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Jahng JWS, Little MP, No HJ, Loo BW, Wu JC. Consequences of ionizing radiation exposure to the cardiovascular system. Nat Rev Cardiol 2024:10.1038/s41569-024-01056-4. [PMID: 38987578 DOI: 10.1038/s41569-024-01056-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/11/2024] [Indexed: 07/12/2024]
Abstract
Ionizing radiation is widely used in various industrial and medical applications, resulting in increased exposure for certain populations. Lessons from radiation accidents and occupational exposure have highlighted the cardiovascular and cerebrovascular risks associated with radiation exposure. In addition, radiation therapy for cancer has been linked to numerous cardiovascular complications, depending on the distribution of the dose by volume in the heart and other relevant target tissues in the circulatory system. The manifestation of symptoms is influenced by numerous factors, and distinct cardiac complications have previously been observed in different groups of patients with cancer undergoing radiation therapy. However, in contemporary radiation therapy, advances in treatment planning with conformal radiation delivery have markedly reduced the mean heart dose and volume of exposure, and these variables are therefore no longer sole surrogates for predicting the risk of specific types of heart disease. Nevertheless, certain cardiac substructures remain vulnerable to radiation exposure, necessitating close monitoring. In this Review, we provide a comprehensive overview of the consequences of radiation exposure on the cardiovascular system, drawing insights from various cohorts exposed to uniform, whole-body radiation or to partial-body irradiation, and identify potential risk modifiers in the development of radiation-associated cardiovascular disease.
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Affiliation(s)
- James W S Jahng
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - Mark P Little
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD, USA
- Faculty of Health and Life Sciences, Oxford Brookes University, Headington Campus, Oxford, UK
| | - Hyunsoo J No
- Department of Radiation Oncology, Southern California Permanente Medical Group, Los Angeles, CA, USA
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Billy W Loo
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Joseph C Wu
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.
- Greenstone Biosciences, Palo Alto, CA, USA.
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Dionisi F, Landoni V, Widesott L, Nardangeli A, Fracchiolla F, Siniscalchi B, Soriani A, Turkaj A, Righetto R, Amelio D, Farace P, Goanta L, Trianni A, Lorentini S, Cianchetti M, Sanguineti G. Dosimetric and NTCP advantages of robust proton therapy over robust VMAT for Stage III NSCLC in the immunotherapy era. Phys Med 2024; 123:103410. [PMID: 38878630 DOI: 10.1016/j.ejmp.2024.103410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 04/29/2024] [Accepted: 06/10/2024] [Indexed: 07/13/2024] Open
Abstract
AIMS To assess the robustness and to define the dosimetric and NTCP advantages of pencil-beam-scanning proton therapy (PBSPT) compared with VMAT for unresectable Stage III non-small lung cancer (NSCLC) in the immunotherapy era. MATERIAL AND METHODS 10 patients were re-planned with VMAT and PBSPT using: 1) ITV-based robust optimization with 0.5 cm setup uncertainties and (for PBSPT) 3.5 % range uncertainties on free-breathing CT 2) CTV-based RO including all 4DCTs anatomies. Target coverage (TC), organs at risk dose and TC robustness (TCR), set at V95%, were compared. The NTCP risk for radiation pneumonitis (RP), 24-month mortality (24MM), G2 + acute esophageal toxicity (ET), the dose to the immune system (EDIC) and the left anterior descending (LAD) coronary artery V15 < 10 % were registered. Wilcoxon test was used. RESULTS Both PBSPT methods improved TC and TCR (p < 0.01). The mean lung dose and lung V20 were lower with PBSPT (p < 0.01). Median mean heart dose reduction with PBSPT was 8 Gy (p < 0.001). PT lowered median LAD V15 (p = 0.004). ΔNTCP > 5 % with PBSPT was observed for two patients for RP and for five patients for 24 MM. ΔNTCP for ≥ G2 ET was not in favor of PBSPT for all patients. PBSPT halved median EDIC (4.9/5.1 Gy for ITV/CTV-based VMAT vs 2.3 Gy for both ITV/CTV-based PBSPT, p < 0.01). CONCLUSIONS PBSPT is a robust approach with significant dosimetric and NTCP advantages over VMAT; the EDIC reduction could allow for a better integration with immunotherapy. A clinical benefit for a subset of NSCLC patients is expected.
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Affiliation(s)
- F Dionisi
- Department of Research and Advanced Technology, Radiotherapy Unit, IRCCS Regina Elena National Cancer Institute-Rome, Italy.
| | - V Landoni
- Laboratory of Medical Physics and Expert Systems, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - L Widesott
- Medical Physics Department, APSS, Trento, Italy
| | - A Nardangeli
- Department of Research and Advanced Technology, Radiotherapy Unit, IRCCS Regina Elena National Cancer Institute-Rome, Italy
| | | | | | - A Soriani
- Laboratory of Medical Physics and Expert Systems, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - A Turkaj
- Proton Therapy Unit, APSS, Trento, Italy
| | - R Righetto
- Medical Physics Department, APSS, Trento, Italy
| | - D Amelio
- Proton Therapy Unit, APSS, Trento, Italy
| | - P Farace
- Medical Physics Department, APSS, Trento, Italy
| | - L Goanta
- Department of Research and Advanced Technology, Radiotherapy Unit, IRCCS Regina Elena National Cancer Institute-Rome, Italy
| | - A Trianni
- Medical Physics Department, APSS, Trento, Italy
| | - S Lorentini
- Medical Physics Department, APSS, Trento, Italy
| | | | - G Sanguineti
- Department of Research and Advanced Technology, Radiotherapy Unit, IRCCS Regina Elena National Cancer Institute-Rome, Italy
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Badiu V, Trier Taasti V, Defraene G, van Elmpt W, Sterpin E. Balancing robustness and adaptation rate for proton therapy of lung cancer patients. Radiother Oncol 2024; 196:110290. [PMID: 38643807 DOI: 10.1016/j.radonc.2024.110290] [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: 01/12/2024] [Revised: 03/22/2024] [Accepted: 04/15/2024] [Indexed: 04/23/2024]
Abstract
INTRODUCTION An increase in plan robustness leads to a higher dose to organs-at-risk (OARs), and an increased chance of post-treatment toxicities. In contrast, more conformal plans lead to sparing of healthy surrounding tissue at the expense of a higher sensitivity to anatomical changes, requiring costly adaptations. In this study, we assess the trade-off and impact of treatment plan robustness on the adaptation rate. METHOD Treatment planning was performed for 40 lung cancer patients, each having a planning 4DCT and up to eight weekly repeated 4DCTs (reCTs). For each patient, plans were made with three different levels of robustness based on setup uncertainty of 3, 6 and 9 mm. These plans were robustly re-evaluated on all reCTs to assess whether the clinical constraints were met. RESULTS For the 3, 6 and 9 mm robustness levels, adaptation rates of 87.5 %, 70.0 % and 57.5 %, respectively, were observed. A mean absolute normal tissue complication probability (NTCP) gain of 2.9 percentage points (pp) was calculated for pneumonitis grade ≥ 2 when transitioning from 9 mm plans to 3 mm plans, 7.6 pp for esophagitis grade ≥ 2, and 2.5 pp for mortality risk 2 years post-treatment. CONCLUSION The lowered risk of post treatment toxicities at lower robustness levels is clinically relevant but comes at the expense of more treatment adaptations, particularly in cases where meeting our clinical goals is not compromised by having a dose that is more conformal to the target. The trade-off between workload and reduced NTCP needs to be individually assessed.
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Affiliation(s)
- Vlad Badiu
- KU Leuven, Department of Oncology, Laboratory of Experimental Radiotherapy, Leuven, Belgium; UZ Leuven, Particle Therapy Interuniversity Center Leuven - PARTICLE, Leuven, Belgium
| | - Vicki Trier Taasti
- Maastricht University Medical Centre+, Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Gilles Defraene
- KU Leuven, Department of Oncology, Laboratory of Experimental Radiotherapy, Leuven, Belgium
| | - Wouter van Elmpt
- Maastricht University Medical Centre+, Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Edmond Sterpin
- KU Leuven, Department of Oncology, Laboratory of Experimental Radiotherapy, Leuven, Belgium; UZ Leuven, Particle Therapy Interuniversity Center Leuven - PARTICLE, Leuven, Belgium; Université Catholique de Louvain, Institut de Recherche Expérimentale et Clinique, Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), Brussels, Belgium
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Nakajima K, Oguri M, Iwata H, Hattori Y, Hashimoto S, Nomura K, Hayashi K, Toshito T, Akita K, Baba F, Ogino H, Hiwatashi A. Long-term survival outcomes and quality of life of image-guided proton therapy for operable stage I non-small cell lung cancer: A phase 2 study. Radiother Oncol 2024; 196:110276. [PMID: 38614284 DOI: 10.1016/j.radonc.2024.110276] [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: 03/12/2024] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND AND PURPOSE This study evaluated long-term efficacy, safety, and changes in quality of life (QOL) of patients after image-guided proton therapy (IGPT) for operable stage I non-small cell lung cancer (NSCLC). MATERIALS AND METHODS This single-institutional prospective phase 2 study enrolled patients with operable histologically confirmed stage IA or IB NSCLC (7th edition of UICC). The prescribed dose was 66 Gy relative biological effectiveness equivalents (GyRBE) in 10 fractions for peripheral lesions, or 72.6 GyRBE in 22 fractions for central lesions. The primary endpoint was the 3-year overall survival (OS). The secondary endpoints included disease control, toxicity, and changes in QOL score. RESULTS We enrolled 43 patients (median age: 68 years; range, 47-79 years) between July 2013 to January 2021, of whom 41 (95 %) had peripheral lesions and 27 (63 %) were stage IA. OS, local control, and progression-free survival rates were 95 % (95 % CI: 83-99), 95 % (82-99), and 86 % (72-94), respectively, at 3 years, and 83 % (66-92), 95 % (82-99), and 77 % (60-88), respectively, at 7 years. Four patients (9 %) developed grade 2, and one patient (2 %) developed grade 3 radiation pneumonitis. No other grade 3 or higher adverse events were observed. In the QOL analysis, global QOL remained favorable; however, approximately 40 % of patients reported dyspnea at 3 and 24 months. CONCLUSION Our findings suggest that IGPT provides effective disease control and survival in operable stage I NSCLC, particularly for peripheral lesions. Moreover, toxicity associated with IGPT was minimal, and patients reported favorable QOL.
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Affiliation(s)
- Koichiro Nakajima
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City University West Medical Center, Nagoya, Japan.
| | - Masanosuke Oguri
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hiromitsu Iwata
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City University West Medical Center, Nagoya, Japan
| | - Yukiko Hattori
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City University West Medical Center, Nagoya, Japan
| | - Shingo Hashimoto
- Department of Radiation Oncology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Kento Nomura
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City University West Medical Center, Nagoya, Japan
| | - Kensuke Hayashi
- Department of Proton Therapy Technology, Nagoya Proton Therapy Center, Nagoya, Japan
| | - Toshiyuki Toshito
- Department of Proton Therapy Physics, Nagoya Proton Therapy Center, Nagoya, Japan
| | - Kenji Akita
- Department of Respiratory Medicine, Thoracic Oncology Center, Nagoya City University West Medical Center, Nagoya, Japan
| | - Fumiya Baba
- Department of Radiotherapy, Nagoya City University West Medical Center, Nagoya, Japan
| | - Hiroyuki Ogino
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City University West Medical Center, Nagoya, Japan
| | - Akio Hiwatashi
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Liu P, Zhao L, Liu G, Cong X, Li X, Ding X. The first investigation of the dosimetric perturbations from the spot position errors in spot-scanning arc therapy (SPArc). Phys Med Biol 2024; 69:135012. [PMID: 38870996 DOI: 10.1088/1361-6560/ad5827] [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: 12/26/2023] [Accepted: 06/13/2024] [Indexed: 06/15/2024]
Abstract
Objective. To quantitatively investigate the impact of spot position error (PE) on the dose distribution in (Spot-scanning arc therapy) SPArc plans compared to Intensity-Modulated Proton Therapy (IMPT).Approach.Twelve representative cases, including brain, lung, liver, and prostate cancers, were retrospectively selected. Spot PEs were simulated during dynamic SPArc treatment delivery. Two types of errors were generated, including random error and systematic error. Two different probability distributions of random errors were used (1) Gaussian distribution (PEran-GS) (2) uniform distribution (PEran-UN). In PEran-UN, four sub-scenarios were considered: 25%, 50%, 75%, and 100% spots were randomly selected in various directions on the scale of 0-1 mm or 0-2 mm of PE. Additionally, systematic error was simulated by shifting all the spot uniformly by 1 or 2 mm in various directions (PEsys). Gamma-index Passing Rate (GPR) is applied to assess the dosimetric perturbation quantitatively.Main results.For PEran-GSin the 1 mm scenario, both SPArc and IMPT are comparable with a GPR exceeding 99%. However, for PEran-GSin 2 mm scenario, SPArc could provide better GPR. As PEsysof 2 mm, SPArc plans have a much better GPR compared to IMPT plans: SPArc's GPR is 99.59 ± 0.47%, 93.82 ± 4.07% and 64.58 ± 15.83% for 3 mm/3%, 2 mm/2% and 1 mm/1% criteria compared to IMPT with 97.49 ± 2.44%, 84.59 ± 4.99% and 42.02 ± 6.31%.Significance.Compared to IMPT, SPArc shows better dosimetric robustness in spot PEs. This study presents the first simulation results and the methodology that serves as a reference to guide future investigations into the accuracy and quality assurance of SPArc treatment delivery.
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Affiliation(s)
- Peilin Liu
- Department of Radiation Oncology, Corewell Health William Beaumont Hospital, Royal Oak, MI, United States of America
| | - Lewei Zhao
- Department of Radiation Oncology, Stanford University, Palo Alto, CA, United States of America
| | - Gang Liu
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
- Hubei Key Laboratory of Precision Radiation Oncology, Wuhan, People's Republic of China
| | - Xiaoda Cong
- Department of Radiation Oncology, Corewell Health William Beaumont Hospital, Royal Oak, MI, United States of America
| | - Xiaoqiang Li
- Department of Radiation Oncology, Corewell Health William Beaumont Hospital, Royal Oak, MI, United States of America
| | - Xuanfeng Ding
- Department of Radiation Oncology, Corewell Health William Beaumont Hospital, Royal Oak, MI, United States of America
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6
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Liu CW, Kolano AM, Gray T, Stephans KL, Videtic GMM, Farr JB, Xia P. Cyclotron and linear accelerator generated scanning proton beams for lung cancer SBRT: Interplay effects and mitigations. Med Phys 2024; 51:3985-3994. [PMID: 38683935 DOI: 10.1002/mp.17082] [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: 02/15/2024] [Accepted: 03/23/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Pencil beam scanning (PBS) proton therapy for moving targets is known to be impacted by interplay effects between the scanning beam and organ motion. While respiratory motion in the thoracic region is the major cause for organ motion, interplay effects depend on the delivery characteristics of proton accelerators. PURPOSE To evaluate the impact of different types of PBS proton accelerators and spot sizes on interplay effects, mitigations, and plan quality for Stereotactic Body Radiation Therapy (SBRT) treatment of non-small cell lung cancer (NSCLC). METHODS Twenty NSCLC patients treated with photon SBRT were selected to represent varying tumor volumes and respiratory motion amplitudes (median: 0.6 cm with abdominal compression) for this retrospective study. For each patient, plans were created using: (1) cyclotron-generated proton beams (CPB) with spot sizes of σ = 2.7-7.0 mm; (2) linear accelerator proton beams (LPB) (σ = 2.9-5.5 mm); and (3) linear accelerator proton minibeams (LPMB) (σ = 0.9-3.9 mm). The energy switching time is one second for CPB, and 0.005 s for LPMB and LPB. Plans were robustly optimized on the gross tumor volume (GTV) using each individual phase of four-dimensional computed tomography (4DCT) scans. Initially, single-field optimization (SFO) plans were evaluated; if the plan quality did not meet the dosimetric requirement, multi-field optimization (MFO) was used. MFO plans were created for all patients for comparisons. For each patient, all plans were normalized to have the same dose received by 99% of the GTV. Interplay effects were evaluated by computing the dose on 10 breathing phases, based on the spot distribution. Volumetric repainting (VR) was performed 2-6 times for each plan. We compared volume receiving 100% of the prescribed dose (V100%RX) of the GTV, and normal lung V20Gy. RESULTS Twelve of 20 plans can be optimized sufficiently with SFO. SFO plans were less sensitive to the interplay effect compared to MFO plans in terms of target coverage for both LPB and LPMB. The following comparisons showed results utilizing the MFO technique. In the interplay evaluation without repainting, the mean V100%RX of the GTV were 99.42 ± 0.6%, 97.52 ± 3.9%, and 94.49 ± 7.3% for CPB, LPB, and LPMB plans, respectively. Following VR (2 × for CPB; 3 × for LPB; 5 × for LPMB), V100%RX of the GTV were improved (on average) by 0.13%, 1.84%, and 4.63%, respectively, achieving the acceptance criteria of V100%RX > 95%. Because of fast energy switch in linear accelerator proton machines, the delivery time for VR plans was the lowest for LPB plans, while delivery time for LPMB was on average 1 min longer than CPB plans. The advantage of small spot machines was better sparing in normal lung V20Gy, even when VR was applied. CONCLUSION In the absence of repainting, proton machines with large spot sizes generated more robust plans against interplay effects. The number of VR increased with decreasing spot sizes to achieve the acceptance criteria. VR improved the plan robustness against interplay effects for modalities with small spot sizes and fast energy changes, preserving the low dose sparing aspect of the LPMB, even when motion is included.
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Affiliation(s)
- Chieh-Wen Liu
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anna M Kolano
- Applications of Detectors and Accelerators to Medicine (ADAM) SA, Meyrin, Switzerland
- Advanced Oncotherapy (AVO) plc, London, UK
| | - Tara Gray
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kevin L Stephans
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gregory M M Videtic
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jonathan B Farr
- Applications of Detectors and Accelerators to Medicine (ADAM) SA, Meyrin, Switzerland
- Advanced Oncotherapy (AVO) plc, London, UK
| | - Ping Xia
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Song G, Zheng Z, Zhu Y, Wang Y, Xue S. A review and bibliometric analysis of global research on proton radiotherapy. Medicine (Baltimore) 2024; 103:e38089. [PMID: 38728501 PMCID: PMC11081588 DOI: 10.1097/md.0000000000038089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 04/11/2024] [Indexed: 05/12/2024] Open
Abstract
Proton beam therapy (PBT) has great advantages as tumor radiotherapy and is progressively becoming a more prevalent choice for individuals undergoing radiation therapy. The objective of this review is to pinpoint collaborative efforts among countries and institutions, while also exploring the hot topics and future outlook in the field of PBT. Data from publications were downloaded from the Web of Science Core Collection. CiteSpace and Excel 2016 were used to conduct the bibliometric and knowledge map analysis. A total of 6516 publications were identified, with the total number of articles steadily increasing and the United States being the most productive country. Harvard University took the lead in contributing the highest number of publications. Paganetti Harald published the most articles and had the most cocitations. PHYS MED BIOL published the greatest number of PBT-related articles, while INT J RADIAT ONCOL received the most citations. Paganetti Harald, 2012, PHYS MED BIOL can be classified as classic literature due to its high citation rate. We believe that research on technology development, dose calculation and relative biological effectiveness were the knowledge bases in this field. Future research hotspots may include clinical trials, flash radiotherapy, and immunotherapy.
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Affiliation(s)
- Ge Song
- Department of Critical Care Medicine, Shandong Provincial Maternal and Child Health Care Hospital Affiliated to Qingdao University, Jinan, China
| | - Zhi Zheng
- Department of Stomatology, Shandong Provincial Maternal and Child Health Care Hospital Affiliated to Qingdao University, Jinan, China
| | - Yingming Zhu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yaoting Wang
- Department of Oncology, Dongying People’s Hospital, Dongying, China
| | - Song Xue
- Experimental Center, Shandong University of Traditional Chinese Medicine, Jinan, China
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Yegya-Raman N, Berman AT, Ciunci CA, Friedes C, Berlin E, Iocolano M, Wang X, Lai C, Levin WP, Cengel KA, O'Reilly SE, Cohen RB, Aggarwal C, Marmarelis ME, Singh AP, Sun L, Bradley JD, Plastaras JP, Simone CB, Langer CJ, Feigenberg SJ. Phase 2 Trial of Consolidation Pembrolizumab After Proton Reirradiation for Thoracic Recurrences of Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2024; 119:56-65. [PMID: 37652303 DOI: 10.1016/j.ijrobp.2023.08.047] [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: 04/26/2023] [Revised: 07/08/2023] [Accepted: 08/17/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE Reirradiation (reRT) with proton beam therapy (PBT) may offer a chance of cure while minimizing toxicity for patients with isolated intrathoracic recurrences of non-small cell lung cancer (NSCLC). However, distant failure remains common, necessitating strategies to integrate more effective systemic therapy. METHODS AND MATERIALS This was a phase 2, single-arm trial (NCT03087760) of consolidation pembrolizumab after PBT reRT for locoregional recurrences of NSCLC. Four to 12 weeks after completion of 60 to 70 Gy PBT reRT, patients without progressive disease received pembrolizumab for up to 12 months. Primary endpoint was progression-free survival (PFS), measured from the start of reRT. Secondary endpoints were overall survival (OS) and National Cancer Institute Common Terminology Criteria for Adverse Events, version 5.0 toxicity. RESULTS Between 2017 and 2021, 22 patients received PBT reRT. Median interval from prior radiation end to reRT start was 20 months. Most recurrences (91%) were centrally located. Most patients received concurrent chemotherapy (95%) and pencil beam scanning PBT (77%), and 36% had received prior durvalumab. Fifteen patients (68%) initiated consolidation pembrolizumab on trial and received a median of 3 cycles (range, 2-17). Pembrolizumab was discontinued most commonly due to toxicity (n = 5; 2 were pembrolizumab-related), disease progression (n = 4), and completion of 1 year (n = 3). Median follow-up was 38.7 months. Median PFS and OS were 8.8 months (95% CI, 4.2-23.7) and 22.8 months (95% CI, 6.9-not reached), respectively. There was only one isolated in-field failure after reRT. Grade ≥3 toxicities occurred in 10 patients (45%); 2 were pembrolizumab-related. There were 2 grade 5 toxicities, an aorto-esophageal fistula at 6.9 months and hemoptysis at 46.8 months, both probably from reRT. The trial closed early due to widespread adoption of immunotherapy off-protocol. CONCLUSIONS In the first-ever prospective trial combining PBT reRT with consolidation immunotherapy, PFS was acceptable and OS favorable. Late grade 5 toxicity occurred in 2 of 22 patients. This approach may be considered in selected patients with isolated thoracic recurrences of NSCLC.
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Affiliation(s)
- Nikhil Yegya-Raman
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Abigail T Berman
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christine A Ciunci
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cole Friedes
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eva Berlin
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michelle Iocolano
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Xingmei Wang
- Department of Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ching Lai
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William P Levin
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Keith A Cengel
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shannon E O'Reilly
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Roger B Cohen
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Charu Aggarwal
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melina E Marmarelis
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Aditi P Singh
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lova Sun
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey D Bradley
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John P Plastaras
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Charles B Simone
- New York Proton Center, New York, New York; Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Corey J Langer
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steven J Feigenberg
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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Valdes G, Scholey J, Nano TF, Gennatas ED, Mohindra P, Mohammed N, Zeng J, Kotecha R, Rosen LR, Chang J, Tsai HK, Urbanic JJ, Vargas CE, Yu NY, Ungar LH, Eaton E, Simone CB. Predicting the Effect of Proton Beam Therapy Technology on Pulmonary Toxicities for Patients With Locally Advanced Lung Cancer Enrolled in the Proton Collaborative Group Prospective Clinical Trial. Int J Radiat Oncol Biol Phys 2024; 119:66-77. [PMID: 38000701 DOI: 10.1016/j.ijrobp.2023.11.026] [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: 10/27/2022] [Revised: 10/27/2023] [Accepted: 11/13/2023] [Indexed: 11/26/2023]
Abstract
PURPOSE This study aimed to predict the probability of grade ≥2 pneumonitis or dyspnea within 12 months of receiving conventionally fractionated or mildly hypofractionated proton beam therapy for locally advanced lung cancer using machine learning. METHODS AND MATERIALS Demographic and treatment characteristics were analyzed for 965 consecutive patients treated for lung cancer with conventionally fractionated or mildly hypofractionated (2.2-3 Gy/fraction) proton beam therapy across 12 institutions. Three machine learning models (gradient boosting, additive tree, and logistic regression with lasso regularization) were implemented to predict Common Terminology Criteria for Adverse Events version 4 grade ≥2 pulmonary toxicities using double 10-fold cross-validation for parameter hyper-tuning without leak of information. Balanced accuracy and area under the curve were calculated, and 95% confidence intervals were obtained using bootstrap sampling. RESULTS The median age of the patients was 70 years (range, 20-97), and they had predominantly stage IIIA or IIIB disease. They received a median dose of 60 Gy in 2 Gy/fraction, and 46.4% received concurrent chemotherapy. In total, 250 (25.9%) had grade ≥2 pulmonary toxicity. The probability of pulmonary toxicity was 0.08 for patients treated with pencil beam scanning and 0.34 for those treated with other techniques (P = 8.97e-13). Use of abdominal compression and breath hold were highly significant predictors of less toxicity (P = 2.88e-08). Higher total radiation delivered dose (P = .0182) and higher average dose to the ipsilateral lung (P = .0035) increased the likelihood of pulmonary toxicities. The gradient boosting model performed the best of the models tested, and when demographic and dosimetric features were combined, the area under the curve and balanced accuracy were 0.75 ± 0.02 and 0.67 ± 0.02, respectively. After analyzing performance versus the number of data points used for training, we observed that accuracy was limited by the number of observations. CONCLUSIONS In the largest analysis of prospectively enrolled patients with lung cancer assessing pulmonary toxicities from proton therapy to date, advanced machine learning methods revealed that pencil beam scanning, abdominal compression, and lower normal lung doses can lead to significantly lower probability of developing grade ≥2 pneumonitis or dyspnea.
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Affiliation(s)
- Gilmer Valdes
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Jessica Scholey
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Tomi F Nano
- Department of Radiation Oncology, University of California, San Francisco, California.
| | - Efstathios D Gennatas
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Pranshu Mohindra
- University of Maryland School of Medicine and Maryland Proton Treatment Center, Baltimore, Maryland
| | - Nasir Mohammed
- Northwestern Medicine Chicago Proton Center, Warrenville, Illinois
| | - Jing Zeng
- University of Washington and Seattle Cancer Care Alliance Proton Therapy Center, Seattle, Washington
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Lane R Rosen
- Willis-Knighton Medical Center, Shreveport, Louisiana
| | - John Chang
- Oklahoma Proton Center, Oklahoma City, Oklahoma
| | - Henry K Tsai
- New Jersey Procure Proton Therapy Center, Somerset, New Jersey
| | - James J Urbanic
- Department of Radiation Oncology, California Protons Therapy Center, San Diego, California
| | - Carlos E Vargas
- Department of Radiation Oncology, Mayo Clinic Proton Center, Phoenix, Arizona
| | - Nathan Y Yu
- Department of Radiation Oncology, Mayo Clinic Proton Center, Phoenix, Arizona
| | - Lyle H Ungar
- Department of Computer and Information Science, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eric Eaton
- Department of Computer and Information Science, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Charles B Simone
- Department of Radiation Oncology, New York Proton Center, New York, New York
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Duetschler A, Safai S, Weber DC, Lomax AJ, Zhang Y. The impact of motion on onboard MRI-guided pencil beam scanned proton therapy treatments. Phys Med Biol 2024; 69:095003. [PMID: 38537287 DOI: 10.1088/1361-6560/ad3885] [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: 10/09/2023] [Accepted: 03/26/2024] [Indexed: 04/16/2024]
Abstract
Objective.Online magnetic resonance imaging (MRI) guidance could be especially beneficial for pencil beam scanned (PBS) proton therapy of tumours affected by respiratory motion. For the first time to our knowledge, we investigate the dosimetric impact of respiratory motion on MRI-guided proton therapy compared to the scenario without magnetic field.Approach.A previously developed analytical proton dose calculation algorithm accounting for perpendicular magnetic fields was extended to enable 4D dose calculations. For two geometrical phantoms and three liver and two lung patient cases, static treatment plans were optimised with and without magnetic field (0, 0.5 and 1.5 T). Furthermore, plans were optimised using gantry angle corrections (0.5 T +5° and 1.5 T +15°) to reproduce similar beam trajectories compared to the 0 T reference plans. The effect of motion was then considered using 4D dose calculations without any motion mitigation and simulating 8-times volumetric rescanning, with motion for the patient cases provided by 4DCT(MRI) data sets. Each 4D dose calculation was performed for different starting phases and the CTV dose coverageV95%and homogeneityD5%-D95%were analysed.Main results.For the geometrical phantoms with rigid motion perpendicular to the beam and parallel to the magnetic field, a comparable dosimetric effect was observed independent of the magnetic field. Also for the five 4DCT(MRI) cases, the influence of motion was comparable for all magnetic field strengths with and without gantry angle correction. On average, the motion-induced decrease in CTVV95%from the static plan was 17.0% and 18.9% for 1.5 T and 0.5 T, respectively, and 19.9% without magnetic field.Significance.For the first time, this study investigates the combined impact of magnetic fields and respiratory motion on MR-guided proton therapy. The comparable dosimetric effects irrespective of magnetic field strength indicate that the effects of motion for future MR-guided proton therapy may not be worse than for conventional PBS proton therapy.
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Affiliation(s)
- Alisha Duetschler
- Center for Proton Therapy, Paul Scherrer Institute, 5232 Villigen PSI, CH, Switzerland
- Department of Physics, ETH Zürich, 8092 Zürich, CH, Switzerland
| | - Sairos Safai
- Center for Proton Therapy, Paul Scherrer Institute, 5232 Villigen PSI, CH, Switzerland
| | - Damien C Weber
- Center for Proton Therapy, Paul Scherrer Institute, 5232 Villigen PSI, CH, Switzerland
- Department of Radiation Oncology, University Hospital of Zürich, 8091 Zürich, CH, Switzerland
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, CH, Switzerland
| | - Antony J Lomax
- Center for Proton Therapy, Paul Scherrer Institute, 5232 Villigen PSI, CH, Switzerland
- Department of Physics, ETH Zürich, 8092 Zürich, CH, Switzerland
| | - Ye Zhang
- Center for Proton Therapy, Paul Scherrer Institute, 5232 Villigen PSI, CH, Switzerland
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11
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Tominaga Y, Suga M, Takeda M, Yamamoto Y, Akagi T, Kato T, Tokumaru S, Yamamoto M, Oita M. Comparing interplay effects in scanned proton therapy of lung cancer: Free breathing with various layer and volume rescanning versus respiratory gating with different gate widths. Phys Med 2024; 120:103323. [PMID: 38461635 DOI: 10.1016/j.ejmp.2024.103323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 02/07/2024] [Accepted: 03/04/2024] [Indexed: 03/12/2024] Open
Abstract
PURPOSE We investigated interplay effects and treatment time (TT) in scanned proton therapy for lung cancer patients. We compared free-breathing (FB) approaches with multiple rescanning strategies and respiratory-gating (RG) methods with various gating widths to identify the superior irradiation technique. METHODS Plans were created with 4/1, 2/2, and 1/4 layered/volume rescans of FB (L4V1, L2V2, and L1V4), and 50%, 30%, and 10% gating widths of the total respiratory curves (G50, G30, and G10) of the RG plans with L4V1. We calculated 4-dimensional dynamic doses assuming a constant sinusoidal curve for six irradiation methods. The reconstructed doses per fraction were compared with planned doses in terms of dose differences in 99% clinical-target-volume (CTV) (ΔD99%), near-maximum dose differences (ΔD2%) at organs-at-risk (OARs), and TT. RESULTS The mean/minimum CTV ΔD99% values for FB were -1.0%/-4.9%, -0.8%/-4.3%, and -0.1%/-1.0% for L4V1, L2V2, and L1V4, respectively. Those for RG were -0.3%/-1.7%, -0.1%/-1.0%, and 0.0%/-0.5% for G50, G30, and G10, respectively. The CTV ΔD99% of the RGs with less than 50% gate width and the FBs of L1V4 were within the desired tolerance (±3.0%), and the OARs ΔD2% for RG were lower than those for FB. The mean TTs were 90, 326, 824, 158, 203, and 422 s for L4V1, L2V2, L1V4, G50, G30, and G10, respectively. CONCLUSIONS FB (L4V1) is the most efficient treatment, but not necessarily the optimal choice due to interplay effects. To satisfy both TT extensions and interplay, RG with a gate width as large as possible within safety limits is desirable.
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Affiliation(s)
- Yuki Tominaga
- Department of Radiotherapy, Medical Co. Hakuhokai, Osaka Proton Therapy Clinic, 27-9 Kasugadenaka, Konohana-ku, Osaka 554-0022, Japan.
| | - Masaki Suga
- Hyogo Ion Beam Medical Center, 1-2-1, Kouto, Shingucho, Tatsuno, Hyogo 679-5165, Japan
| | - Mikuni Takeda
- Hyogo Ion Beam Medical Center, 1-2-1, Kouto, Shingucho, Tatsuno, Hyogo 679-5165, Japan
| | - Yuki Yamamoto
- Hyogo Ion Beam Medical Center, 1-2-1, Kouto, Shingucho, Tatsuno, Hyogo 679-5165, Japan
| | - Takashi Akagi
- Hyogo Ion Beam Medical Support, 1-2-1, Kouto, Shingucho, Tatsuno, Hyogo 679-5165, Japan
| | - Takahiro Kato
- Department of Radiological Sciences, School of Health Sciences, Fukushima Medical University, 1 Hikariga-oka, Fukushima 960-1295, Japan; Department of Radiation Physics and Technology, Southern Tohoku Proton Therapy Center, Fukushima 172, Yatsuyamada 7 Chome, Koriyama, Fukushima 963-8052, Japan
| | - Sunao Tokumaru
- Hyogo Ion Beam Medical Center, 1-2-1, Kouto, Shingucho, Tatsuno, Hyogo 679-5165, Japan
| | - Michinori Yamamoto
- Department of Radiotherapy, Medical Co. Hakuhokai, Osaka Proton Therapy Clinic, 27-9 Kasugadenaka, Konohana-ku, Osaka 554-0022, Japan
| | - Masataka Oita
- Faculty of Interdisciplinary Science and Engineering in Health Systems, Okayama University, 5-1 Shikata-cho, 2-chome, Kita-ku, Okayama 700-8558, Japan
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12
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Fjellanger K, Heijmen BJ, Breedveld S, Sandvik IM, Hysing LB. Comparison of deep inspiration breath hold and free breathing intensity modulated proton therapy of locally advanced lung cancer. Phys Imaging Radiat Oncol 2024; 30:100590. [PMID: 38827886 PMCID: PMC11140793 DOI: 10.1016/j.phro.2024.100590] [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: 02/02/2024] [Revised: 05/14/2024] [Accepted: 05/14/2024] [Indexed: 06/05/2024] Open
Abstract
Background and purpose For locally advanced non-small cell lung cancer (LA-NSCLC), intensity-modulated proton therapy (IMPT) can reduce organ at risk (OAR) doses compared to intensity-modulated radiotherapy (IMRT). Deep inspiration breath hold (DIBH) reduces OAR doses compared to free breathing (FB) in IMRT. In IMPT, differences in dose distributions and robustness between DIBH and FB are unclear. In this study, we compare DIBH to FB in IMPT, and IMPT to IMRT. Materials and methods Fortyone LA-NSCLC patients were prospectively included. 4D computed tomography images (4DCTs) and DIBH CTs were acquired for treatment planning and during weeks 1 and 3 of treatment. A new system for automated robust planning was developed and used to generate a FB and a DIBH IMPT plan for each patient. Plans were compared in terms of dose-volume parameters and normal tissue complication probabilities (NTCPs). Dose recalculations on repeat CTs were used to compare inter-fraction plan robustness. Results In IMPT, DIBH reduced median lungs Dmean from 9.3 Gy(RBE) to 8.0 Gy(RBE) compared to FB, and radiation pneumonitis NTCP from 10.9 % to 9.4 % (p < 0.001). Inter-fraction plan robustness for DIBH and FB was similar. Median NTCPs for radiation pneumonitis and mortality were around 9 percentage points lower with IMPT than IMRT (p < 0.001). These differences were much larger than between FB and DIBH within each modality. Conclusion DIBH IMPT resulted in reduced lung dose and radiation pneumonitis NTCP compared to FB IMPT. Inter-fraction robustness was comparable. OAR doses were far lower in IMPT than IMRT.
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Affiliation(s)
- Kristine Fjellanger
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
- Institute of Physics and Technology, University of Bergen, Bergen, Norway
| | - Ben J.M. Heijmen
- Department of Radiotherapy, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sebastiaan Breedveld
- Department of Radiotherapy, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Inger Marie Sandvik
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Liv B. Hysing
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
- Institute of Physics and Technology, University of Bergen, Bergen, Norway
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13
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Hörberger F, Andersson KM, Enmark M, Kristensen I, Flejmer A, Edvardsson A. Pencil beam scanning proton therapy for mediastinal lymphomas in deep inspiration breath-hold: a retrospective assessment of plan robustness. Acta Oncol 2024; 63:62-69. [PMID: 38415848 DOI: 10.2340/1651-226x.2024.23964] [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: 10/18/2023] [Accepted: 01/29/2024] [Indexed: 02/29/2024]
Abstract
PURPOSE/BACKGROUND The aim of this study was to evaluate pencil beam scanning (PBS) proton therapy (PT) in deep inspiration breath-hold (DIBH) for mediastinal lymphoma patients, by retrospectively evaluating plan robustness to the clinical target volume (CTV) and organs at risk (OARs) on repeated CT images acquired throughout treatment. Methods: Sixteen mediastinal lymphoma patients treated with PBS-PT in DIBH were included. Treatment plans (TPs) were robustly optimized on the CTV (7 mm/4.5%). Repeated verification CTs (vCT) were acquired during the treatment course, resulting in 52 images for the entire patient cohort. The CTV and OARs were transferred from the planning CT to the vCTs with deformable image registration and the TPs were recalculated on the vCTs. Target coverage and OAR doses at the vCTs were compared to the nominal plan. Deviation in lung volume was also calculated. RESULTS The TPs demonstrated high robust target coverage throughout treatment with D98%,CTV deviations within 2% for 14 patients and above the desired requirement of 95% for 49/52 vCTs. However, two patients did not achieve a robust dose to CTV due to poor DIBH reproducibility, with D98%,CTV at 78 and 93% respectively, and replanning was performed for one patient. Adequate OAR sparing was achieved for all patients. Total lung volume variation was below 10% for 39/52 vCTs. CONCLUSION PBS PT in DIBH is generally a robust technique for treatment of mediastinal lymphomas. However, closely monitoring the DIBH-reproducibility during treatment is important to avoid underdosing CTV and achieve sufficient dose-sparing of the OARs.
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Affiliation(s)
- Filip Hörberger
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Sweden.
| | | | - Marika Enmark
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Sweden; Department of Medical Physics, The Skandion Clinic, Uppsala, Sweden
| | - Ingrid Kristensen
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Sweden; Department of Clinical Sciences, Oncology, Lund University, Lund, Sweden
| | - Anna Flejmer
- Department of Medical Physics, The Skandion Clinic, Uppsala, Sweden; Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden; Department of Oncology, Uppsala University Hospital, Uppsala, Sweden
| | - Anneli Edvardsson
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Sweden; Medical Radiation Physics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
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14
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Tominaga Y, Oita M, Miyata J, Kato T. Experimental validation of a 4D dynamic dose calculation model for proton pencil beam scanning without spot time stamp considering free-breathing motion. Med Phys 2024; 51:566-578. [PMID: 37672227 DOI: 10.1002/mp.16725] [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: 03/24/2023] [Revised: 07/28/2023] [Accepted: 08/20/2023] [Indexed: 09/07/2023] Open
Abstract
PURPOSE We developed a 4-dimensional dynamic dose (4DDD) calculation model for proton pencil beam scanning (PBS). This model incorporates the spill start time for all energies and uses the remaining irradiated spot time model instead of irradiated spot time logs. This study aimed to validate the calculation accuracy of a log file-based 4DDD model by comparing it with dose measurements performed under free-breathing conditions, thereby serving as an alternative approach to the conventional log file-based system. METHODS Three cubic verification plans were created using a heterogeneous block phantom; these plans were created using 10 phase 4D-CT datasets of the phantom. The CIRS dynamic platform was used to simulate motion with amplitudes of 2.5, 3.75, and 5.0 mm. These plans consisted of eight- and two-layered rescanning techniques. The lateral profiles were measured using a 2D ionization chamber array (2D-array) and EBT3 Gafchromic films at four starting phases, including three sinusoidal curves (periods of 3, 4, and 6 s) and a representative patient curve during actual treatment. 4DDDs were calculated using in-house scripting that assigned a time stamp to each spot and performed dose accumulation using deformable image registration. Furthermore, to evaluate the impact of parameter selection on our 4DDD model calculations, simulations were performed assuming a ±10% change in irradiation time stamp (0.8 ± 0.08 s) and spot scan speed. We evaluated the 2D gamma index and the absolute point doses between the calculated values and the measurements. RESULTS The 2D-array measurements revealed that the gamma scores for the static plans (no motion) and 4DDD plans exceeded 97.5% and 93.9% at 3%/3 mm, respectively. The average gamma score of the 4DDD plans was at least 96.1%. When using EBT3 films, the gamma scores of the 4DDD model exceeded 92.4% and 98.7% at 2%/2 mm and 3%/3 mm, respectively. Regarding the 4DDD point dose differences, more than 95% of the dose regions exhibited discrepancies within ±5.0% for 97.7% of the total points across all plans. The spot time assignment accuracy of our 4DDD model was acceptable even with ±10% sensitivity. However, the accuracy of the scan speed, when varied within ±10% sensitivity, was not acceptable (minimum gamma scores of 82.6% and maximum dose difference of 12.9%). CONCLUSIONS Our 4DDD calculations under free-breathing conditions using amplitudes of less than 5.0 mm were in good agreement with the measurements regardless of the starting phases, breathing curve patterns (between 3 and 6 s periods), and varying numbers of layered rescanning. The proposed system allows us to evaluate actual irradiated doses in various breathing periods, amplitudes, and starting phases, even on PBS machines without the ability to record spot logs.
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Affiliation(s)
- Yuki Tominaga
- Graduate School of Interdisciplinary Science and Engineering in Health Systems, Okayama University, Okayama, Japan
- Osaka Proton Therapy Clinic, Department of Radiotherapy, Medical Co. Hakuhokai, Osaka, Osaka, Japan
| | - Masataka Oita
- Faculty of Interdisciplinary Science and Engineering in Health Systems, Okayama University, Okayama, Okayama, Japan
| | - Junya Miyata
- Graduate School of Interdisciplinary Science and Engineering in Health Systems, Okayama University, Okayama, Japan
- Department of Radiological Technology, Kurashiki Central Hospital, Okayama, Japan
| | - Takahiro Kato
- Department of Radiological Sciences, School of Health Sciences, Fukushima Medical University, Fukushima, Japan
- Department of Radiation Physics and Technology, Southern Tohoku Proton Therapy Center, Koriyama, Fukushima, Japan
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15
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Knäusl B, Belotti G, Bertholet J, Daartz J, Flampouri S, Hoogeman M, Knopf AC, Lin H, Moerman A, Paganelli C, Rucinski A, Schulte R, Shimizu S, Stützer K, Zhang X, Zhang Y, Czerska K. A review of the clinical introduction of 4D particle therapy research concepts. Phys Imaging Radiat Oncol 2024; 29:100535. [PMID: 38298885 PMCID: PMC10828898 DOI: 10.1016/j.phro.2024.100535] [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: 10/11/2023] [Revised: 12/12/2023] [Accepted: 01/04/2024] [Indexed: 02/02/2024] Open
Abstract
Background and purpose Many 4D particle therapy research concepts have been recently translated into clinics, however, remaining substantial differences depend on the indication and institute-related aspects. This work aims to summarise current state-of-the-art 4D particle therapy technology and outline a roadmap for future research and developments. Material and methods This review focused on the clinical implementation of 4D approaches for imaging, treatment planning, delivery and evaluation based on the 2021 and 2022 4D Treatment Workshops for Particle Therapy as well as a review of the most recent surveys, guidelines and scientific papers dedicated to this topic. Results Available technological capabilities for motion surveillance and compensation determined the course of each 4D particle treatment. 4D motion management, delivery techniques and strategies including imaging were diverse and depended on many factors. These included aspects of motion amplitude, tumour location, as well as accelerator technology driving the necessity of centre-specific dosimetric validation. Novel methodologies for X-ray based image processing and MRI for real-time tumour tracking and motion management were shown to have a large potential for online and offline adaptation schemes compensating for potential anatomical changes over the treatment course. The latest research developments were dominated by particle imaging, artificial intelligence methods and FLASH adding another level of complexity but also opportunities in the context of 4D treatments. Conclusion This review showed that the rapid technological advances in radiation oncology together with the available intrafractional motion management and adaptive strategies paved the way towards clinical implementation.
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Affiliation(s)
- Barbara Knäusl
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Gabriele Belotti
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Jenny Bertholet
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Juliane Daartz
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Mischa Hoogeman
- Department of Medical Physics & Informatics, HollandPTC, Delft, The Netherlands
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, The Netherlands
| | - Antje C Knopf
- Institut für Medizintechnik und Medizininformatik Hochschule für Life Sciences FHNW, Muttenz, Switzerland
| | - Haibo Lin
- New York Proton Center, New York, NY, USA
| | - Astrid Moerman
- Department of Medical Physics & Informatics, HollandPTC, Delft, The Netherlands
| | - Chiara Paganelli
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Antoni Rucinski
- Institute of Nuclear Physics Polish Academy of Sciences, PL-31342 Krakow, Poland
| | - Reinhard Schulte
- Division of Biomedical Engineering Sciences, School of Medicine, Loma Linda University
| | - Shing Shimizu
- Department of Carbon Ion Radiotherapy, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kristin Stützer
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Helmholtz-Zentrum Dresden – Rossendorf, Institute of Radiooncology – OncoRay, Dresden, Germany
| | - Xiaodong Zhang
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ye Zhang
- Center for Proton Therapy, Paul Scherrer Institute, Villigen PSI, Switzerland
| | - Katarzyna Czerska
- Center for Proton Therapy, Paul Scherrer Institute, Villigen PSI, Switzerland
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16
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Peteani G, Paganelli C, Giovannelli AC, Bachtiary B, Safai S, Rogers S, Pusterla O, Riesterer O, Weber DC, Lomax AJ, Baroni G, Fattori G. Retrospective reconstruction of four-dimensional magnetic resonance from interleaved cine imaging - A comparative study with four-dimensional computed tomography in the lung. Phys Imaging Radiat Oncol 2024; 29:100529. [PMID: 38235286 PMCID: PMC10792758 DOI: 10.1016/j.phro.2023.100529] [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: 04/28/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 01/19/2024] Open
Abstract
Background and purpose Imaging of respiration-induced anatomical changes is essential to ensure high accuracy in radiotherapy of lung cancer. We expanded here on methods for retrospective reconstruction of time-resolved volumetric magnetic resonance (4DMR) of the thoracic region and benchmarked the results against 4D computed tomography (4DCT). Materials and method MR data of six lung cancer patients were collected by interleaving cine-navigator images with 2D data frame images, acquired across the thorax. The data frame images have been stacked in volumes based on a similarity metric that considers the anatomical deformation of lungs, while addressing ambiguities in respiratory phase detection and interpolation of missing data. The resulting images were validated against cine-navigator images and compared to paired 4DCTs in terms of amplitude and period of motion, assessing differences in internal target volume (ITV) margin definition. Results 4DMR-based motion amplitude was on average within 1.8 mm of that measured in the corresponding 2D cine-navigator images. In our dataset, the 4DCT motion and the 4DMR median amplitude were always within 3.8 mm. The median period was generally close to CT references, although deviations up to 24 % have been observed. These changes were reflected in the ITV, which was generally larger for MRI than for 4DCT (up to 39.7 %). Conclusions The proposed algorithm for retrospective reconstruction of time-resolved volumetric MR provided quality anatomical images with high temporal resolution for motion modelling and treatment planning. The potential for imaging organ motion variability makes 4DMR a valuable complement to standard 4DCT imaging.
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Affiliation(s)
- Giulia Peteani
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
- Center for Proton Therapy, Paul Scherrer Institut, Villigen, Switzerland
| | - Chiara Paganelli
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Anna Chiara Giovannelli
- Center for Proton Therapy, Paul Scherrer Institut, Villigen, Switzerland
- Department of Physics, ETH Zürich, Zürich, Switzerland
| | - Barbara Bachtiary
- Center for Proton Therapy, Paul Scherrer Institut, Villigen, Switzerland
| | - Sairos Safai
- Center for Proton Therapy, Paul Scherrer Institut, Villigen, Switzerland
| | - Susanne Rogers
- Department of Radiation Oncology, Kantonsspital Aarau, 5001 Aarau, Switzerland
| | - Orso Pusterla
- Department of Radiology, Division of Radiological Physics, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Radiation Oncology, University Hospital of Zürich, 8091 Zürich, Switzerland
| | - Oliver Riesterer
- Department of Radiation Oncology, Kantonsspital Aarau, 5001 Aarau, Switzerland
| | - Damien Charles Weber
- Center for Proton Therapy, Paul Scherrer Institut, Villigen, Switzerland
- Department of Radiation Oncology, University Hospital of Zürich, 8091 Zürich, Switzerland
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Antony John Lomax
- Center for Proton Therapy, Paul Scherrer Institut, Villigen, Switzerland
- Department of Physics, ETH Zürich, Zürich, Switzerland
| | - Guido Baroni
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
- Bioengineering Unit, National Center of Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Giovanni Fattori
- Center for Proton Therapy, Paul Scherrer Institut, Villigen, Switzerland
- Department of Physics, ETH Zürich, Zürich, Switzerland
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17
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Zhang W, Cai X, Sun J, Wang W, Zhao J, Zhang Q, Jiang G, Wang Z. Pencil Beam Scanning Carbon Ion Radiotherapy for Hepatocellular Carcinoma. J Hepatocell Carcinoma 2023; 10:2397-2409. [PMID: 38169909 PMCID: PMC10759913 DOI: 10.2147/jhc.s429186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 12/16/2023] [Indexed: 01/05/2024] Open
Abstract
Purpose Carbon ion radiotherapy (CIRT) has emerged as a promising treatment modality for hepatocellular carcinoma (HCC). However, evidence of using the pencil beam scanning (PBS) technique to treat moving liver tumors remains lacking. The present study investigated the efficacy and toxicity of PBS CIRT in patients with HCC. Methods Between January 2016 and October 2021, 90 consecutive HCC patients treated with definitive CIRT in our center were retrospectively analyzed. Fifty-eight patients received relative biological effectiveness-weighted doses of 50-70 Gy in 10 fractions, and 32 received 60-67.5 Gy in 15 fractions, which were determined by the tumor location and normal tissue constraints. Active motion-management techniques and necessary strategies were adopted to mitigate interplay effects efficiently. Oncologic outcomes and toxicities were evaluated. Results The median follow-up time was 28.6 months (range 5.7-74.6 months). The objective response rate was 75.0% for all 90 patients with 100 treated lesions. The overall survival rates at 1-, 2- and 3-years were 97.8%, 83.3% and 75.4%, respectively. The local control rates at 1-, 2- and 3-years were 96.4%, 96.4% and 93.1%, respectively. Radiation-induced liver disease was not documented, and 4 patients (4.4%) had their Child-Pugh score elevated by 1 point after CIRT. No grade 3 or higher acute non-hematological toxicities were observed. Six patients (6.7%) experienced grade 3 or higher late toxicities. Conclusion The active scanning technique was clinically feasible to treat HCC by applying necessary mitigation measures for interplay effects. The desirable oncologic outcomes as well as favorable toxicity profiles presented in this study will be a valuable reference for other carbon-ion centers using the PBS technique and local effect model-based system, and add to a growing body of evidence about the role of CIRT in the management of HCC.
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Affiliation(s)
- Wenna Zhang
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, People’s Republic of China
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, People’s Republic of China
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, People’s Republic of China
| | - Xin Cai
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, People’s Republic of China
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, People’s Republic of China
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, People’s Republic of China
| | - Jiayao Sun
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, People’s Republic of China
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, People’s Republic of China
- Department of Medical Physics, Shanghai Proton and Heavy Ion Center, Shanghai, People’s Republic of China
| | - Weiwei Wang
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, People’s Republic of China
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, People’s Republic of China
- Department of Medical Physics, Shanghai Proton and Heavy Ion Center, Shanghai, People’s Republic of China
| | - Jingfang Zhao
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, People’s Republic of China
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, People’s Republic of China
- Department of Medical Physics, Shanghai Proton and Heavy Ion Center, Shanghai, People’s Republic of China
| | - Qing Zhang
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, People’s Republic of China
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, People’s Republic of China
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, People’s Republic of China
| | - Guoliang Jiang
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, People’s Republic of China
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, People’s Republic of China
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, People’s Republic of China
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai, People’s Republic of China
| | - Zheng Wang
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, People’s Republic of China
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, People’s Republic of China
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, People’s Republic of China
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai, People’s Republic of China
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18
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Brincker M, Jensen I, Rechner LA, Schut DA, Johansen TS, Nielsen M, Thomsen JB. Multi-center comparison between proton and photon plans for mediastinal lymphomas. Acta Oncol 2023; 62:1251-1255. [PMID: 37624751 DOI: 10.1080/0284186x.2023.2251089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023]
Affiliation(s)
- Mads Brincker
- Department of Medical Physics, Oncology, Aalborg University Hospital, Aalborg, Denmark
| | - Ingelise Jensen
- Department of Medical Physics, Oncology, Aalborg University Hospital, Aalborg, Denmark
| | - Laura Ann Rechner
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Oncology, Radiotherapy Research Unit, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Deborah Anne Schut
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Morten Nielsen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
| | - Jakob Borup Thomsen
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
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19
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Pennock M, Wei S, Cheng C, Lin H, Hasan S, Chhabra AM, Choi JI, Bakst RL, Kabarriti R, Simone II CB, Lee NY, Kang M, Press RH. Proton Bragg Peak FLASH Enables Organ Sparing and Ultra-High Dose-Rate Delivery: Proof of Principle in Recurrent Head and Neck Cancer. Cancers (Basel) 2023; 15:3828. [PMID: 37568644 PMCID: PMC10417542 DOI: 10.3390/cancers15153828] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 07/21/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
Proton pencil-beam scanning (PBS) Bragg peak FLASH combines ultra-high dose rate delivery and organ-at-risk (OAR) sparing. This proof-of-principle study compared dosimetry and dose rate coverage between PBS Bragg peak FLASH and PBS transmission FLASH in head and neck reirradiation. PBS Bragg peak FLASH plans were created via the highest beam single energy, range shifter, and range compensator, and were compared to PBS transmission FLASH plans for 6 GyE/fraction and 10 GyE/fraction in eight recurrent head and neck patients originally treated with quad shot reirradiation (14.8/3.7 CGE). The 6 GyE/fraction and 10 GyE/fraction plans were also created using conventional-rate intensity-modulated proton therapy techniques. PBS Bragg peak FLASH, PBS transmission FLASH, and conventional plans were compared for OAR sparing, FLASH dose rate coverage, and target coverage. All FLASH OAR V40 Gy/s dose rate coverage was 90-100% at 6 GyE and 10 GyE for both FLASH modalities. PBS Bragg peak FLASH generated dose volume histograms (DVHs) like those of conventional therapy and demonstrated improved OAR dose sparing over PBS transmission FLASH. All the modalities had similar CTV coverage. PBS Bragg peak FLASH can deliver conformal, ultra-high dose rate FLASH with a two-millisecond delivery of the minimum MU per spot. PBS Bragg peak FLASH demonstrated similar dose rate coverage to PBS transmission FLASH with improved OAR dose-sparing, which was more pronounced in the 10 GyE/fraction than in the 6 GyE/fraction. This feasibility study generates hypotheses for the benefits of FLASH in head and neck reirradiation and developing biological models.
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Affiliation(s)
- Michael Pennock
- Department of Radiation Oncology, Albert Einstein College of Medicine, Montefiore Medical Center, New York, NY 10461, USA;
| | - Shouyi Wei
- Department of Physics, New York Proton Center, New York, NY 10035, USA; (S.W.); (H.L.); (S.H.); (M.K.)
| | - Chingyun Cheng
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 08901, USA;
| | - Haibo Lin
- Department of Physics, New York Proton Center, New York, NY 10035, USA; (S.W.); (H.L.); (S.H.); (M.K.)
| | - Shaakir Hasan
- Department of Physics, New York Proton Center, New York, NY 10035, USA; (S.W.); (H.L.); (S.H.); (M.K.)
| | - Arpit M. Chhabra
- Department of Radiation Oncology, New York Proton Center, New York, NY 10035, USA; (A.M.C.); (J.I.C.); (C.B.S.II)
| | - J. Isabelle Choi
- Department of Radiation Oncology, New York Proton Center, New York, NY 10035, USA; (A.M.C.); (J.I.C.); (C.B.S.II)
| | - Richard L. Bakst
- Department of Radiation Oncology—Radiation Oncology Associates, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA;
| | - Rafi Kabarriti
- Department of Radiation Oncology, Albert Einstein College of Medicine, Montefiore Medical Center, New York, NY 10461, USA;
| | - Charles B. Simone II
- Department of Radiation Oncology, New York Proton Center, New York, NY 10035, USA; (A.M.C.); (J.I.C.); (C.B.S.II)
| | - Nancy Y. Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA;
| | - Minglei Kang
- Department of Physics, New York Proton Center, New York, NY 10035, USA; (S.W.); (H.L.); (S.H.); (M.K.)
| | - Robert H. Press
- Department of Radiation Oncology, Baptist Health South Florida, Miami Cancer Institute, Miami, FL 33176, USA;
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20
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Spautz S, Haase L, Tschiche M, Makocki S, Richter C, Troost EG, Stützer K. Comparison of 3D and 4D robustly optimized proton treatment plans for non-small cell lung cancer patients with tumour motion amplitudes larger than 5 mm. Phys Imaging Radiat Oncol 2023; 27:100465. [PMID: 37449022 PMCID: PMC10338142 DOI: 10.1016/j.phro.2023.100465] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/22/2023] [Accepted: 06/23/2023] [Indexed: 07/18/2023] Open
Abstract
Background and purpose There is no consensus about an ideal robust optimization (RO) strategy for proton therapy of targets with large intrafractional motion. We investigated the plan robustness of 3D and different 4D RO strategies. Materials and methods For eight non-small cell lung cancer patients with clinical target volume (CTV) motion >5 mm, different RO approaches were investigated: 3DRO considering the average CT (AvgCT) with a target density override, 4DRO considering three/all 4DCT phases, and 4DRO considering the AvgCT and three/all 4DCT phases. Robustness against setup/range errors, interplay effects based on breathing and machine log file data for deliveries with/without rescanning, and interfractional anatomical changes were analyzed for target coverage and OAR sparing. Results All nominal plans fulfilled the clinical requirements with individual CTV coverage differences <2pp; 4DRO without AvgCT generated the most conformal dose distributions. Robustness against setup/range errors was best for 4DRO with AvgCT (18% more passed error scenarios than 3DRO). Interplay effects caused fraction-wise median CTV coverage loss of 3pp and missed maximum dose constraints for heart and esophagus in 18% of scenarios. CTV coverage and OAR sparing fulfilled requirements in all cases when accumulating four interplay scenarios. Interfractional changes caused less target misses for RO with AvgCT compared to 4DRO without AvgCT (≤42%/33% vs. ≥56%/44% failed single/accumulated scenarios). Conclusions All RO strategies provided acceptable plans with equally low robustness against interplay effects demanding other mitigation than rescanning to ensure fraction-wise target coverage. 4DRO considering three phases and the AvgCT provided best compromise on planning effort and robustness.
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Affiliation(s)
- Saskia Spautz
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden, Rossendorf, Fetscherstraße 74, PF 41, 01307 Dresden, Germany
| | - Leon Haase
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden, Rossendorf, Fetscherstraße 74, PF 41, 01307 Dresden, Germany
| | - Maria Tschiche
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, PF 50, 01307 Dresden, Germany
| | - Sebastian Makocki
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, PF 50, 01307 Dresden, Germany
| | - Christian Richter
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden, Rossendorf, Fetscherstraße 74, PF 41, 01307 Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, PF 50, 01307 Dresden, Germany
- Helmholtz-Zentrum Dresden – Rossendorf, Institute of Radiooncology – OncoRay, Bautzner Landstraße 400, 01328 Dresden, Germany
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69192 Heidelberg, Germany
| | - Esther G.C. Troost
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden, Rossendorf, Fetscherstraße 74, PF 41, 01307 Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, PF 50, 01307 Dresden, Germany
- Helmholtz-Zentrum Dresden – Rossendorf, Institute of Radiooncology – OncoRay, Bautzner Landstraße 400, 01328 Dresden, Germany
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69192 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany; Im Neuenheimer Feld 280, 69192 Heidelberg, Germany
| | - Kristin Stützer
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden, Rossendorf, Fetscherstraße 74, PF 41, 01307 Dresden, Germany
- Helmholtz-Zentrum Dresden – Rossendorf, Institute of Radiooncology – OncoRay, Bautzner Landstraße 400, 01328 Dresden, Germany
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21
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Knäusl B, Taasti VT, Poulsen P, Muren LP. Surveying the clinical practice of treatment adaptation and motion management in particle therapy. Phys Imaging Radiat Oncol 2023; 27:100457. [PMID: 37361612 PMCID: PMC10285555 DOI: 10.1016/j.phro.2023.100457] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Affiliation(s)
- Barbara Knäusl
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Vicki T Taasti
- Department of Radiation Oncology (Maastro), GROW - School for Oncology and Reproduction, Maastricht, University Medical Centre+, Maastricht, The Netherlands
| | - Per Poulsen
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Aarhus University, Aarhus, Denmark
| | - Ludvig P Muren
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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22
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Graeff C, Volz L, Durante M. Emerging technologies for cancer therapy using accelerated particles. PROGRESS IN PARTICLE AND NUCLEAR PHYSICS 2023; 131:104046. [PMID: 37207092 PMCID: PMC7614547 DOI: 10.1016/j.ppnp.2023.104046] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Cancer therapy with accelerated charged particles is one of the most valuable biomedical applications of nuclear physics. The technology has vastly evolved in the past 50 years, the number of clinical centers is exponentially growing, and recent clinical results support the physics and radiobiology rationale that particles should be less toxic and more effective than conventional X-rays for many cancer patients. Charged particles are also the most mature technology for clinical translation of ultra-high dose rate (FLASH) radiotherapy. However, the fraction of patients treated with accelerated particles is still very small and the therapy is only applied to a few solid cancer indications. The growth of particle therapy strongly depends on technological innovations aiming to make the therapy cheaper, more conformal and faster. The most promising solutions to reach these goals are superconductive magnets to build compact accelerators; gantryless beam delivery; online image-guidance and adaptive therapy with the support of machine learning algorithms; and high-intensity accelerators coupled to online imaging. Large international collaborations are needed to hasten the clinical translation of the research results.
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Affiliation(s)
- Christian Graeff
- GSI Helmholtzzentrum für Schwerionenforschung, Biophysics Department, Planckstraße 1, 64291 Darmstadt, Germany
- Technische Universität Darmstadt, Darmstadt, Germany
| | - Lennart Volz
- GSI Helmholtzzentrum für Schwerionenforschung, Biophysics Department, Planckstraße 1, 64291 Darmstadt, Germany
| | - Marco Durante
- GSI Helmholtzzentrum für Schwerionenforschung, Biophysics Department, Planckstraße 1, 64291 Darmstadt, Germany
- Technische Universität Darmstadt, Darmstadt, Germany
- Dipartimento di Fisica “Ettore Pancini”, University Federico II, Naples, Italy
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23
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Yan S, Ngoma TA, Ngwa W, Bortfeld TR. Global democratisation of proton radiotherapy. Lancet Oncol 2023; 24:e245-e254. [PMID: 37269856 DOI: 10.1016/s1470-2045(23)00184-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/05/2023] [Accepted: 04/19/2023] [Indexed: 06/05/2023]
Abstract
Proton radiotherapy is an advanced treatment option compared with conventional x-ray treatment, delivering much lower doses of radiation to healthy tissues surrounding the tumour. However, proton therapy is currently not widely available. In this Review, we summarise the evolution of proton therapy to date, together with the benefits to patients and society. These developments have led to an exponential growth in the number of hospitals using proton radiotherapy worldwide. However, the gap between the number of patients who should be treated with proton radiotherapy and those who have access to it remains large. We summarise the ongoing research and development that is contributing to closing this gap, including the improvement of treatment efficiency and efficacy, and advances in fixed-beam treatments that do not require an enormously large, heavy, and costly gantry. The ultimate goal of decreasing the size of proton therapy machines to fit into standard treatment rooms appears to be within reach, and we discuss future research and development opportunities to achieve this goal.
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Affiliation(s)
- Susu Yan
- Division of Radiation Biophysics, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
| | - Twalib A Ngoma
- Department Clinical Oncology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Wilfred Ngwa
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Department of Information and Sciences, ICT University, Yaoundé, Cameroon
| | - Thomas R Bortfeld
- Division of Radiation Biophysics, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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24
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Barna S, Meouchi C, Resch AF, Magrin G, Georg D, Palmans H. 3D printed 2D range modulators preserve radiation quality on a microdosimetric scale in proton and carbon ion beams. Radiother Oncol 2023; 182:109525. [PMID: 36774996 DOI: 10.1016/j.radonc.2023.109525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 02/12/2023]
Abstract
INTRODUCTION Particle therapy using pencil beam scanning (PBS) faces large uncertain- ties related to ranges and target motion. One possibility to improve existing mitigation strategies is a 2D range modulator (2DRM). A 2DRM offers faster irradiation times by reducing the number of layers and spots needed to create a spread-out Bragg peak. We have investigated the impact of 2DRM on microdosimetric spectra measured in proton and carbon ion beams. MATERIALS AND METHODS Two 2DRMs were designed and 3D printed, one for. 124.7 MeV protons and one for 238.6 MeV/u carbon ions. Their dosimetric validation was performed using Roos and PinPoint ionization chamber and EBT3 films. Monte Carlo simulations were done using GATE. A silicon-based solid-state microdosimeter was used to collect pulse-height spectra along three depths for two irradiation modalities, PBS and a single central beam. RESULTS For both particle types, the original pin design had to be optimized via GATE simulations. The difference between the R80 of the simulated and measured depth dose curve was 0.1 mm. The microdosimetric spectra collected with the two irradiation modalities overlap well. Their mean lineal energy values differ over all positions by 5.2 % for the proton 2DRM and 2.1 % for the carbon ion 2DRM. CONCLUSION Radiation quality in terms of lineal energy was independent of the irradiation method. This supports the current approach in reference dosimetry, where the residual range is chosen as a beam quality index to select stopping power ratios.
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Affiliation(s)
- Sandra Barna
- Department of Radiation Oncology, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria.
| | - Cynthia Meouchi
- Atominstitut, Technical University of Vienna, Stadionallee 2, Vienna, Austria
| | - Andreas Franz Resch
- Department of Radiation Oncology, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Giulio Magrin
- MedAustron Ion Therapy Center, Marie-Curie-Straße 5, Wiener Neustadt, Austria
| | - Dietmar Georg
- Department of Radiation Oncology, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria; MedAustron Ion Therapy Center, Marie-Curie-Straße 5, Wiener Neustadt, Austria
| | - Hugo Palmans
- MedAustron Ion Therapy Center, Marie-Curie-Straße 5, Wiener Neustadt, Austria; National Physical Laboratory, Hampton Road, Teddington, United Kingdom
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25
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Knäusl B, Lebbink F, Fossati P, Engwall E, Georg D, Stock M. Patient Breathing Motion and Delivery Specifics Influencing the Robustness of a Proton Pancreas Irradiation. Cancers (Basel) 2023; 15:cancers15092550. [PMID: 37174016 PMCID: PMC10177445 DOI: 10.3390/cancers15092550] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/24/2023] [Accepted: 04/28/2023] [Indexed: 05/15/2023] Open
Abstract
Motion compensation strategies in particle therapy depend on the anatomy, motion amplitude and underlying beam delivery technology. This retrospective study on pancreas patients with small moving tumours analysed existing treatment concepts and serves as a basis for future treatment strategies for patients with larger motion amplitudes as well as the transition towards carbon ion treatments. The dose distributions of 17 hypofractionated proton treatment plans were analysed using 4D dose tracking (4DDT). The recalculation of clinical treatment plans employing robust optimisation for mitigating different organ fillings was performed on phased-based 4D computed tomography (4DCT) data considering the accelerator (pulsed scanned pencil beams delivered by a synchrotron) and the breathing-time structure. The analysis confirmed the robustness of the included treatment plans concerning the interplay of beam and organ motion. The median deterioration of D50% (ΔD50%) for the clinical target volume (CTV) and the planning target volume (PTV) was below 2%, while the only outlier was observed for ΔD98% with -35.1%. The average gamma pass rate over all treatment plans (2%/ 2 mm) was 88.8% ± 8.3, while treatment plans for motion amplitudes larger than 1 mm performed worse. For organs at risk (OARs), the median ΔD2% was below 3%, but for single patients, essential changes, e.g., up to 160% for the stomach were observed. The hypofractionated proton treatment for pancreas patients based on robust treatment plan optimisation and 2 to 4 horizontal and vertical beams showed to be robust against intra-fractional movements up to 3.7 mm. It could be demonstrated that the patient's orientation did not influence the motion sensitivity. The identified outliers showed the need for continuous 4DDT calculations in clinical practice to identify patient cases with more significant deviations.
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Affiliation(s)
- Barbara Knäusl
- Department of Radiation Oncology, Medical University of Vienna, 1090 Vienna, Austria
- MedAustron Ion Therapy Centre, Medical Physics, 2700 Wiener Neustadt, Austria
| | - Franciska Lebbink
- Department of Radiation Oncology, Medical University of Vienna, 1090 Vienna, Austria
- MedAustron Ion Therapy Centre, Medical Physics, 2700 Wiener Neustadt, Austria
| | - Piero Fossati
- MedAustron Ion Therapy Centre, Medical Physics, 2700 Wiener Neustadt, Austria
- Division Medical Physics, Karl Landsteiner University of Health Sciences, 2700 Wiener Neustadt, Austria
| | | | - Dietmar Georg
- Department of Radiation Oncology, Medical University of Vienna, 1090 Vienna, Austria
| | - Markus Stock
- MedAustron Ion Therapy Centre, Medical Physics, 2700 Wiener Neustadt, Austria
- Division Medical Physics, Karl Landsteiner University of Health Sciences, 2700 Wiener Neustadt, Austria
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26
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Tommasino F, Cartechini G, Righetto R, Farace P, Cianchetti M. Does variable RBE affect toxicity risks for mediastinal lymphoma patients? NTCP-based evaluation after proton therapy treatment. Phys Med 2023; 108:102569. [PMID: 36989976 DOI: 10.1016/j.ejmp.2023.102569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 02/04/2023] [Accepted: 03/18/2023] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION Mediastinal lymphoma (ML) is a solid malignancy affecting young patients. Modern combined treatments allow obtaining good survival probability, together with a long life expectancy, and therefore with the need to minimize treatment-related toxicities. We quantified the expected toxicity risk for different organs and endpoints in ML patients treated with intensity-modulated proton therapy (IMPT) at our centre, accounting also for uncertainties related to variable RBE. METHODS Treatment plans for ten ML patients were recalculated with a TOPAS-based Monte Carlo code, thus retrieving information on LET and allowing the estimation of variable RBE. Published NTCP models were adopted to calculate the toxicity risk for hypothyroidism, heart valve defects, coronary heart disease and lung fibrosis. NTCP was calculated assuming both constant (i.e. 1.1) and variable RBE. The uncertainty associated with individual radiosensitivity was estimated by random sampling α/β values before RBE evaluation. RESULTS Variable RBE had a minor impact on hypothyroidism risk for 7 patients, while it led to significant increase for the remaining three (+24% risk maximum increase). Lung fibrosis was slightly affected by variable RBE, with a maximum increase of ≅ 1%. This was similar for heart valve dysfunction, with the exception of one patient showing an about 10% risk increase, which could be explained by means of large heart volume and D1 increase. DISCUSSION The use of NTCP models allows for identifying those patients associated with a higher toxicity risk. For those patients, it might be worth including variable RBE in plan evaluation.
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Zhang Y, Trnkova P, Toshito T, Heijmen B, Richter C, Aznar M, Albertini F, Bolsi A, Daartz J, Bertholet J, Knopf A. A survey of practice patterns for real-time intrafractional motion-management in particle therapy. Phys Imaging Radiat Oncol 2023; 26:100439. [PMID: 37124167 PMCID: PMC10133874 DOI: 10.1016/j.phro.2023.100439] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/05/2023] [Accepted: 04/06/2023] [Indexed: 05/02/2023] Open
Abstract
Background and purpose Organ motion compromises accurate particle therapy delivery. This study reports on the practice patterns for real-time intrafractional motion-management in particle therapy to evaluate current clinical practice and wishes and barriers to implementation. Materials and methods An institutional questionnaire was distributed to particle therapy centres worldwide (7/2020-6/2021) asking which type(s) of real-time respiratory motion management (RRMM) methods were used, for which treatment sites, and what were the wishes and barriers to implementation. This was followed by a three-round DELPHI consensus analysis (10/2022) to define recommendations on required actions and future vision. With 70 responses from 17 countries, response rate was 100% for Europe (23/23 centres), 96% for Japan (22/23) and 53% for USA (20/38). Results Of the 68 clinically operational centres, 85% used RRMM, with 41% using both rescanning and active methods. Sixty-four percent used active-RRMM for at least one treatment site, mostly with gating guided by an external marker. Forty-eight percent of active-RRMM users wished to expand or change their RRMM technique. The main barriers were technical limitations and limited resources. From the DELPHI analysis, optimisation of rescanning parameters, improvement of motion models, and pre-treatment 4D evaluation were unanimously considered clinically important future focus. 4D dose calculation was identified as the top requirement for future commercial treatment planning software. Conclusion A majority of particle therapy centres have implemented RRMM. Still, further development and clinical integration were desired by most centres. Joint industry, clinical and research efforts are needed to translate innovation into efficient workflows for broad-scale implementation.
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Affiliation(s)
- Ye Zhang
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Petra Trnkova
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Toshiyuki Toshito
- Nagoya Proton Therapy Center, Nagoya City University West Medical Center, Nagoya, Japan
| | - Ben Heijmen
- Department of Radiotherapy, Erasmus University Medical Center (Erasmus MC), Rotterdam, the Netherlands
| | - Christian Richter
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
| | - Marianne Aznar
- Faculty of Biology, Medicine and Health, Division of Cancer Sciences, University of Manchester, United Kingdom
| | | | - Alexandra Bolsi
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Juliane Daartz
- F. Burr Proton Therapy, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Jenny Bertholet
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Antje Knopf
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
- Institute for Medical Engineering and Medical Informatics, School of Life Science FHNW, Muttenz, Switzerland
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Jassar H, Tai A, Chen X, Keiper TD, Paulson E, Lathuilière F, Bériault S, Hébert F, Savard L, Cooper DT, Cloake S, Li XA. Real-time motion monitoring using orthogonal cine MRI during MR-guided adaptive radiation therapy for abdominal tumors on 1.5T MR-Linac. Med Phys 2023; 50:3103-3116. [PMID: 36893292 DOI: 10.1002/mp.16342] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 02/01/2023] [Accepted: 02/24/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Real-time motion monitoring (RTMM) is necessary for accurate motion management of intrafraction motions during radiation therapy (RT). PURPOSE Building upon a previous study, this work develops and tests an improved RTMM technique based on real-time orthogonal cine magnetic resonance imaging (MRI) acquired during magnetic resonance-guided adaptive RT (MRgART) for abdominal tumors on MR-Linac. METHODS A motion monitoring research package (MMRP) was developed and tested for RTMM based on template rigid registration between beam-on real-time orthogonal cine MRI and pre-beam daily reference 3D-MRI (baseline). The MRI data acquired under free-breathing during the routine MRgART on a 1.5T MR-Linac for 18 patients with abdominal malignancies of 8 liver, 4 adrenal glands (renal fossa), and 6 pancreas cases were used to evaluate the MMRP package. For each patient, a 3D mid-position image derived from an in-house daily 4D-MRI was used to define a target mask or a surrogate sub-region encompassing the target. Additionally, an exploratory case reviewed for an MRI dataset of a healthy volunteer acquired under both free-breathing and deep inspiration breath-hold (DIBH) was used to test how effectively the RTMM using the MMRP can address through-plane motion (TPM). For all cases, the 2D T2/T1-weighted cine MRIs were captured with a temporal resolution of 200 ms interleaved between coronal and sagittal orientations. Manually delineated contours on the cine frames were used as the ground-truth motion. Common visible vessels and segments of target boundaries in proximity to the target were used as anatomical landmarks for reproducible delineations on both the 3D and the cine MRI images. Standard deviation of the error (SDE) between the ground-truth and the measured target motion from the MMRP package were analyzed to evaluate the RTMM accuracy. The maximum target motion (MTM) was measured on the 4D-MRI for all cases during free-breathing. RESULTS The mean (range) centroid motions for the 13 abdominal tumor cases were 7.69 (4.71-11.15), 1.73 (0.81-3.05), and 2.71 (1.45-3.93) mm with an overall accuracy of <2 mm in the superior-inferior (SI), the left-right (LR), and the anterior-posterior (AP) directions, respectively. The mean (range) of the MTM from the 4D-MRI was 7.38 (2-11) mm in the SI direction, smaller than the monitored motion of centroid, demonstrating the importance of the real-time motion capture. For the remaining patient cases, the ground-truth delineation was challenging under free-breathing due to the target deformation and the large TPM in the AP direction, the implant-induced image artifacts, and/or the suboptimal image plane selection. These cases were evaluated based on visual assessment. For the healthy volunteer, the TPM of the target was significant under free-breathing which degraded the RTMM accuracy. RTMM accuracy of <2 mm was achieved under DIBH, indicating DIBH is an effective method to address large TPM. CONCLUSIONS We have successfully developed and tested the use of a template-based registration method for an accurate RTMM of abdominal targets during MRgART on a 1.5T MR-Linac without using injected contrast agents or radio-opaque implants. DIBH may be used to effectively reduce or eliminate TPM of abdominal targets during RTMM.
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Affiliation(s)
- Hassan Jassar
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - An Tai
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Xinfeng Chen
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Timothy D Keiper
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Eric Paulson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | | | | | | | | | | | - X Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Hong Z, Zhang W, Cai X, Yu Z, Sun J, Wang W, Lin L, Zhao J, Cheng J, Zhang G, Zhang Q, Jiang G, Wang Z. Carbon ion radiotherapy with pencil beam scanning for hepatocellular carcinoma: Long-term outcomes from a phase I trial. Cancer Sci 2023; 114:976-983. [PMID: 36310409 PMCID: PMC9986066 DOI: 10.1111/cas.15633] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 10/13/2022] [Accepted: 10/16/2022] [Indexed: 11/06/2022] Open
Abstract
This study evaluates the feasibility of the pencil beam scanning technique of carbon ion radiotherapy (CIRT) in the setting of hepatocellular carcinoma (HCC) and establishes the maximum tolerated dose (MTD) calculated by the Local Effect Model version I (LEM-I) with a dose escalation plan. The escalated relative biological effectiveness-weighted dose levels included 55, 60, 65, and 70 Gy in 10 fractions. Active motion management techniques were employed, and several measures were applied to mitigate the interplay effect induced by a moving target. CIRT was planned with the LEM-I-based treatment planning system and delivered by raster scanning. Offline PET/CT imaging was used to verify the beam range. Offline adaptive replanning was performed whenever required. Twenty-three patients with a median tumor size of 4.3 cm (range, 1.7-8.5 cm) were enrolled in the present study. The median follow-up time was 56.1 months (range, 5.7-74.4 months). No dose limiting toxicity was observed until 70 Gy, and MTD had not been reached. No patients experienced radiation-induced liver disease within 6 months after the completion of CIRT. The overall survival rates at 1, 3, and 5 years were 91.3%, 81.9%, and 67.1% after CIRT, respectively. The local progression-free survival and progression-free survival rates at 1, 3 and 5 years were 100%, 94.4%, and 94.4% and 73.6%, 59.2%, and 37.0%, respectively. The raster scanning technique could be used to treat HCC. However, caution should be exercised to mitigate the interplay effect. CIRT up to 70 Gy in 10 fractions over 2 weeks was safe and effective for HCC.
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Affiliation(s)
- Zhengshan Hong
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, China.,Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China.,Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China
| | - Wenna Zhang
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, China.,Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China.,Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China
| | - Xin Cai
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, China.,Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China.,Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China
| | - Zhan Yu
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, China.,Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China.,Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China
| | - Jiayao Sun
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China.,Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China.,Department of Medical Physics, Shanghai Proton and Heavy Ion Center, Shanghai, China
| | - Weiwei Wang
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China.,Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China.,Department of Medical Physics, Shanghai Proton and Heavy Ion Center, Shanghai, China
| | - Lienchun Lin
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China.,Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China.,Department of Medical Physics, Shanghai Proton and Heavy Ion Center, Shanghai, China
| | - Jingfang Zhao
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China.,Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China.,Department of Medical Physics, Shanghai Proton and Heavy Ion Center, Shanghai, China
| | - Jingyi Cheng
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China.,Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China.,Department of Nuclear Medicine, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai, China
| | - Guangyuan Zhang
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China.,Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China.,Department of Radiology, Shanghai Proton and Heavy Ion Center, Shanghai, China
| | - Qing Zhang
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, China.,Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China.,Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China
| | - Guoliang Jiang
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, China.,Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China.,Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China.,Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai, China
| | - Zheng Wang
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, China.,Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China.,Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China.,Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai, China
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Liu R, Charyyev S, Wahl N, Liu W, Kang M, Zhou J, Yang X, Baltazar F, Palkowitsch M, Higgins K, Dynan W, Bradley J, Lin L. An Integrated Physical Optimization Framework for Proton Stereotactic Body Radiation Therapy FLASH Treatment Planning Allows Dose, Dose Rate, and Linear Energy Transfer Optimization Using Patient-Specific Ridge Filters. Int J Radiat Oncol Biol Phys 2023:S0360-3016(23)00097-4. [PMID: 36736634 DOI: 10.1016/j.ijrobp.2023.01.048] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 01/04/2023] [Accepted: 01/21/2023] [Indexed: 02/04/2023]
Abstract
PURPOSE Patient-specific ridge filters provide a passive means to modulate proton energy to obtain a conformal dose. Here we describe a new framework for optimization of filter design and spot maps to meet the unique demands of ultrahigh-dose-rate (FLASH) radiation therapy. We demonstrate an integrated physical optimization Intensity-modulated proton therapy (IMPT) (IPO-IMPT) approach for optimization of dose, dose-averaged dose rate (DADR), and dose-averaged linear energy transfer (LETd). METHODS AND MATERIALS We developed an inverse planning software to design patient-specific ridge filters that spread the Bragg peak from a fixed-energy, 250-MeV beam to a proximal beam-specific planning target volume. The software defines patient-specific ridge filter pin shapes and uses a Monte Carlo calculation engine, based on Geant4, to provide dose and LET influence matrices. Plan optimization, using matRAD, accommodates the IPO-IMPT objective function considering dose, dose rate, and LET simultaneously with minimum monitor unit constraints. The framework enables design of both regularly spaced and sparse-optimized ridge filters, from which some pins are omitted to allow faster delivery and selective LET optimization. To demonstrate the framework, we designed ridge filters for 3 example patients with lung cancer and optimized the plans using IPO-IMPT. RESULTS The IPO-IMPT framework selectively spared the organs at risk by reducing LET and increasing dose rate, relative to IMPT planning. Sparse-optimized ridge filters were superior to regularly spaced ridge filters in dose rate. Depending on which parameter is prioritized, volume distributions and histograms for dose, DADR, and LETd, using evaluation structures specific to heart, lung, and esophagus, show high levels of FLASH dose-rate coverage and/or reduced LETd, while maintaining dose coverage within the beam specific planning target volume. CONCLUSIONS This proof-of-concept study demonstrates the feasibility of using an IPO-IMPT framework to accomplish proton FLASH stereotactic body proton therapy, accounting for dose, DADR, and LETd simultaneously.
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Affiliation(s)
- Ruirui Liu
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Serdar Charyyev
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Niklas Wahl
- German Cancer Research Center - DKFZ, Department of Medical Physics in Radiation Oncology, Heidelberg, Germany; Heidelberg Institute for Radiation Oncology - HIRO, Heidelberg, Germany
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | | | - Jun Zhou
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Xiaofeng Yang
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Filipa Baltazar
- German Cancer Research Center - DKFZ, Department of Medical Physics in Radiation Oncology, Heidelberg, Germany; Instituto SuperiorTécnico, Universidade de Lisboa, Lisbon, Portugal
| | - Martina Palkowitsch
- German Cancer Research Center - DKFZ, Department of Medical Physics in Radiation Oncology, Heidelberg, Germany; Heidelberg Institute for Radiation Oncology - HIRO, Heidelberg, Germany; Atominstitut, TU Wien, Vienna, Austria
| | - Kristin Higgins
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - William Dynan
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jeffrey Bradley
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Liyong Lin
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia.
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Cao Y, Zhu X, Yu C, Jiang L, Sun Y, Guo X, Zhang H. Dose evaluations of organs at risk and predictions of gastrointestinal toxicity after re-irradiation with stereotactic body radiation therapy for pancreatic cancer by deformable image registration. Front Oncol 2023; 12:1021058. [PMID: 36793343 PMCID: PMC9923872 DOI: 10.3389/fonc.2022.1021058] [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: 08/17/2022] [Accepted: 12/07/2022] [Indexed: 01/31/2023] Open
Abstract
Purpose Re-irradiation of locally recurrent pancreatic cancer may be an optimal choice as a local ablative therapy. However, dose constraints of organs at risk (OARs) predictive of severe toxicity remain unknown. Therefore, we aim to calculate and identify accumulated dose distributions of OARs correlating with severe adverse effects and determine possible dose constraints regarding re-irradiation. Methods Patients receiving two courses of stereotactic body radiation therapy (SBRT) for the same irradiated regions (the primary tumors) due to local recurrence were included. All doses of the first and second plans were recalculated to an equivalent dose of 2 Gy per fraction (EQD2). Deformable image registration with the workflow "Dose Accumulation-Deformable" of the MIM® System (version: 6.6.8) was performed for dose summations. Dose-volume parameters predictive of grade 2 or more toxicities were identified, and the receiver operating characteristic (ROC) curve was used to determine optimal thresholds of dose constraints. Results Forty patients were included in the analysis. Only the V 10 of the stomach [hazard ratio (HR): 1.02 (95% CI:1.00-1.04), P = 0.035] and D mean of the intestine [HR: 1.78 (95% CI: 1.00-3.18), P = 0.049] correlated with grade 2 or more gastrointestinal toxicity. Hence, the equation of probability of such toxicity was P = 1 1 + e - ( - 4.155 + 0.579 D mean of the intestine + 0.021 V 10 of the stomach ) Additionally, the area under the ROC curve and threshold of dose constraints of V 10 of the stomach and D mean of the intestine were 0.779 and 77.575 cc, 0.769 and 4.22 Gy3 (α/β = 3), respectively. The area under the ROC curve of the equation was 0.821. Conclusion The V 10 of the stomach and D mean of the intestine may be vital parameters to predict grade 2 or more gastrointestinal toxicity, of which the threshold of dose constraints may be beneficial for the practice of re-irradiation of locally relapsed pancreatic cancer.
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Hamaide V, Souris K, Dasnoy D, Glineur F, Macq B. Real-time image-guided treatment of mobile tumors in proton therapy by a library of treatment plans: a simulation study. Med Phys 2023; 50:465-479. [PMID: 36345808 DOI: 10.1002/mp.16084] [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: 05/16/2022] [Revised: 09/08/2022] [Accepted: 10/20/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To improve target coverage and reduce the dose in the surrounding organs-at-risks (OARs), we developed an image-guided treatment method based on a precomputed library of treatment plans controlled and delivered in real-time. METHODS A library of treatment plans is constructed by optimizing a plan for each breathing phase of a four dimensional computed tomography (4DCT). Treatments are delivered by simulation on a continuous sequence of synthetic computed tomographies (CTs) generated from real magnetic resonance imaging (MRI) sequences. During treatment, the plans for which the tumor are at a close distance to the current tumor position are selected to deliver their spots. The study is conducted on five liver cases. RESULTS We tested our approach under imperfect knowledge of the tumor positions with a 2 mm distance error. On average, compared to a 4D robustly optimized treatment plan, our approach led to a dose homogeneity increase of 5% (defined as 1 - D 5 - D 95 prescription $1-\frac{D_5-D_{95}}{\text{prescription}}$ ) in the target and a mean liver dose decrease of 23%. The treatment time was roughly increased by a factor of 2 but remained below 4 min on average. CONCLUSIONS Our image-guided treatment framework outperforms state-of-the-art 4D-robust plans for all patients in this study on both target coverage and OARs sparing, with an acceptable increase in treatment time under the current accuracy of the tumor tracking technology.
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Affiliation(s)
| | | | - Damien Dasnoy
- ICTEAM Institute, UCLouvain, Louvain-la-Neuve, Belgium
| | | | - Benoît Macq
- ICTEAM Institute, UCLouvain, Louvain-la-Neuve, Belgium
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Nankali S, Worm ES, Thomsen JB, Stick LB, Bertholet J, Høyer M, Weber B, Mortensen HR, Poulsen PR. Intrafraction tumor motion monitoring and dose reconstruction for liver pencil beam scanning proton therapy. Front Oncol 2023; 13:1112481. [PMID: 36937392 PMCID: PMC10019817 DOI: 10.3389/fonc.2023.1112481] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/13/2023] [Indexed: 03/06/2023] Open
Abstract
Background Pencil beam scanning (PBS) proton therapy can provide highly conformal target dose distributions and healthy tissue sparing. However, proton therapy of hepatocellular carcinoma (HCC) is prone to dosimetrical uncertainties induced by respiratory motion. This study aims to develop intra-treatment tumor motion monitoring during respiratory gated proton therapy and combine it with motion-including dose reconstruction to estimate the delivered tumor doses for individual HCC treatment fractions. Methods Three HCC-patients were planned to receive 58 GyRBE (n=2) or 67.5 GyRBE (n=1) of exhale respiratory gated PBS proton therapy in 15 fractions. The treatment planning was based on the exhale phase of a 4-dimensional CT scan. Daily setup was based on cone-beam CT (CBCT) imaging of three implanted fiducial markers. An external marker block (RPM) on the patient's abdomen was used for exhale gating in free breathing. This study was based on 5 fractions (patient 1), 1 fraction (patient 2) and 6 fractions (patient 3) where a post-treatment control CBCT was available. After treatment, segmented 2D marker positions in the post-treatment CBCT projections provided the estimated 3D motion trajectory during the CBCT by a probability-based method. An external-internal correlation model (ECM) that estimated the tumor motion from the RPM motion was built from the synchronized RPM signal and marker motion in the CBCT. The ECM was then used to estimate intra-treatment tumor motion. Finally, the motion-including CTV dose was estimated using a dose reconstruction method that emulates tumor motion in beam's eye view as lateral spot shifts and in-depth motion as changes in the proton beam energy. The CTV homogeneity index (HI) The CTV homogeneity index (HI) was calculated as D 2 % - D 98 % D 50 % × 100 % . Results The tumor position during spot delivery had a root-mean-square error of 1.3 mm in left-right, 2.8 mm in cranio-caudal and 1.7 mm in anterior-posterior directions compared to the planned position. On average, the CTV HI was larger than planned by 3.7%-points (range: 1.0-6.6%-points) for individual fractions and by 0.7%-points (range: 0.3-1.1%-points) for the average dose of 5 or 6 fractions. Conclusions A method to estimate internal tumor motion and reconstruct the motion-including fraction dose for PBS proton therapy of HCC was developed and demonstrated successfully clinically.
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Affiliation(s)
- Saber Nankali
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- *Correspondence: Saber Nankali,
| | | | - Jakob Borup Thomsen
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | | | - Jenny Bertholet
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Morten Høyer
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Britta Weber
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Per Rugaard Poulsen
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
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Duetschler A, Prendi J, Safai S, Weber DC, Lomax AJ, Zhang Y. Limitations of phase-sorting based pencil beam scanned 4D proton dose calculations under irregular motion. Phys Med Biol 2022; 68. [PMID: 36571234 DOI: 10.1088/1361-6560/aca9b6] [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: 09/12/2022] [Accepted: 12/07/2022] [Indexed: 12/12/2022]
Abstract
Objective.4D dose calculation (4DDC) for pencil beam scanned (PBS) proton therapy is typically based on phase-sorting of individual pencil beams onto phases of a single breathing cycle 4DCT. Understanding the dosimetric limitations and uncertainties of this approach is essential, especially for the realistic treatment scenario with irregular free breathing motion.Approach.For three liver and three lung cancer patient CTs, the deformable multi-cycle motion from 4DMRIs was used to generate six synthetic 4DCT(MRI)s, providing irregular motion (11/15 cycles for liver/lung; tumor amplitudes ∼4-18 mm). 4DDCs for two-field plans were performed, with the temporal resolution of the pencil beam delivery (4-200 ms) or with 8 phases per breathing cycle (500-1000 ms). For the phase-sorting approach, the tumor center motion was used to determine the phase assignment of each spot. The dose was calculated either using the full free breathing motion or individually repeating each single cycle. Additionally, the use of an irregular surrogate signal prior to 4DDC on a repeated cycle was simulated. The CTV volume with absolute dose differences >5% (Vdosediff>5%) and differences in CTVV95%andD5%-D95%compared to the free breathing scenario were evaluated.Main results.Compared to 4DDC considering the full free breathing motion with finer spot-wise temporal resolution, 4DDC based on a repeated single 4DCT resulted inVdosediff>5%of on average 34%, which resulted in an overestimation ofV95%up to 24%. However, surrogate based phase-sorting prior to 4DDC on a single cycle 4DCT, reduced the averageVdosediff>5%to 16% (overestimationV95%up to 19%). The 4DDC results were greatly influenced by the choice of reference cycle (Vdosediff>5%up to 55%) and differences due to temporal resolution were much smaller (Vdosediff>5%up to 10%).Significance.It is important to properly consider motion irregularity in 4D dosimetric evaluations of PBS proton treatments, as 4DDC based on a single 4DCT can lead to an underestimation of motion effects.
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Affiliation(s)
- A Duetschler
- Center for Proton Therapy, Paul Scherrer Institute, 5232 Villigen PSI, CH, Switzerland.,Department of Physics, ETH Zürich, 8092 Zürich, CH, Switzerland
| | - J Prendi
- Center for Proton Therapy, Paul Scherrer Institute, 5232 Villigen PSI, CH, Switzerland.,Department of Physics, University of Basel, 4056 Basel, CH, Switzerland
| | - S Safai
- Center for Proton Therapy, Paul Scherrer Institute, 5232 Villigen PSI, CH, Switzerland
| | - D C Weber
- Center for Proton Therapy, Paul Scherrer Institute, 5232 Villigen PSI, CH, Switzerland.,Department of Radiation Oncology, University Hospital of Zürich, 8091 Zürich, CH, Switzerland.,Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, CH, Switzerland
| | - A J Lomax
- Center for Proton Therapy, Paul Scherrer Institute, 5232 Villigen PSI, CH, Switzerland.,Department of Physics, ETH Zürich, 8092 Zürich, CH, Switzerland
| | - Ye Zhang
- Center for Proton Therapy, Paul Scherrer Institute, 5232 Villigen PSI, CH, Switzerland
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Patel CG, Peterson J, Aznar M, Tseng YD, Lester S, Pafundi D, Flampouri S, Mohindra P, Parikh RR, Mailhot Vega R, Konig L, Plastaras JP, Bates JE, Loap P, Kirova YM, Orlandi E, Lütgendorf-Caucig C, Ntentas G, Hoppe B. Systematic review for deep inspiration breath hold in proton therapy for mediastinal lymphoma: A PTCOG Lymphoma Subcommittee report and recommendations. Radiother Oncol 2022; 177:21-32. [PMID: 36252635 DOI: 10.1016/j.radonc.2022.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 09/14/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE To systematically review all dosimetric studies investigating the impact of deep inspiration breath hold (DIBH) compared with free breathing (FB) in mediastinal lymphoma patients treated with proton therapy as compared to IMRT (intensity-modulated radiation therapy)-DIBH. MATERIALS AND METHODS We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline using the PubMed database to identify studies of mediastinal lymphoma patients with dosimetric comparisons of proton-FB and/or proton-DIBH with IMRT-DIBH. Parameters included mean heart (MHD), lung (MLD), and breast (MBD) doses, among other parameters. Case reports were excluded. Absolute differences in mean doses > 1 Gy between comparators were considered to be clinically meaningful. RESULTS As of April 2021, eight studies fit these criteria (n = 8), with the following comparisons: proton-FB vs IMRT-DIBH (n = 5), proton-DIBH vs proton-FB (n = 5), and proton-DIBH vs IMRT-DIBH (n = 8). When comparing proton-FB with IMRT-DIBH in 5 studies, MHD was reduced with proton-FB in 2 studies, was similar (<1 Gy difference) in 2 studies, and increased in 1 study. On the other hand, MLD and MBD were reduced with proton-FB in 3 and 4 studies, respectively. When comparing proton-DIBH with proton-FB, MHD and MLD were reduced with proton DIBH in 4 and 3 studies, respectively, while MBD remained similar. Compared with IMRT-DIBH in 8 studies, proton-DIBH reduced the MHD in 7 studies and was similar in 1 study. Furthermore, MLD and MBD were reduced with proton-DIBH in 8 and 6 studies respectively. Integral dose was similar between proton-FB and proton-DIBH, and both were substantially lower than IMRT-DIBH. CONCLUSION Accounting for heart, lung, breast, and integral dose, proton therapy (FB or DIBH) was superior to IMRT-DIBH. Proton-DIBH can lower dose to the lungs and heart even further compared with proton-FB, depending on disease location in the mediastinum, and organ-sparing and target coverage priorities.
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Affiliation(s)
- Chirayu G Patel
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, USA.
| | | | - Marianne Aznar
- University of Manchester, Division of Cancer Sciences, Manchester, United Kingdom
| | - Yolanda D Tseng
- Department of Radiation Oncology, University of Washington, Seattle, USA
| | | | | | - Stella Flampouri
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, USA
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Rahul R Parikh
- Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, New Brunswick, NJ, USA
| | - Raymond Mailhot Vega
- Department of Radiation Oncology, University of Florida, Gainsville, Florida, USA
| | - Laila Konig
- Department of Radiation Oncology, Heidelberg University Hospital; Heidelberg Ion Beam Therapy Centre (HIT); National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - John P Plastaras
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - James E Bates
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, USA
| | - Pierre Loap
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Youlia M Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Ester Orlandi
- National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | | | - Georgios Ntentas
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; Guy's and St Thomas' NHS Foundation Trust, Department of Medical Physics, London, United Kingdom
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Maradia V, Colizzi I, Meer D, Weber DC, Lomax AJ, Actis O, Psoroulas S. Universal and dynamic ridge filter for pencil beam scanning particle therapy: a novel concept for ultra-fast treatment delivery. Phys Med Biol 2022; 67. [DOI: 10.1088/1361-6560/ac9d1f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 10/24/2022] [Indexed: 11/07/2022]
Abstract
Abstract
Objective. In pencil beam scanning particle therapy, a short treatment delivery time is paramount for the efficient treatment of moving targets with motion mitigation techniques (such as breath-hold, rescanning, and gating). Energy and spot position change time are limiting factors in reducing treatment time. In this study, we designed a universal and dynamic energy modulator (ridge filter, RF) to broaden the Bragg peak, to reduce the number of energies and spots required to cover the target volume, thus lowering the treatment time. Approach. Our RF unit comprises two identical RFs placed just before the isocenter. Both RFs move relative to each other, changing the Bragg peak’s characteristics dynamically. We simulated different Bragg peak shapes with the RF in Monte Carlo simulation code (TOPAS) and validated them experimentally. We then delivered single-field plans with 1 Gy/fraction to different geometrical targets in water, to measure the dose delivery time using the RF and compare it with the clinical settings. Main results. Aligning the RFs in different positions produces different broadening in the Bragg peak; we achieved a maximum broadening of 2.5 cm. With RF we reduced the number of energies in a field by more than 60%, and the dose delivery time by 50%, for all geometrical targets investigated, without compromising the dose distribution transverse and distal fall-off. Significance. Our novel universal and dynamic RF allows for the adaptation of the Bragg peak broadening for a spot and/or energy layer based on the requirement of dose shaping in the target volume. It significantly reduces the number of energy layers and spots to cover the target volume, and thus the treatment time. This RF design is ideal for ultra-fast treatment delivery within a single breath-hold (5–10 s), efficient delivery of motion mitigation techniques, and small animal irradiation with ultra-high dose rates (FLASH).
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Zhao L, Liu G, Li X, Ding X. An evolutionary optimization algorithm for proton arc therapy. Phys Med Biol 2022; 67. [DOI: 10.1088/1361-6560/ac8411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 07/25/2022] [Indexed: 11/12/2022]
Abstract
Abstract
Objective. Proton arc plan normally contains thousands of spot numbers and hundreds of energy layers. A recent study reported that the beam delivery time (BDT) is proportional to the spot numbers. Thus, it is critical to find an optimal plan with a fast delivery speed while maintaining a good plan quality. Thus, we developed a novel evolutionary algorithm to directly search for the optimal spot sparsity solution to balance plan quality and BDT. Approach. The planning platform included a plan quality objective, a generator, and a selector. The generator is based on trust-region-reflective solver. A selector was designed to filter or add the spot according to the expected spot number, based on the user’s input of BDT. The generator and selector are used alternatively to optimize a spot sparsity solution. Three clinical cases’ CT and structure datasets, e.g. brain, lung, and liver cancer, were used for testing purposes. A series of user-defined BDTs from 15 to 250 s were used as direct inputs. The relationship between the plan’s cost function value and BDT was evaluated in these three cases. Main results. The evolutionary algorithm could optimize a proton arc plan based on clinical user input BDT directly. The plan quality remains optimal in the brain, lung, and liver cases until the BDT was shorter than 25 s, 50 s and 100 s, respectively. The plan quality degraded as the input delivery time became too short, indicating that the plan lacked enough spot or degree of freedom. Significance. This is the first proton arc planning framework to directly optimize plan quality with the BDT as an input for the new generation of proton therapy systems. This work paved the roadmap for implementing such new technology in a routine clinic and provided a planning platform to explore the trade-off between the BDT and plan quality.
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Wei S, Lin H, Huang S, Shi C, Xiong W, Zhai H, Hu L, Yu G, Press RH, Hasan S, Chhabra AM, Choi JI, Simone CB, Kang M. Dose rate and dose robustness for proton transmission FLASH-RT treatment in lung cancer. Front Oncol 2022; 12:970602. [PMID: 36059710 PMCID: PMC9435957 DOI: 10.3389/fonc.2022.970602] [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: 06/16/2022] [Accepted: 07/27/2022] [Indexed: 11/13/2022] Open
Abstract
Purposes To evaluate the plan quality and robustness of both dose and dose rate of proton pencil beam scanning (PBS) transmission FLASH delivery in lung cancer treatment. Methods and materials An in-house FLASH planning platform was used to optimize 10 lung cancer patients previously consecutively treated with proton stereotactic body radiation therapy (SBRT) to receive 3 and 5 transmission beams (Trx-3fds and Trx-5fds, respectively) to 34 Gy in a single fraction. Perturbation scenarios (n=12) for setup and range uncertainties (5 mm and 3.5%) were introduced, and dose-volume histogram and dose-rate-volume histogram bands were generated. Conventional proton SBRT clinical plans were used as a reference. RTOG 0915 dose metrics and 40 Gy/s dose rate coverage (V40Gy/s) were used to assess the dose and dose rate robustness. Results Trx-5fds yields a comparable iCTV D2% of 105.3%, whereas Trx-3fds resulted in inferior D2% of 111.9% to the clinical SBRT plans with D2% of 105.6% (p<0.05). Both Trx-5fds and Trx-3fds plans had slightly worse dose metrics to organs at risk than SBRT plans. Trx-5fds achieved superior dosimetry robustness for iCTV, esophagus, and spinal cord doses than both Trx-3fds and conventional SBRT plans. There was no significant difference in dose rate robustness for V40Gy/s coverage between Trx-3fds and Trx-5fds. Dose rate distribution has similar distributions to the dose when perturbation exists. Conclusion Transmission plans yield overall modestly inferior plan quality compared to the conventional proton SBRT plans but provide improved robustness and the potential for a toxicity-sparing FLASH effect. By using more beams (5- versus 3-field), both dose and dose rate robustness for transmission plans can be achieved.
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Affiliation(s)
- Shouyi Wei
- New York Proton Center, New York, NY, United States
| | - Haibo Lin
- New York Proton Center, New York, NY, United States
| | - Sheng Huang
- New York Proton Center, New York, NY, United States
| | - Chengyu Shi
- City of Hope, Orange County, Irvine, CA, United States
| | - Weijun Xiong
- New York Proton Center, New York, NY, United States
| | - Huifang Zhai
- New York Proton Center, New York, NY, United States
| | - Lei Hu
- New York Proton Center, New York, NY, United States
| | - Gang Yu
- New York Proton Center, New York, NY, United States
| | | | | | | | | | | | - Minglei Kang
- New York Proton Center, New York, NY, United States
- *Correspondence: Minglei Kang,
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Wei S, Lin H, Isabelle Choi J, Shi C, Simone CB, Kang M. Advanced pencil beam scanning Bragg peak FLASH-RT delivery technique can enhance lung cancer planning treatment outcomes compared to conventional multiple-energy proton PBS techniques. Radiother Oncol 2022; 175:238-247. [PMID: 35961583 DOI: 10.1016/j.radonc.2022.08.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/01/2022] [Accepted: 08/01/2022] [Indexed: 12/25/2022]
Abstract
PURPOSE To investigate the dosimetric characteristics between an advanced proton pencil beam scanning (PBS) Bragg peak FLASH technique and conventional PBS planning technique in lung tumors. To evaluate the "FLASHness" of single-field in a multiple-field delivery scheme for a hypofractionation regimen and move a step forward to clinical application. METHODS Single-energy PBS Bragg peak FLASH treatment plans were optimized based on a novel Bragg peak tracking technique to enable Bragg peaks to stop at the distal edge of the target. Inverse treatment planning using multiple-field optimization (MFO) can achieve sufficient FLASH dose rate and intensity-modulated proton therapy (IMPT)-equivalent dosimetric quality. The dose rate of organs-at-risk (OARs) and the target were calculated under FLASH machine parameters. A group of 10 consecutive lung SBRT patients was optimized to 34 Gy/fraction using a standard treatment of PBS technique with multiple energy layers as references to the Bragg peak plans. The dosimetric quality was compared between Bragg peak FLASH and conventional plans based on RTOG0915 dose metrics. FLASH dose rate ratios (V40Gy/s) were calculated as a metric of the FLASH-sparing effect. RESULTS For higher dose thresholds, the Bragg peak plans achieved greater V40Gy/s FLASH coverage for all major OARs. The V40Gy/s was close to 100% for all OARs when the dose thresholds were > 5 Gy for full plan and single beam evaluations. The less "FLASHness" region was associated with a low dose distribution, mainly occurring in the PBS field penumbra region. The conventional IMPT treatment plans yielded slightly superior target dose uniformity with a D2%(%) of 108.02% versus that of Bragg peak 300 MU plans of 111.81% (p < 0.01) and that of Bragg peak 1200 MU plans of 115.95% (p < 0.01). No significant difference in dose metrics was found between Bragg peak and IMPT treatment plans for the spinal cord, esophagus, heart, or lung-GTV (all p > 0.05). CONCLUSION Hypofractionated lung Bragg peak plans can maintain comparable plan quality to conventional PBS while achieving sufficient FLASH dose rate coverage for major OARs for each field under the multiple-field delivery scheme. The novel Bragg peak FLASH technique has the potential to enhance lung cancer planning treatment outcomes compared to standard PBS treatment techniques.
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Affiliation(s)
- Shouyi Wei
- New York Proton Center, New York, NY 10035, USA
| | - Haibo Lin
- New York Proton Center, New York, NY 10035, USA.
| | | | - Chengyu Shi
- City of Hope, Orange County, Irvine, CA 92618, USA
| | | | - Minglei Kang
- New York Proton Center, New York, NY 10035, USA.
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Algranati C, Strigari L. Imaging Strategies in Proton Therapy for Thoracic Tumors: A Mini Review. Front Oncol 2022; 12:833364. [PMID: 35515119 PMCID: PMC9063639 DOI: 10.3389/fonc.2022.833364] [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: 12/11/2021] [Accepted: 02/09/2022] [Indexed: 11/13/2022] Open
Abstract
Proton beam therapy (PBT) is often more attractive for its high gradient dose distributions than other treatment modalities with external photon beams. However, in thoracic lesions treated particularly with pencil beam scanning (PBS) proton beams, several dosimetric issues are addressed. The PBS approach may lead to large hot or cold spots in dose distributions delivered to the patients, potentially affecting the tumor control and/or increasing normal tissue side effects. This delivery method particularly benefits image-guided approaches. Our paper aims at reviewing imaging strategies and their technological trends for PBT in thoracic lesions. The focus is on the use of imaging strategies in simulation, planning, positioning, adaptation, monitoring, and delivery of treatment and how changes in the anatomy of thoracic tumors are handled with the available tools and devices in PBT. Starting from bibliographic research over the past 5 years, retrieving 174 papers, major key questions, and implemented solutions were identified and discussed; the results aggregated and presented following the methodology of analysis of expert interviews.
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Affiliation(s)
- Carlo Algranati
- Proton Therapy Department, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale (DIMES), University of Bologna, Bologna, Italy
| | - Lidia Strigari
- Department of Medical Physics, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- *Correspondence: Lidia Strigari,
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Badiu V, Souris K, Buti G, Villarroel EB, Lambrecht M, Sterpin E. Improved healthy tissue sparing in proton therapy of lung tumors using statistically sound robust optimization and evaluation. Phys Med 2022; 96:62-69. [DOI: 10.1016/j.ejmp.2022.02.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 02/12/2022] [Accepted: 02/20/2022] [Indexed: 12/25/2022] Open
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Pakela JM, Knopf A, Dong L, Rucinski A, Zou W. Management of Motion and Anatomical Variations in Charged Particle Therapy: Past, Present, and Into the Future. Front Oncol 2022; 12:806153. [PMID: 35356213 PMCID: PMC8959592 DOI: 10.3389/fonc.2022.806153] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 02/04/2022] [Indexed: 12/14/2022] Open
Abstract
The major aim of radiation therapy is to provide curative or palliative treatment to cancerous malignancies while minimizing damage to healthy tissues. Charged particle radiotherapy utilizing carbon ions or protons is uniquely suited for this task due to its ability to achieve highly conformal dose distributions around the tumor volume. For these treatment modalities, uncertainties in the localization of patient anatomy due to inter- and intra-fractional motion present a heightened risk of undesired dose delivery. A diverse range of mitigation strategies have been developed and clinically implemented in various disease sites to monitor and correct for patient motion, but much work remains. This review provides an overview of current clinical practices for inter and intra-fractional motion management in charged particle therapy, including motion control, current imaging and motion tracking modalities, as well as treatment planning and delivery techniques. We also cover progress to date on emerging technologies including particle-based radiography imaging, novel treatment delivery methods such as tumor tracking and FLASH, and artificial intelligence and discuss their potential impact towards improving or increasing the challenge of motion mitigation in charged particle therapy.
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Affiliation(s)
- Julia M Pakela
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, United States
| | - Antje Knopf
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.,Department I of Internal Medicine, Center for Integrated Oncology Cologne, University Hospital of Cologne, Cologne, Germany
| | - Lei Dong
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, United States
| | - Antoni Rucinski
- Institute of Nuclear Physics, Polish Academy of Sciences, Krakow, Poland
| | - Wei Zou
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, United States
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Lebbink F, Stock M, Georg D, Knäusl B. The Influence of Motion on the Delivery Accuracy When Comparing Actively Scanned Carbon Ions versus Protons at a Synchrotron-Based Radiotherapy Facility. Cancers (Basel) 2022; 14:cancers14071788. [PMID: 35406558 PMCID: PMC8997550 DOI: 10.3390/cancers14071788] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/28/2022] [Accepted: 03/28/2022] [Indexed: 02/06/2023] Open
Abstract
Simple Summary The interplay of breathing and beam motion reduces the efficacy of particle irradiation in moving tumours. The effect of motion on protons and carbon ion treatments was investigated dosimetrically and the results were benchmarked against each other by employing an anthropomorphic thorax phantom that was able to simulate tumour, rib, and lung motion. The critical question was whether target coverage and organ-at-risk sparing could be maintained when the application of simple motion mitigation was addressed. Special focus was put on unique synchrotron characteristics, such as pulsed beam delivery and beam intensity variations. It could be demonstrated that the effect of motion was greater for carbon ions than for protons. These findings demonstrated the need for applying motion mitigation techniques depending on the motion amplitude, particle type, and treatment prescription considering complex time correlations. Abstract Motion amplitudes, in need of mitigation for moving targets irradiated with pulsed carbon ions and protons, were identified to guide the decision on treatment and motion mitigation strategy. Measurements with PinPoint ionisation chambers positioned in an anthropomorphic breathing phantom were acquired to investigate different tumour motion scenarios, including rib and lung movements. The effect of beam delivery dynamics and spot characteristics was considered. The dose in the tumour centre was deteriorated up to 10% for carbon ions but only up to 5% for protons. Dose deviations in the penumbra increased by a factor of two when comparing carbon ions to protons, ranging from 2 to 30% for an increasing motion amplitude that was strongly dependent on the beam intensity. Layer rescanning was able to diminish the dose distortion caused by tumour motion, but an increase in spot size could reduce it even further to 5% within the target and 10% at the penumbra. An increased need for motion mitigation of carbon ions compared to protons was identified to assure target coverage and sparing of adjacent organs at risk in the penumbra region and outside the target. For the clinical implementation of moving target treatments at a synchrotron-based particle facility complex, time dependencies needed to be considered.
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Affiliation(s)
- Franciska Lebbink
- MedAustron Ion Therapy Centre, Medical Physics, 2700 Wiener Neustadt, Austria; (F.L.); (M.S.)
- Department of Radiation Oncology, Medical University of Vienna, 1090 Vienna, Austria;
| | - Markus Stock
- MedAustron Ion Therapy Centre, Medical Physics, 2700 Wiener Neustadt, Austria; (F.L.); (M.S.)
| | - Dietmar Georg
- Department of Radiation Oncology, Medical University of Vienna, 1090 Vienna, Austria;
| | - Barbara Knäusl
- MedAustron Ion Therapy Centre, Medical Physics, 2700 Wiener Neustadt, Austria; (F.L.); (M.S.)
- Department of Radiation Oncology, Medical University of Vienna, 1090 Vienna, Austria;
- Correspondence:
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Hoppe BS, Nichols RC, Flampouri S, Pankuch M, Morris CG, Pham DC, Mohindra P, Hartsell WF, Mohammed N, Chon BH, Kestin LL, Simone CB. Chemoradiation with Hypofractionated Proton Therapy in Stage II-III Non-Small Cell Lung Cancer: A YYY Phase 1/2 Trial. Int J Radiat Oncol Biol Phys 2022; 113:732-741. [PMID: 35306151 DOI: 10.1016/j.ijrobp.2022.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 02/23/2022] [Accepted: 03/04/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Hypofractionated radiotherapy has been safely implemented into the treatment of early-stage non-small cell lung cancer (NSCLC), but not locally advanced (LA-) NSCLC due to prohibitive toxicities with photon therapy. Proton therapy, however, may allow for safe delivery of hypofractionated radiotherapy. We sought to determine whether hypofractionated proton therapy with concurrent chemotherapy improves overall survival. METHODS & MATERIALS The YYY conducted a phase 1/2 single-arm nonrandomized prospective multicenter trial from 2013 through 2018. Thirty-two patients were consented; 28 were eligible for on-study treatment. Patients had AJCCv7 stage II or III unresectable NSCLC and received hypofractionated proton therapy at 2.5-4 Gy per fraction to a total 60 Gy with concurrent platin-based doublet chemotherapy. The primary outcome was 1-year overall survival comparable to that reported for RTOG 9410 of 62%. RESULTS The trial closed early due to slow accrual, in part, from a competing trial, NRG 1308. Median patient age was 70 (range, 50-86) years. Patients were predominantly male (N=20), white (N=23), and prior smokers (N=27). Most had stage III NSCLC (N=22), 50% of whom had adenocarcinoma. After a median follow-up of 31 months, the 1- and 3-year overall survival rates were 89% and 49%, and progression-free survival rates were 58% and 32%, respectively. No acute grade 3 or higher esophagitis occurred. Only 14% developed a grade 3 or higher radiation-related pulmonary toxicity. CONCLUSION Hypofractionated proton therapy delivered at 2.5-3.53 Gy per fraction to a total 60 Gy with concurrent chemotherapy provides promising survival and additional examination through larger studies may be warranted.
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Affiliation(s)
- Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida.
| | - Romaine C Nichols
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Stella Flampouri
- Department of Radiation Oncology, Winship Cancer Institute at Emory University, Atlanta, Georgia
| | - Mark Pankuch
- Northwestern Medicine Proton Center, Warrenville, Illinois
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Dat C Pham
- Baptist MD Anderson Cancer Center, Jacksonville, Florida
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine and Maryland Proton Treatment Center, Baltimore, Maryland
| | | | | | - Brian H Chon
- ProCure Proton Therapy Center, Somerset, New Jersey
| | - Larry L Kestin
- MHP Radiation Oncology Institute/GenesisCare USA, Farmington Hills, Michigan
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center and New York Proton Center, New York, New York
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Substantial Sparing of Organs at Risk with Modern Proton Therapy in Lung Cancer, but Altered Breathing Patterns Can Jeopardize Target Coverage. Cancers (Basel) 2022; 14:cancers14061365. [PMID: 35326516 PMCID: PMC8945974 DOI: 10.3390/cancers14061365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/01/2022] [Accepted: 03/04/2022] [Indexed: 02/06/2023] Open
Abstract
Simple Summary Treatment of locally advanced non-small cell lung cancer (LA-NSCLC) is a fine balance between toxicity and cure. Modern proton therapy might offer a more gentle radiation treatment compared to state-of-the-art photon radiotherapy, but is also more susceptible to the influence of breathing motion and anatomical changes. In this study, the influence of such uncertainties on treatment delivery was thoroughly investigated. Modern proton therapy did indeed show potential to reduce the risk of toxicity for the heart and lungs. This potential was maintained under the influence of anatomical and delivery uncertainties. However, changes in breathing motion jeopardized the target dose distribution in a subset of patients. We therefore recommend imaging at onset or early in treatment to recognize these patients and adapt the treatment. Abstract Enhancing treatment of locally advanced non-small cell lung cancer (LA-NSCLC) by using pencil beam scanning proton therapy (PBS-PT) is attractive, but little knowledge exists on the effects of uncertainties occurring between the planning (Plan) and the start of treatment (Start). In this prospective simulation study, we investigated the clinical potential for PBS-PT under the influence of such uncertainties. Imaging with 4DCT at Plan and Start was carried out for 15 patients that received state-of-the-art intensity-modulated radiotherapy (IMRT). Three PBS-PT plans were created per patient: 3D robust single-field uniform dose (SFUD), 3D robust intensity-modulated proton therapy (IMPT), and 4D robust IMPT (4DIMPT). These were exposed to setup and range uncertainties and breathing motion at Plan, and changes in breathing motion and anatomy at Start. Target coverage and dose-volume parameters relevant for toxicity were compared. The organ at risk sparing at Plan was greatest with IMPT, followed by 4DIMPT, SFUD and IMRT, and persisted at Start. All plans met the preset criteria for target robustness at Plan. At Start, three patients had a lack of CTV coverage with PBS-PT. In conclusion, the clinical potential for heart and lung toxicity reduction with PBS-PT was substantial and persistent. Altered breathing patterns between Plan and Start jeopardized target coverage for all PBS-PT techniques.
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Rana S, Traneus E, Jackson M, Tran L, Rosenfeld AB. Quantitative analysis of dose-averaged linear energy transfer (LET d ) robustness in pencil beam scanning proton lung plans. Med Phys 2022; 49:3444-3456. [PMID: 35194809 DOI: 10.1002/mp.15569] [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: 10/04/2021] [Revised: 02/14/2022] [Accepted: 02/14/2022] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The primary objective of our study was to perform a quantitative robustness analysis of the dose-averaged linear energy transfer (LETd ) and related RBE-weighted dose in robustly optimized (in terms of the range and set up uncertainties) pencil beam scanning (PBS) proton lung cancer plans. METHODS In this study, we utilized the 4DCT data set of six anonymized lung patients. PBS lung plans were generated using a robust optimization technique (range uncertainty: ±3.5% and setup errors: ±5 mm) on the CTV for a total dose of 5000 cGy(RBE) in 5 fractions using RBE of 1.1. For each patient, the LETd distributions were calculated for the nominal plan and three groups. Group 1: two plan robustness scenarios for range uncertainties of ±3.5%; Group 2: twelve plan robustness scenarios (range uncertainty (±3.5%) in conjunction with setup errors (±5 mm)); and Group 3: ten different breathing phases of the 4DCT data set. RBE-weighted dose to the OARs was evaluated for all robustness scenarios and breathing phases. The variation (∆) in the mean LETd and mean RBE-weighted dose from each group was recorded. RESULTS The mean LETd in the CTV of nominal PBS lung plans among six patients ranged from 2.2 to 2.6 keV/μm. On average, for the combined range and setup uncertainties, the ∆ in the mean LETd among 12 scenarios of all six patients was 0.6 keV/μm, which is slightly higher than when only the range uncertainties were considered (0.4 keV/μm). The ∆ in the mean LETd in a patient was ≤1.7 keV/μm in the heart and ≤1.2 keV/μm in the esophagus and total lung. The ∆ in the mean RBE-weighted dose in a patient was up to 79 cGy for the total lung, 165 cGy for the heart, and 258 cGy for the esophagus. For ten breathing phases, the ∆ in the mean LETd in a patient was ≤0.3 keV/μm in the CTV, ≤0.5 keV/μm in the heart, ≤0.4 keV/μm in the esophagus, and ≤0.7 keV/μm in the total lung. CONCLUSION The addition of setup errors to the range uncertainties resulted in slightly less homogeneous LETd distributions. The variations in the mean LETd among ten breathing phases were slightly larger in the total lung than in the heart and esophagus. The combination of setup and range uncertainties had a greater impact than the effect of breathing phases on the variations in the mean RBE-weighted dose to the OARs. Overall, the LETd distributions in the CTV were less sensitive than those in the OARs to setup errors, range uncertainties, and breathing phases for robustly optimized PBS proton lung cancer plans. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Suresh Rana
- Department of Radiation Oncology, Lynn Cancer Institute, Boca Raton Regional Hospital, Baptist Health South Florida, Boca Raton, Florida, USA.,Department of Medical Physics, The Oklahoma Proton Center, Oklahoma City, Oklahoma, USA.,Centre for Medical Radiation Physics (CMRP), University of Wollongong, Wollongong, NSW, Australia
| | - Erik Traneus
- RaySearch Laboratories, Medical Physics, Stockholm, Sweden
| | - Michael Jackson
- Prince of Wales Hospital, Radiation Oncology, Randwick, Australia
| | - Linh Tran
- Centre for Medical Radiation Physics (CMRP), University of Wollongong, Wollongong, NSW, Australia
| | - Anatoly B Rosenfeld
- Centre for Medical Radiation Physics (CMRP), University of Wollongong, Wollongong, NSW, Australia
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Jia S, Chen J, Ma N, Zhao J, Mao J, Jiang G, Lu J, Wu K. Adaptive carbon ion radiotherapy for locally advanced non-small cell lung cancer: Organ-sparing potential and target coverage. Med Phys 2022; 49:3980-3989. [PMID: 35192194 PMCID: PMC9314958 DOI: 10.1002/mp.15563] [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: 10/21/2021] [Revised: 01/05/2022] [Accepted: 02/01/2022] [Indexed: 12/24/2022] Open
Abstract
Background The dose distribution of carbon ion radiotherapy (CIRT) for locally advanced non‐small cell lung cancer (LANSCLC) is highly sensitive to anatomical changes. Purpose To demonstrate the dosimetric benefits of adaptive CIRT for LANSCLC and compare the differences between patients with and without adaptive plans based on dosimetry and clinical effect factors. Materials and methods Of the 98 patients with LANSCLC receiving CIRT, 31 patients underwent replanning following re‐evaluations that revealed changes that would have compromised the dose coverage of the target volume or violated dose constraints. Dosimetric parameters and clinical factors were compared between patients with and without adaptive plans. Multivariate analysis identified factors influencing the adaptive planning. Results The median number of fractions delivered using adaptive plans was eight (range: 2‐18). Adaptive plans ensured target coverage, and the maximum spinal cord dose was significantly decreased (p = 0.02). The median reduction in the maximum spinal cord dose was 10.4 Gy (relative biological effectiveness). Patients with adaptive plans had larger tumor volumes (p < 0.001); the median initial internal gross tumor volumes (iGTVs) of patients with adaptive and nonadaptive plans were 125.9 and 49.79 cm3, respectively. Tumor volumes of patients with adaptive plans were altered to a greater extent (p < 0.001); the median absolute percentage of volume changes in patients in the adaptive and in nonadaptive groups were 20.76% and 3.63%, respectively, while the median movements of iGTV centers were 5.75 and 2.44 mm, respectively. Binary logistic regression analysis revealed that the iGTV volume change and iGTV center movements were significantly different between the groups. Conclusions An adaptive plan can effectively ensure target area coverage and protect normal tissues, especially in patients with large tumor volumes and substantial changes. iGTV volume changes and iGTV center movements are the main factors influencing adaptive planning. Weekly simulation computed tomography scans are necessary for treatment evaluation in patients with LANSCLC treated with CIRT.
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Affiliation(s)
- Shubing Jia
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Jian Chen
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, China.,Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China
| | - Ningyi Ma
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, China.,Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China
| | - Jingfang Zhao
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China.,Department of Medical Physics, Shanghai Proton and Heavy Ion Center, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Jingfang Mao
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Shanghai Cancer Center, Shanghai, China.,Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China
| | - Guoliang Jiang
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Shanghai Cancer Center, Shanghai, China.,Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China
| | - Jiade Lu
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, China.,Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China
| | - Kailiang Wu
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Shanghai Cancer Center, Shanghai, China.,Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China
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Li Y, Li X, Yang J, Wang S, Tang M, Xia J, Gao Y. Flourish of Proton and Carbon Ion Radiotherapy in China. Front Oncol 2022; 12:819905. [PMID: 35237518 PMCID: PMC8882681 DOI: 10.3389/fonc.2022.819905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/24/2022] [Indexed: 11/13/2022] Open
Abstract
Proton and heavy ion therapy offer superior relative biological effectiveness (RBE) in the treatment of deep-seated tumors compared with conventional photon radiotherapy due to its Bragg-peak feature of energy deposition in organs. Many proton and carbon ion therapy centers are active all over the world. At present, five particle radiotherapy institutes have been built and are receiving patient in China, mainly including Wanjie Proton Therapy Center (WPTC), Shanghai Proton Heavy Ion Center (SPHIC), Heavy Ion Cancer Treatment Center (HIMM), Chang Gung Memorial Hospital (CGMH), and Ruijin Hospital affiliated with Jiao Tong University. Many cancer patients have benefited from ion therapy, showing unique advantages over surgery and chemotherapy. By the end of 2020, nearly 8,000 patients had been treated with proton, carbon ion or carbon ion combined with proton therapy. So far, there is no systemic review for proton and carbon ion therapy facility and clinical outcome in China. We reviewed the development of proton and heavy ion therapy, as well as providing the representative clinical data and future directions for particle therapy in China. It has important guiding significance for the design and construction of new particle therapy center and patients’ choice of treatment equipment.
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Affiliation(s)
- Yue Li
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, China
- *Correspondence: Yue Li,
| | - Xiaoman Li
- Department of Radiation Medicine, School of Basic Medical Sciences, Peking University Health Science Center, Beijing, China
| | - Jiancheng Yang
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, China
| | - Sicheng Wang
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, China
| | - Meitang Tang
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, China
| | - Jiawen Xia
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, China
- Huizhou Research Center of Ion Science, Chinese Academy of Sciences, Huizhou, China
| | - Yunzhe Gao
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, China
- School of Nuclear Science and Technology, University of Chinese Academy of Sciences, Beijing, China
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Troost EGC, Menkel S, Tschiche M, Thiele J, Jaster M, Haak D, Kunath D. Towards online adaptive proton therapy: first report of plan-library-based plan-of-the-day approach. Acta Oncol 2022; 61:231-234. [PMID: 34697985 DOI: 10.1080/0284186x.2021.1994154] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- E. G. C. Troost
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Institute of Radiooncology – OncoRay, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; and Helmholtz Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - S. Menkel
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - M. Tschiche
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - J. Thiele
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - M. Jaster
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - D. Haak
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - D. Kunath
- OncoRay – National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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Technical challenges in the treatment of mediastinal lymphomas by proton pencil beam scanning and deep inspiration breath-hold. Radiother Oncol 2022; 169:43-50. [DOI: 10.1016/j.radonc.2022.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 02/08/2022] [Accepted: 02/14/2022] [Indexed: 11/18/2022]
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