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Khan AU, Radtke J, Hammer C, Malyshev J, Morris B, Glide‐Hurst C, DeWerd L, Culberson W, Bayliss A. Dose-rate dependence and IMRT QA suitability of EBT3 radiochromic films for pulse reduced dose-rate radiotherapy (PRDR) dosimetry. J Appl Clin Med Phys 2024; 25:e14229. [PMID: 38032123 PMCID: PMC10795427 DOI: 10.1002/acm2.14229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/09/2023] [Accepted: 11/18/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Pulsed reduced dose rate (PRDR) is an emerging radiotherapy technique for recurrent diseases. It is pertinent that the linac beam characteristics are evaluated for PRDR dose rates and a suitable dosimeter is employed for IMRT QA. PURPOSE This study sought to investigate the pulse characteristics of a 6 MV photon beam during PRDR irradiations on a commercial linac. The feasibility of using EBT3 radiochromic film for use in IMRT QA was also investigated by comparing its response to a commercial diode array phantom. METHODS A plastic scintillator detector was employed to measure the photon pulse characteristics across nominal repetition rates (NRRs) in the 5-600 MU/min range. Film was irradiated with dose rates in the 0.033-4 Gy/min range to study the dose rate dependence. Five clinical PRDR treatment plans were selected for IMRT QA with the Delta4 phantom and EBT3 film sheets. The planned and measured dose were compared using gamma analysis with a criterion of 3%/3 mm. EBT3 film QA was performed using a cumulative technique and a weighting factor technique. RESULTS Negligible differences were observed in the pulse width and height data between the investigated NRRs. The pulse width was measured to be 3.15 ± 0.01μ s $\mu s$ and the PRF was calculated to be 3-357 Hz for the 5-600 MU/min NRRs. The EBT3 film was found to be dose rate independent within 3%. The gamma pass rates (GPRs) were above 99% and 90% for the Delta4 phantom and the EBT3 film using the cumulative QA method, respectively. GPRs as low as 80% were noted for the weighting factor EBT3 QA method. CONCLUSIONS Altering the NRRs changes the mean dose rate while the instantaneous dose rate remains constant. The EBT3 film was found to be suitable for PRDR dosimetry and IMRT QA with minimal dose rate dependence.
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Affiliation(s)
- Ahtesham Ullah Khan
- Department of Medical Physics, School of Medicine and Public HealthUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Jeff Radtke
- Department of Medical Physics, School of Medicine and Public HealthUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Clifford Hammer
- Department of Medical Physics, School of Medicine and Public HealthUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Julia Malyshev
- Department of Medical Physics, School of Medicine and Public HealthUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Brett Morris
- Department of Human Oncology, School of Medicine and Public HealthUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Carri Glide‐Hurst
- Department of Medical Physics, School of Medicine and Public HealthUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
- Department of Human Oncology, School of Medicine and Public HealthUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Larry DeWerd
- Department of Medical Physics, School of Medicine and Public HealthUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Wesley Culberson
- Department of Medical Physics, School of Medicine and Public HealthUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Adam Bayliss
- Department of Human Oncology, School of Medicine and Public HealthUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
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Babu B, Stoltz SA, Mittal A, Pawar S, Kolanthai E, Coathup M, Seal S. Inorganic Nanoparticles as Radiosensitizers for Cancer Treatment. NANOMATERIALS (BASEL, SWITZERLAND) 2023; 13:2873. [PMID: 37947718 PMCID: PMC10647410 DOI: 10.3390/nano13212873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 10/25/2023] [Accepted: 10/27/2023] [Indexed: 11/12/2023]
Abstract
Nanotechnology has expanded what can be achieved in our approach to cancer treatment. The ability to produce and engineer functional nanoparticle formulations to elicit higher incidences of tumor cell radiolysis has resulted in substantial improvements in cancer cell eradication while also permitting multi-modal biomedical functionalities. These radiosensitive nanomaterials utilize material characteristics, such as radio-blocking/absorbing high-Z atomic number elements, to mediate localized effects from therapeutic irradiation. These materials thereby allow subsequent scattered or emitted radiation to produce direct (e.g., damage to genetic materials) or indirect (e.g., protein oxidation, reactive oxygen species formation) damage to tumor cells. Using nanomaterials that activate under certain physiologic conditions, such as the tumor microenvironment, can selectively target tumor cells. These characteristics, combined with biological interactions that can target the tumor environment, allow for localized radio-sensitization while mitigating damage to healthy cells. This review explores the various nanomaterial formulations utilized in cancer radiosensitivity research. Emphasis on inorganic nanomaterials showcases the specific material characteristics that enable higher incidences of radiation while ensuring localized cancer targeting based on tumor microenvironment activation. The aim of this review is to guide future research in cancer radiosensitization using nanomaterial formulations and to detail common approaches to its treatment, as well as their relations to commonly implemented radiotherapy techniques.
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Affiliation(s)
- Balaashwin Babu
- Advanced Materials Processing and Analysis Center, Department of Materials Science and Engineering, University of Central Florida, Orlando, FL 32826, USA; (B.B.); (S.A.S.); (A.M.); (S.P.); (E.K.)
| | - Samantha Archer Stoltz
- Advanced Materials Processing and Analysis Center, Department of Materials Science and Engineering, University of Central Florida, Orlando, FL 32826, USA; (B.B.); (S.A.S.); (A.M.); (S.P.); (E.K.)
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, FL 32827, USA
| | - Agastya Mittal
- Advanced Materials Processing and Analysis Center, Department of Materials Science and Engineering, University of Central Florida, Orlando, FL 32826, USA; (B.B.); (S.A.S.); (A.M.); (S.P.); (E.K.)
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, FL 32827, USA
| | - Shreya Pawar
- Advanced Materials Processing and Analysis Center, Department of Materials Science and Engineering, University of Central Florida, Orlando, FL 32826, USA; (B.B.); (S.A.S.); (A.M.); (S.P.); (E.K.)
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, FL 32827, USA
| | - Elayaraja Kolanthai
- Advanced Materials Processing and Analysis Center, Department of Materials Science and Engineering, University of Central Florida, Orlando, FL 32826, USA; (B.B.); (S.A.S.); (A.M.); (S.P.); (E.K.)
| | - Melanie Coathup
- Biionix Cluster, University of Central Florida, Orlando, FL 32827, USA;
- College of Medicine, University of Central Florida, Orlando, FL 32827, USA
| | - Sudipta Seal
- Advanced Materials Processing and Analysis Center, Department of Materials Science and Engineering, University of Central Florida, Orlando, FL 32826, USA; (B.B.); (S.A.S.); (A.M.); (S.P.); (E.K.)
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, FL 32827, USA
- College of Medicine, University of Central Florida, Orlando, FL 32827, USA
- Nanoscience Technology Center, University of Central Florida, Orlando, FL, USA
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Amidon RF, Santos-Pinheiro F, Straza M, Prah MA, Mueller WM, Krucoff MO, Connelly JM, Kleefisch CJ, Coss DJ, Cochran EJ, Bovi JA, Schultz CJ, Schmainda KM. Case report: Fractional brain tumor burden magnetic resonance mapping to assess response to pulsed low-dose-rate radiotherapy in newly-diagnosed glioblastoma. Front Oncol 2022; 12:1066191. [PMID: 36561526 PMCID: PMC9763264 DOI: 10.3389/fonc.2022.1066191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 11/21/2022] [Indexed: 12/12/2022] Open
Abstract
Background Pulsed low-dose-rate radiotherapy (pLDR) is a commonly used reirradiation technique for recurrent glioma, but its upfront use with temozolomide (TMZ) following primary resection of glioblastoma is currently under investigation. Because standard magnetic resonance imaging (MRI) has limitations in differentiating treatment effect from tumor progression in such applications, perfusion-weighted MRI (PWI) can be used to create fractional tumor burden (FTB) maps to spatially distinguish active tumor from treatment-related effect. Methods We performed PWI prior to re-resection in four patients with glioblastoma who had undergone upfront pLDR concurrent with TMZ who had radiographic suspicion for tumor progression at a median of 3 months (0-5 months or 0-143 days) post-pLDR. The pathologic diagnosis was compared to retrospectively-generated FTB maps. Results The median patient age was 55.5 years (50-60 years). All were male with IDH-wild type (n=4) and O6-methylguanine-DNA methyltransferase (MGMT) hypermethylated (n=1) molecular markers. Pathologic diagnosis revealed treatment effect (n=2), a mixture of viable tumor and treatment effect (n=1), or viable tumor (n=1). In 3 of 4 cases, FTB maps were indicative of lesion volumes being comprised predominantly of treatment effect with enhancing tumor volumes comprised of a median of 6.8% vascular tumor (6.4-16.4%). Conclusion This case series provides insight into the radiographic response to upfront pLDR and TMZ and the role for FTB mapping to distinguish tumor progression from treatment effect prior to redo-surgery and within 20 weeks post-radiation.
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Affiliation(s)
- Ryan F. Amidon
- School of Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | | | - Michael Straza
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Melissa A. Prah
- Department of Biophysics, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Wade M. Mueller
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Max O. Krucoff
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
- Department of Biomedical Engineering, Marquette University and Medical College of Wisconsin, Milwaukee, WI, United States
| | - Jennifer M. Connelly
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, United States
| | | | - Dylan J. Coss
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Elizabeth J. Cochran
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Joseph A. Bovi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Christopher J. Schultz
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Kathleen M. Schmainda
- Department of Biophysics, Medical College of Wisconsin, Milwaukee, WI, United States
- Department of Radiology, Medical College of Wisconsin, Milwaukee, WI, United States
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Pulsed-Reduced Dose Rate (PRDR) Radiotherapy for Recurrent Primary Central Nervous System Malignancies: Dosimetric and Clinical Results. Cancers (Basel) 2022; 14:cancers14122946. [PMID: 35740612 PMCID: PMC9221236 DOI: 10.3390/cancers14122946] [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: 05/27/2022] [Revised: 06/07/2022] [Accepted: 06/14/2022] [Indexed: 02/05/2023] Open
Abstract
PURPOSE The objective was to describe PRDR outcomes and report EQD2 OAR toxicity thresholds. METHODS Eighteen patients with recurrent primary CNS tumors treated with PRDR at a single institution between April 2017 and September 2021 were evaluated. The radiotherapy details, cumulative OAR doses, progression-free survival (PFS), overall survival (OS), and toxicities were collected. RESULTS The median PRDR dose was 45 Gy (range: 36-59.4 Gy); the median cumulative EQD2 prescription dose was 102.7 Gy (range: 93.8-120.4 Gy). The median cumulative EQD2 D0.03cc for the brain was 111.4 Gy (range: 82.4-175.2 Gy). Symptomatic radiation necrosis occurred in three patients, for which the median EQD2 brain D0.03cc was 115.9 Gy (110.4-156.7 Gy). The median PFS and OS after PRDR were 6.3 months (95%CI: 0.9-11.6 months) and 8.6 months (95%CI: 4.9-12.3 months), respectively. The systematic review identified five peer-reviewed studies with a median cumulative EQD2 prescription dose of 110.3 Gy. At a median follow-up of 8.7 months, the median PFS and OS were 5.7 months (95%CI: 2.1-15.4 months) and 6.7 months (95%CI: 3.2-14.2 months), respectively. CONCLUSION PRDR re-irradiation is a relatively safe and feasible treatment for recurrent primary CNS tumors. Despite high cumulative dose to OARs, the risk of high-grade, treatment-related toxicity within the first year of follow-up remains acceptable.
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Frosina G. Improving control of high‐grade glioma by ultra‐hyper‐fractionated radiotherapy. J Neurosci Res 2022; 100:933-946. [DOI: 10.1002/jnr.25030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/05/2021] [Accepted: 12/13/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Guido Frosina
- Mutagenesis & Cancer Prevention Unit IRCCS Ospedale Policlinico San Martino Genova Italy
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6
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Ma CMC. Pulsed low dose-rate radiotherapy: radiobiology and dosimetry. Phys Med Biol 2022; 67. [DOI: 10.1088/1361-6560/ac4c2f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 01/17/2022] [Indexed: 11/12/2022]
Abstract
Abstract
Pulsed low dose-rate radiotherapy (PLDR) relies on two radiobiological findings, the hyper-radiosensitivity of tumor cells at small doses and the reduced normal tissue toxicity at low dose rates. This is achieved by delivering the daily radiation dose of 2 Gy in 10 sub-fractions (pulses) with a 3 min time interval, resulting in an effective low dose rate of 0.067 Gy min−1. In vitro cell studies and in vivo animal experiments demonstrated the therapeutic potential of PLDR treatments and provided useful preclinical data. Various treatment optimization strategies and delivery techniques have been developed for PLDR on existing linear accelerators. Preliminary results from early clinical studies have shown favorable outcomes for various treatment sites especially for recurrent cancers. This paper reviews the experimental findings of PLDR and dosimetric requirements for PLDR treatment planning and delivery, and summarizes major clinical studies on PLDR cancer treatments.
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Prabhu AV, Lee M, Galhardo E, Newkirk M, Rodriguez A, Xia F. Pulsed reduced dose-rate radiotherapy for previously irradiated tumors in the brain and spine. Surg Neurol Int 2021; 12:280. [PMID: 34221611 PMCID: PMC8247706 DOI: 10.25259/sni_589_2020] [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: 08/29/2020] [Accepted: 04/27/2021] [Indexed: 11/21/2022] Open
Abstract
Background: Patients with unresectable locoregional cancer recurrences have limited management options. Reirradiation increases the risk of toxicity, particularly when perilesional dose-volume constraints are exceeded. We present and discuss two cases of previously irradiated tumors in the central nervous system (CNS) that was reirradiated using the pulsed reduced dose-rate radiotherapy (PRDR) technique. Case Description: A 58-year-old female with a history of metastatic small cell lung cancer to the brain status post multiple rounds of radiation and chemotherapy presented with increasing weakness in her right arm and leg. Magnetic resonance imaging (MRI) revealed a growly peripherally enhancing 1.2 cm mass in the left precentral gyrus that had previously received prophylactic cranial irradiation and stereotactic radiosurgery. The patient was re-irradiated with 35 Gy in 100 fractions over 3 weeks, using PRDR with improved motor function at 3-month follow-up. A 41-year-old male with recurrent glioblastoma of the thoracic spinal cord presented with worsening neurological symptoms, including inability to ambulate due to bilateral leg weakness, causing wheelchair use. MRI thoracic spine revealed a recurrent thoracic lesion 2.2 × 1 × 0.8 cm. In addition to chronic chemotherapy, the patient was retreated palliatively in the same area at 50 Gy in 250 fractions, over 6 weeks, using PRDR. The treated lesion was stable on follow-up imaging, and the patient was able to walk with the assistance of a walker. Conclusion: In our two cases, PRDR proved effective in the treatment of recurrent malignant CNS tumors that were previously irradiated. Prospective studies are needed to delineate the efficacy and toxicity of PRDR.
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Affiliation(s)
- Arpan V Prabhu
- Department of Radiation Oncology University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Madison Lee
- Department of Neurological Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Edvaldo Galhardo
- Department of Radiation Oncology University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Madison Newkirk
- Department of Radiation Oncology University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Analiz Rodriguez
- Department of Neurological Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Fen Xia
- Department of Radiation Oncology University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
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Abstract
The standard of care treatment for glioblastoma is surgical resection followed by radiotherapy to 60 Gy with concurrent and adjuvant temozolomide with or without tumor-treating fields. Advanced imaging techniques are under evaluation to better guide radiotherapy target volume delineation and allow for dose escalation. Particle therapy, in the form of protons, carbon ions, and boron neutron capture therapy, are being assessed as strategies to improve the radiotherapeutic ratio. Stereotactic, hypofractionated, pulsed-reduced dose-rate, and particle radiotherapy are re-irradiation techniques each uniquely suited for different clinical scenarios. Novel radiotherapy approaches, such as FLASH, represent promising advancements in radiotherapy for glioblastoma.
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Affiliation(s)
- Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA.
| | - Martin C Tom
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
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Mathen P, Smart DK. Reimagining external beam radiotherapy for glioblastoma: "old beam, new trick". Neuro Oncol 2021; 23:345-346. [PMID: 33618364 PMCID: PMC7992895 DOI: 10.1093/neuonc/noab008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Peter Mathen
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - DeeDee K Smart
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
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Kotecha R, Dea N, Detsky JS, Sahgal A. Management of recurrent or progressive spinal metastases: reirradiation techniques and surgical principles. Neurooncol Pract 2020; 7:i45-i53. [PMID: 33299573 PMCID: PMC7705530 DOI: 10.1093/nop/npaa045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
With the growing incidence of new cases and the increasing prevalence of patients living longer with spine metastasis, a methodological approach to the management of patients with recurrent or progressive disease is increasing in relevance and importance in clinical practice. As a result, disease management has evolved in these patients using advanced surgical and radiotherapy technologies. Five key goals in the management of patients with spine metastases include providing pain relief, controlling metastatic disease at the treated site, improving neurologic deficits, maintaining or improving functional status, and minimizing further mechanical instability. The focus of this review is on advanced reirradiation techniques, given that the majority of patients will be treated with upfront conventional radiotherapy and further treatment on progression is often limited by the cumulative tolerance of nearby organs at risk. This review will also discuss novel surgical approaches such as separation surgery, minimally invasive percutaneous instrumentation, and laser interstitial thermal therapy, which is increasingly being coupled with spine reirradiation to maximize outcomes in this patient population. Lastly, given the complexities of managing recurrent spinal disease, this review emphasizes the importance of multidisciplinary care from neurosurgery, radiation oncology, medical oncology, neuro-oncology, rehabilitation medicine, and palliative care.
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Affiliation(s)
- Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, US
| | - Nicolas Dea
- Combined Neurosurgical and Orthopaedic Spine Program, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Jay S Detsky
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
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Bovi JA, Prah MA, Retzlaff AA, Schmainda KM, Connelly JM, Rand SD, Marszalkowski CS, Mueller WM, Siker ML, Schultz CJ. Pulsed Reduced Dose Rate Radiotherapy in Conjunction With Bevacizumab or Bevacizumab Alone in Recurrent High-grade Glioma: Survival Outcomes. Int J Radiat Oncol Biol Phys 2020; 108:979-986. [PMID: 32599030 PMCID: PMC8655709 DOI: 10.1016/j.ijrobp.2020.06.020] [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: 07/19/2019] [Revised: 04/07/2020] [Accepted: 06/08/2020] [Indexed: 11/26/2022]
Abstract
Purpose: Dismal prognosis and limited treatment options for recurrent high-grade glioma have provoked interest in various forms of reirradiation. Pulsed reduced dose rate radiation therapy (pRDR) is a promising technique that exploits low-dose hyper-radiosensitivity of proliferating tumor cells while sparing adjacent nonproliferating normal brain tissue. Large radiation treatment volumes can thus be used to target both contrast-enhancing and FLAIR abnormalities thought to harbor recurrent gross and microscopic disease, respectively. The aim of this retrospective study was to determine whether the addition of pRDR to bevacizumab improves survival over bevacizumab alone for recurrent high-grade glioma. Methods and Materials: Eighty patients with recurrent high-grade glioma were included in this study; 47 patients received bevacizumab monotherapy (BEV), and 33 patients received pRDR with bevacizumab (BEV/pRDR). Progression-free survival (PFS) and overall survival were compared between the BEV and BEV/pRDR groups. Regression analysis was performed to identify and control for confounding influences on survival analyses. Results: Significant (P <.05) advantages in PFS (12 vs 4 months; hazard ratio = 2.37) and OS (16 vs. 9 months; hazard ratio = 1.68) were observed with BEV/pRDR compared with BEV alone. Conclusions: This retrospective analysis suggests that treatment with pRDR in addition to bevacizumab could significantly prolong PFS and overall survival compared with bevacizumab alone for recurrent high-grade glioma.
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Affiliation(s)
- Joseph A Bovi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Melissa A Prah
- Department of Biophysics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Amber A Retzlaff
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kathleen M Schmainda
- Department of Biophysics, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Scott D Rand
- Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Wade M Mueller
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Malika L Siker
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Christopher J Schultz
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Large volume re-irradiation for recurrent meningioma with pulsed reduced dose rate radiotherapy. J Neurooncol 2018; 141:103-109. [PMID: 30392090 DOI: 10.1007/s11060-018-03011-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 09/17/2018] [Indexed: 01/24/2023]
Abstract
PURPOSE Meningiomas comprise up to 30% of primary brain tumors. The majority of meningioma patients enjoy high rates of control after conventional therapies. However, patients with recurrent disease previously treated with radiotherapy have few options for salvage treatment, and systemic interventions have proven largely ineffective. The aim of this study was to determine whether pulsed reduced dose rate radiotherapy (PRDR) was well tolerated in a small cohort of patients with recurrent meningioma. METHODS We retrospectively identified eight patients with recurrent intracranial meningioma treated with PRDR from April 2013 to August of 2017 at a single institution. All patients had radiographic and/or pathologic evidence of progression prior to treatment and had previously completed conventional radiotherapy. Acute and late toxicities were graded based on CTCAE 4.0. RESULTS Of eight patients, six had histologically confirmed atypical meningiomas upon recurrence. All patients were re-treated with IMRT at an apparent dose rate of 0.0667 Gy/min. Median time between radiation courses was 7.7 years. Median PRDR dose was 54 Gy in 27 fractions to a median volume of 261.6 cm3. Two patients (25%) had in field failure with a median follow up of 23.3 months. PFS at 6 months was 100%. All but one (87.5%) patient was still alive at last follow up. No patient experienced grade ≥ 2 acute or late toxicities. CONCLUSIONS PRDR re-irradiation was well tolerated and appeared effective for a small cohort of patients with recurrent meningioma previously treated with radiotherapy. A phase II trial to assess this prospectively is in development.
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Hou Z, Yang Y, Li S, Yan J, Ren W, Liu J, Wang K, Liu B, Wan S. Radiomic analysis using contrast-enhanced CT: predict treatment response to pulsed low dose rate radiotherapy in gastric carcinoma with abdominal cavity metastasis. Quant Imaging Med Surg 2018; 8:410-420. [PMID: 29928606 DOI: 10.21037/qims.2018.05.01] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background To determine the feasibility of radiomic analysis for predicting the therapeutic response of gastric carcinoma (GC) with abdominal cavity metastasis (GCACM) to pulsed low dose rate radiotherapy (PLDRT) using contrast-enhanced computed tomography (CECT) images. Methods Pretreatment CECT images of 43 GCACM patients were analyzed. Patients with complete response (CR) and partial response (PR) were considered responders, while stable disease (SD) and progressive disease (PD) as non-responders. A total of 1,117 image features were quantified from tumor region that segmented from arterial phase CT images. Intra-class correlation coefficient (ICC) and absolute correlation coefficient (ACC) were calculated for selecting influential feature subset. The capability of each influential feature on treatment response classification was assessed using Kruskal-Wallis test and receiver operating characteristic (ROC) analysis. Moreover, artificial neural network (ANN) and k-nearest neighbor (KNN) predictive models were constructed based on the training set (18 responders, 14 non-responders) and the testing set (6 responders, 5 non-responders) validated the reliability of the models. Comparison between the performances of the models was performed by using McNemar's test. Results The analyses showed that 6 features (1 first order-based, 1 texture-based, 1 LoG-based, and 3 wavelet-based) were significantly different between responders and non-responders (AUCs range from 0.686 to 0.728). Both two prediction models based on features extracted from CECT showed potential in predicting the treatment response with higher accuracies (ANN: 0.714, KNN: 0.749 for the training set; ANN: 0.816, KNN: 0.816 for the testing set). No statistical difference was observed between the performance of ANN and KNN (P=0.999). Conclusions Pretreatment radiomic analysis using CECT can potentially provide important information regarding the therapeutic response to PLDRT for GCACM, improving risk stratification.
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Affiliation(s)
- Zhen Hou
- State Key Laboratory of Bioelectronics, Laboratory for Medical Electronics, School of Biological Sciences and Medical Engineering, Southeast University, Nanjing 210096, China
| | - Yang Yang
- The Comprehensive Cancer Centre of Drum Tower Hospital, Medical School of Nanjing University & Clinical Cancer Institute of Nanjing University, Nanjing 210000, China
| | - Shuangshuang Li
- The Comprehensive Cancer Centre of Drum Tower Hospital, Medical School of Nanjing University & Clinical Cancer Institute of Nanjing University, Nanjing 210000, China
| | - Jing Yan
- The Comprehensive Cancer Centre of Drum Tower Hospital, Medical School of Nanjing University & Clinical Cancer Institute of Nanjing University, Nanjing 210000, China
| | - Wei Ren
- The Comprehensive Cancer Centre of Drum Tower Hospital, Medical School of Nanjing University & Clinical Cancer Institute of Nanjing University, Nanjing 210000, China
| | - Juan Liu
- The Comprehensive Cancer Centre of Drum Tower Hospital, Medical School of Nanjing University & Clinical Cancer Institute of Nanjing University, Nanjing 210000, China
| | - Kangxin Wang
- The Comprehensive Cancer Centre of Drum Tower Hospital, Medical School of Nanjing University & Clinical Cancer Institute of Nanjing University, Nanjing 210000, China
| | - Baorui Liu
- The Comprehensive Cancer Centre of Drum Tower Hospital, Medical School of Nanjing University & Clinical Cancer Institute of Nanjing University, Nanjing 210000, China
| | - Suiren Wan
- State Key Laboratory of Bioelectronics, Laboratory for Medical Electronics, School of Biological Sciences and Medical Engineering, Southeast University, Nanjing 210096, China
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Olobatuyi O, de Vries G, Hillen T. Effects of G2-checkpoint dynamics on low-dose hyper-radiosensitivity. J Math Biol 2018; 77:1969-1997. [PMID: 29679122 DOI: 10.1007/s00285-018-1236-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 02/17/2018] [Indexed: 02/03/2023]
Abstract
In experimental studies, it has been found that certain cell lines are more sensitive to low-dose radiation than would be expected from the classical Linear-Quadratic model (LQ model). In fact, it is frequently observed that cells incur more damage at low dose (say 0.3 Gy) than at higher dose (say 1 Gy). This effect has been termed hyper-radiosensitivity (HRS). The effect depends on the type of cells and on their phase in the cell cycle when radiation is applied. Experiments have shown that the G2-checkpoint plays an important role in the HRS effects. Here we design and analyze a differential equation model for the cell cycle that includes G2-checkpoint dynamics and radiation treatment. We fit the model to surviving fraction data for different cell lines including glioma cells, prostate cancer cells, as well as to cell populations that are enriched in certain phases of the cell cycle. The HRS effect is measured in the literature through [Formula: see text], the ratio of slope [Formula: see text] of the surviving fraction curve at zero dose to slope [Formula: see text] of the corresponding LQ model. We derive an explicit formula for this ratio and we show that it corresponds very closely to experimental observations. Finally, we identify the dependence of this ratio on the surviving fraction at 2 Gy. It was speculated in the literature that such dependence exists. Our theoretical analysis will help to more systematically identify the HRS in cell lines, and opens doors to analyze its use in cancer treatment.
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Affiliation(s)
- Oluwole Olobatuyi
- Collaborative Mathematical Biology Group (formerly Center for Mathematical Biology), Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, AB, T6G 2G1, Canada.
| | - Gerda de Vries
- Collaborative Mathematical Biology Group (formerly Center for Mathematical Biology), Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, AB, T6G 2G1, Canada
| | - Thomas Hillen
- Collaborative Mathematical Biology Group (formerly Center for Mathematical Biology), Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, AB, T6G 2G1, Canada
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15
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Yan J, Yang J, Yang Y, Ren W, Liu J, Gao S, Li S, Kong W, Zhu L, Yang M, Qian X, Liu B. Use of Pulsed Low-Dose Rate Radiotherapy in Refractory Malignancies. Transl Oncol 2018; 11:175-181. [PMID: 29306203 PMCID: PMC5756059 DOI: 10.1016/j.tranon.2017.12.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 12/07/2017] [Accepted: 12/07/2017] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Most tumor cell lines exhibited low-dose hyperradiosensitivity (LDHRS) to radiation doses lower than 0.3 Gy. Pulsed low-dose rate radiotherapy (PLDR) took advantage of LDHRS and maximized the tumor control process. In this study, we retrospectively analyzed patients receiving PLDR for refractory malignancies. PATIENTS AND METHODS In total, 22 patients were included in our study: 9 females and 13 males. The median age was 61 years old. All the patients previously received multiline treatments and failed with an estimated survival less than 6 months. Thus, palliative PLDR was given. The PLDR was delivered using 10 fractions of 2 Gy/day, with an interval of 3 minutes, for 5 days per week. The dose rate was 6.67 cGy/min. The median follow-up was 1 year (range 8-30 months). Nine patients underwent PLDR for reirradiation due to locally recurrent diseases. The time interval from last irradiation was 11 to 168 months. Ten patients received PLDR due to poor performance status. Three patients were given PLDR for bulky tumor. The irradiated sites included primary disease (seven patients), locally recurrent disease (nine patients), and retroperitoneal adenopathy (six patients). RESULTS Five patients developed grade 3 or 4 toxicities. No grade 5 toxicities occurred. All the toxicities recovered after treatments. In general, the 1-year local-regional control rate was approximately 40%, and almost all the patients developed progression at the second year after PLDR. The 6-month survival rate was 76%, and the 1-year survival rate was 69%. For the three patients given PLDR for bulky tumor, all of them achieved partial remission 1 month after the PLDR, and one patient achieved complete response at the fourth month. CONCLUSION PLDR is an effective and safe option not only for reirradiation but also for patients with poor performance status or bulky tumors. A prospective clinical trial (NCT03061162) is ongoing to validate our results.
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Affiliation(s)
- Jing Yan
- The Comprehensive Cancer Centre of Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Ju Yang
- The Comprehensive Cancer Centre of Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Yang Yang
- The Comprehensive Cancer Centre of Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Wei Ren
- The Comprehensive Cancer Centre of Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Juan Liu
- The Comprehensive Cancer Centre of Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Shanbao Gao
- The Comprehensive Cancer Centre of Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Shuangshuang Li
- The Comprehensive Cancer Centre of Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Weiwei Kong
- The Comprehensive Cancer Centre of Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Lijing Zhu
- The Comprehensive Cancer Centre of Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Mi Yang
- The Comprehensive Cancer Centre of Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Xiaoping Qian
- The Comprehensive Cancer Centre of Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Baorui Liu
- The Comprehensive Cancer Centre of Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China.
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Affiliation(s)
- Steven J Chmura
- a University of Chicago Department of Radiation and Cellular Oncology Ludwig Center for Metastases , Chicago , IL , USA
| | - Ralph R Weichselbaum
- a University of Chicago Department of Radiation and Cellular Oncology Ludwig Center for Metastases , Chicago , IL , USA
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17
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Murphy ES, Rogacki K, Godley A, Qi P, Reddy CA, Ahluwalia MS, Peereboom DM, Stevens GH, Yu JS, Kotecha R, Suh JH, Chao ST. Intensity modulated radiation therapy with pulsed reduced dose rate as a reirradiation strategy for recurrent central nervous system tumors: An institutional series and literature review. Pract Radiat Oncol 2017; 7:e391-e399. [PMID: 28666902 DOI: 10.1016/j.prro.2017.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 03/27/2017] [Accepted: 04/10/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Pulsed reduced dose rate (PRDR) is a reirradiation technique that potentially overcomes volume and dose limitations in the setting of previous radiation therapy for recurrent central nervous system (CNS) tumors. Intensity modulated radiation therapy (IMRT) has not yet been reported as a PRDR delivery technique. We reviewed our IMRT PRDR outcomes and toxicity and reviewed the literature of available PRDR series for CNS reirradiation. METHODS AND MATERIALS A total of 24 patients with recurrent brain tumors received PRDR reirradiation between August 2012 and December 2014. Twenty-two patients were planned with IMRT. Linear accelerators delivered an effective dose rate of 0.0667 Gy/minute. Data collected included number of prior interventions, diagnosis, tumor grade, radiation therapy dose and fractionation, normal tissue dose, radiation therapy planning parameters, time to progression, overall survival, and adverse events. RESULTS The median time to PRDR from completion of initial radiation therapy was 47.8 months (range, 11-389.1 months). The median PRDR dose was 54 Gy (range, 38-60 Gy). The mean planning target volume was 369.1 ± 177.9 cm3. The median progression-free survival and 6-month progression-free survival after PRDR treatment was 3.1 months and 31%, respectively. The median overall survival and 6-month overall survival after PRDR treatment was 8.7 months and 71%, respectively. Fifty percent of patients had ≥4 chemotherapy regimens before PRDR. Toxicity was similar to initial treatment, including no cases of radiation necrosis. CONCLUSION IMRT PRDR reirradiation is a feasible and appropriate treatment strategy for large volume recurrent CNS tumors resulting in acceptable overall survival with reasonable toxicity in our patients who were heavily pretreated. Prospective studies are necessary to determine the optimal timing of PRDR reirradiation, the role of concurrent systemic agents, and the ideal patient population who would receive the maximal benefit from this treatment approach. SUMMARY Intensity modulated radiation therapy (IMRT) has not yet been reported as a pulsed reduced dose rate (PRDR) delivery technique for recurrent brain tumors and may allow for safe and comprehensive reirradiation for large volume tumors. We reviewed our IMRT PRDR outcomes and toxicity and reviewed the literature of available PRDR series for recurrent central nervous system tumors. We conclude that IMRT PRDR reirradiation is a feasible and appropriate treatment strategy for large volume recurrent brain tumors resulting in acceptable overall survival with reasonable toxicity in our patients who were heavily pretreated.
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Affiliation(s)
- Erin S Murphy
- Department of Radiation Oncology, Cleveland Clinic Radiation Oncology, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland, Ohio.
| | | | - Andrew Godley
- Department of Radiation Oncology, Cleveland Clinic Radiation Oncology, Cleveland, Ohio
| | - Peng Qi
- Department of Radiation Oncology, Cleveland Clinic Radiation Oncology, Cleveland, Ohio
| | - Chandana A Reddy
- Department of Radiation Oncology, Cleveland Clinic Radiation Oncology, Cleveland, Ohio
| | | | - David M Peereboom
- Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland, Ohio
| | - Glen H Stevens
- Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland, Ohio
| | - Jennifer S Yu
- Department of Radiation Oncology, Cleveland Clinic Radiation Oncology, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland, Ohio
| | - Rupesh Kotecha
- Department of Radiation Oncology, Cleveland Clinic Radiation Oncology, Cleveland, Ohio
| | - John H Suh
- Department of Radiation Oncology, Cleveland Clinic Radiation Oncology, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland, Ohio
| | - Samuel T Chao
- Department of Radiation Oncology, Cleveland Clinic Radiation Oncology, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland, Ohio
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Dong Y, Fu C, Guan H, Zhang T, Zhang Z, Zhou T, Li B. Re-irradiation alternatives for recurrent high-grade glioma. Oncol Lett 2016; 12:2261-2270. [PMID: 27703519 PMCID: PMC5038913 DOI: 10.3892/ol.2016.4926] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 03/01/2016] [Indexed: 12/28/2022] Open
Abstract
Despite advances in the fields of surgery, chemotherapy and radiotherapy, the prognosis for high-grade glioma (HGG) remains unsatisfactory. The majority of HGG patients experience disease recurrence. To date, no standard treatments have been established for recurrent HGG. Repeat surgery and chemotherapy demonstrate moderate efficacy. As recurrent lesions are usually located within the previously irradiated field, a second course of irradiation was once considered controversial, as it was considered to exhibit unsatisfactory efficacy and radiation-related toxicities. However, an increasing number of studies have indicated that re-irradiation may present an efficacious treatment for recurrent HGG. Re-irradiation may be delivered via conventionally fractionated stereotactic radiotherapy, hypofractionated stereotactic radiation therapy, stereotactic radiosurgery and brachytherapy techniques. In the present review, the current literature regarding re-irradiation treatment for recurrent HGG is summarized with regard to survival outcome and side effects.
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Affiliation(s)
- Yuanli Dong
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China; School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences, Jinan, Shandong 250014, P.R. China
| | - Chengrui Fu
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| | - Hui Guan
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China; School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences, Jinan, Shandong 250014, P.R. China
| | - Tianyi Zhang
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| | - Zicheng Zhang
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| | - Tao Zhou
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| | - Baosheng Li
- Sixth Department of Radiation Oncology, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
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Zhang P, Wang B, Chen X, Cvetkovic D, Chen L, Lang J, Ma CM. Local Tumor Control and Normal Tissue Toxicity of Pulsed Low-Dose Rate Radiotherapy for Recurrent Lung Cancer: An In Vivo Animal Study. Dose Response 2015; 13:1559325815588507. [PMID: 26675811 PMCID: PMC4674173 DOI: 10.1177/1559325815588507] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES This study investigates (1) local tumor control and (2) normal tissue toxicity of pulsed low-dose rate radiotherapy (PLDR) for recurrent lung cancer. METHODS For study 1, nude mice were implanted with A549 tumors and divided into the following 3 groups: (1) control (n = 10), (2) conventional radiotherapy (RT; n = 10), and (3) PLDR (n = 10). Tumor-bearing mice received 2 Gy daily dose for 2 consecutive days. Weekly magnetic resonance imaging was used for tumor growth monitoring. For study 2, 20 mice received 8 Gy total body irradiation either continuously (n = 10) or 40 × 0.2 Gy pulses with 3-minute intervals (n = 10). RESULTS For study 1, both conventional RT and PLDR significantly inhibited the growth of A549 xenografts compared with the control group (>35% difference in the mean tumor volume; P < .05). The PLDR results were slightly better than conventional RT (8% difference in the mean tumor volume; P > .05). For study 2, the average weight was 20.94 ± 1.68 g and 25.69 ± 1.27 g and the survival time was 8 days and 12 days for mice treated with conventional RT and PLDR (P < .05), respectively. CONCLUSION This study showed that PLDR could control A549 tumors as effectively as conventional RT, and PLDR induced much less normal tissue toxicity than conventional RT. Thus, PLDR would be a good modality for recurrent lung cancers. ADVANCES IN KNOWLEDGE This article reports our results of an in vivo animal investigation of PLDR for the treatment of recurrent cancers, which may not be eligible for treatment because of the dose limitations on nearby healthy organs that have been irradiated in previous treatments. This was the first in vivo study to quantify the tumor control and normal tissue toxicities of PLDR using mice with implanted tumors, and our findings provided evidence to support the clinical trials that employ PLDR treatment techniques.
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Affiliation(s)
- Peng Zhang
- Department of Radiation Oncology, Sichuan Cancer Hospital, Chengdu, Sichuan, P. R. China
| | - Bin Wang
- Radiation Oncology Department, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Xiaoming Chen
- Radiation Oncology Department, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Dusica Cvetkovic
- Radiation Oncology Department, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Lili Chen
- Radiation Oncology Department, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Jinyi Lang
- Department of Radiation Oncology, Sichuan Cancer Hospital, Chengdu, Sichuan, P. R. China
| | - C-M Ma
- Radiation Oncology Department, Fox Chase Cancer Center, Philadelphia, PA, USA
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20
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Intensity-modulated radiation therapy for pancreatic and prostate cancer using pulsed low-dose rate delivery techniques. Med Dosim 2014; 39:330-6. [PMID: 25087084 DOI: 10.1016/j.meddos.2014.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 03/21/2014] [Accepted: 05/12/2014] [Indexed: 11/22/2022]
Abstract
Reirradiation of patients who were previously treated with radiotherapy is vastly challenging. Pulsed low-dose rate (PLDR) external beam radiotherapy has the potential to reduce normal tissue toxicities while providing significant tumor control for recurrent cancers. This work investigates treatment planning techniques for intensity-modulated radiation therapy (IMRT)-based PLDR treatment of various sites, including cases with pancreatic and prostate cancer. A total of 20 patients with clinical recurrence were selected for this study, including 10 cases with pancreatic cancer and 10 with prostate cancer. Large variations in the target volume were included to test the ability of IMRT using the existing treatment planning system and optimization algorithm to deliver uniform doses in individual gantry angles/fields for PLDR treatments. Treatment plans were generated with 10 gantry angles using the step-and-shoot IMRT delivery technique, which can be delivered in 3-minute intervals to achieve an effective low dose rate of 6.7cGy/min. Instead of dose constraints on critical structures, ring structures were mainly used in PLDR-IMRT optimization. In this study, the PLDR-IMRT plans were compared with the PLDR-3-dimensional conformal radiation therapy (3DCRT) plans and the PLDR-RapidArc plans. For the 10 cases with pancreatic cancer that were investigated, the mean planning target volume (PTV) dose for each gantry angle in the PLDR-IMRT plans ranged from 17.6 to 22.4cGy. The maximum doses ranged between 22.9 and 34.8cGy. The minimum doses ranged from 8.2 to 17.5cGy. For the 10 cases with prostate cancer that were investigated, the mean PTV doses for individual gantry angles ranged from 18.8 to 22.6cGy. The maximum doses per gantry angle were between 24.0 and 34.7cGy. The minimum doses per gantry angle ranged from 4.4 to 17.4cGy. A significant reduction in the organ at risk (OAR) dose was observed with the PLDR-IMRT plan when compared with that using the PLDR-3DCRT plan. The volume receiving an 18-Gy (V18) dose for the left and right kidneys was reduced by 10.6% and 12.5%, respectively, for the pancreatic plans. The volume receiving a 45-Gy (V45) dose for the small bowel decreased from 65.3% to 45.5%. For the cases with prostate cancer, the volume receiving a 40-Gy (V40) dose for the bladder and the rectum was reduced significantly by 25.1% and 51.2%, respectively. When compared with the RapidArc technique, the volume receiving a 30-Gy (V30) dose for the left and the right kidneys was lower in the IMRT plans. For most OARs, no significant differences were observed between the PLDR-IMRT and the PLDR-RapidArc plans. These results clearly demonstrated that the PLDR-IMRT plan was suitable for PLDR pancreatic and prostate cancer treatments in terms of the overall plan quality. A significant reduction in the OAR dose was achieved with the PLDR-IMRT plan when compared with that using the PLDR-3DCRT plan. For most OARs, no significant differences were observed between the PLDR-IMRT and the PLDR-RapidArc plans. When compared with the PLDR-3DCRT plan, the PLDR-IMRT plan could provide superior target coverage and normal tissue sparing for PLDR reirradiation of recurrent pancreatic and prostate cancers. The PLDR-IMRT plan is an effective treatment choice for recurrent cancers in most cancer centers.
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Lin MH, Price RA, Li J, Kang S, Li J, Ma CM. Investigation of pulsed IMRT and VMAT for re-irradiation treatments: dosimetric and delivery feasibilities. Phys Med Biol 2014; 58:8179-96. [PMID: 24200917 DOI: 10.1088/0031-9155/58/22/8179] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Many tumor cells demonstrate hyperradiosensitivity at doses below ~50 cGy. Together with the increased normal tissue repair under low dose rate, the pulsed low dose rate radiotherapy (PLDR), which separates a daily fractional dose of 200 cGy into 10 pulses with 3 min interval between pulses (~20 cGy/pulse and effective dose rate 6.7 cGy min−1), potentially reduces late normal tissue toxicity while still providing significant tumor control for re-irradiation treatments. This work investigates the dosimetric and technical feasibilities of intensity modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT)-based PLDR treatments using Varian Linacs. Twenty one cases (12 real re-irradiation cases) including treatment sites of pancreas, prostate, pelvis, lung, head-and-neck, and breast were recruited for this study. The lowest machine operation dose rate (100 MU min−1) was employed in the plan delivery. Ten-field step-and-shoot IMRT and dual-arc VMAT plans were generated using the Eclipse TPS with routine planning strategies. The dual-arc plans were delivered five times to achieve a 200 cGy daily dose (~20 cGy arc−1). The resulting plan quality was evaluated according to the heterogeneity and conformity indexes (HI and CI) of the planning target volume (PTV). The dosimetric feasibility of retaining the hyperradiosensitivity for PLDR was assessed based on the minimum and maximum dose in the target volume from each pulse. The delivery accuracy of VMAT and IMRT at the 100 MU min−1 machine operation dose rate was verified using a 2D diode array and ion chamber measurements. The delivery reproducibility was further investigated by analyzing the Dynalog files of repeated deliveries. A comparable plan quality was achieved by the IMRT (CI 1.10–1.38; HI 1.04–1.10) and the VMAT (CI 1.08–1.26; HI 1.05–1.10) techniques. The minimum/maximum PTV dose per pulse is 7.9 ± 5.1 cGy/33.7 ± 6.9 cGy for the IMRT and 12.3 ± 4.1 cGy/29.2 ± 4.7 cGy for the VMAT. Six out of the 186 IMRT pulses (fields) were found to exceed 50 cGy maximum PTV dose per pulse while the maximum PTV dose per pulse was within 40 cGy for all the VMAT pulses (arcs). However, for VMAT plans, the dosimetric quality of the entire treatment plan was less superior for the breast cases and large irregular targets. The gamma passing rates for both techniques at the 100 MU min−1 dose rate were at least 94.1% (3%/3 mm) and the point dose measurements agreed with the planned values to within 2.2%. The average root mean square error of the leaf position was 0.93 ± 0.83 mm for IMRT and 0.53 ± 0.48 mm for VMAT based on the Dynalog file analysis. The RMS error of the leaf position was nearly identical for the repeated deliveries of the same plans. In general, both techniques are feasible for PLDR treatments. VMAT was more advantageous for PLDR with more uniform target dose per pulse, especially for centrally located tumors. However, for large, irregular and/or peripheral tumors, IMRT could produce more favorable PLDR plans. By taking the biological benefit of PLDR delivery and the dosimetric benefit of IMRT and VMAT, the proposed methods have a great potential for those previously-irradiated recurrent patients.
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Kang S, Lang J, Wang P, Li J, Lin M, Chen X, Guo M, Chen F, Chen L, Ma CM. Optimization strategies for pulsed low-dose-rate IMRT of recurrent lung and head and neck cancers. J Appl Clin Med Phys 2014; 15:4661. [PMID: 24892337 PMCID: PMC5711051 DOI: 10.1120/jacmp.v15i3.4661] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 01/23/2014] [Accepted: 01/19/2014] [Indexed: 11/23/2022] Open
Abstract
Pulsed low‐dose‐rate radiotherapy (PLDR) has been proven to be a valid method of reirradiation. Previous studies of recurrent cancer radiotherapy were mainly based on conventional 3D CRT and VMAT delivery techniques. There are difficulties in IMRT planning using existing commercial treatment planning systems (TPS) to meet the PLDR protocol. This work focuses on PLDR using ten‐field IMRT and a commercial TPS for two specific sites: recurrent lung cancers and head and neck cancers. Our PLDR protocol requires that the maximum dose to the PTV be less than 0.4 Gy and the mean dose to be 0.2 Gy per field. We investigated various planning strategies to meet the PLDR requirements for 20 lung and head and neck patients. The PTV volume for lung cases ranged from 101.7 to 919.4 cm3 and the maximum dose to the PTV ranged from 0.22 to 0.39 Gy. The PTV volume for head and neck cases ranged from 66.2 to 282.1 cm3 and the maximum dose to the PTV ranged from 0.21 to 0.39 Gy. With special beam arrangements and dosimetry parameters, it is feasible to use a commercial TPS to generate quality PLDR IMRT plans for lung and head and neck reirradiation. PACS number: 87.55.D‐
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23
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Beauchesne P. Three-times daily ultrafractionated radiation therapy, a novel and promising regimen for glioblastoma patients. Cancers (Basel) 2013; 5:1199-211. [PMID: 24202441 PMCID: PMC3875935 DOI: 10.3390/cancers5041199] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 08/16/2013] [Accepted: 08/18/2013] [Indexed: 01/11/2023] Open
Abstract
Glioblastomas are considered to be one of the most radio resistant tumors. Despite new therapies, the prognosis of this disease remains dismal. Also, the mechanisms of radiation resistance in mammalian cells are more complex than once believed. Experimental studies have indicated that some human cell lines are sensitive to low radiation doses of <1 Gy. This phenomenon has been termed low-dose hyper-radio-sensitivity (HRS), and is more apparent in radio resistant cell lines, such as glioblastoma cells. Sensitivity may result from the inability of low dose radiation to efficiently induce repair mechanisms, whereas higher doses cause enough damage to trigger repair responses for radio resistance. In vitro studies have demonstrated this phenomenon using various human malignant glioma cell lines: (1) daily repeated irradiation of cells with low doses compared to irradiation using a single biologically equivalent dose resulted in significantly higher cell killing; (2) experiments conducted on glioma xenografts demonstrated that repeated irradiation with low doses was more effective for inhibiting tumor growth than a single dose. In order to confirm and validate these promising studies on HRS, a few phase II trials were developed. For translating the experimental observations into the clinic, ultra fractionation protocols (with three daily doses) were tested in glioblastoma patients. Tolerance and toxicity were the primary endpoints, with overall survival as a secondary endpoint. These protocols were initiated before concomitant radio chemotherapy became the standard of care. For these trials, patients with an unfavorable clinical prognostic factor of newly unresectable GBM were included. When comparing the results of these trials with international literature using multivariate analysis for both progression free survival and overall survival, ultra fractionated irradiation showed superiority over radiotherapy alone. In addition, it was found to be equivalent to treatment using radiotherapy and temozolomide. Therefore, ultra fractionated protocols may prolong survival of glioblastoma patients. In this review, we describe the main experimental data regarding low-dose hypersensitivity as well as the findings of clinical trials that have investigated this new radiotherapy regimen.
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Affiliation(s)
- Patrick Beauchesne
- Neuro-Oncology Department, CHU de Nancy, Hospital Central, Nancy 54035, France.
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Schoenherr D, Krueger SA, Martin L, Marignol L, Wilson GD, Marples B. Determining if low dose hyper-radiosensitivity (HRS) can be exploited to provide a therapeutic advantage: a cell line study in four glioblastoma multiforme (GBM) cell lines. Int J Radiat Biol 2013; 89:1009-16. [PMID: 23859266 DOI: 10.3109/09553002.2013.825061] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To determine if ultra-fractionation using repeated pulses of radiation (10 × 0.2 Gray [Gy]) would be more cytotoxic than continuously-delivered radiation to the same total dose (2 Gy) in four glioma cell lines. MATERIALS AND METHODS Human T98G, U373, U87MG and U138MG cells were conventionally X-irradiated with 0.1-8 Gy and clonogenic survival assessed. Next, cells were treated with either a single dose of 2 Gy or 10 pulses of 0.2 Gy using a 3-min inter-pulse interval and DNA (Deoxyribonucleic acid) repair (pHistone H2A.X), G2-phase cell cycle checkpoint arrest (pHistone H3) and apoptosis (caspase-3) compared between the two regimens. A dose of 0.2 Gy was selected as this reflects the hyper- radiosensitivity (HRS)/increased radioresistance (IRR) transition point of the low-dose cell survival curve. RESULTS T98G, U87MG and U138MG exhibited distinct HRS responses and survival curves were well-described by the Induced Repair model. Despite the prolonged delivery time, ultra-fractionation (10 × 0.2 Gy) was equally effective as a single continuously-delivered 2 Gy dose. However, ultra-fractionation was more effective when given for five consecutive days to a total dose of 10 Gy. The increased effectiveness of ultra-fractionation could not be attributed directly to differences in DNA damage, repair processes or radiation-induced apoptosis. CONCLUSIONS Ultra-fractionation (10 × 0.2 Gy) is an effective modality for killing glioma cell lines compared with standard 2 Gy dosing when multiple days of treatment are given.
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Affiliation(s)
- Diane Schoenherr
- Department of Radiation Oncology, Beaumont Health System , Royal Oak, Michigan , USA
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Dilworth JT, Krueger SA, Dabjan M, Grills IS, Torma J, Wilson GD, Marples B. Pulsed low-dose irradiation of orthotopic glioblastoma multiforme (GBM) in a pre-clinical model: Effects on vascularization and tumor control. Radiother Oncol 2013; 108:149-54. [DOI: 10.1016/j.radonc.2013.05.022] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Revised: 04/23/2013] [Accepted: 05/26/2013] [Indexed: 02/08/2023]
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Tyagi N, Yang K, Sandhu R, Yan D, Park SS, Chen PY, Marples B. External beam pulsed low dose radiotherapy using volumetric modulated arc therapy: Planning and delivery. Med Phys 2012; 40:011704. [DOI: 10.1118/1.4769119] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Ma CM, Lin MH, Dai XF, Koren S, Klayton T, Wang L, Li JS, Chen L, Price RA. Investigation of pulsed low dose rate radiotherapy using dynamic arc delivery techniques. Phys Med Biol 2012; 57:4613-26. [PMID: 22750648 DOI: 10.1088/0031-9155/57/14/4613] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
There has been no consensus standard of care to treat recurrent cancer patients who have previously been irradiated. Pulsed low dose rate (PLDR) external beam radiotherapy has the potential to reduce normal tissue toxicities while still providing significant tumor control for recurrent cancers. This work investigates the dosimetry feasibility of PLDR treatment using dynamic arc delivery techniques. Five treatment sites were investigated in this study including breast, pancreas, prostate, head and neck, and lung. Dynamic arc plans were generated using the Varian Eclipse system and the RapidArc delivery technique with 6 and 10 MV photon beams. Each RapidArc plan consisted of two full arcs and the plan was delivered five times to achieve a daily dose of 200 cGy. The dosimetry requirement was to deliver approximately 20 cGy/arc with a 3 min interval to achieve an effective dose rate of 6.7 cGy min⁻¹. Monte Carlo simulations were performed to calculate the actual dose delivered to the planning target volume (PTV) per arc taking into account beam attenuation/scattering and intensity modulation. The maximum, minimum and mean doses to the PTV were analyzed together with the dose volume histograms and isodose distributions. The dose delivery for the five plans was validated using solid water phantoms inserted with an ionization chamber and film, and a cylindrical detector array. Two intensity-modulated arcs were used to efficiently deliver the PLDR plans that provided conformal dose distributions for treating complex recurrent cancers. For the five treatment sites, the mean PTV dose ranged from 18.9 to 22.6 cGy/arc. For breast, the minimum and maximum PTV dose was 8.3 and 35.2 cGy/arc, respectively. The PTV dose varied between 12.9 and 27.5 cGy/arc for pancreas, 12.6 and 28.3 cGy/arc for prostate, 12.1 and 30.4 cGy/arc for H&N, and 16.2 and 27.6 cGy/arc for lung. Advanced radiation therapy can provide superior target coverage and normal tissue sparing for PLDR reirradiation of recurrent cancers, which can be delivered using dynamic arc delivery techniques with ten full arcs and an effective dose rate of 6.7 ± 4.0 cGy min⁻¹.
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Affiliation(s)
- C-M Ma
- Radiation Oncology Department, Fox Chase Cancer Center, Philadelphia, PA 19111, USA.
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Li GH, Liu Y, Tang JL, Zhang D, Zhou P, Yang DQ, Ma CK. Pulsed reduced dose-rate radiotherapy as re-irradiation for brain metastasis in a patient with lung squamous-celled carcinoma. Jpn J Clin Oncol 2012; 42:856-60. [PMID: 22701036 DOI: 10.1093/jjco/hys091] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The recurrence and progression of brain metastases after brain irradiation are a major cause of mortality and morbidity in patients with cancer. The risk of radiation-induced neurotoxicity and efficacy probably leads oncologists to not consider re-irradiation. We report the case of a 48-year-old Asian male diagnosed with squamous cell lung cancer and multiple brain metastases initially treated with 40 Gy whole-brain radiotherapy and 20 Gy partial brain boost. Fourteen gray stereotactic radiosurgery as salvage for brain metastases in the left occipital lobe was performed after initial irradiation. The recurrence of brain metastases in the left occipital lobe was demonstrated on magnetic resonance imaging at 9 months after initial radiotherapy. He received the second course of 28 Gy stereotactic radiosurgery for the recurrent brain metastases in the left occipital lobe. The third relapse of brain metastases was demonstrated by a magnetic resonance imaging scan at 7 months after the second radiotherapy. The third course of irradiation was performed because he refused to undergo surgical resection of the recurrent brain metastases. The third course of irradiation used a pulsed reduced dose-rate radiotherapy technique. It was delivered in a series of 0.2 Gy pulses separated by 3-min intervals. The recurrent brain metastases were treated with a dose of 60 Gy using 30 daily fractions of 2 Gy. Despite the brain metastases receiving 162 Gy irradiation, this patient had no apparent acute or late neurologic toxicities and showed clinical improvement. This is the first report of the pulsed reduced dose-rate radiotherapy technique being used as the third course of radiotherapy for recurrent brain metastases.
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Affiliation(s)
- Guang-Hui Li
- Institute for Cancer Research in People's Liberation Army, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China.
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Semicontinuous Low-Dose-Rate Teletherapy for the Treatment of Recurrent Glial Brain Tumors: Final Report of a Phase I/II Study. Int J Radiat Oncol Biol Phys 2012; 82:765-72. [DOI: 10.1016/j.ijrobp.2010.10.057] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2009] [Revised: 08/25/2010] [Accepted: 10/28/2010] [Indexed: 11/22/2022]
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MicroPET/CT Imaging of an Orthotopic Model of Human Glioblastoma Multiforme and Evaluation of Pulsed Low-Dose Irradiation. Int J Radiat Oncol Biol Phys 2011; 80:885-92. [DOI: 10.1016/j.ijrobp.2011.01.045] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Revised: 11/17/2010] [Accepted: 01/13/2011] [Indexed: 11/21/2022]
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Rong Y, Paliwal B, Howard SP, Welsh J. Treatment Planning for Pulsed Reduced Dose-Rate Radiotherapy in Helical Tomotherapy. Int J Radiat Oncol Biol Phys 2011; 79:934-42. [DOI: 10.1016/j.ijrobp.2010.05.055] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2009] [Revised: 04/12/2010] [Accepted: 05/01/2010] [Indexed: 11/17/2022]
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Adkison JB, Tomé W, Seo S, Richards GM, Robins HI, Rassmussen K, Welsh JS, Mahler PA, Howard SP. Reirradiation of large-volume recurrent glioma with pulsed reduced-dose-rate radiotherapy. Int J Radiat Oncol Biol Phys 2010; 79:835-41. [PMID: 20472350 DOI: 10.1016/j.ijrobp.2009.11.058] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2009] [Revised: 10/09/2009] [Accepted: 11/12/2009] [Indexed: 10/19/2022]
Abstract
PURPOSE Pulsed reduced-dose-rate radiotherapy (PRDR) is a reirradiation technique that reduces the effective dose rate and increases the treatment time, allowing sublethal damage repair during irradiation. PATIENTS AND METHODS A total of 103 patients with recurrent glioma underwent reirradiation using PRDR (86 considered to have Grade 4 at PRDR). PRDR was delivered using a series of 0.2-Gy pulses at 3-min intervals, creating an apparent dose rate of 0.0667 Gy/min to a median dose of 50 Gy (range, 20-60) delivered in 1.8-2.0-Gy fractions. The mean treatment volume was 403.5±189.4 cm3 according to T2-weighted magnetic resonance imaging and a 2-cm margin. RESULTS For the initial or upgraded Grade 4 cohort (n=86), the median interval from the first irradiation to PRDR was 14 months. Patients undergoing PRDR within 14 months of the first irradiation (n=43) had a median survival of 21 weeks. Those treated ≥14 months after radiotherapy had a median survival of 28 weeks (n=43; p=0.004 and HR=1.82 with a 95% CI ranging from 1.25 to 3.10). These data compared favorably to historical data sets, because only 16% of the patients were treated at first relapse (with 46% treated at the second relapse, 32% at the third or fourth relapse, and 4% at the fourth or fifth relapse). The median survival since diagnosis and retreatment was 6.3 years and 11.4 months for low-grade, 4.1 years and 5.6 months for Grade 3, and 1.6 years and 5.1 months for Grade 4 tumors, respectively, according to the initial histologic findings. Multivariate analysis revealed age at the initial diagnosis, initial low-grade disease, and Karnofsky performance score of ≥80 to be significant predictors of survival after initiation of PRDR. CONCLUSION PRDR allowed for safe retreatment of larger volumes to high doses with palliative benefit.
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Affiliation(s)
- Jarrod B Adkison
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA
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Leal T, Robins HI. Bevacizumab induced reversible thrombocytopenia in a patient with recurrent high-grade glioma: a case report. Cancer Chemother Pharmacol 2009; 65:399-401. [DOI: 10.1007/s00280-009-1118-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2009] [Accepted: 08/26/2009] [Indexed: 10/20/2022]
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Richards GM, Tomé WA, Robins HI, Stewart JA, Welsh JS, Mahler PA, Howard SP. Pulsed reduced dose-rate radiotherapy: a novel locoregional retreatment strategy for breast cancer recurrence in the previously irradiated chest wall, axilla, or supraclavicular region. Breast Cancer Res Treat 2008; 114:307-13. [PMID: 18389365 DOI: 10.1007/s10549-008-9995-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2008] [Accepted: 03/26/2008] [Indexed: 12/29/2022]
Abstract
PURPOSE Reirradiation of breast cancer locoregional recurrence (LRR) in the setting of prior post-mastectomy radiation poses a significant clinical challenge due to the high risk for severe toxicity. In an attempt to reduce these toxicities, we have developed pulsed reduced dose-rate radiotherapy (PRDR), a reirradiation technique in which a series of 0.2 Gy pulses separated by 3-min time intervals is delivered, creating an apparent dose rate of 0.0667 Gy/min. Here we describe our early experience with PRDR. PATIENTS AND METHODS We reirradiated 17 patients with LRR breast cancer to the chest wall, axilla, or supraclavicular region using PRDR. The median prior radiation dose was 60 Gy. We delivered a median PRDR dose of 54 Gy (range 40-66 Gy) in 1.8-2.0 Gy per fraction. Eight patients received concomitant low dose capecitabine for radiosensitization. The median treatment volume was 2,084 cm(3) (range 843-7,881 cm(3)). RESULTS At a median follow-up of 18 months (range 4-75 months) only 2 patients have had tumor failure in the treatment region. Estimated 2-year local control rate is 92%. Treatment was well tolerated with 4 patients experiencing grade 3 acute skin toxicity. Despite a median cumulative dose of 110 Gy (range 80-236 Gy), there has been only one grade 3 and one grade 4 late toxicity. CONCLUSIONS With a median follow-up of 18 months, PRDR appears to be an effective method to reirradiate large volumes of previously irradiated tissue in selected patients with locoregional chest wall, axilla, and supraclavicular recurrences.
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Affiliation(s)
- Gregory M Richards
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA
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