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Yagihashi T, Inoue T, Shiba S, Yamano A, Minagawa Y, Omura M, Inoue K, Nagata H. Impact of delivery time factor on treatment time and plan quality in tomotherapy. Sci Rep 2023; 13:12207. [PMID: 37500671 PMCID: PMC10374581 DOI: 10.1038/s41598-023-39047-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/19/2023] [Indexed: 07/29/2023] Open
Abstract
Delivery time factor (DTF) is a new parameter introduced by the RayStation treatment planning system for tomotherapy treatment planning. This study investigated the effects of this factor on various tomotherapy plans. Twenty-five patients with cancer (head and neck, 6; lung, 9; prostate, 10) were enrolled in this study. Helical tomotherapy plans with a field width of 2.5 cm, pitch of 0.287, and DTF of 2.0 were created. All the initial plans were recalculated by changing the DTF parameter from 1.0 to 3.0 in increments of 0.1. Then, DTF's impact on delivery efficiency and plan quality was evaluated. Treatment time and modulation factor increased monotonically with increasing DTF. Increasing the DTF by 0.1 increased the treatment time and modulation factor by almost 10%. This relationship was similar for all treatment sites. Conformity index (CI), homogeneity index, and organ at risk doses were improved compared to plans with a DTF of 1.0, except for the CI in the lung cancer case. However, the improvement in most indices ceased at a certain DTF; nevertheless, treatment time continued to increase following an increase in DTF. DTF is a critical parameter for improving the quality of tomotherapy plans.
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Affiliation(s)
- Takayuki Yagihashi
- Department of Medical Physics, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
- Graduate School of Human Health Sciences, Tokyo Metropolitan University, 7-2-10 Higashiogu, Arakawa-ku, Tokyo, 116-8551, Japan
| | - Tatsuya Inoue
- Department of Medical Physics, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan.
- Department of Radiation Oncology, Graduate School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Shintaro Shiba
- Department of Radiation Oncology, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Akihiro Yamano
- Department of Medical Physics, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Yumiko Minagawa
- Department of Radiation Oncology, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Motoko Omura
- Department of Radiation Oncology, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Kazumasa Inoue
- Graduate School of Human Health Sciences, Tokyo Metropolitan University, 7-2-10 Higashiogu, Arakawa-ku, Tokyo, 116-8551, Japan
| | - Hironori Nagata
- Department of Medical Physics, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
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Buciuman N, Marcu LG. Is there a dosimetric advantage of volumetric modulated arc therapy over intensity modulated radiotherapy in head and neck cancer? Eur Arch Otorhinolaryngol 2022; 279:5311-5321. [DOI: 10.1007/s00405-022-07452-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 05/13/2022] [Indexed: 11/29/2022]
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Intensity-modulated proton therapy for oropharyngeal cancer reduces rates of late xerostomia. Radiother Oncol 2021; 160:32-39. [PMID: 33839202 DOI: 10.1016/j.radonc.2021.03.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 03/23/2021] [Accepted: 03/28/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND PURPOSE To determine rates of xerostomia after intensity-modulated radiotherapy (IMRT) or intensity-modulated proton therapy (IMPT) for oropharyngeal cancer (OPC) and identify dosimetric factors associated with xerostomia risk. MATERIALS AND METHODS Patients with OPC who received IMRT (n = 429) or IMPT (n = 103) from January 2011 through June 2015 at a single institution were studied retrospectively. Every 3 months after treatment, each patient completed an eight-item self-reported xerostomia-specific questionnaire (XQ; summary XQ score, 0-100). An XQ score of 50 was selected as the demarcation value for moderate-severe (XQs ≥ 50) and no-mild (XQs < 50) xerostomia. The mean doses and percent volumes of organs at risk receiving various doses (V5-V70) were extracted from the initial treatment plans. The dosimetric variables and xerostomia risk were compared using an independent-sample t-test or chi-square test. RESULTS The median follow-up time was 36.2 months. The proportions of patients with moderate-severe xerostomia were similar in the two treatment groups up to 18 months after treatment. However, moderate-severe xerostomia was less common in the IMPT group than in the IMRT group at 18-24 months (6% vs. 20%; p = 0.025) and 24-36 months (6% vs. 20%; p = 0.01). During the late xerostomia period (24-36 months), high dose/volume exposures (V25-V70) in the oral cavity were associated with high proportions of patients with moderate-severe xerostomia (all p < 0.05), but dosimetric variables regarding the salivary glands were not associated with late xerostomia. CONCLUSION IMPT was associated with less late xerostomia than was IMRT in OPC patients. Oral cavity dosimetric variables were related to the occurrence of late xerostomia.
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4
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Pigorsch SU, Kampfer S, Oechsner M, Mayinger MC, Mozes P, Devecka M, Kessel KK, Combs SE, Wilkens JJ. Report on planning comparison of VMAT, IMRT and helical tomotherapy for the ESCALOX-trial pre-study. Radiat Oncol 2020; 15:253. [PMID: 33138837 PMCID: PMC7607845 DOI: 10.1186/s13014-020-01693-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/21/2020] [Indexed: 12/12/2022] Open
Abstract
Background The ESCALOX trial was designed as a multicenter, randomized prospective dose escalation study for head and neck cancer. Therefore, feasibility of treatment planning via different treatment planning systems (TPS) and radiotherapy (RT) techniques is essential. We hypothesized the comparability of dose distributions for simultaneous integrated boost (SIB) volumes respecting the constraints by different TPS and RT techniques. Methods CT data sets of the first six patients (all male, mean age: 61.3 years) of the pre-study (up to 77 Gy) were used for comparison of IMRT, VMAT, and helical tomotherapy (HT). Oropharynx was the primary tumor location. Normalization of the three step SIB (77 Gy, 70 Gy, 56 Gy) was D95% = 77 Gy. Coverage (CVF), healthy tissue conformity index (HTCI), conformation number (CN), and dose homogeneity (HI) were compared for PTVs and conformation index (COIN) for parotids. Results All RT techniques achieved good coverage. For SIB77Gy, CVF was best for IMRT and VMAT, HT achieved highest CN followed by VMAT and IMRT. HT reached good HTCI value, and HI compared to both other techniques. For SIB70Gy, CVF was best by IMRT. HTCI favored HT, consequently CN as well. HI was slightly better for HT. For SIB56Gy, CVF resulted comparably. Conformity favors VMAT as seen by HTCI and CN. Dmean of ipsilateral and contralateral parotids favor HT. Conclusion Different TPS for dose escalation reliably achieved high plan quality. Despite the very good results of HT planning for coverage, conformity, and homogeneity, the TPS also achieved acceptable results for IMRT and VMAT. Trial registration ClinicalTrials.gov Identifier: NCT 01212354, EudraCT-No.: 2010-021139-15. ARO: ARO 14-01
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Affiliation(s)
- Steffi U Pigorsch
- Department of Radiation Oncology, Technical University of Munich (TUM), School of Medicine, Klinikum Rechts Der Isar, Ismaninger Straße 22, 81675, Munich, Germany.
| | - Severin Kampfer
- Department of Radiation Oncology, Technical University of Munich (TUM), School of Medicine, Klinikum Rechts Der Isar, Ismaninger Straße 22, 81675, Munich, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Technical University of Munich (TUM), School of Medicine, Klinikum Rechts Der Isar, Ismaninger Straße 22, 81675, Munich, Germany
| | - Michael C Mayinger
- Department of Radiation Oncology, University Hospital Zurich, Rämistrasse 100, Zurich, Switzerland
| | - Petra Mozes
- Department of Radiation Oncology, Technical University of Munich (TUM), School of Medicine, Klinikum Rechts Der Isar, Ismaninger Straße 22, 81675, Munich, Germany
| | - Michal Devecka
- Department of Radiation Oncology, Technical University of Munich (TUM), School of Medicine, Klinikum Rechts Der Isar, Ismaninger Straße 22, 81675, Munich, Germany
| | - Kerstin K Kessel
- Department of Radiation Oncology, Technical University of Munich (TUM), School of Medicine, Klinikum Rechts Der Isar, Ismaninger Straße 22, 81675, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich (TUM), School of Medicine, Klinikum Rechts Der Isar, Ismaninger Straße 22, 81675, Munich, Germany.,Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Ingolstädter Landstraße 1, Neuherberg, Germany
| | - Jan J Wilkens
- Department of Radiation Oncology, Technical University of Munich (TUM), School of Medicine, Klinikum Rechts Der Isar, Ismaninger Straße 22, 81675, Munich, Germany
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Grant SR, Williamson TD, Stieb S, Shah SJ, David Fuller C, Rosenthal DI, Frank SJ, Garden AS, Morrison WH, Phan J, Moreno AC, Reddy JP, Cardoso RC, Liu AY, Wu RY, Gunn GB. A Dosimetric Comparison of Oral Cavity Sparing in the Unilateral Treatment of Early Stage Tonsil Cancer: IMRT, IMPT, and Tongue-Deviating Oral Stents. Adv Radiat Oncol 2020; 5:1359-1363. [PMID: 33305099 PMCID: PMC7718552 DOI: 10.1016/j.adro.2020.08.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/11/2020] [Accepted: 08/18/2020] [Indexed: 11/26/2022] Open
Abstract
Introduction Tongue-deviating oral stents (TDOS) are commonly used during unilateral neck radiation therapy to reduce unnecessary dose to nontarget oral structures. Their benefit in the setting of highly conformal treatment techniques, however, is not defined. The goal of this study was to investigate the potential benefit of TDOS use on dosimetric parameters in unilateral intensity modulated radiation therapy (IMRT) and intensity modulated proton therapy (IMPT). Methods A total of 16 patients with T1-2 tonsil cancer treated at a single institution were selected, of which 8 were simulated/treated with a TDOS and 8 without a TDOS. All received definitive unilateral IMRT to a dose of 66 Gy in 30 fx. IMPT plans were generated for each patient for study purposes and optimized according to standard institutional practice. Results For IMRT plans, the presence of a TDOS (vs without) was associated with a significantly lower oral mucosa mean dose (31.4 vs 35.3 Gy; P = .020) and V30 (42.7% vs 57.1%; P = .025). For IMPT plans, the presence of TDOS (vs without) was not associated with any improvement in oral mucosa mean dose (18.3 vs 19.9 Gy; P = .274) or V30 (25.0% vs 26.2%; P = .655). IMPT plans without TDOS compared with IMRT plans with TDOS demonstrated reduced oral mucosa mean dose (P < .001) and V30 (P < .001). Conclusion The use of a TDOS for the unilateral treatment of well-lateralized tonsil cancers was associated with oral mucosa sparing for IMRT, but not for IMPT. Moreover, mucosa sparing was improved for IMPT plans without a TDOS compared to IMRT plans with a TDOS.
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Affiliation(s)
- Stephen R Grant
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Tyler D Williamson
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sonja Stieb
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shalin J Shah
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - C David Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Adam S Garden
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - William H Morrison
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jack Phan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amy C Moreno
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jay P Reddy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Richard C Cardoso
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amy Y Liu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Richard Y Wu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - G Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Proton therapy for head and neck squamous cell carcinomas: A review of the physical and clinical challenges. Radiother Oncol 2020; 147:30-39. [PMID: 32224315 DOI: 10.1016/j.radonc.2020.03.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 02/21/2020] [Accepted: 03/05/2020] [Indexed: 12/12/2022]
Abstract
The quality of radiation therapy has been shown to significantly influence the outcomes for head and neck squamous cell carcinoma (HNSCC) patients. The results of dosimetric studies suggest that intensity-modulated proton therapy (IMPT) could be of added value for HNSCC by being more effective than intensity-modulated (photon) radiation therapy (IMRT) for reducing side effects of radiation therapy. However, the physical properties of protons make IMPT more sensitive than photons to planning uncertainties. This could potentially have a negative effect on the quality of IMPT planning and delivery. For this review, the three French proton therapy centers collaborated to evaluate the differences between IMRT and IMPT. The review explored the effects of these uncertainties and their management for developing a robust and optimized IMPT treatment delivery plan to achieve clinical outcomes that are superior to those for IMRT. We also provide practical suggestions for the management of HNSCC carcinoma with IMPT. Because metallic dental implants can increase range uncertainties (3-10%), patient preparation for IMPT may require more systematic removal of in-field alien material than is done for IMRT. Multi-energy CT may be an alternative to calculate more accurately the dose distribution. The practical aspects that we describe are essential to guarantee optimal quality in radiation therapy in both model-based and randomized clinical trials.
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7
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Helical tomotherapy: Comparison of Hi-ART and Radixact clinical patient treatments at the Technical University of Munich. Sci Rep 2020; 10:4928. [PMID: 32188899 PMCID: PMC7080845 DOI: 10.1038/s41598-020-61499-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 02/26/2020] [Indexed: 12/14/2022] Open
Abstract
The helical tomotherapy (HT) Hi-ART system was installed at our department in April 2007. In July 2018 the first Radixact system in Germany has been launched for clinical use. We present differences, advantages and disadvantages and show future perspectives in patient treatment using two HT devices. We investigate patient characteristics, image quality, radiotherapy treatment specifications and analyze the time effort for treatments with the Hi-ART system from April 2010 until May 2017 and compare it to the data acquired in the first nine months of usage of the Radixact system. Comparing the Hi-ART and Radixact system, the unique option of integrated MVCT image acquisition has experienced distinct improvement in image quality. Time effort for irradiation treatment could be improved resulting in a mean beam on time for craniospinal axis treatment of 636.2 s for the Radixact system compared to 915.9 s for the Hi-ART system. The beneficial use of tomotherapy for complex target volumes is demonstrated by a head and neck tumor case and craniospinal axis treatment. With the Radixact system MVCT image quality has been improved allowing for fast and precise interfraction dose adaptation. The improved time effort for patient treatment could increase the accessibility for clinical usage.
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8
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Chuong M, Bryant J, Hartsell W, Larson G, Badiyan S, Laramore GE, Katz S, Tsai H, Vargas C. Minimal acute toxicity from proton beam therapy for major salivary gland cancer. Acta Oncol 2020; 59:196-200. [PMID: 31805791 DOI: 10.1080/0284186x.2019.1698764] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: Proton beam therapy (PBT) reduces normal organ dose compared to intensity-modulated radiation therapy (IMRT) for patients with major salivary gland tumors. It is not known whether this dosimetric advantage is clinically meaningful for reducing acute toxicity.Methods: We evaluated treatment parameters and acute toxicity outcomes of patients with major salivary gland cancers enrolled on the Proton Collaborative Group REG001-09 trial (NCT01255748).Results: One-hundred and five patients with a median age of 61 years were included. The majority had parotid (N = 90) versus submandibular gland (N = 15) tumors. The patients were treated across seven institutions in the United States between 2010 and 2017, most commonly in the postoperative setting (70.5%) although a minority were treated definitively (29.5%). Median PBT dose was 66.5 GyE in 33 fractions; only one patient was prescribed less than 50 GyE. Chemotherapy was given concurrently to 20%. Median follow-up was 14.3 months. Acute grade 2 or higher toxicity included nausea (1.5%), dysgeusia (4.8%), xerostomia (7.6%), mucositis (10.5%) and dysphagia (10.5%).Conclusions: PBT should be strongly considered when ipsilateral radiation therapy is indicated for major salivary gland cancer based on a considerably lower incidence of acute grade 2 or higher toxicity in this analysis compared to historical IMRT outcomes.
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Affiliation(s)
- Michael Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL, USA
| | - John Bryant
- Florida International University Herbert Wertheim College of Medicine, Miami, FL, USA
| | - William Hartsell
- Proton Therapy Center, Northwestern University – Chicago, Chicago, IL, USA
| | - Gary Larson
- ProCure Proton Therapy Center Oklahoma, Oklahoma City, OK, USA
| | - Shahed Badiyan
- Department of Radiation Oncology, Washington University, St. Louis, MO, USA
| | - George E. Laramore
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, WA, USA
| | - Sanford Katz
- Department of Radiation Oncology, Willis-Knighton Medical Center, Shreveport, LA, USA
| | - Henry Tsai
- ProCure Proton Therapy Center Somerset, Somerset, NJ, USA
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Zhang H, Cao Y, Antone J, Riegel AC, Ghaly M, Potters L, Jamshidi A. A Model-Based Method for Assessment of Salivary Gland and Planning Target Volume Dosimetry in Volumetric-Modulated Arc Therapy Planning on Head-and-Neck Cancer. J Med Phys 2019; 44:201-206. [PMID: 31576068 PMCID: PMC6764180 DOI: 10.4103/jmp.jmp_19_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
This study examined the relationship of achievable mean dose and percent volumetric overlap of salivary gland with the planning target volume (PTV) in volumetric-modulated arc therapy (VMAT) plan in radiotherapy for a patient with head-and-neck cancer. The aim was to develop a model to predict the viability of planning objectives for both PTV coverage and organs-at-risk (OAR) sparing based on overlap volumes between PTVs and OARs, before the planning process. Forty patients with head-and-neck cancer were selected for this retrospective plan analysis. The patients were treated using 6 MV photons with 2-arc VMAT plan in prescriptions with simultaneous integrated boost in dose of 70 Gy, 63 Gy, and 58.1 Gy to primary tumor sites, high-risk nodal regions, and low-risk nodal regions, respectively, over 35 fractions. A VMAT plan was generated using Varian Eclipse (V13.6), in optimization with biological-based generalized equivalent uniform dose (gEUD) objective for OARs and targets. Target dose coverage (D95, Dmax, conformity index) and salivary gland dose (Dmean and Dmax) were evaluated in those plans. With a range of volume overlaps between salivary glands and PTVs and dose constraints applied, results showed that dose D95 for each PTV was adequate to satisfy D95 >95% of the prescription. Mean dose to parotid <26 Gy could be achieved with <20% volumetric overlap with PTV58 (parotid-PTV58). On an average, the Dmean was seen at 15.6 Gy, 21.1 Gy, and 24.2 Gy for the parotid-PTV58 volume at <5%, <10%, and <20%, respectively. For submandibular glands (SMGs), an average Dmean of 27.6 Gy was achieved in patients having <10% overlap with PTV58, and 36.1 Gy when <20% overlap. Mean doses on parotid and SMG were linearly correlated with overlap volume (regression R2 = 0.95 and 0.98, respectively), which were statistically significant (P < 0.0001). This linear relationship suggests that the assessment of the structural overlap might provide prospective for achievable planning objectives in the head-and-neck plan.
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Affiliation(s)
- Honglai Zhang
- Department of Radiation Medicine, Northwell Health Cancer Institute, Lake Success, New York, USA
| | - Yijian Cao
- Department of Radiation Medicine, Northwell Health Cancer Institute, Lake Success, New York, USA.,Zucker School of Medicine at Northwell/Hofstra, Hempstead, New York, USA
| | - Jeffrey Antone
- Department of Radiation Medicine, Northwell Health Cancer Institute, Lake Success, New York, USA
| | - Adam C Riegel
- Department of Radiation Medicine, Northwell Health Cancer Institute, Lake Success, New York, USA.,Zucker School of Medicine at Northwell/Hofstra, Hempstead, New York, USA
| | - Maged Ghaly
- Department of Radiation Medicine, Northwell Health Cancer Institute, Lake Success, New York, USA.,Zucker School of Medicine at Northwell/Hofstra, Hempstead, New York, USA
| | - Louis Potters
- Department of Radiation Medicine, Northwell Health Cancer Institute, Lake Success, New York, USA.,Zucker School of Medicine at Northwell/Hofstra, Hempstead, New York, USA
| | - Abolghassem Jamshidi
- Department of Radiation Medicine, Northwell Health Cancer Institute, Lake Success, New York, USA.,Zucker School of Medicine at Northwell/Hofstra, Hempstead, New York, USA
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Beddok A, Vela A, Calugaru V, Tessonnier T, Kubes J, Dutheil P, Gérard A, Vidal M, Goudjil F, Florescu C, Kammerer E, Bénézery K, Hérault J, Bourhis J, Thariat J. [Proton therapy for head and neck squamous cell carcinomas: From physics to clinic]. Cancer Radiother 2019; 23:439-448. [PMID: 31358445 DOI: 10.1016/j.canrad.2019.05.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 05/09/2019] [Accepted: 05/16/2019] [Indexed: 11/17/2022]
Abstract
Intensity-modulated radiation therapy (IMRT) is presently the recommended technique for the treatment of locally advanced head and neck carcinomas. Proton therapy would allow to reduce the volume of irradiated normal tissue and, thus, to decrease the risk of late dysphagia, xerostomia, dysgeusia and hypothyroidism. An exhaustive research was performed with the search engine PubMed by focusing on the papers about the physical difficulties that slow down use of proton therapy for head and neck carcinomas. Range uncertainties in proton therapy (±3 %) paradoxically limit the use of the steep dose gradient in distality. Calibration uncertainties can be important in the treatment of head and neck cancer in the presence of materials of uncertain stoichiometric composition (such as with metal implants, dental filling, etc.) and complex heterogeneities. Dental management for example may be different with IMRT or proton therapy. Some uncertainties can be somewhat minimized at the time of optimization. Inter- and intrafractional variations and uncertainties in Hounsfield units/stopping power can be integrated in a robust optimization process. Additional changes in patient's anatomy (tumour shrinkage, changes in skin folds in the beam patch, large weight loss or gain) require rescanning. Dosimetric and small clinical studies comparing photon and proton therapy have well shown the interest of proton therapy for head and neck cancers. Intensity-modulated proton therapy is a promising treatment as it can reduce the substantial toxicity burden of patients with head and neck squamous cell carcinoma compared to IMRT. Robust optimization will allow to perform an optimal treatment and to use proton therapy in current clinical practice.
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Affiliation(s)
- A Beddok
- Département d'oncologie-radiothérapie, institut Curie, 25, rue d'Ulm, 75005 Paris, France
| | - A Vela
- Département d'oncologie-radiothérapie, centre François-Baclesse, Caen, 3, avenue du Général-Harris, 14000 Caen, France; Unicaen - Normandie Université, 14000 Caen, France; Advanced Resource Centre for Hadrontherapy in Europe (Archade), 3, avenue du Général-Harris, 14000 Caen, France
| | - V Calugaru
- Département d'oncologie-radiothérapie, institut Curie, 25, rue d'Ulm, 75005 Paris, France
| | - T Tessonnier
- Département d'oncologie-radiothérapie, centre François-Baclesse, Caen, 3, avenue du Général-Harris, 14000 Caen, France; Unicaen - Normandie Université, 14000 Caen, France; Advanced Resource Centre for Hadrontherapy in Europe (Archade), 3, avenue du Général-Harris, 14000 Caen, France
| | - J Kubes
- Proton Therapy Centre Czech, Prague, République tchèque
| | - P Dutheil
- Département d'oncologie-radiothérapie, centre François-Baclesse, Caen, 3, avenue du Général-Harris, 14000 Caen, France; Unicaen - Normandie Université, 14000 Caen, France; Advanced Resource Centre for Hadrontherapy in Europe (Archade), 3, avenue du Général-Harris, 14000 Caen, France
| | - A Gérard
- Centre Antoine-Lacassagne, département d'oncologie-radiothérapie, 33, avenue Valombrose, 06000 Nice, France
| | - M Vidal
- Centre Antoine-Lacassagne, département d'oncologie-radiothérapie, 33, avenue Valombrose, 06000 Nice, France
| | - F Goudjil
- Département d'oncologie-radiothérapie, institut Curie, 25, rue d'Ulm, 75005 Paris, France
| | - C Florescu
- Département d'oncologie-radiothérapie, centre François-Baclesse, Caen, 3, avenue du Général-Harris, 14000 Caen, France; Unicaen - Normandie Université, 14000 Caen, France; Advanced Resource Centre for Hadrontherapy in Europe (Archade), 3, avenue du Général-Harris, 14000 Caen, France
| | - E Kammerer
- Département d'oncologie-radiothérapie, centre François-Baclesse, Caen, 3, avenue du Général-Harris, 14000 Caen, France; Unicaen - Normandie Université, 14000 Caen, France; Advanced Resource Centre for Hadrontherapy in Europe (Archade), 3, avenue du Général-Harris, 14000 Caen, France
| | - K Bénézery
- Centre Antoine-Lacassagne, département d'oncologie-radiothérapie, 33, avenue Valombrose, 06000 Nice, France
| | - J Hérault
- Centre Antoine-Lacassagne, département d'oncologie-radiothérapie, 33, avenue Valombrose, 06000 Nice, France
| | - J Bourhis
- Département d'oncologie-radiothérapie, centre hospitalier universitaire vaudois, Lausanne, Suisse
| | - J Thariat
- Département d'oncologie-radiothérapie, centre François-Baclesse, Caen, 3, avenue du Général-Harris, 14000 Caen, France; Unicaen - Normandie Université, 14000 Caen, France; Advanced Resource Centre for Hadrontherapy in Europe (Archade), 3, avenue du Général-Harris, 14000 Caen, France; Laboratoire de physique corpusculaire IN2P3/Ensicaen - UMR6534, Unicaen - Normandie Université, 14000 Caen, France.
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- Département d'oncologie-radiothérapie, institut Curie, 25, rue d'Ulm, 75005 Paris, France; Département d'oncologie-radiothérapie, centre François-Baclesse, Caen, 3, avenue du Général-Harris, 14000 Caen, France; Unicaen - Normandie Université, 14000 Caen, France; Proton Therapy Centre Czech, Prague, République tchèque; Centre Antoine-Lacassagne, département d'oncologie-radiothérapie, 33, avenue Valombrose, 06000 Nice, France; Département d'oncologie-radiothérapie, centre hospitalier universitaire vaudois, Lausanne, Suisse; Laboratoire de physique corpusculaire IN2P3/Ensicaen - UMR6534, Unicaen - Normandie Université, 14000 Caen, France
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11
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Park SG, Ahn YC, Oh D, Noh JM, Ju SG, Kwon D, Jo K, Chung K, Chung E, Lee W, Park S. Early clinical outcomes of helical tomotherapy/intensity-modulated proton therapy combination in nasopharynx cancer. Cancer Sci 2019; 110:2867-2874. [PMID: 31237050 PMCID: PMC6726680 DOI: 10.1111/cas.14115] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 06/17/2019] [Accepted: 06/22/2019] [Indexed: 11/30/2022] Open
Abstract
This study aimed to evaluate the feasibility of combining helical tomotherapy (HT) and intensity‐modulated proton therapy (IMPT) in treating patients with nasopharynx cancer (NPC). From January 2016 to March 2018, 98 patients received definitive radiation therapy (RT) with concurrent chemotherapy (CCRT). Using simultaneous integrated boost and adaptive re‐plan, 3 different dose levels were prescribed: 68.4 Gy in 30 parts to gross tumor volume (GTV), 60 Gy in 30 parts to high‐risk clinical target volume (CTV), and 36 Gy in 18 parts to low‐risk CTV. In all patients, the initial 18 fractions were delivered by HT, and, after rival plan evaluation on the adaptive re‐plan, the later 12 fractions were delivered either by HT in 63 patients (64.3%, HT only) or IMPT in 35 patients (35.7%, HT/IMPT combination), respectively. Propensity‐score matching was conducted to control differences in patient characteristics. In all patients, grade ≥ 2 mucositis (69.8% vs 45.7%, P = .019) and grade ≥ 2 analgesic usage (54% vs 37.1%, P = .110) were found to be less frequent in HT/IMPT group. In matched patients, grade ≥ 2 mucositis were still less frequent numerically in HT/IMPT group (62.9% vs 45.7%, P = .150). In univariate analysis, stage IV disease and larger GTV volume were associated with increased grade ≥ 2 mucositis. There was no significant factor in multivariate analysis. With the median 14 month follow‐up, locoregional and distant failures occurred in 9 (9.2%) and 12 (12.2%) patients without difference by RT modality. In conclusion, comparable early oncologic outcomes with more favorable acute toxicity profiles were achievable by HT/IMPT combination in treating NPC patients.
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Affiliation(s)
- Seung Gyu Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Radiation Oncology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Yong Chan Ahn
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dongryul Oh
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Myoung Noh
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang Gyu Ju
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dongyeol Kwon
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwanghyun Jo
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwangzoo Chung
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eunah Chung
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woojin Lee
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seyjoon Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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12
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Lee A, Kang J, Yu Y, McBride S, Riaz N, Cohen M, Sherman E, Michel L, Lee N, Tsai CJ. Trends and Disparities of Proton Therapy Use among Patients with Head and Neck Cancer: Analysis from the National Cancer Database (2005-14). Int J Part Ther 2019; 5:1-10. [PMID: 31773036 DOI: 10.14338/ijpt-19-00051.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/18/2019] [Indexed: 01/07/2023] Open
Abstract
Purpose The purpose of this study was to analyze national trends and disparities in proton therapy use among patients with head and neck cancer receiving radiotherapy to primary disease sites. Patients and Methods Using the National Cancer Database, we identified patients diagnosed with any nonmetastatic head and neck primary malignancy between 2005 and 2014 who were treated with radiation therapy or proton therapy directed specifically at the primary disease site. Distributions of patient and clinical factors between the two groups were evaluated. Multivariable logistic regression was used to correlate factors associated with proton therapy use compared with other modalities of radiation therapy. Results There were 220 491 patients who received any radiation therapy as part of their initial treatment course, only 417 (0.2%) of whom received proton therapy. The use of protons underwent a small increase from 0.13% in 2005-06 to 0.41% by 2013-14 (P < .001). The most common primary sites treated with proton therapy were the nasal cavity/nasopharynx (n = 151, 36.2%) and the oral cavity (n = 98, 23.5%). Most patients had T4 disease (n = 94, 31.0%). On multivariable logistic regression, all primary sites compared with hypopharynx/larynx sites (odds ratio [OR], 2.53-10.53; P < .001), treatment at an academic facility (OR, 2.54; P < .001), ≥ 13-mile distance from the treating facility (OR, 1.94; P < .001), and highest median household income quartile (> $63 000; OR, 2.52; P = .002) were associated with an increased likelihood of receiving proton therapy. Conclusion Proton use has undergone an incremental increase in the United States but remains an uncommon modality for the treatment of primary head and neck cancer.
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Affiliation(s)
- Anna Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Radiation Oncology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Julie Kang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yao Yu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sean McBride
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nadeem Riaz
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marc Cohen
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Eric Sherman
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Loren Michel
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nancy Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - C Jillian Tsai
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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13
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Cubillos-Mesías M, Baumann M, Troost EGC, Lohaus F, Löck S, Richter C, Stützer K. Impact of robust treatment planning on single- and multi-field optimized plans for proton beam therapy of unilateral head and neck target volumes. Radiat Oncol 2017; 12:190. [PMID: 29183377 PMCID: PMC5706329 DOI: 10.1186/s13014-017-0931-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 11/22/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Proton beam therapy is promising for the treatment of head and neck cancer (HNC), but it is sensitive to uncertainties in patient positioning and particle range. Studies have shown that the planning target volume (PTV) concept may not be sufficient to ensure robustness of the target coverage. A few planning studies have considered irradiation of unilateral HNC targets with protons, but they have only taken into account the dose on the nominal plan, without considering anatomy changes occurring during the treatment course. METHODS Four pencil beam scanning (PBS) proton therapy plans were calculated for 8 HNC patients with unilateral target volumes: single-field (SFO) and multi-field optimized (MFO) plans, either using the PTV concept or clinical target volume (CTV)-based robust optimization. The dose was recalculated on computed tomography (CT) scans acquired during the treatment course. Doses to target volumes and organs at risk (OARs) were compared for the nominal plans, cumulative doses considering anatomical changes, and additional setup and range errors in each fraction. If required, the treatment plan was adapted, and the dose was compared with the non-adapted plan. RESULTS All nominal plans fulfilled the clinical specifications for target coverage, but significantly higher doses on the ipsilateral parotid gland were found for both SFO approaches. MFO PTV-based plans had the lowest robustness against range and setup errors. During the treatment course, the influence of the anatomical variation on the dose has shown to be patient specific, mostly independent of the chosen planning approach. Nine plans in four patients required adaptation, which led to a significant improvement of the target coverage and a slight reduction in the OAR dose in comparison to the cumulative dose without adaptation. CONCLUSIONS The use of robust MFO optimization is recommended for ensuring plan robustness and reduced doses in the ipsilateral parotid gland. Anatomical changes occurring during the treatment course might degrade the target coverage and increase the dose in the OARs, independent of the chosen planning approach. For some patients, a plan adaptation may be required.
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Affiliation(s)
- Macarena Cubillos-Mesías
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden – Rossendorf, Dresden, Germany
| | - Michael Baumann
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden – Rossendorf, Dresden, Germany
| | - Esther G. C. Troost
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden – Rossendorf, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology – OncoRay, Dresden, Germany
- National Center for Tumor Diseases (NCT), partner site Dresden, Dresden, Germany
| | - Fabian Lohaus
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden – Rossendorf, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Steffen Löck
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden – Rossendorf, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Christian Richter
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden – Rossendorf, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology – OncoRay, Dresden, Germany
| | - Kristin Stützer
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden – Rossendorf, Dresden, Germany
- Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology – OncoRay, Dresden, Germany
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14
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Recovery from sublethal damage and potentially lethal damage : Proton beam irradiation vs. X‑ray irradiation. Strahlenther Onkol 2017; 194:343-351. [PMID: 29038831 DOI: 10.1007/s00066-017-1223-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 09/26/2017] [Indexed: 01/06/2023]
Abstract
PURPOSE In order to clarify the biological response of tumor cells to proton beam irradiation, sublethal damage recovery (SLDR) and potentially lethal damage recovery (PLDR) induced after proton beam irradiation at the center of a 10 cm spread-out Bragg peak (SOBP) were compared with those seen after X‑ray irradiation. METHODS Cell survival was determined by a colony assay using EMT6 and human salivary gland tumor (HSG) cells. First, two doses of 4 Gy/GyE (Gray equivalents, GyE) were given at an interfraction interval of 0-6 h. Second, five fractions of 1.6 Gy/GyE were administered at interfraction intervals of 0-5 min. Third, a delayed-plating assay involving cells in plateau-phase cultures was conducted. The cells were plated in plastic dishes immediately or 2-24 h after being irradiated with 8 Gy/GyE of X‑rays or proton beams. Furthermore, we investigated the degree of protection from the effects of X‑rays or proton beams afforded by the radical scavenger dimethyl sulfoxide to estimate the contribution of the indirect effect of radiation. RESULTS In both the first and second experiments, SLDR was more suppressed after proton beam irradiation than after X‑ray irradiation. In the third experiment, there was no difference in PLDR between the proton beam and X‑ray irradiation conditions. The degree of protection tended to be higher after X‑ray irradiation than after proton beam irradiation. CONCLUSION Compared with that seen after X‑ray irradiation, SLDR might take place to a lesser extent after proton beam irradiation at the center of a 10 cm SOBP, while the extent of PLDR does not differ significantly between these two conditions.
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15
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Leeman JE, Romesser PB, Zhou Y, McBride S, Riaz N, Sherman E, Cohen MA, Cahlon O, Lee N. Proton therapy for head and neck cancer: expanding the therapeutic window. Lancet Oncol 2017; 18:e254-e265. [DOI: 10.1016/s1470-2045(17)30179-1] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 12/16/2016] [Accepted: 12/20/2016] [Indexed: 12/25/2022]
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16
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Lin YH, Hung SK, Chiou WY, Lee MS, Shen MD BJ, Chen LC, Liu DW, Tsai WT, Lin PH, Shih YT, Hsu FC, Tsai SJ, Chan MW, Lin HY. Significant symptoms alleviation and tumor volume reduction after combined simultaneously integrated inner-escalated boost and volumetric-modulated arc radiotherapy in a patient with unresectable bulky hepatocellular carcinoma: A care-compliant case report. Medicine (Baltimore) 2016; 95:e4717. [PMID: 27559982 PMCID: PMC5400349 DOI: 10.1097/md.0000000000004717] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Revised: 07/18/2016] [Accepted: 08/03/2016] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Clinically, elderly patients with unresectable bulky hepatocellular carcinoma (HCC) are difficult to manage, especially in those with co-infections of hepatitis B and C virus. Herein, we reported such a case treated with radiotherapy (RT) by using combined simultaneously integrated inner-escalated boost and volumetric-modulated arc radiotherapy (SIEB-VMAT). After RT, significant symptoms alleviation and durable tumor control were observed. CASE SUMMARY At presentation, an 85-year-old male patient complained abdominal distention/pain, poor appetite, and swelling over bilateral lower limbs for 1 month. On physical examination, a jaundice pattern was noted. Laboratory studies showed impaired liver and renal function. Abdominal computed tomography (CT) revealed a 12.5-cm bulky tumor over the caudate lobe of the liver. Biopsy was done, and hepatocellular carcinoma (HCC) was reported histopathologically. As a result, AJCC stage IIIA (cT3aN0M0) and BCLC stage C were classified. Surgery, radiofrequency ablation (RFA), trans-catheter arterial chemoembolization (TACE), and sorafenib were not recommended because of his old age, central bulky tumor, and a bleeding tendency. Thus, RT with SIEB-VMAT technique was given alternatively. RT was delivered in 26 fractions, with dose gradience as follows: 39 Gy on the outer Plan Target Volume (PTV), 52 Gy in the middle PTV, and 57.2 Gy in the inner PTV. Unexpectedly, cyproheptadine (a newly recognized potential anti-HCC agent) was retrospectively found to be prescribed for alleviating skin itching and allergic rhinitis since the last 2 weeks of the RT course (2 mg by mouth Q12h for 24 months).After RT, significant symptoms alleviation and tumor volume reduction were observed for 32 months till multiple bone metastases. Before and after RT, a large tumor volume reduction rate of 88.7% was observed (from 608.4 c.c. to 68.7 c.c.). No severe treatment toxicity was noted during and after RT. The patient died due to aspiration pneumonia with septic shock at 4 months after bone metastases identified. CONCLUSIONS SIEB-VMAT physically demonstrated double benefits of intratumor dose escalation and extra-tumor dose attenuation. Significant tumor regression and symptoms alleviation were observed in this elderly patient with unresectable bulky HCC. Further prospective randomized trials are encouraged to demarcate effective size of SIEB-VMAT with or without cyproheptadine.
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Affiliation(s)
- Young-Hsiang Lin
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
| | - Shih-Kai Hung
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
- School of Medicine, Tzu Chi University, Hualien
| | - Wen-Yen Chiou
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
- School of Medicine, Tzu Chi University, Hualien
| | - Moon-Sing Lee
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
- School of Medicine, Tzu Chi University, Hualien
| | - Bing-Jie Shen MD
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
- School of Medicine, Tzu Chi University, Hualien
| | - Liang-Cheng Chen
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
- School of Medicine, Tzu Chi University, Hualien
| | - Dai-Wei Liu
- Department of Radiation Oncology, Buddhist Tzu Chi General Hospital
- School of Medicine, Tzu Chi University, Hualien
| | - Wei-Ta Tsai
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming University, Taipei
- Department of Medical Imaging and Radiological Sciences, Central Taiwan University of Science and Technology, Taichung
| | - Po-Hao Lin
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
| | - Yi-Ting Shih
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
| | - Feng-Chun Hsu
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
| | - Shiang-Jiun Tsai
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
| | - Michael W.Y. Chan
- Institute of Molecular Biology, Department of Life Science
- Human Epigenomics Center
- National Chung Cheng University, Min-Hsiung, Chia-Yi, Taiwan, ROC
| | - Hon-Yi Lin
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
- School of Medicine, Tzu Chi University, Hualien
- Institute of Molecular Biology, Department of Life Science
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