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Rubino F, Brahimaj B, Hanna EY, Su SY, Phan J, Grosshans DR, DeMonte F, Raza SM. Does Time to Initiation of Adjuvant Radiotherapy Affect Reconstruction Outcomes after Endoscopic Resection of Skull Base Malignancies? J Neurol Surg B Skull Base 2024; 85:445-457. [PMID: 39228888 PMCID: PMC11368463 DOI: 10.1055/a-2114-4563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 06/19/2023] [Indexed: 09/05/2024] Open
Abstract
Introduction and Objective It is unclear if the length of the time interval to initiation of adjuvant radiation therapy (RT) after endoscopic endonasal surgery affects reconstruction outcomes. In this study we present our experience with adjuvant RT after endoscopic endonasal procedures, to determine if the time to RT after surgery impacts post-RT reconstruction complication rates. Methods A retrospective cohort study of 164 patients who underwent endoscopic endonasal surgery between 1998 and 2021 was conducted. Using Cox proportional hazard ratios (HRs), we evaluated several variables and the complications that occurred during the 1-year period after starting RT. Results Seventy-eight (47.5%) and eighty-six patients (52.5%) received RT before and after the sixth postoperative week, respectively. The overall post-RT complication rates were 28%, most of these were severe infections ( n = 20, 12.2%) and delayed CSF leak ( n = 4, 2.5%). There was no significant difference in the post-RT complications between the patients who received postoperative RT before or after the sixth operative week (HR: 1.13; 95% confidence interval: 0.63-2.02; p = 0.675 ). Univariate analysis demonstrated negative impact associated with smoking history ( p = 0.015 ), the use of neoadjuvant chemotherapy ( p = 0.0001 ), and the use of photon therapy ( p = 0.012 ); and we found a positive impact with the use of multilayer reconstruction techniques (overall, p = 0.041 ; with fat, p = 0.038 ; and/or fascia graft, p = 0.035 ). After a multivariate analysis only, smoking history was an independent risk factor for post-RT complications ( p = 0.012 ). Conclusion Delaying RT for more than 6 weeks after endoscopic endonasal surgery does not provide a significant benefit for reconstruction outcomes. However, special attention may be warranted in patients with smoking history who have received neoadjuvant chemotherapy, or in patients who will receive photon-based RT after surgery as these groups were found to have increased complication rates post-RT.
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Affiliation(s)
- Franco Rubino
- Division of Surgery, Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Bledi Brahimaj
- Division of Surgery, Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Ehab Y. Hanna
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Shirley Y. Su
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Jack Phan
- Division of Radiation Oncology, Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - David R. Grosshans
- Division of Radiation Oncology, Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Franco DeMonte
- Division of Surgery, Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Shaan M. Raza
- Division of Surgery, Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
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Nowicka-Matus K, Friborg J, Hansen C, Bernsdorf M, Elstrøm U, Farhadi M, Grau C, Eriksen J, Johansen J, Nielsen M, Holm A, Samsøe E, Sibolt P, Smulders B, Jensen K. Acute toxicities in proton therapy for head and neck cancer - A matched analysis of the DAHANCA 35 feasibility study. Clin Transl Radiat Oncol 2024; 48:100835. [PMID: 39189000 PMCID: PMC11345689 DOI: 10.1016/j.ctro.2024.100835] [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: 04/21/2024] [Revised: 07/30/2024] [Accepted: 07/30/2024] [Indexed: 08/28/2024] Open
Abstract
Background and purpose As preparation for a national randomized study comparing proton radiotherapy to photon radiotherapy, DAHANCA 35, we performed a non-randomized pilot study to investigate patient selection, logistics, planning, and treatment delivery. With the present study, as a comprehensive safety analysis, we want to compare toxicity during and up to two months after therapy to a historically matched group of patients treated with photon radiotherapy. Materials and methods 62 patients treated with protons were matched to 124 patients who received photon treatment outside a protocol. Available data were retrieved from the DAHANCA database. Patients were matched on treatment centre, concurrent chemotherapy, tumour site, stage, p16 status for oropharynx cancers. Selection of patients for proton therapy was based on comparative treatment plans with a NTCP reduction for dysphagia and xerostomia at six months. Results Baseline characteristics between groups were well balanced, except for the type of drug used concurrently; more photon patients received Carboplatin (21.2 % vs 5.8 %, p = 0.01). Proton therapy was associated with significantly less weight loss at the end of treatment, mean weight loss of 3 % for protons and 5 % for photons (p < 0.001). There were more grade 3 skin reactions and grade 3 mucositis after proton treatment compared with photons at the end of treatment, Risk Ratio (RR) 1.9 (95 % CI: 1.01-3.5, p = 0.04) and RR 1.5 (95 % CI: 1.3-1.7, p < 0.001), respectively. All differences resolved at follow up two months after treatment. There were no significant differences between groups on opioid use, use of feeding tubes, or hospitalization during the observation period. Conclusion Proton treatment resulted in excess objective mucositis and dermatitis, which was transient and did not seem to negatively influence weight or treatment compliance and intensity. Selection bias was likely especially since NTCP models were used for selection of proton treatment and photon treated patients were matched manually. We are currently including patients in a randomized controlled trial.
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Affiliation(s)
- K. Nowicka-Matus
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Dept of Oncology, Aalborg University Hospital, Aalborg, Denmark
| | - J. Friborg
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Dept of Oncology, Rigshospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - C.R. Hansen
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - M. Bernsdorf
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Dept of Oncology, Rigshospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - U.V. Elstrøm
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - M. Farhadi
- Dept of Oncology, Zealand University Hospital, Naestved, Denmark
| | - C. Grau
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Dept of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - J.G. Eriksen
- Dept of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
- Dept of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - J. Johansen
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Dept of Oncology, Odense University Hospital, Odense, Denmark
| | - M.S. Nielsen
- Dept of Oncology, Aalborg University Hospital, Aalborg, Denmark
| | - A. Holm
- Dept of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - E. Samsøe
- Dept of Oncology, Zealand University Hospital, Naestved, Denmark
| | - P. Sibolt
- Dept of Oncology, Herlev Hospital, Herlev, Denmark
| | - B. Smulders
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Dept of Oncology, Rigshospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - K. Jensen
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
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Kubeš J, Al-Hamami S, Sláviková S, Vítek P, Haas A, Dědečková K, Ondrová B, Andrlik M, Navrátil M, Rotnáglová E, Vondráček V. Proton pencil beam scanning radiotherapy in the postoperative treatment of p16 positive squamous cell tonsillar cancer - evaluation of toxicity and effectivity. Eur Arch Otorhinolaryngol 2024:10.1007/s00405-024-08747-1. [PMID: 39198306 DOI: 10.1007/s00405-024-08747-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 05/20/2024] [Indexed: 09/01/2024]
Abstract
PURPOSE Patients with p16 positive tonsillar cancer (p16 + TC) have an excellent prognosis and long-life expectancy. Deintensification of therapy is a prevalent topic of discussion. Proton radiotherapy is one way to reduce radiation exposure and thus reduce acute and late toxicity. The aim is to evaluate treatment outcomes and toxicity of postoperative treatment with intensity-modulated proton therapy (IMPT). METHODS Between September 2013 and November 2021, 47 patients with p16 + TC were treated postoperatively with IMPT. Median age was 54.9 (38.2-74.9) years, 31 were males and 16 were females. All patients had squamous cell carcinoma and underwent surgery as a primary treatment. Median dose of radiotherapy was 66 GyE in 33 fractions. Bilateral neck irradiation was used in 39 patients and unilateral in 8. Concomitant chemotherapy was applied in 24 patients. RESULTS Median follow-up time was 4.2 (0.15-9.64) years. Five-year overall survival, relapse free survival and local control were 95.7%, 97.8% and 100%. The most common acute toxicities were dermatitis and mucositis, with grade 2 + in 61.7% and 70.2% of patients. No acute percutaneous gastrostomy insertion was necessary and intravenous rehydration was used in 12.8% of patients. The most common late toxicity was grade 1 xerostomia in 70.2% of patients and grade 2 in 10.6% of patients. Subcutaneous fibrosis of grades 2 and 3 occurred in 17.0% and 2.1% of patients, respectively. One patient developed late severe dysphagia and became PEG-dependent. CONCLUSION IMPT for the postoperative treatment of p16 + TC is feasible with excellent efficiency and acceptable acute and late toxicity.
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Affiliation(s)
- Jiří Kubeš
- Proton Therapy Center Czech, Budínova 1a, Prague 8, 18000, Czech Republic
- Department of Health Care Disciplines and Population Protection, Faculty of Biomedical Engineering, Czech Technical University Prague, Sítná square 3105, Kladno, 272 01, Czech Republic
| | - Sarah Al-Hamami
- Proton Therapy Center Czech, Budínova 1a, Prague 8, 18000, Czech Republic
| | - Silvia Sláviková
- Proton Therapy Center Czech, Budínova 1a, Prague 8, 18000, Czech Republic
| | - Pavel Vítek
- Proton Therapy Center Czech, Budínova 1a, Prague 8, 18000, Czech Republic
| | - Alexandra Haas
- Proton Therapy Center Czech, Budínova 1a, Prague 8, 18000, Czech Republic
| | - Kateřina Dědečková
- Proton Therapy Center Czech, Budínova 1a, Prague 8, 18000, Czech Republic
| | - Barbora Ondrová
- Proton Therapy Center Czech, Budínova 1a, Prague 8, 18000, Czech Republic
| | - Michal Andrlik
- Proton Therapy Center Czech, Budínova 1a, Prague 8, 18000, Czech Republic.
| | - Matěj Navrátil
- Proton Therapy Center Czech, Budínova 1a, Prague 8, 18000, Czech Republic
| | - Eliška Rotnáglová
- Proton Therapy Center Czech, Budínova 1a, Prague 8, 18000, Czech Republic
| | - Vladimír Vondráček
- Proton Therapy Center Czech, Budínova 1a, Prague 8, 18000, Czech Republic
- Department of Health Care Disciplines and Population Protection, Faculty of Biomedical Engineering, Czech Technical University Prague, Sítná square 3105, Kladno, 272 01, Czech Republic
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Vasudevan SS, Deeb H, Katta A, Olinde L, Pang J, Asarkar AA, Katz S, Nathan CAO. Efficacy and safety of proton therapy versus intensity-modulated radiation therapy in the treatment of head and neck tumors: A systematic review and meta-analysis. Head Neck 2024. [PMID: 39007360 DOI: 10.1002/hed.27877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 06/19/2024] [Accepted: 07/07/2024] [Indexed: 07/16/2024] Open
Abstract
To comprehensively evaluate the therapeutic efficacy and safety when utilizing proton therapy (PT) versus intensity-modulated radiation therapy (IMRT) in head and neck cancer patients. Pubmed, ScienceDirect, Embase, Scopus, and Web of Science were systematically searched for studies on comparative PT and IMRT outcomes. We performed a random effect model meta-analysis to estimate the hazard ratio (HR) and odds ratio (OR) for efficacy and safety outcome variables between PT and IMRT. From 641 identified articles, 11 studies met the inclusion criteria, comprising 3087 patients (606 treated with PT and 2481 with IMRT). On toxicity analysis, PT is associated with decreased acute grade 1 nausea (OR = 0.34, 95% CI: 0.13-0.84, p = 0.02) compared to IMRT. In grade 2 toxicity, PT showed significant advantages over IMRT in mucositis (OR = 0.44, p < 0.0001), dysgeusia (OR = 0.35, p = 0.02), dysphagia (OR = 0.36, p < 0.0001), fatigue (OR = 0.29, p = 0.001), pain (OR = 0.34, p = 0.01), and weight loss (OR = 0.54, p = 0.02). Proton therapy also exhibited increased safety in grade 3 dysphagia incidence (OR = 0.44, p < 0.0001) compared to IMRT. PT demonstrated improved overall survival (OS) compared to IMRT across multiple time points: 1-year OS (HR = 0.43, p = 0.02), 2-year OS (HR = 0.44, p < 0.0001), and 5-year OS (HR = 0.78, p = 0.004). In terms of disease-free survival (DFS), PT also showed improved outcomes at 2-year DFS (HR = 0.65, p = 0.03) and 5-year DFS (HR = 0.81, p = 0.03). Proton therapy demonstrated superior overall survival (OS), disease-free survival (DFS), and better local control rate (LCR) compared to IMRT. The data also showed better safety outcomes in PT patients, particularly when involving grade 2 acute toxicity events.
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Affiliation(s)
- Srivatsa Surya Vasudevan
- Department of Otolaryngology - Head and Neck Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Haya Deeb
- Department of Medicine, Faculty of Medicine, Damascus University, Damascus, Syria
| | - Anuhya Katta
- Department of Academics, Jonelta Foundation School of Medicine, University of Perpetual Help System Dalta, Las Piñas, Philippines
| | - Lindsay Olinde
- Department of Otolaryngology - Head and Neck Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - John Pang
- Department of Otolaryngology - Head and Neck Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Ameya A Asarkar
- Department of Otolaryngology - Head and Neck Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Sanford Katz
- Department of Radiation Oncology, Willis-Knighton Cancer Center, Shreveport, Louisiana, USA
| | - Cherie-Ann O Nathan
- Department of Otolaryngology - Head and Neck Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
- Department of Surgery, Overton Brooks Veterans Administration Medical Center, Shreveport, Louisiana, USA
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Romanò R, De Felice F, Ferri A, Della Monaca M, Maroldi R, Licitra L, Locati LD, Alfieri S. Adenoid Cystic carcinoma of minor salivary glands (AdCCmSG): a multidisciplinary update. Expert Rev Anticancer Ther 2024; 24:567-580. [PMID: 38832770 DOI: 10.1080/14737140.2024.2357806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 05/16/2024] [Indexed: 06/05/2024]
Abstract
INTRODUCTION Adenoid cystic carcinoma of minor salivary glands (AdCCmSG) represents a 'rarity in the rarity,' posing a clinical challenge in lack of standardized, evidence-based recommendations. At present, AdCCmSG management is mostly translated from major salivary gland cancers (MSGCs). Ideally, AdCCmSG diagnostic-therapeutic workup should be discussed and carried out within a multidisciplinary, high-expertise setting, including pathologists, surgeons, radiation oncologists and medical oncologists. AREAS COVERED The present review provides an overview of epidemiology and pathologic classification. Moreover, the most recent, clinically relevant updates in the treatment of AdCCmSG (Pubmed searches, specific guidelines) are critically discussed, aiming to a better understanding of this rare pathologic entity, potentially optimizing the care process, and offering a starting point for reflection on future therapeutic developments. EXPERT OPINION The management of rare cancers is often hindered by limited data and clinical trials, lack of evidence-based guidelines, and hardly represented disease heterogeneity, which cannot be successfully tackled with a 'one-size-fits-all' approach. Our goal is to address these potential pitfalls, providing an easy-to-use, updated, multidisciplinary collection of expert opinions concerning AdCCmSG management as of today's clinical practice. We will also cover the most promising future perspectives, based on the potential therapeutic targets highlighted within AdCCmSG's molecular background.
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Affiliation(s)
- Rebecca Romanò
- Head and Neck Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Francesca De Felice
- Department of Radiotherapy, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - Andrea Ferri
- Maxillo-Facial Surgery Division, Head and Neck Department, University Hospital of Parma, Parma, Italy
| | - Marco Della Monaca
- Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Rome, Italy
- Oncological and Reconstructive Maxillo-Facial Surgery Unit, Policlinico Umberto I, Rome, Italy
| | - Roberto Maroldi
- Division of Radiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Lisa Licitra
- Head and Neck Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
- University of Milan, Milan, Italy
| | - Laura Deborah Locati
- Translational Oncology Unit, Istituto di Ricerca e Cura a carattere scientifico (IRCCS) Istituti Clinici Scientifici (ICS) Maugeri, Pavia, Italy
- Department of Internal Medicine and Medical Therapy, University of Pavia, Pavia, Italy
| | - Salvatore Alfieri
- Head and Neck Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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Yahya N, Mohamad Salleh SA, Mohd Nasir NF, Abdul Manan H. Toxicity profile of patients treated with proton and carbon-ion therapy for primary nasopharyngeal carcinoma: A systematic review and meta-analysis. Asia Pac J Clin Oncol 2024; 20:240-250. [PMID: 36683266 DOI: 10.1111/ajco.13915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 07/29/2022] [Accepted: 12/05/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Proton and carbon-ion therapy may spare normal tissues in regions with many critical structures surrounding the target volume. As toxicity outcome data are emerging, we aimed to synthesize the published data for the toxicity outcomes of proton or carbon-ion therapy (together known as particle beam therapy [PBT]) for primary nasopharyngeal carcinoma (NPC). MATERIALS AND METHODS We searched PubMed and Scopus electronic databases to identify original studies reporting toxicity outcomes following PBT of primary NPC. Quality assessment was performed using NIH's Quality Assessment Tool. Reports were extracted for information on demographics, main results, and clinical and dose factors correlates. Meta-analysis was performed using the random-effects model. RESULTS Twelve studies were selected (six using mixed particle-photon beams, five performed comparisons to photon-based therapy). The pooled event rates for acute grade ≥2 toxicities mucositis, dermatitis, xerostomia weight loss are 46% (95% confidence interval [95% CI]-29%-64%, I2 = 87%), 47% (95% CI-28%-67%, I2 = 87%), 16% (95% CI-9%-29%, I2 = 76%), and 36% (95% CI-27%-47%, I2 = 45%), respectively. Only one late endpoint (xerostomia grade ≥2) has sufficient data for analysis with pooled event rate of 9% (95% CI-3%-29%, I2 = 77%), lower than intensity-modulated radiotherapy 27% (95% CI-10%-54%, I2 = 95%). For most endpoints with significant differences between the PBT and photon-based therapies, PBT resulted in better outcomes. In two studies where dose distribution was studied, doses to the organs at risk were independent risk factors for toxicities. CONCLUSION PBT may reduce the risk of acute toxicities for patients treated for primary NPC, likely due to dose reduction to critical structures. The pooled event rate for toxicities derived in this study can be a guide for patient counseling.
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Affiliation(s)
- Noorazrul Yahya
- Diagnostic Imaging and Radiotherapy, CODTIS, Faculty of Health Sciences, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Siti Athiyah Mohamad Salleh
- Diagnostic Imaging and Radiotherapy, CODTIS, Faculty of Health Sciences, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Nurul Faiqah Mohd Nasir
- Functional Image Processing Laboratory, Department of Radiology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Hanani Abdul Manan
- Functional Image Processing Laboratory, Department of Radiology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
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Zlygosteva O, Juvkam IS, Arous D, Sitarz M, Sørensen BS, Ankjærgaard C, Andersen CE, Galtung HK, Søland TM, Edin NJ, Malinen E. Acute normal tissue responses in a murine model following fractionated irradiation of the head and neck with protons or X-rays. Acta Oncol 2023; 62:1574-1580. [PMID: 37703217 DOI: 10.1080/0284186x.2023.2254481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 08/26/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND The purpose of this study was to investigate acute normal tissue responses in the head and neck region following proton- or X-irradiation of a murine model. MATERIALS AND METHODS Female C57BL/6J mice were irradiated with protons (25 or 60 MeV) or X-rays (100 kV). The radiation field covered the oral cavity and the major salivary glands. For protons, two different treatment plans were used, either with the Bragg Peak in the middle of the mouse (BP) or outside the mouse (transmission mode; TM). Delivered physical doses were 41, 45, and 65 Gy given in 6, 7, and 10 fractions for BP, TM, and X-rays, respectively. Alanine dosimetry was used to assess delivered doses. Oral mucositis and dermatitis were scored using CTC v.2.0-based tables. Saliva was collected at baseline, right after end of irradiation, and at day 35. RESULTS The measured dose distribution for protons (TM) and X-rays was very similar. Oral mucositis appeared earlier, had a higher score and was found in a higher percentage of mice after proton irradiation compared to X-irradiation. Dermatitis, on the other hand, had a similar appearance after protons and X-rays. Compared to controls, saliva production was lower right after termination of proton- and X-irradiation. The BP group demonstrated saliva recovery compared to the TM and X-ray group at day 35. CONCLUSION With lower delivered doses, proton irradiation resulted in similar skin reactions and increased oral mucositis compared to X-irradiation. This indicates that the relative biological effectiveness of protons for acute tissue responses in the mouse head and neck is greater than the clinical standard of 1.1. Thus, there is a need for further investigations of the biological effect of protons in normal tissues.
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Affiliation(s)
- Olga Zlygosteva
- Department of Physics, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Inga Solgård Juvkam
- Institute of Oral Biology, Faculty of Dentistry, University of Oslo, Oslo, Norway
| | - Delmon Arous
- Department of Medical Physics, Cancer Clinic, Oslo University Hospital, Oslo, Norway
| | - Mateusz Sitarz
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Brita Singers Sørensen
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Claus E Andersen
- Department of Health Technology, Technical University of Denmark, Roskilde, Denmark
| | - Hilde Kanli Galtung
- Institute of Oral Biology, Faculty of Dentistry, University of Oslo, Oslo, Norway
| | - Tine Merete Søland
- Institute of Oral Biology, Faculty of Dentistry, University of Oslo, Oslo, Norway
- Department of Pathology, Oslo University Hospital, Oslo, Norway
| | - Nina Jeppesen Edin
- Department of Physics, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Eirik Malinen
- Department of Physics, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Department of Medical Physics, Cancer Clinic, Oslo University Hospital, Oslo, Norway
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Mendenhall WM, Beitler JJ, Saba NF, Shaha AR, Nuyts S, Strojan P, Bollen H, Cohen O, Smee R, Ng SP, Eisbruch A, Ng WT, Kirwan JM, Ferlito A. Proton Beam Radiation Therapy for Oropharyngeal Squamous Cell Carcinoma. Int J Part Ther 2023; 9:243-252. [PMID: 37169005 PMCID: PMC10166016 DOI: 10.14338/ijpt-22-00030.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 03/10/2023] [Indexed: 05/13/2023] Open
Abstract
Purpose To discuss the role of proton beam therapy (PBT) in the treatment of patients with oropharyngeal squamous cell carcinoma (OPSCC). Materials and Methods A review of the pertinent literature. Results Proton beam therapy likely results in reduced acute and late toxicity as compared with intensity-modulated radiation therapy (IMRT). The extent of the reduced toxicity, which may be modest, depends on the endpoint and technical factors such as pencil beam versus passive scattered PBT and adaptive replanning. The disease control rates after PBT are likely similar to those after IMRT. Conclusion Proton beam therapy is an attractive option to treat patients with OPSCC. Whether it becomes widely available depends on access.
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Affiliation(s)
- William M. Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Jonathan J. Beitler
- Harold Alfonds Center for Cancer Care, Maine General Hospital, Augusta, ME, USA
| | - Nabil F. Saba
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | - Ashok R. Shaha
- Department of Head and Neck Surgery and Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sandra Nuyts
- Department of Radiation Oncology, Leuven Cancer Institute, University Hospitals Leuven, KU Leuven - University of Leuven, Leuven, Belgium
- Laboratory of Experimental Radiotherapy, Department of Oncology, University of Leuven, Leuven, Belgium
| | - Primož Strojan
- Department of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia
| | - Heleen Bollen
- Department of Radiation Oncology, Leuven Cancer Institute, University Hospitals Leuven, KU Leuven - University of Leuven, Leuven, Belgium
| | - Oded Cohen
- Department of Otolaryngology - Head and Neck Surgery and Oncology, Soroka Medical Center, Tel Aviv, Affiliated with Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Robert Smee
- Department of Radiation Oncology, The Prince of Wales Cancer Centre, Sydney, NSW, Australia
| | - Sweet Ping Ng
- Department of Radiation Oncology, Olivia Newton-John Cancer Centre, Austin Health, Melbourne, Australia
| | - Avraham Eisbruch
- Department of Radiation Oncology, University of Michigan Medicine, Ann Arbor, Michigan, USA
| | - Wai Tong Ng
- Department of Clinical Oncology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Jessica M. Kirwan
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group, Padua, Italy
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Yahya N, Manan HA. Quality of Life and Patient-Reported Outcomes Following Proton Therapy for Oropharyngeal Carcinoma: A Systematic Review. Cancers (Basel) 2023; 15:cancers15082252. [PMID: 37190180 DOI: 10.3390/cancers15082252] [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: 12/08/2022] [Revised: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Complex anatomy surrounding the oropharynx makes proton therapy (PT), especially intensity-modulated PT (IMPT), a potentially attractive option due to its ability to reduce the volume of irradiated healthy tissues. Dosimetric improvement may not translate to clinically relevant benefits. As outcome data are emerging, we aimed to evaluate the evidence of the quality of life (QOL) and patient-reported outcomes (PROs) following PT for oropharyngeal carcinoma (OC). MATERIALS AND METHODS We searched PubMed and Scopus electronic databases (date: 15 February 2023) to identify original studies on QOL and PROs following PT for OC. We employed a fluid strategy in the search strategy by tracking citations of the initially selected studies. Reports were extracted for information on demographics, main results, and clinical and dose factor correlates. Quality assessment was performed using the NIH's Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. The PRISMA guidelines were followed in the preparation of this report. RESULTS Seven reports were selected, including one from a recently published paper captured from citation tracking. Five compared PT and photon-based therapy, although none were randomized controlled trials. Most endpoints with significant differences favored PT, including xerostomia, cough, need for nutritional supplements, dysgeusia, food taste, appetite, and general symptoms. However, some endpoints favored photon-based therapy (sexual symptoms) or showed no significant difference (e.g., fatigue, pain, sleep, mouth sores). The PROs and QOL improve following PT but do not appear to return to baseline. CONCLUSION Evidence suggests that PT causes less QOL and PRO deterioration than photon-based therapy. Biases due to the non-randomized study design remain obstacles to a firm conclusion. Whether or not PT is cost-effective should be the subject of further investigation.
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Affiliation(s)
- Noorazrul Yahya
- Diagnostic Imaging and Radiotherapy, Center for Diagnostic, Therapeutic and Investigative Studies (CODTIS), Faculty of Health Sciences, National University of Malaysia, Jalan Raja Muda Aziz, Kuala Lumpur 50300, Malaysia
| | - Hanani Abdul Manan
- Functional Image Processing Laboratory, Department of Radiology, Universiti Kebangsaan Malaysia Medical Centre, Cheras, Kuala Lumpur 56000, Malaysia
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10
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Kutuk T, McAllister NC, Rzepczynski AE, Williams A, Young G, Crawley MB, Rabinowits G, Kaiser A, Contreras JA, Kalman NS. Submandibular gland transfer for the prevention of radiation-induced xerostomia in oropharyngeal cancer: Dosimetric impact in the intensity modulated radiotherapy era. Head Neck 2022; 44:1213-1222. [PMID: 35243719 DOI: 10.1002/hed.27021] [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: 11/04/2021] [Revised: 02/14/2022] [Accepted: 02/17/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Submandibular gland (SMG) transfer decreased radiation-associated xerostomia in the 2/3-dimensional radiotherapy era. We evaluated the dosimetric implications of SMG transfer on modern intensity modulated radiotherapy (IMRT) plans. METHODS Eighteen oropharynx cancer patients underwent SMG transfer followed by IMRT; reoptimized plans using the baseline SMG location were generated. Mean salivary gland, oral cavity, and larynx doses were compared between clinical plans and reoptimized plans. RESULTS No statistically significant difference in mean SMG dose (27.53 Gy vs. 29.61 Gy) or total salivary gland dose (26.12 Gy vs. 26.41 Gy) was observed with or without SMG transfer (all p > 0.05). Mean oral cavity and larynx doses were not statistically different. Neither tumor site, target volume crossing midline, stage, nor salivary gland volumes were associated with mean doses. CONCLUSIONS Salivary gland doses were similar with or without SMG transfer. IMRT likely decreases the benefit of SMG transfer on the risk of radiation-associated xerostomia.
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Affiliation(s)
- Tugce Kutuk
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Nicole C McAllister
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Amy E Rzepczynski
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Andre Williams
- Office of Clinical Research, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Geoffrey Young
- Department of Surgical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Meghan B Crawley
- Department of Surgical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Guilherme Rabinowits
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA.,Department of Hematology/Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Adeel Kaiser
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Jessika A Contreras
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Noah S Kalman
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
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11
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Wright CM, Lee DY, Kim M, Barsky AR, Teo BKK, Lukens JN, Swisher-McClure S, Lin A. Tubarial salivary gland sparing with proton therapy. Med Dosim 2022; 47:222-226. [DOI: 10.1016/j.meddos.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 02/23/2022] [Accepted: 03/08/2022] [Indexed: 11/17/2022]
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12
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Belotti A, Carpenito L, Bulfamante AM, Maccari A, Bulfamante G. Sinonasal teratocarcinosarcoma treated with surgery and proton beam therapy: clinical, histological aspects and differential diagnosis of a new case. Pathologica 2022; 113:469-474. [PMID: 34974554 PMCID: PMC8720401 DOI: 10.32074/1591-951x-215] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 04/06/2021] [Indexed: 12/03/2022] Open
Abstract
Sinonasal teratocarcinosarcoma is a rare aggressive malignant tumor with a primary setting involving the nasal cavity followed by the ethmoid sinus and maxillary sinus. It accounts for approximately 3% of all head and neck cancers and less than 1% of all tumors. Nasal obstruction, recurrent epistaxis and headache represent the typical clinical presentation. Imaging shows the presence of a mass in the nasal cavity. The treatment usually consists of surgery and adjuvant intensity modulated radiotherapy. The rarity and the variability of the histological features make its diagnosis particularly difficult. In this paper, we report a case of sinonasal teratocarcinosarcoma in a 62-year-old male treated with a multidisciplinary approach. As an alternative to intensity modulated radiotherapy, we proposed proton beam therapy for the first time. The patient benefited from the new and personalized protocol that provided excellent results and few adverse effects. At 45 months follow-up there is no evidence of relapse and the patient is in good health.
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Affiliation(s)
- Alessia Belotti
- Human Pathology and Medical Genetic Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy
| | - Laura Carpenito
- Human Pathology and Medical Genetic Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy
| | - Antonio Mario Bulfamante
- Otolaryngology Unit, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Alberto Maccari
- Otolaryngology Unit, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Gaetano Bulfamante
- Human Pathology and Medical Genetic Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy
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13
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Jeans EB, Shiraishi S, Manzar G, Morris LK, Amundson A, McGee LA, Rwigema JC, Neben-Wittich M, Routman DM, Ma DJ, Patel SH, Foote RL, Lester SC. An comparison of acute toxicities and patient-reported outcomes between intensity-modulated proton therapy and volumetric-modulated arc therapy after ipsilateral radiation for head and neck cancers. Head Neck 2021; 44:359-371. [PMID: 34859516 DOI: 10.1002/hed.26937] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 10/27/2021] [Accepted: 11/05/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Intensity-modulated proton therapy (IMPT) demonstrates superior dose distribution over volumetric-modulated arc therapy (VMAT) for sparing organs-at-risk (OARs) in ipsilateral radiotherapy. To determine a clinical benefit, assessment of patient-reported outcomes (PRO) and physician-reported toxicities alongside a dosimetric analysis is needed. METHODS Plans were analyzed for dosimetric differences. PROs were compared for patients undergoing ipsilateral curative-intent radiotherapy for tonsil and salivary gland cancers with VMAT or IMPT from 2015 to 2020. Physician-reported toxicities were compared. RESULTS In 40 patients, IMPT was associated with decreased dose to multiple OARs and less deterioration in the following PROs: pain, swallowing function, dry mouth, sticky saliva, sensory change, cough, speech, feeling ill, and social eating. Physician-reported toxicities demonstrated less oral pain. CONCLUSION IMPT is associated with decreased dose to OARs and less patient-reported acute deterioration in multiple head and neck domains. A strong consideration for IMPT in ipsilateral head and neck patients with cancer is warranted.
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Affiliation(s)
- Elizabeth B Jeans
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Satomi Shiraishi
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Gohar Manzar
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lindsay K Morris
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Adam Amundson
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | | | | | - David M Routman
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel J Ma
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Samir H Patel
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Scott C Lester
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
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14
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Mohamed N, Lee A, Lee NY. Proton beam radiation therapy treatment for head and neck cancer. PRECISION RADIATION ONCOLOGY 2021. [DOI: 10.1002/pro6.1135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- Nader Mohamed
- Department of Radiation Oncology Memorial Sloan Kettering Cancer Center New York NY USA
| | - Anna Lee
- Department of Radiation Oncology The University of Texas MD Anderson Cancer Center Houston TX USA
| | - Nancy Y. Lee
- Department of Radiation Oncology Memorial Sloan Kettering Cancer Center New York NY USA
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15
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Wright CM, Baron J, Lee DY, Kim M, Barsky AR, Teo BKK, Lukens JN, Swisher-McClure S, Lin A. Dosimetric Results for Adjuvant Proton Radiation Therapy of HPV-Associated Oropharynx Cancer. Int J Part Ther 2021; 8:47-54. [PMID: 35530184 PMCID: PMC9009460 DOI: 10.14338/ijpt-d-21-00018] [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: 05/04/2021] [Accepted: 10/11/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose One significant advantage of proton therapy is its ability to improve normal tissue sparing and toxicity mitigation, which is relevant in the treatment of oropharyngeal squamous cell carcinoma (OPSCC). Here, we report our institutional experience and dosimetric results with adjuvant proton radiation therapy (PRT) versus intensity-modulated radiotherapy (IMRT) for Human Papilloma Virus (HPV)-associated OPSCC. Materials and Methods This was a retrospective, single institutional study of all patients treated with adjuvant PRT for HPV-associated OPSCC from 2015 to 2019. Each patient had a treatment-approved equivalent IMRT plan to serve as a reference. Endpoints included dosimetric outcomes to the organs at risk (OARs), local regional control (LRC), progression-free survival (PFS), and overall survival (OS). Descriptive statistics, a 2-tailed paired t test for dosimetric comparisons, and the Kaplan-Meier method for disease outcomes were used. Results Fifty-three patients were identified. Doses delivered to OARs compared favorably for PRT versus IMRT, particularly for the pharyngeal constrictors, esophagus, larynx, oral cavity, and submandibular and parotid glands. The achieved normal tissue sparing did not negatively impact disease outcomes, with 2-year LRC, PFS, and OS of 97.0%, 90.3%, and 97.5%, respectively. Conclusion Our study suggests that meaningful normal tissue sparing in the postoperative setting is achievable with PRT, without impacting disease outcomes.
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Affiliation(s)
| | - Jonathan Baron
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel Y. Lee
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Michele Kim
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew R. Barsky
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Boon-Keng Kevin Teo
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - John N. Lukens
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Alexander Lin
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
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16
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Gordon KB, Smyk DI, Gulidov IA. Proton Therapy in Head and Neck Cancer Treatment: State of the Problem and Development Prospects (Review). Sovrem Tekhnologii Med 2021; 13:70-80. [PMID: 34603766 PMCID: PMC8482826 DOI: 10.17691/stm2021.13.4.08] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Indexed: 11/24/2022] Open
Abstract
Proton therapy (PT) due to dosimetric characteristics (Bragg peak formation, sharp dose slowdown) is currently one of the most high-tech techniques of radiation therapy exceeding the standards of photon methods. In recent decades, PT has traditionally been used, primarily, for head and neck cancers (HNC) including skull base tumors. Regardless of the fact that recently PT application area has significantly expanded, HNC still remain a leading indication for proton radiation since PT’s physic-dosimetric and radiobiological advantages enable to achieve the best treatment results in these tumors. The present review is devoted to PT usage in HNC treatment in the world and Russian medicine, the prospects for further technique development, the assessment of PT’s radiobiological features, a physical and dosimetric comparison of protons photons distribution. The paper shows PT’s capabilities in the treatment of skull base tumors, HNC (nasal cavity, paranasal sinuses, nasopharynx, oropharynx, and laryngopharynx, etc.), eye tumors, sialomas. The authors analyze the studies on repeated radiation and provide recent experimental data on favorable profile of proton radiation compared to the conventional radiation therapy. The review enables to conclude that currently PT is a dynamic radiation technique opening up new opportunities for improving therapy of oncology patients, especially those with HNC.
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Affiliation(s)
- K B Gordon
- Senior Researcher, Proton Therapy Department; A. Tsyb Medical Radiological Research Centre - Branch of the National Medical Research Radiological Centre of the Ministry of Health of the Russian Federation, 4 Koroleva St., Kaluga Region, Obninsk, 249036, Russia
| | - D I Smyk
- Junior Researcher, Proton Therapy Department; A. Tsyb Medical Radiological Research Centre - Branch of the National Medical Research Radiological Centre of the Ministry of Health of the Russian Federation, 4 Koroleva St., Kaluga Region, Obninsk, 249036, Russia
| | - I A Gulidov
- Professor, Head of the Proton Therapy Department; A. Tsyb Medical Radiological Research Centre - Branch of the National Medical Research Radiological Centre of the Ministry of Health of the Russian Federation, 4 Koroleva St., Kaluga Region, Obninsk, 249036, Russia
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17
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Hung HM, Chan OCM, Mak CH, Hung WM, Ng WT, Lee MCH. Dosimetric comparison of intensity modulated radiotherapy and intensity modulated proton therapy in the treatment of recurrent nasopharyngeal carcinoma. Med Dosim 2021; 47:14-19. [PMID: 34470708 DOI: 10.1016/j.meddos.2021.07.002] [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: 09/16/2020] [Revised: 01/11/2021] [Accepted: 07/13/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE To compare the dosimetric performance of Intensity Modulated Proton Therapy (IMPT) and Intensity Modulated Radiotherapy (IMRT) in terms of target volume coverage and sparing of neurological organs-at-risk (OARs) in salvaging recurrent nasopharyngeal carcinoma (rNPC). The maximum dose to the internal carotid artery (ICA) and nasopharyngeal (NP) mucosa, which are associated with potential carotid blowout and massive epistaxis, were also evaluated. MATERIALS AND METHODS IMRT and IMPT treatment plans were created for twenty patients with locally advanced rNPC. Planning Target Volume (PTV) was used to account for the setup and spatial error/uncertainty in the IMRT planning. Robust optimization on Clinical Target Volume (CTV) coverage with consideration of range and setup uncertainty was employed to produce two IMPT plans with 3-field and 4-field arrangements. The planning objective was to deliver 60 Gy to the PTV (IMRT) and CTV (IMPT) without exceeding the maximum lifetime cumulative Biologically Effective Dose (BED) of the neurological OARs (applied to the Planning organs-at-risk volume). The target dose coverage as well as the maximum dose to the neurological OARs, ICA, and NP mucosa were compared. RESULTS Compared with IMRT, 3-field IMPT achieved better coverage to GTV V100% (83.3% vs. 73.2%, P <0.01) and CTV V100% (80.5% vs. 72.4%, P <0.01), and lower maximum dose to the critical OARs including the spinal cord (19.2 Gy vs. 22.3 Gy, P <0.01), brainstem (30.0 Gy vs. 32.3 Gy, P <0.01) and optic chiasm (6.6 Gy vs. 9.8 Gy, P <0.01). The additional beam with the 4-fields IMPT plans further improved the target coverage from the 3-field IMPT (CTV V98%: 85.3% vs. 82.4%, P <0.01) with similar OAR sparing. However, the target dose was highly non-uniform with both IMPT plans, leading to a significantly higher maximum dose to the ICA (∼68 Gy vs. 62.6 Gy, P <0.01) and NP mucosa (∼72 Gy vs. 62.8 Gy, P <0.01) than IMRT. CONCLUSION IMPT demonstrated some dosimetric advantage over IMRT in treating rNPC. However, IMPT could also result in very high dose hot spots in the target volume. Careful consideration of the ICA and NP mucosal complications is recommended when applying IMPT on rNPC patients.
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Affiliation(s)
- Hing Ming Hung
- Department of Clinical Oncology, Pamela Youde Nethersole Eastern Hospital, Hong Kong.
| | | | - Chi Hang Mak
- Department of Clinical Oncology, Pamela Youde Nethersole Eastern Hospital, Hong Kong
| | - Wai Man Hung
- Department of Clinical Oncology, Pamela Youde Nethersole Eastern Hospital, Hong Kong
| | - Wai Tong Ng
- Department of Clinical Oncology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong; Comprehensive Oncology Center, Hong Kong Sanatorium & Hospital, Hong Kong
| | - Michael Chi Hang Lee
- Department of Medical Physics, Pamela Youde Nethersole Eastern Hospital, Hong Kong
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18
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Thaker NG, Boyce-Fappiano D, Ning MS, Pasalic D, Guzman A, Smith G, Holliday EB, Incalcaterra J, Garden AS, Shaitelman SF, Gunn GB, Fuller CD, Blanchard P, Feeley TW, Kaplan RS, Frank SJ. Activity-Based Costing of Intensity-Modulated Proton versus Photon Therapy for Oropharyngeal Cancer. Int J Part Ther 2021; 8:374-382. [PMID: 34285963 PMCID: PMC8270081 DOI: 10.14338/ijpt-20-00042.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 01/11/2021] [Indexed: 11/29/2022] Open
Abstract
PURPOSE In value-based health care delivery, radiation oncologists need to compare empiric costs of care delivery with advanced technologies, such as intensity-modulated proton therapy (IMPT) and intensity-modulated radiation therapy (IMRT). We used time-driven activity-based costing (TDABC) to compare the costs of delivering IMPT and IMRT in a case-matched pilot study of patients with newly diagnosed oropharyngeal (OPC) cancer. MATERIALS AND METHODS We used clinicopathologic factors to match 25 patients with OPC who received IMPT in 2011-12 with 25 patients with OPC treated with IMRT in 2000-09. Process maps were created for each multidisciplinary clinical activity (including chemotherapy and ancillary services) from initial consultation through 1 month of follow-up. Resource costs and times were determined for each activity. Each patient-specific activity was linked with a process map and TDABC over the full cycle of care. All calculated costs were normalized to the lowest-cost IMRT patient. RESULTS TDABC costs for IMRT were 1.00 to 3.33 times that of the lowest-cost IMRT patient (mean ± SD: 1.65 ± 0.56), while costs for IMPT were 1.88 to 4.32 times that of the lowest-cost IMRT patient (2.58 ± 0.39) (P < .05). Although single-fraction costs were 2.79 times higher for IMPT than for IMRT (owing to higher equipment costs), average full cycle cost of IMPT was 1.53 times higher than IMRT, suggesting that the initial cost increase is partly mitigated by reductions in costs for other, non-RT supportive health care services. CONCLUSIONS In this matched sample, although IMPT was on average more costly than IMRT primarily owing to higher equipment costs, a subset of IMRT patients had similar costs to IMPT patients, owing to greater use of supportive care resources. Multidimensional patient outcomes and TDABC provide vital methodology for defining the value of radiation therapy modalities.
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Affiliation(s)
- Nikhil G. Thaker
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Arizona Oncology, The US Oncology Network, Tucson, AZ, USA
| | - David Boyce-Fappiano
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew S. Ning
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Dario Pasalic
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alexis Guzman
- The Institute for Cancer Care Innovation, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Grace Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Emma B. Holliday
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - James Incalcaterra
- The Institute for Cancer Care Innovation, 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
| | - Simona F. Shaitelman
- Department of Radiation Oncology, 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
| | - C. David Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pierre Blanchard
- Department of Radiation 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
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19
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Spiotto MT, McGovern SL, Gunn GB, Grosshans D, McAleer MF, Frank SJ, Paulino AC. Proton Radiotherapy to Reduce Late Complications in Childhood Head and Neck Cancers. Int J Part Ther 2021; 8:155-167. [PMID: 34285943 PMCID: PMC8270100 DOI: 10.14338/ijpt-20-00069.1] [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: 09/13/2020] [Accepted: 12/07/2020] [Indexed: 11/21/2022] Open
Abstract
In most childhood head and neck cancers, radiotherapy is an essential component of treatment; however, it can be associated with problematic long-term complications. Proton beam therapy is accepted as a preferred radiation modality in pediatric cancers to minimize the late radiation side effects. Given that childhood cancers are a rare and heterogeneous disease, the support for proton therapy comes from risk modeling and a limited number of cohort series. Here, we discuss the role of proton radiotherapy in pediatric head and neck cancers with a focus on reducing radiation toxicities. First, we compare the efficacy and expected toxicities in proton and photon radiotherapy for childhood cancers. Second, we review the benefit of proton radiotherapy in reducing acute and late radiation toxicities, including risks for secondary cancers, craniofacial development, vision, and cognition. Finally, we review the cost effectiveness for proton radiotherapy in pediatric head and neck cancers. This review highlights the benefits of particle radiotherapy for pediatric head and neck cancers to improve the quality of life in cancer survivors, to reduce radiation morbidities, and to maximize efficient health care use.
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Affiliation(s)
- Michael T Spiotto
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan L McGovern
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Brandon Gunn
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David Grosshans
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mary Frances McAleer
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven J Frank
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Arnold C Paulino
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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20
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Bridhikitti J, Viehman JK, Harmsen WS, Amundson AC, Shiraishi S, Mundy DW, Rwigema JCM, McGee LA, Patel SH, Routman DM, Lester SC, Neben-Wittich MA, Garces YI, Ma DJ, Foote RL. Oncologic Outcomes for Head and Neck Skin Malignancies Treated with Protons. Int J Part Ther 2021; 8:294-303. [PMID: 34285955 PMCID: PMC8270091 DOI: 10.14338/ijpt-20-00045.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 02/12/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose Radiation therapy (RT) is the standard treatment for patients with inoperable skin malignancies of the head and neck region (H&N), and as adjuvant treatment post surgery in patients at high risk for local or regional recurrence. This study reports clinical outcomes of intensity-modulated proton therapy (IMPT) for these malignancies. Materials and Methods We retrospectively reviewed cases involving 47 patients with H&N malignancies of the skin (squamous cell, basal cell, melanoma, Merkel cell, angiosarcoma, other) who underwent IMPT for curative intent between July 2016 and July 2019. Overall survival was estimated via Kaplan-Meier analysis, and oncologic outcomes were reported as cumulative incidence with death as a competing risk. Results The 2-year estimated local recurrence rate, regional recurrence rate, local regional recurrence rate, distant metastasis rate, and overall survival were 11.1% (95% confidence interval [CI], 4.1%-30.3%), 4.4% (95% CI, 1.1%-17.4%), 15.5% (95% CI, 7%-34.3%), 23.4% (95% CI, 5.8%-95.5%), and 87.2% (95% CI, 75.7%-100%), respectively. No patient was reported to have a grade 3 or higher adverse event during the last week of treatment or at the 3-month follow-up visit. Conclusion IMPT is safe and effective in the treatment of skin malignancies of the H&N.
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Affiliation(s)
| | - Jason K Viehman
- Division of Biomedical Statistics & Informatics, Mayo Clinic, Rochester, MN, USA
| | - W Scott Harmsen
- Department of Biostatistics and Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Adam C Amundson
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Satomi Shiraishi
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Daniel W Mundy
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Samir H Patel
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - David M Routman
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Scott C Lester
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Yolanda I Garces
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Daniel J Ma
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
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21
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Bahig H, Gunn BG, Garden AS, Ye R, Hutcheson K, Rosenthal DI, Phan J, Fuller CD, Morrison WH, Reddy JP, Ng SP, Gross ND, Sturgis EM, Ferrarotto R, Gillison M, Frank SJ. Patient-Reported Outcomes after Intensity-Modulated Proton Therapy for Oropharynx Cancer. Int J Part Ther 2021; 8:213-222. [PMID: 34285948 PMCID: PMC8270092 DOI: 10.14338/ijpt-20-00081.1] [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: 10/27/2020] [Accepted: 02/02/2021] [Indexed: 01/01/2023] Open
Abstract
PURPOSE To report patient-reported outcomes (PROs) derived from the Functional Assessment of Cancer Therapy-Head and Neck (FACT-HN) tool, in patients with oropharynx cancer (OPC) treated with intensity-modulated proton therapy (IMPT) in the context of first-course irradiation. MATERIALS AND METHODS Patients with locally advanced OPC treated with radical IMPT between 2011 and 2018 were included in a prospective registry. FACT-HN scores were measured serially during and 24 months following IMPT. PRO changes in the FACT-HN scores over time were assessed with mixed-model analysis. RESULTS Fifty-seven patients met inclusion criteria. Median age was 60 years (range, 41-84), and 91% had human papillomavirus-associated disease. In total, 28% received induction chemotherapy and 68% had concurrent chemotherapy. Compliance to FACT-HN questionnaire completion was 59%, 48%, and 42% at 6, 12, and 24 months after treatment, respectively. The mean FACT-General (G), FACT-Total, and FACT-Trial Outcome Index (TOI) score changes were statistically and clinically significant relative to baseline from week 3 of treatment up to week 2 after treatment. Nadir was reached at week 6 of treatment for all scores, with maximum scores dropping by 15%, 20%, and 39% compared to baseline for FACT-G, FACT-Total, and FACT-TOI, respectively. Subdomain scores of physical well-being, functional well-being, and head and neck additional concerns decreased from baseline during treatment and returned to baseline at week 4 after treatment. CONCLUSIONS IMPT was associated with a favorable PRO trajectory, characterized by an acute decline followed by rapid recovery to baseline. This study establishes the expected acute, subacute, and chronic trajectory of PROs for patients undergoing IMPT for OPC.
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Affiliation(s)
- Houda Bahig
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
,Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Brandon G. Gunn
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Adam S. Garden
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rong Ye
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kate Hutcheson
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Jack Phan
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Jay Paul Reddy
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sweet Ping Ng
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
,Peter MacCallum Cancer Center, Melbourne, Australia
| | - Neil D. Gross
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Erich M. Sturgis
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Maura Gillison
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven J. Frank
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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22
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Sherry AD, Pasalic D, Gunn GB, Fuller CD, Phan J, Rosenthal DI, Morrison WH, Sturgis EM, Gross ND, Gillison ML, Ferrarotto R, El-Naggar AK, Garden AS, Frank SJ. Proton Beam Therapy for Head and Neck Carcinoma of Unknown Primary: Toxicity and Quality of Life. Int J Part Ther 2021; 8:234-247. [PMID: 34285950 PMCID: PMC8270080 DOI: 10.14338/ijpt-20-00034.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/21/2020] [Indexed: 12/26/2022] Open
Abstract
Purpose Proton radiation therapy (PRT) may offer dosimetric and clinical benefit in the treatment of head and neck carcinoma of unknown primary (HNCUP). We sought to describe toxicity and quality of life (QOL) in patients with HNCUP treated with PRT. Patients and Methods Toxicity and QOL were prospectively tracked in patients with HNCUP from 2011 to 2019 after institutional review board approval. Patients received PRT to the mucosa of the nasopharynx, oropharynx, and bilateral cervical lymph nodes with sparing of the larynx and hypopharynx. Patient-reported outcomes were tracked with the MD Anderson Symptom Inventory–Head and Neck Module, the Functional Assessment of Cancer Therapy–Head and Neck, the MD Anderson Dysphagia Inventory, and the Xerostomia-Related QOL Scale. Primary study endpoints were the incidence of grade ≥ 3 (G3) toxicity and QOL patterns. Results Fourteen patients (median follow-up, 2 years) were evaluated. Most patients presented with human papillomavirus–positive disease (n = 12, 86%). Rates of G3 oral mucositis, xerostomia, and dermatitis were 7% (n = 1), 21% (n = 3), and 36% (n = 5), respectively. None required a gastrostomy. During PRT, QOL was reduced relative to baseline and recovered shortly after PRT. At 2 years after PRT, the local regional control, disease-free survival, and overall survival were 100% (among 7 patients at risk), 79% (among 6 patients at risk), and 90% (among 7 patients at risk), respectively. Conclusion Therefore, PRT for HNCUP was associated with highly favorable dosimetric and clinical outcomes, including minimal oral mucositis, xerostomia, and dysphagia. Toxicity and QOL may be superior with PRT compared with conventional radiation therapy and PRT maintains equivalent oncologic control. Further prospective studies are needed to evaluate late effects and cost-effectiveness.
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Affiliation(s)
| | - Dario Pasalic
- Department of Radiation Oncology, 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
| | - 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
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William H Morrison
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Erich M Sturgis
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Neil D Gross
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maura L Gillison
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Renata Ferrarotto
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Adel K El-Naggar
- Department of Pathology, 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
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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23
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Smith GL, Fu S, Ning MS, Nguyen DK, Busse PM, Foote RL, Garden AS, Gunn GB, Fuller CD, Morrison WH, Chronowski GM, Shah SJ, Mayo LL, Phan J, Reddy JP, Snider JW, Patel SH, Katz SR, Lin A, Mohammed N, Dagan R, Lee NY, Rosenthal DI, Frank SJ. Work Outcomes after Intensity-Modulated Proton Therapy (IMPT) versus Intensity-Modulated Photon Therapy (IMRT) for Oropharyngeal Cancer. Int J Part Ther 2021; 8:319-327. [PMID: 34285958 PMCID: PMC8270077 DOI: 10.14338/ijpt-20-00067.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 01/29/2021] [Indexed: 01/17/2023] Open
Abstract
Purpose We compared work outcomes in patients with oropharyngeal cancer (OPC), randomized to intensity-modulated proton (IMPT) versus intensity-modulated photon therapy (IMRT) for chemoradiation therapy (CRT). Patients and Methods In 147 patients with stage II-IVB squamous cell OPC participating in patient-reported outcomes assessments, a prespecified secondary aim of a randomized phase II/III trial of IMPT (n = 69) versus IMRT (n = 78), we compared absenteeism, presenteeism (i.e., the extent to which an employee is not fully functional at work), and work productivity losses. We used the work productivity and activity impairment questionnaire at baseline (pre-CRT), at the end of CRT, and at 6 months, 1 year, and 2 years. A one-sided Cochran-Armitage test was used to analyze within-arm temporal trends, and a χ2 test was used to compare between-arm differences. Among working patients, at each follow-up point, a 1-sided Wilcoxon rank-sum test was used to compare work-productivity scores. Results Patient characteristics in IMPT versus IMRT arms were similar. In the IMPT arm, within-arm analysis demonstrated that an increasing proportion of patients resumed working after IMPT, from 60% (40 of 67) pre-CRT and 71% (30 of 42) at 1 year to 78% (18 of 23) at 2 years (P = 0.025). In the IMRT arm, the proportion remained stable, with 57% (43 of 76) pre-CRT, 54% (21 of 39) at 1 year, and 52% (13 of 25) working at 2 years (P = 0.47). By 2 years after CRT, the between-arm difference between patients who had IMPT and those who had IMRT trended toward significance (P = 0.06). Regardless of treatment arm, among working patients, the most severe work impairments occurred from treatment initiation to the end of CRT, with significant recovery from absenteeism, presenteeism, and productivity impairments by the 2-year follow-up (P < 0.001 for all). Higher magnitudes of recovery from absenteeism (at 1 year, P = 0.05; and at 2 years, P = 0.04) and composite work impairment scores (at 1 year, P = 0.04; and at 2 years, P = 0.04) were seen in patients treated with IMPT versus those treated with IMRT. Conclusion In patients with OPC receiving curative CRT, patients randomized to IMPT demonstrated increasing work and productivity recovery trends. Studies are needed to identify mechanisms underlying head and neck CRT treatment causing work disability and impairment.
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Affiliation(s)
- Grace L Smith
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shuangshuang Fu
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew S Ning
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Diem-Khanh Nguyen
- University of California Riverside School of Medicine, Riverside, CA, USA
| | - Paul M Busse
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic and Mayo Clinic School of Medicine and Science, Rochester, MN, USA
| | - Adam S Garden
- Willis-Knighton Proton Therapy Center, Shreveport, LA, USA
| | - Gary B Gunn
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Clifton D Fuller
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William H Morrison
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gregory M Chronowski
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shalin J Shah
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lauren L Mayo
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jack Phan
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jay P Reddy
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - James W Snider
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Samir H Patel
- Department of Radiation Oncology, Mayo Clinic and Mayo Clinic School of Medicine and Science, Phoenix, AZ, USA
| | - Sanford R Katz
- Willis-Knighton Proton Therapy Center, Shreveport, LA, USA
| | - Alexander Lin
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Roi Dagan
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Nancy Y Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David I Rosenthal
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven J Frank
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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24
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Proton Therapy for HPV-Associated Oropharyngeal Cancers of the Head and Neck: a De-Intensification Strategy. Curr Treat Options Oncol 2021; 22:54. [PMID: 34086150 PMCID: PMC8178129 DOI: 10.1007/s11864-021-00847-y] [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] [Accepted: 03/16/2021] [Indexed: 12/02/2022]
Abstract
The rise in the incidence of human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPC), the relatively young age at which it is diagnosed, and its favorable prognosis necessitate the use of treatment techniques that reduce the likelihood of side effects during and after curative treatment. Intensity-modulated proton therapy (IMPT) is a form of radiotherapy that de-intensifies treatment through dose de-escalation to normal tissues without compromising dose to the primary tumor and involved, regional lymph nodes. Preclinical studies have demonstrated that HPV-positive squamous cell carcinoma is more sensitive to proton radiation than is HPV-negative squamous cell carcinoma. Retrospective studies comparing intensity-modulated photon (X-ray) radiotherapy to IMPT for OPC suggest comparable rates of disease control and lower rates of pain, xerostomia, dysphagia, dysgeusia, gastrostomy tube dependence, and osteoradionecrosis with IMPT—all of which meaningfully affect the quality of life of patients treated for HPV-associated OPC. Two phase III trials currently underway—the “Randomized Trial of IMPT versus IMRT for the Treatment of Oropharyngeal Cancer of the Head and Neck” and the “TOxicity Reduction using Proton bEam therapy for Oropharyngeal cancer (TORPEdO)” trial—are expected to provide prospective, level I evidence regarding the effectiveness of IMPT for such patients.
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25
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Intensity-modulated proton therapy for oropharyngeal cancer reduces rates of late xerostomia. Radiother Oncol 2021; 160:32-39. [PMID: 33839202 DOI: 10.1016/j.radonc.2021.03.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 03/23/2021] [Accepted: 03/28/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND PURPOSE To determine rates of xerostomia after intensity-modulated radiotherapy (IMRT) or intensity-modulated proton therapy (IMPT) for oropharyngeal cancer (OPC) and identify dosimetric factors associated with xerostomia risk. MATERIALS AND METHODS Patients with OPC who received IMRT (n = 429) or IMPT (n = 103) from January 2011 through June 2015 at a single institution were studied retrospectively. Every 3 months after treatment, each patient completed an eight-item self-reported xerostomia-specific questionnaire (XQ; summary XQ score, 0-100). An XQ score of 50 was selected as the demarcation value for moderate-severe (XQs ≥ 50) and no-mild (XQs < 50) xerostomia. The mean doses and percent volumes of organs at risk receiving various doses (V5-V70) were extracted from the initial treatment plans. The dosimetric variables and xerostomia risk were compared using an independent-sample t-test or chi-square test. RESULTS The median follow-up time was 36.2 months. The proportions of patients with moderate-severe xerostomia were similar in the two treatment groups up to 18 months after treatment. However, moderate-severe xerostomia was less common in the IMPT group than in the IMRT group at 18-24 months (6% vs. 20%; p = 0.025) and 24-36 months (6% vs. 20%; p = 0.01). During the late xerostomia period (24-36 months), high dose/volume exposures (V25-V70) in the oral cavity were associated with high proportions of patients with moderate-severe xerostomia (all p < 0.05), but dosimetric variables regarding the salivary glands were not associated with late xerostomia. CONCLUSION IMPT was associated with less late xerostomia than was IMRT in OPC patients. Oral cavity dosimetric variables were related to the occurrence of late xerostomia.
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26
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Yoon HG, Ahn YC, Oh D, Noh JM, Park SG, Nam H, Ju SG, Kwon D, Park S. Early Clinical Outcomes of Intensity Modulated Radiation Therapy/Intensity Modulated Proton Therapy Combination in Comparison with Intensity Modulated Radiation Therapy Alone in Oropharynx Cancer Patients. Cancers (Basel) 2021; 13:cancers13071549. [PMID: 33801766 PMCID: PMC8037748 DOI: 10.3390/cancers13071549] [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: 01/29/2021] [Revised: 03/18/2021] [Accepted: 03/24/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Intensity-modulated proton therapy (IMPT) is expected to reduce toxicity more effectively than intensity-modulated radiation therapy (IMRT) in treating oropharynx cancer (OPC) patients. Because of long waiting before starting IMPT, authors began IMRT first and then determined whether to continue IMRT or to switch into IMPT at time of adaptive re-plan, based on the rival plan comparison in 148 OPC patients. Early clinical outcomes were analyzed and compared between IMRT alone and IMRT/IMPT combination groups through propensity score matching method. We found that, with comparable oncologic outcomes, more favorable acute toxicity profiles (mucositis and need for analgesic use) were achieved following IMRT/IMPT combination than IMRT alone. Abstract Purpose: To report the early clinical outcomes of combining intensity-modulated radiation therapy (IMRT) and intensity-modulated proton therapy (IMPT) in comparison with IMRT alone in treating oropharynx cancer (OPC) patients. Materials and Methods: The medical records of 148 OPC patients who underwent definitive radiotherapy (RT) with concurrent systemic therapy, from January 2016 till December 2019 at Samsung Medical Center, were retrospectively reviewed. During the 5.5 weeks’ RT course, the initial 16 (or 18) fractions were delivered by IMRT in all patients, and the subsequent 12 (or 10) fractions were either by IMRT in 81 patients (IMRT only) or by IMPT in 67 (IMRT/IMPT combination), respectively, based on comparison of adaptive re-plan profiles and availability of equipment. Propensity-score matching (PSM) was done on 76 patients (38 from each group) for comparative analyses. Results: With the median follow-up of 24.7 months, there was no significant difference in overall survival and progression free survival between groups, both before and after PSM. Before PSM, the IMRT/IMPT combination group experienced grade ≥ 3 acute toxicities less frequently: mucositis in 37.0% and 13.4% (p < 0.001); and analgesic quantification algorithm (AQA) in 37.0% and 19.4% (p = 0.019), respectively. The same trends were observed after PSM: mucositis in 39.5% and 15.8% (p = 0.021); and AQA in 47.4% and 21.1% (p = 0.016), respectively. In multivariate logistic regression, grade ≥ 3 mucositis was significantly less frequent in the IMRT/IMPT combination group, both before and after PSM (p = 0.027 and 0.024, respectively). AQA score ≥ 3 was also less frequent in the IMRT/IMPT combination group, both before and after PSM (p = 0.085 and 0.018, respectively). Conclusions: In treating the OPC patients, with comparable early oncologic outcomes, more favorable acute toxicity profiles were achieved following IMRT/IMPT combination than IMRT alone.
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Affiliation(s)
- Han Gyul Yoon
- Samsung Medical Center, Department of Radiation Oncology, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (H.G.Y.); (D.O.); (J.M.N.); (S.G.J.); (D.K.); (S.P.)
| | - Yong Chan Ahn
- Samsung Medical Center, Department of Radiation Oncology, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (H.G.Y.); (D.O.); (J.M.N.); (S.G.J.); (D.K.); (S.P.)
- Correspondence:
| | - Dongryul Oh
- Samsung Medical Center, Department of Radiation Oncology, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (H.G.Y.); (D.O.); (J.M.N.); (S.G.J.); (D.K.); (S.P.)
| | - Jae Myoung Noh
- Samsung Medical Center, Department of Radiation Oncology, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (H.G.Y.); (D.O.); (J.M.N.); (S.G.J.); (D.K.); (S.P.)
| | - Seung Gyu Park
- Keimyung University Dongsan Medical Center, Department of Radiation Oncology, Keimyung University School of Medicine, Daegu 42601, Korea;
| | - Heerim Nam
- Department of Radiation Oncology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul 03181, Korea;
| | - Sang Gyu Ju
- Samsung Medical Center, Department of Radiation Oncology, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (H.G.Y.); (D.O.); (J.M.N.); (S.G.J.); (D.K.); (S.P.)
| | - Dongyeol Kwon
- Samsung Medical Center, Department of Radiation Oncology, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (H.G.Y.); (D.O.); (J.M.N.); (S.G.J.); (D.K.); (S.P.)
| | - Seyjoon Park
- Samsung Medical Center, Department of Radiation Oncology, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (H.G.Y.); (D.O.); (J.M.N.); (S.G.J.); (D.K.); (S.P.)
- Yonsei Cancer Center, Department of Radiation Oncology, Yonsei University College of Medicine, Seoul 03722, Korea
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27
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Hernandez M, Lee JJ, Yeap BY, Ye R, Foote RL, Busse P, Patel SH, Dagan R, Snider J, Mohammed N, Lin A, Blanchard P, Cantor SB, Teferra MY, Hutcheson K, Yepes P, Mohan R, Liao Z, DeLaney TF, Frank SJ. The Reality of Randomized Controlled Trials for Assessing the Benefit of Proton Therapy: Critically Examining the Intent-to-Treat Principle in the Presence of Insurance Denial. Adv Radiat Oncol 2020; 6:100635. [PMID: 33732960 PMCID: PMC7940795 DOI: 10.1016/j.adro.2020.100635] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 11/04/2020] [Accepted: 11/17/2020] [Indexed: 11/29/2022] Open
Abstract
Purpose This study hypothesized that insurance denial would lead to bias and loss of statistical power when evaluating the results from an intent-to-treat (ITT), per-protocol, and as-treated analyses using a simulated randomized clinical trial comparing proton therapy to intensity modulated radiation therapy where patients incurred increasing rates of insurance denial. Methods and Materials Simulations used a binary endpoint to assess differences between treatment arms after applying ITT, per-protocol, and as-treated analyses. Two scenarios were developed: 1 with clinical success independent of age and another assuming dependence on age. Insurance denial was assumed possible for patients <65 years. All scenarios considered an age distribution with mean ± standard deviation: 55 ± 15 years, rates of insurance denial ranging from 0%-40%, and a sample of N = 300 patients (150 per arm). Clinical success rates were defined as 70% for proton therapy and 50% for intensity modulated radiation therapy. The average treatment effect, bias, and power were compared after applying 5000 simulations. Results Increasing rates of insurance denial demonstrated inherent weaknesses among all 3 analytical approaches. With clinical success independent of age, a per-protocol analysis demonstrated the least bias and loss of power. When clinical success was dependent on age, the per-protocol and ITT analyses resulted in a similar trend with respect to bias and loss of power, with both outperforming the as-treated analysis. Conclusions Insurance denial leads to misclassification bias in the ITT analysis, a missing data problem in the per-protocol analysis, and covariate imbalance between treatment arms in the as-treated analysis. Moreover, insurance denial forces the critical appraisal of patient features (eg, age) affected by the denial and potentially influencing clinical success. In the presence of insurance denial, our study suggests cautious reporting of ITT and as-treated analyses, and placing primary emphasis on the results of the per-protocol analysis.
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Affiliation(s)
- Mike Hernandez
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - J Jack Lee
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Beow Y Yeap
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Rong Ye
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Paul Busse
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Samir H Patel
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Roi Dagan
- Department of Radiation Oncology, University of Florida Health, Gainesville, Florida
| | - James Snider
- Department of Radiation Oncology, University of Maryland Medical System, Baltimore, Maryland
| | - Nasiruddin Mohammed
- Department of Radiation Oncology, Northwestern Medicine, Warrenville, Illinois
| | - Alexander Lin
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pierre Blanchard
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France.,Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Scott B Cantor
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Menna Y Teferra
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kate Hutcheson
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Pablo Yepes
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Physics and Astronomy, Rice University, Houston, Texas
| | - Radhe Mohan
- Department of Physics and Astronomy, Rice University, Houston, Texas
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Thomas F DeLaney
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Kumari S, Mukherjee S, Sinha D, Abdisalaam S, Krishnan S, Asaithamby A. Immunomodulatory Effects of Radiotherapy. Int J Mol Sci 2020; 21:E8151. [PMID: 33142765 PMCID: PMC7663574 DOI: 10.3390/ijms21218151] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 10/22/2020] [Accepted: 10/26/2020] [Indexed: 02/07/2023] Open
Abstract
Radiation therapy (RT), an integral component of curative treatment for many malignancies, can be administered via an increasing array of techniques. In this review, we summarize the properties and application of different types of RT, specifically, conventional therapy with x-rays, stereotactic body RT, and proton and carbon particle therapies. We highlight how low-linear energy transfer (LET) radiation induces simple DNA lesions that are efficiently repaired by cells, whereas high-LET radiation causes complex DNA lesions that are difficult to repair and that ultimately enhance cancer cell killing. Additionally, we discuss the immunogenicity of radiation-induced tumor death, elucidate the molecular mechanisms by which radiation mounts innate and adaptive immune responses and explore strategies by which we can increase the efficacy of these mechanisms. Understanding the mechanisms by which RT modulates immune signaling and the key players involved in modulating the RT-mediated immune response will help to improve therapeutic efficacy and to identify novel immunomodulatory drugs that will benefit cancer patients undergoing targeted RT.
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Affiliation(s)
- Sharda Kumari
- Division of Molecular Radiation Biology, Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA; (S.K.); (D.S.); (S.A.)
| | - Shibani Mukherjee
- Division of Molecular Radiation Biology, Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA; (S.K.); (D.S.); (S.A.)
| | - Debapriya Sinha
- Division of Molecular Radiation Biology, Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA; (S.K.); (D.S.); (S.A.)
| | - Salim Abdisalaam
- Division of Molecular Radiation Biology, Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA; (S.K.); (D.S.); (S.A.)
| | - Sunil Krishnan
- Department of Radiation Oncology, Mayo Clinic Florida, Jacksonville, FL 32224, USA;
| | - Aroumougame Asaithamby
- Division of Molecular Radiation Biology, Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA; (S.K.); (D.S.); (S.A.)
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Grant SR, Hutcheson KA, Ye R, Garden AS, Morrison WH, Rosenthal DI, Gunn GB, Fuller C, Phan J, Reddy JP, Moreno AC, Lewin JS, Sturgis EM, Ferrarotto R, Frank SJ. Prospective longitudinal patient-reported outcomes of swallowing following intensity modulated proton therapy for oropharyngeal cancer. Radiother Oncol 2020; 148:133-139. [PMID: 32361662 PMCID: PMC9815953 DOI: 10.1016/j.radonc.2020.04.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND PURPOSE With an enlarging population of long-term oropharyngeal cancer survivors, dysphagia is an increasingly important toxicity following oropharynx cancer treatment. While lower doses to normal surrounding structures may be achieved with intensity modulated proton therapy (IMPT) compared to photon-based radiation, the clinical benefit is uncertain. METHODS AND MATERIALS Seventy-one patients with stage III/IV oropharyngeal cancer (AJCC 7th edition) undergoing definitive IMPT on a longitudinal prospective cohort study who had completed the MD Anderson Dysphagia Inventory (MDADI) at pre-specified time points were included. RESULTS The majority of patients had HPV-positive tumors (85.9%) and received bilateral neck radiation (81.4%) with concurrent systemic therapy (61.8%). Mean composite MDADI scores decreased from 88.2 at baseline to 59.6 at treatment week 6, and then increased to 74.4 by follow up week 10, 77.0 by 6 months follow up, 80.5 by 12 months follow up, and 80.1 by 24 months follow up. At baseline, only 5.6% of patients recording a poor composite score (lower than 60), compared to 61.2% at treatment week 6, 19.1% at follow up week 10, 13.0% at 6 months follow up, 13.5% at 1 year follow up, and 11.1% at 2 years follow up. CONCLUSIONS Patient reported outcomes following IMPT for oropharyngeal cancer demonstrates decreased swallowing function at completion of treatment with relatively rapid recovery by 10 weeks follow up and steady improvement through 2 years. The results are comparable to similar longitudinal studies of photon-based radiotherapy for oropharynx cancer, and suggest that IMPT confers no additional excess toxicity related to swallowing.
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Affiliation(s)
- Stephen R. Grant
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Katherine A. Hutcheson
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rong Ye
- Department of Biostatistics, 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
| | - William H. Morrison
- 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
| | - G. Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - C.D. 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 C. Moreno
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jan S. Lewin
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Erich M. Sturgis
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Renata Ferrarotto
- Department of 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
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Saini G, Shukla R, Sood KS, Shukla SK, Chandra R. Role of Proton Beam Therapy in Current Day Radiation Oncology Practice. ASIAN JOURNAL OF ONCOLOGY 2020. [DOI: 10.1055/s-0040-1713703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
AbstractProton beam therapy (PBT), because of its unique physics of no–exit dose deposition in the tissue, is an exciting prospect. The phenomenon of Bragg peak allows protons to deposit their almost entire energy towards the end of the path of the proton and stops any further dose delivery. Braggs peak equips PBT with superior dosimetric advantage over photons or electrons because PBT doesn’t traverse the target/body but is stopped sharply at an energy dependent depth in the target/body. It also has no exit dose. Because of no exit dose and normal tissue sparing, PBT is hailed for its potential to bring superior outcomes. Pediatric malignancies is the most common malignancy where PBT have found utmost application. Nowadays, PBT is also being used in the treatment of other malignancies such as carcinoma prostate, carcinoma breast, head and neck malignancies, and gastrointestinal (GI) malignancies. Despite advantages of PBT, there is not only a high cost of setting up of PBT centers but also a lack of definitive phase-III data. Therefore, we review the role of PBT in current day practice of oncology to bring out the nuances that must guide the practice to choose suitable patients for PBT.
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Affiliation(s)
- Gagan Saini
- Department of Radiation Oncology, MAX Super Speciality Hospital Patparganj and Vaishali, New Delhi, India
| | - Rashmi Shukla
- Department of Radiation Oncology, MAX Super Speciality Hospital Patparganj and Vaishali, New Delhi, India
| | - Kanika S. Sood
- Department of Radiation Oncology, Dharamshila Narayana Superspeciality Hospital, New Delhi, India
| | - Sujit K. Shukla
- Department of Radiation Oncology, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Ritu Chandra
- Department of Radiation Oncology, MAX Super Speciality Hospital Patparganj and Vaishali, New Delhi, India
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Hwang EJ, Gorayski P, Le H, Hanna GG, Kenny L, Penniment M, Buck J, Thwaites D, Ahern V. Particle therapy tumour outcomes: An updated systematic review. J Med Imaging Radiat Oncol 2020; 64:711-724. [PMID: 32270626 DOI: 10.1111/1754-9485.13021] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 12/20/2019] [Accepted: 02/13/2020] [Indexed: 12/25/2022]
Abstract
Particle therapy (PT) offers the potential for reduced normal tissue damage as well as escalation of target dose, thereby enhancing the therapeutic ratio in radiation therapy. Reflecting the building momentum of PT use worldwide, construction has recently commenced for The Australian Bragg Centre for Proton Therapy and Research in Adelaide - the first PT centre in Australia. This systematic review aims to update the clinical evidence base for PT, both proton beam and carbon ion therapy. The purpose is to inform clinical decision-making for referral of patients to PT centres in Australia as they become operational and overseas in the interim. Three major databases were searched by two independent researchers, and evidence quality was classified according to the National Health and Medical Research Council evidence hierarchy. One hundred and thirty-six studies were included, two-thirds related to proton beam therapy alone. PT at the very least provides equivalent tumour outcomes compared to photon controls with the possibility of improved control in the case of carbon ion therapy. There is suggestion of reduced morbidities in a range of tumour sites, supporting the predictions from dosimetric modelling and the wide international acceptance of PT for specific indications based on this. Though promising, this needs to be counterbalanced by the overall low quality of evidence found, with 90% of studies of level IV (case series) evidence. Prospective comparative clinical trials, supplemented by database-derived outcome information, preferably conducted within international and national networks, are strongly recommended as PT is introduced into Australasia.
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Affiliation(s)
- Eun Ji Hwang
- Department of Radiation Oncology, Sydney West Radiation Oncology Network, Crown Princess Mary Cancer Centre, Sydney, New South Wales, Australia.,Medicine, Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia.,Institute of Medical Physics, School of Physics, University of Sydney, Sydney, New South Wales, Australia
| | - Peter Gorayski
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Hien Le
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Gerard G Hanna
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Liz Kenny
- Department of Radiation Oncology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Michael Penniment
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jacqueline Buck
- Department of Radiation Oncology, Sydney West Radiation Oncology Network, Crown Princess Mary Cancer Centre, Sydney, New South Wales, Australia
| | - David Thwaites
- Department of Radiation Oncology, Sydney West Radiation Oncology Network, Crown Princess Mary Cancer Centre, Sydney, New South Wales, Australia.,Institute of Medical Physics, School of Physics, University of Sydney, Sydney, New South Wales, Australia
| | - Verity Ahern
- Department of Radiation Oncology, Sydney West Radiation Oncology Network, Crown Princess Mary Cancer Centre, Sydney, New South Wales, Australia
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Manzar GS, Lester SC, Routman DM, Harmsen WS, Petersen MM, Sloan JA, Mundy DW, Hunzeker AE, Amundson AC, Anderson JL, Patel SH, Garces YI, Halyard MY, McGee LA, Neben-Wittich MA, Ma DJ, Frank SJ, Whitaker TJ, Foote RL. Comparative analysis of acute toxicities and patient reported outcomes between intensity-modulated proton therapy (IMPT) and volumetric modulated arc therapy (VMAT) for the treatment of oropharyngeal cancer. Radiother Oncol 2020; 147:64-74. [PMID: 32234612 DOI: 10.1016/j.radonc.2020.03.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 02/12/2020] [Accepted: 03/06/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND PURPOSE IMPT improves normal tissue sparing compared to VMAT in treating oropharyngeal cancer (OPC). Our aim was to assess if this translates into clinical benefits. MATERIALS AND METHODS OPC patients treated with definitive or adjuvant IMPT or VMAT from 2013 to 2018 were included. All underwent prospective assessment using patient-reported-outcomes (PROs) (EORTC-QLQ-H&N35) and provider-assessed toxicities (CTCAEv4.03). End-of-treatment and pretreatment scores were compared. PEG-tube use, hospitalization, and narcotic use were retrospectively collected. Statistical analysis used the Wilcoxon Rank-Sum Test with propensity matching for PROs/provider-assessed toxicities, and t-tests for other clinical outcomes. RESULTS 46 IMPT and 259 VMAT patients were included; median follow-up was 12 months (IMPT) and 30 months (VMAT). Baseline characteristics were balanced except for age (p = 0.04, IMPT were older) and smoking (p < 0.01, 10.9% IMPT >20PYs, 29.3% VMAT). IMPT was associated with lower PEG placement (OR = 0.27; 95% CI: 0.12-0.59; p = 0.001) and less hospitalization ≤60 days post-RT (OR = 0.21; 95% CI:0.07-0.6, p < 0.001), with subgroup analysis revealing strongest benefits in patients treated definitively or with concomitant chemoradiotherapy (CRT). IMPT was associated with a relative risk reduction of 22.3% for end-of-treatment narcotic use. Patients reported reduced cough and dysgeusia with IMPT (p < 0.05); patients treated definitively or with CRT also reported feeling less ill, reduced feeding tube use, and better swallow. Provider-assessed toxicities demonstrated less pain and mucositis with IMPT, but more mucosal infection. CONCLUSION IMPT is associated with improved PROs, reduced PEG-tube placement, hospitalization, and narcotic requirements. Mucositis, dysphagia, and pain were decreased with IMPT. Benefits were predominantly seen in patients treated definitively or with CRT.
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Affiliation(s)
- Gohar S Manzar
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, USA
| | - Scott C Lester
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA
| | - David M Routman
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA
| | - William S Harmsen
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, USA
| | - Molly M Petersen
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, USA
| | - Jeff A Sloan
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, USA
| | - Daniel W Mundy
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA
| | | | - Adam C Amundson
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA
| | | | - Samir H Patel
- Department of Radiation Oncology, Mayo Clinic, Phoenix, USA
| | | | | | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic, Phoenix, USA
| | | | - Daniel J Ma
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | | | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA.
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Proton therapy for head and neck squamous cell carcinomas: A review of the physical and clinical challenges. Radiother Oncol 2020; 147:30-39. [PMID: 32224315 DOI: 10.1016/j.radonc.2020.03.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 02/21/2020] [Accepted: 03/05/2020] [Indexed: 12/12/2022]
Abstract
The quality of radiation therapy has been shown to significantly influence the outcomes for head and neck squamous cell carcinoma (HNSCC) patients. The results of dosimetric studies suggest that intensity-modulated proton therapy (IMPT) could be of added value for HNSCC by being more effective than intensity-modulated (photon) radiation therapy (IMRT) for reducing side effects of radiation therapy. However, the physical properties of protons make IMPT more sensitive than photons to planning uncertainties. This could potentially have a negative effect on the quality of IMPT planning and delivery. For this review, the three French proton therapy centers collaborated to evaluate the differences between IMRT and IMPT. The review explored the effects of these uncertainties and their management for developing a robust and optimized IMPT treatment delivery plan to achieve clinical outcomes that are superior to those for IMRT. We also provide practical suggestions for the management of HNSCC carcinoma with IMPT. Because metallic dental implants can increase range uncertainties (3-10%), patient preparation for IMPT may require more systematic removal of in-field alien material than is done for IMRT. Multi-energy CT may be an alternative to calculate more accurately the dose distribution. The practical aspects that we describe are essential to guarantee optimal quality in radiation therapy in both model-based and randomized clinical trials.
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Meijer TWH, Scandurra D, Langendijk JA. Reduced radiation-induced toxicity by using proton therapy for the treatment of oropharyngeal cancer. Br J Radiol 2020; 93:20190955. [PMID: 31971818 DOI: 10.1259/bjr.20190955] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Patients with squamous cell carcinoma of the oropharynx are generally treated with (chemo) radiation. Patients with oropharyngeal cancer have better survival than patients with squamous cell carcinoma of other head and neck subsites, especially when related to human papillomavirus. However, radiotherapy results in a substantial percentage of survivors suffering from significant treatment-related side-effects. Late radiation-induced side-effects are mostly irreversible and may even be progressive, and particularly xerostomia and dysphagia affect health-related quality of life. As the risk of radiation-induced side-effects highly depends on dose to healthy normal tissues, prevention of radiation-induced xerostomia and dysphagia and subsequent improvement of health-relatedquality of life can be obtained by applying proton therapy, which offers the opportunity to reduce the dose to both the salivary glands and anatomic structures involved in swallowing.This review describes the results of the first cohort studies demonstrating that proton therapy results in lower dose levels in multiple organs at risk, which translates into reduced acute toxicity (i.e. up to 3 months after radiotherapy), while preserving tumour control. Next to reducing mucositis, tube feeding, xerostomia and distortion of the sense of taste, protons can improve general well-being by decreasing fatigue and nausea. Proton therapy results in decreased rates of tube feeding dependency and severe weight loss up to 1 year after radiotherapy, and may decrease the risk of radionecrosis of the mandible. Also, the model-based approach for selecting patients for proton therapy in the Netherlands is described in this review and future perspectives are discussed.
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Affiliation(s)
- Tineke W H Meijer
- Department of Radiation Oncology, University Medical Center Groningen, Groningen, The Netherlands
| | - Dan Scandurra
- Department of Radiation Oncology, University Medical Center Groningen, Groningen, The Netherlands
| | - Johannes A Langendijk
- Department of Radiation Oncology, University Medical Center Groningen, Groningen, The Netherlands
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Aljabab S, Liu A, Wong T, Liao JJ, Laramore GE, Parvathaneni U. Proton Therapy for Locally Advanced Oropharyngeal Cancer: Initial Clinical Experience at the University of Washington. Int J Part Ther 2019; 6:1-12. [PMID: 32582809 DOI: 10.14338/ijpt-19-00053.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 10/26/2019] [Indexed: 12/16/2022] Open
Abstract
Purpose Proton therapy can potentially improve the therapeutic ratio over conventional radiation therapy for oropharyngeal squamous cell cancer (OPSCC) by decreasing acute and late toxicity. We report our early clinical experience with intensity-modulated proton therapy (IMPT). Materials and Methods We retrospectively reviewed patients with OPSCC treated with IMPT at our center. Endpoints include local regional control (LRC), progression-free survival (PFS), overall survival (OS), tumor response, and toxicity outcomes. Toxicity was graded as per the Common Terminology Criteria for Adverse Events v4.03. Descriptive statistics and Kaplan-Meier method were used. Results We treated 46 patients from March 2015 to August 2017. Median age was 58 years, 93.5% were male, 67% were nonsmokers, 98% had stage III-IVB disease per the 7th edition of the AJCC [American Joint Committee on Cancer] Cancer Staging Manual, and 89% were p16 positive. Twenty-eight patients received definitive IMPT to total dose of 70 to 74.4 Gy(RBE), and 18 patients received postoperative IMPT to 60 to 66 Gy(RBE) following transoral robotic surgery (TORS). Sixty-four percent of patients received concurrent systemic therapy. There were no treatment interruptions or observed acute grade 4 or 5 toxicities. Eighteen patients had percutaneous endoscopic gastrostomy (PEG) tube placement; the majority (14) were placed prophylactically. The most common grade 3 acute toxicities were dermatitis (76%) and mucositis (72%). The most common late toxicity was grade 2 xerostomia (30%). At a median follow-up time of 19.2 months (interquartile range [IQR], 11.2-28.4), primary complete response was 100% and nodal complete response was 92%. One patient required a salvage neck dissection owing to an incomplete response at 4 months. There were no recorded local regional or marginal recurrences, PFS was 93.5%, and OS was 95.7%. Conclusion Our early results for IMPT in OPSCC are promising with no local regional or marginal recurrences and a favorable toxicity profile. Our data add to a body of evidence that supports the clinical use of IMPT. Randomized comparative trials are encouraged.
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Affiliation(s)
- Saif Aljabab
- Department of Radiation Oncology, Roswell Park Cancer Center, Buffalo, NY, USA
| | - Andrew Liu
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, WA, USA
| | - Tony Wong
- Seattle Cancer Care Alliance Proton Therapy Center, Seattle, WA, USA
| | - Jay J Liao
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, WA, USA
| | - George E Laramore
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, WA, USA
| | - Upendra Parvathaneni
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, WA, USA
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Ofuya M, McParland L, Murray L, Brown S, Sebag-Montefiore D, Hall E. Systematic review of methodology used in clinical studies evaluating the benefits of proton beam therapy. Clin Transl Radiat Oncol 2019; 19:17-26. [PMID: 31372521 PMCID: PMC6660607 DOI: 10.1016/j.ctro.2019.07.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/05/2019] [Accepted: 07/05/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Proton beam therapy (PBT) delivers high-energy radiation to target tumours while sparing surrounding normal tissues. The dosimetric advantages of PBT over traditional photon radiotherapy may be clear but the translation of this benefit into clinically meaningful reductions in toxicities and improved quality-of-life (QoL) needs to be determined. Randomised controlled trials (RCTs) are considered the gold standard for generating the highest-level evidence in medicine. The objectives of this systematic review were to provide an overview of published clinical studies evaluating the benefits of PBT, and to examine the methodology used in clinical trials with respect to study design and outcomes. METHODS PubMed, EMBASE and Cochrane databases were systematically searched for published clinical studies where PBT was a cancer treatment intervention. All randomised and non-randomised studies, prospective or retrospective, were eligible for inclusion. RESULTS In total, 219 studies were included. Prospective studies comprised 89/219 (41%), and of these, the number of randomised phase II and III trials were 5/89 (6%) and 3/89 (3%) respectively. Of all the phase II and III trials, 18/24 (75%) were conducted at a single PBT centre. Over one-third of authors recommended an increase in length of follow up. Research design and/or findings were poorly reported in 74/89 (83%) of prospective studies. Patient reported outcomes were assessed in only 19/89 (21%) of prospective studies. CONCLUSIONS Prospective randomised evidence for PBT is limited. The set-up of national PBT services in several countries provides an opportunity to guide the optimal design of prospective studies, including RCTs, to evaluate the benefits of PBT across various disease sites. Collaboration between PBT centres, both nationally and internationally, would increase potential for the generation of practice changing evidence. There is a need to facilitate and guide the collection and analysis of meaningful outcome data, including late toxicities and patient reported QoL.
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Affiliation(s)
- Mercy Ofuya
- Clinical Trials and Statistics Unit at The Institute of Cancer Research, London, United Kingdom
| | - Lucy McParland
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Louise Murray
- Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
- Leeds Institute of Molecular Research, University of Leeds, Leeds, United Kingdom
| | - Sarah Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - David Sebag-Montefiore
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
- Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Emma Hall
- Clinical Trials and Statistics Unit at The Institute of Cancer Research, London, United Kingdom
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37
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Yuan TZ, Zhan ZJ, Qian CN. New frontiers in proton therapy: applications in cancers. Cancer Commun (Lond) 2019; 39:61. [PMID: 31640788 PMCID: PMC6805548 DOI: 10.1186/s40880-019-0407-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 10/11/2019] [Indexed: 12/11/2022] Open
Abstract
Proton therapy offers dominant advantages over photon therapy due to the unique depth-dose characteristics of proton, which can cause a dramatic reduction in normal tissue doses both distal and proximal to the tumor target volume. In turn, this feature may allow dose escalation to the tumor target volume while sparing the tumor-neighboring susceptible organs at risk, which has the potential to reduce treatment toxicity and improve local control rate, quality of life and survival. Some dosimetric studies in various cancers have demonstrated the advantages over photon therapy in dose distributions. Further, it has been observed that proton therapy confers to substantial clinical advantage over photon therapy in head and neck, breast, hepatocellular, and non-small cell lung cancers. As such, proton therapy is regarded as the standard modality of radiotherapy in many pediatric cancers from the technical point of view. However, due to the limited clinical evidence, there have been concerns about the high cost of proton therapy from an economic point of view. Considering the treatment expenses for late radiation-induced toxicities, cost-effective analysis in many studies have shown that proton therapy is the most cost-effective option for brain, head and neck and selected breast cancers. Additional studies are warranted to better unveil the cost-effective values of proton therapy and to develop newer ways for better protection of normal tissues. This review aims at reviewing the recent studies on proton therapy to explore its benefits and cost-effectiveness in cancers. We strongly believe that proton therapy will be a common radiotherapy modality for most types of solid cancers in the future.
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Affiliation(s)
- Tai-Ze Yuan
- Department of Radiation Oncology, Guangzhou Concord Cancer Center, Guangzhou, 510045, Guangdong, P. R. China
| | - Ze-Jiang Zhan
- Department of Radiation Oncology, Cancer Center of Guangzhou Medical University, Guangzhou, 510095, Guangdong, P. R. China
| | - Chao-Nan Qian
- Department of Radiation Oncology, Guangzhou Concord Cancer Center, Guangzhou, 510045, Guangdong, P. R. China.
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Bagley AF, Ye R, Garden AS, Gunn GB, Rosenthal DI, Fuller CD, Morrison WH, Phan J, Sturgis EM, Ferrarotto R, Wu R, Liu AY, Frank SJ. Xerostomia-related quality of life for patients with oropharyngeal carcinoma treated with proton therapy. Radiother Oncol 2019; 142:133-139. [PMID: 31431373 DOI: 10.1016/j.radonc.2019.07.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 05/17/2019] [Accepted: 07/09/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE We report longitudinal patient-reported quality-of-life (QoL) outcomes related to xerostomia in patients with oropharyngeal cancer treated with intensity-modulated proton therapy (IMPT). MATERIALS AND METHODS Patients treated from May 2012 through December 2016 at a single institution for AJCC7 stage III-IV, M0 oropharyngeal cancer were given the 15-item Xerostomia-Related QoL Scale (XeQoLS) before, during, and for up to 2 years after treatment. We evaluated the evolution of xerostomia-related QoL over that time, and examined potential associations between those measures with clinical characteristics. RESULTS Sixty-nine patients had XeQoLS scores at baseline and at least once either during or after treatment. The mean (±SD) XeQoLS score (0-4) was 0.24 ± 0.57 at baseline. Subsequent scores were 2.00 ± 1.01 at 6 weeks on treatment, and 1.03 ± 0.76, 0.97 ± 0.78, 0.82 ± 0.69, and 0.70 ± 0.75 at 10 weeks, 6 months, 1 year, and 2 years after treatment, respectively. All were statistically different from baseline (p < 0.001). Univariate analyses demonstrated associations between XeQoLS score and time (p < 0.0001 for each interval), baseline XeQoLS score (p < 0.0001), stage (p = 0.008), N status (p = 0.006), and mean oral cavity dose (p = 0.038), but not for age, sex, T status, receipt of chemotherapy, smoking history, disease site, laterality of neck irradiation, mean parotid dose, or mean submandibular dose. Multivariate analysis suggested that baseline XeQoLS scores, phase of treatment, and N status were associated with XeQoLS scores measured during treatment and recovery. CONCLUSIONS Patients receiving IMPT reported the greatest xerostomia-related QoL impairment at 6 weeks on treatment, with a 49% improvement by 10 weeks after treatment; however, XeQoLS scores remained above baseline after 2 years. As we aim to establish the value of IMPT in oropharyngeal tumors to de-intensify treatment over conventional therapy, these data help inform discussions about xerostomia-related quality of life for patients with oropharyngeal cancer treated with IMPT.
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Affiliation(s)
- Alexander F Bagley
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Rong Ye
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Adam S Garden
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Gary Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Clifton David Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - William H Morrison
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Jack Phan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Erich M Sturgis
- Department of Head & Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Renata Ferrarotto
- Department of Thoracic/Head & Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Richard Wu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Amy Y Liu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA.
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Wang L, Hu J, Liu X, Wang W, Kong L, Lu JJ. Intensity-modulated carbon-ion radiation therapy versus intensity-modulated photon-based radiation therapy in locally recurrent nasopharyngeal carcinoma: a dosimetric comparison. Cancer Manag Res 2019; 11:7767-7777. [PMID: 31496819 PMCID: PMC6701671 DOI: 10.2147/cmar.s205421] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 07/21/2019] [Indexed: 11/30/2022] Open
Abstract
Purpose To identify the specific dose advantage of intensity-modulated carbon-ion radiation therapy (IMCT) over photon-based intensity-modulated radiation therapy (IMRT) in the treatment of locally recurrent nasopharyngeal carcinoma (NPC). Materials and methods Ten patients with locally recurrent NPC underwent IMCT and IMRT planning. Target definition followed the recommendations of the International Commission on Radiation Units and Measurements (ICRU) reports no. 50, 62 and 83. The real treatment plans which were delivered to patients were designed on the Siemens Syngo planning system while the control plans for dosimetric comparison were generated from the Varian Medical Systems. The optimization constraints of the two designs were basically the same. Target coverage was evaluated using the following parameters: Dmin, Dmax, D1, D2, D50, D95, D98 and D99. Target dose distribution and conformality were evaluated using the homogeneity index and conformity index. Normal tissue sparing of organs at risk (OARs) were evaluated using Dmean, D1 and Dmax. SPSS 22.0 software was used for data analysis. Results Both IMCT and IMRT plans met clinical prescription dose requirements. Target coverage of D1, D2, D50, D95, D98, D99 were not significantly different between the two plans (P>0.05). The two plans showed satisfactory coverage of the target without significant difference. There was no significant difference in terms of the homogeneity and conformability between the two plans. Dosimetric parameters for the brain stem, spinal cord, parotid gland, optic chiasm, eyeball, lens, temporal lobe and inner ear were significantly reduced in the IMCT plan (P<0.05). Conclusion As compared with photon-based IMRT, IMCT significantly reduces radiation dose to the OARs in the treatment of locally recurrent NPC while maintaining the dose coverage to the target volumes. Such a feature is particularly important for patients who experienced previous high-dose irradiation.
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Affiliation(s)
- Lei Wang
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai 201315, People's Republic of China.,Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, People's Republic of China.,Department of Radiation Oncology, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, People's Republic of China
| | - Jiyi Hu
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, People's Republic of China.,Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai 201315, People's Republic of China
| | - Xiaoli Liu
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, People's Republic of China.,Department of Medical Physics, Shanghai Proton and Heavy Ion Center, Shanghai 201315, People's Republic of China
| | - Weiwei Wang
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, People's Republic of China.,Department of Medical Physics, Shanghai Proton and Heavy Ion Center, Shanghai 201315, People's Republic of China
| | - Lin Kong
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai 201315, People's Republic of China.,Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, People's Republic of China
| | - Jiade J Lu
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, People's Republic of China.,Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai 201315, People's Republic of China
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Alterio D, Marvaso G, Ferrari A, Volpe S, Orecchia R, Jereczek-Fossa BA. Modern radiotherapy for head and neck cancer. Semin Oncol 2019; 46:233-245. [PMID: 31378376 DOI: 10.1053/j.seminoncol.2019.07.002] [Citation(s) in RCA: 129] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 07/15/2019] [Indexed: 02/07/2023]
Abstract
Radiation therapy (RT) plays a key role in curative-intent treatments for head and neck cancers. Its use is indicated as a sole therapy in early stage tumors or in combination with surgery or concurrent chemotherapy in advanced stages. Recent technologic advances have resulted in both improved oncologic results and expansion of the indications for RT in clinical practice. Despite this, RT administered to the head and neck region is still burdened by a high rate of acute and late side effects. Moreover, about 50% of patients with high-risk disease experience loco-regional recurrence within 3 years of follow-up. Therefore, in recent decades, efforts have been dedicated to optimize the cost/benefit ratio of RT in this subset of patients. The aim of the present review was to highlight modern concepts of RT for head and neck cancers considering both the technological advances that have been achieved and recent knowledge that has informed the biological interaction between radiation and both tumor and healthy tissues.
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Affiliation(s)
- Daniela Alterio
- Division of Radiotherapy, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Giulia Marvaso
- Division of Radiotherapy, IEO European Institute of Oncology, IRCCS, Milan, Italy.
| | - Annamaria Ferrari
- Division of Radiotherapy, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Stefania Volpe
- Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | | | - Barbara Alicja Jereczek-Fossa
- Division of Radiotherapy, IEO European Institute of Oncology, IRCCS, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
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41
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Wang L, Han S, Zhu J, Wang X, Li Y, Wang Z, Lin E, Wang X, Molkentine DP, Blanchard P, Yang Y, Zhang R, Sahoo N, Gillin M, Zhu XR, Zhang X, Myers JN, Frank SJ. Proton versus photon radiation-induced cell death in head and neck cancer cells. Head Neck 2018; 41:46-55. [PMID: 30561022 DOI: 10.1002/hed.25357] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 04/04/2018] [Accepted: 05/16/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Photon (X-ray) radiotherapy (XRT) kills cells via DNA damage, however, how proton radiotherapy (PRT) causes cell death in head and neck squamous cell carcinoma (HNSCC) is unclear. We investigated mechanisms of HNSCC cell death after XRT versus PRT. METHODS We assessed type of death in 2 human papillomavirus (HPV)-positive and two HPV-negative cell lines: necrosis and apoptosis (Annexin-V fluorescein isothiocyanate [FITC]); senescence (β-galactosidase); and mitotic catastrophe (γ-tubulin and diamidino-phenylindole [DAPI]). RESULTS The XRT-induced or PRT-induced cellular senescence and mitotic catastrophe in all cell lines studied suggested that PRT caused cell death to a greater extent than XRT. After PRT, mitotic catastrophe peaked in HPV-negative and HPV-positive cells at 48 and 72 hours, respectively. No obvious differences were noted in the extent of cell necrosis or apoptosis after XRT versus PRT. CONCLUSION Under the conditions and in the cell lines reported here, mitotic catastrophe and senescence were the major types of cell death induced by XRT and PRT, and PRT may be more effective.
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Affiliation(s)
- Li Wang
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shichao Han
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Gynecology, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Jinming Zhu
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Radiation Oncology, The Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning, China
| | - Xiaochun Wang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yuting Li
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Zeming Wang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eric Lin
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Xiaofang Wang
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David P Molkentine
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Pierre Blanchard
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Radiation Oncology, Institut Gustave Roussy, Villejuif, France
| | - Yining Yang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ruiping Zhang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Narayan Sahoo
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael Gillin
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Xiaorong Ronald Zhu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Xiaodong Zhang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeffrey N Myers
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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42
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Intensity modulated proton therapy (IMPT) - The future of IMRT for head and neck cancer. Oral Oncol 2018; 88:66-74. [PMID: 30616799 DOI: 10.1016/j.oraloncology.2018.11.015] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 11/11/2018] [Accepted: 11/12/2018] [Indexed: 12/13/2022]
Abstract
Radiation therapy plays an integral role in the management of head and neck cancers (HNCs). While most HNC patients have historically been treated with photon-based radiation techniques such as intensity modulated radiation therapy (IMRT), there is a growing awareness of the potential clinical benefits of proton therapy over IMRT in the definitive, postoperative and reirradiation settings given the unique physical properties of protons. Intensity modulated proton therapy (IMPT), also known as "pencil beam proton therapy," is a sophisticated mode of proton therapy that is analogous to IMRT and an active area of investigation in cancer care. Multifield optimization IMPT allows for high quality plans that can target superficially located HNCs as well as large neck volumes while significantly reducing integral doses. Several dosimetric studies have demonstrated the superiority of IMPT over IMRT to improve dose sparing of nearby organs such as the larynx, salivary glands, and esophagus. Evidence of the clinical translation of these dosimetric advantages has been demonstrated with documented toxicity reductions (such as decreased feeding tube dependency) after IMPT for patients with HNCs. While there are relative challenges to IMPT planning that exist today such as particle range uncertainties and high sensitivity to anatomical changes, ongoing investigations in image-guidance techniques and robust optimization methods are promising. A systematic approach towards utilizing IMPT and additional prospective studies are necessary in order to more accurately estimate the clinical benefit of IMPT over IMRT and passive proton therapy on a case-by-case basis for patients with sub-site specific HNCs.
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43
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Radiotherapy Advances in Pediatric Neuro-Oncology. Bioengineering (Basel) 2018; 5:bioengineering5040097. [PMID: 30400370 PMCID: PMC6315761 DOI: 10.3390/bioengineering5040097] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 10/26/2018] [Accepted: 11/01/2018] [Indexed: 12/31/2022] Open
Abstract
Radiation therapy (RT) represents an integral component in the treatment of many pediatric brain tumors. Multiple advances have emerged within pediatric radiation oncology that aim to optimize the therapeutic ratio—improving disease control while limiting RT-related toxicity. These include innovations in treatment planning with magnetic resonance imaging (MRI) simulation, as well as increasingly sophisticated radiation delivery techniques. Advanced RT techniques, including photon-based RT such as intensity-modulated RT (IMRT) and volumetric-modulated arc therapy (VMAT), as well as particle beam therapy and stereotactic RT, have afforded an array of options to dramatically reduce radiation exposure of uninvolved normal tissues while treating target volumes. Along with advances in image guidance of radiation treatments, novel RT approaches are being implemented in ongoing and future prospective clinical trials. As the era of molecular risk stratification unfolds, personalization of radiation dose, target, and technique holds the promise to meaningfully improve outcomes for pediatric neuro-oncology patients.
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44
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Thorpe CS, Niska JR, Brunnhoelzl DC, McGee LA, Kesslering CM, Hartsell WF, Vargas CE. First report of proton beam therapy for breast angiosarcoma from the prospective PCG registry. Acta Oncol 2018; 57:992-994. [PMID: 29303019 DOI: 10.1080/0284186x.2017.1423179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
| | - Joshua R. Niska
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Daniel C. Brunnhoelzl
- Creighton University School of Medicine at St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Lisa A. McGee
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
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45
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Cristaudo A, Hickman M, Fong C, Sanghera P, Hartley A. Assessing Novel Drugs and Radiation Technology in the Chemoradiation of Oropharyngeal Cancer. MEDICINES (BASEL, SWITZERLAND) 2018; 5:E65. [PMID: 29954154 PMCID: PMC6163293 DOI: 10.3390/medicines5030065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 06/21/2018] [Accepted: 06/25/2018] [Indexed: 01/21/2023]
Abstract
Integrating immunotherapy, proton therapy and biological dose escalation into the definitive chemoradiation of oropharyngeal cancer poses several challenges. Reliable and reproducible data must be obtained in a timely fashion. However, despite recent international radiotherapy contouring guidelines, controversy persists as to the applicability of such guidelines to all cases. Similarly, a lack of consensus exists concerning both the definition of the organ at risk for oral mucositis and the most appropriate endpoint to measure for this critical toxicity. Finally, the correlation between early markers of efficacy such as complete response on PET CT following treatment and subsequent survival needs elucidation for biological subsets of oropharyngeal cancer.
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Affiliation(s)
- Agostino Cristaudo
- Department of Radiation Oncology, University of Pisa, 56100 Pisa PI, Italy.
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, Birmingham B15 2TH, UK.
| | - Mitchell Hickman
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, Birmingham B15 2TH, UK.
| | - Charles Fong
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, Birmingham B15 2TH, UK.
| | - Paul Sanghera
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, Birmingham B15 2TH, UK.
| | - Andrew Hartley
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, Birmingham B15 2TH, UK.
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Blanchard P, Gunn GB, Lin A, Foote RL, Lee NY, Frank SJ. Proton Therapy for Head and Neck Cancers. Semin Radiat Oncol 2018; 28:53-63. [PMID: 29173756 DOI: 10.1016/j.semradonc.2017.08.004] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Because of its sharp lateral penumbra and steep distal fall-off, proton therapy offers dosimetric advantages over photon therapy. In head and neck cancer, proton therapy has been used for decades in the treatment of skull-base tumors. In recent years the use of proton therapy has been extended to numerous other disease sites, including nasopharynx, oropharynx, nasal cavity and paranasal sinuses, periorbital tumors, skin, and salivary gland, or to reirradiation. The aim of this review is to present the physical properties and dosimetric benefit of proton therapy over advanced photon therapy; to summarize the clinical benefit described for each disease site; and to discuss issues of patient selection and cost-effectiveness.
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Affiliation(s)
- Pierre Blanchard
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Department of Radiation Oncology, Institut Gustave Roussy, Villejuif, France
| | - Gary Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Alexander Lin
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Robert L Foote
- Departments of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Nancy Y Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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47
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Kim JK, Leeman JE, Riaz N, McBride S, Tsai CJ, Lee NY. Proton Therapy for Head and Neck Cancer. Curr Treat Options Oncol 2018; 19:28. [PMID: 29744681 DOI: 10.1007/s11864-018-0546-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OPINION STATEMENT The application of proton beam radiation therapy in the treatment of head and neck cancer has grown tremendously in the past few years. Globally, widespread interest in proton beam therapy has led to multiple research efforts regarding its therapeutic value and cost-effectiveness. The current standard of care using modern photon radiation technology has demonstrated excellent treatment outcomes, yet there are some situations where disease control remains suboptimal with the potential for detrimental acute and chronic toxicities. Due to the advantageous physical properties of the proton beam, proton beam therapy may be superior to photon therapy in some patient subsets for both disease control and patient quality of life. As enthusiasm and excitement for proton beam therapy continue to increase, clinical research and widespread adoption will elucidate the true value of proton beam therapy and give a greater understanding of the full risks and benefits of proton therapy in head and neck cancer.
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Affiliation(s)
- Joseph K Kim
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1250 1st Avenue, New York, NY, 10065, USA
| | - Jonathan E Leeman
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1250 1st Avenue, New York, NY, 10065, USA
| | - Nadeem Riaz
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1250 1st Avenue, New York, NY, 10065, USA
| | - Sean McBride
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1250 1st Avenue, New York, NY, 10065, USA
| | - Chiaojung Jillian Tsai
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1250 1st Avenue, New York, NY, 10065, USA
| | - Nancy Y Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1250 1st Avenue, New York, NY, 10065, USA.
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48
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Cost-Effectiveness Analysis of Intensity Modulated Radiation Therapy Versus Proton Therapy for Oropharyngeal Squamous Cell Carcinoma. Int J Radiat Oncol Biol Phys 2018; 101:875-882. [PMID: 29976499 DOI: 10.1016/j.ijrobp.2018.04.018] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 03/29/2018] [Accepted: 04/05/2018] [Indexed: 11/22/2022]
Abstract
PURPOSE To compared the cost-effectiveness of intensity modulated proton beam therapy (PBT) and intensity modulated radiation therapy (IMRT) in the management of stage III-IVB oropharynx cancer (OPC). METHODS AND MATERIALS A Markov model was constructed to compare IMRT with PBT for a 65-year-old patient with stage IVA OPSCC. We assumed PBT led to a 25% reduction in long-term xerostomia, short-term dysgeusia, and the need for gastrostomy tube. Fewer dental complications were also expected with PBT. Incremental cost-effectiveness ratios (ICERs) were calculated, and value of information analyses were performed. The societal willingness-to-pay was defined as $100K per quality-adjusted life year (QALY). RESULTS The ICERs for PBT for favorable human papillomavirus (HPV)-positive OPC were $288,000/QALY and $390,000/QALY in the payer perspective (PP) and societal perspective, respectively. Under nearly every scenario, PBT was not cost-effective, with ICERs above $150,000/QALY in the PP. The ICERs for HPV-negative OPC were typically greater than $250K/QALY in both perspectives. For HPV-positive patients, the ICER was less than $100,000/QALY in the PP only in younger patients who experienced a 50% reduction in both xerostomia and gastrostomy use. On probabilistic sensitivity analyses, there were 0% and 0.4% probabilities that PBT was cost-effective for 65- and 55-year old patients, respectively. The value of information was zero or negligible for all ages and perspectives at willingness-to-pay of $100,000/QALY and only meaningful in the PP for younger patients at a willingness-to-pay of $150,000/QALY. CONCLUSIONS Intensity modulated proton beam therapy was only cost-effective in the PP if assumed to achieve profound reductions in long-term morbidity for younger patients; it was never cost-effective in the societal perspective. Prospective data are needed (and may be valuable) to better characterize the comparative toxicities of these treatments but are unlikely to change this calculation, except potentially in the most favorable cohort of patients.
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49
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Frank SJ, Blanchard P, Lee JJ, Sturgis EM, Kies MS, Machtay M, Vikram B, Garden AS, Rosenthal DI, Gunn GB, Fuller CD, Hutcheson K, Lai S, Busse PM, Lee NY, Lin A, Foote RL. Comparing Intensity-Modulated Proton Therapy With Intensity-Modulated Photon Therapy for Oropharyngeal Cancer: The Journey From Clinical Trial Concept to Activation. Semin Radiat Oncol 2018; 28:108-113. [PMID: 29735186 PMCID: PMC5942581 DOI: 10.1016/j.semradonc.2017.12.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Intensity-modulated proton therapy minimizes the incidental irradiation of normal tissues in patients with head and neck cancer relative to intensity-modulated photon (x-ray) therapy and has been associated with lesser treatment-related toxicity and improved quality of life. A phase II/III randomized trial sponsored by the US National Cancer Institute is currently underway to compare deintensification treatment strategies with intensity-modulated proton therapy vs intensity-modulated photon (x-ray) therapy for patients with advanced-stage oropharyngeal tumors. After significant input from numerous stakeholders, the phase III portion of the randomized trial was redesigned as a noninferiority trial with progression-free survival as the primary endpoint. The process by which that redesign took place is described here.
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Affiliation(s)
- Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Pierre Blanchard
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - J Jack Lee
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Erich M Sturgis
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Merrill S Kies
- Department of Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mitchell Machtay
- Department of Radiation Oncology, UH Cleveland Medical Center, Cleveland, OH
| | - Bhadrasain Vikram
- Clinical Radiation Oncology Branch, National Cancer Institute, Bethesda, MD
| | - Adam S Garden
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - G Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - C David Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Katherine Hutcheson
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Stephen Lai
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Paul M Busse
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | - Nancy Y Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alexander Lin
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Robert L Foote
- Department of Radiation Oncology, The Mayo Clinic, Rochester, MN
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Mirghani H, Blanchard P. Treatment de-escalation for HPV-driven oropharyngeal cancer: Where do we stand? Clin Transl Radiat Oncol 2018; 8:4-11. [PMID: 29594236 PMCID: PMC5862680 DOI: 10.1016/j.ctro.2017.10.005] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 10/28/2017] [Accepted: 10/29/2017] [Indexed: 01/30/2023] Open
Abstract
HPV-driven oropharyngeal cancers have significantly better survival rates than tobacco and alcohol induced head and neck cancers. As HPV-positive patients are younger, healthier and far more likely to survive their disease, long-term treatment side effects are becoming a major issue. This has led the scientific and medical community to reassess the current treatment protocols in order to develop less toxic strategies while maintaining good oncological outcomes. In this article, we discuss the ongoing treatment de-escalation trials and highlight the issues raised by these studies.
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Affiliation(s)
- Haitham Mirghani
- Department of Head and Neck Oncology, Gustave Roussy Cancer Campus, 114 Rue Edouard Vaillant, Villejuif, France
| | - Pierre Blanchard
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, 114 Rue Edouard Vaillant, Villejuif, France
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