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Turcas A, Homorozeanu B, Gheara C, Balan C, Cosnarovici R, Diaconu O, Fekete Z, Mihut E, Olteanu D, Pruteanu P, Tipcu A, Turcas A, Cernea D, Leucuta D, Achimas-Cadariu P. Dynamics and predictors of hematologic toxicity during cranio-spinal irradiation. Rep Pract Oncol Radiother 2024; 29:362-372. [PMID: 39144265 PMCID: PMC11321791 DOI: 10.5603/rpor.101094] [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: 11/17/2023] [Accepted: 05/31/2024] [Indexed: 08/16/2024] Open
Abstract
Background Craniospinal irradiation (CSI) is a complex radiotherapy (RT) technique required for treating specific brain tumors and some hematologic malignancies. With large volumes of hematogenous bone marrow (BM) being irradiated, CSI could cause acute hematologic toxicity, leading to treatment interruptions or severe complications. We report on the dynamics and dose/volume predictors of hematologic toxicity during CSI. Materials and methods Pediatric patients (≤ 18years) undergoing CSI in a tertiary cancer center were included. Medical records were retrospectively reviewed for clinical data and blood parameters were collected at baseline and weekly, until four weeks after the end of RT. The BM substructures were contoured, and dose-volume parameters were extracted. We used Wilcoxon rank-sum test to compare quantitative data, Chi square test for qualitative data and receiver operating characteristics (ROC) curves for dose/volume thresholds. Results Fifty-one patients were included. Severe toxicities (grade 3-4) were recorded as follows: 2% anemia, 8% thrombocytopenia, 25% leukopenia, 24% neutropenia. Ninety-eight percent of patients had lymphopenia (grade 1-4) at some point. Twenty-nine percent required granulocyte-colony stimulating factor, 50% had an infection and 8% required a blood transfusion. Dmean > 3.6 Gy and V15 Gy > 10.6% for Pelvic Bones were associated with a higher risk of developing any ≥ G3 toxicities. Dmean > 30-35 Gy to the thoracic and lumbar spine was predictive for G3-4 anemia and thrombocytopenia, and Cervical Spine Dmean > 30 Gy was associated with ≥ G3 neutropenia. Conclusion CSI was well tolerated, without life-threatening complications in our cohort, but hematologic toxicity was frequent, with severity increasing with higher mean doses delivered to the hematogenous BM and larger volumes of BM receiving 30-35 Gy.
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Affiliation(s)
- Andrada Turcas
- Radiotherapy Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
- Oncology Department, The University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
| | - Bianca Homorozeanu
- Radiotherapy Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
- Oncology Department, The University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
| | - Cristina Gheara
- Radiotherapy Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
- Faculty of Physics, “Babes-Bolyai” University, Cluj-Napoca, Romania
| | - Cristina Balan
- Radiotherapy Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
- Faculty of Physics, “Babes-Bolyai” University, Cluj-Napoca, Romania
| | - Rodica Cosnarovici
- Paediatric Oncology Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
| | - Oana Diaconu
- Radiotherapy Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
- Faculty of Physics, “Babes-Bolyai” University, Cluj-Napoca, Romania
| | - Zsolt Fekete
- Radiotherapy Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
- Oncology Department, The University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
| | - Emilia Mihut
- Paediatric Oncology Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
| | - Diana Olteanu
- Paediatric Oncology Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
| | - Paula Pruteanu
- Paediatric Oncology Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
| | - Alexandru Tipcu
- Radiotherapy Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
- Oncology Department, The University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
| | - Adrian Turcas
- Oncology Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
| | - Dana Cernea
- Radiotherapy Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
| | - Daniel Leucuta
- Department of Medical Informatics and Biostatistics, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
| | - Patriciu Achimas-Cadariu
- Oncology Department, The University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
- Surgical Oncology Department, The Oncology Institute “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
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Baghani HR, Porouhan P. Secondary cancer risk assessment in healthy organs following craniospinal irradiation. Int J Radiat Biol 2024; 100:1174-1182. [PMID: 38889539 DOI: 10.1080/09553002.2024.2369110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 05/13/2024] [Accepted: 05/29/2024] [Indexed: 06/20/2024]
Abstract
INTRODUCTION Medulloblastoma is a central nerves tumor that often occurs in pediatrics. The main radiotherapy technique for this tumor type is craniospinal irradiation (CSI), through which the whole brain and spinal cord are exposed to radiation. Due to the immaturity of healthy organs in pediatrics, radiogenic side effects such as second cancer are more severe. Accordingly, the current study aimed to evaluate the risk of secondary cancer development in healthy organs following CSI. MATERIALS AND METHODS Seven organs at risk (OARs) including skin, eye lens, thyroid, lung, liver, stomach, bladder, colon, and gonads were considered and the dose received by each OAR during CSI was measured inside an anthropomorphic RANDO phantom by TLDs. Then, the mean obtained dose for each organ was used to estimate the probability of secondary malignancy development according to the recommended cancer risk coefficients for specific organs. RESULTS The results demonstrated that the stomach and colon are at high risk of secondary malignancy occurrence, while the skin has the lowest probability of secondary cancer development. The total received dose after the treatment course by all considered organs was lower than the corresponding tolerable dose levels. CONCLUSIONS From the results, it can be concluded that some OARs during CSI are highly at risk of secondary cancer development. This issue may be of concern due to organ immaturity in pediatrics which can intensify the radiogenic effects of radiation exposure. Accordingly, strict shielding the OARs during craniospinal radiotherapy and/or sparing them from the radiation field through modern techniques such as hadron therapy is highly recommended.
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Affiliation(s)
| | - Pejman Porouhan
- Radiation Oncology Department, Vasei Hospital, Sabzevar University of Medical Sciences, Sabzevar, Iran
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Savagner J, Ducassou A, Cabarrou B, Hangard G, Gambart M, Bertozzi AI, Baudou E, Boetto S, Larrieu D, Laprie A. Helical tomotherapy craniospinal irradiation in primary brain tumours: Toxicities and outcomes in a peadiatric and adult population. Clin Transl Radiat Oncol 2024; 46:100777. [PMID: 38628594 PMCID: PMC11019098 DOI: 10.1016/j.ctro.2024.100777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 03/30/2024] [Accepted: 04/04/2024] [Indexed: 04/19/2024] Open
Abstract
Objective As craniospinal irradiation (CSI) is delivered more frequently by helical tomotherapy (HT) with few reports about late effects, we analysed all patients treated in our centre over an 11-year period. Methods and materials Our study included all patients that underwent CSI by HT, between September 2009 and January 2020, in the Department of Radiation Oncology of the Toulouse Cancer Institute. Acute radiotherapy toxicities were reported and medium- to long-term outcomes analysed. Results Among the 79 patients included, 70.9 % were younger than 18 years at diagnosis, the median age was 13 (range: 1-52) at the time of radiation therapy, 67.1 % of patients had medulloblastoma. Half of them (49.4 %) had a metastatic disease at diagnosis. The median dose of CSI was 36 Gy (range, 18-36). Seventy-seven patients received a radiation boost to the original location of the primary tumour (97.5 %), 32 patients also received a boost to their metastatic sites (40.5 %). Median follow-up was 55.5 months (95 %CI = [41.2; 71.8]). The 3-year event-free survival rate was 66.3 % (95 %CI = [54.2; 75.9]). Most patients presented with acute haematological toxicities during CSI (85.9 %), predominantly severe thrombocytopenia (39.7 %). Among the 64 patients assessed for medium- and long-term outcomes, 52 survived and 47 were alive and disease-free at the latest follow-up visit on record. There were 3.8 % secondary tumours: two meningiomas and one diffuse intrinsic pontine glioma. Adult and paediatric patients respectively presented with secondary cataract (4.3 % vs 22.0 %), persistent hearing disorders (26.1 % vs 29.3 %), pulmonary or cardiac late effects (4.3 % vs 2.4 %), hormonal pituitary gland deficiencies (30.0 % vs 56.8 %) and psycho-cognitive disorders (56.5 % vs 53.7 %). Conclusion CSI dispensed by HT, did not result in any additional acute or late toxicities when compared to 3D-CSI. There was no increase in the secondary tumour rate compared to that reported in the literature.
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Affiliation(s)
- Julie Savagner
- Department of Paediatric Neurology, Children’s Hospital of Toulouse, 330 Avenue de Grande Bretagne, 31300 Toulouse, France
| | - Anne Ducassou
- Department of Radiation Oncology, Toulouse Cancer Institute (IUCT), 1 avenue Irene Joliot-Curie, 31100 Toulouse, France
| | - Bastien Cabarrou
- Department of Biostatistics, Toulouse Cancer Institute (IUCT), 1 avenue Irene Joliot-Curie, 31100 Toulouse, France
| | - Gregory Hangard
- Department of Radiation Oncology, Toulouse Cancer Institute (IUCT), 1 avenue Irene Joliot-Curie, 31100 Toulouse, France
| | - Marion Gambart
- Department of Paediatric Oncology, Children’s Hospital of Toulouse, 330 Avenue de Grande Bretagne, 31300 Toulouse, France
| | - Anne-Isabelle Bertozzi
- Department of Paediatric Oncology, Children’s Hospital of Toulouse, 330 Avenue de Grande Bretagne, 31300 Toulouse, France
| | - Eloise Baudou
- Department of Paediatric Neurology, Children’s Hospital of Toulouse, 330 Avenue de Grande Bretagne, 31300 Toulouse, France
| | - Sergio Boetto
- Department of Neurosurgery, Toulouse University Hospital, Pierre-Paul Riquet Hospital, Place du Docteur Baylac, Toulouse, France
| | - Delphine Larrieu
- Department of Oncology, Toulouse Cancer Institute (IUCT), 1 avenue Irene Joliot-Curie, 31100 Toulouse, France
| | - Anne Laprie
- Department of Radiation Oncology, Toulouse Cancer Institute (IUCT), 1 avenue Irene Joliot-Curie, 31100 Toulouse, France
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Fukumitsu N, Kubota H, Demizu Y, Suzuki T, Hasegawa D, Kosaka Y, Kawamura A, Soejima T. Comparison of passive-scattered and intensity-modulated proton beam therapy of craniospinal irradiation with proton beams for pediatric and young adult patients with brain tumors. Jpn J Radiol 2024; 42:182-189. [PMID: 37874526 PMCID: PMC10811119 DOI: 10.1007/s11604-023-01499-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 09/06/2023] [Indexed: 10/25/2023]
Abstract
PURPOSE To investigate the dose stability of craniospinal irradiation based on irradiation method of proton beam therapy (PBT). METHODS AND MATERIALS Twenty-four pediatric and young adult brain tumor patients (age: 1-24 years) were examined. Treatment method was passive-scattered PBT (PSPT) in 8 patients and intensity-modulated PBT (IMPT) in 16 patients. The whole vertebral body (WVB) technique was used in 13 patients whose ages were younger than 10, and vertebral body sparing (VBS) technique was used for the remaining 11 patients aged 10 and above. Dose stability of planning target volume (PTV) against set-up error was investigated. RESULTS The minimum dose (Dmin) of IMPT was higher than that of PSPT (p = 0.01). Inhomogeneity index (INH) of IMPT was lower than that of PSPT (p = 0.004). When the irradiation field of the cervical spinal cord level (C level) was shifted, the maximum dose (Dmax) was lower in IMPT, and mean dose (Dmean) was higher than PSPT as movement became greater to the cranial-caudal direction (p = 0.000-0.043). Dmin was higher and INH was lower in IMPT in all directions (p = 0.000-0.034). When the irradiation field of the lumber spinal cord level (L level) was shifted, Dmax was lower in IMPT as movement became greater to the cranial direction (p = 0.000-0.028). Dmin was higher and INH was lower in IMPT in all directions (p = 0.000-0.022). CONCLUSIONS The PTV doses of IMPT and PSPT are robust and stable in both anterior-posterior and lateral directions at both C level and L level, but IMPT is more robust and stable than PSPT for cranial-caudal movements. TRIAL REGISTRY Clinical Trial Registration number: No. 04-03.
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Affiliation(s)
- Nobuyoshi Fukumitsu
- Department of Radiation Oncology, Kobe Proton Center, 1-6-8, Minatojima-Minamimachi, Kobe, 650-0047, Japan.
| | - Hikaru Kubota
- Department of Radiation Oncology, Kobe Proton Center, 1-6-8, Minatojima-Minamimachi, Kobe, 650-0047, Japan
| | - Yusuke Demizu
- Department of Radiation Oncology, Kobe Proton Center, 1-6-8, Minatojima-Minamimachi, Kobe, 650-0047, Japan
| | - Takeshi Suzuki
- Department of Anesthesiology, Kobe Proton Center, Kobe, Japan
| | - Daiichiro Hasegawa
- Department of Hematology and Oncology, Hyogo Children's Hospital, Kobe, Japan
| | - Yoshiyuki Kosaka
- Department of Hematology and Oncology, Hyogo Children's Hospital, Kobe, Japan
| | | | - Toshinori Soejima
- Department of Radiation Oncology, Kobe Proton Center, 1-6-8, Minatojima-Minamimachi, Kobe, 650-0047, Japan
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Harrison AS, Landers A, Nettleton V, Palermo K, Vakhnenko Y, Shi W. Integrated feathering for craniospinal irradiation improves patient safety and departmental efficiency. Med Dosim 2023; 49:77-80. [PMID: 37805281 DOI: 10.1016/j.meddos.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 08/14/2023] [Accepted: 08/25/2023] [Indexed: 10/09/2023]
Abstract
This paper presents to the dosimetrist audience an integrated feathering technique for craniospinal irradiation which improves dosimetry, physics, physician and therapist efficiencies while increasing patient safety and decreasing portal imaging time. This technique has been presented by other authors in physics journals stressing technical and quality assurance aspects, this article is presented to the treatment planners with a focus on the planning process including field design and weighting, efficiency improvements and patient safety.
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Affiliation(s)
- Amy S Harrison
- Department of Radiation Oncology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States.
| | - Angelia Landers
- Department of Radiation Oncology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Virginia Nettleton
- Department of Radiation Oncology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Katelyn Palermo
- Department of Radiation Oncology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Yelena Vakhnenko
- Department of Radiation Oncology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Wenyin Shi
- Department of Radiation Oncology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
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Fukumitsu N, Kubota H, Mima M, Demizu Y, Suzuki T, Hasegawa D, Kosaka Y, Kawamura A, Soejima T. Comparison of Craniospinal Irradiation Using Proton Beams According to Irradiation Method and Initial Experience Treating Pediatric Patients. Adv Radiat Oncol 2023; 8:101251. [PMID: 37408669 PMCID: PMC10318217 DOI: 10.1016/j.adro.2023.101251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/11/2023] [Indexed: 07/07/2023] Open
Abstract
Purpose This study compared craniospinal irradiation using proton beam therapy (PBT) according to irradiation method and investigated the initial effects. Methods and Materials Twenty-four pediatric patients (1-24 years old) who received proton craniospinal irradiation were examined. Passive scattered PBT (PSPT) and intensity modulated PBT (IMPT) were used in 8 and 16 patients, respectively. The whole vertebral body technique was used for 13 patients <10 years old, and the vertebral body sparing (VBS) technique was used for the remaining 11 patients aged ≥10 years. The follow-up period was 17 to 44 (median, 27) months. Organ-at-risk and planning target volume (PTV) doses and other clinical data were examined. Results The maximum lens dose using IMPT was lower than that using PSPT (P = .008). The mean thyroid, lung, esophagus, and kidney doses were lower in patients treated using the VBS technique compared with the whole vertebral body technique (all P < .001). The minimum PTV dose of IMPT was higher than that of PSPT (P = .01). The inhomogeneity index of IMPT was lower than that of PSPT (P = .004). Conclusions IMPT is better than PSPT at reducing the dose to the lens. The VBS technique can decrease the doses to neck-chest-abdomen organs. The PTV coverage of IMPT is superior to that of PSPT.
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Affiliation(s)
| | | | | | | | | | | | | | - Atsufumi Kawamura
- Neurosurgery, Hyogo Prefectual Kobe Children's Hospital, Kobe, Japan
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Hrinivich WT, Li H, Tran A, Acharya S, Ladra MM, Sheikh K. Clinical Characterization of a Table Mounted Range Shifter Board for Synchrotron-Based Intensity Modulated Proton Therapy for Pediatric Craniospinal Irradiation. Cancers (Basel) 2023; 15:cancers15112882. [PMID: 37296845 DOI: 10.3390/cancers15112882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/13/2023] [Accepted: 05/18/2023] [Indexed: 06/12/2023] Open
Abstract
Purpose: To report our design, manufacturing, commissioning and initial clinical experience with a table-mounted range shifter board (RSB) intended to replace the machine-mounted range shifter (MRS) in a synchrotron-based pencil beam scanning (PBS) system to reduce penumbra and normal tissue dose for image-guided pediatric craniospinal irradiation (CSI). Methods: A custom RSB was designed and manufactured from a 3.5 cm thick slab of polymethyl methacrylate (PMMA) to be placed directly under patients, on top of our existing couch top. The relative linear stopping power (RLSP) of the RSB was measured using a multi-layer ionization chamber, and output constancy was measured using an ion chamber. End-to-end tests were performed using the MRS and RSB approaches using an anthropomorphic phantom and radiochromic film measurements. Cone beam CT (CBCT) and 2D planar kV X-ray image quality were compared with and without the RSB present using image quality phantoms. CSI plans were produced using MRS and RSB approaches for two retrospective pediatric patients, and the resultant normal tissue doses were compared. Results: The RLSP of the RSB was found to be 1.163 and provided computed penumbra of 6.9 mm in the phantom compared to 11.8 mm using the MRS. Phantom measurements using the RSB demonstrated errors in output constancy, range, and penumbra of 0.3%, -0.8%, and 0.6 mm, respectively. The RSB reduced mean kidney and lung dose compared to the MRS by 57.7% and 46.3%, respectively. The RSB decreased mean CBCT image intensities by 86.8 HU but did not significantly impact CBCT or kV spatial resolution providing acceptable image quality for patient setup. Conclusions: A custom RSB for pediatric proton CSI was designed, manufactured, modeled in our TPS, and found to significantly reduce lateral proton beam penumbra compared to a standard MRS while maintaining CBCT and kV image-quality and is in routine use at our center.
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Affiliation(s)
- William T Hrinivich
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Johns Hopkins Proton Therapy Center, Johns Hopkins University School of Medicine, Washington, DC 20016, USA
| | - Heng Li
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Johns Hopkins Proton Therapy Center, Johns Hopkins University School of Medicine, Washington, DC 20016, USA
| | - Anh Tran
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Johns Hopkins Proton Therapy Center, Johns Hopkins University School of Medicine, Washington, DC 20016, USA
| | - Sahaja Acharya
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Johns Hopkins Proton Therapy Center, Johns Hopkins University School of Medicine, Washington, DC 20016, USA
| | - Matthew M Ladra
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Johns Hopkins Proton Therapy Center, Johns Hopkins University School of Medicine, Washington, DC 20016, USA
| | - Khadija Sheikh
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Johns Hopkins Proton Therapy Center, Johns Hopkins University School of Medicine, Washington, DC 20016, USA
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Sharma DS, Padanthaiyil NM, Krishnan G, Arjunan M, Reddy AK, Mahammood S, Gayen S, Thiyagarajan R, Gaikwad U, Sudarsan RT, Chilukuri S, Jalali R. Critical Appraisal of Paediatric Embryonal Cancers Treated with Image-guided Intensity-modulated Proton Therapy. Clin Oncol (R Coll Radiol) 2023; 35:227-236. [PMID: 36609026 DOI: 10.1016/j.clon.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 11/15/2022] [Accepted: 12/09/2022] [Indexed: 01/06/2023]
Abstract
AIM To carry out a comprehensive critical appraisal of image-guided intensity-modulated proton therapy practice for craniospinal irradiation (CSI). MATERIALS AND METHODS An image-guided intensity-modulated proton therapy database of 45 consecutive paediatric patients with central nervous system embryonal malignancies treated between January 2019 and April 2022 were critically appraised for demography, diagnosis, treatment planning strategy and treatment delivery accuracy. RESULTS Most patients (median age: 7.5 years; male:female ratio: 34:11) had medulloblastoma (56%), followed by recurrent ependymoma (19%), pinealoblastoma (5%), germ cell (5%) and others (15%). The dose to the planning target volume-craniospinal (PTV-CS; length 39.06-79.59 cm) varied from 21 to 35 GyRBE, whereas the combined median dose to craniospinal and boost was 54 GyRBE. In all patients, the 95% isodose line covered the cribriform plate completely and optic nerves mostly, with a median V95% of 100% and 82.96%, keeping Dmax to the lens <3.9 GyRBE. In skeletally immature patients (88.38%), the anterior vertebral body was completely covered in 18.18% and underdosed in 70.15% of the cases, resulting in a median Dmean of 10.11 GyRBE to the oesophagus. Lateral spine coverage was maintained on the edges of the vertebral body in 52.2%, whereas it extended beyond in 48.8%. The median V98% for clinical target volumes and V95% for PTVs of the brain, spine and craniospinal were >97%, with excellent conformity (0.89) and homogeneity (0.07) indices for PTV-CS. All neurological organs at risk received a median Dmax ranging from 36 to 44 GyRBE from the combined CSI and boost regimens. Analysis of patient-specific quality assurance results revealed that 545 (97.67%) planar dosage verification had gamma (3% at 3 mm) values >95%. The online patient set-up verification showed translational and rotational deviation within 2 mm and 0.5° in 88-94% and 97% of the cases. Systematic and random error were within 0.90 mm and 1.71 mm in translation and 0.1° and 0.2° in rotation. CONCLUSION A change in practice pattern was observed. The findings from our comprehensive critical appraisal add to the growing library of CSI practice and may serve as a reference for inter-institutional comparison.
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Affiliation(s)
- D S Sharma
- Department of Medical Physics, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India.
| | - N M Padanthaiyil
- Department of Medical Physics, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - G Krishnan
- Department of Medical Physics, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - M Arjunan
- Department of Medical Physics, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - A K Reddy
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - S Mahammood
- Department of Medical Physics, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - S Gayen
- Department of Medical Physics, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - R Thiyagarajan
- Department of Medical Physics, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - U Gaikwad
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - R T Sudarsan
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - S Chilukuri
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - R Jalali
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
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Turcas A, Kelly SM, Clementel E, Cernea D. Tomotherapy for Cranio-Spinal Irradiation. Clin Transl Radiat Oncol 2022; 38:96-103. [PMID: 36407491 PMCID: PMC9672131 DOI: 10.1016/j.ctro.2022.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/30/2022] [Accepted: 11/05/2022] [Indexed: 11/13/2022] Open
Abstract
Tomotherapy is safe and effective for cranio-spinal irradiation, both in paediatric patients and in adults, with similar disease-specific outcomes and toxicities as other techniques such as 3DCRT or IMRT/VMAT. Tomotherapy offers several technical advantages when compared to other radiotherapy techniques such as higher target conformity and better dose homogeneity. Helical Tomotherapy provides good organ-at-risk sparing for several structures, especially the vertebrae, parotids, and optic system. Reported treatment time/ beam-on-time is longer with helical Tomotherapy compared to other techniques.
Tomotherapy is a method of delivering rotational IMRT offering various advantages, notably for complex and large targets such as the cranio-spinal axis. This systematic literature review reports on main clinical outcomes and toxicities in patients with various cancer types that received whole craniospinal axis irradiation (CSI) using Tomotherapy and offers a comprehensive comparison between Tomotherapy and other radiotherapy delivery techniques. Databases including PubMed, PubMed Central, Embase, and Cochrane were searched using the keywords “tomotherapy” AND “craniospinal”. Fifty-six papers were included in the review. Patient population was adult in 9 papers, paediatric in 26 papers and mixed in 14 papers. Patients treated with helical Tomotherapy had similar disease-specific clinical outcomes and toxicities as patients treated using other techniques. Compared to any other technique, Tomotherapy provides better target coverage, homogeneity, and conformity in 23, 34 and 22 reports. Tomotherapy showed better organ-at-risk sparing for the thyroid, parotids, cochlea, eyes, heart and esophagus. Beam-On-Time (BOT) was reported to be longer for Tomotherapy in most studies (Median BOT: HT = 11 min, VMAT = 5.49 min, 3DCRT = 1.46 min). In conclusion, Tomotherapy offers good cranio-spinal axis coverage with improved homogeneity and conformity compared to other techniques, but with a considerably longer treatment time. Clinical outcome and toxicities suggest using Tomotherapy for CSI is efficient and safe.
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Ferini *G, Palmisciano P, Scalia G, Haider AS, Bin-Alamer O, Sagoo NS, Bozkurt I, Deora H, Priola SM, Aoun SG, Umana GE. The role of radiation therapy in the treatment of spine metastases from hepatocellular carcinoma: a systematic review and meta-analysis. Neurosurg Focus 2022; 53:E12. [DOI: 10.3171/2022.8.focus2255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 08/23/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE
Spine hepatocellular carcinoma (HCC) metastases severely worsen quality of life and prognosis, with the role of radiotherapy being controversial. The authors systematically reviewed the literature on radiotherapy for spine metastatic HCCs.
METHODS
The PubMed, Scopus, Web of Science, and Cochrane databases were searched according to the PRISMA guidelines to include studies of radiotherapy for spine metastatic HCCs. Outcomes, complications, and local control were analyzed with indirect random-effect meta-analyses.
RESULTS
The authors included 12 studies comprising 713 patients. The median time interval from diagnosis of HCC to spine metastases was 12 months (range 0–105 months). Most lesions were thoracic (35.9%) or lumbar (24.7%). Radiotherapy was delivered with conventional external-beam (67.3%) or stereotactic (31.7%) techniques. The median dose was 30.3 Gy (range 12.5–52 Gy) in a median of 5 fractions (range 1–20 fractions). The median biologically effective dose was 44.8 Gy10 (range 14.4–112.5 Gy10). Actuarial rates of postradiotherapy pain relief and radiological response were 87% (95% CI 84%–90%) and 70% (95% CI 65%–75%), respectively. Radiation-related adverse events and vertebral fractures had actuarial rates of 8% (95% CI 5%–11%) and 16% (95% CI 10%–23%), respectively, with fracture rates significantly higher after stereotactic radiotherapy (p = 0.033). Fifty-eight patients (27.6%) had local recurrences after a median of 6.8 months (range 0.1–59 months), with pooled local control rates of 61.6% at 6 months and 40.8% at 12 months, and there were no significant differences based on radiotherapy type (p = 0.068). The median survival was 6 months (range 0.1–62 months), with pooled rates of 52.5% at 6 months and 23.4% at 12 months.
CONCLUSIONS
Radiotherapy in spine metastatic HCCs shows favorable rates of pain relief, radiological responses, and local control. Rates of postradiotherapy vertebral fractures are higher after high-dose stereotactic radiotherapy.
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Affiliation(s)
- *Gianluca Ferini
- Department of Radiation Oncology, REM Radioterapia srl, Viagrande, Catania, Italy
| | | | - Gianluca Scalia
- Department of Neurosurgery, Highly Specialized Hospital of National Importance "Garibaldi," Catania, Italy
| | - Ali S Haider
- Texas A&M University College of Medicine, Houston, Texas
| | - Othman Bin-Alamer
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Navraj S Sagoo
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ismail Bozkurt
- Department of Neurosurgery, Cankiri State Hospital, Cankiri, Turkey
| | - Harsh Deora
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| | - Stefano M Priola
- Division of Neurosurgery, Health Sciences North, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Salah G Aoun
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas; and
| | - Giuseppe E Umana
- Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Catania, Italy
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11
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Chou B, Hopper A, Elster J, Crawford JR, McConnell K, Chang A, Mundt AJ, MacEwan I. Volumetric de-escalation and improved acute toxicity with proton craniospinal irradiation using a vertebral body-sparing technique. Pediatr Blood Cancer 2022; 69:e29489. [PMID: 34866330 DOI: 10.1002/pbc.29489] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 08/30/2021] [Accepted: 10/26/2021] [Indexed: 11/06/2022]
Abstract
PURPOSE In growing children, craniospinal irradiation (CSI) has historically treated the entire vertebral body (VB) to avoid potential long-term spinal abnormalities. Vertebral body-sparing proton craniospinal irradiation (VBSpCSI) is a technique that spares the majority of the VB from significant irradiation, and long-term safety outcomes have been reported previously. This retrospective study reviews the acute toxicity profile of children treated with VBSpCSI in a cohort comparison with photon-based craniospinal radiotherapy (3DCRT). METHODS Thirty-eight pediatric CSI patients treated between 2008 and 2018 were retrospectively evaluated for treatment-related toxicity. Acute toxicity outcomes and acute hematologic profiles were compared according to treatment modality, either VBSpCSI or 3DCRT. Statistical analysis was performed using Fisher's exact test for toxicity. RESULTS Twenty-five patients received VBSpCSI and 13 patients received photon CSI. Mean patient age at treatment was 7.5 years (range 2-16). The cohorts were well matched with respect to gender, age, and CSI dose. Patients receiving VBSpCSI had lower rates of grade 2+ gastrointestinal (GI) toxicity (24% vs. 76.5%, p = .005), grade 2+ nausea (24% vs. 61.5%, p = .035), and any-grade esophagitis (0% vs. 38%, p = .0026). Patients treated with VBSpCSI had lower red blood cell transfusion rates (21.7% vs. 60%, p = .049) and grade 4+ lymphopenia (33.3% vs. 77.8%, p = .046). CONCLUSIONS VBSpCSI in children is a volumetric de-escalation from traditional volumes, which irradiate the entire VB to full or intermediate doses. In our study, VBSpCSI was associated with lower rates of acute GI and hematologic toxicities. Long-term growth outcomes and disease control outcomes are needed for this technique.
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Affiliation(s)
- Brian Chou
- Department of Radiation Oncology, Loyola University Medical Center, Maywood, Illinois, USA
| | - Austin Hopper
- Department of Radiation Medicine and Applied Sciences, University of California - San Diego, San Diego, California, USA
| | - Jennifer Elster
- Department of Pediatric Hematology and Oncology, University of California - San Diego, San Diego, California, USA
| | - John R Crawford
- Department of Neurosciences and Pediatrics, University of California - San Diego and Rady Children's Hospital, San Diego, California, USA
| | - Kristen McConnell
- Department of Radiation Medicine and Applied Sciences, University of California - San Diego, San Diego, California, USA
| | - Andrew Chang
- California Protons Cancer Therapy Center, San Diego, California, USA
| | - Arno J Mundt
- Department of Radiation Medicine and Applied Sciences, University of California - San Diego, San Diego, California, USA
| | - Iain MacEwan
- Department of Radiation Medicine and Applied Sciences, University of California - San Diego, San Diego, California, USA
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12
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Pediatric radiotherapy for thoracic and abdominal targets: organ motion, reported margin sizes, and delineation variations – a systematic review. Radiother Oncol 2022; 173:134-145. [DOI: 10.1016/j.radonc.2022.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 05/09/2022] [Accepted: 05/26/2022] [Indexed: 11/21/2022]
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13
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Weil CR, Lew FH, Williams VM, Burt LM, Ermoian RP, Poppe MM. Patterns of Care and Utilization Disparities in Proton Radiation Therapy for Pediatric Central Nervous System Malignancies. Adv Radiat Oncol 2022; 7:100868. [DOI: 10.1016/j.adro.2021.100868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/29/2021] [Indexed: 10/19/2022] Open
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14
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Yoo GS, Yu JI, Cho S, Han Y, Oh Y, Lim DH, Nam HR, Lee JW, Sung KW, Shin HJ. Chronological Analysis of Acute Hematological Outcomes after Proton and Photon Beam Craniospinal Irradiation in Pediatric Brain Tumors. Cancer Res Treat 2021; 54:907-916. [PMID: 34665955 PMCID: PMC9296930 DOI: 10.4143/crt.2021.332] [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: 03/15/2021] [Accepted: 10/14/2021] [Indexed: 12/02/2022] Open
Abstract
Purpose This study aimed to compare the early hematological dynamics and acute toxicities between proton beam craniospinal irradiation (PrCSI) and photon beam craniospinal irradiation (PhCSI) for pediatric brain tumors. Materials and Methods We retrospectively reviewed patients with pediatric brain tumors who received craniospinal irradiation (CSI). The average change in hemoglobin levels (ΔHbavg), absolute lymphocyte counts (ΔALCavg), and platelet counts (ΔPLTavg) from baseline values was evaluated and compared between the PrCSI and PhCSI groups at 1 and 2 weeks after the initiation of CSI, 1 week before and at the end of radiotherapy, and 3–4 weeks after the completion of radiotherapy using t-test and mixed-model analysis. Results The PrCSI and PhCSI groups consisted of 36 and 30 patients, respectively. There were no significant differences in ΔHbavg between the two groups at any timepoint. However, ΔALCavg and ΔPLTavg were significantly lower in the PhCSI group than in PrCSI group at every timepoint, demonstrating that PrCSI resulted in a significantly lower rate of decline and better recovery of absolute lymphocyte and platelet counts. The rate of grade 3 acute anemia was significantly lower in the PrCSI group than in in the PhCSI group. Conclusion PrCSI showed a lower rate of decline and better recovery of absolute lymphocyte and platelet counts than PhCSI in the CSI for pediatric brain tumors. Grade 3 acute anemia was significantly less frequent in the PrCSI group than in the PhCSI group. Further large-scale studies are warranted to confirm these results.
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Affiliation(s)
- Gyu Sang Yoo
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Il Yu
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sungkoo Cho
- Department of Radiation Oncology, Samsung Medical Center, Seoul, Korea
| | - Youngyih Han
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoonjin Oh
- Department of Radiation Oncology, Samsung Medical Center, Seoul, Korea
| | - Do Hoon Lim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Rim Nam
- Department of Radiation Oncology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji-Won Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ki-Woong Sung
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyung Jin Shin
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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15
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Balasubramanian S, Shobana MK. Pediatric Craniospinal Irradiation - The implementation and Use of Normal Tissue Complication Probability in Comparing Photon versus Proton Planning. J Med Phys 2021; 46:244-252. [PMID: 35261494 PMCID: PMC8853445 DOI: 10.4103/jmp.jmp_75_21] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/12/2021] [Accepted: 08/13/2021] [Indexed: 12/03/2022] Open
Abstract
Purpose: The preferred radiotherapy treatment for medulloblastoma is craniospinal irradiation (CSI). With the aim of developing the potential to reduce normal tissue dose and associated post-treatment complications with photon and proton radiotherapy techniques for CSI. This report aims to carefully compare and rank treatment planning and dosimetric outcomes for pediatric medulloblastoma patients using normal tissue complication probability (NTCP) formalism between photon (three-dimensional conformal radiotherapy, intensity-modulated radiotherapy [IMRT], volumetric-modulated arc therapy [VMAT], and HT) and proton CSI. Methods and Materials: The treatment data of eight pediatric patients who typically received CSI treatment were used in this study. The patients were 7 years of age on average, with ages ranging from 3 to 11 years. A prescription dose of 3600 cGy was delivered in 20 fractions by the established planning methods. The Niemierko's and Lyman–Kutcher–Burman models were followed to carefully estimate NTCP and compare different treatment plans. Results: The NTCP of VMAT plans in upper and middle thoracic volumes was relatively high compared to helical tomotherapy (HT) and pencil beam scanning (PBS) (all P < 0.05). PBS rather than IMRT and VMAT in the middle thoracic region (P < 0.06) could significantly reduce the NTCP of the heart. PBS significantly reduced NTCP of the lungs and liver (all P < 0.05). Conclusion: The NTCP and tumor control probability (TCP) model-based plan ranking along with dosimetric indices will help the clinical practitioner or medical physicists to choose the best treatment plan for each patient based on their anatomical or clinical challenges.
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Affiliation(s)
- S Balasubramanian
- Department of Radiation Oncology, Max Super Specialty Hospital, Ghaziabad, Uttar Pradesh, India.,Department of Physics, School of Advanced Sciences, Vellore Institute of Technology, Vellore, Tamil Nadu, India
| | - M K Shobana
- Department of Physics, School of Advanced Sciences, Vellore Institute of Technology, Vellore, Tamil Nadu, India
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16
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Leach K, Tang S, Sturgeon J, Lee AK, Grover R, Sanghvi P, Urbanic J, Chang C. Beam-Specific Spot Guidance and Optimization for PBS Proton Treatment of Bilateral Head and Neck Cancers. Int J Part Ther 2021; 8:50-61. [PMID: 34285935 PMCID: PMC8270101 DOI: 10.14338/ijpt-20-00060.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 02/19/2021] [Indexed: 12/05/2022] Open
Abstract
PURPOSE A multi-field optimization (MFO) technique that uses beam-specific spot placement volumes (SPVs) and spot avoidance volumes (SAVs) is introduced for bilateral head and neck (H&N) cancers. These beam-specific volumes are used to guide the optimizer to consistently achieve optimal organ-at-risk (OAR) sparing with target coverage and plan robustness. MATERIALS AND METHODS Implementation of this technique using a 4-beam, 5-beam, and variant 5-beam arrangement is discussed. The generation of beam-specific SPVs and SAVs derived from target and OARs are shown. The SPVs for select fields are further partitioned into optimization volumes for uniform dose distributions that resemble those of single-field optimization (SFO). A conventional MFO plan that does not use beam-specific spot placement guidance (MFOcon) and an MFO plan that uses only beam-specific SPV (MFOspv) are compared with current technique (MFOspv/sav), using both simulated scenarios and forward-calculated plans on weekly verification computed tomography (VFCT) scans. RESULTS Dose distribution characteristics of the 4-beam, 5-beam, and variant 5-beam technique are demonstrated with discussion on OAR sparing. When comparing the MFOcon, MFOspv, and MFOspv/sav, the MFOspv/sav is shown to have superior OAR sparing in 9 of the 14 OARs examined. It also shows clinical plan robustness when evaluated by using both simulated uncertainty scenarios and forward-calculated weekly VFCTs throughout the 7-week treatment course. CONCLUSION The MFOspv/sav technique is a systematic approach using SPVs and SAVs to guide the optimizer to consistently reach desired OAR dose values and plan robustness.
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Affiliation(s)
- Karla Leach
- California Protons Cancer Therapy Center, San Diego, CA, USA
- Texas Center for Proton Therapy, Irving, TX, USA
| | - Shikui Tang
- Texas Center for Proton Therapy, Irving, TX, USA
| | | | | | - Ryan Grover
- California Protons Cancer Therapy Center, San Diego, CA, USA
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, CA, USA
| | - Parag Sanghvi
- California Protons Cancer Therapy Center, San Diego, CA, USA
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, CA, USA
| | - James Urbanic
- California Protons Cancer Therapy Center, San Diego, CA, USA
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, CA, USA
| | - Chang Chang
- California Protons Cancer Therapy Center, San Diego, CA, USA
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, CA, USA
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17
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Kang DJ, Shin YJ, Jeong S, Jung JY, Lee H, Lee B. Development of clinical application program for radiotherapy induced cancer risk calculation using Monte Carlo engine in volumetric-modulated arc therapy. Radiat Oncol 2021; 16:108. [PMID: 34118968 PMCID: PMC8199704 DOI: 10.1186/s13014-020-01722-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 12/06/2020] [Indexed: 11/10/2022] Open
Abstract
Background The purpose of this study is to develop a clinical application program that automatically calculates the effect for secondary cancer risk (SCR) of individual patient. The program was designed based on accurate dose calculations using patient computed tomography (CT) data and Monte Carlo engine. Automated patient-specific evaluation program was configured to calculate SCR. Methods The application program is designed to re-calculate the beam sequence of treatment plan using the Monte Carlo engine and patient CT data, so it is possible to accurately calculate and evaluate scatter and leakage radiation, difficult to calculate in TPS. The Monte Carlo dose calculation system was performed through stoichiometric calibration using patient CT data. The automatic SCR evaluation program in application program created with a MATLAB was set to analyze the results to calculate SCR. The SCR for organ of patient was calculated based on Biological Effects of Ionizing Radiation (BEIR) VII models. The program is designed to sequentially calculate organ equivalent dose (OED), excess absolute risk (EAR), excess relative risk (ERR), and the lifetime attributable risk (LAR) in consideration of 3D dose distribution analysis. In order to confirm the usefulness of the developed clinical application program, the result values from clinical application program were compared with the manual calculation method used in the previous study. Results The OED values calculated in program were calculated to be at most approximately 13.3% higher than results in TPS. The SCR result calculated by the developed clinical application program showed a maximum difference of 1.24% compared to the result of the conventional manual calculation method. And it was confirmed that EAR, ERR and LAR values can be easily calculated by changing the biological parameters. Conclusions We have developed a patient-specific SCR evaluation program that can be used conveniently in the clinic. The program consists of a Monte Carlo dose calculation system for accurate calculation of scatter and leakage radiation and a patient-specific automatic SCR evaluation program using 3D dose distribution. The clinical application program that improved the disadvantages of the existing process can be used as an index for evaluating a patient treatment plan.
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Affiliation(s)
- Dong-Jin Kang
- Department of Radiation Oncology, Inje University Sanggye Paik Hospital, 1342, Dongil-ro, Nowon-gu, Seoul, Korea
| | - Young-Joo Shin
- Department of Radiation Oncology, Inje University Sanggye Paik Hospital, 1342, Dongil-ro, Nowon-gu, Seoul, Korea.
| | - Seonghoon Jeong
- Proton Therapy Center, National Cancer Center, Goyang, Korea
| | - Jae-Yong Jung
- Department of Radiation Oncology, Inje University Sanggye Paik Hospital, 1342, Dongil-ro, Nowon-gu, Seoul, Korea
| | | | - Boram Lee
- Department of Radiation Oncology, Samsung Medical Center, School of Medicine, Sungkyunkwan University, 81, Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea.
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18
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Liu IC, Holtzman AL, Rotondo RL, Indelicato DJ, Gururangan S, Cavaliere R, Carter B, Morris CG, Tavanaiepour D, Rutenberg MS. Proton therapy for adult medulloblastoma: Acute toxicity and disease control outcomes. J Neurooncol 2021; 153:467-476. [PMID: 34105033 DOI: 10.1007/s11060-021-03783-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 06/03/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE We report disease control, survival outcomes, and treatment-related toxicity among adult medulloblastoma patients who received proton craniospinal irradiation (CSI) as part of multimodality therapy. METHODS We reviewed 20 adults with medulloblastoma (≥ 22 years old) who received postoperative proton CSI ± chemotherapy between 2008 and 2020. Patient, disease, and treatment details and prospectively obtained patient-reported acute CSI toxicities were collected. Acute hematologic data were analyzed. RESULTS Median age at diagnosis was 27 years; 45% of patients had high-risk disease; 75% received chemotherapy, most (65%) after CSI. Eight (40%) patients received concurrent vincristine with radiotherapy. Median CSI dose was 36GyE with a median tumor bed boost of 54GyE. Median duration of radiotherapy was 44 days. No acute ≥ grade 3 gastrointestinal or hematologic toxicities attributable to CSI occurred. Grade 2 nausea and vomiting affected 25% and 5% of patients, respectively, while 36% developed acute grade 2 hematologic toxicity (36% grade 2 leukopenia and 7% grade 2 neutropenia). Those receiving concurrent chemotherapy with CSI had a 38% rate of grade 2 hematologic toxicity compared to 33% among those not receiving concurrent chemotherapy. Among patients receiving adjuvant chemotherapy (n = 13), 100% completed ≥ 4 cycles and 85% completed all planned cycles. With a median follow-up of 3.1 years, 4-year actuarial local control, disease-free survival, and overall survival rates were 90%, 90%, and 95%, respectively. CONCLUSIONS Proton CSI in adult medulloblastoma patients is very well tolerated and shows promising disease control and survival outcomes. These data support the standard use of proton CSI for adult medulloblastoma.
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Affiliation(s)
- I-Chia Liu
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, 2015 North Jefferson Street, Jacksonville, FL, 32206, USA
| | - Adam L Holtzman
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, 2015 North Jefferson Street, Jacksonville, FL, 32206, USA
| | - Ronny L Rotondo
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, 2015 North Jefferson Street, Jacksonville, FL, 32206, USA
| | - Sridharan Gururangan
- Department of Neurosurgery and the Preston A. Wells Jr. Center for Brain Tumor Therapy, University of Florida College of Medicine, Gainesville, FL, USA
| | | | - Bridgette Carter
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, 2015 North Jefferson Street, Jacksonville, FL, 32206, USA
| | - Daryoush Tavanaiepour
- Department of Neurosurgery, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Michael S Rutenberg
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, 2015 North Jefferson Street, Jacksonville, FL, 32206, USA.
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19
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Mizumoto M, Fuji H, Miyachi M, Soejima T, Yamamoto T, Aibe N, Demizu Y, Iwata H, Hashimoto T, Motegi A, Kawamura A, Terashima K, Fukushima T, Nakao T, Takada A, Sumi M, Oshima J, Moriwaki K, Nozaki M, Ishida Y, Kosaka Y, Ae K, Hosono A, Harada H, Ogo E, Akimoto T, Saito T, Fukushima H, Suzuki R, Takahashi M, Matsuo T, Matsumura A, Masaki H, Hosoi H, Shigematsu N, Sakurai H. Proton beam therapy for children and adolescents and young adults (AYAs): JASTRO and JSPHO Guidelines. Cancer Treat Rev 2021; 98:102209. [PMID: 33984606 DOI: 10.1016/j.ctrv.2021.102209] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 04/02/2021] [Accepted: 04/11/2021] [Indexed: 11/19/2022]
Abstract
Children and adolescents and young adults (AYAs) with cancer are often treated with a multidisciplinary approach. This includes use of radiotherapy, which is important for local control, but may also cause adverse events in the long term, including second cancer. The risks for limited growth and development, endocrine dysfunction, reduced fertility and second cancer in children and AYAs are reduced by proton beam therapy (PBT), which has a dose distribution that decreases irradiation of normal organs while still targeting the tumor. To define the outcomes and characteristics of PBT in cancer treatment in pediatric and AYA patients, this document was developed by the Japanese Society for Radiation Oncology (JASTRO) and the Japanese Society of Pediatric Hematology/Oncology (JSPHO).
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Affiliation(s)
- Masashi Mizumoto
- Departments of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hiroshi Fuji
- Department of Radiology and National Center for Child Health and Development, Tokyo, Japan
| | - Mitsuru Miyachi
- Department of Pediatrics, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto, Japan
| | - Toshinori Soejima
- Department of Radiation Oncology, Hyogo Ion Beam Medical Center Kobe Proton Center, Kobe, Hyogo, Japan
| | - Tetsuya Yamamoto
- Department of Neurosurgery, Graduate School of Medicine, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Norihiro Aibe
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yusuke Demizu
- Department of Radiation Oncology, Hyogo Ion Beam Medical Center Kobe Proton Center, Kobe, Hyogo, Japan
| | - Hiromitsu Iwata
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City University West Medical Center, Nagoya, Aichi, Japan
| | - Takayuki Hashimoto
- Department of Radiation Biomedical Science and Engineering, Faculty of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Atsushi Motegi
- Department of Radiation Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Atsufumi Kawamura
- Department of Neurosurgery, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo, Japan
| | - Keita Terashima
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Takashi Fukushima
- Department of Pediatric Hematology and Oncology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Tomohei Nakao
- Department of Pediatrics, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Akinori Takada
- Department of Radiology, Mie University Hospital, Tsu-shi, Mie, Japan
| | - Minako Sumi
- Department of Radiation Oncology and Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan; Department of Radiation Oncology, Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan
| | | | - Kensuke Moriwaki
- Department of Medical Statistics, Kobe Pharmaceutical University, Kobe, Hyogo, Japan
| | - Miwako Nozaki
- Department of Radiology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Yuji Ishida
- Department of Pediatrics, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
| | - Yoshiyuki Kosaka
- Department of Hematology and Oncology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo, Japan
| | - Keisuke Ae
- Department of Orthopaedic Oncology, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Ako Hosono
- Department of Pediatric Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Hideyuki Harada
- Division of Radiation Therapy, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
| | - Etsuyo Ogo
- Department of Radiology, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Tetsuo Akimoto
- Department of Radiation Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Takashi Saito
- Departments of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hiroko Fukushima
- Department of Child Health, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Ryoko Suzuki
- Department of Child Health, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Mitsuru Takahashi
- Department of Orthopaedic Oncology, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
| | - Takayuki Matsuo
- Department of Neurosurgery, Nagasaki University Graduate School of Medicine, Nagasaki, Japan
| | - Akira Matsumura
- Departments of Neurosurgery, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hidekazu Masaki
- Proton Therapy Center, Aizawa Hospital, Matsumoto, Nagano, Japan
| | - Hajime Hosoi
- Department of Pediatrics, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto, Japan
| | - Naoyuki Shigematsu
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Hideyuki Sakurai
- Departments of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan.
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Practical aspects of the application of helical tomotherapy for craniospinal irradiation. Sci Rep 2021; 11:6120. [PMID: 33731843 PMCID: PMC7969733 DOI: 10.1038/s41598-021-85574-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 03/03/2021] [Indexed: 11/26/2022] Open
Abstract
We investigated the practical aspects of the application of craniospinal irradiation using helical tomotherapy (HT-CSI) by evaluating interfractional setup errors and intrafractional movement during each treatment in 83 patients undergoing HT-CSI between January 2014 and December 2018. Interfractional setup errors in each axis (mediolateral; ML, craniocaudal; CC, and anteroposterior; AP) were assessed as differences between pre-treatment megavoltage computed tomography (MVCT) images scanned (zygomatic arch to the C4 spine) and planning CT images. Intrafractional movements were evaluated as the difference between pre-treatment and post-treatment MVCT (T12–L4 spine) images at each fraction. Median interfractional setup error was acceptable in every axis (ML: 1.6 mm, CC: 1.9 mm, AP: 3.1 mm). Seven patients (8.4%) experienced significant intrafractional displacement from 1 to 10 fractions (0.34% for ML, 0.74% for CC, 1.21% for AP). Weight loss grade 1+ during treatment (p = 0.016) was an independent risk factor for significant intrafractional displacement. The risk factor for significant intrafractional movement in pediatric patients was weight loss grade 1+ (p = 0.020), while there was no factor in adults. HT-CSI could be a feasible treatment modality with acceptable setup verification. Inter- and intrafractional errors were acceptable; paying attention to weight loss during treatment is necessary, especially in pediatric patients.
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21
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A novel inverse optimization based three-dimensional conformal radiotherapy technique in craniospinal irradiation. Phys Eng Sci Med 2021; 44:265-275. [PMID: 33559040 DOI: 10.1007/s13246-021-00976-6] [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] [Received: 07/28/2020] [Revised: 01/15/2021] [Accepted: 01/19/2021] [Indexed: 10/22/2022]
Abstract
Our aim was to develop a novel inverse optimization-based three-dimensional conformal radiotherapy (i3DCRT) technique for craniospinal irradiation. The imaging data of 20 patients with medulloblastoma were used retrospectively. The first group included 10 pediatric patients with supine position treated under anesthesia/sedation, and the second group included 10 young adult/adult patients treated with prone position. Three different treatment plans were created for each patient via i3DCRT, forward-planned three-dimensional conformal radiotherapy (f3DCRT) and intensity-modulated radiotherapy (IMRT) techniques. A total dose of 36 Gy was prescribed in 20 fractions for all plans. The comparative evaluation was conducted by using the parameters of conformity-index, homogeneity-index, and doses to the target volumes and organs at risk (OARs). The plans created with i3DCRT technique achieved better conformity and homogeneity compared to f3DCRT. In terms of OARs sparing, we found pronounced dose reductions in esophagus and heart in i3DCRT compared to f3DCRT plans. i3DCRT technique also provided a well-conformed dose distribution not superior, but comparable, to IMRT without increase in the total monitor unit per fraction (MU/fx) with respect to f3DCRT. The average monitor unit per fraction (MU/fx) for i3DCRT, f3DCRT and IMRT plans were found as 379.3, 378.0 and 1051.7 MU for the first group and 577.4, 563.5 and 1368.7 MU for the second group, respectively. Novel i3DCRT technique solves the problems associated with field junctions and beam edge matching encountered in f3DCRT plans. Additionally, i3DCRT technique can create almost similar plans as with IMRT with lower total MU/fx.
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22
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Kumar N, Madan R, Gupta K, Chatterjee D, Uppal DK, Goyal S, Ballari N, Khosla D, Sahoo SK, Ahuja CK. Embryonal tumors with multilayered rosettes: A tertiary care centre experience. Clin Neurol Neurosurg 2021; 202:106508. [PMID: 33556852 DOI: 10.1016/j.clineuro.2021.106508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/15/2021] [Accepted: 01/16/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Embryonal tumors with multilayered rosettes (ETMR) is an extremely rare and highly aggressive tumor. It includes three distinct entities i.e, embryonal tumor with abundant neuropil and true rosettes (ETANTR), ependymoblastoma (EBL) and medulloepithelioma (MEPL). Here, we present our institutional experience of seven ETMR cases treated over a period of five years. MATERIALS AND METHODS Patients' records from 2015 to 2019 were reviewed manually and electronically to retrieve the data. Clinicopathological and outcome details of ETMR cases were entered in a predesigned proforma. RESULTS A total of seven cases of ETMR were registered from 2015 to 2019 with a median age at presentation of four years (range 3-7 years). All patients underwent surgery. However, only three patients completed the planned adjuvant treatment, comprising of focal radiotherapy (RT) alone, craniospinal irradiation (CSI) alone and CSI followed by six cycles of chemotherapy in one patient each respectively. Two patients commenced CSI but deteriorated during RT and thereafter needed best supportive care. Two patients could not be started on any adjuvant treatment. Unfortunately, six patients succumbed to their disease within one year of their diagnosis. Only one patient who received both CSI and adjuvant chemotherapy is alive at 15 months of diagnosis. CONCLUSION ETMR is a rare and aggressive entity. Majority of the patients die within one year of the diagnosis despite multimodality treatment.
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MESH Headings
- Brain Neoplasms/diagnostic imaging
- Brain Neoplasms/mortality
- Brain Neoplasms/pathology
- Brain Neoplasms/therapy
- Chemoradiotherapy, Adjuvant
- Child
- Child, Preschool
- Female
- Humans
- Male
- Neoplasms, Germ Cell and Embryonal/diagnostic imaging
- Neoplasms, Germ Cell and Embryonal/mortality
- Neoplasms, Germ Cell and Embryonal/pathology
- Neoplasms, Germ Cell and Embryonal/therapy
- Neuroectodermal Tumors, Primitive/diagnostic imaging
- Neuroectodermal Tumors, Primitive/mortality
- Neuroectodermal Tumors, Primitive/pathology
- Neuroectodermal Tumors, Primitive/therapy
- Neurosurgical Procedures
- Radiotherapy, Adjuvant
- Tertiary Care Centers
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Affiliation(s)
- N Kumar
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - R Madan
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - K Gupta
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - D Chatterjee
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - D K Uppal
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - S Goyal
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - N Ballari
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - D Khosla
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - S K Sahoo
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - C K Ahuja
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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23
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An Analysis of Vertebral Body Growth after Proton Beam Therapy for Pediatric Cancer. Cancers (Basel) 2021; 13:cancers13020349. [PMID: 33477867 PMCID: PMC7832908 DOI: 10.3390/cancers13020349] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/13/2021] [Accepted: 01/15/2021] [Indexed: 12/03/2022] Open
Abstract
Simple Summary Radiotherapy has a key role in treatment of pediatric cancer and has greatly improved survival in recent years. However, vertebrae are often included in the irradiated area, and this may affect growth after treatment. In this study, we examined the relationship of the dose of proton beam therapy with subsequent growth of 353 vertebral bodies in 23 children (10 boys, 13 girls) with a median age at treatment of 4 years old and a median observation period of 13.9 months. Most importantly, we found that the growth rate of vertebral bodies decreased even at a low proton beam therapy dose, which indicates the need for careful planning of the irradiation area in this patient population. Growth inhibition was clearly dose-dependent, and proton beam therapy had the same growth inhibitory effect as photon radiotherapy, at least within the irradiated field. Abstract Impairment of bone growth after radiotherapy for pediatric bone cancer is a well-known adverse event. However, there is limited understanding of the relationship between bone growth and irradiation dose. In this study, we retrospectively analyzed bone growth impairment after proton beam therapy for pediatric cancer. A total of 353 vertebral bodies in 23 patients under 12 years old who received proton beam therapy were evaluated. Compared to the non-irradiated vertebral body growth rate, the irradiated vertebral body rate (%/year) was significantly lower: 77.2%, 57.6%, 40.8%, 26.4%, and 14.1% at 10, 20, 30, 40, and 50 Gy (RBE) irradiation, respectively. In multivariate analysis, radiation dose was the only factor correlated with vertebral body growth. Age, gender, and vertebral body site were not significant factors. These results suggest that the growth rate of the vertebral body is dose-dependent and decreases even at a low irradiated dose. This is the first report to show that proton beam therapy has the same growth inhibitory effect as photon radiotherapy within the irradiated field.
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Brandal P, Bergfeldt K, Aggerholm-Pedersen N, Bäckström G, Kerna I, Gubanski M, Björnlinger K, Evensen ME, Kuddu M, Pettersson E, Brydøy M, Hellebust TP, Dale E, Valdman A, Weber L, Høyer M. A Nordic-Baltic perspective on indications for proton therapy with strategies for identification of proper patients. Acta Oncol 2020; 59:1157-1163. [PMID: 32902341 DOI: 10.1080/0284186x.2020.1817977] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The beneficial effects of protons are primarily based on reduction of low to intermediate radiation dose bath to normal tissue surrounding the radiotherapy target volume. Despite promise for reduced long-term toxicity, the percentage of cancer patients treated with proton therapy remains low. This is probably caused by technical improvements in planning and delivery of photon therapy, and by high cost, low availability and lack of high-level evidence on proton therapy. A number of proton treatment facilities are under construction or have recently opened; there are now two operational Scandinavian proton centres and two more are under construction, thereby eliminating the availability hurdle. Even with the advantageous physical properties of protons, there is still substantial ambiguity and no established criteria related to which patients should receive proton therapy. This topic was discussed in a session at the Nordic Collaborative Workshop on Particle Therapy, held in Uppsala 14-15 November 2019. This paper resumes the Nordic-Baltic perspective on proton therapy indications and discusses strategies to identify patients for proton therapy. As for indications, neoplastic entities, target volume localisation, size, internal motion, age, second cancer predisposition, dose escalation and treatment plan comparison based on the as low as reasonably achievable (ALARA) principle or normal tissue complication probability (NTCP) models were discussed. Importantly, the patient selection process should be integrated into the radiotherapy community and emphasis on collaboration across medical specialties, involvement of key decision makers and knowledge dissemination in general are important factors. An active Nordic-Baltic proton therapy organisation would also serve this purpose.
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Affiliation(s)
- Petter Brandal
- Department of Oncology, Oslo University Hospital, Oslo, Norway
- Section for Cancer Cytogenetics, Institute for Cancer Genetics and Informatics, Oslo University Hospital, Oslo, Norway
| | | | | | | | - Irina Kerna
- North Estonia Medical Centre, Tallinn, Estonia
| | | | | | | | - Maire Kuddu
- North Estonia Medical Centre, Tallinn, Estonia
| | | | | | - Taran P. Hellebust
- Department of Oncology, Oslo University Hospital, Oslo, Norway
- Department of Physics, University of Oslo, Oslo, Norway
| | - Einar Dale
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | | | | | - Morten Høyer
- Danish Center for Particle Therapy, Aarhus University Hospital, Denmark
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25
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Kotecha R, Tom MC, Naik M, Angelov L, Benzel EC, Reddy CA, Prayson RA, Kalfas I, Schlenk R, Krishnaney A, Steinmetz MP, Bingaman W, Suh JH, Chao ST. Analyzing the role of adjuvant or salvage radiotherapy for spinal myxopapillary ependymomas. J Neurosurg Spine 2020; 33:392-397. [PMID: 32357340 DOI: 10.3171/2020.2.spine191534] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 02/20/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors sought to describe the long-term recurrence patterns, prognostic factors, and effect of adjuvant or salvage radiotherapy (RT) on treatment outcomes for patients with spinal myxopapillary ependymoma (MPE). METHODS The authors reviewed a tertiary institution IRB-approved database and collected data regarding patient, tumor, and treatment characteristics for all patients treated consecutively from 1974 to 2015 for histologically confirmed spinal MPE. Key outcomes included relapse-free survival (RFS), postrecurrence RFS, failure patterns, and influence of timing of RT on recurrence patterns. Cox proportional hazards regression and Kaplan-Meier analyses were utilized. RESULTS Of the 59 patients included in the study, the median age at initial surgery was 34 years (range 12-74 years), 30 patients (51%) were female, and the most common presenting symptom was pain (n = 52, 88%). Extent of resection at diagnosis was gross-total resection (GTR) in 39 patients (66%), subtotal resection (STR) in 15 (25%), and unknown in 5 patients (9%). After surgery, 10 patients (17%) underwent adjuvant RT (5/39 GTR [13%] and 5/15 STR [33%] patients). Median follow-up was 6.2 years (range 0.1-35.3 years). Overall, 20 patients (34%) experienced recurrence (local, n = 15; distant, n = 5). The median RFS was 11.2 years (95% CI 77 to not reached), and the 5- and 10-year RFS rates were 72.3% (95% CI 59.4-86.3) and 54.0% (95% CI, 36.4-71.6), respectively.STR was associated with a higher risk of recurrence (HR 6.45, 95% CI 2.15-19.23, p < 0.001) than GTR, and the median RFS after GTR was 17.2 years versus 5.5 years after STR. Adjuvant RT was not associated with improved RFS, regardless of whether it was delivered after GTR or STR. Of the 20 patients with recurrence, 12 (60%) underwent salvage treatment with surgery alone (GTR, n = 6), 4 (20%) with RT alone, and 4 (20%) with surgery and RT. Compared to salvage surgery alone, salvage RT, with or without surgery, was associated with a significantly longer postrecurrence RFS (median 9.5 years vs 1.6 years; log-rank, p = 0.006). CONCLUSIONS At initial diagnosis of spinal MPE, GTR is key to long-term RFS, with no benefit to immediate adjuvant RT observed in this series. RT at the time of recurrence, however, is associated with a significantly longer time to second disease recurrence. Surveillance imaging of the entire neuraxis remains crucial, as distant failure is not uncommon in this patient population.
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Affiliation(s)
- Rupesh Kotecha
- 1Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami
- 2Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Martin C Tom
- 3Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic; and Departments of
| | - Mihir Naik
- 3Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic; and Departments of
| | | | | | - Chandana A Reddy
- 3Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic; and Departments of
| | | | | | | | | | | | | | - John H Suh
- 3Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic; and Departments of
| | - Samuel T Chao
- 3Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic; and Departments of
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26
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Isobe T, Mori Y, Takei H, Sato E, Sakae T. [14. Biological Dose and Effects of Neutrons in Proton Beam Therapy]. Nihon Hoshasen Gijutsu Gakkai Zasshi 2020; 76:863-869. [PMID: 32814743 DOI: 10.6009/jjrt.2020_jsrt_76.8.863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
| | | | | | - Eisuke Sato
- Faculty of Health Science, Juntendo University
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27
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Carbonara R, Di Rito A, Monti A, Rubini G, Sardaro A. Proton versus Photon Radiotherapy for Pediatric Central Nervous System Malignancies: A Systematic Review and Meta-Analysis of Dosimetric Comparison Studies. JOURNAL OF ONCOLOGY 2019; 2019:5879723. [PMID: 31885580 PMCID: PMC6900940 DOI: 10.1155/2019/5879723] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 10/21/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Radiotherapy (RT) plays a fundamental role in the treatment of pediatric central nervous system (CNS) malignancies, but its late sequelae are still a challenging question. Despite developments in modern high-conformal photon techniques and proton beam therapy (PBT) are improving the normal tissues dose-sparing while maintaining satisfactory target coverage, clinical advantages supporting the optimal treatment strategy have to be better evaluated in long-term clinical studies and assessed in further radiobiological analyses. Our analysis aimed to systematically review current knowledge on the dosimetric advantages of PBT in the considered setting, which should be the basis for future specific studies. MATERIALS AND METHODS A PubMed and Google Scholar search was conducted in June 2019 to select dosimetric studies comparing photon versus proton RT for pediatric patients affected by CNS tumors. Then, a systematic review and meta-analysis according to the PRISMA statement was performed. Average and standard deviation values of Conformity Index, Homogeneity Index, and mean and maximum doses to intracranial and extracranial organs at risk (OARs) were specifically evaluated for secondary dosimetric comparisons. The standardized mean differences (SMDs) for target parameters and the mean differences (MDs) for OARs were summarized in forest plots (P < 0.05 was considered statistically significant). Publication bias was also assessed by the funnel plot and Egger's regression test. RESULTS Among the 88 identified papers, a total of twelve studies were included in the meta-analysis. PBT showed dosimetric advantages in target homogeneity (significant especially in the subgroup comparing PBT and 3D conformal RT), as well as in the dose sparing of almost all analyzed OARs (significantly superior results for brainstem, normal brain, and hippocampal dose constraints and for extracranial OARs parameters, excluding the kidneys). Publication bias was observed for Conformity Index. CONCLUSION Our analysis supports the evidence of dosimetric advantages of PBT over photon RT, especially in the dose sparing of normal growing tissues. Confirmations from wider well-designed studies are required.
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Affiliation(s)
- Roberta Carbonara
- Interdisciplinary Department of Medicine, Section of Radiology and Radiation Oncology, University of Bari Aldo Moro, Bari, Italy
| | - Alessia Di Rito
- Radiation Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Bari, Italy
| | - Angela Monti
- Interdisciplinary Department of Medicine, Section of Radiology and Radiation Oncology, University of Bari Aldo Moro, Bari, Italy
| | - Giuseppe Rubini
- Interdisciplinary Department of Medicine, Section of Nuclear Medicine, University of Bari Aldo Moro, Bari, Italy
| | - Angela Sardaro
- Interdisciplinary Department of Medicine, Section of Radiology and Radiation Oncology, University of Bari Aldo Moro, Bari, Italy
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Plan Quality and Secondary Cancer Risk Assessment in Patients with Benign Intracranial Lesions after Radiosurgery using the CyberKnife M6 Robotic Radiosurgery System. Sci Rep 2019; 9:9953. [PMID: 31289294 PMCID: PMC6616465 DOI: 10.1038/s41598-019-46133-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 06/17/2019] [Indexed: 12/31/2022] Open
Abstract
This study was performed to examine the quality of planning and treatment modality using a CyberKnife (CK) robotic radiosurgery system with multileaf collimator (MLC)-based plans and IRIS (variable aperture collimator system)-based plans in relation to the dose–response of secondary cancer risk (SCR) in patients with benign intracranial tumors. The study population consisted of 15 patients with benign intracranial lesions after curative treatment using a CyberKnife M6 robotic radiosurgery system. Each patient had a single tumor with a median volume of 6.43 cm3 (range, 0.33–29.72 cm3). The IRIS-based plan quality and MLC-based plan quality were evaluated by comparing the dosimetric indices, taking into account the planning target volume (PTV) coverage, the conformity index (CI), and the dose gradient (R10% and R50%). The dose–response SCR with sarcoma/carcinoma induction was calculated using the concept of the organ equivalent dose (OED). Analyses of sarcoma/carcinoma induction were performed using excess absolute risk (EAR) and various OED models of dose–response type/lifetime attributable risk (LAR). Moreover, analyses were performed using the BEIR VII model. PTV coverage using both IRIS-based plans and MLC-based plans was identical, although the CI values obtained using the MLC-based plans showed greater statistical significance. In comparison with the IRIS-based plans, the MLC-based plans showed better dose falloff for R10% and R50% evaluation. The estimated difference between Schneider’s model and BEIR VII in linear-no-threshold (Lnt) cumulative EAR was about twofold. The average values of LAR/EAR for carcinoma, for the IRIS-based plans, were 25% higher than those for the MLC-based plans using four SCR models; for sarcoma, they were 15% better in Schneider’s SCR models. MLC-based plans showed slightly better conformity, dose gradients, and SCR reduction. There was a slight increase in SCR with IRIS-based plans in comparison with MLC-based plans. EAR analyses did not show any significant difference between PTV and brainstem analyses, regardless of the tumor volume. Nevertheless, an increase in target volume led to an increase in the probability of SCR. EAR showed statistically significant differences in the soft tissue according to tumor volume (1–10 cc and ≥10 cc).
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29
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Sherif RS, Elshemey WM, Attalla EM. The risk of secondary cancer in pediatric medulloblastoma patients due to three-dimensional conformal radiotherapy and intensity-modulated radiotherapy. Indian J Cancer 2019; 55:372-376. [PMID: 30829273 DOI: 10.4103/ijc.ijc_410_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Craniospinal irradiation (CSI) is the standard radiation therapy treatment for medulloblastoma. The aim of this study was to estimate and compare the lifetime risk of radiation-induced secondary cancer in pediatric medulloblastoma patients using three-dimensional conformal radiotherapy (3D-CRT) and intensity-modulated radiotherapy (IMRT). MATERIALS AND METHODS 3D-CRT and IMRT plans were performed for 10 CSI pediatric patients. The average absorbed doses for organs at risk (OARs) was calculated from dose-volume histograms on the treatment planning system. The average lifetime risk of radiation-induced secondary cancer was then calculated. RESULTS Lifetime risk of secondary cancer for CSI pediatric patients treated using IMRT decreases in some OARs compared with those treated using 3D-CRT. This is attributable to the decrease in the average absorbed dose in some OARs when using IMRT technique. CONCLUSION Follow-up of medulloblastoma pediatric patients should be performed after ending the treatment course in order to diagnose early secondary tumors. IMRT technique is substantially better than 3D-CRT in terms of lifetime risk of radiation-induced secondary cancer, probably due to reduced dose to OARs especially to the thyroid, which is the most sensitive organ to radiation.
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Affiliation(s)
- Reham S Sherif
- Department of Biophysics, Faculty of Science, Cairo University, Cairo, Egypt
| | - Wael M Elshemey
- Department of Biophysics, Faculty of Science, Cairo University, Cairo, Egypt
| | - Ehab M Attalla
- Department of Radiotherapy and Nuclear Medicine, National Cancer Institute, Cairo University, Giza; Department of Radiotherapy, Children Cancer Hospital, Cairo, Egypt
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Kotecha R, Mehta MP, Chang EL, Brown PD, Suh JH, Lo SS, Das S, Samawi HH, Keith J, Perry J, Sahgal A. Updates in the management of intradural spinal cord tumors: a radiation oncology focus. Neuro Oncol 2019; 21:707-718. [PMID: 30977511 PMCID: PMC6556849 DOI: 10.1093/neuonc/noz014] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Primary spinal cord tumors represent a hetereogeneous group of central nervous system malignancies whose management is complex given the relatively uncommon nature of the disease and variety of tumor subtypes, functional neurologic deficits from the tumor, and potential morbidities associated with definitive treatment. Advances in neuroimaging; integration of diagnostic, prognostic, and predictive molecular testing into tumor classification; and developments in neurosurgical techniques have refined the current role of radiotherapy in the multimodal management of patients with primary spinal cord tumors, and corroborated the need for prospective, multidisciplinary discussion and treatment decision making. Radiotherapeutic technological advances have dramatically improved the entire continuum from treatment planning to treatment delivery, and the development of stereotactic radiosurgery and proton radiotherapy provides new radiotherapy options for patients treated in the definitive, adjuvant, or salvage setting. The objective of this comprehensive review is to provide a contemporary overview of the management of primary intradural spinal cord tumors, with a focus on radiotherapy.
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Affiliation(s)
- Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Eric L Chang
- Department of Radiation Oncology, University of Southern California, Los Angeles, California, USA
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland, Ohio, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Sunit Das
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Haider H Samawi
- Division of Hematology/Oncology, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Julia Keith
- Department of Anatomical Pathology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - James Perry
- Department of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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31
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Sun Y, Liu G, Chen W, Chen T, Liu P, Zeng Q, Hong J, Wei R. Dosimetric comparisons of craniospinal axis irradiation using helical tomotherapy, volume-modulated arc therapy and intensity-modulated radiotherapy for medulloblastoma. Transl Cancer Res 2019; 8:191-202. [PMID: 35116748 PMCID: PMC8797767 DOI: 10.21037/tcr.2019.01.30] [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] [Received: 10/08/2018] [Accepted: 01/15/2019] [Indexed: 11/06/2022]
Abstract
Background To evaluate the potential dosimetric gains of helical tomotherapy (HT) versus intensity-modulated radiotherapy (IMRT) and volume-modulated arc therapy (VMAT) for craniospinal axis irradiation (CSI) of medulloblastoma. Methods A total of 36 treatment plans were calculated retrospectively for 12 patients with medulloblastoma receiving CSI using HT with TomoTherapy Hi-Art Software (Version 2.0.7) (Accuray, Madison, WI, USA). For each case, the other two different delivery techniques were re-planned with IMRT/VMAT optimized with Eclipse treatment planning system (TPS) (Version 11.0.31). Homogeneity index (HI) and conformity index (CI) of the planning target volume (PTV) and organs at risk (OARs) sparing were analyzed. Differences in plans were evaluated using paired-samples t-test for various dosimetric parameters. Results HT yielded the highest CI in all PTV coverage including PTV of gross tumor volume (PGTV) (HT: 0.7163; VMAT: 0.6688; IMRT: 0.6096), PTVbrain (HT: 0.8490; VMAT: 0.8384; IMRT: 0.7815) and PTVspine (HT: 0.5904; VMAT: 0.5862; IMRT: 0.5797). Meanwhile, HT yielded better HI in PGTV (HT: 0.0543; VMAT: 0.0759; IMRT: 0.0736), PTVbrain (HT: 0.5525; VMAT: 0.5619; IMRT: 0.5554) and PTVspine (HT: 0.0700; VMAT: 0.0782; IMRT: 0.0877). As for OARs, HT demonstrated marked superiority in critical organs including maximal/mean doses of brainstem PRV, optical chiasm and optic nerves. Conclusions For CSI of medulloblastoma, HT offers superior outcomes in terms of PTV conformity, PTV homogeneity and critical OAR sparing as compared with IMRT/VMAT.
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Affiliation(s)
- Yangqing Sun
- Department of Oncology, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Gui Liu
- Department of Oncology, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Wen Chen
- Department of Oncology, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Taili Chen
- Department of Oncology, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Pei Liu
- Department of Oncology, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Qian Zeng
- Department of Oncology, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Jidong Hong
- Department of Oncology, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Rui Wei
- Department of Oncology, Xiangya Hospital, Central South University, Changsha 410008, China
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Black PJ, Velten C, Wang YF, Na YH, Wuu CS. An investigation of clinical treatment field delivery verification using cherenkov imaging: IMRT positioning shifts and field matching. Med Phys 2018; 46:302-317. [PMID: 30346639 DOI: 10.1002/mp.13250] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 10/01/2018] [Accepted: 10/10/2018] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Cherenkov light emission has been shown to correlate with ionizing radiation dose delivery in solid tissue. An important clinical application of Cherenkov light is the real-time verification of radiation treatment delivery in vivo. To test the feasibility of treatment field verification, Cherenkov light images were acquired concurrent with radiation beam delivery to standard and anthropomorphic phantoms. Specifically, we tested two clinical treatment scenarios: (a) Observation of field overlaps or gaps in matched 3D fields and (b) Patient positioning shifts during intensity modulated radiation therapy (IMRT) field delivery. Further development of this technique would allow real-time detection of treatment delivery errors on the order of millimeters so that patient safety and treatment quality can be improved. METHODS Cherenkov light emission was captured using a PI-MAX4 intensified charge coupled device (ICCD) system (Princeton Instruments). All radiation delivery was performed using a Varian Trilogy linear accelerator (linac) operated at 6 MV or 18 MV for photon and 6 MeV or 16 MeV for electron studies. Field matching studies were conducted with photon and electron beams at gantry angles of 0°, 15°, and 45°. For each modality and gantry angle, a total of three data sets were acquired. Overlap and gap distances of 0, 2, 5, and 10 mm were tested and delivered to solid phantom material of 30 × 30 × 5 cm3 . Phantom materials used were white plastic water and brown solid water. Tests were additionally performed on an anthropomorphic phantom with an irregular surface. Positioning shift studies were performed using IMRT fields delivered to a thoracic anthropomorphic phantom. For thoracic phantom measurements, the camera was placed laterally to observe the entire right side of the phantom. Fields were delivered with known translational patient positioning shifts in four directions. Changes in the Cherenkov fluence were evaluated through the generation of difference maps from unshifted Cherenkov images. All images were evaluated using ImageJ, Python, and MATLAB software packages. RESULTS For matched fields, Cherenkov images were able to quantitate matched field separations with discrepancies between 2 and 4 mm, depending on gantry angle and beam energy or modality. For all photon and electron beams delivered at a gantry angle of 0°, image analysis indicated average discrepancies of less than 2 mm for all field gaps and overlaps, with 83% of matched fields exhibiting discrepancies less than 1 mm. Beams delivered obliquely to the phantom surface exhibited average discrepancies as high as 4 mm for electron beams delivered at large oblique angles. Finally, for IMRT field delivery, vertical and lateral patient positioning shifts of 2 mm were detected in some cases, indicating the potential detectability threshold of using this technique alone. CONCLUSIONS Our study indicates that Cherenkov imaging can be used to support and bolster current treatment delivery verification techniques, improving our ability to recognize and rectify millimeter-scale delivery and positioning errors.
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Affiliation(s)
- Paul J Black
- Department of Radiation Oncology, Columbia University, New York, NY, 10032, USA.,Department of Radiation Oncology, Novant Health, Winston-Salem, NC, 27103, USA
| | - Christian Velten
- Department of Radiation Oncology, Columbia University, New York, NY, 10032, USA
| | - Yi-Fang Wang
- Department of Radiation Oncology, Columbia University, New York, NY, 10032, USA
| | - Yong Hum Na
- Department of Radiation Oncology, Columbia University, New York, NY, 10032, USA
| | - Cheng-Shie Wuu
- Department of Radiation Oncology, Columbia University, New York, NY, 10032, USA.,Department of Applied Physics and Applied Mathematics, Columbia University, New York, NY, 10027, USA
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Jaramillo S, Grosshans DR, Philip N, Varan A, Akyüz C, McAleer MF, Mahajan A, McGovern SL. Radiation for ETMR: Literature review and case series of patients treated with proton therapy. Clin Transl Radiat Oncol 2018; 15:31-37. [PMID: 30582019 PMCID: PMC6297264 DOI: 10.1016/j.ctro.2018.11.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/05/2018] [Accepted: 11/05/2018] [Indexed: 12/21/2022] Open
Abstract
Background and purpose Embryonal tumors with multilayered rosettes (ETMRs) are aggressive tumors that typically occur in young children. Radiation is often deferred or delayed for these patients due to late effects; proton therapy may mitigate some of these concerns. This study reviews the role of radiation in ETMR and describes initial results with proton therapy. Materials and methods Records of patients with embryonal tumor with abundant neuropil and true rosettes (ETANTR), medulloepithelioma (MEP), and ependymoblastoma (EPL) treated with proton therapy at our institution were retrospectively reviewed. A literature review of cases of CNS ETANTR, MEP, and EPL published since 1990 was also conducted. Results Seven patients were treated with proton therapy. Their median age at diagnosis was 33 months (range 10-57 months) and their median age at radiation start was 42 months (range 17-58 months). Their median overall survival (OS) was 16 months (range 8-64 months), with three patients surviving 36 months or longer. Five patients had disease progression prior to starting radiation; all 5 of these patients failed in the tumor bed. A search of the literature identified 204 cases of ETMR with a median OS of 10 months (range 0.03-161 months). Median OS of 18 long-term survivors (≥36 months) in the literature was 77 months (range 37-184 months). Of these 18 long-term survivors, 17 (94%) received radiotherapy as part of their initial treatment; 14 of them were treated with craniospinal irradiation. Conclusions Outcomes of patients with ETMR treated with proton therapy are encouraging compared to historical results. Further study of this rare tumor is warranted to better define the role of radiotherapy.
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Affiliation(s)
- Sergio Jaramillo
- Department of Radiation Oncology, Baylor College of Medicine, Houston, TX, United States
| | - David R Grosshans
- Department of Radiation Oncology, UT MD Anderson Cancer Center, Houston, TX, United States
| | - Nancy Philip
- Department of Radiation Oncology, UT MD Anderson Cancer Center, Houston, TX, United States
| | - Ali Varan
- Department of Pediatric Oncology, Hacettepe University, Institute of Oncology, Ankara, Turkey
| | - Canan Akyüz
- Department of Pediatric Oncology, Hacettepe University, Institute of Oncology, Ankara, Turkey
| | - Mary Frances McAleer
- Department of Radiation Oncology, UT MD Anderson Cancer Center, Houston, TX, United States
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Susan L McGovern
- Department of Radiation Oncology, UT MD Anderson Cancer Center, Houston, TX, United States
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Seravalli E, Bosman M, Lassen-Ramshad Y, Vestergaard A, Oldenburger F, Visser J, Koutsouveli E, Paraskevopoulou C, Horan G, Ajithkumar T, Timmermann B, Fuentes CS, Whitfield G, Marchant T, Padovani L, Garnier E, Gandola L, Meroni S, Hoeben BAW, Kusters M, Alapetite C, Losa S, Goudjil F, Magelssen H, Evensen ME, Saran F, Smyth G, Rombi B, Righetto R, Kortmann RD, Janssens GO. Dosimetric comparison of five different techniques for craniospinal irradiation across 15 European centers: analysis on behalf of the SIOP-E-BTG (radiotherapy working group) . Acta Oncol 2018; 57:1240-1249. [PMID: 29698060 DOI: 10.1080/0284186x.2018.1465588] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE Conventional techniques (3D-CRT) for craniospinal irradiation (CSI) are still widely used. Modern techniques (IMRT, VMAT, TomoTherapy®, proton pencil beam scanning [PBS]) are applied in a limited number of centers. For a 14-year-old patient, we aimed to compare dose distributions of five CSI techniques applied across Europe and generated according to the participating institute protocols, therefore representing daily practice. MATERIAL AND METHODS A multicenter (n = 15) dosimetric analysis of five different techniques for CSI (3D-CRT, IMRT, VMAT, TomoTherapy®, PBS; 3 centers per technique) was performed using the same patient data, set of delineations and dose prescription (36.0/1.8 Gy). Different treatment plans were optimized based on the same planning target volume margin. All participating institutes returned their best treatment plan applicable in clinic. RESULTS The modern radiotherapy techniques investigated resulted in superior conformity/homogeneity-indices (CI/HI), particularly in the spinal part of the target (CI: 3D-CRT:0.3 vs. modern:0.6; HI: 3D-CRT:0.2 vs. modern:0.1), and demonstrated a decreased dose to the thyroid, heart, esophagus and pancreas. Dose reductions of >10.0 Gy were observed with PBS compared to modern photon techniques for parotid glands, thyroid and pancreas. Following this technique, a wide range in dosimetry among centers using the same technique was observed (e.g., thyroid mean dose: VMAT: 5.6-24.6 Gy; PBS: 0.3-10.1 Gy). CONCLUSIONS The investigated modern radiotherapy techniques demonstrate superior dosimetric results compared to 3D-CRT. The lowest mean dose for organs at risk is obtained with proton therapy. However, for a large number of organs ranges in mean doses were wide and overlapping between techniques making it difficult to recommend one radiotherapy technique over another.
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Affiliation(s)
- Enrica Seravalli
- Department of Radiation Oncology, University Medical Center Utrecht and Princess Maxima Centre for Pediatric Oncology, Utrecht, The Netherlands
| | - Mirjam Bosman
- Department of Radiation Oncology, University Medical Center Utrecht and Princess Maxima Centre for Pediatric Oncology, Utrecht, The Netherlands
| | - Yasmin Lassen-Ramshad
- Department of Oncology and Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Anne Vestergaard
- Department of Oncology and Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Foppe Oldenburger
- Department of Radiation Oncology, Academic Medical Center, Amsterdam, The Netherlands
| | - Jorrit Visser
- Department of Radiation Oncology, Academic Medical Center, Amsterdam, The Netherlands
| | - Efi Koutsouveli
- Department of Radiation Oncology, Hygeia Hospital, Athens, Greece
| | | | - Gail Horan
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Thankamma Ajithkumar
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Beate Timmermann
- Clinic for Particle Therapy, West German Protontherapy Center Essen, University Hospital Essen, Essen, Germany
| | - Carolina-Sofia Fuentes
- Clinic for Particle Therapy, West German Protontherapy Center Essen, University Hospital Essen, Essen, Germany
| | - Gillian Whitfield
- The University of Manchester, Manchester Academic Health Science Centre, The Christie NHS Foundation Trust, Manchester, UK and The Children's Brain Tumour Research Network, University of Manchester, Royal Mancheste Children's Hospital, Manchester, UK
| | | | - Laetitia Padovani
- Department of Radiotherapy, Centre Hospitalier Universitaire de La Timone, Marseille, France
| | - Eloise Garnier
- Department of Radiotherapy, Centre Hospitalier Universitaire de La Timone, Marseille, France
| | - Lorenza Gandola
- Pediatric Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Silvia Meroni
- Pediatric Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Bianca A. W. Hoeben
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Martijn Kusters
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Claire Alapetite
- Department of Radiation Oncology, Institut Curie and Centre de protontherapie, Paris and Orsay, France
| | - Sandra Losa
- Department of Radiation Oncology, Institut Curie and Centre de protontherapie, Paris and Orsay, France
| | - Farid Goudjil
- Department of Radiation Oncology, Institut Curie and Centre de protontherapie, Paris and Orsay, France
| | - Henriette Magelssen
- Department of Oncology, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Morten Egeberg Evensen
- Department of Oncology, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Frank Saran
- The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - Gregory Smyth
- Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Barbara Rombi
- Protontherapy Center, Azienda Provinciale per i Servizi Sanitari APSS, Trento, Italy
| | - Roberto Righetto
- Protontherapy Center, Azienda Provinciale per i Servizi Sanitari APSS, Trento, Italy
| | | | - Geert O. Janssens
- Department of Radiation Oncology, University Medical Center Utrecht and Princess Maxima Centre for Pediatric Oncology, Utrecht, The Netherlands
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Cardiac Toxicity After Craniospinal Irradiation: A Late Effect That May be Eliminated With Proton Therapy. J Pediatr Hematol Oncol 2018; 40:e330-e333. [PMID: 29200158 DOI: 10.1097/mph.0000000000001029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Craniospinal irradiation (CSI) is commonly required for pediatric patients with central nervous system malignancies. Traditionally, CSI is given using x-rays to deliver radiation to the brain and spine, exposing normal anterior structures, including heart, to unnecessary radiation. OBSERVATIONS We present a patient treated with x-ray CSI for medulloblastoma with spinal metastasis (3600 cGy CSI with focal boost to 5000 cGy), who subsequently developed significant cardiac toxicity, likely related to radiation exposure. CONCLUSIONS Spinal irradiation can cause significant cardiac risk due to exit dose through anterior structures. This toxicity may be avoided with proton therapy, which eliminates visceral exit dose.
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Proton therapy for pediatric malignancies: Fact, figures and costs. A joint consensus statement from the pediatric subcommittee of PTCOG, PROS and EPTN. Radiother Oncol 2018; 128:44-55. [PMID: 29937209 DOI: 10.1016/j.radonc.2018.05.020] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 05/11/2018] [Accepted: 05/15/2018] [Indexed: 12/18/2022]
Abstract
Radiotherapy plays an important role in the management of childhood cancer, with the primary aim of achieving the highest likelihood of cure with the lowest risk of radiation-induced morbidity. Proton therapy (PT) provides an undisputable advantage by reducing the radiation 'bath' dose delivered to non-target structures/volume while optimally covering the tumor with tumoricidal dose. This treatment modality comes, however, with an additional costs compared to conventional radiotherapy that could put substantial financial pressure to the health care systems with societal implications. In this review we assess the data available to the oncology community of PT delivered to children with cancer, discuss on the urgency to develop high-quality data. Additionally, we look at the advantage of combining systemic agents with protons and look at the cost-effectiveness data published so far.
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Mokhtech M, Rotondo RL, Bradley JA, Sandler ES, Nanda R, Logie N, Aldana PR, Morris CG, Indelicato DJ. Early outcomes and patterns of failure following proton therapy for nonmetastatic intracranial nongerminomatous germ cell tumors. Pediatr Blood Cancer 2018; 65:e26997. [PMID: 29380526 DOI: 10.1002/pbc.26997] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 12/15/2017] [Accepted: 12/29/2017] [Indexed: 11/12/2022]
Abstract
BACKGROUND Although dosimetric comparisons demonstrate the advantage of proton therapy (PT) over conventional radiotherapy for nongerminomatous germ cell tumors (NGGCT), clinical outcome data for this rare tumor are lacking. We sought to evaluate outcomes for children with NGGCT treated with PT. METHODS Between 2007 and 2016, 14 children (median age 11, range, 5-19 years) with nonmetastatic NGGCT were treated with PT after induction chemotherapy. Most (8/14) were mixed germ cell. Five of 14 patients had complete resection of their primary tumor before radiation. Off study, eight patients received 36 Gy (RBE [relative biological effectiveness]) craniospinal irradiation (CSI). On study, two patients received 30.6 Gy (RBE) whole-ventricle irradiation and four received focal radiation alone. All patients received a total dose of 54 Gy (RBE) to the tumor/tumor bed. RESULTS At a median follow-up of 2.8 years, all patients were alive with no local recurrences. Three-year progression-free survival was 86%. Both metastatic recurrences occurred in patients treated with focal radiation alone; one with an immature teratoma developed an isolated spinal recurrence 5 months after treatment. Another with a mixed germ cell tumor developed a multifocal ventricular and shunt tract recurrence 7 months after treatment. Serious toxicity was minimal, including cataracts and hormone deficiency, and limited to children who received CSI. CONCLUSION Early outcomes in children treated for NGGCT suggest the high conformality of PT does not compromise disease control and yields low toxicity. This pattern of failure data adds to growing evidence suggesting chemotherapy followed by focal radiotherapy alone is inadequate in controlling localized NGGCT.
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Affiliation(s)
- Meriem Mokhtech
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Ronny L Rotondo
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Eric S Sandler
- Department of Pediatrics, University of Florida College of Medicine, Jacksonville, Florida
| | - Ronica Nanda
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Natalie Logie
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Philipp R Aldana
- Department of Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
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Lee HF, Lan JH, Chao PJ, Ting HM, Chen HC, Hsu HC, Lee TF. Radiation-induced secondary malignancies for nasopharyngeal carcinoma: a pilot study of patients treated via IMRT or VMAT. Cancer Manag Res 2018; 10:131-141. [PMID: 29403311 PMCID: PMC5783017 DOI: 10.2147/cmar.s145713] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Patients treated with radiotherapy are at risk of developing a second cancer during their lifetime, which can directly impact treatment decision-making and patient management. The aim of this study was to qualify and compare the secondary cancer risk (SCR) after intensity-modulated radiation therapy (IMRT) and volumetric-modulated arc therapy (VMAT) in nasopharyngeal carcinoma (NPC) patients. Patients and methods We analyzed the treatment plans of a cohort of 10 NPC patients originally treated with IMRT or VMAT. Dose distributions in these plans were used to calculate the organ equivalent dose (OED) with Schneider’s full model. Analyses were applied to the brain stem, spinal cord, oral cavity, pharynx, parotid glands, lung, mandible, healthy tissue, and planning target volume. Results We observed that the OED-based risks of SCR were slightly higher for the oral cavity and mandible when VMAT was used. No significant difference was found in terms of the doses to other organs, including the brain stem, parotids, pharynx, submandibular gland, lung, spinal cord, and healthy tissue. In the NPC cohort, the lungs were the organs that were most sensitive to radiation-induced cancer. Conclusion VMAT afforded superior results in terms of organ-at-risk-sparing compared with IMRT. Most OED-based second cancer risks for various organs were similar when VMAT and IMRT were employed, but the risks for the oral cavity and mandible were slightly higher when VMAT was used.
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Affiliation(s)
- Hsiao-Fei Lee
- Medical Physics and Informatics Laboratory of Electronics Engineering, National Kaohsiung University of Applied Sciences, Kaohsiung, Taiwan, Republic of China.,Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, Republic of China
| | - Jen-Hong Lan
- Medical Physics and Informatics Laboratory of Electronics Engineering, National Kaohsiung University of Applied Sciences, Kaohsiung, Taiwan, Republic of China.,Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, Republic of China
| | - Pei-Ju Chao
- Medical Physics and Informatics Laboratory of Electronics Engineering, National Kaohsiung University of Applied Sciences, Kaohsiung, Taiwan, Republic of China.,Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, Republic of China
| | - Hui-Min Ting
- Medical Physics and Informatics Laboratory of Electronics Engineering, National Kaohsiung University of Applied Sciences, Kaohsiung, Taiwan, Republic of China.,Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, Republic of China
| | - Hui-Chun Chen
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, Republic of China
| | - Hsuan-Chih Hsu
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, Republic of China
| | - Tsair-Fwu Lee
- Medical Physics and Informatics Laboratory of Electronics Engineering, National Kaohsiung University of Applied Sciences, Kaohsiung, Taiwan, Republic of China.,Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, Republic of China.,Graduate Institute of Clinical Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, Republic of China.,Department of Radiation Oncology, Kaohsiung Yuan's General Hospital, Kaohsiung, Taiwan, Republic of China
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Tasson A, Laack NN, Beltran C. Clinical Implementation of Robust Optimization for Craniospinal Irradiation. Cancers (Basel) 2018; 10:cancers10010007. [PMID: 29301336 PMCID: PMC5789357 DOI: 10.3390/cancers10010007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 12/15/2017] [Accepted: 12/26/2017] [Indexed: 12/02/2022] Open
Abstract
With robust optimization for spot scanning proton therapy now commercially available, the ability exists to account for setup, range, and interfield uncertainties during optimization. Robust optimization is particularly beneficial for craniospinal irradiation (CSI) where the large target volume lends itself to larger setup uncertainties and the need for robust match lines can all be handled with the uncertainty parameters found inside the optimizer. Suggested robust optimization settings, parameters, and image guidance for CSI patients using proton therapy spot scanning are provided. Useful structures are defined and described. Suggestions are given for perturbations to be entered into the optimizer in order to achieve a plan that provides robust target volume coverage and critical structure sparing as well as a robust match line. Interfield offset effects, a concern when using multifield optimization, can also be addressed within the robust optimizer. A robust optimizer can successfully be employed to produce robust match lines, target volume coverage, and critical structure sparing under specified uncertainties. The robust optimizer can also be used to reduce effects arising from interfield uncertainties. Using robust optimization, a plan robust against setup, range, and interfield uncertainties for craniospinal treatments can be created. Utilizing robust optimization allows one to ensure critical structures are spared and target volumes are covered under the desired uncertainty parameters.
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Affiliation(s)
- Alexandria Tasson
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA.
| | - Nadia N Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA.
| | - Chris Beltran
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA.
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A dosimetric comparison of craniospinal irradiation using TomoDirect radiotherapy, TomoHelical radiotherapy and 3D conventional radiotherapy. JOURNAL OF RADIOTHERAPY IN PRACTICE 2017. [DOI: 10.1017/s1460396917000309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
AbstractAimThe purpose of this study was to dosimetrically compare TomoDirect, TomoHelical and linear accelerator-based 3D-conformal radiotherapy (Linac-3DCRT) for craniospinal irradiation (CSI) in the treatment of medulloblastoma.MethodsFive CSI patients were replanned with Linac-3DCRT, TomoHelical, TomoDirect-3DCRT and TomoDirect-intensity-modulated radiotherapy (IMRT). Dose of 36 Gy in 20 fractions was prescribed to the planning target volume (PTV). Homogeneity index (HI), non-target integral dose (NTID), dose–volume histograms, organs-at-risk (OARs)Dmax,Dmeanand treatment times were compared.ResultsTomoHelical achieved the best PTV homogeneity compared with Linac-3DCRT, TomoDirect-3DCRT and TomoDirect-IMRT (HI of 3·6 versus 20·9, 8·7 and 9·4%, respectively). TomoDirect-IMRT achieved the lowest NTID compared with TomoDirect-3DCRT, TomoHelical and Linac-3DCRT (141 J versus 151 J, 181 J and 250 J), indicating least biological damage to normal tissues. TomoHelical plans achieved the lowestDmaxin all organs except the breasts, and lowestDmeanfor most OARs, except in laterally situated OARs, where TomoDirect triumphed. Beam-on time was longest for TomoHelical, followed by TomoDirect and Linac-3DCRT.FindingsTomoDirect has the potential to lower NTID and shorten treatment times compared with TomoHelical. It reduces PTV inhomogeneity and better spares OARs compared with Linac-3DCRT. Therefore, TomoDirect may be a CSI treatment alternative to TomoHelical and in place of Linac-3DCRT.
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Mizumoto M, Oshiro Y, Yamamoto T, Kohzuki H, Sakurai H. Proton Beam Therapy for Pediatric Brain Tumor. Neurol Med Chir (Tokyo) 2017; 57:343-355. [PMID: 28603224 PMCID: PMC5566707 DOI: 10.2176/nmc.ra.2017-0003] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Cancer is a major cause of childhood death, with central nervous system (CNS) neoplasms being the second most common pediatric malignancy, following hematological cancer. Treatment of pediatric CNS malignancies requires multimodal treatment using a combination of surgery, chemotherapy, and radiotherapy, and advances in these treatments have given favorable results and longer survival. However, treatment-related toxicities have also occurred, particularly for radiotherapy, after which secondary cancer, reduced function of irradiated organs, and retarded growth are significant problems. Proton beam therapy (PBT) is a particle radiotherapy with excellent dose localization that permits treatment of liver and lung cancer by administration of a high dose to the tumor while minimizing damage to surrounding normal tissues. Thus, PBT has the potential advantages for pediatric cancer. In this context, we review the current knowledge on PBT for treatment of pediatric CNS malignancies.
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Affiliation(s)
| | - Yoshiko Oshiro
- Department of Radiation Oncology, University of Tsukuba.,Department of Radiation Oncology, Tsukuba Medical Center Hospital
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Tamura M, Sakurai H, Mizumoto M, Kamizawa S, Murayama S, Yamashita H, Takao S, Suzuki R, Shirato H, Ito YM. Lifetime attributable risk of radiation-induced secondary cancer from proton beam therapy compared with that of intensity-modulated X-ray therapy in randomly sampled pediatric cancer patients. JOURNAL OF RADIATION RESEARCH 2017; 58:363-371. [PMID: 27789564 PMCID: PMC5440886 DOI: 10.1093/jrr/rrw088] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 08/01/2016] [Accepted: 08/05/2016] [Indexed: 05/20/2023]
Abstract
To investigate the amount that radiation-induced secondary cancer would be reduced by using proton beam therapy (PBT) in place of intensity-modulated X-ray therapy (IMXT) in pediatric patients, we analyzed lifetime attributable risk (LAR) as an in silico surrogate marker of the secondary cancer after these treatments. From 242 pediatric patients with cancers who were treated with PBT, 26 patients were selected by random sampling after stratification into four categories: (i) brain, head and neck, (ii) thoracic, (iii) abdominal, and (iv) whole craniospinal (WCNS) irradiation. IMXT was replanned using the same computed tomography and region of interest. Using the dose-volume histograms (DVHs) of PBT and IMXT, the LARs of Schneider et al. were calculated for the same patient. All the published dose-response models were tested for the organs at risk. Calculation of the LARs of PBT and IMXT based on the DVHs was feasible for all patients. The means ± standard deviations of the cumulative LAR difference between PBT and IMXT for the four categories were (i) 1.02 ± 0.52% (n = 7, P = 0.0021), (ii) 23.3 ± 17.2% (n = 8, P = 0.0065), (iii) 16.6 ± 19.9% (n = 8, P = 0.0497) and (iv) 50.0 ± 21.1% (n = 3, P = 0.0274), respectively (one tailed t-test). The numbers needed to treat (NNT) were (i) 98.0, (ii) 4.3, (iii) 6.0 and (iv) 2.0 for WCNS, respectively. In pediatric patients who had undergone PBT, the LAR of PBT was significantly lower than the LAR of IMXT estimated by in silico modeling. Although a validation study is required, it is suggested that the LAR would be useful as an in silico surrogate marker of secondary cancer induced by different radiotherapy techniques.
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Affiliation(s)
- Masaya Tamura
- Department of Radiation Medicine, Hokkaido University Graduate School of Medicine, Kita 15, Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Hideyuki Sakurai
- Proton Medical Research Center, University of Tsukuba, Amakubo 2-1-1, Tsukuba, 305-8576, Japan
| | - Masashi Mizumoto
- Proton Medical Research Center, University of Tsukuba, Amakubo 2-1-1, Tsukuba, 305-8576, Japan
| | - Satoshi Kamizawa
- Proton Medical Research Center, University of Tsukuba, Amakubo 2-1-1, Tsukuba, 305-8576, Japan
| | - Shigeyuki Murayama
- Proton Therapy Division, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Shizuoka, 411-8777, Japan
| | - Haruo Yamashita
- Proton Therapy Division, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Shizuoka, 411-8777, Japan
| | - Seishin Takao
- Department of Medical Physics, Hokkaido University Hospital, Kita 14, Nishi 5, Kita-ku, Sapporo, 060-8648, Japan
| | - Ryusuke Suzuki
- Department of Medical Physics, Hokkaido University Hospital, Kita 14, Nishi 5, Kita-ku, Sapporo, 060-8648, Japan
| | - Hiroki Shirato
- Department of Radiation Medicine, Hokkaido University Graduate School of Medicine, Kita 15, Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
- Quantum Medical Science and Engineering, Hokkaido University Graduate School of Medicine, Kita 15, Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Yoichi M. Ito
- Department of Biostatistics, Hokkaido University Graduate School of Medicine, Kita 15, Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
- Corresponding author. Department of Biostatistics, Hokkaido University Graduate School of Medicine, Kita 15, Nishi 7, Kita-ku, Sapporo, 060-8638, Japan. Tel: +81-11-706-5896; Fax: +81-11-706-6050;
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Farace P, Bizzocchi N, Righetto R, Fellin F, Fracchiolla F, Lorentini S, Widesott L, Algranati C, Rombi B, Vennarini S, Amichetti M, Schwarz M. Supine craniospinal irradiation in pediatric patients by proton pencil beam scanning. Radiother Oncol 2017; 123:112-118. [DOI: 10.1016/j.radonc.2017.02.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 01/19/2017] [Accepted: 02/12/2017] [Indexed: 10/20/2022]
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Schiopu SR, Habl G, Häfner M, Katayama S, Herfarth K, Debus J, Sterzing F. Craniospinal irradiation using helical tomotherapy for central nervous system tumors. JOURNAL OF RADIATION RESEARCH 2017; 58:238-246. [PMID: 28096196 PMCID: PMC5439401 DOI: 10.1093/jrr/rrw095] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Revised: 05/16/2016] [Accepted: 08/11/2016] [Indexed: 06/06/2023]
Abstract
The aim of this study was to describe early and late toxicity, survival and local control in 45 patients with primary brain tumors treated with helical tomotherapy craniospinal irradiation (HT-CSI). From 2006 to 2014, 45 patients with central nervous system malignancies were treated with HT-CSI. The most common tumors were medulloblastoma in 20 patients, ependymoma in 10 patients, intracranial germinoma (ICG) in 7 patients, and primitive neuroectodermal tumor in 4 patients. Hematological toxicity during treatment included leukopenia Grades 1-4 (6.7%, 33.3%, 37.8% and 17.8%, respectively), anemia Grades 1-4 (44.4%, 22.2%, 22.2% and 0%, respectively) and thrombocytopenia Grades 1-4 (51.1%, 15.6%, 15.6% and 6.7%, respectively). The most common acute toxicities were nausea, vomiting, fatigue, loss of appetite, alopecia and neurotoxicity. No Grade 3 or higher late toxicity occurred. The overall 3- and 5-year survival rates were 80% and 70%, respectively. Survival for the main tumor entities included 3- and 5-year survival rates of 80% and 70%, respectively, for patients with medulloblastoma, 70% for both in patients with ependymoma, and 100% for both in patients with ICG. Relapse occurred in 11 patients (24.4%): 10 with local and 1 with multifocal relapse. One patient experienced a secondary cancer. M-status and the results of the re-evaluation at the end of treatment were significantly related to survival. Survival after HT-CSI was in line with the existing literature, and acute treatment-induced toxicity resolved quickly. Compared with conventional radiotherapy, HT offers benefits such as avoiding gaps and junctions, sparing organs, and better and more homogeneous dose distribution and coverage of the target volume.
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Affiliation(s)
- Sanziana R.I. Schiopu
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, Heidelberg 69120, Germany
| | - Gregor Habl
- Klinikum rechts der Isar, Department of Radiation Oncology, Technische Universität München, Ismaninger Straße 22, 81675 München, Germany
| | - Matthias Häfner
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, Heidelberg 69120, Germany
| | - Sonja Katayama
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, Heidelberg 69120, Germany
| | - Klaus Herfarth
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, Heidelberg 69120, Germany
| | - Juergen Debus
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, Heidelberg 69120, Germany
| | - Florian Sterzing
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, Heidelberg 69120, Germany
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Holmes JA, Chera BS, Brenner DJ, Shuryak I, Wilson AK, Lehman-Davis M, Fried DV, Somasundaram V, Lian J, Cullip T, Marks LB. Estimating the excess lifetime risk of radiation induced secondary malignancy (SMN) in pediatric patients treated with craniospinal irradiation (CSI): Conventional radiation therapy versus helical intensity modulated radiation therapy. Pract Radiat Oncol 2017; 7:35-41. [DOI: 10.1016/j.prro.2016.07.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 06/08/2016] [Accepted: 07/05/2016] [Indexed: 11/30/2022]
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Athiyaman H, m A, Chougule A, Hs K. Estimated Risk of Radiation Induced Contra Lateral Breast Cancer Following Chest Wall Irradiation by Conformal Wedge Field and Forward Intensity Modulated Radiotherapy Technique for Post-Mastectomy Breast Cancer Patients. Asian Pac J Cancer Prev 2016; 17:5107-5111. [PMID: 28122442 PMCID: PMC5454644 DOI: 10.22034/apjcp.2016.17.12.5107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: Epidemiological studies have indicated an increasing incidence of radiation induced secondary cancer (SC) in breast cancer patients after radiotherapy (RT), most commonly in the contra-lateral breast (CLB). The present study was conducted to estimate the SC risk in the CLB following 3D conformal radiotherapy techniques (3DCRT) including wedge field and forward intensity modulated radiotherapy (fIMRT) based on the organ equivalent dose (OED). Material and Methods: RT plans treating the chest wall with conformal wedge field and fIMRT plans were created for 30 breast cancer patients. The risks of radiation induced cancer were estimated for the CLB using dose-response models: a linear model, a linear-plateau model and a bell-shaped model with full dose response accounting for fractionated RT on the basis of OED. Results: The plans were found to be ranked quite differently according to the choice of model; calculations based on a linear dose response model fIMRT predict statistically significant lower risk compared to the enhanced dynamic wedge (EDW) technique (p-0.0089) and a non-significant difference between fIMRT and physical wedge (PW) techniques (p-0.054). The widely used plateau dose response model based estimation showed significantly lower SC risk associated with fIMRT technique compared to both wedge field techniques (fIMRT vs EDW p-0.013, fIMRT vs PW p-0.04). The full dose response model showed a non-significant difference between all three techniques in the view of second CLB cancer. Finally the bell shaped model predicted interestingly that PW is associated with significantly higher risk compared to both fIMRT and EDW techniques (fIMRT vs PW p-0.0003, EDW vs PW p-0.0032). Conclusion: In conclusion, the SC risk estimations of the CLB revealed that there is a clear relation between risk associated with wedge field and fIMRT technique depending on the choice of model selected for risk comparison.
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Proton therapy in craniospinal irradiation: a systematic review. JOURNAL OF RADIOTHERAPY IN PRACTICE 2016. [DOI: 10.1017/s146039691500045x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractAimCraniospinal irradiation is a technique indicated when a patient has a malignancy that has either disseminated, or is at risk of disseminating, throughout the subarachnoid space. While the craniospinal axis is treatable with conventional radiotherapy, the high doses to organs at risk carry an increased risk of acute and late side effects. Proton craniospinal irradiation is an expensive technique that shows great theoretical promise arising from reduced exit doses. The purpose of this systematic review is to determine the potential role of proton therapy as a standard modality for craniospinal irradiation.Materials and methodsA literature review was performed to determine the efficacy and cost of proton craniospinal irradiation. The Cochrane Library and the Inspec, Medline (via Pubmed) and Scopus databases were searched. After exclusion criteria were applied, the remaining papers were systematically appraised utilising the Scottish Intercollegiate Guidelines Network critical appraisal checklists.ResultsA total of 14 articles remained following the application of the screening and critical appraisal processes. In total, five of the articles concluded that the risk of secondary malignancy was lower with proton therapy, while ten of the articles included data showing that toxicity rates and organs at risk doses were lower with proton therapy. Doses to most thoracic and abdominal organs at risk analysed in the literature were reduced when proton therapy was used, with the sole exception of the oesophagus, the dose to which depended on whether or not the entire vertebral body was treated. Proton therapy also delivered optimal doses to organs at risk in the head and neck compared with conformal radiation therapy. However, in one study that compared tomotherapy to proton therapy, tomotherapy outperformed proton therapy by delivering lower doses to organs at risk in the head and neck, as well as the kidneys. The two cost-effectiveness studies did not indicate proton therapy as an optimal modality for all treatment sites; however, one of the studies found that for medulloblastoma, protons were more cost effective than conventional radiation therapy.FindingsProton therapy is a superior treatment option for craniospinal irradiation. The reduction in risk of toxicity and radiocarcinogenesis offered by proton craniospinal irradiation appear to outweigh the increased costs.
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Pediatric craniospinal irradiation with conventional technique or helical tomotherapy: impact of age and body volume on integral dose. TUMORI JOURNAL 2016; 102:387-92. [PMID: 27056336 DOI: 10.5301/tj.5000512] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2016] [Indexed: 11/20/2022]
Abstract
PURPOSE The use of helical tomotherapy (HT) for craniospinal irradiation (CSI) in pediatric patients remains an issue of discussion. In this study, we evaluated the integral dose (ID) to organs at risk (OARs) and to the whole body delivered with conventional 3-dimensional conformal radiotherapy (3D-CRT) and HT for pediatric patients and made a comparison according to different whole body volumes. METHODS We selected 10 pediatric patients with different body volumes and of different ages undergoing CSI. Plans for 3D-CRT and HT were developed for each patient. The ID to OARs and to the whole body were compared and statistical analyses were performed to determine differences. RESULTS We noticed that variations of ID depend on the different anatomical location of the organs relatively to the target, with lower ID to OARs opposed to the target and increased ID to lateral organs: ID tomotherapy/3D-CRT ratio was higher in lungs, kidneys, and mammary region, while it was lower in heart, liver, thyroid, and esophagus. The ID of the body increased with large volumes both in HT and in 3D-CRT plans, but in tomotherapy plans ID increased significantly more with large volumes than with small ones. CONCLUSIONS While there are no differences in using tomotherapy or 3D-CRT with small body volumes, we found a difference with large volumes (≥20,000 mL vs ≤20,000 mL). Therefore, for very small patients, the use of intensity-modulated radiotherapy provided with tomotherapy to reduce the dose to OARs can be reconsidered.
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Li Q, Gu W, Mu J, Yin W, Gao M, Mo J, Pei H. Collimator rotation in volumetric modulated arc therapy for craniospinal irradiation and the dose distribution in the beam junction region. Radiat Oncol 2015; 10:235. [PMID: 26584626 PMCID: PMC4653929 DOI: 10.1186/s13014-015-0544-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 10/27/2015] [Indexed: 11/10/2022] Open
Abstract
PURPOSE The purpose of this study was to investigate the role of beam collimator rotation in Volumetric Modulated Arc Therapy (VMAT) for craniospinal irradiation (CSI), and the impact on dose distribution in the beam junctions. METHODS Six adult patients were selected for the study. Six VMAT plans with different collimator angles were generated for each patient. The patients were treated in supine position with two beam isocenters. The plans were evaluated by analysis of Dose-Volume Histogram (DVHs) data for planning target volume (PTV) and organs at risk (OAR), and conformity index (CI) and homogeneity index (HI) for the target. Dose distributions in the beam junctions were examined carefully and experimentally validated in phantom, with measurement using an ion chamber array and film. RESULTS The mean values of HI and CI for the plans with different beam collimator angles were not significantly different. The numbers of segments, monitor units (MUs) and the delivery time of the plans with 45° beam collimator were obviously higher than those in plans with other beam collimator angles. When collimator angle for both sets of beams were set at 0°, there was a 1 mm low dose gap measured in the junction region. CONCLUSIONS By setting the collimator angle to 45°, only two isocenters were needed for the treatment of a target with the length up to 90 cm. The HI and CI of the plans were almost the same, regardless if the collimator angles were at 0°. The collimator angles for at least one set of beams should be off 0° in order to avoid a dose gap in the beam junction region.
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Affiliation(s)
- Qilin Li
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, The First People's Hospital of Changzhou City, 185 Ju Qian Jie, Changzhou City, 213003, Jiangsu Province, China.
| | - Wendong Gu
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, The First People's Hospital of Changzhou City, 185 Ju Qian Jie, Changzhou City, 213003, Jiangsu Province, China.
| | - Jinming Mu
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, The First People's Hospital of Changzhou City, 185 Ju Qian Jie, Changzhou City, 213003, Jiangsu Province, China.
| | - Wenming Yin
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, The First People's Hospital of Changzhou City, 185 Ju Qian Jie, Changzhou City, 213003, Jiangsu Province, China.
| | - Min Gao
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, The First People's Hospital of Changzhou City, 185 Ju Qian Jie, Changzhou City, 213003, Jiangsu Province, China.
| | - Juncong Mo
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, The First People's Hospital of Changzhou City, 185 Ju Qian Jie, Changzhou City, 213003, Jiangsu Province, China.
| | - Honglei Pei
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, The First People's Hospital of Changzhou City, 185 Ju Qian Jie, Changzhou City, 213003, Jiangsu Province, China.
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Dwyer M. Defining the role of proton therapy in the optimal management of paediatric patients in Australia and New Zealand. J Med Imaging Radiat Oncol 2015; 60:105-11. [DOI: 10.1111/1754-9485.12391] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 08/16/2015] [Indexed: 02/01/2023]
Affiliation(s)
- Mary Dwyer
- Department of Radiation Oncology and Cancer Imaging; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
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