibe N, Demizu Y, Iwata H, Hashimoto T, Motegi A, Kawamura A, Terashima K, Fukushima T, Nakao T, Takada A, Sumi M, Oshima J, Moriwaki K, Nozaki M, Ishida Y, Kosaka Y, Ae K, Hosono A, Harada H, Ogo E, Akimoto T, Saito T, Fukushima H, Suzuki R, Takahashi M, Matsuo T, Matsumura A, Masaki H, Hosoi H, Shigematsu N, Sakurai H. Proton beam therapy for children and adolescents and young adults (AYAs): JASTRO and JSPHO Guidelines. Cancer Treat Rev 2021; 98:102209. [PMID: 33984606 DOI: 10.1016/j.ctrv.2021.102209] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 04/02/2021] [Accepted: 04/11/2021] [Indexed: 11/19/2022]
Abstract
Children and adolescents and young adults (AYAs) with cancer are often treated with a multidisciplinary approach. This includes use of radiotherapy, which is important for local control, but may also cause adverse events in the long term, including second cancer. The risks for limited growth and development, endocrine dysfunction, reduced fertility and second cancer in children and AYAs are reduced by proton beam therapy (PBT), which has a dose distribution that decreases irradiation of normal organs while still targeting the tumor. To define the outcomes and characteristics of PBT in cancer treatment in pediatric and AYA patients, this document was developed by the Japanese Society for Radiation Oncology (JASTRO) and the Japanese Society of Pediatric Hematology/Oncology (JSPHO).
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Affiliation(s)
- Masashi Mizumoto
- Departments of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hiroshi Fuji
- Department of Radiology and National Center for Child Health and Development, Tokyo, Japan
| | - Mitsuru Miyachi
- Department of Pediatrics, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto, Japan
| | - Toshinori Soejima
- Department of Radiation Oncology, Hyogo Ion Beam Medical Center Kobe Proton Center, Kobe, Hyogo, Japan
| | - Tetsuya Yamamoto
- Department of Neurosurgery, Graduate School of Medicine, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Norihiro Aibe
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yusuke Demizu
- Department of Radiation Oncology, Hyogo Ion Beam Medical Center Kobe Proton Center, Kobe, Hyogo, Japan
| | - Hiromitsu Iwata
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City University West Medical Center, Nagoya, Aichi, Japan
| | - Takayuki Hashimoto
- Department of Radiation Biomedical Science and Engineering, Faculty of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Atsushi Motegi
- Department of Radiation Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Atsufumi Kawamura
- Department of Neurosurgery, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo, Japan
| | - Keita Terashima
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Takashi Fukushima
- Department of Pediatric Hematology and Oncology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Tomohei Nakao
- Department of Pediatrics, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Akinori Takada
- Department of Radiology, Mie University Hospital, Tsu-shi, Mie, Japan
| | - Minako Sumi
- Department of Radiation Oncology and Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan; Department of Radiation Oncology, Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan
| | | | - Kensuke Moriwaki
- Department of Medical Statistics, Kobe Pharmaceutical University, Kobe, Hyogo, Japan
| | - Miwako Nozaki
- Department of Radiology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Yuji Ishida
- Department of Pediatrics, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
| | - Yoshiyuki Kosaka
- Department of Hematology and Oncology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo, Japan
| | - Keisuke Ae
- Department of Orthopaedic Oncology, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Ako Hosono
- Department of Pediatric Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Hideyuki Harada
- Division of Radiation Therapy, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
| | - Etsuyo Ogo
- Department of Radiology, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Tetsuo Akimoto
- Department of Radiation Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Takashi Saito
- Departments of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hiroko Fukushima
- Department of Child Health, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Ryoko Suzuki
- Department of Child Health, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Mitsuru Takahashi
- Department of Orthopaedic Oncology, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
| | - Takayuki Matsuo
- Department of Neurosurgery, Nagasaki University Graduate School of Medicine, Nagasaki, Japan
| | - Akira Matsumura
- Departments of Neurosurgery, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hidekazu Masaki
- Proton Therapy Center, Aizawa Hospital, Matsumoto, Nagano, Japan
| | - Hajime Hosoi
- Department of Pediatrics, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto, Japan
| | - Naoyuki Shigematsu
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Hideyuki Sakurai
- Departments of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan.
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Lim PS, Rompokos V, Bizzocchi N, Gillies C, Gosling A, Royle G, Chang YC, Gaze MN, Gains JE. Pencil Beam Scanning Proton Therapy Case Selection for Paediatric Abdominal Neuroblastoma: Effects of Tumour Location and Bowel Gas. Clin Oncol (R Coll Radiol) 2021; 33:e132-e142. [PMID: 32962907 DOI: 10.1016/j.clon.2020.08.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/28/2020] [Indexed: 12/12/2022]
Abstract
AIMS Pencil beam scanning (PBS) proton therapy is an increasingly used radiation modality for childhood malignancies due to its ability to minimise dose to surrounding organs. However, the dosimetry is extremely sensitive to anatomical and density changes. The aims of this study were to investigate if there is a dosimetric benefit or detriment with PBS for paediatric abdominal neuroblastoma, assess gastrointestinal air variability and its dosimetric consequences, plus identify if there are factors that could assist case selection for PBS referral. MATERIALS AND METHODS Twenty neuroblastoma cases were double-planned with PBS and intensity-modulated arc therapy (IMAT). Cases were divided into unilateral, midline unilateral and midline bilateral locations in relation to the kidneys. Plans were recalculated after the gastrointestinal volume was simulated as air (Hounsfield Units -700) and water (Hounsfield Units 0), then compared with nominal plans (recalculated - nominal, ΔD). Forty-three weekly cone beam computed tomography scans were analysed to quantify gastrointestinal air variability during treatment. RESULTS PBS reduced the mean dose to normal tissues at all tumour locations, particularly unilateral tumours. However, 15% had better dosimetry with IMAT, all of which were midline tumours. Increased gastrointestinal air caused significant compromises to PBS versus IMAT plans for midline tumours [median/maximum ΔD95% clinical target volume (CTV) -2.4%/-15.7% PBS versus 1.4%/0% IMAT, P = 0.003], whereas minimal impact was observed for unilateral tumours (ΔD95% CTV -0.5%/-1.9% PBS versus 0.5%/-0.5% IMAT, P = 0.008). D95% CTV was significantly decreased in PBS plans if planning target volume (PTV) ≥400 cm3 (median -4.1%, P = 0.001) or PTV extension ≥60% anterior to vertebral body (-2.1%, P = 0.002). A larger variation in gastrointestinal air was observed in patients treated under general anaesthesia (median 38.4%) versus awake (11.5%); P = 0.004. CONCLUSION In this planning study, tumours at the unilateral location consistently showed improved dose reductions to normal tissue with minimal dose degradation from increased gastrointestinal air with PBS plans. Tumour location, PTV volume and anterior extension of PTV are useful characteristics in facilitating patient selection for PBS.
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Affiliation(s)
- P S Lim
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK; Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - V Rompokos
- Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, UK
| | - N Bizzocchi
- Centre for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - C Gillies
- Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, UK
| | - A Gosling
- Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, UK
| | - G Royle
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK; Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Y-C Chang
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - M N Gaze
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - J E Gains
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK.
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Jazmati D, Butzer S, Hero B, Ahmad Khalil D, Merta J, Bäumer C, Plum G, Fuchs J, Koerber F, Steinmeier T, Peters S, Doyen J, Thole T, Schmidt M, Blase C, Tippelt S, Eggert A, Schwarz R, Simon T, Timmermann B. Proton Beam Therapy for Children With Neuroblastoma: Experiences From the Prospective KiProReg Registry. Front Oncol 2021; 10:617506. [PMID: 33552991 PMCID: PMC7855697 DOI: 10.3389/fonc.2020.617506] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 11/30/2020] [Indexed: 12/11/2022] Open
Abstract
Objective Radiotherapy (RT) is an integral part of the interdisciplinary treatment of patients with high-risk neuroblastoma (NB). With the continuous improvements of outcome, the interest in local treatment strategies that reduce treatment-related side effects while achieving optimal oncological results is growing. Proton beam therapy (PBT) represents a promising alternative to conventional photon irradiation with regard to the reduction of treatment burden. Method Retrospective analysis of children with high or intermediate risk NB receiving PBT of the primary tumor site during first-line therapy between 2015 and 2020 was performed. Data from the prospective in-house registry Standard Protonentherapie WPE - Kinder- (KiProReg) with respect to tumor control and treatment toxicity were analyzed. Adverse events were classified according to CTCAE Version 4 (V4.0) before, during, and after PBT. Results In total, 44 patients (24 male, 20 female) with high (n = 39) or intermediate risk NB (n = 5) were included in the analysis. Median age was 3.4 years (range, 1.4-9.9 years). PBT doses ranged from 21.0 to 39.6 Gray (Gy) (median 36.0 Gy). Five patients received PBT to the MIBG-avid residual at the primary tumor site at time of PBT according to the NB-2004 protocol. In 39 patients radiation was given to the pre-operative tumor bed with or without an additional boost in case of residual tumor. After a median follow-up (FU) of 27.6 months, eight patients developed progression, either local recurrence (n = 1) or distant metastases (n = 7). Four patients died due to tumor progression. At three years, the estimated local control, distant metastatic free survival, progression free survival, and overall survival was 97.7, 84.1, 81.8, and 90.9%, respectively. During radiation, seven patients experienced higher-grade (CTCAE ≥ °3) hematologic toxicity. No other higher grade acute toxicity occurred. After PBT, one patient developed transient myelitis while receiving immunotherapy. No higher grade long-term toxicity was observed up to date. Conclusion PBT was a well tolerated and effective local treatment in children with high and intermediate risk NB. The role of RT in an intensive multidisciplinary treatment regimen remains to be studied in the future in order to better define timing, doses, target volumes, and general need for RT in a particularly sensitive cohort of patients.
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Affiliation(s)
- Danny Jazmati
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), Essen, Germany
| | - Sarina Butzer
- Children's Hospital, University of Cologne, Cologne, Germany
| | - Barbara Hero
- Children's Hospital, University of Cologne, Cologne, Germany
| | - Dalia Ahmad Khalil
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), Essen, Germany
| | - Julien Merta
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), Essen, Germany
| | - Christian Bäumer
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), Essen, Germany.,Faculty of Physics, TU Dortmund University, Dortmund, Germany.,Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), German Cancer Consortium (DKTK), Essen, Germany
| | - Gina Plum
- Children's Hospital, University of Cologne, Cologne, Germany
| | - Jörg Fuchs
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital Tuebingen, Tübingen, Germany
| | | | - Theresa Steinmeier
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), Essen, Germany
| | - Sarah Peters
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), Essen, Germany
| | - Jerome Doyen
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), Essen, Germany
| | - Theresa Thole
- Department of Pediatric Oncology/Hematology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Schmidt
- Department of Nuclear Medicine, University Hospital of Cologne, Cologne, Germany
| | | | - Stephan Tippelt
- University Hospital of Essen, Paediatrics III, Paediatric Haematology and Oncology, Essen, Germany
| | - Angelika Eggert
- Department of Pediatric Oncology/Hematology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Rudolf Schwarz
- Department of Radiotherapy and Radiooncology, Outpatient Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thorsten Simon
- Children's Hospital, University of Cologne, Cologne, Germany
| | - Beate Timmermann
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), Essen, Germany.,Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), German Cancer Consortium (DKTK), Essen, Germany
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9
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Greenberger BA, Yock TI. The role of proton therapy in pediatric malignancies: Recent advances and future directions. Semin Oncol 2020; 47:8-22. [PMID: 32139101 DOI: 10.1053/j.seminoncol.2020.02.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/03/2020] [Accepted: 02/03/2020] [Indexed: 11/11/2022]
Abstract
Proton radiotherapy has promised an advantage in safely treating pediatric malignancies with an increased capability to spare normal tissues, reducing the risk of both acute and late toxicity. The past decade has seen the proliferation of more than 30 proton facilities in the United States, with increased capacity to provide access to approximately 3,000 children per year who will require radiotherapy for their disease. We provide a review of the initial efforts to describe outcomes after proton therapy across the common pediatric disease sites. We discuss the main attempts to assess comparative efficacy between proton and photon radiotherapy concerning toxicity. We also discuss recent efforts of multi-institutional registries aimed at accelerating research to better define the optimal treatment paradigm for children requiring radiotherapy for cure.
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Affiliation(s)
- Benjamin A Greenberger
- Department of Radiation Oncology, Sidney Kimmel Medical College & Cancer Center at Thomas Jefferson University, Philadelphia, PA
| | - Torunn I Yock
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Francis H. Burr Proton Therapy Center, Boston, MA.
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10
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Pencil Beam Scanning Proton Therapy for Paediatric Neuroblastoma with Motion Mitigation Strategy for Moving Target Volumes. Clin Oncol (R Coll Radiol) 2020; 32:467-476. [PMID: 32081577 DOI: 10.1016/j.clon.2020.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 11/27/2019] [Accepted: 12/23/2019] [Indexed: 02/04/2023]
Abstract
AIMS More efforts are required to minimise late radiation side-effects for paediatric patients. Pencil beam scanning proton beam therapy (PBS-PT) allows increased sparing of normal tissues while maintaining conformality, but is prone to dose degradation from interplay effects due to respiratory motion. We report our clinical experience of motion mitigation with volumetric rescanning (vRSC) and outcomes of children with neuroblastoma. MATERIALS AND METHODS Nineteen patients with high-risk (n = 16) and intermediate-risk (n = 3) neuroblastoma received PBS-PT. The median age at PBS-PT was 3.5 years (range 1.2-8.6) and the median PBS-PT dose was 21 Gy (relative biological effectiveness). Most children (89%) were treated under general anaesthesia. Seven patients (37%) underwent four-dimensional computed tomography for motion assessment and were treated with vRSC for motion mitigation. RESULTS The mean result of maximum organ motion was 2.7 mm (cranial-caudal), 1.2 mm (left-right), 1.0 mm (anterior-posterior). Four anaesthetised children (21%) showing <5 mm motion had four-dimensional dose calculations (4DDC) to guide the number of vRSC. The mean deterioration or improvement to the planning target volume covered by 95% of the prescribed dose compared with static three-dimensional plans were: 4DDC no vRSC, -0.6%; 2 vRSC, +0.3%; 4 vRSC, +0.3%; and 8 vRSC, +0.1%. With a median follow-up of 14.9 months (range 2.7-49.0) there were no local recurrences. The 2-year overall survival was 94% and distant progression-free survival was 76%. Acute grade 2-4 toxicity was 11%. During the limited follow-up time, no late toxicities were observed. CONCLUSIONS The early outcomes of mainly high-risk patients with neuroblastoma treated with PBS-PT were excellent. With a subset of our cohort undergoing PBS-PT with vRSC we have shown that it is logistically feasible and safe. The clinical relevance of vRSC is debatable in anaesthetised children with small pre-PBS-PT motion of <5 mm.
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11
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Patient Transfer to Receive Proton Beam Therapy During Intensive Multimodal Therapy is Safe and Feasible for Patients With Newly Diagnosed High-risk Neuroblastoma. J Pediatr Hematol Oncol 2020; 42:e18-e24. [PMID: 31449498 DOI: 10.1097/mph.0000000000001570] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Neuroblastoma (NB) predominantly presents as high-risk disease, requiring intensive multimodal therapy. Proton beam therpy (PBT) is a promising option for many childhood cancers, but is not widely available. Patients with NB hoping to receive PBT may therefore need to be transferred between institutions during intensive multimodal therapy, risking undesirable effects. We evaluated patients with high-risk NB who received PBT at our institute as part of first-line therapy, mainly focusing on the safety and feasibility of mid-treatment patient transfer. Eighteen patients with newly diagnosed high-risk NB who received PBT between April 2010 and June 2016 were retrospectively analyzed for local control, outcomes, and toxicity. Survival (3-y overall survival 71%±11%; 3-y event-free survival 44%±12%) and local control rate (100%) were comparable with previous studies. Few acute adverse events were recorded, and all patients completed PBT without treatment delay. PBT for high-risk NB was safe and feasible for patients requiring mid-treatment interinstitutional transfer.
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12
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Bagley AF, Grosshans DR, Philip NV, Foster J, McAleer MF, McGovern SL, Lassen-Ramshad Y, Mahajan A, Paulino AC. Efficacy of proton therapy in children with high-risk and locally recurrent neuroblastoma. Pediatr Blood Cancer 2019; 66:e27786. [PMID: 31050179 PMCID: PMC6588416 DOI: 10.1002/pbc.27786] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 03/11/2019] [Accepted: 04/15/2019] [Indexed: 11/11/2022]
Abstract
PURPOSE Proton therapy is currently used in the management of pediatric tumors to decrease late toxicities. However, one of the criticisms of proton therapy is the limited data regarding efficacy on disease control. The purpose of this study was to examine local and distant control rates after proton therapy for neuroblastoma. METHODS AND MATERIALS Eighteen patients with high-risk (n = 16) and locally recurrent neuroblastoma (n = 2) were treated with curative intent and received proton therapy to the primary site and up to three post-induction MIBG-avid metastatic sites. Primary sites (n = 18) were treated to 21-36 Gy (relative biological effectiveness [RBE]), and metastatic sites (n = 16) were treated to 21-24 Gy (RBE). Local control and survival rates were calculated using the Kaplan-Meier method. RESULTS With a median follow-up of 60.2 months, two- and five-year local control rates at the irradiated primary site were 94% and 87%, respectively. No failures at irradiated distant metastatic sites were observed. The five-year progression-free survival (PFS) was 64%, and the five-year overall survival (OS) was 94%. The extent of surgical resection was not associated with local control, PFS, or OS. No radiation-related nephropathy or hepatopathy was reported. CONCLUSIONS Excellent local control was achieved using proton therapy to the primary and post-induction MIBG-positive distant sites. The predominant site of failure is progression in post-induction non-MIBG-avid distant sites. Although proton therapy provides high rates of local control with acceptable toxicity for neuroblastoma, further advances in systemic therapy are needed for the improved control of systemic disease.
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Affiliation(s)
- Alexander F. Bagley
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David R. Grosshans
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nancy V. Philip
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jennifer Foster
- Department of Pediatrics, Texas Children’s Hospital, Houston, TX
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Susan L. McGovern
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Arnold C. Paulino
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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13
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Casey DL, Kushner BH, Cheung NKV, Modak S, Basu EM, Roberts SS, LaQuaglia MP, Wolden SL. Reduced-Dose Radiation Therapy to the Primary Site is Effective for High-Risk Neuroblastoma: Results From a Prospective Trial. Int J Radiat Oncol Biol Phys 2019; 104:409-414. [PMID: 30763661 DOI: 10.1016/j.ijrobp.2019.02.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 01/30/2019] [Accepted: 02/03/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE For patients with high-risk neuroblastoma (HR-NB), a dose of 21 Gy to the primary tumor site after gross total resection (GTR) provides excellent local control. However, no clinical trial has specifically evaluated the optimal dose of radiation therapy (RT), and RT-related long-term toxicities are of increasing concern. We sought to assess local control, survival outcomes, and toxicity after a reduction in dose to the primary site from 21 Gy to 18 Gy. METHODS AND MATERIALS After induction chemotherapy and GTR, patients with HR-NB were enrolled and treated on an RT dose-reduction prospective trial with 18 Gy hyperfractionated RT given in twice-daily fractions of 1.5 Gy each. RESULTS The 25 study subjects were 1.6 to 9.5 (median, 4.3) years old at enrollment and included 23 (92%) with stage IV and II (8%) with MYCN-amplified stage III disease. Eleven (44%) were in complete remission (CR), and 14 (56%) had persistence of osteomedullary disease postinduction. Three patients (12%) received proton therapy, and the rest received intensity modulated photon therapy. After a follow-up of 1.8 to 4.2 (median, 3.5) years from initiation of RT, no failures occurred within the RT field; 3 patients had marginal recurrences. The respective 3-year progression-free and overall survival rates were 54.5% and 90.9% for patients in first CR and 42.9% and 76.2% for patients not in metastatic CR. Acute toxicity was negligible. CONCLUSIONS Reduced-dose RT with 18 Gy did not compromise local control or survival outcomes in our cohort of patients with HR-NB after GTR. These findings support assessing further RT dose reduction and validation on a larger, multi-institutional trial.
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Affiliation(s)
- Dana L Casey
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Brian H Kushner
- Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Nai-Kong V Cheung
- Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Shakeel Modak
- Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Ellen M Basu
- Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Stephen S Roberts
- Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Michael P LaQuaglia
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Suzanne L Wolden
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York.
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14
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Hill-Kayser CE, Tochner Z, Li Y, Kurtz G, Lustig RA, James P, Balamuth N, Womer R, Mattei P, Grupp S, Mosse YP, Maris JM, Bagatell R. Outcomes After Proton Therapy for Treatment of Pediatric High-Risk Neuroblastoma. Int J Radiat Oncol Biol Phys 2019; 104:401-408. [PMID: 30738983 DOI: 10.1016/j.ijrobp.2019.01.095] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 01/04/2019] [Accepted: 01/31/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE Patients with high-risk neuroblastoma (HR-NBL) require radiation to the primary tumor site and sites of persistent metastatic disease. Proton radiation therapy (PRT) may promote organ sparing, but long-term outcomes have not been studied. METHODS AND MATERIALS Sequential patients with HR-NBL received PRT: 2160 cGy (relative biological effectiveness) to primary tumor bed and persistent metastatic sites, with 3600 cGy (relative biological effectiveness) to gross residual disease. RESULTS From September 2010 through September 2015, 45 patients with HR-NBL received PRT after systemic therapy, primary tumor resection, and high-dose chemotherapy with stem cell rescue. Median age was 46 months at the time of PRT (range, 10 months to 12 years); 23 patients (51%) were male. Primary tumors were adrenal in 40 (89%); 11 (24%) received boost. Ten metastatic sites in 8 patients were radiated. Double scattered proton beams were used for 19 (42%) patients, in combination with x-rays for 2 (5%). The remaining 26 (58%) received pencil beam scanning, available since January 2013. We observed 97% freedom from primary site recurrence at 3, 4, and 5 years. Overall survival rates were 89%, 80%, and 80% and disease-free survival rates were 77%, 70%, and 70%, at 3, 4, and 5 years, respectively. With median follow-up of 48.7 months from diagnosis (range, 11-90 months) for all patients (57.4 months for those alive), 37 (82%) patients are alive, and 32 (71%) are without evidence of disease. One patient experienced locoregional recurrence; the remaining 12 (27%) experienced relapse at distant, nonradiated sites. Acute toxicities during treatment were mainly grade 1. No patient has experienced World Health Organization grade 3 or 4 long-term renal or hepatic toxicity. Pencil beam scanning plans required less planning time and resources than double scattered plans. CONCLUSIONS We observe excellent outcomes in patients treated with PRT for HR-NBL from 2010 through 2015, with 82% of patients alive and 97% free of primary site recurrence. No patient has experienced long-term renal or liver toxicity. This treatment maximizes normal tissue preservation and is appropriate for this patient population.
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Affiliation(s)
- Christine E Hill-Kayser
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Zelig Tochner
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yimei Li
- Department of Pediatrics, Division of Oncology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Biostatics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Goldie Kurtz
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert A Lustig
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul James
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Naomi Balamuth
- Department of Pediatrics, Division of Oncology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Richard Womer
- Department of Pediatrics, Division of Oncology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter Mattei
- Department of Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephen Grupp
- Department of Pediatrics, Division of Oncology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yael P Mosse
- Department of Pediatrics, Division of Oncology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John M Maris
- Department of Pediatrics, Division of Oncology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rochelle Bagatell
- Department of Pediatrics, Division of Oncology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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15
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Arumugam S, Manning-Cork NJ, Gains JE, Boterberg T, Gaze MN. The Evidence for External Beam Radiotherapy in High-Risk Neuroblastoma of Childhood: A Systematic Review. Clin Oncol (R Coll Radiol) 2018; 31:182-190. [PMID: 30509728 DOI: 10.1016/j.clon.2018.11.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 10/27/2018] [Indexed: 12/15/2022]
Abstract
AIMS External beam radiotherapy is widely used in various ways in the management of neuroblastoma. Despite extensive clinical experience, the precise role of radiotherapy in neuroblastoma remains unclear. The purpose of this systematic review was to survey the published literature to identify, without bias, the evidence for the clinical effectiveness of external beam radiotherapy as part of the initial multimodality treatment of high-risk neuroblastoma. We considered four areas: treatment of the tumour bed and residual primary tumour, identification of any dose-response relationship, treatment of metastatic sites, identification of any technical advances that may be beneficial. We also aimed to define uncertainties, which may be clarified in future clinical trials. MATERIALS AND METHODS Bibliographic databases were searched for neuroblastoma and radiotherapy. Reviewers assessed 1283 papers for inclusion by title and abstract, with consensus achieved through discussion. Data extraction on 57 included papers was carried out by one reviewer and checked by another. Studies were assessed for their level of evidence and risk of bias, and a descriptive analysis of data was carried out. RESULTS Fifteen papers provided some evidence that radiotherapy to the tumour bed and residual tumour may possibly be of value. However, there is a significant risk of bias and no evidence that all subgroups will benefit. There is some suggestion from six papers that dose may be important, but no hard evidence. It remains unclear whether irradiation of metastatic sites is helpful. Technical advances may be of value in radiotherapy of high-risk neuroblastoma. CONCLUSIONS There are data that show that radiotherapy is of some efficacy in the management of high-risk neuroblastoma, but there is no level one evidence that shows that it is being used in the best possible way. Prospective randomised trials are necessary to provide more evidence to guide development of optimal radiotherapy treatment schedules.
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Affiliation(s)
- S Arumugam
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - N J Manning-Cork
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - J E Gains
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - T Boterberg
- Department of Radiation Oncology, Ghent University Hospital, Gent, Belgium
| | - M N Gaze
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK.
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16
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Smith V, Foster J. High-Risk Neuroblastoma Treatment Review. CHILDREN-BASEL 2018; 5:children5090114. [PMID: 30154341 PMCID: PMC6162495 DOI: 10.3390/children5090114] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 08/18/2018] [Accepted: 08/20/2018] [Indexed: 02/06/2023]
Abstract
Neuroblastoma is the most common extracranial solid tumor in children. One subset, high-risk neuroblastoma, is very difficult to treat and requires multi-modal therapy. Intensification of therapy has vastly improved survival rates, and research is focused on novel treatments to further improve survival rates. The current treatment schema is divided into three stages-induction, consolidation, and maintenance. This review serves as an overview of the current treatment for high-risk neuroblastoma and a glimpse at current research for future therapy.
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Affiliation(s)
- Valeria Smith
- Baylor College of Medicine Department of Pediatrics, Texas Children's Cancer and Hematology Center, Houston, TX 77030, USA.
| | - Jennifer Foster
- Baylor College of Medicine Department of Pediatrics, Texas Children's Cancer and Hematology Center, Houston, TX 77030, USA.
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17
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Proton therapy for pediatric malignancies: Fact, figures and costs. A joint consensus statement from the pediatric subcommittee of PTCOG, PROS and EPTN. Radiother Oncol 2018; 128:44-55. [PMID: 29937209 DOI: 10.1016/j.radonc.2018.05.020] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 05/11/2018] [Accepted: 05/15/2018] [Indexed: 12/18/2022]
Abstract
Radiotherapy plays an important role in the management of childhood cancer, with the primary aim of achieving the highest likelihood of cure with the lowest risk of radiation-induced morbidity. Proton therapy (PT) provides an undisputable advantage by reducing the radiation 'bath' dose delivered to non-target structures/volume while optimally covering the tumor with tumoricidal dose. This treatment modality comes, however, with an additional costs compared to conventional radiotherapy that could put substantial financial pressure to the health care systems with societal implications. In this review we assess the data available to the oncology community of PT delivered to children with cancer, discuss on the urgency to develop high-quality data. Additionally, we look at the advantage of combining systemic agents with protons and look at the cost-effectiveness data published so far.
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18
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Nakagawara A, Li Y, Izumi H, Muramori K, Inada H, Nishi M. Neuroblastoma. Jpn J Clin Oncol 2018; 48:214-241. [PMID: 29378002 DOI: 10.1093/jjco/hyx176] [Citation(s) in RCA: 118] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Indexed: 02/07/2023] Open
Abstract
Neuroblastoma is one of the most common solid tumors in children and has a diverse clinical behavior that largely depends on the tumor biology. Neuroblastoma exhibits unique features, such as early age of onset, high frequency of metastatic disease at diagnosis in patients over 1 year of age and the tendency for spontaneous regression of tumors in infants. The high-risk tumors frequently have amplification of the MYCN oncogene as well as segmental chromosome alterations with poor survival. Recent advanced genomic sequencing technology has revealed that mutation of ALK, which is present in ~10% of primary tumors, often causes familial neuroblastoma with germline mutation. However, the frequency of gene mutations is relatively small and other aberrations, such as epigenetic abnormalities, have also been proposed. The risk-stratified therapy was introduced by the Japan Neuroblastoma Study Group (JNBSG), which is now moving to the Neuroblastoma Committee of Japan Children's Cancer Group (JCCG). Several clinical studies have facilitated the reduction of therapy for children with low-risk neuroblastoma disease and the significant improvement of cure rates for patients with intermediate-risk as well as high-risk disease. Therapy for patients with high-risk disease includes intensive induction chemotherapy and myeloablative chemotherapy, followed by the treatment of minimal residual disease using differentiation therapy and immunotherapy. The JCCG aims for better cures and long-term quality of life for children with cancer by facilitating new approaches targeting novel driver proteins, genetic pathways and the tumor microenvironment.
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Affiliation(s)
| | - Yuanyuan Li
- Laboratory of Molecular Biology, Life Science Research Institute, Saga Medical Center Koseikan
| | - Hideki Izumi
- Laboratory of Molecular Biology, Life Science Research Institute, Saga Medical Center Koseikan
| | | | - Hiroko Inada
- Department of Pediatrics, Saga Medical Center Koseikan
| | - Masanori Nishi
- Department of Pediatrics, Saga University, Saga 849-8501, Japan
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19
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Kannan S, Teo BKK, Solberg T, Hill-Kayser C. Organ motion in pediatric high-risk neuroblastoma patients using four-dimensional computed tomography. J Appl Clin Med Phys 2017; 18:107-114. [PMID: 28291918 PMCID: PMC5689899 DOI: 10.1002/acm2.12012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 10/16/2016] [Indexed: 11/15/2022] Open
Abstract
Purpose/objective(s) High‐risk neuroblastoma (HR‐NBL) requires multimodality treatment, including external beam radiation of the primary tumor site following resection. Radiotherapy planning must take into account motion of the target and adjacent normal anatomy, both of which are poorly understood in the pediatric population, and which may differ significantly from those in adults. Methods/materials We examined 4DCT scans of 15 consecutive pediatric patients treated for HR‐NBL, most with tumors in the abdominal cavity. The diaphragm and organs at risk were contoured at full inhale, full exhale, and on free‐breathing scans. Maximum displacement of organs between full inhale and full exhale was measured in the anterior, posterior, superior, inferior, left, and right directions, as was displacement of centroids in the A/P, S/I, and L/R axes. Contours on free‐breathing scans were compared to those on 4D scans. Results Maximum displacement was along the S/I axis, with the superior aspects of organs moving more than the inferior, implying organ compression with respiration. Liver and spleen exhibited the largest motion, which correlated strongly with the S/I motion of the diaphragm. The maximum organ motion observed in the abdomen and thorax were 4.5 mm and 7.4 mm, respectively, while maximum diaphragm displacement was 5.7 mm. Overall findings mirrored observations in adults, but with smaller magnitudes, as expected. No consistent margins could be added to the free‐breathing scans to encompass the motion determined using 4DCT. Conclusions Organ motion within the pediatric abdomen and pelvis is similar to that observed in adults, but with smaller magnitude. Precise margins to accommodate motion are patient‐specific, underscoring the need for 4DCT scanning when possible.
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Affiliation(s)
- Sneha Kannan
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Boon-Keng Kevin Teo
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Timothy Solberg
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Christine Hill-Kayser
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, 19104, USA
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Abstract
Though the treatment of pediatric cancers has come a long way, acute and chronic effects of cancer are still affecting the life of many children. These effects may be caused not only by the malignancy itself but also by the interventions used for the purpose of treatment. This article focuses primarily on the indirect effects of pediatric cancers and their treatment on the central and peripheral nervous system. Chemotherapy, radiation, and stem cell transplantation cause an immune-compromised state and place the patient at risk of infection, the leading cause of mortality in pediatric cancer. The underlying cancer and the treatments also cause neurovascular changes that may lead to neurological sequelae immediately or many years in the future. Chemotherapy and radiation have both immediate and long-term neurotoxic effects on the central and peripheral nervous system. Cancers may also trigger an immune response that damages nervous system components, leading to altered mental status, seizures, abnormal movements, and even psychosis. Knowledge of these effects can help the practitioner be more vigilant for the signs and symptoms of potential neurological complications during the management of pediatric cancers.
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Affiliation(s)
- Lauren Weaver
- From the Section of Neurology, Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA
| | - Ayman Samkari
- Section of Oncology, Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA.
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Feasibility Study on Cardiac Arrhythmia Ablation Using High-Energy Heavy Ion Beams. Sci Rep 2016; 6:38895. [PMID: 27996023 PMCID: PMC5171237 DOI: 10.1038/srep38895] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 11/09/2016] [Indexed: 01/19/2023] Open
Abstract
High-energy ion beams are successfully used in cancer therapy and precisely deliver high doses of ionizing radiation to small deep-seated target volumes. A similar noninvasive treatment modality for cardiac arrhythmias was tested here. This study used high-energy carbon ions for ablation of cardiac tissue in pigs. Doses of 25, 40, and 55 Gy were applied in forced-breath-hold to the atrioventricular junction, left atrial pulmonary vein junction, and freewall left ventricle of intact animals. Procedural success was tracked by (1.) in-beam positron-emission tomography (PET) imaging; (2.) intracardiac voltage mapping with visible lesion on ultrasound; (3.) lesion outcomes in pathohistolgy. High doses (40–55 Gy) caused slowing and interruption of cardiac impulse propagation. Target fibrosis was the main mediator of the ablation effect. In irradiated tissue, apoptosis was present after 3, but not 6 months. Our study shows feasibility to use high-energy ion beams for creation of cardiac lesions that chronically interrupt cardiac conduction.
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Luksch R, Castellani MR, Collini P, De Bernardi B, Conte M, Gambini C, Gandola L, Garaventa A, Biasoni D, Podda M, Sementa AR, Gatta G, Tonini GP. Neuroblastoma (Peripheral neuroblastic tumours). Crit Rev Oncol Hematol 2016; 107:163-181. [PMID: 27823645 DOI: 10.1016/j.critrevonc.2016.10.001] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 09/05/2016] [Accepted: 10/03/2016] [Indexed: 02/07/2023] Open
Abstract
Peripheral neuroblastic tumours (PNTs), a family of tumours arising in the embryonal remnants of the sympathetic nervous system, account for 7-10% of all tumours in children. In two-thirds of cases, PNTs originate in the adrenal glands or the retroperitoneal ganglia. At least one third present metastases at onset, with bone and bone marrow being the most frequent metastatic sites. Disease extension, MYCN oncogene status and age are the most relevant prognostic factors, and their influence on outcome have been considered in the design of the recent treatment protocols. Consequently, the probability of cure has increased significantly in the last two decades. In children with localised operable disease, surgical resection alone is usually a sufficient treatment, with 3-year event-free survival (EFS) being greater than 85%. For locally advanced disease, primary chemotherapy followed by surgery and/or radiotherapy yields an EFS of around 75%. The greatest problem is posed by children with metastatic disease or amplified MYCN gene, who continue to do badly despite intensive treatments. Ongoing trials are exploring the efficacy of new drugs and novel immunological approaches in order to save a greater number of these patients.
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Affiliation(s)
- Roberto Luksch
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | | | - Paola Collini
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Massimo Conte
- Giannina Gaslini Children's Research Hospital, Genoa, Italy
| | | | - Lorenza Gandola
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Davide Biasoni
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Marta Podda
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Gemma Gatta
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Gian Paolo Tonini
- Neuroblastoma Laboratory, Paediatric Research Institute, Padua, Italy
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Mizumoto M, Murayama S, Akimoto T, Demizu Y, Fukushima T, Ishida Y, Oshiro Y, Numajiri H, Fuji H, Okumura T, Shirato H, Sakurai H. Proton beam therapy for pediatric malignancies: a retrospective observational multicenter study in Japan. Cancer Med 2016; 5:1519-25. [PMID: 27165972 PMCID: PMC4867672 DOI: 10.1002/cam4.743] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 02/18/2016] [Accepted: 03/29/2016] [Indexed: 12/19/2022] Open
Abstract
Recent progress in the treatment for pediatric malignancies using a combination of surgery, chemotherapy, and radiotherapy has improved survival. However, late toxicities of radiotherapy are a concern in long‐term survivors. A recent study suggested reduced secondary cancer and other late toxicities after proton beam therapy (PBT) due to dosimetric advantages. In this study, we evaluated the safety and efficacy of PBT for pediatric patients treated in Japan. A retrospective observational study in pediatric patients who received PBT was performed. All patients aged <20 years old who underwent PBT from January 1983 to August 2014 at four sites in Japan were enrolled in the study. There were 343 patients in the study. The median follow‐up periods were 22.6 months (0.4–374.3 months) for all patients and 30.6 months (0.6–374.3 months) for survivors. The estimated 1‐, 3‐, 5‐, and 10‐year survival rates were 82.7% (95% CI: 78.5–87.0%), 67.4% (61.7–73.2%), 61.4% (54.8–67.9%), and 58.7% (51.5–65.9%), respectively. Fifty‐two events of toxicity ≥ grade 2 occurred in 43 patients. Grade 4 toxicities of myelitis, visual loss (two cases), cerebral vascular disease, and tissue necrosis occurred in five patients. This study provides preliminary results for PBT in pediatric patients in Japan. More experience and follow‐up with this technique are required to establish the efficacy of PBT in this patient population.
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Affiliation(s)
- Masashi Mizumoto
- Department of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Shigeyuki Murayama
- Division of Proton Therapy, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
| | - Tetsuo Akimoto
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Yusuke Demizu
- Department of Radiology, Hyogo Ion Beam Medical Center, Tatsuno, Hyogo, Japan
| | - Takashi Fukushima
- Department of Child Health, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yuji Ishida
- Division of Pediatrics, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
| | - Yoshiko Oshiro
- Department of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Haruko Numajiri
- Department of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hiroshi Fuji
- Department of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Toshiyuki Okumura
- Department of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hiroki Shirato
- Department of Radiation Oncology, Hokkaido University Hospital, Sapporo, Japan
| | - Hideyuki Sakurai
- Department of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
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Kandula S, Sutter A, Prabhu RS, Jegadeesh N, Esiashvili N. Reassessing dose constraints of organs at risk in children with abdominal neuroblastoma treated with definitive radiation therapy: a correlation with late toxicity. Pediatr Blood Cancer 2015; 62:970-5. [PMID: 25545501 DOI: 10.1002/pbc.25372] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 10/29/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND In children treated with definitive radiation therapy (RT) for abdominal neuroblastoma, normal tissue constraints for organs at risk (OARs) are not well-standardized or evidence-based. In this study, we analyze dosimetric data of principal abdominal OARs, reassess existing RT planning constraints, and examine corresponding acute and late toxicity to OARs. PROCEDURE The treatment plans of 30 consecutive children who underwent definitive RT for high-risk abdominal neuroblastoma were reviewed. Dose-volume histogram (DVH) statistics were recorded for the ipsilateral kidney (if unresected), contralateral kidney, and liver. DVH data were analyzed to determine if OAR constraints from recent protocols were met and correlated with the development of toxicity. RESULTS The median follow-up period was 53.0 months. Ten, thirteen, and ten percent of patients' RT plans did not meet OAR DVH constraints for the liver, ipsilateral kidney, and contralateral kidney, respectively. Of the three patients whose plans did not achieve ipsilateral kidney DVH constraint(s), two developed evidence of late ipsilateral kidney hypoplasia, but maintained normal laboratory kidney function. No patient experienced late toxicity of the contralateral kidney nor developed RT-related late hepatic complications. CONCLUSIONS In children treated for abdominal neuroblastoma, the risk of developing clinically significant RT-related late toxicity of the kidney and liver is not appreciable, even when current DVH parameters for OARs are not achieved in planning. Toxicity outcomes did not necessarily correlate with present-day OAR dose constraints. Currently utilized DVH constraints are highly variable, and must be further studied and supported by toxicity outcomes to more accurately characterize risk of complications.
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Affiliation(s)
- Shravan Kandula
- Department of Radiation Oncology, Emory University, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
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Long-term side effects of radiotherapy for pediatric localized neuroblastoma : results from clinical trials NB90 and NB94. Strahlenther Onkol 2015; 191:604-12. [PMID: 25896312 DOI: 10.1007/s00066-015-0837-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 03/25/2015] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Neuroblastoma (NB) is the most frequent indication for extracranial pediatric radiotherapy. As long-term survival of high-risk localized NB has greatly improved, we reviewed treatment-related late toxicities in pediatric patients who received postoperative radiotherapy (RT) for localized NB within two French prospective clinical trials: NB90 and NB94. PATIENTS AND METHODS From 1990-2000, 610 children were enrolled. Among these, 35 were treated with induction chemotherapy, surgery, and RT. The recommended RT dose was 24 Gy at ≤ 2 years, 34 Gy at > 2 years, ± a 5 Gy boost in both age groups. RESULTS The 22 patients still alive after 5 years were analyzed. The median follow-up time was 14 years (range 5-21 years). Late effects after therapy occurred in 73 % of patients (16/22), within the RT field for 50 % (11/22). The most frequent in-field effects were musculoskeletal abnormalities (n = 7) that occurred only with doses > 31 Gy/1.5 Gy fraction (p = 0.037). Other effects were endocrine in 3 patients and second malignancies in 2 patients. Four patients presented with multiple in-field late effects only with doses > 31 Gy. CONCLUSION After a median follow-up of 14 years, late effects with multimodality treatment were frequent. The most frequent effects were musculoskeletal abnormalities and the threshold for their occurrence was 31 Gy.
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Lehmann HI, Richter D, Prokesch H, Graeff C, Prall M, Simoniello P, Fournier C, Bauer J, Kaderka R, Weymann A, Szabó G, Sonnenberg K, Constantinescu AM, Johnson SB, Misiri J, Takami M, Miller RC, Herman MG, Asirvatham SJ, Brons S, Jäkel O, Haberer T, Debus J, Durante M, Bert C, Packer DL. Atrioventricular node ablation in Langendorff-perfused porcine hearts using carbon ion particle therapy: methods and an in vivo feasibility investigation for catheter-free ablation of cardiac arrhythmias. Circ Arrhythm Electrophysiol 2015; 8:429-38. [PMID: 25609687 DOI: 10.1161/circep.114.002436] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 01/08/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Particle therapy, with heavy ions such as carbon-12 ((12)C), delivered to arrhythmogenic locations of the heart could be a promising new means for catheter-free ablation. As a first investigation, we tested the feasibility of in vivo atrioventricular node ablation, in Langendorff-perfused porcine hearts, using a scanned 12C beam. METHODS AND RESULTS Intact hearts were explanted from 4 (30-40 kg) pigs and were perfused in a Langendorff organ bath. Computed tomographic scans (1 mm voxel and slice spacing) were acquired and (12)C ion beam treatment planning (optimal accelerator energies, beam positions, and particle numbers) for atrioventricular node ablation was conducted. Orthogonal x-rays with matching of 4 implanted clips were used for positioning. Ten Gray treatment plans were repeatedly administered, using pencil beam scanning. After delivery, positron emission tomography-computed tomographic scans for detection of β(+) ((11)C) activity were obtained. A (12)C beam with a full width at half maximum of 10 mm was delivered to the atrioventricular node. Delivery of 130 Gy caused disturbance of atrioventricular conduction with transition into complete heart block after 160 Gy. Positron emission computed tomography demonstrated dose delivery into the intended area. Application did not induce arrhythmias. Macroscopic inspection did not reveal damage to myocardium. Immunostaining revealed strong γH2AX signals in the target region, whereas no γH2AX signals were detected in the unirradiated control heart. CONCLUSIONS This is the first report of the application of a (12)C beam for ablation of cardiac tissue to treat arrhythmias. Catheter-free ablation using 12C beams is feasible and merits exploration in intact animal studies as an energy source for arrhythmia elimination.
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Affiliation(s)
- H Immo Lehmann
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.).
| | - Daniel Richter
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Hannah Prokesch
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Christian Graeff
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Matthias Prall
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Palma Simoniello
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Claudia Fournier
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Julia Bauer
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Robert Kaderka
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Alexander Weymann
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Gábor Szabó
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Karin Sonnenberg
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Anna M Constantinescu
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Susan B Johnson
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Juna Misiri
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Mitsuru Takami
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Robert C Miller
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Michael G Herman
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Samuel J Asirvatham
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Stephan Brons
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Oliver Jäkel
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Thomas Haberer
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Jürgen Debus
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Marco Durante
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Christoph Bert
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Douglas L Packer
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
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Ohta K, Shimohira M, Sasaki S, Iwata H, Nishikawa H, Ogino H, Hara M, Hashizume T, Shibamoto Y. Transarterial Fiducial Marker Placement for Image-guided Proton Therapy for Malignant Liver Tumors. Cardiovasc Intervent Radiol 2014; 38:1288-93. [PMID: 25366091 DOI: 10.1007/s00270-014-1013-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Accepted: 08/31/2014] [Indexed: 11/24/2022]
Abstract
PURPOSE The aim of this study is to analyze the technical and clinical success rates and safety of transarterial fiducial marker placement for image-guided proton therapy for malignant liver tumors. METHODS AND MATERIALS Fifty-five patients underwent this procedure as an interventional treatment. Five patients had 2 tumors, and 4 tumors required 2 markers each, so the total number of procedures was 64. The 60 tumors consisted of 46 hepatocellular carcinomas and 14 liver metastases. Five-mm-long straight microcoils of 0.018 inches in diameter were used as fiducial markers and placed in appropriate positions for each tumor. We assessed the technical and clinical success rates of transarterial fiducial marker placement, as well as the complications associated with it. Technical success was defined as the successful delivery and placement of the fiducial coil, and clinical success was defined as the completion of proton therapy. RESULTS All 64 fiducial coils were successfully installed, so the technical success rate was 100 % (64/64). Fifty-four patients underwent proton therapy without coil migration. In one patient, proton therapy was not performed because of obstructive jaundice due to bile duct invasion by hepatocellular carcinoma. Thus, the clinical success rate was 98 % (54/55). Slight bleeding was observed in one case, but it was stopped immediately and then observed. None of the patients developed hepatic infarctions due to fiducial marker migration. CONCLUSION Transarterial fiducial marker placement appears to be a useful and safe procedure for proton therapy for malignant liver tumors.
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Affiliation(s)
- Kengo Ohta
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, 467-8601, Japan.
| | - Masashi Shimohira
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, 467-8601, Japan.
| | - Shigeru Sasaki
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City West Medical Center, Nagoya, 462-8508, Japan.
| | - Hiromitsu Iwata
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City West Medical Center, Nagoya, 462-8508, Japan.
| | - Hiroko Nishikawa
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City West Medical Center, Nagoya, 462-8508, Japan.
| | - Hiroyuki Ogino
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City West Medical Center, Nagoya, 462-8508, Japan.
| | - Masaki Hara
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City West Medical Center, Nagoya, 462-8508, Japan.
| | - Takuya Hashizume
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, 467-8601, Japan.
| | - Yuta Shibamoto
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, 467-8601, Japan.
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Patel S, Kostaras X, Parliament M, Olivotto IA, Nordal R, Aronyk K, Hagen N. Recommendations for the referral of patients for proton-beam therapy, an Alberta Health Services report: a model for Canada? ACTA ACUST UNITED AC 2014; 21:251-62. [PMID: 25302033 DOI: 10.3747/co.21.2207] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Compared with photon therapy, proton-beam therapy (pbt) offers compelling advantages in physical dose distribution. Worldwide, gantry-based proton facilities are increasing in number, but no such facilities exist in Canada. To access pbt, Canadian patients must travel abroad for treatment at high cost. In the face of limited access, this report seeks to provide recommendations for the selection of patients most likely to benefit from pbt and suggests an out-of-country referral process. METHODS The medline, embase, PubMed, and Cochrane databases were systematically searched for studies published between January 1990 and May 2014 that evaluated clinical outcomes after pbt. A draft report developed through a review of evidence was externally reviewed and then approved by the Alberta Health Services Cancer Care Proton Therapy Guidelines steering committee. RESULTS Proton therapy is often used to treat tumours close to radiosensitive tissues and to treat children at risk of developing significant late effects of radiation therapy (rt). In uncontrolled and retrospective studies, local control rates with pbt appear similar to, or in some cases higher than, photon rt. Randomized trials comparing equivalent doses of pbt and photon rt are not available. SUMMARY Referral for pbt is recommended for patients who are being treated with curative intent and with an expectation for long-term survival, and who are able and willing to travel abroad to a proton facility. Commonly accepted indications for referral include chordoma and chondrosarcoma, intraocular melanoma, and solid tumours in children and adolescents who have the greatest risk for long-term sequelae. Current data do not provide sufficient evidence to recommend routine referral of patients with most head-and-neck, breast, lung, gastrointestinal tract, and pelvic cancers, including prostate cancer. It is recommended that all referrals be considered by a multidisciplinary team to select appropriate cases.
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Affiliation(s)
- S Patel
- Department of Radiation Oncology, Cross Cancer Institute, and Department of Oncology, University of Alberta, Edmonton, AB
| | - X Kostaras
- Guideline Utilization Resource Unit, Alberta Health Services, Calgary, AB
| | - M Parliament
- Department of Radiation Oncology, Cross Cancer Institute, and Department of Oncology, University of Alberta, Edmonton, AB
| | - I A Olivotto
- Division of Radiation Oncology, Tom Baker Cancer Centre, and University of Calgary, Calgary, AB
| | - R Nordal
- Division of Radiation Oncology, Tom Baker Cancer Centre, and University of Calgary, Calgary, AB
| | - K Aronyk
- Division of Neurosurgery, University of Alberta, Edmonton, AB
| | - N Hagen
- Guideline Utilization Resource Unit, Alberta Health Services, Calgary, AB
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Rombi B, Vennarini S, Vinante L, Ravanelli D, Amichetti M. Proton radiotherapy for pediatric tumors: review of first clinical results. Ital J Pediatr 2014; 40:74. [PMID: 25260976 PMCID: PMC4421929 DOI: 10.1186/s13052-014-0074-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 08/04/2014] [Indexed: 12/03/2022] Open
Abstract
Radiation therapy is a part of multidisciplinary management of several childhood cancers. Proton therapy is a new method of irradiation, which uses protons instead of photons. Proton radiation has been used safely and effectively for medulloblastoma, primitive neuro-ectodermal tumors, craniopharyngioma, ependymoma, germ cell intracranial tumors, low-grade glioma, retinoblastoma, rhabdomyosarcoma and other soft tissue sarcomas, Ewing’s sarcoma and other bone sarcomas. Moreover, other possible applications are emerging, in particular for lymphoma and neuroblastoma. Although both photon and proton techniques allow similar target volume coverage, the main advantage of proton radiation therapy is to sparing of intermediate-to-low-dose to healthy tissues. This characteristic could translate into clinical reduction of side effects, including a lower risk for secondary cancers. The following review presents the state of the art of proton therapy in the treatment of pediatric malignancies.
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Affiliation(s)
- Barbara Rombi
- Unità Operativa di Protonterapia, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy.
| | - Sabina Vennarini
- Unità Operativa di Protonterapia, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy.
| | - Lorenzo Vinante
- Unità Operativa di Protonterapia, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy. .,Dipartimento di Medicina, Università di Padova, Padova, Italy.
| | - Daniele Ravanelli
- Unità Operativa di Protonterapia, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy.
| | - Maurizio Amichetti
- Unità Operativa di Protonterapia, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy.
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Treatment of high-risk neuroblastoma in children: recent clinic trial results. ACTA ACUST UNITED AC 2013. [DOI: 10.4155/cli.13.90] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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