1
|
Huang EY, Ho MW, Wang YM. Dosimetric Correlation of Acute Radiation Dermatitis in Patients With Breast Cancer Undergoing Hypofractionated Proton Beam Therapy Using Pencil Beam Scanning. J Breast Cancer 2024; 27:187-200. [PMID: 38769685 PMCID: PMC11221205 DOI: 10.4048/jbc.2024.0012] [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: 01/06/2024] [Revised: 02/24/2024] [Accepted: 03/31/2024] [Indexed: 05/22/2024] Open
Abstract
PURPOSE Pencil-beam scanning (PBS) is a modern delivery technique used in proton beam therapy (PBT) to reduce normal tissue reactions. No dosimetric correlation between dermatitis and PBS has been reported for breast cancer. The current study aimed to investigate the factors associated with grade 2 or higher dermatitis in patients with breast cancer undergoing PBT using PBS. METHODS The medical data of 42 patients with breast cancer who underwent adjuvant radiotherapy between December 2019 and September 2023 were reviewed. All patients received hypofractionated radiotherapy (HFRT), either 26 Gy (relative biological effectiveness [RBE])/five fractions or 40.05 or 43.5 Gy (RBE)/15 fractions, for the whole breast/chest wall with or without nodal irradiation. The duration of acute radiation dermatitis was defined as within 90 days from the start of radiotherapy. The Kaplan-Meier method and Cox proportional hazards model were used for univariate and multivariate analyses of the actuarial rates of grade 2-3 dermatitis. RESULTS Twenty-two (52.4%) and 20 (47.6%) patients were diagnosed with grade 1 and 2 dermatitis, respectively. Multivariate analysis revealed a clinical target volume (CTV) ≥ of 320 cc (p = 0.035) and a skin dose of D10cc ≥ 38.3 Gy (RBE) (p = 0.009) as independent factors of grade 2 dermatitis. The 10-week cumulative grade 2 dermatitis rates were 88.2%, 39.4%, and 8.3% (p < 0.001) for patients with both high, either high, and neither high CTV and D10cc, respectively. CONCLUSION To the best of our knowledge, this is the first study on dosimetric correlations for dermatitis in patients with breast cancer who underwent hypofractionated PBT using PBS. In the era of HFRT, skin dose modulation using PBS may reduce the incidence of dermatitis.
Collapse
Affiliation(s)
- Eng-Yen Huang
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Proton and Radiation Therapy Center, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital, School of Medicine, College of Medicine, National Sun Yat-Sen University, Kaohsiung, Taiwan
- School of Traditional Chinese Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Meng Wei Ho
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Proton and Radiation Therapy Center, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yu-Ming Wang
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Proton and Radiation Therapy Center, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital, School of Medicine, College of Medicine, National Sun Yat-Sen University, Kaohsiung, Taiwan
- School of Traditional Chinese Medicine, Chang Gung University, Taoyuan, Taiwan.
| |
Collapse
|
2
|
Bonaccorsi SG, Tessonnier T, Hoeltgen L, Meixner E, Harrabi S, Hörner-Rieber J, Haberer T, Abdollahi A, Debus J, Mairani A. Exploring Helium Ions' Potential for Post-Mastectomy Left-Sided Breast Cancer Radiotherapy. Cancers (Basel) 2024; 16:410. [PMID: 38254899 PMCID: PMC10814201 DOI: 10.3390/cancers16020410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/04/2024] [Accepted: 01/11/2024] [Indexed: 01/24/2024] Open
Abstract
Proton therapy presents a promising modality for treating left-sided breast cancer due to its unique dose distribution. Helium ions provide increased conformality thanks to a reduced lateral scattering. Consequently, the potential clinical benefit of both techniques was explored. An explorative treatment planning study involving ten patients, previously treated with VMAT (Volumetric Modulated Arc Therapy) for 50 Gy in 25 fractions for locally advanced, node-positive breast cancer, was carried out using proton pencil beam therapy with a fixed relative biological effectiveness (RBE) of 1.1 and helium therapy with a variable RBE described by the mMKM (modified microdosimetric kinetic model). Results indicated that target coverage was improved with particle therapy for both the clinical target volume and especially the internal mammary lymph nodes compared to VMAT. Median dose value analysis revealed that proton and helium plans provided lower dose on the left anterior descending artery (LAD), heart, lungs and right breast than VMAT. Notably, helium therapy exhibited improved ipsilateral lung sparing over protons. Employing NTCP models as available in the literature, helium therapy showed a lower probability of grade ≤ 2 radiation pneumonitis (22% for photons, 5% for protons and 2% for helium ions), while both proton and helium ions reduce the probability of major coronary events with respect to VMAT.
Collapse
Affiliation(s)
| | - Thomas Tessonnier
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- Division of Molecular and Translational Radiation Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Line Hoeltgen
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Eva Meixner
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Semi Harrabi
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Thomas Haberer
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Amir Abdollahi
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- Division of Molecular and Translational Radiation Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK), 69120 Heidelberg, Germany
| | - Jürgen Debus
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK), 69120 Heidelberg, Germany
| | - Andrea Mairani
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- Division of Molecular and Translational Radiation Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- Centro Nazionale di Adroterapia Oncologica (CNAO), 27100 Pavia, Italy
| |
Collapse
|
3
|
Rudigkeit S, Schmid TE, Dombrowsky AC, Stolz J, Bartzsch S, Chen CB, Matejka N, Sammer M, Bergmaier A, Dollinger G, Reindl J. Proton-FLASH: effects of ultra-high dose rate irradiation on an in-vivo mouse ear model. Sci Rep 2024; 14:1418. [PMID: 38228747 PMCID: PMC10791610 DOI: 10.1038/s41598-024-51951-6] [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: 06/23/2023] [Accepted: 01/11/2024] [Indexed: 01/18/2024] Open
Abstract
FLASH-radiotherapy may provide significant sparing of healthy tissue through ultra-high dose rates in protons, electrons, and x-rays while maintaining the tumor control. Key factors for the FLASH effect might be oxygen depletion, the immune system, and the irradiated blood volume, but none could be fully confirmed yet. Therefore, further investigations are necessary. We investigated the protective (tissue sparing) effect of FLASH in proton treatment using an in-vivo mouse ear model. The right ears of Balb/c mice were irradiated with 20 MeV protons at the ion microprobe SNAKE in Garching near Munich by using three dose rates (Conv = 0.06 Gy/s, Flash9 = 9.3 Gy/s and Flash930 = 930 Gy/s) at a total dose of 23 Gy or 33 Gy. The ear thickness, desquamation, and erythema combined in an inflammation score were measured for 180 days. The cytokines TGF-β1, TNF-α, IL1α, and IL1β were analyzed in the blood sampled in the first 4 weeks and at termination day. No differences in inflammation reactions were visible in the 23 Gy group for the different dose rates. In the 33 Gy group, the ear swelling and the inflammation score for Flash9 was reduced by (57 ± 12) % and (67 ± 17) % and for Flash930 by (40 ± 13) % and (50 ± 17) % compared to the Conv dose rate. No changes in the cytokines in the blood could be measured. However, an estimation of the irradiated blood volume demonstrates, that 100-times more blood is irradiated when using Conv compared to using Flash9 or Flash930. This indicates that blood might play a role in the underlying mechanisms in the protective effect of FLASH.
Collapse
Affiliation(s)
- Sarah Rudigkeit
- Institute of Applied Physics and Measurement Technologies, Universität der Bundeswehr München, Neubiberg, Germany
| | - Thomas E Schmid
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Neuherberg, Germany
- Department of Radiooncology, School of Medicine, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Annique C Dombrowsky
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Neuherberg, Germany
| | - Jessica Stolz
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Neuherberg, Germany
| | - Stefan Bartzsch
- Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Neuherberg, Germany
- Department of Radiooncology, School of Medicine, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Ce-Belle Chen
- Centre for Ion Beam Applications, Department of Physics, National University of Singapore, Singapore, Singapore
- Singapore Synchrotron Light Source, National University of Singapore, Singapore, Singapore
| | - Nicole Matejka
- Institute of Applied Physics and Measurement Technologies, Universität der Bundeswehr München, Neubiberg, Germany
| | - Matthias Sammer
- Institute of Applied Physics and Measurement Technologies, Universität der Bundeswehr München, Neubiberg, Germany
| | - Andreas Bergmaier
- Institute of Applied Physics and Measurement Technologies, Universität der Bundeswehr München, Neubiberg, Germany
| | - Günther Dollinger
- Institute of Applied Physics and Measurement Technologies, Universität der Bundeswehr München, Neubiberg, Germany
| | - Judith Reindl
- Institute of Applied Physics and Measurement Technologies, Universität der Bundeswehr München, Neubiberg, Germany.
| |
Collapse
|
4
|
Wu XY, Chen M, Cao L, Li M, Chen JY. Proton Therapy in Breast Cancer: A Review of Potential Approaches for Patient Selection. Technol Cancer Res Treat 2024; 23:15330338241234788. [PMID: 38389426 PMCID: PMC10894553 DOI: 10.1177/15330338241234788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/25/2023] [Accepted: 02/06/2024] [Indexed: 02/24/2024] Open
Abstract
Proton radiotherapy may be a compelling technical option for the treatment of breast cancer due to its unique physical property known as the "Bragg peak." This feature offers distinct advantages, promising superior dose conformity within the tumor area and reduced radiation exposure to surrounding healthy tissues, enhancing the potential for better treatment outcomes. However, proton therapy is accompanied by inherent challenges, primarily higher costs and limited accessibility when compared to well-developed photon irradiation. Thus, in clinical practice, it is important for radiation oncologists to carefully select patients before recommendation of proton therapy to ensure the transformation of dosimetric benefits into tangible clinical benefits. Yet, the optimal indications for proton therapy in breast cancer patients remain uncertain. While there is no widely recognized methodology for patient selection, numerous attempts have been made in this direction. In this review, we intended to present an inspiring summarization and discussion about the current practices and exploration on the approaches of this treatment decision-making process in terms of treatment-related side-effects, tumor control, and cost-efficiency, including the normal tissue complication probability (NTCP) model, the tumor control probability (TCP) model, genomic biomarkers, cost-effectiveness analyses (CEAs), and so on. Additionally, we conducted an evaluation of the eligibility criteria in ongoing randomized controlled trials and analyzed their reference value in patient selection. We evaluated the pros and cons of various potential patient selection approaches and proposed possible directions for further optimization and exploration. In summary, while proton therapy holds significant promise in breast cancer treatment, its integration into clinical practice calls for a thoughtful, evidence-driven strategy. By continuously refining the patient selection criteria, we can harness the full potential of proton radiotherapy while ensuring maximum benefit for breast cancer patients.
Collapse
Affiliation(s)
- Xiao-Yu Wu
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Mei Chen
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Lu Cao
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Min Li
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Jia-Yi Chen
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| |
Collapse
|
5
|
Chang CL, Lin KC, Chen WM, Shia BC, Wu SY. Comparative Effectiveness of Intensity-Modulated Proton Therapy Versus Intensity-Modulated Radiotherapy for Patients With Inoperable Esophageal Squamous Cell Carcinoma Undergoing Curative-Intent Concurrent Chemoradiotherapy. J Thorac Oncol 2023:S1556-0864(23)02430-9. [PMID: 38154513 DOI: 10.1016/j.jtho.2023.12.021] [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: 09/25/2023] [Revised: 12/13/2023] [Accepted: 12/16/2023] [Indexed: 12/30/2023]
Abstract
INTRODUCTION This study compared outcomes in patients with inoperable esophageal squamous cell carcinoma (ESCC) undergoing curative-intent concurrent chemoradiotherapy (CCRT) with intensity-modulated radiotherapy (IMRT) versus intensity-modulated proton therapy (IMPT). METHODS The study encompassed a retrospective cohort analysis of patients with inoperable ESCC who underwent curative-intent CCRT from January 1, 2015, to December 31, 2020, with data sourced from the Taiwan Cancer Registry Database. In this study, both IMRT and IMPT delivered a total equivalent effective dose of approximately 5040 cGy in 28 fractions, accompanied by platinum-based chemotherapy administered as per established protocols. Multivariate Cox regression analyses were performed to assess oncologic outcomes, and statistical analyses were conducted, including inverse probability of treatment-weighted and Fine and Gray method for competing risks. RESULTS The observed risks of ESCC-specific and all-cause mortality were lower in patients treated with IMPT compared with those treated with IMRT, with adjusted hazard ratios (aHRs) of 0.62 (95% confidence interval [CI]: 0.58-0.70) and 0.72 (95% CI: 0.66-0.80), respectively. IMPT also reduced grade 2 radiation-induced side effects, such as pneumonitis, fatigue, and major adverse cardiovascular events, with aHRs (95% CI) of 0.76 (0.66-0.82), 0.10 (0.07-0.14), and 0.70 (0.67-0.73), respectively. However, IMPT was associated with an increased risk of grade 2 radiation dermatitis, with aHR (95% CI) of 1.48 (1.36-1.60). No substantial differences were found in the incidence of radiation esophagitis between IMPT and IMRT when adjusting for covariates. CONCLUSION IMPT seems to be associated with superiority over IMRT in managing patients with inoperable ESCC undergoing curative-intent CCRT, suggesting improved survival outcomes and reduced toxicity. These findings have significant implications for the treatment of ESCC, particularly when surgery is not an option.
Collapse
Affiliation(s)
- Chia-Lun Chang
- Department of Hemato-Oncology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Kuan-Chou Lin
- Division of Oral and Maxillofacial Surgery, Department of Dentistry, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; School of Dentistry, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Wan-Ming Chen
- Graduate Institute of Business Administration, College of Management, Fu Jen Catholic University, Taipei, Taiwan; Artificial Intelligence Development Center, Fu Jen Catholic University, Taipei, Taiwan
| | - Ben-Chang Shia
- Graduate Institute of Business Administration, College of Management, Fu Jen Catholic University, Taipei, Taiwan; Artificial Intelligence Development Center, Fu Jen Catholic University, Taipei, Taiwan
| | - Szu-Yuan Wu
- Graduate Institute of Business Administration, College of Management, Fu Jen Catholic University, Taipei, Taiwan; Artificial Intelligence Development Center, Fu Jen Catholic University, Taipei, Taiwan; Department of Food Nutrition and Health Biotechnology, College of Medical and Health Science, Asia University, Taichung, Taiwan; Division of Radiation Oncology, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan, Taiwan; Big Data Center, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan, Taiwan; Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan; Cancer Center, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan, Taiwan; Centers for Regional Anesthesia and Pain Medicine, Taipei Municipal Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Department of Management, College of Management, Fo Guang University, Yilan, Taiwan.
| |
Collapse
|
6
|
Kang Y, Bues M, Halyard MY, McGee LA, Vern-Gross TZ, Wong WW, Keole SR, Vargas C, James SE, Ahmed SK, Archuleta JP, Ridgway AK, Lara PR, Fatyga M. Dose delivery reproducibility for PBS proton treatment of breast cancer patients with and without mask immobilization. Radiat Oncol 2023; 18:157. [PMID: 37736727 PMCID: PMC10515054 DOI: 10.1186/s13014-023-02323-3] [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: 06/29/2023] [Accepted: 07/10/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Setup reproducibility of the tissue in the proton beam path is critical in maintaining the planned clinical target volume (CTV) dose coverage and sparing the organs at risk (OAR). In this study, we retrospectively evaluated radiation therapy dose reproducibility for proton pencil beam scanning (PBS) treatment of breast cancer patients with and without mask immobilization. METHODS Ninety-four patients treated between January 2019 and September 2022 with at least one verification CT scan (V-CT) in treatment position were included for this study. All patients were set up with arms up using the Orfit AIO patient positioning system, with (69 patients) or without (25 patients) mask immobilization in chin, neck, shoulder, upper arm, and chest areas. Two to three enface or near enface single field uniform dose PBS beams were optimized using a commercial treatment planning system. Prescription doses were 25 to 60 GyRBE in 5 to 45 fractions. Treatment plan doses re-calculated on V-CTs were compared to the corresponding planned doses. Cumulative doses were also calculated for patients with at least 3 V-CTs by deform and weighted sum doses from V-CTs to corresponding P-CTs. CTV D95%, ipsilateral-lung V40%, esophagus D0.01cc, and heart mean dose were evaluated and reported as percentages of prescription doses. Differences were large dose deteriorations (LDD) if: (1) CTV (V-CT/cumulative D95%) - (Planned D95%) < - 5%; or (2) Ipsilateral-lung (V-CT/cumulative V40%) - (Planned V40%) > 5%; or (3) Esophagus (V-CT/cumulative D0.01cc) - (Planned D0.01cc) > 10%; or (4) Heart (V-CT/cumulative mean) - (Planned mean) > 1.5%. RESULTS On average, V-CT/cumulative and planned CTV/OAR dose parameter differences were less than 2.2%/1.7% and 3.4%/3.7% for masked and maskless patients, respectively. The percentages of patients with at least one CTV or OAR V-CT/cumulative dose LDD were 20.3%/25.0% and 72.0%/54.0% for masked and maskless patients, respectively. CONCLUSIONS On average, masked/maskless setups achieved delivered and planned CTV/OAR dose parameters agreed within 2.2%/3.7% for PBS treatment of breast cancer patients in this study. Maskless patients had higher rate of CTV/OAR LDDs compared to masked patients. Dosimetric differences large enough to raise clinical concerns in either group were able to be addressed with replannings.
Collapse
Affiliation(s)
- Yixiu Kang
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA.
| | - Martin Bues
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Michele Y Halyard
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Tamara Z Vern-Gross
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - William W Wong
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Sameer R Keole
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Carlos Vargas
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Sarah E James
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Safia K Ahmed
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - James P Archuleta
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Ana K Ridgway
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Pedro R Lara
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Mirek Fatyga
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| |
Collapse
|
7
|
Kirby AM, Holt F, Taylor CW, Haviland JS, MacKenzie M, Coles CE. Should patients requiring radiotherapy for breast cancer be treated with proton beam therapy? BMJ 2023; 381:e072896. [PMID: 37295798 DOI: 10.1136/bmj-2022-072896] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Anna M Kirby
- Royal Marsden NHS Foundation Trust & Institute of Cancer Research, Sutton, UK
| | - Francesca Holt
- Nuffield Department of Population Health, University of Oxford, UK
| | - Carolyn W Taylor
- Nuffield Department of Population Health, University of Oxford, UK
| | - Joanne S Haviland
- Centre for Evaluation and Methods, Wolfson Institute of Population Health, Queen Mary University of London, UK
| | | | | |
Collapse
|
8
|
Nangia S, Burela N, Noufal MP, Patro K, Wakde MG, Sharma DS. Proton therapy for reducing heart and cardiac substructure doses in Indian breast cancer patients. Radiat Oncol J 2023; 41:69-80. [PMID: 37403349 DOI: 10.3857/roj.2023.00073] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/10/2023] [Indexed: 07/06/2023] Open
Abstract
PURPOSE Indians have a higher incidence of cardiovascular diseases, often at a younger age, than other ethnic groups. This higher baseline risk requires consideration when assessing additional cardiac morbidity of breast cancer treatment. Superior cardiac sparing is a critical dosimetric advantage of proton therapy in breast cancer radiotherapy. We report here the heart and cardiac-substructure doses and early toxicities in breast cancer patients treated post-operatively with proton therapy in India's first proton therapy center. MATERIALS AND METHODS We treated twenty breast cancer patients with intensity-modulated proton therapy (IMPT) from October 2019 to September 2022, eleven after breast conservation, nine following mastectomy, and appropriate systemic therapy, when indicated. The most prescribed dose was 40 GyE to the whole breast/chest wall and 48 GyE by simultaneous integrated boost to the tumor bed and 37.5 GyE to appropriate nodal volumes, delivered in 15 fractions. RESULTS Adequate coverage was achieved for clinical target volume (breast/chest wall), i.e., CTV40, and regional nodes, with 99% of the targets receiving 95% of the prescribed dose (V95% > 99%). The mean heart dose was 0.78 GyE and 0.87 GyE for all and left breast cancer patients, respectively. The mean left anterior descending artery (LAD) dose, LAD D0.02cc, and left ventricle dose were 2.76, 6.46, and 0.2 GyE, respectively. Mean ipsilateral lung dose, V20Gy, V5Gy, and contralateral breast dose (Dmean) were 6.87 GyE, 14.6%, 36.4%, and 0.38 GyE, respectively. CONCLUSION The dose to heart and cardiac substructures is lower with IMPT than published photon therapy data. Despite the limited access to proton therapy at present, given the higher cardiovascular risk and coronary artery disease prevalence in India, the cardiac sparing achieved using this technique merits consideration for wider adoption in breast cancer treatment.
Collapse
Affiliation(s)
- Sapna Nangia
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - Nagarjuna Burela
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - M P Noufal
- Department of Medical Physics, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - Kartikeswar Patro
- Department of Medical Physics, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - Manoj Gulabrao Wakde
- Department of Medical Physics, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - Dayanada S Sharma
- Department of Medical Physics, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| |
Collapse
|
9
|
Chen Z, Dominello MM, Joiner MC, Burmeister JW. Proton versus photon radiation therapy: A clinical review. Front Oncol 2023; 13:1133909. [PMID: 37064131 PMCID: PMC10091462 DOI: 10.3389/fonc.2023.1133909] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 03/13/2023] [Indexed: 03/31/2023] Open
Abstract
While proton radiation therapy offers substantially better dose distribution characteristics than photon radiation therapy in certain clinical applications, data demonstrating a quantifiable clinical advantage is still needed for many treatment sites. Unfortunately, the number of patients treated with proton radiation therapy is still comparatively small, in some part due to the lack of evidence of clear benefits over lower-cost photon-based treatments. This review is designed to present the comparative clinical outcomes between proton and photon therapies, and to provide an overview of the current state of knowledge regarding the effectiveness of proton radiation therapy.
Collapse
Affiliation(s)
- Zhe Chen
- School of Medicine, Wayne State University, Detroit, MI, United States
- *Correspondence: Zhe Chen,
| | - Michael M. Dominello
- Karmanos Cancer Institute, Department of Oncology, Wayne State University School of Medicine, Detroit, MI, United States
| | - Michael C. Joiner
- Karmanos Cancer Institute, Department of Oncology, Wayne State University School of Medicine, Detroit, MI, United States
| | - Jay W. Burmeister
- Karmanos Cancer Institute, Department of Oncology, Wayne State University School of Medicine, Detroit, MI, United States
| |
Collapse
|
10
|
Absolute dosimetry for FLASH proton pencil beam scanning radiotherapy. Sci Rep 2023; 13:2054. [PMID: 36739297 PMCID: PMC9899251 DOI: 10.1038/s41598-023-28192-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 01/13/2023] [Indexed: 02/05/2023] Open
Abstract
A paradigm shift is occurring in clinical oncology exploiting the recent discovery that short pulses of ultra-high dose rate (UHDR) radiation-FLASH radiotherapy-can significantly spare healthy tissues whilst still being at least as effective in curing cancer as radiotherapy at conventional dose rates. These properties promise reduced post-treatment complications, whilst improving patient access to proton beam radiotherapy and reducing costs. However, accurate dosimetry at UHDR is extremely complicated. This work presents measurements performed with a primary-standard proton calorimeter and derivation of the required correction factors needed to determine absolute dose for FLASH proton beam radiotherapy with an uncertainty of 0.9% (1[Formula: see text]), in line with that of conventional treatments. The establishment of a primary standard for FLASH proton radiotherapy improves accuracy and consistency of the dose delivered and is crucial for the safe implementation of clinical trials, and beyond, for this new treatment modality.
Collapse
|
11
|
Laughlin BS, Bhangoo RS, Niska JR, Thorpe CS, Girardo ME, Anderson JD, Kosiorek HE, McGee LA, Hartsell WF, Chang JH, Rossi CJ, Tsai HK, Choi IJ, Vargas CE. Proton therapy for isolated local regional recurrence of breast cancer after mastectomy alone. Front Oncol 2022; 12:925078. [DOI: 10.3389/fonc.2022.925078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 11/10/2022] [Indexed: 11/29/2022] Open
Abstract
Purpose/ObjectivesTo assess adverse events (AEs) and disease-specific outcomes after proton therapy for isolated local-regional recurrence (LRR) of breast cancer after mastectomy without prior radiotherapy (RT).Materials/MethodsPatients were identified from a multi-institutional prospective registry and included if diagnosed with invasive breast cancer, initially underwent mastectomy without adjuvant RT, experienced an LRR, and subsequently underwent salvage treatment, including proton therapy. Follow-up and cancer outcomes were measured from the date of RT completion.ResultsNineteen patients were included. Seventeen patients were treated with proton therapy to the chest wall and comprehensive regional lymphatics (17/19, 90%). Maximum grade AE was grade 2 in 13 (69%) patients and grade 3 in 4 (21%) patients. All patients with grade 3 AE received > 60 GyE (p=0.04, Spearman correlation coefficient=0.5). At the last follow-up, 90% of patients were alive with no LRR or distant recurrence.ConclusionsFor breast cancer patients with isolated LRR after initial mastectomy without adjuvant RT, proton therapy is well-tolerated in the salvage setting with excellent loco-regional control. All grade 3 AEs occurred in patients receiving > 60 GyE.
Collapse
|
12
|
Dosimetric Parameters Related to Acute Radiation Dermatitis of Patients with Nasopharyngeal Carcinoma Treated by Intensity-Modulated Proton Therapy. J Pers Med 2022; 12:jpm12071095. [PMID: 35887590 PMCID: PMC9318665 DOI: 10.3390/jpm12071095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/25/2022] [Accepted: 06/29/2022] [Indexed: 12/08/2022] Open
Abstract
Background: Growing patients with nasopharyngeal carcinoma (NPC) were treated with intensity-modulated proton therapy (IMPT). However, a high probability of severe acute radiation dermatitis (ARD) was observed. The objective of the study is to investigate the dosimetric parameters related to ARD for NPC patients treated with IMPT. Methods: Sixty-two patients with newly diagnosed NPC were analyzed. The ARD was recorded based on the criteria of Common Terminology Criteria for Adverse Events version 4.0. Logistic regression model was performed to identify the clinical and dosimetric parameters related to ARD. Receiver operating characteristic (ROC) curve analysis and the area under the curve (AUC) were used to evaluate the performance of the models. Results: The maximum ARD grade was 1, 2, and 3 in 27 (43.5%), 26 (42.0%), and 9 (14.5%) of the patients, respectively. Statistically significant differences (p < 0.01) in average volume to skin 5 mm with the respective doses were observed in the range 54−62 Cobalt Gray Equivalent (CGE) for grade 2 and 3 versus grade 1 ARD. Smoking habit and N2-N3 status were identified as significant predictors to develop grade 2 and 3 ARD in clinical model, and V58CGE to skin 5 mm as an independent predictor in dosimetric model. After adding the variable of V58CGE to the metric incorporating two parameters of smoking habit and N status, the AUC value of the metric increases from 0.78 (0.66−0.90) to 0.82 (0.72−0.93). The most appropriate cut-off value of V58CGE to skin 5 mm as determined by ROC curve was 5.0 cm3, with a predicted probability of 54% to develop grade 2 and 3 ARD. Conclusion: The dosimetric parameter of V58CGE to skin 5 mm < 5.0 cm3 could be used as a constraint in treatment planning for NPC patients treated by IMPT.
Collapse
|
13
|
Nuyts S, Bollen H, Ng SP, Corry J, Eisbruch A, Mendenhall WM, Smee R, Strojan P, Ng WT, Ferlito A. Proton Therapy for Squamous Cell Carcinoma of the Head and Neck: Early Clinical Experience and Current Challenges. Cancers (Basel) 2022; 14:cancers14112587. [PMID: 35681568 PMCID: PMC9179360 DOI: 10.3390/cancers14112587] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 05/18/2022] [Accepted: 05/20/2022] [Indexed: 11/19/2022] Open
Abstract
Simple Summary Proton therapy is a promising type of radiation therapy used to destroy tumor cells. It has the potential to further improve the outcomes for patients with head and neck cancer since it allows to minimize the radiation dose to vital structures around the tumor, leading to less toxicity. This paper describes the current experience worldwide with proton therapy in head and neck cancer. Abstract Proton therapy (PT) is a promising development in radiation oncology, with the potential to further improve outcomes for patients with squamous cell carcinoma of the head and neck (HNSCC). By utilizing the finite range of protons, healthy tissue can be spared from beam exit doses that would otherwise be irradiated with photon-based treatments. Current evidence on PT for HNSCC is limited to comparative dosimetric analyses and retrospective single-institution series. As a consequence, the recognized indications for the reimbursement of PT remain scarce in most countries. Nevertheless, approximately 100 PT centers are in operation worldwide, and initial experiences for HNSCC are being reported. This review aims to summarize the results of the early clinical experience with PT for HNSCC and the challenges that are currently faced.
Collapse
Affiliation(s)
- Sandra Nuyts
- Laboratory of Experimental Radiotherapy, Department of Oncology, Katholieke Universiteit Leuven, 3000 Leuven, Belgium;
- Department of Oncology, Leuven Cancer Institute, Universitair Ziekenhuis Leuven, 3000 Leuven, Belgium
- Correspondence:
| | - Heleen Bollen
- Laboratory of Experimental Radiotherapy, Department of Oncology, Katholieke Universiteit Leuven, 3000 Leuven, Belgium;
- Department of Oncology, Leuven Cancer Institute, Universitair Ziekenhuis Leuven, 3000 Leuven, Belgium
| | - Sweet Ping Ng
- Department of Radiation Oncology, Austin Health, The University of Melbourne, Melbourne, VIC 3000, Australia;
| | - June Corry
- Division of Medicine, Department of Radiation Oncology, St. Vincent’s Hospital, The University of Melbourne, Melbourne, VIC 3000, Australia;
| | - Avraham Eisbruch
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI 48109, USA;
| | - William M Mendenhall
- Department of Radiation Oncology, College of Medicine, University of Florida, Gainesville, FL 32209, USA;
| | - Robert Smee
- Department of Radiation Oncology, The Prince of Wales Cancer Centre, Sydney, NSW 2031, Australia;
| | - Primoz Strojan
- Department of Radiation Oncology, Institute of Oncology, University of Ljubljana, 1000 Ljubljana, Slovenia;
| | - Wai Tong Ng
- Department of Clinical Oncology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China;
| | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group, 35125 Padua, Italy;
| |
Collapse
|
14
|
Bogers S, Petoukhova A, Penninkhof J, Mast M, Poortmans P, Hoogeman M, Struikmans H. Target Volume Coverage and Organ at Risk Doses for Left-sided Whole-breast Irradiation With or Without Internal Mammary Chain Irradiation: A Comparison Between Three Techniques Representing the Past and the Present. Clin Oncol (R Coll Radiol) 2022; 34:537-544. [DOI: 10.1016/j.clon.2022.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 02/24/2022] [Accepted: 04/06/2022] [Indexed: 11/03/2022]
|
15
|
Garda AE, Hunzeker AE, Michel AK, Fattahi S, Shiraishi S, Remmes NB, Schultz HL, Harmsen WS, Shumway DA, Yan ES, Park SS, Mutter RW, Corbin KS. Intensity Modulated Proton Therapy for Bilateral Breast or Chest Wall and Comprehensive Nodal Irradiation for Synchronous Bilateral Breast Cancer: Initial Clinical Experience and Dosimetric Comparison. Adv Radiat Oncol 2022; 7:100901. [PMID: 35647397 PMCID: PMC9133394 DOI: 10.1016/j.adro.2022.100901] [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: 08/04/2021] [Accepted: 01/09/2022] [Indexed: 12/14/2022] Open
Abstract
Purpose Synchronous bilateral breast cancer (SBBC) poses distinct challenges for radiation therapy planning. We report our proton therapy experience in treating patients with SBBC. We also provide a dosimetric comparison of intensity modulated proton therapy (IMPT) versus photon therapy. Methods and Materials Patients with SBBC who received IMPT at our institution were retrospectively analyzed. The clinical target volume (CTV) included the breast or chest wall and comprehensive regional lymph nodes, including axilla, supraclavicular fossa, and the internal mammary chain. Intensity modulated proton therapy and volumetric modulated arc therapy (VMAT) plans were generated with the goal that 90% of the CTV would recieve at least 90% of the prescription dose (D90>=90%). Comparisons between modalities were made using the Wilcoxon signed rank test. Physician-reported acute toxic effects and photography were collected at baseline, end of treatment, and each follow-up visit. Results Between 2015 and 2018, 11 patients with SBBC were treated with IMPT. The prescription was 50 Gy in 25 fractions. The median CTV D90 was 99.9% for IMPT and 97.6% for VMAT (P = .001). The mean heart dose was 0.7 Gy versus 7.2 Gy (P = .001), the total lung mean dose was 7.8 Gy versus 17.3 Gy (P = .001), and the total lung volume recieving 20 Gy was 13.0% versus 27.4% (P = .001). The most common acute toxic effects were dermatitis (mostly grade 1-2 with 1 case of grade 3) and grade 1 to 2 fatigue. The most common toxic effects at the last-follow up (median, 32 months) were grade 1 skin hyperpigmentation, superficial fibrosis, and extremity lymphedema. No nondermatologic or nonfatigue adverse events of grade >1 were recorded. Conclusions Bilateral breast and/or chest wall and comprehensive nodal IMPT is technically feasible and associated with low rates of severe acute toxic effects. Treatment with IMPT offered improved target coverage and normal-tissue sparing compared with photon therapy. Long-term follow-up is ongoing to assess efficacy and toxic effects.
Collapse
Affiliation(s)
- Allison E. Garda
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Ann K. Michel
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Sayeh Fattahi
- Mayo Clinic Alix School of Medicine, Rochester, Minnesota
| | - Satomi Shiraishi
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | | | - W. Scott Harmsen
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Dean A. Shumway
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth S. Yan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Sean S. Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Robert W. Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | |
Collapse
|
16
|
Proton therapy for the treatment of inflammatory breast cancer. Radiother Oncol 2022; 171:77-83. [DOI: 10.1016/j.radonc.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 04/07/2022] [Accepted: 04/08/2022] [Indexed: 11/24/2022]
|
17
|
Banfield W, Ioakeim-Ioannidou M, Goldberg S, Ahmed S, Schwab J, Cote G, Choy E, Shin J, Hornicek F, Liebsch N, Chen Y, MacDonald SM, DeLaney T. Definitive high-dose, proton-based radiation for unresected mobile spine and sacral chordomas. Radiother Oncol 2022; 171:139-145. [DOI: 10.1016/j.radonc.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 03/18/2022] [Accepted: 04/06/2022] [Indexed: 10/18/2022]
|
18
|
A pilot study of a novel method to visualize three-dimensional dose distribution on skin surface images to evaluate radiation dermatitis. Sci Rep 2022; 12:2729. [PMID: 35177737 PMCID: PMC8854641 DOI: 10.1038/s41598-022-06713-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 01/27/2022] [Indexed: 11/09/2022] Open
Abstract
Predicting the radiation dose‒toxicity relationship is important for local tumor control and patients’ quality of life. We developed a first intuitive evaluation system that directly matches the three-dimensional (3D) dose distribution with the skin surface image of patients with radiation dermatitis (RD) to predict RD in patients undergoing radiotherapy. Using an RGB-D camera, 82 3D skin surface images (3DSSIs) were acquired from 19 patients who underwent radiotherapy. 3DSSI data acquired included 3D skin surface shape and optical imaging of the area where RD occurs. Surface registration between 3D skin dose (3DSD) and 3DSSI is performed using the iterative closest point algorithm, then reconstructed as a two-dimensional color image. The developed system successfully matched 3DSSI and 3DSD, and visualized the planned dose distribution onto the patient's RD image. The dose distribution pattern was consistent with the occurrence pattern of RD. This new approach facilitated the evaluation of the direct correlation between skin-dose distribution and RD and, therefore, provides a potential to predict the probability of RD and thereby decrease RD severity by enabling informed treatment decision making by physicians. However, the results need to be interpreted with caution due to the small sample size.
Collapse
|
19
|
Fuglsang Jensen M, Stick LB, Høyer M, Kronborg CJS, Lorenzen EL, Mortensen HR, Nyström PW, Petersen SE, Randers P, Thai LMH, Yates ES, Offersen BV. Proton therapy for early breast cancer patients in the DBCG proton trial: planning, adaptation, and clinical experience from the first 43 patients. Acta Oncol 2022; 61:223-230. [PMID: 34632922 DOI: 10.1080/0284186x.2021.1986229] [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] [Indexed: 12/14/2022]
Abstract
BACKGROUND The Danish Breast Cancer Group (DBCG) Proton Trial randomizes breast cancer patients selected on high mean heart dose (MHD) or high lung dose (V20Gy/V17Gy) in the photon plan between photon and proton therapy. This study presents the proton plans and adaptation strategy for the first 43 breast cancer patients treated with protons in Denmark. MATERIAL AND METHODS Forty-four proton plans (one patient with bilateral cancer) were included; 2 local and 42 loco-regional including internal mammary nodes (IMN). Nineteen patients had a mastectomy and 25 a lumpectomy. The prescribed dose was either 50 Gy in 25 fractions (n = 30) or 40 Gy in 15 fractions (n = 14) wherefrom five received simultaneous integrated boost to the tumor bed. Using 2-3 en face proton fields, single-field optimization, robust optimization and a 5 cm range shifter ensured robustness towards breathing motion, setup- and range uncertainties. An anatomical evaluation was performed by evaluating the dose after adding/removing 3 mm and 5 mm tissue to/from the body-outline and used to define treatment tolerances for anatomical changes. RESULTS The nominal and robust criteria were met for all patients except two. The median MHD was 1.5 Gy (0.5-3.4 Gy, 50 Gy) and 1.1 Gy (0.0-1.5 Gy, 40 Gy). The anatomical evaluations showed how 5 mm shrinkage approximately doubled the MHD while 5 mm swelling reduced target coverage of the IMN below constraints. Ensuring 3-5 mm robustness toward swelling was prioritized but not always achieved by robust optimization alone emphasizing the need for a distal margin. Twenty-eight patients received plan adaptation, eight patients received two, and one received five. CONCLUSION This proton planning strategy ensured robust treatment plans within a pre-defined level of acceptable anatomical changes that fulfilled the planning criteria for most of the patients and ensured low MHD.
Collapse
Affiliation(s)
| | | | - Morten Høyer
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | | | | | | | - Petra Witt Nyström
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Uppsala University Hospital, Uppsala, Sweden
| | | | - Pia Randers
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Linh My Hoang Thai
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | | | - Birgitte Vrou Offersen
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| |
Collapse
|
20
|
Loap P, De Marzi L, Almeida CE, Barcellini A, Bradley J, de Santis MC, Dendale R, Jimenez R, Orlandi E, Kirova Y. Hadrontherapy techniques for breast cancer. Crit Rev Oncol Hematol 2021; 169:103574. [PMID: 34958916 DOI: 10.1016/j.critrevonc.2021.103574] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/22/2021] [Accepted: 12/22/2021] [Indexed: 12/31/2022] Open
Abstract
Radiotherapy plays a key role in breast cancer treatment, and recent technical advances have been made to improve the therapeutic window by limiting the risk of radiation-induced toxicity or by increasing tumor control. Hadrontherapy is a form a radiotherapy relying on particle beams; compared with photon beams, particle beams have specific physical, radiobiological and immunological properties, which can be valuable in diverse clinical situations. To date, available hadrontherapy techniques for breast cancer irradiation include proton therapy, carbon ion radiation therapy, fast neutron therapy and boron neutron capture therapy. This review analyzes the current rationale and level of evidence for each hadrontherapy technique for breast cancer.
Collapse
Affiliation(s)
- Pierre Loap
- Proton Therapy Center, Institut Curie, Orsay, France.
| | | | - Carlos Eduardo Almeida
- Department of Radiological Sciences, Rio de Janeiro State University, Rio de Janeiro, Brazil
| | | | - Julie Bradley
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, United States
| | | | - Remi Dendale
- Proton Therapy Center, Institut Curie, Orsay, France
| | - Rachel Jimenez
- Massachusetts General Hospital, Boston, MA, United States
| | - Ester Orlandi
- National Center for Oncological Hadrontherapy, Pavia, Italy
| | - Youlia Kirova
- Proton Therapy Center, Institut Curie, Orsay, France
| |
Collapse
|
21
|
Bayasgalan U, Moon SH, Kim TH, Kim TY, Lee SH, Suh YG. Dosimetric Comparisons between Proton Beam Therapy and Modern Photon Radiation Techniques for Stage I Non-Small Cell Lung Cancer According to Tumor Location. Cancers (Basel) 2021; 13:cancers13246356. [PMID: 34944976 PMCID: PMC8699272 DOI: 10.3390/cancers13246356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/15/2021] [Accepted: 12/16/2021] [Indexed: 12/26/2022] Open
Abstract
Simple Summary Stereotactic ablative radiotherapy (SABR) is a well-established technique used to treat stage I non-small cell lung cancer (NSCLC). Proton beam therapy (PBT) offers dosimetric advantages over photon SABR techniques by reducing doses to normal organs. Hence, it is believed that PBT is helpful for patients with tumors located centrally in stage I NSCLC. However, the benefits of PBT for other locations, such as peripherally located tumors, have not been well-described. We investigated dosimetric benefits for PBT over modern photon radiation techniques for stage I NSCLC according to tumor locations. A total of 42 patients’ (including tumors that were central (11), peripheral (nine), and close to the chest wall (22)) PBT plans were compared with those of modern photon radiation techniques. In all locations, PBT significantly reduced radiation exposure to the lung and heart. To reduce potential lung and heart toxicities, PBT is ideal, even in the peripherally located stage I NSCLC. Abstract Herein, we investigated the dosimetric benefits for proton beam therapy (PBT) over modern photon radiation techniques according to tumor location (central, peripheral, and close to the chest wall) for stage I non-small cell lung cancer (NSCLC) patients. A total of 42 patients with stage I NSCLC were treated with PBT with a total dose of 50–70 Gy in four or 10 fractions considering the risk of treatment-related toxicities. Simulation plans for three-dimensional conformal radiation therapy (3D-CRT), static-field intensity-modulated radiotherapy (IMRT), and volumetric-modulated arc therapy (VMAT) were retrospectively generated using the same treatment volumes as implemented in the PBT plans for these patients. Dosimetric improvements were observed with PBT as compared with all the photon-based radiation techniques with regards to the mean lung dose, lung V5 and V10, mean heart dose, and heart V5 and V10 in all locations. Moreover, lower radiation exposure to the chest wall was observed within PBT for peripherally located and close to the chest wall tumors. All radiotherapy modalities achieved clinically satisfactory treatment plans in the current study. Notably, the usage of PBT resulted in significant dosimetric improvements in the lung and heart over photon-based techniques at all tumor locations, including the periphery, for stage I NSCLC.
Collapse
Affiliation(s)
- Unurjargal Bayasgalan
- Proton Therapy Center, Research Institute and Hospital, National Cancer Center, Goyang 10408, Korea; (U.B.); (S.H.M.); (T.H.K.); (T.Y.K.); (S.H.L.)
- Department of Radiation Oncology, National Cancer Center, Ulaanbaatar 13370, Mongolia
| | - Sung Ho Moon
- Proton Therapy Center, Research Institute and Hospital, National Cancer Center, Goyang 10408, Korea; (U.B.); (S.H.M.); (T.H.K.); (T.Y.K.); (S.H.L.)
| | - Tae Hyun Kim
- Proton Therapy Center, Research Institute and Hospital, National Cancer Center, Goyang 10408, Korea; (U.B.); (S.H.M.); (T.H.K.); (T.Y.K.); (S.H.L.)
| | - Tae Yoon Kim
- Proton Therapy Center, Research Institute and Hospital, National Cancer Center, Goyang 10408, Korea; (U.B.); (S.H.M.); (T.H.K.); (T.Y.K.); (S.H.L.)
| | - Seung Hyun Lee
- Proton Therapy Center, Research Institute and Hospital, National Cancer Center, Goyang 10408, Korea; (U.B.); (S.H.M.); (T.H.K.); (T.Y.K.); (S.H.L.)
| | - Yang-Gun Suh
- Proton Therapy Center, Research Institute and Hospital, National Cancer Center, Goyang 10408, Korea; (U.B.); (S.H.M.); (T.H.K.); (T.Y.K.); (S.H.L.)
- Correspondence: ; Tel.: +82-31-920-1722
| |
Collapse
|
22
|
Stick LB, Jensen MF, Bentzen SM, Kamby C, Lundgaard AY, Maraldo MV, Offersen BV, Yu J, Vogelius IR. Radiation-Induced Toxicity Risks in Photon Versus Proton Therapy for Synchronous Bilateral Breast Cancer. Int J Part Ther 2021; 8:1-13. [PMID: 35530186 PMCID: PMC9009461 DOI: 10.14338/ijpt-21-00023.1] [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: 06/18/2021] [Accepted: 10/05/2021] [Indexed: 11/28/2022] Open
Abstract
Purpose This study compares photon and proton therapy plans for patients with synchronous bilateral early breast cancer and estimates risks of early and late radiation-induced toxicities. Materials and Methods Twenty-four patients with synchronous bilateral early breast cancer receiving adjuvant radiation therapy using photons, 3-dimensional conformal radiation therapy or volumetric modulated arc therapy, were included and competing pencil beam scanning proton therapy plans were created. Risks of dermatitis, pneumonitis, acute esophageal toxicity, lung and breast fibrosis, hypothyroidism, secondary lung and esophageal cancer and coronary artery events were estimated using published dose-response relationships and normal tissue complication probability (NTCP) models. Results The primary clinical target volume V95% and/or nodal clinical target volume V90% were less than 95% in 17 photon therapy plans and none of the proton plans. Median NTCP of radiation dermatitis ≥ grade 2 was 18.3% (range, 5.4-41.7) with photon therapy and 58.4% (range, 31.4-69.7) with proton therapy. Median excess absolute risk (EAR) of secondary lung cancer at age 80 for current and former smokers was 4.8% (range, 0.0-17.0) using photons and 2.7% (range, 0.0-13.6) using protons. Median EAR of coronary event at age 80, assuming all patients have preexisting cardiac risk factors, was 1.0% (range, 0.0-5.6) with photons and 0.2% (range, 0.0-1.3) with protons. Conclusion Proton therapy plans improved target coverage and reduced risk of coronary artery event and secondary lung cancer while increasing the risk of radiation dermatitis.
Collapse
Affiliation(s)
- Line Bjerregaard Stick
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Niels Bohr Institute, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | | | - Søren M. Bentzen
- Greenebaum Comprehensive Cancer Center and Department of Epidemiology and Public, Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Claus Kamby
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anni Young Lundgaard
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Maja Vestmø Maraldo
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Birgitte Vrou Offersen
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Experimental Clinical Oncology & Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Jen Yu
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Ivan Richter Vogelius
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
23
|
Choi JI, Khan AJ, Powell SN, McCormick B, Lozano AJ, Del Rosario G, Mamary J, Liu H, Fox P, Gillespie E, Braunstein LZ, Mah D, Cahlon O. Proton reirradiation for recurrent or new primary breast cancer in the setting of prior breast irradiation. Radiother Oncol 2021; 165:142-151. [PMID: 34688807 DOI: 10.1016/j.radonc.2021.10.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 10/07/2021] [Accepted: 10/11/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Late local recurrences and second primary breast cancers are increasingly common. Proton beam therapy (PBT) reirradiation (reRT) may allow safer delivery of a second definitive radiotherapy (RT) course. We analyzed outcomes of patients with recurrent or new primary breast cancer who underwent reRT. MATERIALS AND METHODS In an IRB-approved retrospective study, patient/tumor characteristics, treatment parameters, outcomes, and toxicities were collected for all consecutive patients with recurrent or new primary non-metastatic breast cancer previously treated with breast or chest wall RT who underwent PBT reRT. RESULTS Forty-six patients received reRT using uniform (70%) or pencil beam (30%) scanning PBT. Median first RT, reRT, and cumulative doses were 60 Gy (range 45-66 Gy), 50.4 Gy(RBE) (40-66.6 Gy(RBE)), and 110 Gy(RBE) (96.6-169.4 Gy(RBE)), respectively. Median follow-up was 21 months. There were no local or regional recurrences; 17% developed distant recurrence. Two-year DMFS and OS were 92.0% and 93.6%, respectively. Nine of 13 (69.2%) patients who underwent implant or flap reconstruction developed capsular contracture, 3 (23.1%) requiring surgical intervention. One (7.7%) patient developed grade 3 breast pain requiring mastectomy after breast conserving surgery. No acute or late grade 4-5 toxicities were seen. Increased body mass index (BMI) was protective of grade ≥ 2 acute toxicity (OR = 0.84, 95%CI = 0.70-1.00). CONCLUSION In the largest series to date of PBT reRT for breast cancer recurrence or new primary after prior definitive breast or chest wall RT, excellent locoregional control and few high-grade toxicities were encountered. PBT reRT may provide a relatively safe and highly effective salvage option. Additional patients and follow-up are needed to correlate composite normal tissue doses with toxicities and assess long-term outcomes.
Collapse
Affiliation(s)
- J Isabelle Choi
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA; New York Proton Center, New York, USA.
| | - Atif J Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Simon N Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Beryl McCormick
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | | | | | | | - Haoyang Liu
- ProCure Proton Therapy Center, Somerset, USA
| | - Pamela Fox
- ProCure Proton Therapy Center, Somerset, USA
| | - Erin Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Lior Z Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Dennis Mah
- ProCure Proton Therapy Center, Somerset, USA
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA; New York Proton Center, New York, USA
| |
Collapse
|
24
|
Kang Y, Shen J, Bues M, Hu Y, Liu W, Ding X. Technical Note: Clinical modeling and validation of breast tissue expander metallic ports in a commercial treatment planning system for proton therapy. Med Phys 2021; 48:7512-7525. [PMID: 34519357 DOI: 10.1002/mp.15225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 08/20/2021] [Accepted: 09/05/2021] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To validate breast tissue expander metallic port (MP) models in a commercial treatment planning system (TPS) in proton pencil beam scanning (PBS) treatments for breast cancer patients with breast tissue expanders. METHODS AND MATERIALS Three types of MPs taken out of a Mentor CPX4, a Natrelle 133, and a PMT Integra breast tissue expanders and a 650 cc saline filled Mentor CPX4 expander were placed on top of acrylic slabs, and scanned using a Siemens Somatom Definition AS Open RT CT scanner. Structure templates for each of the MPs were designed within Eclipse TPS. The CT numbers for the metallic parts were overridden to reflect measured or calculated relative proton stopping powers (RPSPs). Mock targets were contoured in acrylic to represent postmastectomy chest-wall radiation therapy (PMRT) targets. Plans with different beam incident angles were optimized using the Eclipse TPS to deliver uniform prescription dose to the target using Hitachi Probeat-V PBS beams. Eclipse calculated doses and an in-house Monte Carlo (MC) code calculated doses were compared to the measured Gafchromic EBT3 film doses in acrylic. RESULTS TPS/MC and film dose comparison results showed that (1) 3%/2 mm/10% threshold Gamma pass rates were better than 90.8% in the acrylic target region for all plans; (2) comparing TPS and film doses for the individual beam plans in the MP dose shadow areas, the area with dose difference above 5% ([ΔA] 5%) ranged from 1.1 to 5.0 cm2 , and the maximum dose difference ([ΔD] 0.01 cm2 ) ranged from 12.5% to 25.0%; (3) comparing MC and film doses for the individual beam plans in the MP dose shadow areas, the (ΔA) 5% varied from 1.1 to 2.9 cm2 and (ΔD) 0.01 cm2 varied from 8.5% to 24.2%; (4) for a plan composed of three individual beams treating through the Mentor CPX4 expander, the TPS (ΔA) 5% was less than 0.13 cm2 , and the (ΔD) 0.01 cm2 was less than 6% in the MP dose shadow areas. CONCLUSIONS It is feasible to treat patients with tissue expanders using multiple PBS beams using a structure template with CT number overridden to represent the measured/calculated RPSP for MPs for PBS treatment planning. MC dose was more accurate than analytical dose in the areas with high dose gradient caused by the density heterogeneity of the breast tissue expander MPs.
Collapse
Affiliation(s)
- Yixiu Kang
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Jiajian Shen
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Martin Bues
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Yanle Hu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Xiaoning Ding
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| |
Collapse
|
25
|
Bayasgalan U, Moon SH, Jeong JH, Kim TH, Cho KH, Suh YG. Treatment outcomes of passive scattering proton beam therapy for stage I non-small cell lung cancer. Radiat Oncol 2021; 16:155. [PMID: 34407855 PMCID: PMC8371847 DOI: 10.1186/s13014-021-01855-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 07/05/2021] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION To investigate the treatment outcomes of passive scattering proton beam therapy using stereotactic ablative radiotherapy (SABR) or hypofractionated radiation therapy (RT) for inoperable patients or those who refused surgery for stage I non-small cell lung cancer (NSCLC). METHODS From January 2016 to December 2019, we retrospectively analyzed 42 patients with stage I NSCLC treated with proton beam therapy. The initially intended dose regimen was 60 cobalt Gray equivalents (CGE) in 4 fractions; however, sequentially modified dose regimens were used when the dose-volume constraints could not be met. The median total dose was 50 CGE (range 50-70 CGE), while the corresponding median biologically effective dose using [Formula: see text]= 10 (BED10) was 112.5 CGE (range 96-150 CGE). RESULTS The median follow-up time was 40 months (interquartile range 32-48 months). Among the 42 treated patients, 33 had pathologically proven cancers of which most were adenocarcinoma (n = 21, 64%). The 3-year overall survival rate was 71.8%. The estimated rates of local control and progression free survival at 3 years were 91.5% and 66.9%, respectively. Thirteen patients experienced disease progression consisting of three local, six regional, and nine distant failures. No grade 4 or 5 toxicities were observed. CONCLUSION Passive scattering proton beam therapy for stage I NSCLC using SABR or hypofractionated RT was safe and showed high LC rates.
Collapse
Affiliation(s)
- Unurjargal Bayasgalan
- Proton Therapy Center, Research Institute and Hospital, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, 10408, Republic of Korea.,Department of Radiation Oncology, National Cancer Center, Ulaanbaatar, Mongolia
| | - Sung Ho Moon
- Proton Therapy Center, Research Institute and Hospital, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, 10408, Republic of Korea
| | - Jong Hwi Jeong
- Proton Therapy Center, Research Institute and Hospital, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, 10408, Republic of Korea
| | - Tae Hyun Kim
- Proton Therapy Center, Research Institute and Hospital, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, 10408, Republic of Korea
| | - Kwan Ho Cho
- Proton Therapy Center, Research Institute and Hospital, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, 10408, Republic of Korea
| | - Yang-Gun Suh
- Proton Therapy Center, Research Institute and Hospital, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, 10408, Republic of Korea.
| |
Collapse
|
26
|
DeCesaris CM, Mossahebi S, Jatczak J, Rao AD, Zhu M, Mishra MV, Nichols E. Outcomes of and treatment planning considerations for a hybrid technique delivering proton pencil-beam scanning radiation to women with metal-containing tissue expanders undergoing post-mastectomy radiation. Radiother Oncol 2021; 164:289-298. [PMID: 34280402 DOI: 10.1016/j.radonc.2021.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Following mastectomy, immediate breast reconstruction often involves the use of temporary tissue expanders (TEs). TEs contain metallic ports (MPs), which complicate proton pencil-beam scanning (PBS) planning. A technique was implemented for delivering PBS post-mastectomy radiation (PMRT) to patients with TEs and MPs. METHODS A protocol utilizing a hybrid single- and multi-field optimization (SFO, MFO) technique was developed. Plans were robustly optimized using a Monte Carlo algorithm. A CTV_eval structure including chest wall (CW) and regional nodal (RNI) targets and excluding the TE was evaluated. Organ at risk (OAR) dosimetry and acute toxicities were analyzed. RESULTS Twenty-nine women were treated with this technique. A 2-field SFO technique was used superior and inferior to the MP, with a 3 or 4-field MFO technique used at the level of the MP. Virtual blocks were utilized so that beams did not travel through the MP. A port-to-CW distance of 1 cm was required. Patients underwent daily image-guidance to ensure the port remained within a 0.5 cm internal planning volume (ITV). Median RT dose to CTV_eval was 50.4 Gy (45.0-50.4). Median 95% CTV_eval coverage was 99.5% (95-100). Optically stimulated luminescent dosimeter (OSLD) readings were available for 8 patients and correlated to the dose measurements in the treatment planning system (TPS); median OSLD ratio was 0.99 (range, 0.93-1.02). CONCLUSIONS Delivering PMRT with PBS for women with metal-containing TEs using a hybrid SFO/MFO technique is feasible, reproducible, and achieves excellent dose distributions. Specialized planning and image-guidance techniques are required to safely utilize this treatment in the clinic.
Collapse
Affiliation(s)
- Cristina M DeCesaris
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, United States.
| | - Sina Mossahebi
- Division of Physics, Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, United States
| | - Jenna Jatczak
- Maryland Proton Treatment Center, Baltimore, United States
| | - Avani D Rao
- Department of Radiation Oncology, Inova Schar Cancer Institute, Fairfax, United States
| | - Mingyao Zhu
- Department of Radiation Oncology, Emory University, Atlanta, United States
| | - Mark V Mishra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, United States
| | - Elizabeth Nichols
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, United States
| |
Collapse
|
27
|
Chou YC, Fan KH, Lin CY, Hung TM, Huang BS, Chang KP, Kang CJ, Huang SF, Chang PH, Hsu CL, Wang HM, Hsieh JCH, Cheng AJ, Chang JTC. Intensity Modulated Proton Beam Therapy versus Volumetric Modulated Arc Therapy for Patients with Nasopharyngeal Cancer: A Propensity Score-Matched Study. Cancers (Basel) 2021; 13:cancers13143555. [PMID: 34298769 PMCID: PMC8307135 DOI: 10.3390/cancers13143555] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/06/2021] [Accepted: 07/06/2021] [Indexed: 11/16/2022] Open
Abstract
(1) Background: We compared the outcomes of patients with nasopharyngeal carcinoma treated with IMPT and VMAT. (2) Methods: We performed a retrospective propensity score matching analysis (1:1) of patients treated with IMPT (years: 2016-2018) and VMAT (2014-2018). Survival was estimated using the Kaplan-Meier method. Multivariate Cox proportional hazards regression analysis was used to identify the independent predictors of survival. Binary toxicity endpoint analyses were performed using a Cox model and logistic regression. (3) Results: Eighty patients who received IMPT and VMAT were included. The median follow-up time was 24.1 months in the IMPT group. Progression-free survival (PFS) and overall survival (OS) were not statistically different between the two groups but potentially better in IMPT group. In multivariate analysis, advanced N-stage and body weight loss (BWL; >7%) during radiotherapy were associated with decreased PFS. The IMPT group had significantly less requirement for nasogastric (NG) tube placement and BWL during treatment. The mean oral cavity dose was the only predictive factor in stepwise regression analysis, and IMPT required a significantly lower mean dose. However, IMPT increased the grade 3 radiation dermatitis. (4) Conclusions: IMPT is associated with reduced rates of NG tube insertion and BWL through reducing oral mean dose, potentially producing better oncologic outcomes.
Collapse
Affiliation(s)
- Yung-Chih Chou
- Proton and Radiation Therapy Center, Department of Radiation Oncology, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan; (Y.-C.C.); (K.-H.F.); (C.-Y.L.); (T.-M.H.); (B.-S.H.); (A.-J.C.)
- Department of Radiation Oncology, New Taipei Municipal Tucheng Hospital, New Taipei City 236, Taiwan
| | - Kang-Hsing Fan
- Proton and Radiation Therapy Center, Department of Radiation Oncology, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan; (Y.-C.C.); (K.-H.F.); (C.-Y.L.); (T.-M.H.); (B.-S.H.); (A.-J.C.)
- Department of Radiation Oncology, New Taipei Municipal Tucheng Hospital, New Taipei City 236, Taiwan
| | - Chien-Yu Lin
- Proton and Radiation Therapy Center, Department of Radiation Oncology, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan; (Y.-C.C.); (K.-H.F.); (C.-Y.L.); (T.-M.H.); (B.-S.H.); (A.-J.C.)
| | - Tsung-Min Hung
- Proton and Radiation Therapy Center, Department of Radiation Oncology, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan; (Y.-C.C.); (K.-H.F.); (C.-Y.L.); (T.-M.H.); (B.-S.H.); (A.-J.C.)
| | - Bing-Shen Huang
- Proton and Radiation Therapy Center, Department of Radiation Oncology, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan; (Y.-C.C.); (K.-H.F.); (C.-Y.L.); (T.-M.H.); (B.-S.H.); (A.-J.C.)
| | - Kai-Ping Chang
- Department of Otolaryngology-Head Neck Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan; (K.-P.C.); (C.-J.K.); (S.-F.H.); (P.-H.C.)
| | - Chung-Jan Kang
- Department of Otolaryngology-Head Neck Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan; (K.-P.C.); (C.-J.K.); (S.-F.H.); (P.-H.C.)
| | - Shiang-Fu Huang
- Department of Otolaryngology-Head Neck Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan; (K.-P.C.); (C.-J.K.); (S.-F.H.); (P.-H.C.)
| | - Po-Hung Chang
- Department of Otolaryngology-Head Neck Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan; (K.-P.C.); (C.-J.K.); (S.-F.H.); (P.-H.C.)
| | - Cheng-Lung Hsu
- Division of Medical Oncology, Department of Internal Medicine, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan; (C.-L.H.); (H.-M.W.); (J.C.-H.H.)
| | - Hung-Ming Wang
- Division of Medical Oncology, Department of Internal Medicine, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan; (C.-L.H.); (H.-M.W.); (J.C.-H.H.)
| | - Jason Chia-Hsun Hsieh
- Division of Medical Oncology, Department of Internal Medicine, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan; (C.-L.H.); (H.-M.W.); (J.C.-H.H.)
| | - Ann-Joy Cheng
- Proton and Radiation Therapy Center, Department of Radiation Oncology, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan; (Y.-C.C.); (K.-H.F.); (C.-Y.L.); (T.-M.H.); (B.-S.H.); (A.-J.C.)
- Department of Medical Biotechnology and Laboratory Science, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Joseph Tung-Chieh Chang
- Proton and Radiation Therapy Center, Department of Radiation Oncology, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan; (Y.-C.C.); (K.-H.F.); (C.-Y.L.); (T.-M.H.); (B.-S.H.); (A.-J.C.)
- Department of Radiation Oncology, Xiamen Chang Gung Memorial Hospital, Xiamen 361000, China
- Correspondence: ; Tel.: +886-3-3281200 (ext. 7000); Fax: +886-3-3280797
| |
Collapse
|
28
|
Clinical Outcomes of Pencil Beam Scanning Proton Therapy in Locally Advanced Non-Small Cell Lung Cancer: Propensity Score Analysis. Cancers (Basel) 2021; 13:cancers13143497. [PMID: 34298711 PMCID: PMC8307066 DOI: 10.3390/cancers13143497] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/07/2021] [Accepted: 07/12/2021] [Indexed: 12/25/2022] Open
Abstract
This study compared the efficacy and safety of pencil beam scanning proton therapy (PBSPT) versus intensity-modulated (photon) radiotherapy (IMRT) in patients with stage III non-small cell lung cancer (NSCLC). We retrospectively reviewed 219 patients with stage III NSCLC who received definitive concurrent chemoradiotherapy between November 2016 and December 2018. Twenty-five patients (11.4%) underwent PBSPT (23 with single-field optimization) and 194 patients (88.6%) underwent IMRT. Rates of locoregional control (LRC), overall survival, and acute/late toxicities were compared between the groups using propensity score-adjusted analyses. Patients treated with PBSPT were older (median: 67 vs. 62 years) and had worse pulmonary function at baseline (both FEV1 and DLCO) compared to those treated with IMRT. With comparable target coverage, PBSPT exhibited superior sparing of the lung, heart, and spinal cord to radiation exposure compared to IMRT. At a median follow-up of 21.7 (interquartile range: 16.8-26.8) months, the 2-year LRC rates were 72.1% and 84.1% in the IMRT and PBSPT groups, respectively (p = 0.287). The rates of grade ≥ 3 esophagitis were 8.2% and 20.0% after IMRT and PBSPT (p = 0.073), respectively, while corresponding rates of grade ≥ 2 radiation pneumonitis were 28.9% and 16.0%, respectively (p = 0.263). PBSPT appears to be an effective and safe treatment technique even for patients with poor lung function, and it does not jeopardize LRC.
Collapse
|
29
|
Hanania AN, Zhang X, Gunn GB, Rosenthal DI, Garden AS, Fuller CD, Phan J, Reddy JP, Moreno A, Chronowski G, Shah S, Ausat N, Hanna E, Ferrarotto R, Frank SJ. Proton Therapy for Major Salivary Gland Cancer: Clinical Outcomes. Int J Part Ther 2021; 8:261-272. [PMID: 34285952 PMCID: PMC8270094 DOI: 10.14338/ijpt-20-00044.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 11/23/2020] [Indexed: 11/21/2022] Open
Abstract
Purpose To report clinical outcomes in terms of disease control and toxicity in patients with major salivary gland cancers (SGCs) treated with proton beam therapy. Materials and Methods Clinical and dosimetric characteristics of patients with SGCs treated from August 2011 to February 2020 on an observational, prospective, single-institution protocol were abstracted. Local control and overall survival were calculated by the Kaplan-Meier method. During radiation, weekly assessments of toxicity were obtained, and for patients with ≥ 90 days of follow-up, late toxicity was assessed. Results Seventy-two patients were identified. Median age was 54 years (range, 23-87 years). Sixty-three patients (88%) received postoperative therapy, and nine patients (12%) were treated definitively. Twenty-six patients (36%) received concurrent chemotherapy. Nine patients (12%) had received prior radiation. All (99%) but one patient received unilateral treatment with a median dose of 64 GyRBE (relative biological effectiveness) (interquartile range [IQR], 60-66), and 53 patients (74%) received intensity-modulated proton therapy with either single-field or multifield optimization. The median follow-up time was 30 months. Two-year local control and overall survival rates were 96% (95% confidence interval [CI] 85%-99%) and 89% (95% CI 76%-95%], respectively. Radiation dermatitis was the predominant grade-3 toxicity (seen in 21% [n = 15] of the patients), and grade ≥ 2 mucositis was rare (14%; n = 10 patients). No late-grade ≥ 3 toxicities were reported. Conclusion Proton beam therapy for treatment of major SGCs manifests in low rates of acute mucosal toxicity. In addition, the current data suggest a high rate of local control and minimal late toxicity.
Collapse
Affiliation(s)
- Alexander N Hanania
- Department of Radiation Oncology, Baylor College of Medicine, Houston, TX, USA.,Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xiaodong Zhang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Adam S Garden
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - C David Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jack Phan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jay P Reddy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amy Moreno
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gregory Chronowski
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shalin Shah
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Noveen Ausat
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ehab Hanna
- Department of Head and Neck Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Renata Ferrarotto
- Department of Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|
30
|
Möllerberg ML, Langegård U, Johansson B, Ohlsson-Nevo E, Fransson P, Ahlberg K, Witt-Nyström P, Sjövall K. Evaluation of skin reactions during proton beam radiotherapy - Patient-reported versus clinician-reported. Tech Innov Patient Support Radiat Oncol 2021; 19:11-17. [PMID: 34195393 PMCID: PMC8233127 DOI: 10.1016/j.tipsro.2021.05.001] [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: 01/31/2021] [Revised: 05/17/2021] [Accepted: 05/24/2021] [Indexed: 11/28/2022] Open
Abstract
Radiotherapy is used in the treatment for primary brain tumours. Radiotherapy causes acute and late toxicities where skin reactions are most common. The potential for misreporting of toxicity in specific cases may be significant. Oncologist-reported and patient-reported outcomes of skin reactions are crucial. A combination of PROs and oncologists’ assessments is most accurate.
Background Skin reaction is a common side-effect of radiotherapy and often only assessed as clinician-reported outcome (CRO). The aim was to examine and compare patient-reported outcome (PRO) of skin reactions with CRO for signs of acute skin reactions for patients with primary brain tumour receiving proton beam radiotherapy (PBT). A further aim was to explore patients’ experiences of the skin reactions. Methods Acute skin reactions were assessed one week after start of treatment, mid-treatment and end of treatment among 253 patients with primary brain tumour who underwent PBT. PRO skin reactions were assessed with the RSAS and CRO according to the RTOG scale. Fleiss’ kappa was performed to measure the inter-rater agreement of the assessments of skin reactions. Results The results showed a discrepancy between PRO and CRO acute skin reactions. Radiation dose was associated with increased skin reactions, but no correlations were seen for age, gender, education, occupation, other treatment or smoking. There was a poor agreement between patients and clinicians (κ = −0.016) one week after the start of PBT, poor (κ = −0.045) to (κ = 0.396) moderate agreement at mid treatment and poor (κ = −0.010) to (κ = 0.296) moderate agreement at end of treatment. Generally, patients’ symptom distress toward skin reactions was low at all time points. Conclusion The poor agreement between PRO and CRO shows that the patient needs to be involved in assessments of skin reactions for a more complete understanding of skin reactions due to PBT. This may also improve patient experience regarding involvement in their own care.
Collapse
Affiliation(s)
| | - Ulrica Langegård
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Birgitta Johansson
- Experimental Oncology, Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala University Hospital, Sweden
| | - Emma Ohlsson-Nevo
- University Healthcare Research Centre, Faculty of Medicine and Health, Örebro University, Sweden
| | - Per Fransson
- Department of Nursing, Umeå University, and Department of Cancercentrum, Norrlands University Hospital, Umeå, Sweden
| | - Karin Ahlberg
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Petra Witt-Nyström
- Danish Centre for Particle Therapy, Aarhus, Palle Juul-Jensens Boulevard 25, DK-8200 Aarhus, Denmark
| | - Katarina Sjövall
- Faculty of Health Sciences, Kristianstad University, SE-291 88 Kristianstad, Sweden
| |
Collapse
|
31
|
Meattini I, Poortmans PM, Aznar MC, Becherini C, Bonzano E, Cardinale D, Lenihan DJ, Marrazzo L, Curigliano G, Livi L. Association of Breast Cancer Irradiation With Cardiac Toxic Effects: A Narrative Review. JAMA Oncol 2021; 7:924-932. [PMID: 33662107 DOI: 10.1001/jamaoncol.2020.7468] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
IMPORTANCE To promptly recognize and manage cardiovascular (CV) risk factors before, during, and after cancer treatment, decreasing the risk of cancer therapy-related cardiac dysfunction is crucial. After recent advances in breast cancer treatment, mortality rates from cancer have decreased, and the prevalence of survivors with a potentially higher CV disease risk has increased. Cardiovascular risks might be associated with the multimodal approach, including systemic therapies and breast radiotherapy (RT). OBSERVATIONS The heart disease risk seems to be higher in patients with tumors in the left breast, when other classic CV risk factors are present, and when adjunctive anthracycline-based chemotherapy is administered, suggesting a synergistic association. Respiratory control as well as modern RT techniques and their possible further refinement may decrease the prevalence and severity of radiation-induced heart disease. Several pharmacological cardioprevention strategies for decreasing cardiac toxic effects have been identified in several guidelines. However, further research is needed to ascertain the feasibility of these strategies in routine practice. CONCLUSIONS AND RELEVANCE This review found that evidence-based recommendations are lacking on the modalities for and intensity of heart disease screening, surveillance of patients after RT, and treatment of these patients. A multidisciplinary and multimodal approach is crucial to guide optimal management.
Collapse
Affiliation(s)
- Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences Mario Serio, University of Florence, Florence, Italy
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Philip M Poortmans
- Department of Radiation Oncology, Iridium Kankernetwerk, Wilrijk-Antwerp, Belgium
- University of Antwerp, Faculty of Medicine and Health Sciences, Wilrijk-Antwerp, Belgium
| | - Marianne Camille Aznar
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, The Christie NHS Foundation Trust, Manchester, United Kingdom
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Carlotta Becherini
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Elisabetta Bonzano
- Department of Radiation Oncology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Matteo Polyclinic Foundation, Pavia, Italy
- PhD School in Experimental Medicine, University of Pavia, Pavia, Italy
| | - Daniela Cardinale
- Cardioncology Unit, European Institute of Oncology, IRCCS, Milan, Italy
| | - Daniel J Lenihan
- Cardio-Oncology Center of Excellence, Washington University in St Louis, St Louis, Missouri
| | - Livia Marrazzo
- Medical Physics Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Giuseppe Curigliano
- Division of Early Drug Development, European Institute of Oncology, IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Lorenzo Livi
- Department of Experimental and Clinical Biomedical Sciences Mario Serio, University of Florence, Florence, Italy
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| |
Collapse
|
32
|
Patel AA, Arquette CP, Rowley MA, Borrelli MR, Lee GK, Nazerali RS. Comparing Outcomes of Flap-Based Salvage Reconstructions in the Radiated Breast. Ann Plast Surg 2021; 86:S403-S408. [PMID: 33976069 DOI: 10.1097/sap.0000000000002761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Chest wall irradiation significantly decreases the strength and quality of breast tissue supporting prostheses, increasing the risk of skin breakdown and implant or tissue expander extrusion. Autologous tissue, including the latissimus dorsi (LD) or abdominal-based flaps, including the muscle-sparing transverse rectus abdominis myocutaneous or deep inferior epigastric perforator flaps, may be used to salvage reconstructions. However, data comparing outcomes of the two flap options remains limited. We compare postoperative outcomes from both flap types after autologous salvage reconstruction in irradiated breasts. METHODS Charts were retrospectively reviewed from patients who underwent either chest wall radiation or postmastectomy radiation therapy followed by salvage autologous reconstruction with either a LD and an implant or an abdominal-based flap (muscle-sparing transverse rectus abdominis myocutaneous or deep inferior epigastric perforator flaps). Patients with a history of tissue expander or implant failure requiring autologous salvage as part of 2-staged or delayed-immediate breast reconstruction that were operated on between January 2005 and November 2015 were included. Basic demographics, comorbidities, and recipient site complications (infection, wound dehiscence, seroma, hematoma, fat necrosis, and flap failure) were collected. RESULTS A total of 72 patients met the inclusion criteria which included 72 flaps; 35 LD and 37 abdominally based flaps. Demographics and comorbidities did not vary significantly between patient groups. Mean follow-up was 767.6 weeks, and all reconstructions were unilateral. Nineteen (26.4%) patients had at least one complication, most commonly minor infections (9.7%). Overall complication rates were not significantly different between flap groups (P = 0.083). Wound dehiscence was significantly higher in the abdominal group (P = 0.045), and fat necrosis also trended higher in this group (P = 0.085). Major infection trended higher in the latissimus group (P = 0.069). CONCLUSIONS When comparing outcomes of salvage flap-based reconstruction in radiated breast tissue, overall complication rates were similar when comparing postoperative outcomes between the LD- and abdominal-based flaps. Wound dehiscence was significantly higher when salvage reconstruction used an abdominal flap. Understanding the complications after salvage procedures can help inform decision making and optimize patient care to improve outcomes after breast reconstruction in the radiated breast.
Collapse
Affiliation(s)
| | - Connor P Arquette
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Mallory A Rowley
- From the College of Medicine, SUNY Upstate Medical University, Syracuse, NY
| | - Mimi R Borrelli
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Gordon K Lee
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Rahim S Nazerali
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA
| |
Collapse
|
33
|
Aristei C, Perrucci E, Alì E, Marazzi F, Masiello V, Saldi S, Ingrosso G. Personalization in Modern Radiation Oncology: Methods, Results and Pitfalls. Personalized Interventions and Breast Cancer. Front Oncol 2021; 11:616042. [PMID: 33816246 PMCID: PMC8012886 DOI: 10.3389/fonc.2021.616042] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 02/02/2021] [Indexed: 12/31/2022] Open
Abstract
Breast cancer, the most frequent malignancy in women worldwide, is a heterogeneous group of diseases, characterized by distinct molecular aberrations. In precision medicine, radiation oncology for breast cancer aims at tailoring treatment according to tumor biology and each patient’s clinical features and genetics. Although systemic therapies are personalized according to molecular sub-type [i.e. endocrine therapy for receptor-positive disease and anti-human epidermal growth factor receptor 2 (HER2) therapy for HER2-positive disease] and multi-gene assays, personalized radiation therapy has yet to be adopted in the clinical setting. Currently, attempts are being made to identify prognostic and/or predictive factors, biomarkers, signatures that could lead to personalized treatment in order to select appropriate patients who might, or might not, benefit from radiation therapy or whose radiation therapy might be escalated or de-escalated in dosages and volumes. This overview focuses on what has been achieved to date in personalized post-operative radiation therapy and individual patient radiosensitivity assessments by means of tumor sub-types and genetics.
Collapse
Affiliation(s)
- Cynthia Aristei
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Perugia, Italy
| | | | - Emanuele Alì
- Radiation Oncology Section, University of Perugia, Perugia, Italy
| | - Fabio Marazzi
- Radiation Oncology Department, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Valeria Masiello
- Radiation Oncology Department, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Simonetta Saldi
- Radiation Oncology Section, Perugia General Hospital, Perugia, Italy
| | - Gianluca Ingrosso
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Perugia, Italy
| |
Collapse
|
34
|
Stick LB, Lorenzen EL, Yates ES, Anandadas C, Andersen K, Aristei C, Byrne O, Hol S, Jensen I, Kirby AM, Kirova YM, Marrazzo L, Matías-Pérez A, Nielsen MMB, Nissen HD, Oliveros S, Verhoeven K, Vikström J, Offersen BV. Selection criteria for early breast cancer patients in the DBCG proton trial - The randomised phase III trial strategy. Clin Transl Radiat Oncol 2021; 27:126-131. [PMID: 33659716 PMCID: PMC7892790 DOI: 10.1016/j.ctro.2021.01.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/27/2021] [Accepted: 01/31/2021] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND AND PURPOSE Adjuvant radiotherapy of internal mammary nodes (IMN) improves survival in high-risk early breast cancer patients but inevitably leads to more dose to heart and lung. Target coverage is often compromised to meet heart/lung dose constraints. We estimate heart and lung dose when target coverage is not compromised in consecutive patients. These estimates are used to guide the choice of selection criteria for the randomised Danish Breast Cancer Group (DBCG) Proton Trial. MATERIALS AND METHODS 179 breast cancer patients already treated with loco-regional IMN radiotherapy from 18 European departments were included. If the clinically delivered treatment plan did not comply with defined target coverage requirements, the plan was modified retrospectively until sufficient coverage was reached. The choice of selection criteria was based on the estimated number of eligible patients for different heart and lung dose thresholds in combination with proton therapy capacity limitations and dose-response relationships for heart and lung. RESULTS Median mean heart dose was 3.0 Gy (range, 1.1-8.2 Gy) for left-sided and 1.4 Gy (0.4-11.5 Gy) for right-sided treatment plans. Median V17Gy/V20Gy (hypofractionated/normofractionated plans) for ipsilateral lung was 31% (9-57%). The DBCG Radiotherapy Committee chose mean heart dose ≥ 4 Gy and/or lung V17Gy/V20Gy ≥ 37% as thresholds for inclusion in the randomised trial. Using these thresholds, we estimate that 22% of patients requiring loco-regional IMN radiotherapy will be eligible for the trial. CONCLUSION The patient selection criteria for the DBCG Proton Trial are mean heart dose ≥ 4 Gy and/or lung V17Gy/V20Gy ≥ 37%.
Collapse
Affiliation(s)
- Line Bjerregaard Stick
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Niels Bohr Institute, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Carmel Anandadas
- Department of Clinical Oncology, The Christie Hospital NHS Foundation Trust, Manchester, UK
| | - Karen Andersen
- Department of Radiotherapy, Herlev & Gentofte Hospital, Herlev, Denmark
| | - Cynthia Aristei
- Department of Medicine and Surgery, Radiation Oncology Section, University of Perugia & Perugia General Hospital, Perugia, Italy
| | - Orla Byrne
- Department of Medical Physics, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Sandra Hol
- Department of Radiation Oncology, Institute Verbeeten, Tilburg, the Netherlands
| | - Ingelise Jensen
- Department of Medical Physics, Aalborg University Hospital, Aalborg, Denmark
| | - Anna M. Kirby
- Department of Radiotherapy, The Royal Marsden Hospital NHS Foundation Trust & Institute of Cancer Research, London, UK
| | | | - Livia Marrazzo
- Department of Medical Physics, Careggi University Hospital, Florence, Italy
| | | | | | | | - Sileida Oliveros
- Department of Oncology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Karolien Verhoeven
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Johan Vikström
- Department of Radiotherapy, Stavanger University Hospital, Stavanger, Norway
| | - Birgitte Vrou Offersen
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Experimental Clinical Oncology & Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| |
Collapse
|
35
|
Cunningham S, McCauley S, Vairamani K, Speth J, Girdhani S, Abel E, Sharma RA, Perentesis JP, Wells SI, Mascia A, Sertorio M. FLASH Proton Pencil Beam Scanning Irradiation Minimizes Radiation-Induced Leg Contracture and Skin Toxicity in Mice. Cancers (Basel) 2021; 13:cancers13051012. [PMID: 33804336 PMCID: PMC7957631 DOI: 10.3390/cancers13051012] [Citation(s) in RCA: 109] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/18/2021] [Accepted: 02/22/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Dose and efficacy of radiation therapy are limited by the toxicity to normal tissue adjacent to the treated tumor region. Recently, ultra-high dose rate radiotherapy (FLASH radiotherapy) has shown beneficial reduction of normal tissue damage while preserving similar tumor efficacy with electron, photon and scattered proton beam irradiation in preclinical models. Proton therapy is increasingly delivered by pencil beam scanning (PBS) technology, and we therefore set out to test PBS FLASH radiotherapy on normal tissue toxicity and tumor control in vivo in mouse using a clinical proton delivery system. This validation of the FLASH normal tissue-sparing hypothesis with a clinical delivery system provides supporting data for PBS FLASH radiotherapy and its potential role in improving radiotherapy outcomes. Abstract Ultra-high dose rate radiation has been reported to produce a more favorable toxicity and tumor control profile compared to conventional dose rates that are used for patient treatment. So far, the so-called FLASH effect has been validated for electron, photon and scattered proton beam, but not yet for proton pencil beam scanning (PBS). Because PBS is the state-of-the-art delivery modality for proton therapy and constitutes a wide and growing installation base, we determined the benefit of FLASH PBS on skin and soft tissue toxicity. Using a pencil beam scanning nozzle and the plateau region of a 250 MeV proton beam, a uniform physical dose of 35 Gy (toxicity study) or 15 Gy (tumor control study) was delivered to the right hind leg of mice at various dose rates: Sham, Conventional (Conv, 1 Gy/s), Flash60 (57 Gy/s) and Flash115 (115 Gy/s). Acute radiation effects were quantified by measurements of plasma and skin levels of TGF-β1 and skin toxicity scoring. Delayed irradiation response was defined by hind leg contracture as a surrogate of irradiation-induced skin and soft tissue toxicity and by plasma levels of 13 different cytokines (CXCL1, CXCL10, Eotaxin, IL1-beta, IL-6, MCP-1, Mip1alpha, TNF-alpha, TNF-beta, VEGF, G-CSF, GM-CSF and TGF- β1). Plasma and skin levels of TGF-β1, skin toxicity and leg contracture were all significantly decreased in FLASH compared to Conv groups of mice. FLASH and Conv PBS had similar efficacy with regards to growth control of MOC1 and MOC2 head and neck cancer cells transplanted into syngeneic, immunocompetent mice. These results demonstrate consistent delivery of FLASH PBS radiation from 1 to 115 Gy/s in a clinical gantry. Radiation response following delivery of 35 Gy indicates potential benefits of FLASH versus conventional PBS that are related to skin and soft tissue toxicity.
Collapse
Affiliation(s)
- Shannon Cunningham
- Cincinnati Children’s Hospital Medical Center, Division of Oncology, Cincinnati, OH 45229, USA; (S.C.); (S.M.); (K.V.); (J.P.P.); (S.I.W.)
| | - Shelby McCauley
- Cincinnati Children’s Hospital Medical Center, Division of Oncology, Cincinnati, OH 45229, USA; (S.C.); (S.M.); (K.V.); (J.P.P.); (S.I.W.)
| | - Kanimozhi Vairamani
- Cincinnati Children’s Hospital Medical Center, Division of Oncology, Cincinnati, OH 45229, USA; (S.C.); (S.M.); (K.V.); (J.P.P.); (S.I.W.)
| | - Joseph Speth
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA; (J.S.); (A.M.)
| | - Swati Girdhani
- Varian Medical Systems, Inc., Palo Alto, CA 94304, USA; (S.G.); (E.A.); (R.A.S.)
| | - Eric Abel
- Varian Medical Systems, Inc., Palo Alto, CA 94304, USA; (S.G.); (E.A.); (R.A.S.)
| | - Ricky A. Sharma
- Varian Medical Systems, Inc., Palo Alto, CA 94304, USA; (S.G.); (E.A.); (R.A.S.)
| | - John P. Perentesis
- Cincinnati Children’s Hospital Medical Center, Division of Oncology, Cincinnati, OH 45229, USA; (S.C.); (S.M.); (K.V.); (J.P.P.); (S.I.W.)
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
| | - Susanne I. Wells
- Cincinnati Children’s Hospital Medical Center, Division of Oncology, Cincinnati, OH 45229, USA; (S.C.); (S.M.); (K.V.); (J.P.P.); (S.I.W.)
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
| | - Anthony Mascia
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA; (J.S.); (A.M.)
| | - Mathieu Sertorio
- Cincinnati Children’s Hospital Medical Center, Division of Oncology, Cincinnati, OH 45229, USA; (S.C.); (S.M.); (K.V.); (J.P.P.); (S.I.W.)
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
- Correspondence:
| |
Collapse
|
36
|
Kern A, Bäumer C, Kröninger K, Wulff J, Timmermann B. Impact of air gap, range shifter, and delivery technique on skin dose in proton therapy. Med Phys 2020; 48:831-840. [PMID: 33368345 DOI: 10.1002/mp.14626] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 11/20/2020] [Accepted: 11/20/2020] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE Side effects of radiation therapy may include skin damage. The surface dose is of great interest and contains the buildup effect. In particular, the proton therapy community requires further experimental data to quantify doses in the surface region. This specification includes the skin dose, which is defined according to ICRU Report No. 39 at 70 μm water equivalent depth. The aim of this study is to gather more knowledge of the skin dose by varying key parameters defined by the patient treatment plan. This consists of clinical aspects such as the influence of the air gap, the application of a range shifter (RS), or the proton delivery technique. MATERIAL/METHODS Skin doses were determined with a PTW 23391 extrapolation chamber with three thin Kapton® entrance windows operated as a conventional ionization chamber. The impact on the skin dose for quasi-monoenergetic pencil beam scanning (PBS) proton beams was evaluated for clinical air gaps between 3.5 and 51.1 cm. The differences in skin dose were assessed by irradiating equivalent fields with an RS of 51 mm water equivalent thickness (RS51) and without. Furthermore, the delivery techniques PBS, uniform scanning (US), and double scattering (DS) were compared by defining a spread-out Bragg peak (SOBP). TOPAS (V.3.1.2) was used to model an IBA nozzle with PBS and to score dose to water at the surface of a water phantom. RESULTS For the monoenergetic fields without the application of the RS the skin dose was constant down to an air gap of 6.2 cm. A lower air gap of 3.5 cm showed a variation in skin dose by up to 2.4% compared to the results obtained with larger air gaps. With the inserted RS51 an increase in the skin dose was found for air gaps smaller than 11.3 cm. Experimentally, a dose difference of 1.4% was recorded for an air gap of 6.2 cm by inserting an RS and none. With the Monte Carlo calculations the largest dose increase was observed at the air gap of 3.5 cm with 1.7% and 4.0% relative to the skin dose results without the RS and to the largest evaluated air gap of 51.1 cm, respectively. The SOBP comparison of the beam modalities at the measuring plane at the isocenter revealed higher skin doses without RS (including RS) by up to +1.9% (+1.5%) for DS and +1.3% (+1.1%) for US compared to PBS. For all three techniques an approx. 2% rise in skin dose was observed for the largest evaluated air gap of 37.7 cm to an air gap of 6.2 cm when using an RS51. CONCLUSION The study investigated aspects of skin dose of a water equivalent phantom by varying key parameters of a proton treatment plan. Parameters like the RS, the air gap, and the delivery modality have an impact on the order of 4.0% for the skin dose at the depth of 70 μm. The increases in skin dose are the effects of the contribution of the increased electron fluence at small air gaps and the emitted hadronic particles produced by the RS.
Collapse
Affiliation(s)
- A Kern
- West German Proton Therapy Centre Essen (WPE), Essen, 45147, Germany.,University Hospital Essen, Essen, 45147, Germany.,Faculty of Physics, TU Dortmund University, Dortmund, 44227, Germany.,West German Cancer Center (WTZ), Essen, 45147, Germany
| | - C Bäumer
- West German Proton Therapy Centre Essen (WPE), Essen, 45147, Germany.,University Hospital Essen, Essen, 45147, Germany.,West German Cancer Center (WTZ), Essen, 45147, Germany.,German Cancer Consortium (DKTK), Heidelberg, 69120, Germany.,Faculty of Physics, Essen, 45147, Germany
| | - K Kröninger
- Faculty of Physics, TU Dortmund University, Dortmund, 44227, Germany
| | - J Wulff
- West German Proton Therapy Centre Essen (WPE), Essen, 45147, Germany.,University Hospital Essen, Essen, 45147, Germany.,West German Cancer Center (WTZ), Essen, 45147, Germany
| | - B Timmermann
- West German Proton Therapy Centre Essen (WPE), Essen, 45147, Germany.,University Hospital Essen, Essen, 45147, Germany.,West German Cancer Center (WTZ), Essen, 45147, Germany.,German Cancer Consortium (DKTK), Heidelberg, 69120, Germany.,Clinic for Particle Therapy, Essen, 45147, Germany
| |
Collapse
|
37
|
Ingargiola R, De Santis MC, Iacovelli NA, Facchinetti N, Cavallo A, Ivaldi E, Dispinzieri M, Franceschini M, Giandini C, Romanello DA, Di Biaso S, Sabetti M, Locati L, Alfieri S, Bossi P, Guglielmo M, Macchi F, Lozza L, Valdagni R, Fallai C, Pignoli E, Orlandi E. A monocentric, open-label randomized standard-of-care controlled study of XONRID®, a medical device for the prevention and treatment of radiation-induced dermatitis in breast and head and neck cancer patients. Radiat Oncol 2020; 15:193. [PMID: 32791985 PMCID: PMC7427075 DOI: 10.1186/s13014-020-01633-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/04/2020] [Indexed: 12/26/2022] Open
Abstract
Background This study was an open-label, 2-arms, monocentric, randomized clinical trial comparing Xonrid®, a topical medical device, versus standard of care (SOC) in preventing and treating acute radiation dermatitis (ARD) in Head and Neck Cancer (HNC) and Breast Cancer (BC) patients undergoing radiotherapy (RT). Methods Eligible HNC and BC patients were randomized 1:1 to receive Xonrid® + SOC or SOC during RT. Patients were instructed to apply Xonrid® on the irradiated area three times daily, starting on the first day of RT and until 2 weeks after RT completion or until the development of grade ≥ 3 skin toxicity. The primary endpoint was to evaluate the proportion of patients who developed an ARD grade < 2 at the 5th week in both groups. Secondary endpoints were median time to grade 2 (G2) skin toxicity onset; changes in skin erythema and pigmentation and trans-epidermal water loss (TEWL); patient-reported skin symptoms. All patients were evaluated at baseline, weekly during RT and 2 weeks after treatment completion. The evaluation included: clinical toxicity assessment; reflectance spectrometry (RS) and TEWL examination; measurement of patients’ quality of life (QoL) through Skindex-16 questionnaire. Results Eighty patients (40 for each cancer site) were enrolled between June 2017 and July 2018. Groups were well balanced for population characteristics. All BC patients underwent 3-Dimensional Conformal RT (3D-CRT) whereas HNC patients underwent Volumetric-Modulated Arc Therapy (VMAT). At week 5 the proportion of BC patients who did not exhibit G2 ARD was higher in Xonrid® + SOC group (p = 0.091). In the same group the onset time of G2 ARD was significantly longer than in SOC-alone group (p < 0.0491). For HNC groups there was a similar trend, but it did not reach statistical significance. For both cancer sites, patients’ QoL, measured by the Skindex-16 score, was always lower in the Xonrid® + SOC group. Conclusion Despite the failure to achieve the primary endpoint, this study suggests that Xonrid® may represent a valid medical device in the prevention and treatment of ARD at least in BC patients, delaying time to develop skin toxicity and reducing the proportion of patients who experienced G2 ARD during RT treatment and 2 weeks later. Trial registration The study was approved by the Ethical Committee of Fondazione IRCCS Istituto Nazionale dei Tumori di Milano (INT 52/14 - NCT02261181). Registered on ClinicalTrial.gov on 21st August 2017.
Collapse
Affiliation(s)
- Rossana Ingargiola
- Radiation Oncology Unit 2, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Via Venezian 1, 20133, Milan, Italy
| | - Maria Carmen De Santis
- Radiation Oncology Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Nicola Alessandro Iacovelli
- Radiation Oncology Unit 2, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Via Venezian 1, 20133, Milan, Italy.
| | - Nadia Facchinetti
- Radiation Oncology Unit 2, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Via Venezian 1, 20133, Milan, Italy
| | - Anna Cavallo
- Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Eliana Ivaldi
- Radiation Oncology Unit 2, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Via Venezian 1, 20133, Milan, Italy.,Radiotherapy Department, Sassari Hospital, University of Sassari, Sassari, Italy
| | - Michela Dispinzieri
- Radiation Oncology Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Marzia Franceschini
- Radiation Oncology Unit 2, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Via Venezian 1, 20133, Milan, Italy
| | - Carlotta Giandini
- Radiation Oncology Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Domenico Attilio Romanello
- Radiation Oncology Unit 2, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Via Venezian 1, 20133, Milan, Italy.,School of Medicine, University of Milan-Bicocca, Milan, Italy
| | - Simona Di Biaso
- Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy.,Post Graduation School in Medical Physics, University of Milan, Milan, Italy
| | - Michela Sabetti
- Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy.,Post Graduation School in Medical Physics, University of Milan, Milan, Italy
| | - Laura Locati
- Head and Neck Medical Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Salvatore Alfieri
- Head and Neck Medical Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Paolo Bossi
- Medical Oncology, University of Brescia, ASST-Spedali Civili, Brescia, Italy
| | - Mauro Guglielmo
- Oncology-Supportive Care Unit, Fondazione IRCCS, Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | | | - Laura Lozza
- Radiation Oncology Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Riccardo Valdagni
- Radiation Oncology Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.,Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Carlo Fallai
- Radiation Oncology Unit 2, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Via Venezian 1, 20133, Milan, Italy
| | - Emanuele Pignoli
- Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Ester Orlandi
- Radiation Oncology Unit 2, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Via Venezian 1, 20133, Milan, Italy.,Radiation Oncology Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| |
Collapse
|
38
|
Thorpe CS, Niska JR, Anderson JD, Girardo ME, McGee LA, Hartsell WF, Larson GL, Tsai HK, Rossi CJ, Rosen LR, Vargas CE. Acute toxicities after proton beam therapy following breast-conserving surgery for breast cancer: Multi-institutional prospective PCG registry analysis. Breast J 2020; 26:1760-1764. [PMID: 32297453 DOI: 10.1111/tbj.13812] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 02/26/2020] [Accepted: 02/27/2020] [Indexed: 11/29/2022]
Abstract
We investigated adverse events (AEs) and clinical outcomes for proton beam therapy (PBT) after breast-conserving surgery (BCS) for breast cancer. From 2012 to 2016, 82 patients received PBT in the prospective multi-institutional Proton Collaborative Group registry. AEs were recorded prospectively at each institution. Median follow-up was 8.1 months. Median dose was 50.4 Gy in 28 fractions. Most patients received a lumpectomy bed boost (90%) and regional nodal irradiation (RNI)(83%). Six patients (7.3%) experienced grade 3 AEs (5 with dermatitis, 5 with breast pain). Body mass index (BMI) was associated with grade 3 dermatitis (P = .015). Fifty-eight patients (70.7%) experienced grade ≥2 dermatitis. PBT including RNI after BCS is well-tolerated. Elevated BMI is associated with grade 3 dermatitis.
Collapse
Affiliation(s)
| | - Joshua R Niska
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | | | - Marlene E Girardo
- Health Sciences Research, Division of Biostatistics, Mayo Clinic, Scottsdale, Arizona
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | | | - Gary L Larson
- ProCure Proton Therapy Center, Oklahoma City, Oklahoma
| | - Henry K Tsai
- ProCure Proton Therapy Center, Somerset, New Jersey
| | - Carl J Rossi
- Scripps Proton Therapy Center, San Diego, California
| | - Lane R Rosen
- Willis-Knighton Proton Therapy Center, Shreveport, Louisiana
| | - Carlos E Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| |
Collapse
|
39
|
Palma G, Monti S, Conson M, Xu T, Hahn S, Durante M, Mohan R, Liao Z, Cella L. NTCP Models for Severe Radiation Induced Dermatitis After IMRT or Proton Therapy for Thoracic Cancer Patients. Front Oncol 2020; 10:344. [PMID: 32257950 PMCID: PMC7090153 DOI: 10.3389/fonc.2020.00344] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 02/27/2020] [Indexed: 12/25/2022] Open
Abstract
Radiation therapy (RT) of thoracic cancers may cause severe radiation dermatitis (RD), which impacts on the quality of a patient's life. Aim of this study was to analyze the incidence of acute RD and develop normal tissue complication probability (NTCP) models for severe RD in thoracic cancer patients treated with Intensity-Modulated RT (IMRT) or Passive Scattering Proton Therapy (PSPT). We analyzed 166 Non-Small-Cell Lung Cancer (NSCLC) patients prospectively treated at a single institution with IMRT (103 patients) or PSPT (63 patients). All patients were treated to a prescribed dose of 60 to 74 Gy in conventional daily fractionation with concurrent chemotherapy. RD was scored according to CTCAE v3 scoring system. For each patient, the epidermis structure (skin) was automatically defined by an in house developed segmentation algorithm. The absolute dose-surface histogram (DSH) of the skin were extracted and normalized using the Body Surface Area (BSA) index as scaling factor. Patient and treatment-related characteristics were analyzed. The Lyman-Kutcher-Burman (LKB) NTCP model recast for DSH and the multivariable logistic model were adopted. Models were internally validated by Leave-One-Out method. Model performance was evaluated by the area under the receiver operator characteristic curve, and calibration plot parameters. Fifteen of 166 (9%) patients developed severe dermatitis (grade 3). RT technique did not impact RD incidence. Total gross tumor volume (GTV) size was the only non dosimetric variable significantly correlated with severe RD (p = 0.027). Multivariable logistic modeling resulted in a single variable model including S20Gy, the relative skin surface receiving more than 20 Gy (OR = 31.4). The cut off for S20Gy was 1.1% of the BSA. LKB model parameters were TD50 = 9.5 Gy, m = 0.24, n = 0.62. Both NTCP models showed comparably high prediction and calibration performances. Despite skin toxicity has long been considered a potential limiting factor in the clinical use of PSPT, no significant differences in RD incidence was found between RT modalities. Once externally validated, the availability of NTCP models for prediction of severe RD may advance treatment planning optimization.
Collapse
Affiliation(s)
- Giuseppe Palma
- Institute of Biostructures and Bioimaging, National Research Council, Naples, Italy.,National Institute for Nuclear Physics, (INFN), Naples, Italy
| | - Serena Monti
- Institute of Biostructures and Bioimaging, National Research Council, Naples, Italy
| | - Manuel Conson
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy
| | - Ting Xu
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Stephen Hahn
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Marco Durante
- GSI Helmholtz Centre for Heavy Ion Research, Department of Biophysics, Darmstadt, Germany
| | - Radhe Mohan
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Zhongxing Liao
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Laura Cella
- Institute of Biostructures and Bioimaging, National Research Council, Naples, Italy.,National Institute for Nuclear Physics, (INFN), Naples, Italy
| |
Collapse
|
40
|
Kern A, Bäumer C, Kröninger K, Mertens L, Timmermann B, Walbersloh J, Wulff J. Determination of surface dose in pencil beam scanning proton therapy. Med Phys 2020; 47:2277-2288. [PMID: 32037577 DOI: 10.1002/mp.14086] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 02/03/2020] [Accepted: 02/03/2020] [Indexed: 11/11/2022] Open
Abstract
PURPOSE/OBJECTIVE Quantification of surface dose within the first few hundred water equivalent µm is challenging. Nevertheless, it is of large interest for the proton therapy community to study dose effects in the skin. The experimental determination is affected by the detector properties, such as the detector volume and material. The International Commission on Radiation Units and Measurements in its report 39 recommends assessing the skin dose at a depth of 0.07 mm. The aim of this study is the estimation of the absorbed dose at and around a depth of 70 µm. We used various dosimetric approaches in conjunction with proton pencil beam scanning delivery to determine the skin dose in a clinical setting. MATERIAL/METHODS Five different detectors were tested for determining the surface dose in water: EBT3 and HD-V2 GAFCHROMIC™ radiochromic film, LiF:Mg,Ti thermoluminescent dosimeter, IBA PPC05 plane-parallel ionization chamber, and PTW 23391 extrapolation chamber. The irradiation setup consisted of quasi-monoenergetic scanned proton pencil beams with kinetic energies of 100, 150, and 226.7 MeV, respectively. Radiochromic films were placed within a vertical stack and in wedge geometry and were analyzed with FilmQA Pro™ adopting triple channel dosimetry. The extrapolation chamber PTW 23391, which served as a reference in the current work, was used in a conventional ionization chamber setup with a fixed electrode gap of 2 mm. Three Kapton® entrance windows with thicknesses of 25, 50, and 75 µm were employed. Thermoluminescent dosimeters were provided as powder and were pressed onto a sheet of aluminum. Furthermore, the Monte Carlo code TOol for PArticle Simulation (TOPAS) in version 3.1.p2 was used to model an IBA pencil beam scanning nozzle and score dose to water in a water phantom. RESULTS The resulting depth dose curves were normalized to their 100% dose at the reference depth of 3 cm. We obtained the skin doses with the extrapolation chamber and with TOPAS. For the experimental approach this resulted in 79.7 ± 0.3%, 86.0 ± 0.6%, and 87.1 ± 0.1% for the proton energies 100, 150, and 226.7 MeV, respectively. The results for TOPAS were 80.1 ± 0.2% (100 MeV), 87.1 ± 0.5% (150 MeV), and 86.9 ± 0.4% (226.7 MeV), respectively. Based on the experimental results of the skin dose, we provided a clinically relevant surface extrapolation factor for the common measurement methods. This allows the result of the first measurement depth of a detector to be scaled to the dose at the skin depth. Most practical would be the use of the surface extrapolation factor for the PPC05 chamber, due to its direct reading, the wide availability in clinics and the low uncertainties. The calculated factors were 0.986 ± 0.004 for 100 MeV, 0.961 ± 0.008 for 150 MeV, and 0.963 ± 0.003 for 226.7 MeV. CONCLUSIONS In this study, dissimilar experimental approaches were evaluated with respect to measurements at depths close to the surface. The experimental depth dose curves are in good agreement with the simulation with TOPAS Monte Carlo. To the author's knowledge this was the first experimental determination of the skin dose according to the International Commission on Radiation Units and Measurements 39 definition in proton pencil beam scanning.
Collapse
Affiliation(s)
- A Kern
- West German Proton Therapy Center Essen (WPE), Essen, 45147, Germany.,University Hospital Essen, Essen, 45147, Germany.,Experimentelle Physik IV, TU Dortmund University, Dortmund, 44227, Germany.,West German Cancer Center (WTZ), Essen, 45147, Germany
| | - C Bäumer
- West German Proton Therapy Center Essen (WPE), Essen, 45147, Germany.,University Hospital Essen, Essen, 45147, Germany.,Experimentelle Physik IV, TU Dortmund University, Dortmund, 44227, Germany.,West German Cancer Center (WTZ), Essen, 45147, Germany.,German Cancer Consortium (DKTK), Heidelberg, 69120, Germany
| | - K Kröninger
- Experimentelle Physik IV, TU Dortmund University, Dortmund, 44227, Germany
| | - L Mertens
- University Medical Center Mannheim, University of Heidelberg, Mannheim, 68167, Germany
| | - B Timmermann
- West German Proton Therapy Center Essen (WPE), Essen, 45147, Germany.,University Hospital Essen, Essen, 45147, Germany.,West German Cancer Center (WTZ), Essen, 45147, Germany.,German Cancer Consortium (DKTK), Heidelberg, 69120, Germany.,Clinic for Particle Therapy, Essen, 45147, Germany
| | - J Walbersloh
- Materialprüfungsamt Nordrhein-Westfalen, Dortmund, 44287, Germany
| | - J Wulff
- West German Proton Therapy Center Essen (WPE), Essen, 45147, Germany.,University Hospital Essen, Essen, 45147, Germany.,West German Cancer Center (WTZ), Essen, 45147, Germany
| |
Collapse
|
41
|
DeCesaris C, Rice SR, Bentzen SM, Jatczak J, Mishra MV, Mossahebi S, Nichols EM. In Reply to Tommasino et al. Int J Radiat Oncol Biol Phys 2019; 105:677-678. [DOI: 10.1016/j.ijrobp.2019.06.2548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 06/20/2019] [Accepted: 06/25/2019] [Indexed: 11/30/2022]
|
42
|
Tommasino F, Cella L, Farace P. In Regard to DeCesaris et al. Int J Radiat Oncol Biol Phys 2019; 105:676-677. [PMID: 31540598 DOI: 10.1016/j.ijrobp.2019.06.2547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 05/22/2019] [Accepted: 06/25/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Francesco Tommasino
- University of Trento, Department of Physics, Trento, Italy; Istituto Nazionale di Fisica Nucleare, Trento Institute for Fundamental Physics and Applications, Trento, Italy
| | - Laura Cella
- National Research Council Institute of Biostructures and Bioimaging, Napoli, Italy
| | - Paolo Farace
- Protontherapy Department, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| |
Collapse
|