1
|
Drabek-Maunder ER, Mankad K, Aquilina K, Dean JA, Nisbet A, Clark CA. Using diffusion MRI to understand white matter damage and the link between brain microstructure and cognitive deficits in paediatric medulloblastoma patients. Eur J Radiol 2024; 177:111562. [PMID: 38901074 DOI: 10.1016/j.ejrad.2024.111562] [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: 03/01/2024] [Revised: 05/09/2024] [Accepted: 06/10/2024] [Indexed: 06/22/2024]
Abstract
PURPOSE Survivors of medulloblastoma face a range of challenges after treatment, involving behavioural, cognitive, language and motor skills. Post-treatment outcomes are associated with structural changes within the brain resulting from both the tumour and the treatment. Diffusion magnetic resonance imaging (MRI) has been used to investigate the microstructure of the brain. In this review, we aim to summarise the literature on diffusion MRI in patients treated for medulloblastoma and discuss future directions on how diffusion imaging can be used to improve patient quality. METHOD This review summarises the current literature on medulloblastoma in children, focusing on the impact of both the tumour and its treatment on brain microstructure. We review studies where diffusion MRI has been correlated with either treatment characteristics or cognitive outcomes. We discuss the role diffusion MRI has taken in understanding the relationship between microstructural damage and cognitive and behavioural deficits. RESULTS We identified 35 studies that analysed diffusion MRI changes in patients treated for medulloblastoma. The majority of these studies found significant group differences in measures of brain microstructure between patients and controls, and some of these studies showed associations between microstructure and neurocognitive outcomes, which could be influenced by patient characteristics (e.g. age), treatment, radiation dose and treatment type. CONCLUSIONS In future, studies would benefit from being able to separate microstructural white matter damage caused by the tumour, tumour-related complications and treatment. Additionally, advanced diffusion modelling methods can be explored to understand and describe microstructural changes to white matter.
Collapse
Affiliation(s)
- Emily R Drabek-Maunder
- UCL Great Ormond Street Institute of Child Health, 30 Guildford Street, London WC1N 1EH, UK; UCL Dept of Medical Physics and Biomedical Engineering, Malet Place, Gower St, London WC1E 6BT, UK; Great Ormond Street Hospital for Children, Great Ormond St, London WC1N 3JH, UK.
| | - Kshitij Mankad
- UCL Great Ormond Street Institute of Child Health, 30 Guildford Street, London WC1N 1EH, UK; Great Ormond Street Hospital for Children, Great Ormond St, London WC1N 3JH, UK
| | - Kristian Aquilina
- UCL Great Ormond Street Institute of Child Health, 30 Guildford Street, London WC1N 1EH, UK; Great Ormond Street Hospital for Children, Great Ormond St, London WC1N 3JH, UK
| | - Jamie A Dean
- UCL Dept of Medical Physics and Biomedical Engineering, Malet Place, Gower St, London WC1E 6BT, UK
| | - Andrew Nisbet
- UCL Dept of Medical Physics and Biomedical Engineering, Malet Place, Gower St, London WC1E 6BT, UK
| | - Chris A Clark
- UCL Great Ormond Street Institute of Child Health, 30 Guildford Street, London WC1N 1EH, UK; Great Ormond Street Hospital for Children, Great Ormond St, London WC1N 3JH, UK
| |
Collapse
|
2
|
Lucas JT, Abramson ZR, Epstein K, Morin CE, Jaju A, Lee JW, Lee CL, Sitaram R, Voss SD, Hudson MM, Constine LS, Hua CH. Imaging Assessment of Radiation Therapy-Related Normal Tissue Injury in Children: A PENTEC Visionary Statement. Int J Radiat Oncol Biol Phys 2024; 119:669-680. [PMID: 38760116 DOI: 10.1016/j.ijrobp.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 03/08/2024] [Indexed: 05/19/2024]
Abstract
The Pediatric Normal Tissue Effects in the Clinic (PENTEC) consortium has made significant contributions to understanding and mitigating the adverse effects of childhood cancer therapy. This review addresses the role of diagnostic imaging in detecting, screening, and comprehending radiation therapy-related late effects in children, drawing insights from individual organ-specific PENTEC reports. We further explore how the development of imaging biomarkers for key organ systems, alongside technical advancements and translational imaging approaches, may enhance the systematic application of imaging evaluations in childhood cancer survivors. Moreover, the review critically examines knowledge gaps and identifies technical and practical limitations of existing imaging modalities in the pediatric population. Addressing these challenges may expand access to, minimize the risk of, and optimize the real-world application of, new imaging techniques. The PENTEC team envisions this document as a roadmap for the future development of imaging strategies in childhood cancer survivors, with the overarching goal of improving long-term health outcomes and quality of life for this vulnerable population.
Collapse
Affiliation(s)
| | - Zachary R Abramson
- Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Katherine Epstein
- Division of Radiology and Medical Imaging, UC Department of Radiology, Cincinnati, Ohio
| | - Cara E Morin
- Division of Radiology and Medical Imaging, UC Department of Radiology, Cincinnati, Ohio
| | - Alok Jaju
- Department of Medical Imaging, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Chang-Lung Lee
- Department of Radiation Oncology and; Pathology, Duke University School of Medicine, Durham, North Carolina
| | - Ranganatha Sitaram
- Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Stephan D Voss
- Department of Radiology, Harvard Medical School, Boston, Massachusetts
| | - Melissa M Hudson
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Louis S Constine
- Department of Radiation Oncology, James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | | |
Collapse
|
3
|
Halilibrahimoğlu H, Polat K, Keskin S, Genç O, Aslan O, Öztürk-Işık E, Yakıcıer C, Danyeli AE, Pamir MN, Özduman K, Dinçer A, Özcan A. Associating IDH and TERT Mutations in Glioma with Diffusion Anisotropy in Normal-Appearing White Matter. AJNR Am J Neuroradiol 2023; 44:553-561. [PMID: 37105678 PMCID: PMC10171376 DOI: 10.3174/ajnr.a7855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 03/21/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND AND PURPOSE IDH and TERT mutations might infiltratively manifest within normal-appearing white matter with specific phenotypes such as microstructural changes undetectable by standard MR imaging contrasts but potentially associable with DTI variables. The aim of this retrospective glioma study was to statistically investigate IDH and TERT associations and classifications with DTI reported microstructure in normal-appearing white matter. MATERIALS AND METHODS Retrospective data from patients imaged between March 2012 and February 2016 were analyzed by grouping them as IDH-TERT subgroups and by IDH and TERT mutation status. DTI variables in the IDH-TERT subgroups were first identified by the Kruskal-Wallis test, followed by Dunn-Šidák multiple comparisons with Bonferroni correction. IDH and TERT mutations were compared with the Mann-Whitney U test. Classification by thresholding was tested using receiver operating characteristic analysis. RESULTS Of 170 patients, 70 patients (mean age, 43.73 [SD, 15.32] years; 40 men) were included. Whole-brain normal-appearing white matter fractional anisotropy (FA) and relative anisotropy (RA) (P = .002) were significantly higher and the contralateral-ipsilateral hemispheric differences, ΔFA and ΔRA, (P < .001) were significantly lower in IDHonly patients compared with TERTonly, with a higher whole-brain normal-appearing white matter FA and RA (P = .01) and ΔFA and ΔRA (P = .002) compared to double positive patients. Whole-brain normal-appearing white matter ADC (P = .02), RD (P = .001), λ2 (P = .001), and λ3 (P = .001) were higher in IDH wild-type. Whole-brain normal-appearing white matter λ1 (AD) (P = .003), FA (P < .001), and RA (P = .003) were higher, but Δλ1 (P = .002), ΔFA, and ΔRA (P < .001) were lower in IDH mutant versus IDH wild-type. ΔFA (P = .01) and ΔRA (P = .02) were significantly higher in TERT mutant versus TERT wild-type. CONCLUSIONS Axial and nonaxial diffusivities, anisotropy indices in the normal-appearing white matter and their interhemispheric differences demonstrated microstructural differences between IDH and TERT mutations, with the potential for classification methods.
Collapse
Affiliation(s)
- H Halilibrahimoğlu
- Department of Biomedical Engineering (H.H.), McGill University, Montréal, Quebec, Canada
- Biomedical Imaging Research and Development Center (H.H., K.P., S.K., O.A.)
- Institute of Biomedical Engineering (H.H., O.G., E.Ö.-I.), Boğaziçi University Kandilli Campus, Çengelköy, Istanbul, Turkey
| | - K Polat
- From the Department of Electrical and Electronics Engineering (K.P., A.Ö.), Boğaziçi University, Bebek, Istanbul, Turkey
- Biomedical Imaging Research and Development Center (H.H., K.P., S.K., O.A.)
| | - S Keskin
- Biomedical Imaging Research and Development Center (H.H., K.P., S.K., O.A.)
| | - O Genç
- Institute of Biomedical Engineering (H.H., O.G., E.Ö.-I.), Boğaziçi University Kandilli Campus, Çengelköy, Istanbul, Turkey
| | - O Aslan
- Biomedical Imaging Research and Development Center (H.H., K.P., S.K., O.A.)
| | - E Öztürk-Işık
- Brain Tumor Research Group (E.Ö.-I., A.E.D., M.N.P., K.Ö., A.D.)
- Center for Neuroradiological Advanced Research (E.Ö.-I., M.N.P., K.Ö., A.D.), Acibadem Mehmet Ali Aydinlar University, Ataşehir, Istanbul, Turkey
- Institute of Biomedical Engineering (H.H., O.G., E.Ö.-I.), Boğaziçi University Kandilli Campus, Çengelköy, Istanbul, Turkey
| | - C Yakıcıer
- YoctoSensum Biotechnoogy (C.Y.), Fenerbahçe, Istanbul, Turkey
| | - A E Danyeli
- Department of Pathology (A.E.D.)
- Brain Tumor Research Group (E.Ö.-I., A.E.D., M.N.P., K.Ö., A.D.)
| | - M N Pamir
- Department of Neurosurgery (M.N.P., K.Ö.)
- Brain Tumor Research Group (E.Ö.-I., A.E.D., M.N.P., K.Ö., A.D.)
- Center for Neuroradiological Advanced Research (E.Ö.-I., M.N.P., K.Ö., A.D.), Acibadem Mehmet Ali Aydinlar University, Ataşehir, Istanbul, Turkey
| | - K Özduman
- Department of Neurosurgery (M.N.P., K.Ö.)
- Brain Tumor Research Group (E.Ö.-I., A.E.D., M.N.P., K.Ö., A.D.)
- Center for Neuroradiological Advanced Research (E.Ö.-I., M.N.P., K.Ö., A.D.), Acibadem Mehmet Ali Aydinlar University, Ataşehir, Istanbul, Turkey
| | - A Dinçer
- Department of Radiology (A.D.)
- Brain Tumor Research Group (E.Ö.-I., A.E.D., M.N.P., K.Ö., A.D.)
- Center for Neuroradiological Advanced Research (E.Ö.-I., M.N.P., K.Ö., A.D.), Acibadem Mehmet Ali Aydinlar University, Ataşehir, Istanbul, Turkey
| | - A Özcan
- From the Department of Electrical and Electronics Engineering (K.P., A.Ö.), Boğaziçi University, Bebek, Istanbul, Turkey
| |
Collapse
|
4
|
A case-control study of linear energy transfer and relative biological effectiveness related to symptomatic brainstem toxicity following pediatric proton therapy. Radiother Oncol 2022; 175:47-55. [PMID: 35917900 DOI: 10.1016/j.radonc.2022.07.022] [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: 04/07/2022] [Revised: 06/28/2022] [Accepted: 07/25/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND PURPOSE A fixed relative biological effectiveness (RBE) of 1.1 (RBE1.1) is used clinically in proton therapy even though the RBE varies with properties such as dose level and linear energy transfer (LET). We therefore investigated if symptomatic brainstem toxicity in pediatric brain tumor patients treated with proton therapy could be associated with a variable LET and RBE. MATERIALS AND METHODS 36 patients treated with passive scattering proton therapy were selected for a case-control study from a cohort of 954 pediatric brain tumor patients. Nine children with symptomatic brainstem toxicity were each matched to three controls based on age, diagnosis, adjuvant therapy, and brainstem RBE1.1 dose characteristics. Differences across cases and controls related to the dose-averaged LET (LETd) and variable RBE-weighted dose from two RBE models were analyzed in the high-dose region. RESULTS LETd metrics were marginally higher for cases vs. controls for the majority of dose levels and brainstem substructures. Considering areas with doses above 54 Gy(RBE1.1), we found a moderate trend of 13% higher median LETd in the brainstem for cases compared to controls (P = .08), while the difference in the median variable RBE-weighted dose for the same structure was only 2% (P = .6). CONCLUSION Trends towards higher LETd for cases compared to controls were noticeable across structures and LETd metrics for this patient cohort. While case-control differences were minor, an association with the observed symptomatic brainstem toxicity cannot be ruled out.
Collapse
|
5
|
Şahin S, Ertekin E, Şahin T, Özsunar Y. Evaluation of normal-appearing white matter with perfusion and diffusion MRI in patients with treated glioblastoma. MAGMA (NEW YORK, N.Y.) 2022; 35:153-162. [PMID: 34951690 DOI: 10.1007/s10334-021-00990-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 12/10/2021] [Accepted: 12/12/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE We tried to reveal how the normal appearing white matter (NAWM) was affected in patients with glioblastoma treated with chemo-radiotherapy (CRT) in the period following the treatment, by multiparametric MRI. MATERIALS AND METHODS 43 multiparametric MRI examinations of 17 patients with glioblastoma treated with CRT were examined. A total of six different series or maps were analyzed in the examinations: Apparent Diffusion Coefficient (ADC) and Fractional Anisotropy (FA) maps, Gradient Echo (GRE) sequence, Dynamic susceptibility contrast (DSC) and Arterial spin labeling (ASL) perfusion sequences. Each sequence in each examination was examined in detail with 14 Region of Interest (ROI) measurements. The obtained values were proportioned to the contralateral NAWM values and the results were recorded as normalized values. Time dependent changes of normalized values were statistically analyzed. RESULTS The most prominent changes in follow-up imaging occurred in the perilesional region. In perilesional NAWM, we found a decrease in normalized FA (nFA), rCBV (nrCBV), rCBF (nrCBF), ASL (nASL)values (p < 0.005) in the first 3 months after treatment, followed by a plateau and an increase approaching pretreatment values, although it did not reach. Similar but milder findings were present in other NAWM areas. In perilesional NAWM, nrCBV values were found to be positively high correlated with nrCBF and nASL, and negatively high correlated with nADC values (r: 0.963, 0.736, - 0.973, respectively). We also found high correlations between the mean values of nrCBV, nrCBF, nASL in other NAWM areas (r: 0.891, 0.864, respectively). DISCUSSION We showed that both DSC and ASL perfusion values decreased correlatively in the first 3 months and showed a plateau after 1 year in patients with glioblastoma treated with CRT, unlike the literature. Although it was not as evident as perfusion MRI, it was observed that the ADC values also showed a plateau pattern following the increase in the first 3 months. Further studies are needed to explain late pathophysiological changes. Because of the high correlation, our results support ASL perfusion instead of contrast enhanced perfusion methods.
Collapse
Affiliation(s)
- Sinan Şahin
- Department of Radiology, Adnan Menderes University, Aydın, Turkey
| | - Ersen Ertekin
- Department of Radiology, Adnan Menderes University, Aydın, Turkey.
| | - Tuna Şahin
- Department of Radiology, Adnan Menderes University, Aydın, Turkey
| | - Yelda Özsunar
- Department of Radiology, Adnan Menderes University, Aydın, Turkey
| |
Collapse
|
6
|
Wang K, Tepper JE. Radiation therapy-associated toxicity: Etiology, management, and prevention. CA Cancer J Clin 2021; 71:437-454. [PMID: 34255347 DOI: 10.3322/caac.21689] [Citation(s) in RCA: 149] [Impact Index Per Article: 49.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/25/2021] [Accepted: 05/27/2021] [Indexed: 12/25/2022] Open
Abstract
Radiation therapy (RT) is a curative treatment for many malignancies and provides effective palliation in patients with tumor-related symptoms. However, the biophysical effects of RT are not specific to tumor cells and may produce toxicity due to exposure of surrounding organs and tissues. In this article, the authors review the clinical context, pathophysiology, risk factors, presentation, and management of RT side effects in each human organ system. Ionizing radiation works by producing DNA damage leading to tumor death, but effects on normal tissue may result in acute and/or late toxicity. The manifestation of toxicity depends on both cellular characteristics and affected organs' anatomy and physiology. There is usually a direct relationship between the radiation dose and volume to normal tissues and the risk of toxicity, which has led to guidelines and recommended dose limits for most tissues. Side effects are multifactorial, with contributions from baseline patient characteristics and other oncologic treatments. Technological advances in recent decades have decreased RT toxicity by dramatically improving the ability to deliver RT that maximizes tumor dose and minimizes organ dose. Thus the study of RT-associated toxicity is a complex, core component of radiation oncology training that continues to evolve alongside advances in cancer management. Because RT is used in up to one-half of all patients with cancer, an understanding of its acute and late effects in different organ systems is clinically pertinent to both oncologists and nononcologists.
Collapse
Affiliation(s)
- Kyle Wang
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, Ohio
| | - Joel E Tepper
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| |
Collapse
|
7
|
Bontempi P, Scartoni D, Amelio D, Cianchetti M, Turkaj A, Amichetti M, Farace P. Multicomponent T 2 relaxometry reveals early myelin white matter changes induced by proton radiation treatment. Magn Reson Med 2021; 86:3236-3245. [PMID: 34268786 DOI: 10.1002/mrm.28913] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/21/2021] [Accepted: 06/14/2021] [Indexed: 11/11/2022]
Abstract
PURPOSE To investigate MRI myelin water imaging (MWI) by multicomponent T2 relaxometry as a quantitative imaging biomarker for brain radiation-induced changes and to compare it with DTI. METHODS Sixteen patients underwent fractionated proton therapy (PT) receiving dose to the healthy tissue because of direct or indirect (base skull tumors) irradiation. MWI was performed by a multi-echo sequence with 32 equally spaced echoes (10-320 ms). Decay data were processed to identify 3 T2 compartments: myelin water (Mw) below 40 ms, intra-extracellular water (IEw) between 40 and 250 ms, and free water (CSFw) above 250 ms. Both MWI and DTI scans were acquired pre (pre)-treatment and immediately at the end (end) of PT. After image registration, voxel-wise difference maps, obtained by subtracting MWI and DTI pre from those acquired at the end of PT, were compared with the corresponding biological equivalent dose (BED). RESULTS Mw difference showed a positive correlation and IEw difference showed a negative correlation with BED considering end-pre changes (P < .01). The changes in CSFw were not significantly correlated with the delivered BED. The changes in DTI data, considering end-pre acquisitions, showed a positive correlation between fractional anisotropy and the delivered BED. CONCLUSION MWI might detect early white matter radiation-induced alterations, providing additional information to DTI, which might improve the understanding of the pathogenesis of the radiation damage.
Collapse
Affiliation(s)
- Pietro Bontempi
- Proton Therapy Unit, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Daniele Scartoni
- Proton Therapy Unit, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Dante Amelio
- Proton Therapy Unit, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Marco Cianchetti
- Proton Therapy Unit, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Ana Turkaj
- Proton Therapy Unit, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Maurizio Amichetti
- Proton Therapy Unit, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Paolo Farace
- Proton Therapy Unit, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| |
Collapse
|
8
|
Skaarup M, Lundemann MJ, Darkner S, Jørgensen M, Marner L, Mirkovic D, Grosshans D, Peeler C, Mohan R, Vogelius IR, Appelt A. A framework for voxel-based assessment of biological effect after proton radiotherapy in pediatric brain cancer patients using multi-modal imaging. Med Phys 2021; 48:4110-4121. [PMID: 34021597 DOI: 10.1002/mp.14989] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 04/19/2021] [Accepted: 05/13/2021] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION The exact dependence of biological effect on dose and linear energy transfer (LET) in human tissue when delivering proton therapy is unknown. In this study, we propose a framework for measuring this dependency using multi-modal image-based assays with deformable registrations within imaging sessions and across time. MATERIALS AND METHODS 3T MRI scans were prospectively collected from 6 pediatric brain cancer patients before they underwent proton therapy treatment, and every 3 months for a year after treatment. Scans included T1-weighted with contrast enhancement (T1), T2-FLAIR (T2) and fractional anisotropy (FA) images. In addition, the planning CT, dose distributions and Monte Carlo-calculated LET distributions were collected. A multi-modal deformable image registration framework was used to create a dataset of dose, LET and imaging intensities at baseline and follow-up on a voxel-by-voxel basis. We modelled the biological effect of dose and LET from proton therapy using imaging changes over time as a surrogate for biological effect. We investigated various models to show the feasibility of the framework to model imaging changes. To account for interpatient and intrapatient variations, we used a nested generalized linear mixed regression model. The models were applied to predict imaging changes over time as a function of dose and LET for each modality. RESULTS Using the nested models to predict imaging changes, we saw a decrease in the FA signal as a function of dose; however, the signal increased with increasing LET. Similarly, we saw an increase in T2 signal as a function of dose, but a decrease in signal with LET. We saw no changes in T1 voxel values as a function of either dose or LET. CONCLUSIONS The imaging changes could successfully model biological effect as a function of dose and LET using our proposed framework. Due to the low number of patients, the imaging changes observed for FA and T2 scans were not marked enough to draw any firm conclusions.
Collapse
Affiliation(s)
- Mikkel Skaarup
- Department of Oncology, Rigshospitalet, Copenhagen, Denmark
- Faculty of Science, Niels Bohr Institute, University of Copenhagen, Copenhagen, Denmark
| | | | - Sune Darkner
- Department of Computer Science, University of Copenhagen, Copenhagen, Denmark
| | | | - Lisbeth Marner
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Dragan Mirkovic
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Grosshans
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Christopher Peeler
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Radhe Mohan
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ivan Richter Vogelius
- Department of Oncology, Rigshospitalet, Copenhagen, Denmark
- Faculty of Health and Medical Science, Copenhagen University, Copenhagen, Denmark
| | - Ane Appelt
- Leeds Institute of Medical Research at St James's, University of Leeds and Leeds Cancer Centre, St. James's University Hospital, Leeds, UK
| |
Collapse
|
9
|
Fjæra LF, Indelicato DJ, Ytre-Hauge KS, Muren LP, Lassen-Ramshad Y, Toussaint L, Dahl O, Stokkevåg CH. Spatial Agreement of Brainstem Dose Distributions Depending on Biological Model in Proton Therapy for Pediatric Brain Tumors. Adv Radiat Oncol 2021; 6:100551. [PMID: 33490724 PMCID: PMC7811129 DOI: 10.1016/j.adro.2020.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/13/2020] [Accepted: 08/20/2020] [Indexed: 11/02/2022] Open
Abstract
Purpose During radiation therapy for pediatric brain tumors, the brainstem is a critical organ at risk, possibly with different radio-sensitivity across its substructures. In proton therapy, treatment planning is currently performed using a constant relative biological effectiveness (RBE) of 1.1 (RBE1.1), whereas preclinical studies point toward spatial variability of this factor. To shed light on this biological uncertainty, we investigated the spatial agreement between isodose maps produced by different RBE models, with emphasis on (smaller) substructures of the brainstem. Methods and Materials Proton plans were recalculated using Monte Carlo simulations in 3 anonymized pediatric patients with brain tumors (a craniopharyngioma, a low-grade glioma, and a posterior fossa ependymoma) to obtain dose and linear energy transfer distributions. Doses and volume metrics for the brainstem and its substructures were calculated using a constant RBE1.1, 4 phenomenological RBE models with varying (α/β)x parameters, and with a simpler linear energy transfer-dependent model. The spatial agreement between the dose distributions of constant RBE1.1 versus the variable RBE models was compared using the Dice similarity coefficient. Results The spatial agreement between the variable RBE dose distributions and RBE1.1 decreased with increasing isodose levels in all patient cases. The patient with ependymoma showed the greatest variation in dose and dose volumes, where V50Gy(RBE) in the brainstem increased from 32% (RBE1.1) to 35% to 49% depending on the applied model, corresponding to a spatial agreement (Dice similarity coefficient) between 0.79 and 0.95. The remaining patients showed similar trends, however, with lower absolute values due to lower brainstem doses. Conclusions All phenomenological RBE models fully enclosed the isodose volumes of the constant RBE1.1, and the volumes based on variable RBE spatially agreed. The spatial agreement was dependent on the isodose level, where higher isodose levels showed larger expansions and less agreement between the variable RBE models and RBE1.1.
Collapse
Affiliation(s)
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida
| | | | - Ludvig P Muren
- Department of Medical Physics, Aarhus University/Aarhus University Hospital, Denmark
| | | | - Laura Toussaint
- Department of Medical Physics, Aarhus University/Aarhus University Hospital, Denmark
| | - Olav Dahl
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Camilla H Stokkevåg
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| |
Collapse
|
10
|
Neuroimaging Biomarkers and Neurocognitive Outcomes in Pediatric Medulloblastoma Patients: a Systematic Review. THE CEREBELLUM 2021; 20:462-480. [PMID: 33417160 DOI: 10.1007/s12311-020-01225-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/06/2020] [Indexed: 10/22/2022]
Abstract
Medulloblastoma is a malign posterior fossa brain tumor, mostly occurring in childhood. The CNS-directed chemoradiotherapy treatment can be very harmful to the developing brain and functional outcomes of these patients. However, what the underlying neurotoxic mechanisms are remain inconclusive. Hence, this review summarizes the existing literature on the association between advanced neuroimaging and neurocognitive changes in patients that were treated for pediatric medulloblastoma. The PubMed/Medline database was extensively screened for studies investigating the link between cognitive outcomes and multimodal magnetic resonance (MR) imaging in childhood medulloblastoma survivors. A behavioral meta-analysis was performed on the available IQ scores. A total of 649 studies were screened, of which 22 studies were included. Based on this literature review, we conclude medulloblastoma patients to be at risk for white matter volume loss, more frequent white matter lesions, and changes in white matter microstructure. Such microstructural alterations were associated with lower IQ, which reached the clinical cut-off in survivors across studies. Using functional MR scans, changes in activity were observed in cerebellar areas, associated with working memory and processing speed. Finally, cerebral microbleeds were encountered more often, but these were not associated with cognitive outcomes. Regarding intervention studies, computerized cognitive training was associated with changes in prefrontal and cerebellar activation and physical training might result in microstructural and cortical alterations. Hence, to better define the neural targets for interventions in pediatric medulloblastoma patients, this review suggests working towards neuroimaging-based predictions of cognitive outcomes. To reach this goal, large multimodal prospective imaging studies are highly recommended.
Collapse
|
11
|
Yahya N, Manan HA. Diffusion tensor imaging indices to predict cognitive changes following adult radiotherapy. Eur J Cancer Care (Engl) 2020; 30:e13329. [PMID: 32909654 DOI: 10.1111/ecc.13329] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 05/01/2020] [Accepted: 08/07/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Diffusion tensor imaging (DTI) can detect changes to white matter tracts following assaults including high dose radiation. This study aimed to systematically evaluate DTI indices to predict cognitive changes following adult radiotherapy. MATERIALS AND METHODS We searched PubMed and Scopus electronic databases to identify eligible studies according to PRISMA guidelines. Studies were extracted for information on demographics, DTI changes and associations to cognitive outcomes. RESULTS Six studies were selected for inclusion with 110 patients (median study size: 20). 5/6 studies found significant cognitive decline and analysed relationships to DTI changes. Decreased fractional anisotropy (FA) was consistently associated with cognitive decline. Associations clustered at specific regions of cingulum and corpus callosum. Only one study conducted multivariable analysis. CONCLUSION Fractional anisotropy is a clinically meaningful biomarker for radiotherapy-related cognitive decline. Studies accruing larger patient cohorts are needed to guide therapeutic changes that can abate the decline.
Collapse
Affiliation(s)
- Noorazrul Yahya
- Diagnostic Imaging and Radiotherapy, Faculty of Health Sciences, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Hanani A Manan
- Functional Image Processing Laboratory, Department of Radiology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| |
Collapse
|
12
|
Tringale KR, Nguyen TT, Karunamuni R, Seibert T, Huynh-Le MP, Connor M, Moiseenko V, Gorman MK, Marshall A, Tibbs MD, Farid N, Simpson D, Sanghvi P, McDonald CR, Hattangadi-Gluth JA. Quantitative Imaging Biomarkers of Damage to Critical Memory Regions Are Associated With Post-Radiation Therapy Memory Performance in Brain Tumor Patients. Int J Radiat Oncol Biol Phys 2019; 105:773-783. [PMID: 31408667 PMCID: PMC6876859 DOI: 10.1016/j.ijrobp.2019.08.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 05/23/2019] [Accepted: 08/05/2019] [Indexed: 01/06/2023]
Abstract
PURPOSE We used quantitative magnetic resonance imaging to prospectively analyze the association between microstructural damage to memory-associated structures within the medial temporal lobe and longitudinal memory performance after brain radiation therapy (RT). METHODS AND MATERIALS Patients with a primary brain tumor receiving fractionated brain RT were enrolled on a prospective trial (n = 27). Patients underwent high-resolution volumetric brain magnetic resonance imaging, diffusion-weighted imaging, and neurocognitive testing before and 3, 6, and 12 months post-RT. Medial temporal lobe regions (hippocampus; entorhinal, parahippocampal, and temporal pole white matter [WM]) were autosegmented, quantifying volume and diffusion biomarkers of WM integrity (mean diffusivity [MD]; fractional anisotropy [FA]). Reliable change indices measured changes in verbal (Hopkins Verbal Learning Test-Revised) and visuospatial (Brief Visuospatial Memory Test-Revised [BVMT-R]) memory. Linear mixed-effects models assessed longitudinal associations between imaging parameters and memory. RESULTS Visuospatial memory significantly declined at 6 months post-RT (mean reliable change indices, -1.3; P = .012). Concurrent chemotherapy and seizures trended toward a significant association with greater decline in visuospatial memory (P = .053 and P = .054, respectively). Higher mean dose to the left temporal pole WM was significantly associated with decreased FA (r = -0.667; P = .002). Over all time points, smaller right hippocampal volume (P = .021), lower right entorhinal FA (P = .023), greater right entorhinal MD (P = .047), and greater temporal pole MD (BVMT-R total recall, P = .003; BVMT-R delayed recall, P = .042) were associated with worse visuospatial memory. The interaction between right entorhinal MD (BVMT-R total recall, P = .021; BVMT-R delayed recall, P = .004) and temporal pole FA (BVMT-R delayed recall, P = .024) significantly predicted visuospatial memory performance. CONCLUSIONS Brain tumor patients exhibited visuospatial memory decline post-RT. Microstructural damage to critical memory regions, including the hippocampus and medial temporal lobe WM, were associated with post-RT memory decline. The integrity of medial temporal lobe structures is critical to memory performance post-RT, representing possible avoidance targets for memory preservation.
Collapse
Affiliation(s)
- Kathryn R Tringale
- Department of Radiation Medicine and Applied Sciences; Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Roshan Karunamuni
- Department of Radiation Medicine and Applied Sciences; Center for Multimodal Imaging and Genetics
| | - Tyler Seibert
- Department of Radiation Medicine and Applied Sciences; Center for Multimodal Imaging and Genetics
| | | | | | | | | | | | | | - Nikdokht Farid
- Department of Radiology, University of California, San Diego, La Jolla, California
| | | | - Parag Sanghvi
- Department of Radiation Medicine and Applied Sciences
| | - Carrie R McDonald
- Department of Radiation Medicine and Applied Sciences; Department of Psychiatry; Center for Multimodal Imaging and Genetics
| | - Jona A Hattangadi-Gluth
- Department of Radiation Medicine and Applied Sciences; Center for Multimodal Imaging and Genetics.
| |
Collapse
|
13
|
Haas-Kogan D, Indelicato D, Paganetti H, Esiashvili N, Mahajan A, Yock T, Flampouri S, MacDonald S, Fouladi M, Stephen K, Kalapurakal J, Terezakis S, Kooy H, Grosshans D, Makrigiorgos M, Mishra K, Poussaint TY, Cohen K, Fitzgerald T, Gondi V, Liu A, Michalski J, Mirkovic D, Mohan R, Perkins S, Wong K, Vikram B, Buchsbaum J, Kun L. National Cancer Institute Workshop on Proton Therapy for Children: Considerations Regarding Brainstem Injury. Int J Radiat Oncol Biol Phys 2019; 101:152-168. [PMID: 29619963 DOI: 10.1016/j.ijrobp.2018.01.013] [Citation(s) in RCA: 117] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 12/21/2017] [Accepted: 01/01/2018] [Indexed: 01/08/2023]
Abstract
PURPOSE Proton therapy can allow for superior avoidance of normal tissues. A widespread consensus has been reached that proton therapy should be used for patients with curable pediatric brain tumor to avoid critical central nervous system structures. Brainstem necrosis is a potentially devastating, but rare, complication of radiation. Recent reports of brainstem necrosis after proton therapy have raised concerns over the potential biological differences among radiation modalities. We have summarized findings from the National Cancer Institute Workshop on Proton Therapy for Children convened in May 2016 to examine brainstem injury. METHODS AND MATERIALS Twenty-seven physicians, physicists, and researchers from 17 institutions with expertise met to discuss this issue. The definition of brainstem injury, imaging of this entity, clinical experience with photons and photons, and potential biological differences among these radiation modalities were thoroughly discussed and reviewed. The 3 largest US pediatric proton therapy centers collectively summarized the incidence of symptomatic brainstem injury and physics details (planning, dosimetry, delivery) for 671 children with focal posterior fossa tumors treated with protons from 2006 to 2016. RESULTS The average rate of symptomatic brainstem toxicity from the 3 largest US pediatric proton centers was 2.38%. The actuarial rate of grade ≥2 brainstem toxicity was successfully reduced from 12.7% to 0% at 1 center after adopting modified radiation guidelines. Guidelines for treatment planning and current consensus brainstem constraints for proton therapy are presented. The current knowledge regarding linear energy transfer (LET) and its relationship to relative biological effectiveness (RBE) are defined. We review the current state of LET-based planning. CONCLUSIONS Brainstem injury is a rare complication of radiation therapy for both photons and protons. Substantial dosimetric data have been collected for brainstem injury after proton therapy, and established guidelines to allow for safe delivery of proton radiation have been defined. Increased capability exists to incorporate LET optimization; however, further research is needed to fully explore the capabilities of LET- and RBE-based planning.
Collapse
Affiliation(s)
- Daphne Haas-Kogan
- Department of Radiation Oncology, Harvard Medical School and Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, Massachusetts
| | - Daniel Indelicato
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida
| | - Harald Paganetti
- Department of Radiation Oncology, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - Natia Esiashvili
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Anita Mahajan
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas; Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Torunn Yock
- Department of Radiation Oncology, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - Stella Flampouri
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida
| | - Shannon MacDonald
- Department of Radiation Oncology, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - Maryam Fouladi
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kry Stephen
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - John Kalapurakal
- Department of Radiation Oncology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Stephanie Terezakis
- Department of Radiation Oncology, Johns Hopkins Medical Institute, Baltimore, Maryland
| | - Hanne Kooy
- Department of Radiation Oncology, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - David Grosshans
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mike Makrigiorgos
- Department of Radiation Oncology, Harvard Medical School and Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kavita Mishra
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | - Tina Young Poussaint
- Department of Radiology, Harvard Medical School and Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, Massachusetts
| | - Kenneth Cohen
- Department of Pediatrics, Johns Hopkins Medical Institute, Baltimore, Maryland
| | - Thomas Fitzgerald
- Department of Radiation Oncology, UMass Memorial Medical Center, Worcester, Massachusetts
| | - Vinai Gondi
- Northwestern Medicine Chicago Proton Center, Chicago, Illinois
| | - Arthur Liu
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Jeff Michalski
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Dragan Mirkovic
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Radhe Mohan
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stephanie Perkins
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Kenneth Wong
- Children's Hospital of Angeles and University of Southern California Keck School of Medicine, Los Angles, California
| | - Bhadrasain Vikram
- Radiation Research Program, National Cancer Institute, National Institutes of Health, Rockville, Maryland
| | - Jeff Buchsbaum
- Radiation Research Program, National Cancer Institute, National Institutes of Health, Rockville, Maryland
| | - Larry Kun
- Department of Radiation Oncology, University of Texas Southwestern Medical School, Dallas, Texas.
| |
Collapse
|
14
|
FitzGerald TJ, Donaldson SS, Wharam M, Laurie F, Bishop-Jodoin M, Moni J, Tarbell N, Shulkin B, McCarville E, Merchant T, Krasin M, Wolden S, Halperin E, Constine LS, Haas-Kogan D, Marcus K, Freeman C, Wilson JF, Hoppe R, Cox J, Terezakis S, Million L, Smith MA, Mendenhall NP, Marcus RB, Cherlow J, Kalapurakal J, Breneman J, Yock T, MacDonald S, Laack N, Donahue B, Indelicato D, Michalski J, Perkins S, Kachnic L, Choy H, Braunstein S, Esiashvilli N, Roberts KB. Larry Emanuel Kun, March 10, 1946-May 27, 2018. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2018.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
15
|
Fu Z, Zhao Y, Zhang K, Wang J, Zhang M, Zhao X. Age-Dependent Responses of Brain Myelin Integrity and Behavioral Performance to Radiation in Mice. Radiat Res 2017; 188:505-516. [PMID: 28937316 DOI: 10.1667/rr14732.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Radiation therapy is widely used to treat primary and metastatic brain tumors, but it may also lead to delayed neurological complications. Oligodendrocytes in the central nervous system produce myelin, and myelin integrity becomes highly vulnerable after brain irradiation. In this study, mice at different developmental stages were used to test the age-dependent sensitivity of myelin formation and maintenance, as well as behavioral performance after whole-brain irradiation (WBI). Mice at postnatal days 21 and 28 and at 2 months received a single dose of 25 Gy WBI. Behavioral tests for general locomotor activity and motor coordination revealed an age-dependent response after WBI. Quantitative observation revealed a sharp decrease in the number of oligodendrocytes beginning at day 1 after WBI, which recovered during different observation intervals in white matter and gray matter in mice of different ages. Myelin basic protein (MBP) staining revealed disparate quantities in an age- and brain-region-dependent pattern between groups after WBI, which was confirmed using Black-Gold staining. In summary, the response to radiation in mice of different ages provided insight into the potential of oligogenesis in microenvironments at respective stages of myelin regeneration, which may reduce central nervous system impairment and optimize the prognosis after radiation treatment.
Collapse
Affiliation(s)
- Zhimeng Fu
- a Department of Neurobiology and Collaborative Innovation Center for Brain Science, School of Basic Medicine, Fourth Military Medical University, Xi'an 710032 China
| | - Yunfei Zhao
- a Department of Neurobiology and Collaborative Innovation Center for Brain Science, School of Basic Medicine, Fourth Military Medical University, Xi'an 710032 China.,b 93514 Hospital, Tangshan 064200 China
| | - Kaixiang Zhang
- a Department of Neurobiology and Collaborative Innovation Center for Brain Science, School of Basic Medicine, Fourth Military Medical University, Xi'an 710032 China
| | - Jian Wang
- a Department of Neurobiology and Collaborative Innovation Center for Brain Science, School of Basic Medicine, Fourth Military Medical University, Xi'an 710032 China
| | - Min Zhang
- a Department of Neurobiology and Collaborative Innovation Center for Brain Science, School of Basic Medicine, Fourth Military Medical University, Xi'an 710032 China
| | - Xianghui Zhao
- a Department of Neurobiology and Collaborative Innovation Center for Brain Science, School of Basic Medicine, Fourth Military Medical University, Xi'an 710032 China
| |
Collapse
|
16
|
Fjæra LF, Li Z, Ytre-Hauge KS, Muren LP, Indelicato DJ, Lassen-Ramshad Y, Engeseth GM, Brydøy M, Mairani A, Flampouri S, Dahl O, Stokkevåg CH. Linear energy transfer distributions in the brainstem depending on tumour location in intensity-modulated proton therapy of paediatric cancer. Acta Oncol 2017; 56:763-768. [PMID: 28423966 DOI: 10.1080/0284186x.2017.1314007] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND For tumours near organs at risk, there is concern about unintended increase in biological dose from elevated linear energy transfer (LET) at the distal end of treatment fields. The objective of this study was therefore to investigate how different paediatric posterior fossa tumour locations impact LET and biological dose to the brainstem during intensity-modulated proton therapy (IMPT). MATERIAL AND METHODS Multiple IMPT plans were generated for four different simulated tumour locations relative to the brainstem for a five-year-old male patient. A prescribed dose of 59.4 Gy(RBE) was applied to the planning target volumes (PTVs). Plans with two lateral and one posterior non-coplanar fields were created, along with plans with modified field arrangements. The dose-averaged LET (LETd) and the physical dose × RBELET (D × RBELET), where RBELET=1+c × LETd, were calculated using the FLUKA Monte Carlo code. A scaling parameter c was applied to make the RBELET represent variations in the biological effect due to LET. RESULTS High LETd values surrounded parts of the PTV and encompassed portions of the brainstem. Mean LETd values in the brainstem were 3.2-6.6 keV/μm. The highest absolute brainstem LETd values were seen with the tumour located most distant from the brainstem, whereas lower and more homogeneous LETd values were seen when the tumour invaded the brainstem. In contrast, the highest mean D × RBELET values were found in the latter case (54.0 Gy(RBE)), while the case with largest distance between tumour and brainstem had a mean D × RBELET of 1.8 Gy(RBE). CONCLUSIONS Using IMPT to treat posterior fossa tumours may result in high LETd values within the brainstem, particularly if the tumour volume is separated from the brainstem. However, the D × RBELET was greater for tumours that approached or invaded the brainstem. Changing field angles showed a reduction of LETd and D × RBELET in the brainstem.
Collapse
Affiliation(s)
- Lars Fredrik Fjæra
- Department of Physics and Technology, University of Bergen, Bergen, Norway
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Zuofeng Li
- Department of Radiation Oncology, University of Florida, Jacksonville, FL, USA
| | | | - Ludvig P. Muren
- Department of Medical Physics, Aarhus University/Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Grete May Engeseth
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Marianne Brydøy
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Andrea Mairani
- Medical Physics Unit, CNAO Foundation, Pavia, Italy
- Heidelberg Ion Beam Therapy Center (HIT), Heidelberg, Germany
| | - Stella Flampouri
- Department of Radiation Oncology, University of Florida, Jacksonville, FL, USA
| | - Olav Dahl
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Camilla H. Stokkevåg
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| |
Collapse
|
17
|
Tunç B, Ingalhalikar M, Parker D, Lecoeur J, Singh N, Wolf RL, Macyszyn L, Brem S, Verma R. Individualized Map of White Matter Pathways: Connectivity-Based Paradigm for Neurosurgical Planning. Neurosurgery 2016; 79:568-77. [PMID: 26678299 PMCID: PMC4911597 DOI: 10.1227/neu.0000000000001183] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Advances in white matter tractography enhance neurosurgical planning and glioma resection, but white matter tractography is limited by biological variables such as edema, mass effect, and tract infiltration or selection biases related to regions of interest or fractional anisotropy values. OBJECTIVE To provide an automated tract identification paradigm that corrects for artifacts created by tumor edema and infiltration and provides a consistent, accurate method of fiber bundle identification. METHODS An automated tract identification paradigm was developed and evaluated for glioma surgery. A fiber bundle atlas was generated from 6 healthy participants. Fibers of a test set (including 3 healthy participants and 10 patients with brain tumors) were clustered adaptively with this atlas. Reliability of the identified tracts in both groups was assessed by comparison with 2 experts with the Cohen κ used to quantify concurrence. We evaluated 6 major fiber bundles: cingulum bundle, fornix, uncinate fasciculus, arcuate fasciculus, inferior fronto-occipital fasciculus, and inferior longitudinal fasciculus, the last 3 tracts mediating language function. RESULTS The automated paradigm demonstrated a reliable and practical method to identify white mater tracts, despite mass effect, edema, and tract infiltration. When the tumor demonstrated significant mass effect or shift, the automated approach was useful for providing an initialization to guide the expert with identification of the specific tract of interest. CONCLUSION We report a reliable paradigm for the automated identification of white matter pathways in patients with gliomas. This approach should enhance the neurosurgical objective of maximal safe resections. ABBREVIATIONS AF, arcuate fasciculusDTI, diffusion tensor imagingIFOF, inferior fronto-occipital fasciculusILF, inferior longitudinal fasciculusROI, region of interestWM, white matter.
Collapse
Affiliation(s)
- Birkan Tunç
- Center for Biomedical Image Computing and Analytics, University of Pennsylvania, Philadelphia, PA, USA
| | - Madhura Ingalhalikar
- Center for Biomedical Image Computing and Analytics, University of Pennsylvania, Philadelphia, PA, USA
| | - Drew Parker
- Center for Biomedical Image Computing and Analytics, University of Pennsylvania, Philadelphia, PA, USA
| | - Jérémy Lecoeur
- Center for Biomedical Image Computing and Analytics, University of Pennsylvania, Philadelphia, PA, USA
| | - Nickpreet Singh
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ronald L. Wolf
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Luke Macyszyn
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven Brem
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ragini Verma
- Center for Biomedical Image Computing and Analytics, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
18
|
Alongi F, Fiorentino A, Mancosu P, Navarria P, Giaj Levra N, Mazzola R, Scorsetti M. Stereotactic radiosurgery for intracranial metastases: linac-based and gamma-dedicated unit approach. Expert Rev Anticancer Ther 2016; 16:731-40. [DOI: 10.1080/14737140.2016.1190648] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Filippo Alongi
- Radiation Oncology Department, Sacro Cuore Hospital, Negrar, Italy
| | - Alba Fiorentino
- Radiation Oncology Department, Sacro Cuore Hospital, Negrar, Italy
| | - Pietro Mancosu
- Radiation Oncology Department, Istituto Clinico Humanitas, Milan, Italy
| | - Pierina Navarria
- Radiation Oncology Department, Istituto Clinico Humanitas, Milan, Italy
| | | | - Rosario Mazzola
- Radiation Oncology Department, Sacro Cuore Hospital, Negrar, Italy
| | - Marta Scorsetti
- Radiation Oncology Department, Istituto Clinico Humanitas, Milan, Italy
| |
Collapse
|
19
|
Piao J, Major T, Auyeung G, Policarpio E, Menon J, Droms L, Gutin P, Uryu K, Tchieu J, Soulet D, Tabar V. Human embryonic stem cell-derived oligodendrocyte progenitors remyelinate the brain and rescue behavioral deficits following radiation. Cell Stem Cell 2015; 16:198-210. [PMID: 25658373 DOI: 10.1016/j.stem.2015.01.004] [Citation(s) in RCA: 153] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Revised: 11/24/2014] [Accepted: 01/13/2015] [Indexed: 10/24/2022]
Abstract
Radiation therapy to the brain is a powerful tool in the management of many cancers, but it is associated with significant and irreversible long-term side effects, including cognitive decline and impairment of motor coordination. Depletion of oligodendrocyte progenitors and demyelination are major pathological features that are particularly pronounced in younger individuals and severely limit therapeutic options. Here we tested whether human ESC-derived oligodendrocytes can functionally remyelinate the irradiated brain using a rat model. We demonstrate the efficient derivation and prospective isolation of human oligodendrocyte progenitors, which, upon transplantation, migrate throughout the major white matter tracts resulting in both structural and functional repair. Behavioral testing showed complete recovery of cognitive function while additional recovery from motor deficits required concomitant transplantation into the cerebellum. The ability to repair radiation-induced damage to the brain could dramatically improve the outlook for cancer survivors and enable more effective use of radiation therapies, especially in children.
Collapse
Affiliation(s)
- Jinghua Piao
- Department of Neurosurgery and Center for Stem Cell Biology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Tamara Major
- Department of Neurosurgery and Center for Stem Cell Biology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Gordon Auyeung
- Department of Neurosurgery and Center for Stem Cell Biology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Edelweiss Policarpio
- Department of Neurosurgery and Center for Stem Cell Biology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Jayanthi Menon
- Department of Neurosurgery and Center for Stem Cell Biology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Leif Droms
- Department of Neurosurgery and Center for Stem Cell Biology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Philip Gutin
- Department of Neurosurgery and Center for Stem Cell Biology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Kunihiro Uryu
- Resource Center (EMRC), The Rockefeller University, New York, NY 10065, USA
| | - Jason Tchieu
- Developmental Biology Program, Sloan Kettering Institute, New York, NY 10065, USA
| | - Denis Soulet
- Department of Psychiatry and Neuroscience, Faculty of Medicine, Laval University, QC, Canada, G1V 0A6; Axe Neuroscience, Centre de recherche du CHU de Québec, QC, Canada, G1V 0A6
| | - Viviane Tabar
- Department of Neurosurgery and Center for Stem Cell Biology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA.
| |
Collapse
|
20
|
Trifiletti DM, Lee CC, Winardi W, Patel NV, Yen CP, Larner JM, Sheehan JP. Brainstem metastases treated with stereotactic radiosurgery: safety, efficacy, and dose response. J Neurooncol 2015; 125:385-92. [PMID: 26341374 DOI: 10.1007/s11060-015-1927-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 09/01/2015] [Indexed: 11/28/2022]
Abstract
The safety and efficacy of stereotactic radiosurgery (SRS) in the brainstem is questioned by some over concern of violating historical brainstem SRS dose tolerance. Our purpose was to report on the clinical outcomes of patients treated at our institution with radiosurgery for brainstem metastases. Patients with metastatic tumors within or directly abutting the brainstem from 1992 to 2014 were analyzed. Patient and tumor characteristics, SRS parameters, and toxicity were recorded and analyzed for associations with local control and survival. Multivariate statistical analysis was performed using Cox proportional hazards modeling. One-hundred and eighty-nine (189) brainstem metastases from 161 patients were included in our analysis. Whole brain irradiation was administered prior to SRS in 52 % of patients. The median margin dose was 18 Gy prescribed to the 50 % isodose line. Median imaging follow up was 5.4 months and median survival was 5.5 months after SRS. At last follow up, local control was achieved in 87.3 % of brainstem lesions treated. There were 3 recorded events of grade 3-5 toxicity (1.8 %). On multivariate analysis, a margin dose ≥16 Gy was associated with improved local control (p = 0.049) and greater KPS score was associated with improved overall survival following SRS (p = 0.024). Patients with brainstem metastases who have limited intracranial disease and/or who have received whole brain irradiation should be considered for SRS. Margin doses of at least 16 Gy are associated with superior local control, and serious radiation toxicity in SRS for brainstem metastasis appears rare.
Collapse
Affiliation(s)
- Daniel M Trifiletti
- Department of Radiation Oncology, University of Virginia, 1240 Lee Street, Box 800383, Charlottesville, VA, 22908, USA.
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan, ROC
| | - William Winardi
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Nirav V Patel
- Department of Radiation Oncology, University of Virginia, 1240 Lee Street, Box 800383, Charlottesville, VA, 22908, USA
| | - Chun-Po Yen
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan, ROC
| | - James M Larner
- Department of Radiation Oncology, University of Virginia, 1240 Lee Street, Box 800383, Charlottesville, VA, 22908, USA
| | - Jason P Sheehan
- Department of Radiation Oncology, University of Virginia, 1240 Lee Street, Box 800383, Charlottesville, VA, 22908, USA.,Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan, ROC
| |
Collapse
|
21
|
Farjam R, Pramanik P, Aryal MP, Srinivasan A, Chapman CH, Tsien CI, Lawrence TS, Cao Y. A Radiation-Induced Hippocampal Vascular Injury Surrogate Marker Predicts Late Neurocognitive Dysfunction. Int J Radiat Oncol Biol Phys 2015; 93:908-15. [PMID: 26530761 DOI: 10.1016/j.ijrobp.2015.08.014] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 07/10/2015] [Accepted: 08/05/2015] [Indexed: 12/17/2022]
Abstract
PURPOSE We aimed to develop a hippocampal vascular injury surrogate marker for early prediction of late neurocognitive dysfunction in patients receiving brain radiation therapy (RT). METHODS AND MATERIALS Twenty-seven patients (17 males and 10 females, 31-80 years of age) were enrolled in an institutional review board-approved prospective longitudinal study. Patients received diagnoses of low-grade glioma or benign tumor and were treated by (3D) conformal or intensity-modulated RT with a median dose of 54 Gy (50.4-59.4 Gy in 1.8-Gy fractions). Six dynamic-contrast enhanced MRI scans were performed from pre-RT to 18-month post-RT, and quantified for vascular parameters related to blood-brain barrier permeability, K(trans), and the fraction of blood plasma volume, Vp. The temporal changes in the means of hippocampal transfer constant K(trans) and Vp after starting RT were modeled by integrating the dose effects with age, sex, hippocampal laterality, and presence of tumor or edema near a hippocampus. Finally, the early vascular dose response in hippocampi was correlated with neurocognitive dysfunction at 6 and 18 months post-RT. RESULTS The mean K(trans) Increased significantly from pre-RT to 1-month post-RT (P<.0004), which significantly depended on sex (P<.0007) and age (P<.00004), with the dose response more pronounced in older females. Also, the vascular dose response in the left hippocampus of females correlated significantly with changes in memory function at 6 (r=-0.95, P<.0006) and 18-months (r=-0.88, P<.02) post-RT. CONCLUSIONS The early hippocampal vascular dose response could be a predictor of late neurocognitive dysfunction. A personalized hippocampus sparing strategy may be considered in the future.
Collapse
Affiliation(s)
- Reza Farjam
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Priyanka Pramanik
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Madhava P Aryal
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Ashok Srinivasan
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | | | - Christina I Tsien
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, Missouri
| | - Theodore S Lawrence
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Yue Cao
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan; Department of Radiology, University of Michigan, Ann Arbor, Michigan; Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan.
| |
Collapse
|
22
|
Brainstem white matter integrity is related to loss of consciousness and postconcussive symptomatology in veterans with chronic mild to moderate traumatic brain injury. Brain Imaging Behav 2015; 9:500-12. [DOI: 10.1007/s11682-015-9432-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
|
23
|
Rueckriegel SM, Bruhn H, Thomale UW, Hernáiz Driever P. Cerebral white matter fractional anisotropy and tract volume as measured by MR imaging are associated with impaired cognitive and motor function in pediatric posterior fossa tumor survivors. Pediatr Blood Cancer 2015; 62:1252-8. [PMID: 25850573 DOI: 10.1002/pbc.25485] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 02/02/2015] [Indexed: 01/18/2023]
Abstract
BACKGROUND Disease and therapy cause brain damage and subsequent functional loss in pediatric patients with posterior fossa tumors. Treatment-related toxicity factors are resection in patients with pilocytic astrocytoma (PA) and, additionally, cranio-spinal irradiation together with chemotherapy in patients with medulloblastoma (MB). We tested whether damage to white matter (WM) as revealed by diffusion tensor MR imaging (DTI) correlated with specific cognitive and motor impairments in survivors of pediatric posterior fossa tumors. PROCEDURES Eighteen MB (mean age ± SD, 15.2 ± 4.9 y) and 14 PA (12.6 ± 5.0 y) survivors were investigated with DTI on a 3-Tesla-MR system. We identified fractional anisotropy (FA) of WM, the volume ratio of WM to gray matter and cerebrospinal fluid (WM/GM + CSF), and volume of specific frontocerebellar tracts. Ataxia was assessed using the International Cooperative Ataxia Rating Scale (ICARS), while the Wechsler Intelligence Scale for Children determined full-scale intelligence quotients (FSIQ). Amsterdam Neuropsychological Tasks (ANT) was used to assess processing speed. Handwriting automation was analyzed using a digitizing graphic tablet. RESULTS The WM/GM + CSF ratio correlated significantly with cognitive measures (IQ, P = 0.002; ANT baseline speed, P = 0.04; ANT shifting attention, P = 0.004). FA of skeletonized tracts correlated significantly with FSIQ (P = 0.008), ANT baseline speed (P = 0.028) and ANT shifting attention (P = 0.045). Moreover, frontocerebellar tract volumes correlated with both the FSIQ (P = 0.011) and ICARS (P = 0.007). CONCLUSION DTI provides a method for quantification of WM damage by tumor and by therapy-associated effects in survivors of pediatric posterior fossa tumors. DTI-derived WM integrity may be a representative marker for cognitive and motor deterioration.
Collapse
Affiliation(s)
- Stefan M Rueckriegel
- Pediatric Neurooncology Program, Department of Pediatric Oncology and Hematology, Charité-CVK, Berlin, Germany.,Department of Neurosurgery, University Hospital Würzburg, Würzburg, Germany
| | - Harald Bruhn
- Department of Radiology, Charité-CVK, Berlin, Germany
| | - Ulrich W Thomale
- Section of Pediatric Neurosurgery, Charité- CVK, Berlin, Germany
| | - Pablo Hernáiz Driever
- Pediatric Neurooncology Program, Department of Pediatric Oncology and Hematology, Charité-CVK, Berlin, Germany
| |
Collapse
|
24
|
Effects of Surgery and Proton Therapy on Cerebral White Matter of Craniopharyngioma Patients. Int J Radiat Oncol Biol Phys 2015; 93:64-71. [PMID: 26279025 DOI: 10.1016/j.ijrobp.2015.05.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 04/22/2015] [Accepted: 05/12/2015] [Indexed: 11/20/2022]
Abstract
PURPOSE The purpose of this study was to determine radiation dose effect on the structural integrity of cerebral white matter in craniopharyngioma patients receiving surgery and proton therapy. METHODS AND MATERIALS Fifty-one patients (2.1-19.3 years of age) with craniopharyngioma underwent surgery and proton therapy in a prospective therapeutic trial. Anatomical magnetic resonance images acquired after surgery but before proton therapy were inspected to identify white matter structures intersected by surgical corridors and catheter tracks. Longitudinal diffusion tensor imaging (DTI) was performed to measure microstructural integrity changes in cerebral white matter. Fractional anisotropy (FA) derived from DTI was statistically analyzed for 51 atlas-based white matter structures of the brain to determine radiation dose effect. FA in surgery-affected regions in the corpus callosum was compared to that in its intact counterpart to determine whether surgical defects affect radiation dose effect. RESULTS Surgical defects were seen most frequently in the corpus callosum because of transcallosal resection of tumors and insertion of ventricular or cyst catheters. Longitudinal DTI data indicated reductions in FA 3 months after therapy, which was followed by a recovery in most white matter structures. A greater FA reduction was correlated with a higher radiation dose in 20 white matter structures, indicating a radiation dose effect. The average FA in the surgery-affected regions before proton therapy was smaller (P=.0001) than that in their non-surgery-affected counterparts with more intensified subsequent reduction of FA (P=.0083) after therapy, suggesting that surgery accentuated the radiation dose effect. CONCLUSIONS DTI data suggest that mild radiation dose effects occur in patients with craniopharyngioma receiving surgery and proton therapy. Surgical defects present at the time of proton therapy appear to accentuate the radiation dose effect longitudinally. This study supports consideration of pre-existing surgical defects and their locations in proton therapy planning and studies of treatment effect.
Collapse
|
25
|
Ambady P, Bettegowda C, Holdhoff M. Emerging methods for disease monitoring in malignant gliomas. CNS Oncol 2015; 2:511-22. [PMID: 25054821 DOI: 10.2217/cns.13.44] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
MRI remains the backbone of measuring disease burden and treatment response in individuals with malignant gliomas. Traditional radiographic approaches, however, are largely limited to depicting anatomic changes and are not a direct measure of disease burden. For example, contrast enhancement is related to blood-brain barrier integrity rather than actual tumor size. Without accurate measures of disease, common clinical dilemmas include 'pseudo-progression' (e.g., after chemoradiation) or 'pseudo-response' (e.g., with steroid treatment and antiangiogenic agents), which can lead to delays in therapy, premature discontinuation of successful treatments and to unnecessary surgical procedures. This overview focuses on novel, minimally invasive approaches in the area of imaging and blood-based biomarkers that aim to more accurately determine disease status and response to treatment in malignant brain tumors.
Collapse
Affiliation(s)
- Prakash Ambady
- Brain Cancer Program, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, 1550 Orleans Street, 1M16, Baltimore, MD 21287, USA
| | | | | |
Collapse
|
26
|
Moberget T, Andersson S, Lundar T, Due-Tønnessen B, Heldal A, Endestad T, Westlye L. Long-term supratentorial brain structure and cognitive function following cerebellar tumour resections in childhood. Neuropsychologia 2015; 69:218-31. [DOI: 10.1016/j.neuropsychologia.2015.02.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Revised: 01/21/2015] [Accepted: 02/05/2015] [Indexed: 01/17/2023]
|
27
|
Tan W, Han G, Wei S, Hu D. Sparing functional anatomical structures during intensity-modulated radiotherapy: an old problem, a new solution. Future Oncol 2014; 10:1863-72. [PMID: 23987920 DOI: 10.2217/fon.13.172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
ABSTRACT During intensity-modulated radiotherapy, an organ is usually assumed to be functionally homogeneous and, generally, its anatomical and spatial heterogeneity with respect to radiation response are not taken into consideration. However, advances in imaging and radiation techniques as well as an improved understanding of the radiobiological response of organs have raised the possibility of sparing the critical functional structures within various organs at risk during intensity-modulated radiotherapy. Here, we discuss these structures, which include the critical brain structure, or neural nuclei, and the nerve fiber tracts in the CNS, head and neck structures related to radiation-induced salivary and swallowing dysfunction, and functional structures in the heart and lung. We suggest that these structures can be used as potential surrogate organs at risk in order to minimize their radiation dose and/or irradiated volume without compromising the dose coverage of the target volume during radiation treatment.
Collapse
Affiliation(s)
- Wenyong Tan
- Department of Radiation Oncology, Hubei Cancer Hospital, 116 South Road, Zhuodaoquan, Wuhan 430079, China
| | - Guang Han
- Department of Radiation Oncology, Hubei Cancer Hospital, 116 South Road, Zhuodaoquan, Wuhan 430079, China
| | - Shaozhong Wei
- Department of Gastrointestinal & Genitourinary Oncology, Hubei Cancer Hospital, 116 South Road, Zhuodaoquan, Wuhan 430079, China
| | - Desheng Hu
- Department of Radiation Oncology, Hubei Cancer Hospital, 116 South Road, Zhuodaoquan, Wuhan 430079, China
| |
Collapse
|
28
|
Wetmore C, Herington D, Lin T, Onar-Thomas A, Gajjar A, Merchant TE. Reirradiation of recurrent medulloblastoma: does clinical benefit outweigh risk for toxicity? Cancer 2014; 120:3731-7. [PMID: 25080363 DOI: 10.1002/cncr.28907] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 05/23/2014] [Accepted: 06/16/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND Patients with recurrent medulloblastoma (MB) have a dismal prognosis. There has been a reluctance to use radiation in the salvage therapy regimens for these patients because of concerns about toxicity and unknown efficacy. Comparing survival outcomes and toxicities in relapsed patients treated with and without radiation may help to define its role. METHODS A retrospective review was conducted that included 38 patients with recurrent MB treated with similar risk-adapted therapy at initial diagnosis; reirradiation was a component of salvage therapy in 14. Overall survival (OS) and toxicity were evaluated according to the use of radiation, prior risk stratification, and other factors. RESULTS For relapsed standard-risk patients, the use of additional irradiation resulted in a statistically significant improvement in OS from initial diagnosis (P = .036), with 5- and 10-year OS rates of 55% ± 14% and 33% ± 16% versus 46% ± 14% and 0% for reirradiated patients versus others, respectively. Similar improvement was observed in high-risk patients (P = .003). There was an association between the use of additional irradiation and an increased rate of necrosis as determined by neuroimaging (P = .0468). CONCLUSIONS The use of irradiation as a component of salvage therapy for relapsed MB may prolong survival. The benefit appears to be greatest for relapsed standard-risk patients.
Collapse
Affiliation(s)
- Cynthia Wetmore
- Emory University/Children's Healthcare of Atlanta, Aflac Cancer & Blood Disorders Center, Atlanta, Georgia
| | | | | | | | | | | |
Collapse
|
29
|
Nelson MB, Macey PM, Harper RM, Jacob E, Patel SK, Finlay JL, Nelson MD, Compton P. Structural brain alterations in children an average of 5 years after surgery and chemotherapy for brain tumors. J Neurooncol 2014; 119:317-26. [PMID: 24830985 DOI: 10.1007/s11060-014-1480-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 05/05/2014] [Indexed: 12/01/2022]
Abstract
Young children with brain tumors are often treated with high-dose chemotherapy after surgery to avoid brain tissue injury associated with irradiation. The effects of systemic chemotherapy on healthy brain tissue in this population, however, are unclear. Our objective was to compare gray and white matter integrity using MRI procedures in children with brain tumors (n = 7, mean age 8.3 years), treated with surgery and high-dose chemotherapy followed by autologous hematopoietic cell rescue (AuHCR) an average of 5.4 years earlier, to age- and gender-matched healthy controls (n = 9, mean age 9.3 years). Diffusion tensor imaging data were collected to evaluate tissue integrity throughout the brain, as measured by mean diffusivity (MD), a marker of glial, neuronal, and axonal status, and fractional anisotropy (FA), an index of axonal health. Individual MD and FA maps were calculated, normalized, smoothed, and compared between groups using analysis of covariance, with age and sex as covariates. Higher MD values, indicative of injury, emerged in patients compared with controls (p < .05, corrected for multiple comparisons), and were especially apparent in the central thalamus, external capsule, putamen, globus pallidus and pons. Reduced FA values in some regions did not reach significance after correction for multiple comparisons. Children treated with surgery and high-dose chemotherapy with AuHCR for brain tumors an average of 5.4 years earlier show alterations in white and gray matter in multiple brain areas distant from the tumor site, raising the possibility for long-term consequences of the tumor or treatment.
Collapse
Affiliation(s)
- Mary Baron Nelson
- Children's Hospital Los Angeles, 4650 Sunset Blvd. MS #54, Los Angeles, CA, 90027, USA,
| | | | | | | | | | | | | | | |
Collapse
|
30
|
Nguyen NP, Nguyen ML, Vock J, Lemanski C, Kerr C, Vinh-Hung V, Chi A, Khan R, Woods W, Altdorfer G, D'Andrea M, Karlsson U, Hamilton R, Ampil F. Potential applications of imaging and image-guided radiotherapy for brain metastases and glioblastoma to improve patient quality of life. Front Oncol 2013; 3:284. [PMID: 24312897 PMCID: PMC3832799 DOI: 10.3389/fonc.2013.00284] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 11/04/2013] [Indexed: 11/17/2022] Open
Abstract
Treatment of glioblastoma multiforme (GBM) and brain metastasis remains a challenge because of the poor survival and the potential for brain damage following radiation. Despite concurrent chemotherapy and radiation dose escalation, local recurrence remains the predominant pattern of failure in GBM most likely secondary to repopulation of cancer stem cells. Even though radiotherapy is highly effective for local control of radio-resistant tumors such as melanoma and renal cell cancer, systemic disease progression is the cause of death in most patients with brain metastasis. Preservation of quality of life (QOL) of cancer survivors is the main issue for patients with brain metastasis. Image-guided radiotherapy (IGRT) by virtue of precise radiation dose delivery may reduce treatment time of patients with GBM without excessive toxicity and potentially improve neurocognitive function with preservation of local control in patients with brain metastasis. Future prospective trials for primary brain tumors or brain metastasis should include IGRT to assess its efficacy to improve patient QOL.
Collapse
Affiliation(s)
- Nam P Nguyen
- Department of Radiation Oncology, The University of Arizona , Tucson, AZ , USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Ravn S, Holmberg M, Sørensen P, Frøkjær JB, Carl J. Differences in supratentorial white matter diffusion after radiotherapy--new biomarker of normal brain tissue damage? Acta Oncol 2013; 52:1314-9. [PMID: 23981047 DOI: 10.3109/0284186x.2013.812797] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Therapy-induced injury to normal brain tissue is a concern in the treatment of all types of brain tumours. The purpose of this study was to investigate if magnetic resonance diffusion tensor imaging (DTI) could serve as a potential biomarker for the assessment of radiation-induced long-term white matter injury. MATERIAL AND METHODS DTI- and T1-weighted images of the brain were obtained in 19 former radiotherapy patients [nine men and 10 women diagnosed with astrocytoma (4), pituitary adenoma (6), meningioma (8) and craniopharyngioma (1), average age 57.8 (range 35-71) years]. Average time from radiotherapy to DTI scan was 4.6 (range 2.0-7.1) years. NordicICE software (NIC) was used to calculate apparent diffusion coefficient maps (ADC-maps). The co-registration between T1 images and ADC-maps were done using the auto function in NIC. The co-registration between the T1 images and the patient dose plans were done using the auto function in the treatment planning system Eclipse from Varian. Regions of interest were drawn on the T1-weighted images in NIC based on isocurves from Eclipse. Data was analysed by t-test. Estimates are given with 95% CI. RESULTS A mean ADC difference of 4.6(0.3;8.9)× 10(-5) mm(2)/s, p = 0.03 was found between paired white matter structures with a mean dose difference of 31.4 Gy. Comparing the ADC-values of the areas with highest dose from the paired data (dose > 33 Gy) with normal white matter (dose < 5 Gy) resulted in a mean dose difference of 44.1 Gy and a mean ADC difference of 7.87(3.15;12.60)× 10(-5) mm(2)/s, p = 0.003. Following results were obtained when looking at differences between white matter mean ADC in average dose levels from 5 to 55 Gy in steps of 10 Gy with normal white matter mean ADC: 5 Gy; 1.91(-1.76;5.58)× 10(-5) mm(2)/s, p = 0.29; 15 Gy; 5.81(1.53;10.11)× 10(-5) mm(2)/s, p = 0.01; 25 Gy; 5.80(2.43;9.18)× 10(-5) mm(2)/s, p = 0.002; 35 Gy; 5.93(2.89;8.97)× 10(-5) mm(2)/s, p = 0.0007; 45 Gy; 4.32(-0.24;8.89)× 10(-5) mm(2)/s, p = 0.06; 55 Gy; -4.04(-14.96;6.89)× 10(-5) mm(2)/s, p = 0.39. CONCLUSION The results indicate that the structural integrity of white matter, assessed by ADC-values based on DTI, undergoes changes after radiation therapy starting as early as total dose levels between 5 and 15 Gy.
Collapse
Affiliation(s)
- Søren Ravn
- Department of Radiology, Aalborg University Hospital , Aalborg , Denmark
| | | | | | | | | |
Collapse
|