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Das IJ, Yadav P, Andersen AD, Chen ZJ, Huang L, Langer MP, Lee C, Li L, Popple RA, Rice RK, Schiff PB, Zhu TC, Abazeed ME. Dose prescription and reporting in stereotactic body radiotherapy: A multi-institutional study. Radiother Oncol 2023; 182:109571. [PMID: 36822361 PMCID: PMC10121952 DOI: 10.1016/j.radonc.2023.109571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 02/07/2023] [Accepted: 02/12/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND AND PURPOSE Radiation dose prescriptions are foundational for optimizing treatment efficacy and limiting treatment-related toxicity. We sought to assess the lack of standardization of SBRT dose prescriptions across institutions. MATERIALS & METHODS Dosimetric data from 1298 patients from 9 academic institutions treated with IMRT and VMAT were collected. Dose parameters D100, D98, D95, D50, and D2 were used to assess dosimetric variability. RESULTS Disease sites included lung (48.3 %) followed by liver (29.7 %), prostate (7.5 %), spine (6.8 %), brain (4.1 %), and pancreas (2.5 %). The PTV volume in lung varied widely with bimodality into two main groups (22.0-28.7 cm3) and (48.0-67.1 cm3). A hot spot ranging from 120-150 % was noted in nearly half of the patients, with significant variation across institutions. A D50 ≥ 110 % was found in nearly half of the institutions. There was significant dosimetric variation across institutions. CONCLUSIONS The SBRT prescriptions in the literature or in treatment guidelines currently lack nuance and hence there is significant variation in dose prescriptions across academic institutions. These findings add greater importance to the identification of dose parameters associated with improved clinical outcome comparisons as we move towards more hypofractionated treatments. There is a need for standardized reporting to help institutions in adapting treatment protocols based on the outcome of clinical trials. Dosimetric parameters are subsequently needed for uniformity and thereby standardizing planning guidelines to maximize efficacy, mitigate toxicity, and reduce treatment disparities are urgently needed.
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Affiliation(s)
- Indra J Das
- Department of Radiation Oncology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Poonam Yadav
- Department of Radiation Oncology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Aaron D Andersen
- Department of Radiation Oncology, Renown Medical Center, Reno, NV, USA
| | - Zhe Jay Chen
- Department of Therapeutic Radiology, Yale University, New haven, CT, USA
| | - Long Huang
- Department of Radiation Oncology, University of Utah, Salt Lake City, UT, USA
| | - Mark P Langer
- Department of Radiation Oncology, Indiana University Health, Indianapolis, IN, USA
| | - Choonik Lee
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Lin Li
- Division of Biostatistics, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Richard A Popple
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Roger K Rice
- Department of Radiation Medicine and Applied Science, University of California, San Diego, CA, USA
| | - Peter B Schiff
- Department of Radiation Oncology, New York University Grossman School of Medicine, New York, NY, USA
| | - Timothy C Zhu
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Mohamed E Abazeed
- Department of Radiation Oncology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Volpe S, Piperno G, Colombo F, Biffi A, Comi S, Mastroleo F, Maria Camarda A, Casbarra A, Cattani F, Corrao G, de Marinis F, Spaggiari L, Guckenberger M, Orecchia R, Alterio D, Alicja Jereczek-Fossa B. Hypofractionated proton therapy for non-small cell lung cancer: Ready for prime time? A systematic review and meta-analysis. Cancer Treat Rev 2022; 110:102464. [DOI: 10.1016/j.ctrv.2022.102464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/02/2022] [Accepted: 09/14/2022] [Indexed: 11/02/2022]
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Clinical Outcomes Following Proton and Photon Stereotactic Body Radiation Therapy for Early-Stage Lung Cancer. Cancers (Basel) 2022; 14:cancers14174152. [PMID: 36077688 PMCID: PMC9454659 DOI: 10.3390/cancers14174152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/25/2022] [Accepted: 08/25/2022] [Indexed: 12/25/2022] Open
Abstract
Simple Summary The current study reports the clinical outcomes of proton and photon stereotactic body radiation therapy (SBRT) for early-stage lung cancer. Out of 202 patients who met the inclusion criteria, 34 received proton SBRT and 168 received photon SBRT. Patients at high risk of developing post-SBRT radiation pneumonitis tended to receive proton SBRT. Oncologic outcomes and toxicity profiles were comparable between treatment modalities. Proton SBRT could be considered for patients with high risk of radiation pneumonitis. Abstract We aimed to report the clinical outcomes following stereotactic body radiation therapy (SBRT) using photon or proton equipment in early-stage lung cancer. We retrospectively reviewed 202 cT1-2N0M0 lung cancer patients who underwent SBRT with 60 Gy in four consecutive fractions between 2010 and 2019 at our institution: 168 photon SBRT and 34 proton SBRT. Patients who underwent proton SBRT had relatively poor baseline lung condition compared to those who underwent photon SBRT. Clinical outcomes were comparable between treatment modalities: 5-year local control (90.8% vs. 83.6%, p = 0.602); progression-free survival (61.6% vs. 57.8%, p = 0.370); overall survival (51.7% vs. 51.9%, p = 0.475); and cause-specific survival (70.3% vs. 62.6%, p = 0.618). There was no statistically significant difference in grade ≥ 2 toxicities: radiation pneumonitis (19.6% vs. 26.4%, p = 0.371); musculoskeletal (13.7% vs. 5.9%, p = 0.264); and skin (3.6% vs. 0.0%, p = 0.604). In the binary logistic regression analysis of grade ≥3 radiation pneumonitis, poor performance status and poor baseline diffusion capacity of lung for carbon monoxide were significant. To summarize, though patients with high risk of developing lung toxicity underwent proton SBRT more frequently, the SBRT techniques resulted in comparable oncologic outcomes with similar toxicity profiles. Proton SBRT could be considered for patients at high risk of radiation pneumonitis.
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Liu G, Zhao L, Qin A, Grills I, Deraniyagala R, Stevens C, Zhang S, Yan D, Li X, Ding X. Lung Stereotactic Body Radiotherapy (SBRT) Using Spot-Scanning Proton Arc (SPArc) Therapy: A Feasibility Study. Front Oncol 2021; 11:664455. [PMID: 33968770 PMCID: PMC8100671 DOI: 10.3389/fonc.2021.664455] [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: 02/05/2021] [Accepted: 03/26/2021] [Indexed: 12/26/2022] Open
Abstract
Purpose We developed a 4D interplay effect model to quantitatively evaluate breathing-induced interplay effects and assess the feasibility of utilizing spot-scanning proton arc (SPArc) therapy for hypo-fractionated lung stereotactic body radiotherapy (SBRT). The model was then validated by retrospective application to clinical cases. Materials and Methods A digital lung 4DCT phantoms was used to mimic targets in diameter of 3cm with breathing motion amplitudes: 5, 10, 15, and 20 mm, respectively. Two planning groups based on robust optimization were generated: (1) Two-field Intensity Modulated Proton Therapy (IMPT) plans and (2) SPArc plans via a partial arc. 5,000 cGy relative biological effectiveness (RBE) was prescribed to the internal target volume (ITV) in five fractions. To quantitatively assess the breathing induced interplay effect, the 4D dynamic dose was calculated by synchronizing the breathing pattern with the simulated proton machine delivery sequence, including IMPT, Volumetric repainting (IMPTvolumetric), iso-layered repainting (IMPTlayer) and SPArc. Ten lung patients’ 4DCT previously treated with VMAT SBRT, were used to validate the digital lung tumor model. Normal tissue complicated probability (NTCP) of chestwall toxicity was calculated. Result Target dose were degraded as the tumor motion amplitude increased. The 4D interplay effect phantom model indicated that motion mitigation effectiveness using SPArc was about five times of IMPTvolumetric or IMPTlayer using maximum MU/spot as 0.5 MU at 20 mm motion amplitude. The retrospective study showed that SPArc has an advantage in normal tissue sparing. The probability of chestwall’s toxicity were significantly improved from 40.2 ± 29.0% (VMAT) (p = 0.01) and 16.3 ± 12.0% (IMPT) (p = 0.01) to 10.1 ± 5.4% (SPArc). SPArc could play a significant role in the interplay effect mitigation with breathing-induced motion more than 20 mm, where the target D99 of 4D dynamic dose for patient #10 was improved from 4,514 ± 138 cGy [RBE] (IMPT) vs. 4,755 ± 129 cGy [RBE] (SPArc) (p = 0.01). Conclusion SPArc effectively mitigated the interplay effect for proton lung SBRT compared to IMPT with repainting and was associated with normal tissue sparing. This technology may make delivery of proton SBRT more technically feasible and less complex with fewer concerns over underdosing the target compared to other proton therapy techniques.
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Affiliation(s)
- Gang Liu
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Lewei Zhao
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - An Qin
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Inga Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Rohan Deraniyagala
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Craig Stevens
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Sheng Zhang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Di Yan
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Xiaoqiang Li
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
| | - Xuanfeng Ding
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, United States
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Vlaskou Badra E, Baumgartl M, Fabiano S, Jongen A, Guckenberger M. Stereotactic radiotherapy for early stage non-small cell lung cancer: current standards and ongoing research. Transl Lung Cancer Res 2021; 10:1930-1949. [PMID: 34012804 PMCID: PMC8107760 DOI: 10.21037/tlcr-20-860] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Stereotactic body radiation therapy (SBRT) allows for the non-invasive and precise delivery of ablative radiation dose. The use and availability of SBRT has increased rapidly over the past decades. SBRT has been proven to be a safe, effective and efficient treatment for early stage non-small cell lung cancer (NSCLC) and is presently considered the standard of care in the treatment of medically or functionally inoperable patients. Evidence from prospective randomized trials on the optimal treatment of patients deemed medically operable remains owing, as three trials comparing SBRT to surgery in this cohort were terminated prematurely due to poor accrual. Yet, SBRT in early stage NSCLC is associated with favorable toxicity profiles and excellent rates of local control, prompting discussion in regard of the treatment of medically operable patients, where the standard of care currently remains surgical resection. Although local control in early stage NSCLC after SBRT is high, distant failure remains an issue, prompting research interest to the combination of SBRT and systemic treatment. Evolving advances in SBRT technology further facilitate the safe treatment of patients with medically or anatomically challenging situations. In this review article, we discuss international guidelines and the current standard of care, ongoing clinical challenges and future directions from the clinical and technical point of view.
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Affiliation(s)
- Eugenia Vlaskou Badra
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Michael Baumgartl
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Silvia Fabiano
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Aurélien Jongen
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Kharod SM, Nichols RC, Henderson RH, Morris CG, Pham DC, Seeram VK, Jones LM, Antonio-Miranda M, Siragusa DA, Li Z, Flampouri S, Hoppe BS. Image-Guided Hypofractionated Proton Therapy in Early-Stage Non-Small Cell Lung Cancer: A Phase 2 Study. Int J Part Ther 2020; 7:1-10. [PMID: 33274252 PMCID: PMC7707327 DOI: 10.14338/ijpt-20-00013.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 07/28/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose Due to the excellent outcomes with image-guided stereotactic body radiotherapy for patients with early-stage non–small cell lung cancer (NSCLC) and the low treatment-related toxicities using proton therapy (PT), we investigated treatment outcomes and toxicities when delivering hypofractionated PT. Materials and Methods Between 2009 and 2018, 22 patients with T1 to T2 N0M0 NSCLC (45% T1, 55% T2) received image-guided hypofractionated PT. The median age at diagnosis was 72 years (range, 58-90). Patients underwent 4-dimensional computed tomography simulation following fiducial marker placement, and daily image guidance was performed. Nine patients (41%) were treated with 48 GyRBE in 4 fractions for peripheral lesions, and 13 patients (59%) were treated with 60 GyRBE in 10 fractions for central lesions. Patients were assessed for CTCAEv4 toxicities with computed tomography imaging for tumor assessment. The primary endpoint was grade 3 to 5 toxicity at 1 year. Results The median follow-up for all patients was 3.5 years (range, 0.2-8.8 years). The overall survival rates at 3 and 5 years were 81% and 49%, respectively. Cause-specific survival rates at 3 and 5 years were 100% and 75%, respectively. The 3-year local, regional, and distant control rates were 86%, 85%, and 95%, respectively. Four patients experienced in-field recurrences between 18 and 45 months after treatment. One patient (5%) developed a late grade 3 bronchial stricture requiring hospitalization and stent. Conclusion Image-guided hypofractionated PT for early-stage NSCLC provides promising local control and long-term survival with a low likelihood of toxicity. Regional nodal and distant relapses remain a problem.
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Affiliation(s)
- Shivam M Kharod
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - R Charles Nichols
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Randal H Henderson
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Dat C Pham
- Department of Medicine, Division of Hematology and Medical Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Vandana K Seeram
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Lisa M Jones
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, College of Medicine, Jacksonville, FL, USA
| | | | - Daniel A Siragusa
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Zuofeng Li
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Stella Flampouri
- Department of Radiation Oncology, Emory Proton Therapy Center, Atlanta, GA, USA
| | - Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
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7
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Kharod SM, Nichols RC, Henderson RH, Morris CG, Pham DC, Seeram VK, Jones LM, Antonio-Miranda M, Huh S, Li Z, Hoppe BS. Image-guided hypofractionated double-scattering proton therapy in the management of centrally-located early-stage non-small cell lung cancer. Acta Oncol 2020; 59:1164-1170. [PMID: 32394776 DOI: 10.1080/0284186x.2020.1759821] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The treatment of centrally-located early-stage non-small cell lung cancer (NSCLC) with image-guided stereotactic body radiotherapy (SBRT) is challenging due to the proximity of critical normal structures to the tumor target. The purpose of this study was to report the results of our experience in treating centrally-located early-stage NSCLC with hypofractionated proton therapy (PT). MATERIAL AND METHODS Between 2009 and 2018, 23 patients with T1-T2N0M0 NSCLC (T1, 46%; T2, 54%) were treated with image-guided hypofractionated double-scattering PT. The median age at the time of treatment was 74 years (range, 58-88). Patients underwent 4-dimensional computed tomography (CT) simulation following fiducial marker placement, and daily image guidance was performed. All patients were treated with 60 GyRBE in 10 fractions. Patients were assessed for CTCAEv4 toxicities weekly during treatment, and at regular follow-up intervals with CT imaging for tumor assessment. Overall survival, cause-specific survival, local control, regional control, and metastases-free survival were evaluated using cumulative incidence with competing risks. RESULTS Median follow-up for all patients was 3.2 years (range, 0.2-9.2 years). Overall survival rates at 3 and 5 years were 81% and 50% (95% CI, 27-79%), respectively. Cause-specific survival rates at 3 and 5 years were 81% and 71% (95% CI, 46-92%). The 3-year local, regional, and distant control rates were 90%, 81%, and 87%, respectively. Three patients (13%) experienced local recurrences as their first recurrence, at a median time of 28 months from completion of radiation (range, 18-61 months). Two patients (9%) experienced late grade 3 toxicities, including 1 patient who developed a bronchial stricture that required stent placement. CONCLUSION Image-guided hypofractionated PT for centrally-located early-stage NSCLC provides excellent local control with low rates of grade ≥3 toxicities. For tumors in sensitive locations, PT may provide safer treatment than photon-based treatments due to its dosimetric advantages.
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Affiliation(s)
- Shivam M. Kharod
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - R. Charles Nichols
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Randal H. Henderson
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Christopher G. Morris
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Dat C. Pham
- Department of Medicine, Division of Hematology and Medical Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Vandana K. Seeram
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Lisa M. Jones
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, College of Medicine, Jacksonville, FL, USA
| | | | - Soon Huh
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Zuofeng Li
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Bradford S. Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
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Jie AW, Marignol L. Pro-con of proton: Dosimetric advantages of intensity-modulation over passive scatter for thoracic malignancies. Tech Innov Patient Support Radiat Oncol 2020; 15:37-46. [PMID: 32954018 PMCID: PMC7486544 DOI: 10.1016/j.tipsro.2019.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/18/2019] [Accepted: 11/11/2019] [Indexed: 12/25/2022] Open
Abstract
Intensity Modulated Proton Therapy (IMPT) results in significant reduction of dose to organ at risk. Improving plan robustness mitigates interplay effects. Blanket use of small spots on a group of patients may severely worsen interplay in selected patients. Hypofractionated regimes have fewer interplay effects in both fractional and overall simulations. Randomised control trials are required before any clinical benefit of IMPT can be confirmed.
The use of passively scattered proton therapy (PSPT) or intensity modulated proton therapy (IMPT) opens the potential for dose escalation or critical structure sparing in thoracic malignancies. While the latter offers greater dose conformality, dose distributions are subjected to greater uncertainties, especially due to interplay effects. Exploration in this area is warranted to determine if there is any dosimetric advantages in using IMPT for thoracic malignancies. This review aims to both compare organs-at-risk sparing and plan robustness between PSPT and IMPT and examine the mitigation strategies for the reduction of interplay effects currently available. Early evidence suggests that IMPT is dosimetrically superior to PSPT in thoracic malignancies. Randomised control trials are required before any clinical benefit of IMPT can be confirmed.
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Key Words
- BSPTV, Beam Specific Planning Target Volume
- CT, Computed Tomography
- DIBH, Deep Inspiration Breath-Hold
- Dosimetry
- EUD, Equivalent Uniform Dose
- HI, Homogeneity Index
- IMPT, Intensity Modulated Proton Therapy
- IMRT, Intensity Modulated Radiation Therapy
- ITV, Internal Target Volume
- Intensity modulated proton therapy (IMPT)
- Interplay
- MFO, Multi Field Optimisation
- MU, Monitor Unit
- NSCLC, Non-Small-Cell Lung cancer
- OAR, Organ-At-Risk
- Organ at risks
- PSPT, Passively Scattered Proton Therapy
- PTV, Planning Target Volume
- Passively scattered proton therapy (PSPT)
- RT, Radiation Therapy
- SFO, Single Field Optimisation
- SFUD, Single Field Uniform Dose
- Thoracic malignancies
- iCTV, Internal Clinical Target Volume
- iGTV/HU, Internal Gross Tumour Volume/Hounsfield Unit
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Affiliation(s)
- Ang Wei Jie
- Singapore Institute of Technology, Singapore
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, Trinity Centre for Health Sciences, St. James’s Hospital, Dublin, Ireland
| | - Laure Marignol
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, Trinity Centre for Health Sciences, St. James’s Hospital, Dublin, Ireland
- Corresponding author.
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Giaj-Levra N, Borghetti P, Bruni A, Ciammella P, Cuccia F, Fozza A, Franceschini D, Scotti V, Vagge S, Alongi F. Current radiotherapy techniques in NSCLC: challenges and potential solutions. Expert Rev Anticancer Ther 2020; 20:387-402. [PMID: 32321330 DOI: 10.1080/14737140.2020.1760094] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Radiotherapy is an important therapeutic strategy in the management of non-small cell lung cancer (NSCLC). In recent decades, technological implementations and the introduction of image guided radiotherapy (IGRT) have significantly increased the accuracy and tolerability of radiation therapy.Area covered: In this review, we provide an overview of technological opportunities and future prospects in NSCLC management.Expert opinion: Stereotactic body radiotherapy (SBRT) is now considered the standard approach in patients ineligible for surgery, while in operable cases, it is still under debate. Additionally, in combination with systemic treatment, SBRT is an innovative option for managing oligometastatic patients and features encouraging initial results in clinical outcomes. To date, in inoperable locally advanced NSCLC, the radical dose prescription has not changed (60 Gy in 30 fractions), despite the median overall survival progressively increasing. These results arise from technological improvements in precisely hitting target treatment volumes and organ at risk sparing, which are associated with better treatment qualities. Finally, for the management of NSCLC, proton and carbon ion therapies and the recent development of MR-Linac are new, intriguing technological approaches under investigation.
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Affiliation(s)
- Niccolò Giaj-Levra
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Italy
| | - Paolo Borghetti
- Dipartimento di Radioterapia Oncologica, Università e ASST Spedali Civili di Brescia, Brescia, Italy
| | - Alessio Bruni
- Radiotherapy Unit, Department of Oncology and Hematology, University Hospital of Modena, Modena, Italy
| | - Patrizia Ciammella
- Radiation Therapy Unit, Department of Oncology and Advanced Technology, AUSL-IRCCS, Reggio, Emilia, Italy
| | - Francesco Cuccia
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Italy
| | - Alessandra Fozza
- Department of Radiation Oncology, SS.Antonio e Biagio e C.Arrigo Hospital Alessandria, Alessandria, Italy
| | - Davide Franceschini
- Department of Radiotherapy and Radiosurgery, Humanitas Clinical and Research Center- IRCCS - Rozzano (MI), Milano, Italy
| | - Vieri Scotti
- Radiation Therapy Unit, Department of Oncology, Careggi University Hospital, Firenze, Italy
| | - Stefano Vagge
- Radiation oncology Department, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Filippo Alongi
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Italy.,University of Brescia, Italy
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Ohnishi K, Nakamura N, Harada H, Tokumaru S, Wada H, Arimura T, Iwata H, Sato Y, Sekino Y, Tamamura H, Mizoe JE, Ogino T, Ishikawa H, Kikuchi Y, Okimoto T, Murayama S, Akimoto T, Sakurai H. Proton Beam Therapy for Histologically or Clinically Diagnosed Stage I Non-Small Cell Lung Cancer (NSCLC): The First Nationwide Retrospective Study in Japan. Int J Radiat Oncol Biol Phys 2019; 106:82-89. [PMID: 31580927 DOI: 10.1016/j.ijrobp.2019.09.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/23/2019] [Accepted: 09/10/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE To investigate the efficacy and safety of proton beam therapy (PBT) for the treatment of stage I non-small cell lung cancer (NSCLC). METHODS AND MATERIALS Six hundred sixty-nine patients with 682 tumors histologically or clinically diagnosed stage I NSCLC according to the seventh edition of Union for International Cancer Control who received passive-scattering PBT from April 2004 and December 2013 in Japan were retrospectively reviewed to analyze survival, local control, and toxicities. RESULTS Of 669 patients, 486 (72.6%) were men, with a median age of 76 years (range, 42-94 years). NSCLC was histologically confirmed in 440 patients (65.7%). Clinical T stages included T1a (n = 265; 38.9%), T1b (n = 216; 31.7%), and T2a (n = 201; 29.4%). The total irradiation doses of PBT ranged from 74.4 to 131.3 biological effective dose GyE (median, 109.6 biological effective dose GyE). The median follow-up period was 38.2 months (range, 0.6-154.5 months) for all patients. The 3-year overall survival and progression-free survival rates for all patients were 79.5% and 64.1%, respectively. For patients with stage IA tumors, the 3-year overall survival and progression-free survival rates were 82.8% and 70.6%, respectively, and the corresponding rates for patients with stage IB tumors were 70.8% and 47.3%, respectively. The 3-year local progression-free rates for all, stage IA, and stage IB patients were 89.8%, 93.5%, and 79.4%, respectively. The incidence of grade 2, 3, 4, and 5 pneumonitis was 9.8%, 1.0%, 0%, and 0.7%, respectively. The incidence of grade ≥3 dermatitis was 0.4%. No grade 4 or severe adverse events, other than pneumonitis, were observed. CONCLUSIONS PBT appears to yield acceptable survival rates, with a low rate of toxicities.
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Affiliation(s)
- Kayoko Ohnishi
- Department of Radiation Oncology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Naoki Nakamura
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Hideyuki Harada
- Proton Therapy Division, Shizuoka Cancer Center, Nagaizumi, Shizuoka, Japan
| | - Sunao Tokumaru
- Department of Radiology, Hyogo Ion Beam Medical Center, Tatsuno, Hyogo, Japan
| | - Hitoshi Wada
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Koriyama, Fukushima, Japan
| | - Takeshi Arimura
- Medipolis Proton Therapy and Research Center, Ibusuki, Kagoshima, Japan
| | - Hiromitsu Iwata
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City West Medical Center, Nagoya, Aichi, Japan
| | - Yoshitaka Sato
- Proton Therapy Center, Fukui Prefecture Hospital, Fukui, Fukui, Japan
| | - Yuta Sekino
- Department of Radiation Oncology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hiroyasu Tamamura
- Proton Therapy Center, Fukui Prefecture Hospital, Fukui, Fukui, Japan
| | - Jun-Etsu Mizoe
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City West Medical Center, Nagoya, Aichi, Japan
| | - Takashi Ogino
- Medipolis Proton Therapy and Research Center, Ibusuki, Kagoshima, Japan
| | - Hitoshi Ishikawa
- Department of Radiation Oncology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yasuhito Kikuchi
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Koriyama, Fukushima, Japan
| | - Tomoaki Okimoto
- Department of Radiology, Hyogo Ion Beam Medical Center, Tatsuno, Hyogo, Japan
| | - Shigeyuki Murayama
- Proton Therapy Division, Shizuoka Cancer Center, Nagaizumi, Shizuoka, Japan
| | - Tetsuo Akimoto
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Hideyuki Sakurai
- Department of Radiation Oncology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan.
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Brooks ED, Ning MS, Verma V, Zhu XR, Chang JY. Proton therapy for non-small cell lung cancer: the road ahead. Transl Lung Cancer Res 2019; 8:S202-S212. [PMID: 31673525 PMCID: PMC6795573 DOI: 10.21037/tlcr.2019.07.08] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 07/17/2019] [Indexed: 12/14/2022]
Abstract
Proton therapy is an evolving radiotherapy modality with indication for numerous cancer types. With the benefits of reducing dose and sparing normal tissue, protons offer a clear physical and dosimetric advantage over photon radiotherapy for many patients. However, its impact on one type of disease, non-small cell lung cancer (NSCLC), is still not fully understood. Our review aims to highlight the data for using proton therapy in NSCLC, with a focus on the clinical data-or lack thereof-supporting proton treatment for early and advanced stage disease. In evaluating these data, we consider how future directions and advances in proton technology give rise for hope in defining a role for protons in improving NSCLC outcomes. We close with considerations for next steps and the challenges ahead in using proton therapy for this unique patient population.
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Affiliation(s)
- Eric D. Brooks
- 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
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA, USA
| | - X. Ronald Zhu
- Proton Therapy Center, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joe Y. Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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12
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Li X, Kabolizadeh P, Yan D, Qin A, Zhou J, Hong Y, Guerrero T, Grills I, Stevens C, Ding X. Improve dosimetric outcome in stage III non-small-cell lung cancer treatment using spot-scanning proton arc (SPArc) therapy. Radiat Oncol 2018; 13:35. [PMID: 29486782 PMCID: PMC6389253 DOI: 10.1186/s13014-018-0981-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 02/20/2018] [Indexed: 12/25/2022] Open
Abstract
Background To evaluate spot-scanning proton arc therapy (SPArc) and multi-field robust optimized intensity modulated proton therapy (RO-IMPT) in treating stage III non-small-cell lung cancer (NSCLC) patients. Methods Two groups of stage IIIA or IIIB NSCLC patients (group 1: eight patients with tumor motion less than 5 mm; group 2: six patients with tumor motion equal to or more than 5 mm) were re-planned with SPArc and RO-IMPT. Both plans were generated using robust optimization to achieve an optimal coverage with 99% of internal target volume (ITV) receiving 66 Gy (RBE) in 33 fractions. The dosimetric results and plan robustness were compared for both groups. The interplay effect was evaluated based on the ITV coverage by single-fraction 4D dynamic dose. Total delivery time was simulated based on a full gantry rotation with energy-layer-switching-time (ELST) from 0.2 to 4 s. Statistical analysis was also evaluated via Wilcoxon signed rank test. Results Both SPArc and RO-IMPT plans achieved similar robust target volume coverage for all patients, while SPArc significantly reduced the doses to critical structures as well as the interplay effect. Specifically, compared to RO-IMPT, SPArc reduced the average integral dose by 7.4% (p = 0.001), V20, and mean lung dose by an average of 3.2% (p = 0.001) and 1.6 Gy (RBE) (p = 0.001), the max dose to cord by 4.6 Gy (RBE) (p = 0.04), and the mean dose to heart and esophagus by 0.7 Gy (RBE) (p = 0.01) and 1.7 Gy (RBE) (p = 0.003) respectively. The average total estimated delivery time was 160.1 s, 213.8 s, 303.4 s, 840.8 s based on ELST of 0.2 s, 0.5 s, 1 s, and 4 s for SPArc plans, compared with the respective values of 182.0 s (p = 0.001), 207.9 s (p = 0.22), 250.9 s (p = 0.001), 509.4 s (p = 0.001) for RO-IMPT plans. Hence, SPArc plans could be clinically feasible when using a shorter ELST. Conclusions This study has indicated that SPArc could further improve the dosimetric results in patients with locally advanced stage NSCLC and potentially be implemented into routine clinical practice.
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Affiliation(s)
- Xiaoqiang Li
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, USA.
| | - Peyman Kabolizadeh
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, USA
| | - Di Yan
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, USA
| | - An Qin
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, USA
| | - Jun Zhou
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, USA
| | - Ye Hong
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, USA
| | - Thomas Guerrero
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, USA
| | - Inga Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, USA
| | - Craig Stevens
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, USA
| | - Xuanfeng Ding
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, USA.
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13
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Harada H, Murayama S. Proton beam therapy in non-small cell lung cancer: state of the art. LUNG CANCER-TARGETS AND THERAPY 2017; 8:141-145. [PMID: 28883747 PMCID: PMC5574682 DOI: 10.2147/lctt.s117647] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
This review summarizes the past and present status of proton beam therapy (PBT) for lung cancer. PBT has a unique characteristic called the Bragg peak that enables a reduction in the dose of normal tissue around the tumor, but is sensitive to the uncertainties of density changes. The heterogeneity in electron density for thoracic lesions, such as those in the lung and mediastinum, and tumor movement according to respiration necessitates respiratory management for PBT to be applied in lung cancer patients. There are two types of PBT - a passively scattered approach and a scanning approach. Typically, a passively scattered approach is more robust for respiratory movement and a scanning approach could result in a more conformal dose distribution even when the tumor shape is complex. Large tumors of centrally located lung cancer may be more suitably irradiated than with intensity-modulated radiotherapy (IMRT) or stereotactic body radiotherapy (SBRT). For a locally advanced lung cancer, PBT can spare the lung and heart more than photon IMRT. However, no randomized controlled trial has reported differences between PBT and IMRT or SBRT for early-stage and locally advanced lung cancers. Therefore, a well-designed controlled trial is warranted.
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Affiliation(s)
- Hideyuki Harada
- Radiation and Proton Therapy Center, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
| | - Shigeyuki Murayama
- Radiation and Proton Therapy Center, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
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14
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Chi A, Lin LC, Wen S, Yan H, Hsi WC. Comparison of photon volumetric modulated arc therapy, intensity-modulated proton therapy, and intensity-modulated carbon ion therapy for delivery of hypo-fractionated thoracic radiotherapy. Radiat Oncol 2017; 12:132. [PMID: 28810881 PMCID: PMC5558745 DOI: 10.1186/s13014-017-0866-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 08/09/2017] [Indexed: 02/08/2023] Open
Abstract
Purpose The aim of the present study was to compare the dose distribution generated from photon volumetric modulated arc therapy (VMAT), intensity modulated proton therapy (IMPT), and intensity modulated carbon ion therapy (IMCIT) in the delivery of hypo-fractionated thoracic radiotherapy. Methods and materials Ten selected patients who underwent thoracic particle therapy between 2015 and 2016 were re-planned to receive a relative biological effectiveness (RBE) weighted dose of 60 Gy (i.e., GyE) in 15 fractions delivered with VMAT, IMPT, or IMCIT with the same optimization criteria. Treatment plans were then compared. Results There were no significant differences in target volume dose coverage or dose conformity, except improved D95 was found with IMCIT compared with VMAT (p = 0.01), and IMCIT was significantly better than IMPT in all target volume dose parameters. Particle therapy led to more prominent lung sparing at low doses, and this result was most prominent with IMCIT (p < 0.05). Improved sparing of other thoracic organs at risk (OARs) was observed with particle therapy, and IMCIT further lowered the D1cc and D5cc for major blood vessels, as compared with IMPT (p = 0.01). Conclusion Although it was comparable to VMAT, IMCIT led to significantly better tumor target dose coverage and conformity than did IMPT. Particle therapy, compared with VMAT, improved thoracic OAR sparing. IMCIT, compared with IMPT, may further improve normal lung and major blood vessel sparing under limited respiratory motion. Electronic supplementary material The online version of this article (doi:10.1186/s13014-017-0866-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alexander Chi
- Shanghai Proton and Heavy Ion Center, Shanghai, China.
| | - Lien-Chun Lin
- Shanghai Proton and Heavy Ion Center, Shanghai, China
| | - Sijin Wen
- Department of Biostatistics, West Virginia University, Morgantown, WV, USA
| | - Haijuan Yan
- Department of Biostatistics, West Virginia University, Morgantown, WV, USA
| | - Wen-Chien Hsi
- Shanghai Proton and Heavy Ion Center, Shanghai, China.
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15
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Ishikawa Y, Nakamura T, Kato T, Kadoya N, Suzuki M, Azami Y, Hareyama M, Kikuchi Y, Jingu K. Dosemetric Parameters Predictive of Rib Fractures after Proton Beam Therapy for Early-Stage Lung Cancer. TOHOKU J EXP MED 2017; 238:339-45. [PMID: 27087118 DOI: 10.1620/tjem.238.339] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Proton beam therapy (PBT) is the preferred modality for early-stage lung cancer. Compared with X-ray therapy, PBT offers good dose concentration as revealed by the characteristics of the Bragg peak. Rib fractures (RFs) after PBT lead to decreased quality of life for patients. However, the incidence of and the risk factors for RFs after PBT have not yet been clarified. We therefore explored the relationship between irradiated rib volume and RFs after PBT for early-stage lung cancer. The purpose of this study was to investigate the incidence and the risk factors for RFs following PBT for early-stage lung cancer. We investigated 52 early-stage lung cancer patients and analyzed a total of 215 irradiated ribs after PBT. Grade 2 RFs occurred in 12 patients (20 ribs); these RFs were symptomatic without displacement. No patient experienced more severe RFs. The median time to grade 2 RFs development was 17 months (range: 9-29 months). The three-year incidence of grade 2 RFs was 30.2%. According to the analysis comparing radiation dose and rib volume using receiver operating characteristic curves, we demonstrated that the volume of ribs receiving more than 120 Gy3 (relative biological effectiveness (RBE)) was more than 3.7 cm(3) at an area under the curve of 0.81, which increased the incidence of RFs after PBT (P < 0.001). In this study, RFs were frequently observed following PBT for early-stage lung cancer. We demonstrated that the volume of ribs receiving more than 120 Gy3 (RBE) was the most significant parameter for predicting RFs.
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Affiliation(s)
- Yojiro Ishikawa
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine
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16
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Chi A, Chen H, Wen S, Yan H, Liao Z. Comparison of particle beam therapy and stereotactic body radiotherapy for early stage non-small cell lung cancer: A systematic review and hypothesis-generating meta-analysis. Radiother Oncol 2017; 123:346-354. [PMID: 28545956 DOI: 10.1016/j.radonc.2017.05.007] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 03/28/2017] [Accepted: 05/05/2017] [Indexed: 12/12/2022]
Abstract
PURPOSE To assess hypo-fractionated particle beam therapy (PBT)'s efficacy relative to that of photon stereotactic body radiotherapy (SBRT) for early stage (ES) non-small cell lung cancer (NSCLC). METHODS Eligible studies were identified through extensive searches of the PubMed, Medline, Google-scholar, and Cochrane library databases from 2000 to 2016. Original English publications of ES NSCLC were included. A meta-analysis was performed to compare the survival outcome, toxicity profile, and patterns of failure following each treatment. RESULTS 72 SBRT studies and 9 hypo-fractionated PBT studies (mostly single-arm) were included. PBT was associated with improved overall survival (OS; p=0.005) and progression-free survival (PFS; p=0.01) in the univariate meta-analysis. The OS benefit did not reach its statistical significance after inclusion of operability into the final multivariate meta-analysis (p=0.11); while the 3-year local control (LC) still favored PBT (p=0.03). CONCLUSION Although hypo-fractionated PBT may lead to additional clinical benefit when compared with photon SBRT, no statistically significant survival benefit from PBT over SBRT was observed in the treatment of ES NSCLC in this hypothesis-generating meta-analysis after adjusting for potential confounding variables.
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Affiliation(s)
- Alexander Chi
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, China.
| | - Haiquan Chen
- Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, China
| | - Sijin Wen
- Department of Biostatistics, School of Public Health, West Virginia University, Morgantown, USA.
| | - Haijuan Yan
- Department of Biostatistics, School of Public Health, West Virginia University, Morgantown, USA
| | - Zhongxing Liao
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, USA
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17
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Chang JY, Jabbour SK, De Ruysscher D, Schild SE, Simone CB, Rengan R, Feigenberg S, Khan AJ, Choi NC, Bradley JD, Zhu XR, Lomax AJ, Hoppe BS. Consensus Statement on Proton Therapy in Early-Stage and Locally Advanced Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2016; 95:505-516. [PMID: 27084663 PMCID: PMC10868643 DOI: 10.1016/j.ijrobp.2016.01.036] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 12/08/2015] [Accepted: 01/19/2016] [Indexed: 12/25/2022]
Abstract
Radiation dose escalation has been shown to improve local control and survival in patients with non-small cell lung cancer in some studies, but randomized data have not supported this premise, possibly owing to adverse effects. Because of the physical characteristics of the Bragg peak, proton therapy (PT) delivers minimal exit dose distal to the target volume, resulting in better sparing of normal tissues in comparison to photon-based radiation therapy. This is particularly important for lung cancer given the proximity of the lung, heart, esophagus, major airways, large blood vessels, and spinal cord. However, PT is associated with more uncertainty because of the finite range of the proton beam and motion for thoracic cancers. PT is more costly than traditional photon therapy but may reduce side effects and toxicity-related hospitalization, which has its own associated cost. The cost of PT is decreasing over time because of reduced prices for the building, machine, maintenance, and overhead, as well as newer, shorter treatment programs. PT is improving rapidly as more research is performed particularly with the implementation of 4-dimensional computed tomography-based motion management and intensity modulated PT. Given these controversies, there is much debate in the oncology community about which patients with lung cancer benefit significantly from PT. The Particle Therapy Co-operative Group (PTCOG) Thoracic Subcommittee task group intends to address the issues of PT indications, advantages and limitations, cost-effectiveness, technology improvement, clinical trials, and future research directions. This consensus report can be used to guide clinical practice and indications for PT, insurance approval, and clinical or translational research directions.
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Affiliation(s)
- Joe Y Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Salma K Jabbour
- Rutgers Cancer Institute of New Jersey Rutgers, Robert Wood Johnson Medical School, The State University of New Jersey, New Brunswick, New Jersey
| | | | | | - Charles B Simone
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ramesh Rengan
- University of Washington Medical Center, Seattle, Washington
| | | | - Atif J Khan
- Rutgers Cancer Institute of New Jersey Rutgers, Robert Wood Johnson Medical School, The State University of New Jersey, New Brunswick, New Jersey
| | - Noah C Choi
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Xiaorong R Zhu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Bradford S Hoppe
- University of Florida Proton Therapy Institute, Jacksonville, Florida
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18
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Deep Inspiration Breath Hold-Based Radiation Therapy: A Clinical Review. Int J Radiat Oncol Biol Phys 2015; 94:478-92. [PMID: 26867877 DOI: 10.1016/j.ijrobp.2015.11.049] [Citation(s) in RCA: 154] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 11/03/2015] [Accepted: 11/29/2015] [Indexed: 01/06/2023]
Abstract
Several recent developments in linear accelerator-based radiation therapy (RT) such as fast multileaf collimators, accelerated intensity modulation paradigms like volumeric modulated arc therapy and flattening filter-free (FFF) high-dose-rate therapy have dramatically shortened the duration of treatment fractions. Deliverable photon dose distributions have approached physical complexity limits as a consequence of precise dose calculation algorithms and online 3-dimensional image guided patient positioning (image guided RT). Simultaneously, beam quality and treatment speed have continuously been improved in particle beam therapy, especially for scanned particle beams. Applying complex treatment plans with steep dose gradients requires strategies to mitigate and compensate for motion effects in general, particularly breathing motion. Intrafractional breathing-related motion results in uncertainties in dose delivery and thus in target coverage. As a consequence, generous margins have been used, which, in turn, increases exposure to organs at risk. Particle therapy, particularly with scanned beams, poses additional problems such as interplay effects and range uncertainties. Among advanced strategies to compensate breathing motion such as beam gating and tracking, deep inspiration breath hold (DIBH) gating is particularly advantageous in several respects, not only for hypofractionated, high single-dose stereotactic body RT of lung, liver, and upper abdominal lesions but also for normofractionated treatment of thoracic tumors such as lung cancer, mediastinal lymphomas, and breast cancer. This review provides an in-depth discussion of the rationale and technical implementation of DIBH gating for hypofractionated and normofractionated RT of intrathoracic and upper abdominal tumors in photon and proton RT.
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Santiago A, Fritz P, Mühlnickel W, Engenhart-Cabillic R, Wittig A. Changes in the radiological depth correlate with dosimetric deterioration in particle therapy for stage I NSCLC patients under high frequency jet ventilation. Acta Oncol 2015; 54:1631-7. [PMID: 26228661 DOI: 10.3109/0284186x.2015.1067716] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Particle dose distributions are highly sensitive to anatomy changes in the beam path, which may lead to substantial dosimetric deviations. Robust planning and dedicated image guidance together with strategies for online decision making to counteract dosimetric deterioration are thus mandatory. We aimed to develop methods to quantify anatomical discrepancies as depicted by repeated computed tomography (CT) imaging and to test whether they can predict deviations in target coverage. MATERIAL AND METHODS Dedicated software tools allowed for voxel-based calculations of changes in the water equivalent path length (WEPL) in beam directions. We prepared proton and carbon ion plans with different coplanar beam angle settings on a series of lung cancer patients, for which planning and localization CT scans under high frequency jet ventilation (HFJV) for tumor fixation were performed. We investigated the reproducibility of target coverage between the optimized and recalculated treatment plans. We then studied how different raster scan and planning settings influence the robustness. Finally, we carried out a systematic analysis of the variations in the WEPL along different coplanar beam angles to find beam directions, which could minimize such variations. RESULTS The Spearman's correlations for the GTV ΔV95 and ΔV98 with the ΔWEPL for the proton plans with a 0° and -45° two-field configuration were 0.701 (p = 0.02) and 0.719 (p = 0.08), respectively. For beam configurations 0° and -90°, or 0° and + 45°, with lower ΔWEPL, the correlations were no significant. The same trends were observed for the carbon ion plans. Increased beam spot overlap reduced dosimetric deterioration in case of large ΔWEPL. CONCLUSION Software tools for fast online analysis of WEPL changes might help supporting clinical decision making of image guidance. Raster scan and treatment planning settings can help to compensate for anatomical deviations.
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Affiliation(s)
- Alina Santiago
- a Philipps-University Marburg and University Hospital Giessen and Marburg , Department of Radiotherapy and Radiation Oncology , Marburg , Germany
| | - Peter Fritz
- b St Marien-Krankenhaus , Department of Radiotherapy , Siegen , Germany
| | - Werner Mühlnickel
- b St Marien-Krankenhaus , Department of Radiotherapy , Siegen , Germany
| | - Rita Engenhart-Cabillic
- a Philipps-University Marburg and University Hospital Giessen and Marburg , Department of Radiotherapy and Radiation Oncology , Marburg , Germany
| | - Andrea Wittig
- a Philipps-University Marburg and University Hospital Giessen and Marburg , Department of Radiotherapy and Radiation Oncology , Marburg , Germany
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20
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Li Y, Kardar L, Li X, Li H, Cao W, Chang JY, Liao L, Zhu RX, Sahoo N, Gillin M, Liao Z, Komaki R, Cox JD, Lim G, Zhang X. On the interplay effects with proton scanning beams in stage III lung cancer. Med Phys 2014; 41:021721. [PMID: 24506612 DOI: 10.1118/1.4862076] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE To assess the dosimetric impact of interplay between spot-scanning proton beam and respiratory motion in intensity-modulated proton therapy (IMPT) for stage III lung cancer. METHODS Eleven patients were sampled from 112 patients with stage III nonsmall cell lung cancer to well represent the distribution of 112 patients in terms of target size and motion. Clinical target volumes (CTVs) and planning target volumes (PTVs) were defined according to the authors' clinical protocol. Uniform and realistic breathing patterns were considered along with regular- and hypofractionation scenarios. The dose contributed by a spot was fully calculated on the computed tomography (CT) images corresponding to the respiratory phase that the spot is delivered, and then accumulated to the reference phase of the 4DCT to generate the dynamic dose that provides an estimation of what might be delivered under the influence of interplay effect. The dynamic dose distributions at different numbers of fractions were compared with the corresponding 4D composite dose which is the equally weighted average of the doses, respectively, computed on respiratory phases of a 4DCT image set. RESULTS Under regular fractionation, the average and maximum differences in CTV coverage between the 4D composite and dynamic doses after delivery of all 35 fractions were no more than 0.2% and 0.9%, respectively. The maximum differences between the two dose distributions for the maximum dose to the spinal cord, heart V40, esophagus V55, and lung V20 were 1.2 Gy, 0.1%, 0.8%, and 0.4%, respectively. Although relatively large differences in single fraction, correlated with small CTVs relative to motions, were observed, the authors' biological response calculations suggested that this interfractional dose variation may have limited biological impact. Assuming a hypofractionation scenario, the differences between the 4D composite and dynamic doses were well confined even for single fraction. CONCLUSIONS Despite the presence of interplay effect, the delivered dose may be reliably estimated using the 4D composite dose. In general the interplay effect may not be a primary concern with IMPT for lung cancers for the authors' institution. The described interplay analysis tool may be used to provide additional confidence in treatment delivery.
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Affiliation(s)
- Yupeng Li
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030 and Applied Research, Varian Medical Systems, Palo Alto, California 94304
| | - Laleh Kardar
- Department of Industrial Engineering, The University of Houston, Houston, Texas 77204
| | - Xiaoqiang Li
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030
| | - Heng Li
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030
| | - Wenhua Cao
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030 and Department of Industrial Engineering, The University of Houston, Houston, Texas 77204
| | - Joe Y Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030
| | - Li Liao
- Department of Industrial Engineering, The University of Houston, Houston, Texas 77204
| | - Ronald X Zhu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030
| | - Narayan Sahoo
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030
| | - Michael Gillin
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030
| | - Ritsuko Komaki
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030
| | - James D Cox
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030
| | - Gino Lim
- Department of Industrial Engineering, The University of Houston, Houston, Texas 77204
| | - Xiaodong Zhang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030
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Welsh J, Amini A, Ciura K, Nguyen N, Palmer M, Allen PK, Paolini M, Liao Z, Bluett J, Mohan R, Gomez D, Cox JD, Komaki R, Chang JY. Evaluating proton stereotactic body radiotherapy to reduce chest wall dose in the treatment of lung cancer. Med Dosim 2014; 38:442-447. [PMID: 24200220 DOI: 10.1016/j.meddos.2013.08.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 03/26/2013] [Accepted: 08/13/2013] [Indexed: 11/28/2022]
Abstract
Stereotactic body radiotherapy (SBRT) can produce excellent local control of several types of solid tumor; however, toxicity to nearby critical structures is a concern. We found previously that in SBRT for lung cancer, the chest wall (CW) volume receiving 20, 30, or 40Gy (V20, V30, or V40) was linked with the development of neuropathy. Here we sought to determine whether the dosimetric advantages of protons could produce lower CW doses than traditional photon-based SBRT. We searched an institutional database to identify patients treated with photon SBRT for lung cancer with tumors within < 2.5cm of the CW. We found 260 cases; of these, chronic grade ≥ 2 CW pain was identified in 23 patients. We then selected 10 representative patients from this group and generated proton SBRT treatment plans, using the identical dose of 50Gy in 4 fractions, and assessed potential differences in CW dose between the 2 plans. The proton SBRT plans reduced the CW doses at all dose levels measured. The median CW V20 was 364.0cm(3) and 160.0cm(3) (p < 0.0001), V30 was 144.6cm(3)vs 77.0cm(3) (p = 0.0012), V35 was 93.9cm(3)vs 57.9cm(3) (p = 0.005), V40 was 66.5cm(3)vs 45.4cm(3) (p = 0.0112), and mean lung dose was 5.9Gy vs 3.8Gy (p = 0.0001) for photons and protons, respectively. Coverage of the planning target volume (PTV) was comparable between the 2 sets of plans (96.4% for photons and 97% for protons). From a dosimetric standpoint, proton SBRT can achieve the same coverage of the PTV while significantly reducing the dose to the CW and lung relative to photon SBRT and therefore may be beneficial for the treatment of lesions closer to critical structures.
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Affiliation(s)
- James Welsh
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Arya Amini
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.,UC Irvine School of Medicine, Irvine, CA
| | - Katherine Ciura
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ngoc Nguyen
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Matt Palmer
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Pamela K Allen
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael Paolini
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Zhongxing Liao
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jaques Bluett
- Departments of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Radhe Mohan
- Departments of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Daniel Gomez
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - James D Cox
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ritsuko Komaki
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Joe Y Chang
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Grant JD, Chang JY. Proton-based stereotactic ablative radiotherapy in early-stage non-small-cell lung cancer. BIOMED RESEARCH INTERNATIONAL 2014; 2014:389048. [PMID: 25136582 PMCID: PMC4124720 DOI: 10.1155/2014/389048] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 05/30/2014] [Accepted: 06/21/2014] [Indexed: 12/12/2022]
Abstract
Stereotactic ablative radiotherapy (SABR), a recent implementation in the practice of radiation oncology, has been shown to confer high rates of local control in the treatment of early stage non-small-cell lung cancer (NSCLC). This technique, which involves limited invasive procedures and reduced treatment intervals, offers definitive treatment for patients unable or unwilling to undergo an operation. The use of protons in SABR delivery confers the added physical advantage of normal tissue sparing due to the absence of collateral radiation dose delivered to regions distal to the target. This may translate into clinical benefit and a decreased risk of clinical toxicity in patients with nearby critical structures or limited pulmonary reserve. In this review, we present the rationale for proton-based SABR, principles relating to the delivery and planning of this modality, and a summary of published clinical studies.
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Affiliation(s)
- Jonathan D. Grant
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA
| | - Joe Y. Chang
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA
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Mou B, Beltran CJ, Park SS, Olivier KR, Furutani KM. Feasibility of proton transmission-beam stereotactic ablative radiotherapy versus photon stereotactic ablative radiotherapy for lung tumors: a dosimetric and feasibility study. PLoS One 2014; 9:e98621. [PMID: 24887068 PMCID: PMC4041776 DOI: 10.1371/journal.pone.0098621] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 05/06/2014] [Indexed: 12/25/2022] Open
Abstract
Stereotactic ablative radiotherapy is being increasingly adopted in the treatment of lung tumors. The use of proton beam therapy can further reduce dose to normal structures. However, uncertainty exists in proton-based treatment plans, including range uncertainties, large sensitivity to position uncertainty, and calculation of dose deposition in heterogeneous areas. This study investigated the feasibility of proton transmission beams, i.e. without the Bragg peak, to treat lung tumors with stereotactic ablative radiotherapy. We compared three representative treatment plans using proton transmission beams versus conformal static-gantry photon beams. It was found that proton treatment plans using transmission beams passing through the patient were feasible and demonstrated lower dose to normal structures and markedly reduced treatment times than photon plans. This is the first study to demonstrate the feasibility of proton-based stereotactic ablative radiotherapy planning for lung tumors using proton transmission beams alone. Further research using this novel approach for proton-based planning is warranted.
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Affiliation(s)
- Benjamin Mou
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Chris J. Beltran
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Sean S. Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Kenneth R. Olivier
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Keith M. Furutani
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, United States of America
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Tian G, Li N, Li G. [Dosimetric comparing between protons beam and photons beam
for lung cancer radiotherapy: a meta-analysis]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2014; 16:252-60. [PMID: 23676982 PMCID: PMC6000611 DOI: 10.3779/j.issn.1009-3419.2013.05.07] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
背景与目的 由于缺乏质子治疗与传统光子治疗比较的临床随机对照研究,导致质子治疗在肺癌放疗中的应用没有充足的临床证据。本研究旨在探讨质子射线在肺癌放疗中的剂量学优势,以期为临床提供有价值的循证医学依据。 方法 计算机检索Cochrane Library、PubMed、EMbase、中国生物医学文献数据库、中国学术期刊全文数据库和中国科技期刊数据库,同时辅助其它检索,搜集所有比较质子射线与光子射线治疗肺癌的剂量学研究的文章,应用RevMan 5.2软件对满足条件的数据进行meta分析。 结果 6篇文献纳入本次研究。质子射线与光子射线三维适形放疗(three-dimensional conformal radiotherapy, 3D-CRT)技术比较,降低了双肺Dmean(MD=-4.15, 95%CI: -5.56--2.74, P < 0.001)及V20、V10、V5(MD=-10.92, 95%CI: -13.23--8.62, P < 0.001);降低了食管Dmean及心脏Dmean,差异有统计学意义。质子射线与光子射线调强放疗(intensity-modulated radiotherapy, IMRT)技术比较,V20、V10、V5在质子射线治疗组明显降低(MD=-3.70, 95%CI: -5.31--2.10, P < 0.001; MD=-8.86, 95%CI: -10.74--6.98, P < 0.001; MD=-20.13, 95%CI: -27.11--13.14, P < 0.001);而相比于光子射线(IMRT),质子射线治疗肺癌在食管Dmean差异无统计学意义,但心脏Dmean明显降低,差异有统计学意义。 结论 与目前普遍采用的光子射线(3D-CRT技术及IMRT技术)放疗相比,质子射线在治疗肺癌的剂量学方面有明显的优势,具有临床应用价值。
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Affiliation(s)
- Guangwei Tian
- Department of Radiation Oncology, First Affiliated Hospital of China Medical University, Shenyang 110001, China
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Santiago A, Jelen U, Ammazzalorso F, Engenhart-Cabillic R, Fritz P, Mühlnickel W, Enghardt W, Baumann M, Wittig A. Reproducibility of target coverage in stereotactic spot scanning proton lung irradiation under high frequency jet ventilation. Radiother Oncol 2013; 109:45-50. [PMID: 24128803 DOI: 10.1016/j.radonc.2013.09.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2013] [Revised: 09/13/2013] [Accepted: 09/20/2013] [Indexed: 12/21/2022]
Abstract
PURPOSE To investigate scanned-beam proton dose distribution reproducibility in the lung under high frequency jet ventilation (HFJV). MATERIALS AND METHODS For 11 patients (12 lesions), treated with single-fraction photon stereotactic radiosurgery under HFJV, scanned-beam proton plans were prepared with the TRiP98 treatment planning system using 2, 3-4 and 5-7 beams. The planning objective was to deliver at least 95% of the prescription of 33 Gy (RBE) to 98% of the PTV. Plans were subsequently recomputed on localization CT scans. Additionally, for selected cases, the effects of range uncertainties were investigated. RESULTS Median GTV V(98%) was 98.7% in the original 2-field plans and 93.7% in their recomputation (p=0.039). The respective values were 99.0% and 98.0% (p=0.039) for the 3-4-field plans and 100.0% and 99.6% (p=0.125) for the 5-7-field plans. CT calibration uncertainties of ±3.5% led to a GTV V(98%) reduction below 1.5 percentual points in most cases and reaching 3 percentual points for 2-field plans with beam undershoot. CONCLUSIONS Through jet ventilation, reproducible tumor fixation for proton radiotherapy of lung lesions is achievable, ensuring excellent target coverage in most cases. In few cases, non-optimal patient setup reproducibility induced density changes across beam entrance channels, leading to dosimetric deterioration between planning and delivery.
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Affiliation(s)
- Alina Santiago
- University of Marburg, Department of Radiotherapy and Radiation Oncology, Germany.
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Fujii O, Demizu Y, Hashimoto N, Araya M, Takagi M, Terashima K, Mima M, Iwata H, Niwa Y, Jin D, Daimon T, Sasaki R, Hishikawa Y, Abe M, Murakami M, Fuwa N. A retrospective comparison of proton therapy and carbon ion therapy for stage I non-small cell lung cancer. Radiother Oncol 2013; 109:32-7. [DOI: 10.1016/j.radonc.2013.08.038] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Revised: 08/21/2013] [Accepted: 08/25/2013] [Indexed: 12/25/2022]
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Shi W, Nichols Jr RC, Flampouri S, Li Z, Hsi W, Huh S, Ho MW, Henderson RH, Mendenhall NP, Hoppe BS. Proton-based chemoradiation for synchronous bilateral non-small-cell lung cancers: A case report. Thorac Cancer 2013; 4:198-202. [DOI: 10.1111/j.1759-7714.2012.00141.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Abstract
INTRODUCTION The physical properties of proton beam radiation may offer advantages for treating patients with non-small-cell lung cancer (NSCLC). However, its utility for the treatment of medically inoperable stage I NSCLC patients with stereotactic body radiation therapy (SBRT) is unknown. METHODS Outcomes for patients with medically inoperable stage I NSCLC treated with proton SBRT were retrospectively analyzed. Proton SBRT was selected as the treatment modality based on pulmonary comorbidities (n = 5), prior chest radiation or/and multiple primary tumors (n = 7), or other reasons (n = 3). Treatments were administered using 2 to 3 proton beams. Treatment toxicity was scored according to common toxicity criteria for adverse events version 4 criteria. RESULTS Fifteen consecutive patients and 20 tumors were treated with proton SBRT to 42 to 50 Gy(relative biological effectiveness) in 3 to 5 fractions between July 2008 and September 2010. Treatments were well tolerated with only one case of grade 2 fatigue, one case of grade 2 dermatitis, three cases of rib fracture (maximum grade 2), and one case of grade 3 pneumonitis in a patient with severe chronic obstructive pulmonary disease. With a median follow-up of 24.1 months, 2-year overall survival and local control rates were 64% (95% confidence limits, 34%-83%) and 100% (83%-100%), respectively. CONCLUSIONS We conclude that proton SBRT is effective and well tolerated in this unfavorable group of patients. Prospective clinical trials testing the utility of proton SBRT in stage I NSCLC are warranted.
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Results of a multicentric in silico clinical trial (ROCOCO): comparing radiotherapy with photons and protons for non-small cell lung cancer. J Thorac Oncol 2012; 7:165-76. [PMID: 22071782 DOI: 10.1097/jto.0b013e31823529fc] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION This multicentric in silico trial compares photon and proton radiotherapy for non-small cell lung cancer patients. The hypothesis is that proton radiotherapy decreases the dose and the volume of irradiated normal tissues even when escalating to the maximum tolerable dose of one or more of the organs at risk (OAR). METHODS Twenty-five patients, stage IA-IIIB, were prospectively included. On 4D F18-labeled fluorodeoxyglucose-positron emission tomography-computed tomography scans, the gross tumor, clinical and planning target volumes, and OAR were delineated. Three-dimensional conformal radiotherapy (3DCRT) and intensity-modulated radiotherapy (IMRT) photon and passive scattered conformal proton therapy (PSPT) plans were created to give 70 Gy to the tumor in 35 fractions. Dose (de-)escalation was performed by rescaling to the maximum tolerable dose. RESULTS Protons resulted in the lowest dose to the OAR, while keeping the dose to the target at 70 Gy. The integral dose (ID) was higher for 3DCRT (59%) and IMRT (43%) than for PSPT. The mean lung dose reduced from 18.9 Gy for 3DCRT and 16.4 Gy for IMRT to 13.5 Gy for PSPT. For 10 patients, escalation to 87 Gy was possible for all 3 modalities. The mean lung dose and ID were 40 and 65% higher for photons than for protons, respectively. CONCLUSIONS The treatment planning results of the Radiation Oncology Collaborative Comparison trial show a reduction of ID and the dose to the OAR when treating with protons instead of photons, even with dose escalation. This shows that PSPT is able to give a high tumor dose, while keeping the OAR dose lower than with the photon modalities.
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Nichols RC, Henderson RH, Huh S, Flampouri S, Li Z, Bajwa AA, D'Agostino HJ, Pham DC, Mendenhall NP, Hoppe BS. Proton therapy for lung cancer. Thorac Cancer 2012; 3:109-116. [PMID: 28920285 DOI: 10.1111/j.1759-7714.2011.00098.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Proton therapy is an emerging radiotherapy technology with the potential to improve the therapeutic index in the treatment of lung cancer patients. Since charged particles, such as protons, have a penetration length that can be modified by using different energies, protons offer the clinician the ability to modulate radiation dose deposition along the beam path. This facilitates an increase of the dose to the tumor target while minimizing the volume of normal tissue irradiation. Such precise delivery is particularly relevant in the setting of lung cancer where the targeted tissues are in close proximity to moderately radiation-sensitive organs like the spinal cord, heart, and esophagus, but are also effectively surrounded by the normal lung, which is extremely sensitive to radiation damage. Proton therapy has been investigated for the treatment of surgically curable yet medically inoperable patients as well as patients with regionally advanced disease.
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Affiliation(s)
- Romaine C Nichols
- University of Florida Proton Therapy Institute, Jacksonville, FL, USA Department of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Jacksonville, FL, USA Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA Department of Medical Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Randal H Henderson
- University of Florida Proton Therapy Institute, Jacksonville, FL, USA Department of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Jacksonville, FL, USA Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA Department of Medical Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Soon Huh
- University of Florida Proton Therapy Institute, Jacksonville, FL, USA Department of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Jacksonville, FL, USA Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA Department of Medical Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Stella Flampouri
- University of Florida Proton Therapy Institute, Jacksonville, FL, USA Department of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Jacksonville, FL, USA Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA Department of Medical Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Zuofeng Li
- University of Florida Proton Therapy Institute, Jacksonville, FL, USA Department of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Jacksonville, FL, USA Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA Department of Medical Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Abubakr A Bajwa
- University of Florida Proton Therapy Institute, Jacksonville, FL, USA Department of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Jacksonville, FL, USA Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA Department of Medical Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Harry J D'Agostino
- University of Florida Proton Therapy Institute, Jacksonville, FL, USA Department of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Jacksonville, FL, USA Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA Department of Medical Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Dat C Pham
- University of Florida Proton Therapy Institute, Jacksonville, FL, USA Department of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Jacksonville, FL, USA Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA Department of Medical Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Nancy P Mendenhall
- University of Florida Proton Therapy Institute, Jacksonville, FL, USA Department of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Jacksonville, FL, USA Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA Department of Medical Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Bradford S Hoppe
- University of Florida Proton Therapy Institute, Jacksonville, FL, USA Department of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Jacksonville, FL, USA Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA Department of Medical Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
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Treatment of Non-Small Cell Lung Cancer Patients With Proton Beam-Based Stereotactic Body Radiotherapy: Dosimetric Comparison With Photon Plans Highlights Importance of Range Uncertainty. Int J Radiat Oncol Biol Phys 2012; 83:354-61. [DOI: 10.1016/j.ijrobp.2011.05.062] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Revised: 05/05/2011] [Accepted: 05/28/2011] [Indexed: 12/25/2022]
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Monitoring tumor motion by real time 2D/3D registration during radiotherapy. Radiother Oncol 2011; 102:274-80. [PMID: 21885144 PMCID: PMC3276833 DOI: 10.1016/j.radonc.2011.07.031] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Revised: 07/29/2011] [Accepted: 07/29/2011] [Indexed: 02/03/2023]
Abstract
Background and purpose In this paper, we investigate the possibility to use X-ray based real time 2D/3D registration for non-invasive tumor motion monitoring during radiotherapy. Materials and methods The 2D/3D registration scheme is implemented using general purpose computation on graphics hardware (GPGPU) programming techniques and several algorithmic refinements in the registration process. Validation is conducted off-line using a phantom and five clinical patient data sets. The registration is performed on a region of interest (ROI) centered around the planned target volume (PTV). Results The phantom motion is measured with an rms error of 2.56 mm. For the patient data sets, a sinusoidal movement that clearly correlates to the breathing cycle is shown. Videos show a good match between X-ray and digitally reconstructed radiographs (DRR) displacement. Mean registration time is 0.5 s. Conclusions We have demonstrated that real-time organ motion monitoring using image based markerless registration is feasible.
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Register SP, Zhang X, Mohan R, Chang JY. Proton stereotactic body radiation therapy for clinically challenging cases of centrally and superiorly located stage I non-small-cell lung cancer. Int J Radiat Oncol Biol Phys 2011; 80:1015-22. [PMID: 20615629 PMCID: PMC2952351 DOI: 10.1016/j.ijrobp.2010.03.012] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2009] [Revised: 03/03/2010] [Accepted: 03/17/2010] [Indexed: 11/29/2022]
Abstract
PURPOSE To minimize toxicity while maintaining tumor coverage with stereotactic body radiation therapy (SBRT) for centrally or superiorly located stage I non-small-cell lung cancer (NSCLC), we investigated passive-scattering proton therapy (PSPT) and intensity-modulated proton therapy (IMPT). METHODS AND MATERIALS Fifteen patients with centrally or superiorly located (within 2 cm of critical structures) stage I NSCLC were treated clinically with three-dimensional photon SBRT (50 Gy in 4 fractions). The photon SBRT plan was compared with the PSPT and IMPT plans. The maximum tolerated dose (MTD) was defined as the dose that exceeded the dose--volume constraints in the critical structures. RESULTS Only 6 photon plans satisfied the >95% planning target volume (PTV) coverage and MTD constraints, compared to 12 PSPT plans (p = 0.009) and 14 IMPT plans (p = 0.001). Compared with the photon SBRT plans, the PSPT and IMPT plans significantly reduced the mean total lung dose from 5.4 Gy to 3.5 Gy (p < 0.001) and 2.8 Gy (p < 0.001) and reduced the total lung volume receiving 5 Gy, 10 Gy, and 20 Gy (p < 0.001). When the PTV was within 2 cm of the critical structures, the PSPT and IMPT plans significantly reduced the mean maximal dose to the aorta, brachial plexus, heart, pulmonary vessels, and spinal cord. CONCLUSIONS For centrally or superiorly located stage I NSCLC, proton therapy, particularly IMPT, delivered ablative doses to the target volume and significantly reduced doses to the surrounding normal tissues compared with photon SBRT.
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Affiliation(s)
- Steven P. Register
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Xiaodong Zhang
- Department of Radiation Physics, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Radhe Mohan
- Department of Radiation Physics, The University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Joe Y. Chang
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
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Hoppe BS, Huh S, Flampouri S, Nichols RC, Oliver KR, Morris CG, Mendenhall NP, Li Z. Double-scattered proton-based stereotactic body radiotherapy for stage I lung cancer: a dosimetric comparison with photon-based stereotactic body radiotherapy. Radiother Oncol 2010; 97:425-30. [PMID: 20934768 DOI: 10.1016/j.radonc.2010.09.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Revised: 09/01/2010] [Accepted: 09/04/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE Stereotactic body radiotherapy (SBRT) has gained popularity in the treatment of early-stage non-small-cell lung cancer (NSCLC) because of its ability to deliver conformal radiation doses to small targets. However, photon-based SBRT (xSBRT) is associated with significant grade 3+ toxicities. In this study, we compare xSBRT treatment plans with proton-based SBRT (pSBRT) to determine whether dose to normal structures could be reduced if SBRT was delivered with protons. MATERIALS AND METHODS Eight patients with medically inoperable, peripherally located stage I NSCLC were treated with xSBRT to 48 Gy in 4 12-Gy fractions. These patients were retrospectively re-planned using the same treatment volumes with 3-dimensional conformal double-scatter proton therapy. A Wilcoxon paired test compared dosimetric parameters between the plans for each patient. RESULTS Compared with xSBRT there was a dosimetric improvement with pSBRT for these volumes: lung V5 (median difference [MD]=10.4%, p=0.01); V10 (MD=6.4%, p=0.01); V20 (MD=2.1%, p=0.01); V40 (MD=1.5%, p=0.05); and mean lung dose (MD=2.17 Gy, p=0.01). There were also benefits (p=<0.05) in D0.1cm3 and D5cm3 with pSBRT to the heart, esophagus, and bronchus. CONCLUSIONS In a dosimetric comparison between photon and proton-based SBRT, protons resulted in lower doses to critical organs at risk and a smaller volume of non-targeted normal lung exposed to radiation (V5, V10, V20, and V40). The clinical significance and relevance of these dosimetric improvements remain unknown.
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Affiliation(s)
- Bradford S Hoppe
- University of Florida Proton Therapy Institute, Jacksonville, USA.
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Munck af Rosenschöld P, Aznar MC, Nygaard DE, Persson GF, Korreman SS, Engelholm SA, Nyström H. A treatment planning study of the potential of geometrical tracking for intensity modulated proton therapy of lung cancer. Acta Oncol 2010; 49:1141-8. [PMID: 20831506 DOI: 10.3109/0284186x.2010.500620] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Proton therapy of lung cancer holds the potential for a reduction of the volume of irradiated normal lung tissue. In this work we investigate the robustness of intensity modulated proton therapy (IMPT) plans to motion, and evaluate a geometrical tumour tracking method to compensate for tumour motion. MATERIAL AND METHODS Seven patients with a nine targets with 4DCT scans were selected. IMPT plans were made on the midventilation phase using a 3-field technique. The plans were transferred and calculated on the remaining nine phases of the 4DCT, and the combined dose distribution was summed using deformable image registration (DIR). An additional set of plans were made in which the proton beam was simply geometrically shifted to the centre of the gross tumour volume (GTV), i.e. simulating tracking of the tumour motion but without on-line adjustment of the proton energies. A possible interplay effect between the dynamics of the spot scanning delivery and the tumour motion has not been considered in this work. RESULTS Around 97-100% of the GTV was covered by 95% of the prescribed dose (V95) for a tumour displacement of less than about 1 cm with a static beam. For the remaining three of nine targets with a larger motion the tracking method studied provided a marked improvement over static beam; raising the GTV V95 from 95 to 100%, 82 to 98% and 51 to 97%, respectively. CONCLUSION The possibility of performing DIR and summing the dose on the 4DCT data set was shown to be feasible. The fairly simplistic tracking method suggested here resulted in a marked improvement in GTV coverage for tumours with large intra-fractional motion (>1 cm displacement), indicating that on-line adjustment of the proton energies may be redundant.
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Affiliation(s)
- Per Munck af Rosenschöld
- Department of Radiation Oncology, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark.
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Kadoya N, Obata Y, Kato T, Kagiya M, Nakamura T, Tomoda T, Takada A, Takayama K, Fuwa N. Dose-volume comparison of proton radiotherapy and stereotactic body radiotherapy for non-small-cell lung cancer. Int J Radiat Oncol Biol Phys 2010; 79:1225-31. [PMID: 20732759 DOI: 10.1016/j.ijrobp.2010.05.016] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2009] [Revised: 05/09/2010] [Accepted: 05/12/2010] [Indexed: 12/25/2022]
Abstract
PURPOSE This study designed photon and proton treatment plans for patients treated with hypofractionated proton radiotherapy (PT) at the Southern Tohoku Proton Therapy Center (STPTC). We then calculated dosimetric parameters and compared results with simulated treatment plans for stereotactic body radiotherapy (SBRT), using dose--volume histograms to clearly explain differences in dose distributions between PT and SBRT. METHODS AND MATERIALS Twenty-one patients with stage I non-small-cell lung cancer (stage IA, n = 15 patients; stage IB, n = 6 patients) were studied. All tumors were located in the peripheral lung, and total dose was 66 Gray equivalents (GyE) (6.6 GyE/fraction). For treatment planning, beam incidence for proton beam technique was restricted to two to three directions for PT, and seven or eight noncoplanar beams were manually selected for SBRT to achieve optimal planning target volume (PTV) coverage and minimal dose to organs at risk. RESULTS Regarding lung tissues, mean dose, V5, V10, V13, V15, and V20 values were 4.6 Gy, 13.2%, 11.4%, 10.6%, 10.1%, and 9.1%, respectively, for PT, whereas those values were 7.8 Gy, 32.0%, 21.8%, 17.4%, 15.3%, and 11.4%, respectively, for SBRT with a prescribed dose of 66 Gy. Pearson product moment correlation coefficients between PTV and dose--volume parameters of V5, V10, V15, and V20 were 0.45, 0.52, 0.58, and 0.63, respectively, for PT, compared to 0.52, 0.45, 0.71, and 0.74, respectively, for SBRT. CONCLUSIONS Correlations between dose--volume parameters of the lung and PTV were observed and may indicate that PT is more advantageous than SBRT when treating a tumor with a relatively large PTV or several tumors.
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Affiliation(s)
- Noriyuki Kadoya
- Department of Medical Physics, Southern Tohoku Proton Therapy Center, Southern Tohoku Institute of Neuroscience, Koriyama, Fukushima, Japan.
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Wertz H, Stsepankou D, Blessing M, Rossi M, Knox C, Brown K, Gros U, Boda-Heggemann J, Walter C, Hesser J, Lohr F, Wenz F. Fast kilovoltage/megavoltage (kVMV) breathhold cone-beam CT for image-guided radiotherapy of lung cancer. Phys Med Biol 2010; 55:4203-17. [PMID: 20616405 DOI: 10.1088/0031-9155/55/15/001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Long image acquisition times of 60-120 s for cone-beam CT (CBCT) limit the number of patients with lung cancer who can undergo volume image guidance under breathhold. We developed a low-dose dual-energy kilovoltage-megavoltage-cone-beam CT (kVMV-CBCT) based on a clinical treatment unit reducing imaging time to < or =15 s. Simultaneous kVMV-imaging was achieved by dedicated synchronization hardware controlling the output of the linear accelerator (linac) based on detector panel readout signals, preventing imaging artifacts from interference of the linac's MV-irradiation and panel readouts. Optimization was performed to minimize the imaging dose. Single MV-projections, reconstructed MV-CBCT images and images of simultaneous 90 degrees kV- and 90 degrees MV-CBCT (180 degrees kVMV-CBCT) were acquired with different parameters. Image quality and imaging dose were evaluated and compared to kV-imaging. Hardware-based kVMV synchronization resulted in artifact-free projections. A combined 180 degrees kVMV-CBCT scan with a total MV-dose of 5 monitor units was acquired in 15 s and with sufficient image quality. The resolution was 5-6 line pairs cm(-1) (Catphan phantom). The combined kVMV-scan dose was equivalent to a kV-radiation scan dose of approximately 33 mGy. kVMV-CBCT based on a standard linac is promising and can provide ultra-fast online volume image guidance with low imaging dose and sufficient image quality for fast and accurate patient positioning for patients with lung cancer under breathhold.
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Affiliation(s)
- Hansjoerg Wertz
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany.
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Evaluation of Potential Proton Therapy Utilization in a Market-Based Environment. J Am Coll Radiol 2010; 7:522-8. [DOI: 10.1016/j.jacr.2010.01.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Accepted: 01/29/2010] [Indexed: 11/22/2022]
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Iwata H, Murakami M, Demizu Y, Miyawaki D, Terashima K, Niwa Y, Mima M, Akagi T, Hishikawa Y, Shibamoto Y. High-dose proton therapy and carbon-ion therapy for stage I nonsmall cell lung cancer. Cancer 2010; 116:2476-85. [PMID: 20225229 DOI: 10.1002/cncr.24998] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND A study was undertaken to evaluate the clinical outcome of particle therapy for stage I nonsmall cell lung cancer (NSCLC). METHODS From April 2003 to April 2007, 80 patients with stage I NSCLC were treated with proton therapy or carbon-ion therapy (57 with proton therapy and 23 with carbon-ion therapy) using 3 treatment protocols. In the first protocol, 80 gray equivalents (GyE) of proton therapy was given in 20 fractions, and the second proton therapy protocol used 60 GyE in 10 fractions. For carbon-ion therapy, 52.8 GyE was given in 4 fractions. After achieving promising preliminary results for the first protocol, the authors started to use the second proton therapy protocol to shorten the overall treatment time. Carbon-ion therapy was started in 2005, and thereafter, both proton and carbon-ion therapy plans were made for each patient, and the 1 that appeared superior was adopted. Patient age ranged from 48 to 89 years (median, 76 years). Thirty-seven patients were medically inoperable, and 43 refused surgery. Forty-two patients had T1 tumors, and 38 had T2 tumors. RESULTS The median follow-up period for living patients was 35.5 months. For all 80 patients, the 3-year overall survival, cause-specific survival, and local control rates were 75% (IA: 74%; IB: 76%), 86% (IA: 84%; IB: 88%), and 82% (IA: 87%; IB: 77%), respectively. There were no significant differences in treatment results among the 3 protocols. Grade 3 pulmonary toxicity was observed in only 1 patient. CONCLUSIONS Proton therapy and carbon-ion therapy are safe and effective for stage I NSCLC. Further investigation of particle therapy for stage I NSCLC is warranted.
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Affiliation(s)
- Hiromitsu Iwata
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.
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Olsen DR, Overgaard J. Leveraging clinical performance by technological excellence – The case of particle therapy. Radiother Oncol 2010; 95:1-2. [DOI: 10.1016/j.radonc.2010.03.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2010] [Accepted: 03/22/2010] [Indexed: 11/25/2022]
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Thwaites DI, Verellen D. Vorsprung durch Technik: evolution, implementation, QA and safety of new technology in radiotherapy. Radiother Oncol 2010; 94:125-8. [PMID: 20170973 DOI: 10.1016/j.radonc.2010.02.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Accepted: 02/09/2010] [Indexed: 11/18/2022]
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Künzler T, Fotina I, Stock M, Georg D. Experimental verification of a commercial Monte Carlo-based dose calculation module for high-energy photon beams. Phys Med Biol 2009; 54:7363-77. [DOI: 10.1088/0031-9155/54/24/008] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Proton beam radiotherapy versus three-dimensional conformal stereotactic body radiotherapy in primary peripheral, early-stage non-small-cell lung carcinoma: a comparative dosimetric analysis. Int J Radiat Oncol Biol Phys 2009; 75:950-8. [PMID: 19801106 DOI: 10.1016/j.ijrobp.2009.04.023] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2008] [Revised: 04/05/2009] [Accepted: 04/10/2009] [Indexed: 11/23/2022]
Abstract
PURPOSE Proton radiotherapy (PT) and stereotactic body radiotherapy (SBRT) have the capacity to optimize the therapeutic ratio. We analyzed the dosimetric differences between PT and SBRT in treating primary peripheral early-stage non-small-cell lung cancer. METHODS AND MATERIALS Eight patients were simulated, planned, and treated with SBRT according to accepted techniques. SBRT treatments were retrospectively planned using heterogeneity corrections. PT treatment plans were generated using single-, two-, and three-field passively scattered and actively scanned proton beams. Calculated dose characteristics were compared. RESULTS Comparable planning target volume (PTV) median minimum and maximum doses were observed between PT and SBRT plans. Higher median maximum doses 2 cm from the PTV were observed for PT, but higher median PTV doses were observed for SBRT. The total lung mean and V5 doses were significantly lower with actively scanned PT. The lung V13 and V20 were comparable. The dose to normal tissues was lower with PT except to skin and ribs. Although the maximum doses to skin and ribs were similar or higher with PT, the median doses to these structures were higher with SBRT. Passively scattered plans, compared with actively scanned plans, typically demonstrated higher doses to the PTV, lung, and organs at risk. CONCLUSIONS Single-, two-, or three-field passively or actively scanned proton therapy delivered comparable PTV dose with generally less dose to normal tissues in these hypothetic treatments. Actively scanned beam plans typically had more favorable dose characteristics to the target, lung, and other soft tissues compared with the passively scanned plans. The clinical significance of these findings remains to be determined.
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Baumann M, Zips D, Appold S. Radiotherapy of lung cancer: Technology meets biology meets multidisciplinarity. Radiother Oncol 2009; 91:279-81. [DOI: 10.1016/j.radonc.2009.05.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2009] [Accepted: 05/07/2009] [Indexed: 11/26/2022]
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Comparisons of dose-volume histograms for proton-beam versus 3-D conformal x-ray therapy in patients with stage I non-small cell lung cancer. Strahlenther Onkol 2009; 185:231-4. [PMID: 19370425 DOI: 10.1007/s00066-009-1923-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2008] [Accepted: 12/10/2008] [Indexed: 12/25/2022]
Abstract
PURPOSE Dose-volume histograms (DVHs) were reviewed to determine if there is an advantage of the two modalities when treating patients with non-small cell lung cancer (NSCLC). PATIENTS AND METHODS 24 stage I NSCLC patients who underwent proton-beam therapy (PBT) from June 2003 to May 2007 were included in this study. Based on the same clinical target volumes (CTVs), treatment planning was made to cover CTV within 90% isodose lines. Each patient was evaluated by two sets of DVHs, one for PBT and the other for three-dimensional conformal X-ray therapy (3D-CRT). RESULTS For all patients, the 95% isodose line covered 86.4% of the CTV for PBT, and 43.2% for 3D-CRT. PBT was associated with significantly lower mean doses to the ipsilateral lung, total lung, heart, esophagus, and spinal cord than 3D-CRT. PBT offered reduced radiation doses to the lung when evaluated in terms of percentage lung volumes receiving > or = 5 Gy (V(5)), > or = 10 Gy (V(10)), and > or = 20 Gy (V(20)) when compared to 3D-CRT. CONCLUSION PBT is advantageous over 3D-CRT in reducing doses to the lung, heart, esophagus, and spinal cord in treating stage I NSCLC.
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