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Constine LS, Marks LB, Milano MT, Ronckers CM, Jackson A, Hudson MM, Marcus KJ, Hodgson DC, Hua CH, Howell RM, Marples B, Yorke E, Olch A, Bentzen SM. A User's Guide and Summary of Pediatric Normal Tissue Effects in the Clinic (PENTEC): Radiation Dose-Volume Response for Adverse Effects After Childhood Cancer Therapy and Future Directions. Int J Radiat Oncol Biol Phys 2024; 119:321-337. [PMID: 37999712 DOI: 10.1016/j.ijrobp.2023.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/01/2023] [Accepted: 09/06/2023] [Indexed: 11/25/2023]
Abstract
Pediatric Normal Tissue Effects in the Clinic (PENTEC) is an international multidisciplinary effort that aims to summarize normal-tissue toxicity risks based on published dose-volume data from studies of children and adolescents treated with radiation therapy (RT) for cancer. With recognition that children are uniquely vulnerable to treatment-related toxic effects, our mission and challenge was to assemble our group of physicians (radiation and pediatric oncologists, subspecialists), physicists with clinical and modeling expertise, epidemiologists, and other scientists to develop evidence-based radiation dosimetric guidelines, as affected by developmental status and other factors (eg, other cancer therapies and host factors). These quantitative toxicity risk estimates could serve to inform RT planning and thereby improve outcomes. Tandem goals included the description of relevant medical physics issues specific to pediatric RT and the proposal of dose-volume outcome reporting standards to inform future studies. We created 19 organ-specific task forces and methodology to unravel the wealth of data from heterogeneous published studies. This report provides a high-level summary of PENTEC's genesis, methods, key findings, and associated concepts that affected our work and an explanation of how our findings may be interpreted and applied in the clinic. We acknowledge our predecessors in these efforts, and we pay homage to the children whose lives informed us and to future generations who we hope will benefit from this additional step in our path forward.
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Affiliation(s)
- Louis S Constine
- Departments of Radiation Oncology and; Pediatrics, University of Rochester Medical Center, Wilmot Cancer Institute, Rochester, New York.
| | - Lawrence B Marks
- Department of Radiation Oncology and Lineberger Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Cécile M Ronckers
- Division of Childhood Cancer Epidemiology (EpiKiK) and the German Childhood Cancer Registry (DKKR), Johannes Gutenberg University of Mainz, Germany
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Melissa M Hudson
- Department of Oncology, Division of Cancer Survivorship, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Karen J Marcus
- Department of Radiation Oncology, Dana Farber/ Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - David C Hodgson
- Department of Radiation Oncology, University of Toronto, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Chia-Ho Hua
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Rebecca M Howell
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | | | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Arthur Olch
- Department of Radiation Oncology, University of Southern California and Children's Hospital of Los Angeles, Los Angeles, California
| | - Soren M Bentzen
- Department of Epidemiology and Public Health, University of Maryland, Baltimore, Maryland
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2
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Song G, Zheng Z, Zhu Y, Wang Y, Xue S. A review and bibliometric analysis of global research on proton radiotherapy. Medicine (Baltimore) 2024; 103:e38089. [PMID: 38728501 PMCID: PMC11081588 DOI: 10.1097/md.0000000000038089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 04/11/2024] [Indexed: 05/12/2024] Open
Abstract
Proton beam therapy (PBT) has great advantages as tumor radiotherapy and is progressively becoming a more prevalent choice for individuals undergoing radiation therapy. The objective of this review is to pinpoint collaborative efforts among countries and institutions, while also exploring the hot topics and future outlook in the field of PBT. Data from publications were downloaded from the Web of Science Core Collection. CiteSpace and Excel 2016 were used to conduct the bibliometric and knowledge map analysis. A total of 6516 publications were identified, with the total number of articles steadily increasing and the United States being the most productive country. Harvard University took the lead in contributing the highest number of publications. Paganetti Harald published the most articles and had the most cocitations. PHYS MED BIOL published the greatest number of PBT-related articles, while INT J RADIAT ONCOL received the most citations. Paganetti Harald, 2012, PHYS MED BIOL can be classified as classic literature due to its high citation rate. We believe that research on technology development, dose calculation and relative biological effectiveness were the knowledge bases in this field. Future research hotspots may include clinical trials, flash radiotherapy, and immunotherapy.
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Affiliation(s)
- Ge Song
- Department of Critical Care Medicine, Shandong Provincial Maternal and Child Health Care Hospital Affiliated to Qingdao University, Jinan, China
| | - Zhi Zheng
- Department of Stomatology, Shandong Provincial Maternal and Child Health Care Hospital Affiliated to Qingdao University, Jinan, China
| | - Yingming Zhu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yaoting Wang
- Department of Oncology, Dongying People’s Hospital, Dongying, China
| | - Song Xue
- Experimental Center, Shandong University of Traditional Chinese Medicine, Jinan, China
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Wilson JS, Main C, Thorp N, Taylor RE, Majothi S, Kearns PR, English M, Dandapani M, Phillips R, Wheatley K, Pizer B. Correction to: The effectiveness and safety of proton beam radiation therapy in children and young adults with Central Nervous System (CNS) tumours: a systematic review. J Neurooncol 2024; 167:35-37. [PMID: 38441841 PMCID: PMC10978623 DOI: 10.1007/s11060-024-04612-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Affiliation(s)
- Jayne S Wilson
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK.
| | - Caroline Main
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Nicky Thorp
- The Clatterbridge Cancer Centre, Liverpool, UK
- The Christie Hospital Foundation Trust Proton Beam Therapy Centre, Manchester, UK
| | | | - Saimma Majothi
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Pamela R Kearns
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
- Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Martin English
- Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Madhumita Dandapani
- Children's Brain Tumour Research Centre, University of Nottingham, Nottingham, UK
- Queen's Medical Centre, Nottingham University Hospitals' NHS Trust, Nottingham, UK
| | - Robert Phillips
- Centre for Reviews and Dissemination (CRD), University of York, York, UK
| | - Keith Wheatley
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Barry Pizer
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- University of Liverpool, Liverpool, UK
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Wilson JS, Main C, Thorp N, Taylor RE, Majothi S, Kearns PR, English M, Dandapani M, Phillips R, Wheatley K, Pizer B. The effectiveness and safety of proton beam radiation therapy in children and young adults with Central Nervous System (CNS) tumours: a systematic review. J Neurooncol 2024; 167:1-34. [PMID: 38294638 PMCID: PMC10978619 DOI: 10.1007/s11060-023-04510-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 11/14/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND Central nervous system (CNS) tumours account for around 25% of childhood neoplasms. With multi-modal therapy, 5-year survival is at around 75% in the UK. Conventional photon radiotherapy has made significant contributions to survival, but can be associated with long-term side effects. Proton beam radiotherapy (PBT) reduces the volume of irradiated tissue outside the tumour target volume which may potentially reduce toxicity. Our aim was to assess the effectiveness and safety of PBT and make recommendations for future research for this evolving treatment. METHODS A systematic review assessing the effects of PBT for treating CNS tumours in children/young adults was undertaken using methods recommended by Cochrane and reported using PRISMA guidelines. Any study design was included where clinical and toxicity outcomes were reported. Searches were to May 2021, with a narrative synthesis employed. RESULTS Thirty-one case series studies involving 1731 patients from 10 PBT centres were included. Eleven studies involved children with medulloblastoma / primitive neuroectodermal tumours (n = 712), five ependymoma (n = 398), four atypical teratoid/rhabdoid tumour (n = 72), six craniopharyngioma (n = 272), three low-grade gliomas (n = 233), one germ cell tumours (n = 22) and one pineoblastoma (n = 22). Clinical outcomes were the most frequently reported with overall survival values ranging from 100 to 28% depending on the tumour type. Endocrine outcomes were the most frequently reported toxicity outcomes with quality of life the least reported. CONCLUSIONS This review highlights areas of uncertainty in this research area. A well-defined, well-funded research agenda is needed to best maximise the potential of PBT. SYSTEMATIC REVIEW REGISTRATION PROSPERO-CRD42016036802.
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Affiliation(s)
- Jayne S Wilson
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK.
| | - Caroline Main
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Nicky Thorp
- The Clatterbridge Cancer Centre, Liverpool, UK
- The Christie Hospital Foundation Trust Proton Beam Therapy Centre, Manchester, UK
| | | | - Saimma Majothi
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Pamela R Kearns
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
- Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Martin English
- Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Madhumita Dandapani
- Children's Brain Tumour Research Centre, University of Nottingham, Nottingham, UK
- Queen's Medical Centre, Nottingham University Hospitals' NHS Trust, Nottingham, UK
| | - Robert Phillips
- Centre for Reviews and Dissemination (CRD), University of York, York, UK
| | - Keith Wheatley
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Barry Pizer
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- University of Liverpool, Liverpool, UK
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Overgaard CB, Reaz F, Sitarz M, Poulsen P, Overgaard J, Bassler N, Grau C, Sørensen BS. An experimental setup for proton irradiation of a murine leg model for radiobiological studies. Acta Oncol 2023; 62:1566-1573. [PMID: 37603112 DOI: 10.1080/0284186x.2023.2246641] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/03/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND The purpose of this study was to introduce an experimental radiobiological setup used for in vivo irradiation of a mouse leg target in multiple positions along a proton beam path to investigate normal tissue- and tumor models with varying linear energy transfer (LET). We describe the dosimetric characterizations and an acute- and late-effect assay for normal tissue damage. METHODS The experimental setup consists of a water phantom that allows the right hind leg of three to five mice to be irradiated at the same time. Absolute dosimetry using a thimble (Semiflex) and a plane parallel (Advanced Markus) ionization chamber and Monte Carlo simulations using Geant4 and SHIELD-HIT12A were applied for dosimetric validation of positioning along the spread-out Bragg peak (SOBP) and at the distal edge and dose fall-off. The mice were irradiated in the center of the SOBP delivered by a pencil beam scanning system. The SOBP was 2.8 cm wide, centered at 6.9 cm depth, with planned physical single doses from 22 to 46 Gy. The biological endpoint was acute skin damage and radiation-induced late damage (RILD) assessed in the mouse leg. RESULTS The dose-response curves illustrate the percentage of mice exhibiting acute skin damage, and at a later point, RILD as a function of physical doses (Gy). Each dose-response curve represents a specific severity score of each assay, demonstrating a higher ED50 (50% responders) as the score increases. Moreover, the results reveal the reversible nature of acute skin damage as a function of time and the irreversible nature of RILD as time progresses. CONCLUSIONS We want to encourage researchers to report all experimental details of their radiobiological setups, including experimental protocols and model descriptions, to facilitate transparency and reproducibility. Based on this study, more experiments are being performed to explore all possibilities this radiobiological experimental setup permits.
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Affiliation(s)
- Cathrine Bang Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Fardous Reaz
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Danish Centre for Particle Therapy, Aarhus University Hospital, Denmark
| | - Mateusz Sitarz
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Danish Centre for Particle Therapy, Aarhus University Hospital, Denmark
| | - Per Poulsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Danish Centre for Particle Therapy, Aarhus University Hospital, Denmark
| | - Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Niels Bassler
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Danish Centre for Particle Therapy, Aarhus University Hospital, Denmark
| | - Cai Grau
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Danish Centre for Particle Therapy, Aarhus University Hospital, Denmark
| | - Brita Singers Sørensen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Danish Centre for Particle Therapy, Aarhus University Hospital, Denmark
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6
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Smulders B, Stolarczyk L, Seiersen K, Nørrevang O, Sommer Kristensen B, Schut DA, Thomsen K, Lassen-Ramshad Y, Høyer M, Muhic A, Vestergaard A. Prediction of dose-sparing by protons assessed by a knowledge-based planning tool in radiotherapy of brain tumours. Acta Oncol 2023; 62:1541-1545. [PMID: 37793798 DOI: 10.1080/0284186x.2023.2264482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 09/22/2023] [Indexed: 10/06/2023]
Affiliation(s)
- Bob Smulders
- Danish Centre for Particle Therapy (DCPT), Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Liliana Stolarczyk
- Danish Centre for Particle Therapy (DCPT), Aarhus University Hospital, Aarhus, Denmark
| | - Klaus Seiersen
- Danish Centre for Particle Therapy (DCPT), Aarhus University Hospital, Aarhus, Denmark
| | - Ole Nørrevang
- Danish Centre for Particle Therapy (DCPT), Aarhus University Hospital, Aarhus, Denmark
| | - Bente Sommer Kristensen
- Department of Oncology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Deborah Anne Schut
- Department of Oncology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Karsten Thomsen
- Department of Oncology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Yasmin Lassen-Ramshad
- Danish Centre for Particle Therapy (DCPT), Aarhus University Hospital, Aarhus, Denmark
| | - Morten Høyer
- Danish Centre for Particle Therapy (DCPT), Aarhus University Hospital, Aarhus, Denmark
| | - Aida Muhic
- Danish Centre for Particle Therapy (DCPT), Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Anne Vestergaard
- Danish Centre for Particle Therapy (DCPT), Aarhus University Hospital, Aarhus, Denmark
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7
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Izairi-Bexheti R, Fejzulahi-Izairi M, Ristova M. Uncertainty in the range of the protons and C-ions in particle therapy due to a hydration level of a human body model. Appl Radiat Isot 2023; 200:110951. [PMID: 37487427 DOI: 10.1016/j.apradiso.2023.110951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 07/26/2023]
Abstract
Cancer treatment with protons and carbon ions relies on the property of the accelerated charged particles to deposit most of their energy in the vicinity of their range (around the Bragg peak). The level of hydration in a cancer patient's body may vary within hours. Some patients may be heavy to moderately dehydrated, and some may be well and even excessively hydrated. In this research, we aim to estimate the uncertainty of the protons and C-ion ranges because of the different hydration levels of the human body. For the study of the impact of body hydration level on the particle's ranges, we have designed a new phantom model - a homogeneous mixture of an Average HUuman BOdy constituting elements (AHUBO) in three states of hydration: normal (n), dehydrated (d), and excessively hydrated (e) by applying corresponding recalibration in the "atomic-stoichiometry model" due to the water sufficiency/deficiency. The purpose of the study is to estimate the shift in the ranges depending on the hydration level, possibly suggest particle beam energy adjustments to overcome the range uncertainties, to deliver the prescribed dose to the tumour while sparing the healthy tissue. Herein we present the results of the FLUKA-Flair simulations of the therapeutic range of energies of protons (50-105 MeV) and C-ions (30-210 MeV) respectively, into an AHUBO head phantom model at three levels of hydration (normal, dehydrated, and excessively hydrated). The range uncertainty was estimated via the shifts of the Bragg-peaks position for the three different hydration levels. The estimations showed that the range uncertainty (ΔR) due to body hydration for the maximum energy in the range for protons at 105 MeV is about 0.04 mm and for C-ions at 190 MeV/u is about 0.06 mm.
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Affiliation(s)
- Redona Izairi-Bexheti
- Physics Department, Faculty of Natural Sciences and Mathematics, University Ss Cyril and Methodius, Arhimedova St. 3, Skopje, Macedonia
| | - Mimoza Fejzulahi-Izairi
- Physics Department, Faculty of Natural Sciences and Mathematics, University Ss Cyril and Methodius, Arhimedova St. 3, Skopje, Macedonia
| | - Mimoza Ristova
- Physics Department, Faculty of Natural Sciences and Mathematics, University Ss Cyril and Methodius, Arhimedova St. 3, Skopje, Macedonia; SEEIIST, Southeast European International Institute for Sustainable Technologies, Geneva, Switzerland.
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8
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Bernardo T, Kuntze A, Klein D, Heinzelmann F, Timmermann B, von Neubeck C. Endothelial Cell Response to Combined Photon or Proton Irradiation with Doxorubicin. Int J Mol Sci 2023; 24:12833. [PMID: 37629014 PMCID: PMC10454477 DOI: 10.3390/ijms241612833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 08/27/2023] Open
Abstract
Surgery, radiotherapy, and chemotherapy are essential treatment modalities to target cancer cells, but they frequently cause damage to the normal tissue, potentially leading to side effects. As proton beam radiotherapy (PBT) can precisely spare normal tissue, this therapeutic option is of increasing importance regarding (neo-)adjuvant and definitive anti-cancer therapies. Akin to photon-based radiotherapy, PBT is often combined with systemic treatment, such as doxorubicin (Dox). This study compares the cellular response of human microvascular endothelial cells (HMEC-1) following irradiation with photons (X) or protons (H) alone and also in combination with different sequences of Dox. The cellular survival, cell cycle, apoptosis, proliferation, viability, morphology, and migration were all investigated. Dox monotreatment had minor effects on all endpoints. Both radiation qualities alone and in combination with longer Dox schedules significantly reduced clonogenic survival and proliferation, increased the apoptotic cell fraction, induced a longer G2/M cell cycle arrest, and altered the cell morphology towards endothelial-to-mesenchymal-transition (EndoMT) processes. Radiation quality effects were seen for metabolic viability, proliferation, and motility of HMEC-1 cells. Additive effects were found for longer Dox schedules. Overall, similar effects were found for H/H-Dox and X/X-Dox. Significant alterations between the radiation qualities indicate different but not worse endothelial cell damage by H/H-Dox.
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Affiliation(s)
- Teresa Bernardo
- Department of Particle Therapy, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany; (T.B.); (B.T.)
| | - Anna Kuntze
- Gerhard Domagk Institute of Pathology, University Hospital Muenster, 48149 Muenster, Germany;
| | - Diana Klein
- Institute of Cell Biology (Cancer Research), University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany;
| | - Feline Heinzelmann
- West German Proton Therapy Centre Essen (WPE), 45147 Essen, Germany;
- West German Cancer Centre (WTZ), University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
- Faculty of Physics, Technical University (TU) Dortmund University, 44227 Dortmund, Germany
| | - Beate Timmermann
- Department of Particle Therapy, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany; (T.B.); (B.T.)
- West German Proton Therapy Centre Essen (WPE), 45147 Essen, Germany;
- West German Cancer Centre (WTZ), University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
- German Cancer Consortium (DKTK), 45147 Essen, Germany
| | - Cläre von Neubeck
- Department of Particle Therapy, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany; (T.B.); (B.T.)
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9
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Clements N, Esplen N, Bazalova-Carter M. A feasibility study of ultra-high dose rate mini-GRID therapy using very-high-energy electron beams for a simulated pediatric brain case. Phys Med 2023; 112:102637. [PMID: 37454482 DOI: 10.1016/j.ejmp.2023.102637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 05/09/2023] [Accepted: 07/04/2023] [Indexed: 07/18/2023] Open
Abstract
Ultra-high dose rate (UHDR, >40 Gy/s), spatially-fractionated minibeam GRID (mini-GRID) therapy using very-high-energy electrons (VHEE) was investigated using Monte Carlo simulations. Multi-directional VHEE treatments with and without mini-GRID-fractionation were compared to a clinical 6 MV volumetric modulated arc therapy (VMAT) plan for a pediatric glioblastoma patient using dose-volume histograms, volume-averaged dose rates in critical patient structures, and planning target volume D98s. Peak-to-valley dose ratios (PVDRs) and dose rates in organs at risk (OARs) were evaluated due to their relevance for normal-tissue sparing in FLASH and spatially-fractionated techniques. Depths of convergence, defined where the PVDR is first ≤1.1, and depths at which dose rates fall below the UHDR threshold were also evaluated. In a water phantom, the VHEE mini-GRID treatments presented a surface (5 mm depth) PVDR of (51±2) and a depth of convergence of 42 mm at 150 MeV and a surface PVDR of (33±1) with a depth of convergence of 57 mm at 250 MeV. For a pediatric GBM case, VHEE treatments without mini-GRID-fractionation produced 25% and 22% lower volume-averaged doses to OARs compared to the 6 MV VMAT plan and 8/9 and 9/9 of the patient structures were exposed to volume-averaged dose rates >40 Gy/s for the 150 MeV and 250 MeV plans, respectively. The 150 MeV and 250 MeV mini-GRID treatments produced 17% and 38% higher volume-averaged doses to OARs and 3/9 patient structures had volume-averaged dose rates above 40 Gy/s. VHEE mini-GRID plans produced many comparable dose metrics to the clinical VMAT plan, encouraging further optimization.
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Affiliation(s)
- Nathan Clements
- Department of Physics and Astronomy, University of Victoria, Victoria, BC, Canada.
| | - Nolan Esplen
- Department of Physics and Astronomy, University of Victoria, Victoria, BC, Canada
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10
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Hu Y, Paris S, Sahoo N, Bertolet G, Wang Q, Wang Q, Barsoumian HB, Da Silva J, Huang A, Doss DJ, Pollock DP, Hsu E, Selene N, Leyton CSK, Voss TA, Masrorpour F, Ganjoo S, Leuschner C, Pietz JT, Puebla-Osorio N, Gandhi S, Nguyen QN, Wang J, Cortez MA, Welsh JW. Nanoparticle-enhanced proton beam immunoradiotherapy drives immune activation and durable tumor rejection. JCI Insight 2023; 8:e167749. [PMID: 37345658 PMCID: PMC10371249 DOI: 10.1172/jci.insight.167749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 05/16/2023] [Indexed: 06/23/2023] Open
Abstract
The combination of radiation therapy (RT) and immunotherapy has emerged as a promising treatment option in oncology. Historically, x-ray radiation (XRT) has been the most commonly used form of RT. However, proton beam therapy (PBT) is gaining recognition as a viable alternative, as it has been shown to produce similar outcomes to XRT while minimizing off-target effects. The effects of PBT on the antitumor immune response have only just begun to be described, and to our knowledge no studies to date have examined the effect of PBT as part of a combinatorial immunoradiotherapeutic strategy. Here, using a 2-tumor model of lung cancer in mice, we show that PBT in tandem with an anti-PD1 antibody substantially reduced growth in both irradiated and unirradiated tumors. This was accompanied by robust activation of the immune response, as evidenced by whole-tumor and single-cell RNA sequencing showing upregulation of a multitude of immune-related transcripts. This response was further significantly enhanced by the injection of the tumor to be irradiated with NBTXR3 nanoparticles. Tumors of mice treated with the triple combination exhibited increased infiltration and activation of cytotoxic immune cells. This triple combination eradicated both tumors in 37.5% of the treated mice and showed robust long-term immunity to cancer.
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Affiliation(s)
- Yun Hu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sébastien Paris
- Department of Translational Science, Nanobiotix, Paris, France
| | | | - Genevieve Bertolet
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Qi Wang
- Department of Bioinformatics and Computational Biology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Qianxia Wang
- Department of Radiation Physics, and
- Department of Physics and Astronomy, Rice University, Houston, Texas, USA
| | - Hampartsoum B Barsoumian
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jordan Da Silva
- Department of Translational Science, Nanobiotix, Paris, France
| | - Ailing Huang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | | | - Ethan Hsu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nanez Selene
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Claudia S Kettlun Leyton
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tiffany A Voss
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Fatemeh Masrorpour
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Shonik Ganjoo
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Carola Leuschner
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jordan T Pietz
- Department of Strategic Communication, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nahum Puebla-Osorio
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Saumil Gandhi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jing Wang
- Department of Bioinformatics and Computational Biology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maria Angelica Cortez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - James W Welsh
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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11
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Helm A, Totis C, Durante M, Fournier C. Are charged particles a good match for combination with immunotherapy? Current knowledge and perspectives. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2023; 376:1-36. [PMID: 36997266 DOI: 10.1016/bs.ircmb.2023.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Charged particle radiotherapy, mainly using protons and carbon ions, provides physical characteristics allowing for a volume conformal irradiation and a reduction of the integral dose to normal tissue. Carbon ion therapy additionally features an increased biological effectiveness resulting in peculiar molecular effects. Immunotherapy, mostly performed with immune checkpoint inhibitors, is nowadays considered a pillar in cancer therapy. Based on the advantageous features of charged particle radiotherapy, we review pre-clinical evidence revealing a strong potential of its combination with immunotherapy. We argue that the combination therapy deserves further investigation with the aim of translation in clinics, where a few studies have been set up already.
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Affiliation(s)
- A Helm
- Biophysics Department, GSI, Darmstadt, Germany
| | - C Totis
- Biophysics Department, GSI, Darmstadt, Germany
| | - M Durante
- Biophysics Department, GSI, Darmstadt, Germany.
| | - C Fournier
- Biophysics Department, GSI, Darmstadt, Germany
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12
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Eulitz J, G C Troost E, Klünder L, Raschke F, Hahn C, Schulz E, Seidlitz A, Thiem J, Karpowitz C, Hahlbohm P, Grey A, Engellandt K, Löck S, Krause M, Lühr A. Increased relative biological effectiveness and periventricular radiosensitivity in proton therapy of glioma patients. Radiother Oncol 2023; 178:109422. [PMID: 36435337 DOI: 10.1016/j.radonc.2022.11.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 10/25/2022] [Accepted: 11/17/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Currently, there is an intense debate on variations in intra-cerebral radiosensitivity and relative biological effectiveness (RBE) in proton therapy of primary brain tumours. Here, both effects were retrospectively investigated using late radiation-induced brain injuries (RIBI) observed in follow-up after proton therapy of patients with diagnosed glioma. METHODS In total, 42 WHO grade 2-3 glioma patients out of a consecutive patient cohort having received (adjuvant) proton radio(chemo)therapy between 2014 and 2017 were eligible for analysis. RIBI lesions (symptomatic or clinically asymptomatic) were diagnosed and delineated on contrast-enhanced T1-weighted magnetic resonance imaging scans obtained in the first two years of follow-up. Correlation of RIBI location and occurrence with dose (D), proton dose-averaged linear energy transfer (LET) and variable RBE dose parameters were tested in voxel- and in patient-wise logistic regression analyses. Additionally, anatomical and clinical parameters were considered. Model performance was estimated through cross-validated area-under-the-curve (AUC) values. RESULTS In total, 64 RIBI lesions were diagnosed in 21 patients. The median time between start of proton radio(chemo)therapy and RIBI appearance was 10.2 months. Median distances of the RIBI volume centres to the cerebral ventricles and to the clinical target volume border were 2.1 mm and 1.3 mm, respectively. In voxel-wise regression, the multivariable model with D, D × LET and periventricular region (PVR) revealed the highest AUC of 0.90 (95 % confidence interval: 0.89-0.91) while the corresponding model without D × LET revealed a value of 0.84 (0.83-0.86). In patient-level analysis, the equivalent uniform dose (EUD11, a = 11) in the PVR using a variable RBE was the most prominent predictor for RIBI with an AUC of 0.63 (0.32-0.90). CONCLUSIONS In this glioma cohort, an increased radiosensitivity within the PVR was observed as well as a spatial correlation of RIBI with an increased RBE. Both need to be considered when delivering radio(chemo)therapy using proton beams.
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Affiliation(s)
- Jan Eulitz
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Esther G C Troost
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumour Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany; German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Lauritz Klünder
- Department of Physics, TU Dortmund University, Dortmund, Germany
| | - Felix Raschke
- Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Christian Hahn
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Department of Physics, TU Dortmund University, Dortmund, Germany
| | - Erik Schulz
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Annekatrin Seidlitz
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumour Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany; German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Justus Thiem
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumour Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany; German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Caroline Karpowitz
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumour Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany; German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Patricia Hahlbohm
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Institute and Polyclinic for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Arne Grey
- National Center for Tumour Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany; German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; Institute and Polyclinic for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Kay Engellandt
- National Center for Tumour Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany; German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; Institute and Polyclinic for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Steffen Löck
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumour Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany; German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Mechthild Krause
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumour Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany; German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Armin Lühr
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; Department of Physics, TU Dortmund University, Dortmund, Germany.
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13
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Azcona JD, Aguilar B, Perales Á, Polo R, Zucca D, Irazola L, Viñals A, Cabello P, Delgado JM, Pedrero D, Bermúdez R, Fayos-Solá R, Huesa-Berral C, Burguete J. Commissioning of a synchrotron-based proton beam therapy system for use with a Monte Carlo treatment planning system. Radiat Phys Chem Oxf Engl 1993 2022. [DOI: 10.1016/j.radphyschem.2022.110708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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14
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Vaniqui A, Vaassen F, Di Perri D, Eekers D, Compter I, Rinaldi I, van Elmpt W, Unipan M. Linear Energy Transfer and Relative Biological Effectiveness Investigation of Various Structures for a Cohort of Proton Patients With Brain Tumors. Adv Radiat Oncol 2022; 8:101128. [PMID: 36632089 PMCID: PMC9827037 DOI: 10.1016/j.adro.2022.101128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 10/31/2022] [Indexed: 11/27/2022] Open
Abstract
Purpose The current knowledge on biological effects associated with proton therapy is limited. Therefore, we investigated the distributions of dose, dose-averaged linear energy transfer (LETd), and the product between dose and LETd (DLETd) for a patient cohort treated with proton therapy. Different treatment planning system features and visualization tools were explored. Methods and Materials For a cohort of 24 patients with brain tumors, the LETd, DLETd, and dose was calculated for a fixed relative biological effectiveness value and 2 variable models: plan-based and phenomenological. Dose threshold levels of 0, 5, and 20 Gy were imposed for LETd visualization. The relationship between physical dose and LETd and the frequency of LETd hotspots were investigated. Results The phenomenological relative biological effectiveness model presented consistently higher dose values. For lower dose thresholds, the LETd distribution was steered toward higher values related to low treatment doses. Differences up to 26.0% were found according to the threshold. Maximum LETd values were identified in the brain, periventricular space, and ventricles. An inverse relationship between LETd and dose was observed. Frequency information to the domain of dose and LETd allowed for the identification of clusters, which steer the mean LETd values, and the identification of higher, but sparse, LETd values. Conclusions Identifying, quantifying, and recording LET distributions in a standardized fashion is necessary, because concern exists over a link between toxicity and LET hotspots. Visualizing DLETd or dose × LETd during treatment planning could allow for clinicians to make informed decisions.
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15
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Sensitization of Patient-Derived Colorectal Cancer Organoids to Photon and Proton Radiation by Targeting DNA Damage Response Mechanisms. Cancers (Basel) 2022; 14:cancers14204984. [PMID: 36291768 PMCID: PMC9599341 DOI: 10.3390/cancers14204984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/27/2022] [Accepted: 10/05/2022] [Indexed: 12/04/2022] Open
Abstract
Simple Summary Radiotherapy plays an important role in the treatment of colorectal cancer (CRC). Approximately one-third of patients with rectal cancer show a pathological complete response upon total neoadjuvant treatment. Patient-derived CRC organoids were investigated regarding their radiotherapeutic treatment response—both in terms of conventional photon irradiation, the combination thereof with chemotherapy, as well as proton irradiation. By inhibition of an important sensor molecule for DNA damage, which has been shown to be activated upon irradiation, radioresistant organoids could be resensitized. Abstract Pathological complete response (pCR) has been correlated with overall survival in several cancer entities including colorectal cancer. Novel total neoadjuvant treatment (TNT) in rectal cancer has achieved pathological complete response in one-third of the patients. To define better treatment options for nonresponding patients, we used patient-derived organoids (PDOs) as avatars of the patient’s tumor to apply both photon- and proton-based irradiation as well as single and combined chemo(radio)therapeutic treatments. While response to photon and proton therapy was similar, PDOs revealed heterogeneous responses to irradiation and different chemotherapeutic drugs. Radiotherapeutic response of the PDOs was significantly correlated with their ability to repair irradiation-induced DNA damage. The classical combination of 5-FU and irradiation could not sensitize radioresistant tumor cells. Ataxia-telangiectasia mutated (ATM) kinase was activated upon radiation, and by inhibition of this central sensor of DNA damage, radioresistant PDOs were resensitized. The study underlined the capability of PDOs to define nonresponders to irradiation and could delineate therapeutic approaches for radioresistant patients.
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16
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Schneider M, Bodenstein E, Bock J, Dietrich A, Gantz S, Heuchel L, Krause M, Lühr A, von Neubeck C, Nexhipi S, Schürer M, Tillner F, Beyreuther E, Suckert T, Müller JR. Combined proton radiography and irradiation for high-precision preclinical studies in small animals. Front Oncol 2022; 12:982417. [PMID: 36419890 PMCID: PMC9677333 DOI: 10.3389/fonc.2022.982417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/02/2022] [Indexed: 08/22/2023] Open
Abstract
BACKGROUND AND PURPOSE Proton therapy has become a popular treatment modality in the field of radiooncology due to higher spatial dose conformity compared to conventional radiotherapy, which holds the potential to spare normal tissue. Nevertheless, unresolved research questions, such as the much debated relative biological effectiveness (RBE) of protons, call for preclinical research, especially regarding in vivo studies. To mimic clinical workflows, high-precision small animal irradiation setups with image-guidance are needed. MATERIAL AND METHODS A preclinical experimental setup for small animal brain irradiation using proton radiographies was established to perform planning, repositioning, and irradiation of mice. The image quality of proton radiographies was optimized regarding the resolution, contrast-to-noise ratio (CNR), and minimal dose deposition in the animal. Subsequently, proof-of-concept histological analysis was conducted by staining for DNA double-strand breaks that were then correlated to the delivered dose. RESULTS The developed setup and workflow allow precise brain irradiation with a lateral target positioning accuracy of<0.26mm for in vivo experiments at minimal imaging dose of<23mGy per mouse. The custom-made software for image registration enables the fast and precise animal positioning at the beam with low observer-variability. DNA damage staining validated the successful positioning and irradiation of the mouse hippocampus. CONCLUSION Proton radiography enables fast and effective high-precision lateral alignment of proton beam and target volume in mouse irradiation experiments with limited dose exposure. In the future, this will enable irradiation of larger animal cohorts as well as fractionated proton irradiation.
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Affiliation(s)
- Moritz Schneider
- OncoRay, National Center for Radiation Research in Oncology- Faculty of Medicine and University Hospital Carl Gustav Carus- Technische Universitat Dresden-Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiation Physics, Dresden, Germany
| | - Elisabeth Bodenstein
- OncoRay, National Center for Radiation Research in Oncology- Faculty of Medicine and University Hospital Carl Gustav Carus- Technische Universitat Dresden-Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Johanna Bock
- OncoRay, National Center for Radiation Research in Oncology- Faculty of Medicine and University Hospital Carl Gustav Carus- Technische Universitat Dresden-Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
| | - Antje Dietrich
- OncoRay, National Center for Radiation Research in Oncology- Faculty of Medicine and University Hospital Carl Gustav Carus- Technische Universitat Dresden-Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- German Cancer Consortium Deutsches Konsortium für Translationale Krebsforschung (DKTK), partner site Dresden- German Cancer Research Center DKFZ, Heidelberg, Germany
| | - Sebastian Gantz
- OncoRay, National Center for Radiation Research in Oncology- Faculty of Medicine and University Hospital Carl Gustav Carus- Technische Universitat Dresden-Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Lena Heuchel
- Technical University (TU) Dortmund- Faculty of Physics, Medical Physics and Radiotherapy, Dortmund, Germany
| | - Mechthild Krause
- OncoRay, National Center for Radiation Research in Oncology- Faculty of Medicine and University Hospital Carl Gustav Carus- Technische Universitat Dresden-Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
- German Cancer Consortium Deutsches Konsortium für Translationale Krebsforschung (DKTK), partner site Dresden- German Cancer Research Center DKFZ, Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universitat Dresden, Dresden, Germany
| | - Armin Lühr
- OncoRay, National Center for Radiation Research in Oncology- Faculty of Medicine and University Hospital Carl Gustav Carus- Technische Universitat Dresden-Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
- Technical University (TU) Dortmund- Faculty of Physics, Medical Physics and Radiotherapy, Dortmund, Germany
| | - Cläre von Neubeck
- OncoRay, National Center for Radiation Research in Oncology- Faculty of Medicine and University Hospital Carl Gustav Carus- Technische Universitat Dresden-Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- German Cancer Consortium Deutsches Konsortium für Translationale Krebsforschung (DKTK), partner site Dresden- German Cancer Research Center DKFZ, Heidelberg, Germany
- Department of Particle Therapy, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Sindi Nexhipi
- OncoRay, National Center for Radiation Research in Oncology- Faculty of Medicine and University Hospital Carl Gustav Carus- Technische Universitat Dresden-Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Michael Schürer
- OncoRay, National Center for Radiation Research in Oncology- Faculty of Medicine and University Hospital Carl Gustav Carus- Technische Universitat Dresden-Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany
| | - Falk Tillner
- OncoRay, National Center for Radiation Research in Oncology- Faculty of Medicine and University Hospital Carl Gustav Carus- Technische Universitat Dresden-Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universitat Dresden, Dresden, Germany
| | - Elke Beyreuther
- OncoRay, National Center for Radiation Research in Oncology- Faculty of Medicine and University Hospital Carl Gustav Carus- Technische Universitat Dresden-Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiation Physics, Dresden, Germany
| | - Theresa Suckert
- OncoRay, National Center for Radiation Research in Oncology- Faculty of Medicine and University Hospital Carl Gustav Carus- Technische Universitat Dresden-Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- German Cancer Consortium Deutsches Konsortium für Translationale Krebsforschung (DKTK), partner site Dresden- German Cancer Research Center DKFZ, Heidelberg, Germany
| | - Johannes Richard Müller
- OncoRay, National Center for Radiation Research in Oncology- Faculty of Medicine and University Hospital Carl Gustav Carus- Technische Universitat Dresden-Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- Deutsche Forschungsgemeinschaft Cluster of Excellence 'Physics of Life', Technische Universität Dresden, Dresden, Germany
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Naumann M, Czempiel T, Lößner AJ, Pape K, Beyreuther E, Löck S, Drukewitz S, Hennig A, von Neubeck C, Klink B, Krause M, William D, Stange DE, Bütof R, Dietrich A. Combined Systemic Drug Treatment with Proton Therapy: Investigations on Patient-Derived Organoids. Cancers (Basel) 2022; 14:cancers14153781. [PMID: 35954444 PMCID: PMC9367296 DOI: 10.3390/cancers14153781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/27/2022] [Accepted: 07/29/2022] [Indexed: 02/01/2023] Open
Abstract
To optimize neoadjuvant radiochemotherapy of pancreatic ductal adenocarcinoma (PDAC), the value of new irradiation modalities such as proton therapy needs to be investigated in relevant preclinical models. We studied individual treatment responses to RCT using patient-derived PDAC organoids (PDO). Four PDO lines were treated with gemcitabine, 5-fluorouracile (5FU), photon and proton irradiation and combined RCT. Therapy response was subsequently measured via viability assays. In addition, treatment-naive PDOs were characterized via whole exome sequencing and tumorigenicity was investigated in NMRI Foxn1nu/nu mice. We found a mutational pattern containing common mutations associated with PDAC within the PDOs. Although we could unravel potential complications of the viability assay for PDOs in radiobiology, distinct synergistic effects of gemcitabine and 5FU with proton irradiation were observed in two PDO lines that may lead to further mechanistical studies. We could demonstrate that PDOs are a powerful tool for translational proton radiation research.
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Affiliation(s)
- Max Naumann
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden—Rossendorf, 01307 Dresden, Germany; (M.N.); (E.B.); (S.L.); (C.v.N.); (M.K.); (R.B.)
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Tabea Czempiel
- Core Unit for Molecular Tumor Diagnostics (CMTD), National Center for Tumor Diseases (NCT), Partner Site Dresden, 01307 Dresden, Germany; (T.C.); (S.D.); (B.K.); (D.W.)
| | - Anna Jana Lößner
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany; (A.J.L.); (K.P.); (A.H.); (D.E.S.)
| | - Kristin Pape
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany; (A.J.L.); (K.P.); (A.H.); (D.E.S.)
| | - Elke Beyreuther
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden—Rossendorf, 01307 Dresden, Germany; (M.N.); (E.B.); (S.L.); (C.v.N.); (M.K.); (R.B.)
- Institute of Radiation Physics, Helmholtz-Zentrum Dresden-Rossendorf, 01328 Dresden, Germany
| | - Steffen Löck
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden—Rossendorf, 01307 Dresden, Germany; (M.N.); (E.B.); (S.L.); (C.v.N.); (M.K.); (R.B.)
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, 01307 Dresden, Germany
- German Cancer Consortium (DKTK), Partner Site Dresden, German Cancer Research Center (DKFZ), 69192 Heidelberg, Germany
- Institute of Radiooncology—OncoRay, Helmholtz-Zentrum Dresden—Rossendorf, 01307 Dresden, Germany
| | - Stephan Drukewitz
- Core Unit for Molecular Tumor Diagnostics (CMTD), National Center for Tumor Diseases (NCT), Partner Site Dresden, 01307 Dresden, Germany; (T.C.); (S.D.); (B.K.); (D.W.)
- Institute of Human Genetics, University of Leipzig Medical Center, 04103 Leipzig, Germany
| | - Alexander Hennig
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany; (A.J.L.); (K.P.); (A.H.); (D.E.S.)
- National Center for Tumor Diseases (NCT), Partner Site Dresden, 01307 Dresden, Germany
| | - Cläre von Neubeck
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden—Rossendorf, 01307 Dresden, Germany; (M.N.); (E.B.); (S.L.); (C.v.N.); (M.K.); (R.B.)
- German Cancer Consortium (DKTK), Partner Site Dresden, German Cancer Research Center (DKFZ), 69192 Heidelberg, Germany
- Clinic for Particle Therapy, University Hospital Essen, Universität Duisburg Essen, 45147 Essen, Germany
| | - Barbara Klink
- Core Unit for Molecular Tumor Diagnostics (CMTD), National Center for Tumor Diseases (NCT), Partner Site Dresden, 01307 Dresden, Germany; (T.C.); (S.D.); (B.K.); (D.W.)
- Department of Genetics, Laboratoire National de Santé, 3555 Dudelange, Luxembourg
- Institute for Clinical Genetics, University Hospital Carl Gustav Carus, Technische Universität Dresden, ERN-GENTURIS, Hereditary Cancer Syndrome Center Dresden, 01307 Dresden, Germany
| | - Mechthild Krause
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden—Rossendorf, 01307 Dresden, Germany; (M.N.); (E.B.); (S.L.); (C.v.N.); (M.K.); (R.B.)
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, 01307 Dresden, Germany
- German Cancer Consortium (DKTK), Partner Site Dresden, German Cancer Research Center (DKFZ), 69192 Heidelberg, Germany
- Institute of Radiooncology—OncoRay, Helmholtz-Zentrum Dresden—Rossendorf, 01307 Dresden, Germany
| | - Doreen William
- Core Unit for Molecular Tumor Diagnostics (CMTD), National Center for Tumor Diseases (NCT), Partner Site Dresden, 01307 Dresden, Germany; (T.C.); (S.D.); (B.K.); (D.W.)
- Institute for Clinical Genetics, University Hospital Carl Gustav Carus, Technische Universität Dresden, ERN-GENTURIS, Hereditary Cancer Syndrome Center Dresden, 01307 Dresden, Germany
| | - Daniel E. Stange
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany; (A.J.L.); (K.P.); (A.H.); (D.E.S.)
- National Center for Tumor Diseases (NCT), Partner Site Dresden, 01307 Dresden, Germany
| | - Rebecca Bütof
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden—Rossendorf, 01307 Dresden, Germany; (M.N.); (E.B.); (S.L.); (C.v.N.); (M.K.); (R.B.)
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, 01307 Dresden, Germany
- Institute of Radiooncology—OncoRay, Helmholtz-Zentrum Dresden—Rossendorf, 01307 Dresden, Germany
| | - Antje Dietrich
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden—Rossendorf, 01307 Dresden, Germany; (M.N.); (E.B.); (S.L.); (C.v.N.); (M.K.); (R.B.)
- German Cancer Consortium (DKTK), Partner Site Dresden, German Cancer Research Center (DKFZ), 69192 Heidelberg, Germany
- Correspondence:
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Heuchel L, Hahn C, Pawelke J, Sørensen BS, Dosanjh M, Lühr A. Clinical use and future requirements of relative biological effectiveness: survey among all european proton therapy centres. Radiother Oncol 2022; 172:134-139. [PMID: 35605747 DOI: 10.1016/j.radonc.2022.05.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/29/2022] [Accepted: 05/15/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND PURPOSE The relative biological effectiveness (RBE) varies along the treatment field. However, in clinical practice, a constant RBE of 1.1 is assumed, which can result in undesirable side effects. This study provides an accurate overview of current clinical practice for considering proton RBE in Europe. MATERIALS AND METHODS A survey was devised and sent to all proton therapy centres in Europe that treat patients. The online questionnaire consisted of 39 questions addressing various aspects of RBE consideration in clinical practice, including treatment planning, patient follow-up and future demands. RESULTS All 25 proton therapy centres responded. All centres prescribed a constant RBE of 1.1, but also applied measures (except for one eye treatment centre) to counteract variable RBE effects such as avoiding beams stopping inside or in front of an organ at risk and putting restrictions on the minimum number and opening angle of incident beams for certain treatment sites. For the future, most centres (16) asked for more retrospective or prospective outcome studies investigating the potential effect of the effect of a variable RBE. To perform such studies, 18 centres asked for LET and RBE calculation and visualisation tools developed by treatment planning system vendors. CONCLUSION All European proton centres are aware of RBE variability but comply with current guidelines of prescribing a constant RBE. However, they actively mitigate uncertainty and risk of side effects resulting from increased RBE by applying measures and restrictions during treatment planning. To change RBE-related clinical guidelines in the future more clinical data on RBE are explicitly demanded.
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Affiliation(s)
- Lena Heuchel
- Department of Physics, TU Dortmund University, Germany
| | - Christian Hahn
- Department of Physics, TU Dortmund University, Germany; OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Jörg Pawelke
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Germany; Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Germany
| | - Brita Singers Sørensen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark; Danish Center for Particle Therapy, DCPT, Aarhus University Hospital, Denmark
| | - Manjit Dosanjh
- Department of Physics, University of Oxford, UK; CERN, Geneva, Switzerland
| | - Armin Lühr
- Department of Physics, TU Dortmund University, Germany.
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19
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Jones B. Risk assessment for proton therapy in the central nervous system by assuming small increments in RBE. Radiat Phys Chem Oxf Engl 1993 2022. [DOI: 10.1016/j.radphyschem.2022.110213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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20
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Favaudon V, Labarbe R, Limoli CL. Model studies of the role of oxygen in the FLASH effect. Med Phys 2022; 49:2068-2081. [PMID: 34407219 PMCID: PMC8854455 DOI: 10.1002/mp.15129] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 06/02/2021] [Accepted: 06/10/2021] [Indexed: 12/13/2022] Open
Abstract
Current radiotherapy facilities are standardized to deliver dose rates around 0.1-0.4 Gy/s in 2 Gy daily fractions, designed to deliver total accumulated doses to reach the tolerance limit of normal tissues undergoing irradiation. FLASH radiotherapy (FLASH-RT), on the other hand, relies on facilities capable of delivering ultrahigh dose rates in large doses in a single microsecond pulse, or in a few pulses given over a very short time sequence. For example, most studies to date have implemented 4-6 MeV electrons with intra-pulse dose rates in the range 106 -107 Gy/s. The proposed dependence of the FLASH effect on oxygen tension has stimulated several theoretical models based on three different hypotheses: (i) Radiation-induced transient oxygen depletion; (ii) cell-specific differences in the ability to detoxify and/or recover from injury caused by reactive oxygen species; (iii) self-annihilation of radicals by bimolecular recombination. This article focuses on the observations supporting or refuting these models in the frame of the chemical-biological bases of the impact of oxygen on the radiation response of cell free, in vitro and in vivo model systems.
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Affiliation(s)
- Vincent Favaudon
- Institut Curie, Inserm U 1021- CNRS UMR 3347, University Paris-Saclay, PSL Research University, Centre Universitaire, 91405 Orsay Cedex, France
- Corresponding author:
| | - Rudi Labarbe
- Ion Beam Applications S.A. (IBA), Louvain-la-Neuve, Belgium
| | - Charles L. Limoli
- Dept. of Radiation Oncology, Medical Sciences I, B146B, Irvine, California 92697-2695, USA
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21
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Hahn C, Ödén J, Dasu A, Vestergaard A, Fuglsang Jensen M, Sokol O, Pardi C, Bourhaleb F, Leite A, de Marzi L, Smith E, Aitkenhead A, Rose C, Merchant M, Kirkby K, Grzanka L, Pawelke J, Lühr A. Towards harmonizing clinical linear energy transfer (LET) reporting in proton radiotherapy: a European multi-centric study. Acta Oncol 2022; 61:206-214. [PMID: 34686122 DOI: 10.1080/0284186x.2021.1992007] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 10/06/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Clinical data suggest that the relative biological effectiveness (RBE) in proton therapy (PT) varies with linear energy transfer (LET). However, LET calculations are neither standardized nor available in clinical routine. Here, the status of LET calculations among European PT institutions and their comparability are assessed. MATERIALS AND METHODS Eight European PT institutions used suitable treatment planning systems with their center-specific beam model to create treatment plans in a water phantom covering different field arrangements and fulfilling commonly agreed dose objectives. They employed their locally established LET simulation environments and procedures to determine the corresponding LET distributions. Dose distributions D1.1 and DRBE assuming constant and variable RBE, respectively, and LET were compared among the institutions. Inter-center variability was assessed based on dose- and LET-volume-histogram parameters. RESULTS Treatment plans from six institutions fulfilled all clinical goals and were eligible for common analysis. D1.1 distributions in the target volume were comparable among PT institutions. However, corresponding LET values varied substantially between institutions for all field arrangements, primarily due to differences in LET averaging technique and considered secondary particle spectra. Consequently, DRBE using non-harmonized LET calculations increased inter-center dose variations substantially compared to D1.1 and significantly in mean dose to the target volume of perpendicular and opposing field arrangements (p < 0.05). Harmonizing LET reporting (dose-averaging, all protons, LET to water or to unit density tissue) reduced the inter-center variability in LET to the order of 10-15% within and outside the target volume for all beam arrangements. Consequentially, inter-institutional variability in DRBE decreased to that observed for D1.1. CONCLUSION Harmonizing the reported LET among PT centers is feasible and allows for consistent multi-centric analysis and reporting of tumor control and toxicity in view of a variable RBE. It may serve as basis for harmonized variable RBE dose prescription in PT.
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Affiliation(s)
- Christian Hahn
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Medical Physics and Radiotherapy, Department of Physics, TU Dortmund University, Dortmund, Germany
| | - Jakob Ödén
- RaySearch Laboratories AB, Stockholm, Sweden
| | - Alexandru Dasu
- The Skandion Clinic, Uppsala, Sweden
- Medical Radiation Sciences, Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Anne Vestergaard
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | | | - Olga Sokol
- GSI Helmholtz Centre for Heavy Ion Research, Darmstadt, Germany
| | - Claudia Pardi
- I-SEE (Internet-Simulation Evaluation Envision), Torino, Italy
| | - Faiza Bourhaleb
- I-SEE (Internet-Simulation Evaluation Envision), Torino, Italy
| | - Amélia Leite
- Institut Curie, PSL Research University, Radiation Oncology Department, Proton Therapy Centre, Centre Universitaire, Orsay, France
| | - Ludovic de Marzi
- Institut Curie, PSL Research University, Radiation Oncology Department, Proton Therapy Centre, Centre Universitaire, Orsay, France
- Institut Curie, PSL Research University, University Paris Saclay, Inserm LITO, Orsay, France
| | - Edward Smith
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, UK
| | - Adam Aitkenhead
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, UK
| | - Christopher Rose
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, UK
| | - Michael Merchant
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, UK
| | - Karen Kirkby
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, UK
| | - Leszek Grzanka
- Institute of Nuclear Physics Polish Academy of Sciences, Krakow, Poland
| | - Jörg Pawelke
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Armin Lühr
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Medical Physics and Radiotherapy, Department of Physics, TU Dortmund University, Dortmund, Germany
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
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22
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Cui Bono, Proton Radiotherapy? Clin Oncol (R Coll Radiol) 2022; 34:258-260. [DOI: 10.1016/j.clon.2022.01.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/07/2022] [Accepted: 01/14/2022] [Indexed: 11/19/2022]
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23
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Nangia S, Gaikwad U, Noufal MP, Chilukuri S, Patro K, Nakra V, Panda P, Mathew A, Sharma D, Jalali R. Proton therapy for skull-base adenoid cystic carcinomas: A case series and review of literature. J Cancer Res Ther 2022; 18:629-637. [DOI: 10.4103/jcrt.jcrt_1236_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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24
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Silicon 3D Microdosimeters for Advanced Quality Assurance in Particle Therapy. APPLIED SCIENCES-BASEL 2021. [DOI: 10.3390/app12010328] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The Centre for Medical Radiation Physics introduced the concept of Silicon On Insulator (SOI) microdosimeters with 3-Dimensional (3D) cylindrical sensitive volumes (SVs) mimicking the dimensions of cells in an array. Several designs of high-definition 3D SVs fabricated using 3D MEMS technology were implemented. 3D SVs were fabricated in different sizes and configurations with diameters between 18 and 30 µm, thicknesses of 2–50 µm and at a pitch of 50 µm in matrices with volumes of 20 × 20 and 50 × 50. SVs were segmented into sub-arrays to reduce capacitance and avoid pile up in high-dose rate pencil beam scanning applications. Detailed TCAD simulations and charge collection studies in individual SVs have been performed. The microdosimetry probe (MicroPlus) is composed of the silicon microdosimeter and low-noise front–end readout electronics housed in a PMMA waterproof sheath that allows measurements of lineal energies as low as 0.4 keV/µm in water or PMMA. Microdosimetric quantities measured with SOI microdosimeters and the MicroPlus probe were used to evaluate the relative biological effectiveness (RBE) of heavy ions and protons delivered by pencil-beam scanning and passive scattering systems in different particle therapy centres. The 3D detectors and MicroPlus probe developed for microdosimetry have the potential to provide confidence in the delivery of RBE optimized particle therapy when introduced into routine clinical practice.
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25
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Yap J, De Franco A, Sheehy S. Future Developments in Charged Particle Therapy: Improving Beam Delivery for Efficiency and Efficacy. Front Oncol 2021; 11:780025. [PMID: 34956897 PMCID: PMC8697351 DOI: 10.3389/fonc.2021.780025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/16/2021] [Indexed: 01/09/2023] Open
Abstract
The physical and clinical benefits of charged particle therapy (CPT) are well recognized. However, the availability of CPT and complete exploitation of dosimetric advantages are still limited by high facility costs and technological challenges. There are extensive ongoing efforts to improve upon these, which will lead to greater accessibility, superior delivery, and therefore better treatment outcomes. Yet, the issue of cost remains a primary hurdle as utility of CPT is largely driven by the affordability, complexity and performance of current technology. Modern delivery techniques are necessary but limited by extended treatment times. Several of these aspects can be addressed by developments in the beam delivery system (BDS) which determines the overall shaping and timing capabilities enabling high quality treatments. The energy layer switching time (ELST) is a limiting constraint of the BDS and a determinant of the beam delivery time (BDT), along with the accelerator and other factors. This review evaluates the delivery process in detail, presenting the limitations and developments for the BDS and related accelerator technology, toward decreasing the BDT. As extended BDT impacts motion and has dosimetric implications for treatment, we discuss avenues to minimize the ELST and overview the clinical benefits and feasibility of a large energy acceptance BDS. These developments support the possibility of advanced modalities and faster delivery for a greater range of treatment indications which could also further reduce costs. Further work to realize methodologies such as volumetric rescanning, FLASH, arc, multi-ion and online image guided therapies are discussed. In this review we examine how increased treatment efficiency and efficacy could be achieved with improvements in beam delivery and how this could lead to faster and higher quality treatments for the future of CPT.
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Affiliation(s)
- Jacinta Yap
- School of Physics, University of Melbourne, Melbourne, VIC, Australia
| | - Andrea De Franco
- IFMIF Accelerator Development Group, Rokkasho Fusion Institute, National Institutes for Quantum Science and Technology, Aomori, Japan
| | - Suzie Sheehy
- School of Physics, University of Melbourne, Melbourne, VIC, Australia
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26
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Smit T, Schickel E, Azimzadeh O, von Toerne C, Rauh O, Ritter S, Durante M, Schroeder IS. A Human 3D Cardiomyocyte Risk Model to Study the Cardiotoxic Influence of X-rays and Other Noxae in Adults. Cells 2021; 10:cells10102608. [PMID: 34685588 PMCID: PMC8533903 DOI: 10.3390/cells10102608] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/23/2021] [Accepted: 09/26/2021] [Indexed: 02/06/2023] Open
Abstract
The heart tissue is a potential target of various noxae contributing to the onset of cardiovascular diseases. However, underlying pathophysiological mechanisms are largely unknown. Human stem cell-derived models are promising, but a major concern is cell immaturity when estimating risks for adults. In this study, 3D aggregates of human embryonic stem cell-derived cardiomyocytes were cultivated for 300 days and characterized regarding degree of maturity, structure, and cell composition. Furthermore, effects of ionizing radiation (X-rays, 0.1–2 Gy) on matured aggregates were investigated, representing one of the noxae that are challenging to assess. Video-based functional analyses were correlated to changes in the proteome after irradiation. Cardiomyocytes reached maximum maturity after 100 days in cultivation, judged by α-actinin lengths, and displayed typical multinucleation and branching. At this time, aggregates contained all major cardiac cell types, proven by the patch-clamp technique. Matured and X-ray-irradiated aggregates revealed a subtle increase in beat rates and a more arrhythmic sequence of cellular depolarisation and repolarisation compared to non-irradiated sham controls. The proteome analysis provides first insights into signaling mechanisms contributing to cardiotoxicity. Here, we propose an in vitro model suitable to screen various noxae to target adult cardiotoxicity by preserving all the benefits of a 3D tissue culture.
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Affiliation(s)
- Timo Smit
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung GmbH, 64291 Darmstadt, Germany; (T.S.); (E.S.); (S.R.); (M.D.)
- Biology Department, Technische Universität Darmstadt, 64289 Darmstadt, Germany;
| | - Esther Schickel
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung GmbH, 64291 Darmstadt, Germany; (T.S.); (E.S.); (S.R.); (M.D.)
| | - Omid Azimzadeh
- Section Radiation Biology, Federal Office for Radiation Protection (BfS), 85764 Neuherberg, Germany;
- Helmholtz Zentrum München-German Research Center for Environmental Health, Institute of Radiation Biology, 85764 Neuherberg, Germany
| | - Christine von Toerne
- Helmholtz Zentrum München-German Research Center for Environmental Health, Research Unit Protein Science, 80939 Munich, Germany;
| | - Oliver Rauh
- Biology Department, Technische Universität Darmstadt, 64289 Darmstadt, Germany;
| | - Sylvia Ritter
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung GmbH, 64291 Darmstadt, Germany; (T.S.); (E.S.); (S.R.); (M.D.)
| | - Marco Durante
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung GmbH, 64291 Darmstadt, Germany; (T.S.); (E.S.); (S.R.); (M.D.)
- Institute for Condensed Matter Physics, Technische Universität Darmstadt, 64289 Darmstadt, Germany
| | - Insa S. Schroeder
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung GmbH, 64291 Darmstadt, Germany; (T.S.); (E.S.); (S.R.); (M.D.)
- Correspondence:
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27
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Sørensen BS, Pawelke J, Bauer J, Burnet NG, Dasu A, Høyer M, Karger CP, Krause M, Schwarz M, Underwood TSA, Wagenaar D, Whitfield GA, Lühr A. Does the uncertainty in relative biological effectiveness affect patient treatment in proton therapy? Radiother Oncol 2021; 163:177-184. [PMID: 34480959 DOI: 10.1016/j.radonc.2021.08.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 08/09/2021] [Accepted: 08/22/2021] [Indexed: 10/20/2022]
Abstract
Clinical treatment with protons uses the concept of relative biological effectiveness (RBE) to convert the absorbed dose into an RBE-weighted dose that equals the dose for radiotherapy with photons causing the same biological effect. Currently, in proton therapy a constant RBE of 1.1 is generically used. However, empirical data indicate that the RBE is not constant, but increases at the distal edge of the proton beam. This increase in RBE is of concern, as the clinical impact is still unresolved, and clinical studies demonstrating a clinical effect of an increased RBE are emerging. Within the European Particle Therapy Network (EPTN) work package 6 on radiobiology and RBE, a workshop was held in February 2020 in Manchester with one day of discussion dedicated to the impact of proton RBE in a clinical context. Current data on RBE effects, patient outcome and modelling from experimental as well as clinical studies were presented and discussed. Furthermore, representatives from European clinical proton therapy centres, who were involved in patient treatment, laid out their current clinical practice on how to consider the risk of a variable RBE in their centres. In line with the workshop, this work considers the actual impact of RBE issues on patient care in proton therapy by reviewing preclinical data on the relation between linear energy transfer (LET) and RBE, current clinical data sets on RBE effects in patients, and applied clinical strategies to manage RBE uncertainties. A better understanding of the variability in RBE would allow development of proton treatments which are safer and more effective.
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Affiliation(s)
- Brita S Sørensen
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark; Experimental Clinical Oncology - Department of Oncology, Aarhus University Hospital, Aarhus, Denmark.
| | - Jörg Pawelke
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Institute of Radiooncology-OncoRay, Dresden, Germany
| | - Julia Bauer
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute for Radiation Oncology (HIRO) and National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany
| | | | - Alexandru Dasu
- The Skandion Clinic, Uppsala, Sweden; Medical Radiation Sciences, Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Morten Høyer
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Christian P Karger
- Dept. of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany; Heidelberg Institute for Radiation Oncology (HIRO) and National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany
| | - Mechthild Krause
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Institute of Radiooncology-OncoRay, Dresden, Germany; German Cancer Consortium Dresden and German Cancer Research Center Heidelberg, Germany; Dept. of Radiation Oncology, University Hospital and Faculty of Medicine C.G. Carus, Dresden, Germany; National Center for Tumor Diseases Dresden, German Cancer Research Center Heidelberg, University Hospital and Faculty of Medicine C.G. Carus Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
| | - Marco Schwarz
- Protontherapy Department -Trento Hospital, and TIFPA-INFN, Trento, Italy
| | - Tracy S A Underwood
- Division of Cancer Sciences, School of Medical Sciences, The University of Manchester, UK
| | - Dirk Wagenaar
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Gillian A Whitfield
- The Christie NHS Foundation Trust, Manchester, UK; University of Manchester, UK
| | - Armin Lühr
- Department of Physics, TU Dortmund University, Dortmund, Germany
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Garbacz M, Cordoni FG, Durante M, Gajewski J, Kisielewicz K, Krah N, Kopeć R, Olko P, Patera V, Rinaldi I, Rydygier M, Schiavi A, Scifoni E, Skóra T, Tommasino F, Rucinski A. Study of relationship between dose, LET and the risk of brain necrosis after proton therapy for skull base tumors. Radiother Oncol 2021; 163:143-149. [PMID: 34461183 DOI: 10.1016/j.radonc.2021.08.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 07/27/2021] [Accepted: 08/21/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE We investigated the relationship between RBE-weighted dose (DRBE) calculated with constant (cRBE) and variable RBE (vRBE), dose-averaged linear energy transfer (LETd) and the risk of radiographic changes in skull base patients treated with protons. METHODS Clinical treatment plans of 45 patients were recalculated with Monte Carlo tool FRED. Radiographic changes (i.e. edema and/or necrosis) were identified by MRI. Dosimetric parameters for cRBE and vRBE were computed. Biological margin extension and voxel-based analysis were employed looking for association of DRBE(vRBE) and LETd with brain edema and/or necrosis. RESULTS When using vRBE, Dmax in the brain was above the highest dose limits for 38% of patients, while such limit was never exceeded assuming cRBE. Similar values of Dmax were observed in necrotic regions, brain and temporal lobes. Most of the brain necrosis was in proximity to the PTV. The voxel-based analysis did not show evidence of an association with high LETd values. CONCLUSIONS When looking at standard dosimetric parameters, the higher dose associated with vRBE seems to be responsible for an enhanced risk of radiographic changes. However, as revealed by a voxel-based analysis, the large inter-patient variability hinders the identification of a clear effect for high LETd.
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Affiliation(s)
- Magdalena Garbacz
- Institute of Nuclear Physics Polish Academy of Sciences, 31342 Krakow, Poland.
| | - Francesco Giuseppe Cordoni
- University of Verona, Department of Computer Science, Verona, Italy; Trento Institute for Fundamental Physics and Applications, TIFPA-INFN, Trento, Italy
| | - Marco Durante
- GSI Helmholtzzentrum fur Schwerionenforschung, Darmstadt, Germany; The Technical University of Darmstadt, Germany
| | - Jan Gajewski
- Institute of Nuclear Physics Polish Academy of Sciences, 31342 Krakow, Poland
| | - Kamil Kisielewicz
- National Oncology Institute, National Research Institute, Krakow Branch, Krakow, Poland
| | - Nils Krah
- University of Lyon, CREATIS, CNRS UMR5220, Inserm U1044, INSA-Lyon, Université Lyon 1, Centre Léon Bérard, France; University of Lyon, Université Claude Bernard Lyon 1, CNRS/IN2P3, IP2I Lyon, UMR 5822, Villeurbanne, France
| | - Renata Kopeć
- Institute of Nuclear Physics Polish Academy of Sciences, 31342 Krakow, Poland
| | - Paweł Olko
- Institute of Nuclear Physics Polish Academy of Sciences, 31342 Krakow, Poland
| | - Vincenzo Patera
- INFN - Section of Rome, Italy; Department of Basic and Applied Sciences for Engineering, Sapienza University of Rome, Italy
| | - Ilaria Rinaldi
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Marzena Rydygier
- Institute of Nuclear Physics Polish Academy of Sciences, 31342 Krakow, Poland
| | - Angelo Schiavi
- Department of Basic and Applied Sciences for Engineering, Sapienza University of Rome, Italy
| | - Emanuele Scifoni
- Trento Institute for Fundamental Physics and Applications, TIFPA-INFN, Trento, Italy
| | - Tomasz Skóra
- National Oncology Institute, National Research Institute, Krakow Branch, Krakow, Poland
| | - Francesco Tommasino
- Trento Institute for Fundamental Physics and Applications, TIFPA-INFN, Trento, Italy; Department of Physics, University of Trento, Trento, Italy
| | - Antoni Rucinski
- Institute of Nuclear Physics Polish Academy of Sciences, 31342 Krakow, Poland
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Suckert T, Nexhipi S, Dietrich A, Koch R, Kunz-Schughart LA, Bahn E, Beyreuther E. Models for Translational Proton Radiobiology-From Bench to Bedside and Back. Cancers (Basel) 2021; 13:4216. [PMID: 34439370 PMCID: PMC8395028 DOI: 10.3390/cancers13164216] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/09/2021] [Accepted: 08/17/2021] [Indexed: 12/25/2022] Open
Abstract
The number of proton therapy centers worldwide are increasing steadily, with more than two million cancer patients treated so far. Despite this development, pending questions on proton radiobiology still call for basic and translational preclinical research. Open issues are the on-going discussion on an energy-dependent varying proton RBE (relative biological effectiveness), a better characterization of normal tissue side effects and combination treatments with drugs originally developed for photon therapy. At the same time, novel possibilities arise, such as radioimmunotherapy, and new proton therapy schemata, such as FLASH irradiation and proton mini-beams. The study of those aspects demands for radiobiological models at different stages along the translational chain, allowing the investigation of mechanisms from the molecular level to whole organisms. Focusing on the challenges and specifics of proton research, this review summarizes the different available models, ranging from in vitro systems to animal studies of increasing complexity as well as complementing in silico approaches.
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Affiliation(s)
- Theresa Suckert
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, 01309 Dresden, Germany; (T.S.); (S.N.); (A.D.); (L.A.K.-S.)
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Sindi Nexhipi
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, 01309 Dresden, Germany; (T.S.); (S.N.); (A.D.); (L.A.K.-S.)
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology-OncoRay, 01309 Dresden, Germany
| | - Antje Dietrich
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, 01309 Dresden, Germany; (T.S.); (S.N.); (A.D.); (L.A.K.-S.)
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Robin Koch
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany; (R.K.); (E.B.)
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Leoni A. Kunz-Schughart
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, 01309 Dresden, Germany; (T.S.); (S.N.); (A.D.); (L.A.K.-S.)
- National Center for Tumor Diseases (NCT), Partner Site Dresden, 01307 Dresden, Germany
| | - Emanuel Bahn
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany; (R.K.); (E.B.)
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- German Cancer Research Center (DKFZ), Clinical Cooperation Unit Radiation Oncology, 69120 Heidelberg, Germany
| | - Elke Beyreuther
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, 01309 Dresden, Germany; (T.S.); (S.N.); (A.D.); (L.A.K.-S.)
- Helmholtz-Zentrum Dresden—Rossendorf, Institute of Radiation Physics, 01328 Dresden, Germany
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Howard ME, Denbeigh JM, Debrot EK, Garcia DA, Remmes NB, Herman MG, Beltran CJ. Dosimetric Assessment of a High Precision System for Mouse Proton Irradiation to Assess Spinal Cord Toxicity. Radiat Res 2021; 195:541-548. [PMID: 33826742 DOI: 10.1667/rade-20-00153.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 03/11/2021] [Indexed: 11/03/2022]
Abstract
The uncertainty associated with the relative biological effectiveness (RBE) in proton therapy, particularly near the Bragg peak (BP), has led to the shift towards biological-based treatment planning. Proton RBE uncertainty has recently been reported as a possible cause for brainstem necrosis in pediatric patients treated with proton therapy. Despite this, in vivo studies have been limited due to the complexity of accurate delivery and absolute dosimetry. The purpose of this investigation was to create a precise and efficient method of treating the mouse spinal cord with various portions of the proton Bragg curve and to quantify associated uncertainties for the characterization of proton RBE. Mice were restrained in 3D printed acrylic boxes, shaped to their external contour, with a silicone insert extending down to mold around the mouse. Brass collimators were designed for parallel opposed beams to treat the spinal cord while shielding the brain and upper extremities of the animal. Up to six animals may be accommodated for simultaneous treatment within the restraint system. Two plans were generated targeting the cervical spinal cord, with either the entrance (ENT) or the BP portion of the beam. Dosimetric uncertainty was measured using EBT3 radiochromic film with a dose-averaged linear energy transfer (LETd) correction. Positional uncertainty was assessed by collecting a library of live mouse scans (n = 6 mice, two independent scans per mouse) and comparing the following dosimetric statistics from the mouse cervical spinal cord: Volume receiving 90% of the prescription dose (V90); mean dose to the spinal cord; and LETd. Film analysis results showed the dosimetric uncertainty to be ±1.2% and ±5.4% for the ENT and BP plans, respectively. Preliminary results from the mouse library showed the V90 to be 96.3 ± 4.8% for the BP plan. Positional uncertainty of the ENT plan was not measured due to the inherent robustness of that treatment plan. The proposed high-throughput mouse proton irradiation setup resulted in accurate dose delivery to mouse spinal cords positioned along the ENT and BP. Future directions include adapting the setup to account for weight fluctuations in mice undergoing fractionated irradiation.
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Affiliation(s)
| | - Janet M Denbeigh
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Darwin A Garcia
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Michael G Herman
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Chris J Beltran
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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Engeseth GM, He R, Mirkovic D, Yepes P, Mohamed ASR, Stieb S, Fuller CD, Wu R, Zhang X, Hysing LB, Pettersen HES, Stokkevåg CH, Mohan R, Frank SJ, Gunn GB. Mixed Effect Modeling of Dose and Linear Energy Transfer Correlations With Brain Image Changes After Intensity Modulated Proton Therapy for Skull Base Head and Neck Cancer. Int J Radiat Oncol Biol Phys 2021; 111:684-692. [PMID: 34153379 PMCID: PMC8855940 DOI: 10.1016/j.ijrobp.2021.06.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/23/2021] [Accepted: 06/10/2021] [Indexed: 11/18/2022]
Abstract
Purpose: Intensity modulated proton therapy (IMPT) could yield high linear energy transfer (LET) in critical structures and increased biological effect. For head and neck cancers at the skull base this could potentially result in radiation-associated brain image change (RAIC). The purpose of the current study was to investigate voxel-wise dose and LET correlations with RAIC after IMPT. Methods and Materials: For 15 patients with RAIC after IMPT, contrast enhancement observed on T1-weighted magnetic resonance imaging was contoured and coregistered to the planning computed tomography. Monte Carlo calculated dose and dose-averaged LET (LETd) distributions were extracted at voxel level and associations with RAIC were modelled using uni- and multivariate mixed effect logistic regression. Model performance was evaluated using the area under the receiver operating characteristic curve and precision-recall curve. Results: An overall statistically significant RAIC association with dose and LETd was found in both the uni- and multivariate analysis. Patient heterogeneity was considerable, with standard deviation of the random effects of 1.81 (1.30–2.72) for dose and 2.68 (1.93–4.93) for LETd, respectively. Area under the receiver operating characteristic curve was 0.93 and 0.95 for the univariate dose-response model and multivariate model, respectively. Analysis of the LETd effect demonstrated increased risk of RAIC with increasing LETd for the majority of patients. Estimated probability of RAIC with LETd = 1 keV/μm was 4% (95% confidence interval, 0%, 0.44%) and 29% (95% confidence interval, 0.01%, 0.92%) for 60 and 70 Gy, respectively. The TD15 were estimated to be 63.6 and 50.1 Gy with LETd equal to 2 and 5 keV/μm, respectively. Conclusions: Our results suggest that the LETd effect could be of clinical significance for some patients; LETd assessment in clinical treatment plans should therefore be taken into consideration.
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Affiliation(s)
- Grete May Engeseth
- The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, Texas; Haukeland University Hospital, Department of Oncology and Medical Physics, Bergen, Norway; The University of Bergen, Department of Clinical Science, Bergen, Norway.
| | - Renjie He
- The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, Texas
| | - Dragan Mirkovic
- The University of Texas MD Anderson Cancer Center, Department of Radiation Physics, Houston, Texas
| | - Pablo Yepes
- Rice University, Physics and Astronomy Department, Houston, Texas
| | | | - Sonja Stieb
- The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, Texas
| | - Clifton Dave Fuller
- The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, Texas
| | - Richard Wu
- The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, Texas
| | - Xiadong Zhang
- The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, Texas
| | - Liv Bolstad Hysing
- Haukeland University Hospital, Department of Oncology and Medical Physics, Bergen, Norway; The University of Bergen, Department of Physics and Technology, Bergen, Norway
| | | | - Camilla Hanquist Stokkevåg
- Haukeland University Hospital, Department of Oncology and Medical Physics, Bergen, Norway; The University of Bergen, Department of Physics and Technology, Bergen, Norway
| | - Radhe Mohan
- The University of Texas MD Anderson Cancer Center, Department of Radiation Physics, Houston, Texas
| | - Steven Jay Frank
- The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, Texas
| | - Gary Brandon Gunn
- The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, Texas
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Musielak M, Suchorska WM, Fundowicz M, Milecki P, Malicki J. Future Perspectives of Proton Therapy in Minimizing the Toxicity of Breast Cancer Radiotherapy. J Pers Med 2021; 11:jpm11050410. [PMID: 34068305 PMCID: PMC8153289 DOI: 10.3390/jpm11050410] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/10/2021] [Accepted: 05/12/2021] [Indexed: 11/16/2022] Open
Abstract
The toxicity of radiotherapy is a key issue when analyzing the eligibility criteria for patients with breast cancer. In order to obtain better results, proton therapy is proposed because of the more favorable distribution of the dose in the patient’s body compared with photon radiotherapy. Scientific groups have conducted extensive research into the improved efficacy and lower toxicity of proton therapy for breast cancer. Unfortunately, there is no complete insight into the potential reasons and prospects for avoiding undesirable results. Cardiotoxicity is considered challenging; however, researchers have not presented any realistic prospects for preventing them. We compared the clinical evidence collected over the last 20 years, providing the rationale for the consideration of proton therapy as an effective solution to reduce cardiotoxicity. We analyzed the parameters of the dose distribution (mean dose, Dmax, V5, and V20) in organs at risk, such as the heart, blood vessels, and lungs, using the following two irradiation techniques: whole breast irradiation and accelerated partial breast irradiation. Moreover, we presented the possible causes of side effects, taking into account biological and technical issues. Finally, we collected potential improvements in higher quality predictions of toxic cardiac effects, like biomarkers, and model-based approaches to give the full background of this complex issue.
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Affiliation(s)
- Marika Musielak
- Electro-Radiology Department, Poznan University of Medical Sciences, 61-701 Poznan, Poland; (W.M.S.); (P.M.); (J.M.)
- Greater Poland Cancer Centre, Radiobiology Laboratory, Department of Medical Physics, 61-866 Poznan, Poland
- Correspondence: ; Tel.: +48-505372290
| | - Wiktoria M. Suchorska
- Electro-Radiology Department, Poznan University of Medical Sciences, 61-701 Poznan, Poland; (W.M.S.); (P.M.); (J.M.)
- Greater Poland Cancer Centre, Radiobiology Laboratory, Department of Medical Physics, 61-866 Poznan, Poland
| | | | - Piotr Milecki
- Electro-Radiology Department, Poznan University of Medical Sciences, 61-701 Poznan, Poland; (W.M.S.); (P.M.); (J.M.)
- Greater Poland Cancer Centre, Radiotherapy Ward I, 61-866 Poznan, Poland;
| | - Julian Malicki
- Electro-Radiology Department, Poznan University of Medical Sciences, 61-701 Poznan, Poland; (W.M.S.); (P.M.); (J.M.)
- Greater Poland Cancer Centre, Medical Physics Department, 61-866 Poznan, Poland
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Jablonska PA, Bosch-Barrera J, Serrano D, Valiente M, Calvo A, Aristu J. Challenges and Novel Opportunities of Radiation Therapy for Brain Metastases in Non-Small Cell Lung Cancer. Cancers (Basel) 2021; 13:cancers13092141. [PMID: 33946751 PMCID: PMC8124815 DOI: 10.3390/cancers13092141] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/18/2021] [Accepted: 04/26/2021] [Indexed: 12/25/2022] Open
Abstract
Simple Summary Lung cancer is the most common primary malignancy that tends to metastasize to the brain. Owing to improved survival of lung cancer patients, the prevalence of brain metastases is a matter of growing concern. Brain radiotherapy remains the mainstay in the management of metastatic CNS disease. However, new targeted therapies such as the tyrosine kinase or immune checkpoint inhibitors have demonstrated intracranial activity and promising tumor response rates. Here, we review the current and emerging therapeutical strategies for brain metastases from non-small cell lung cancer, both brain-directed and systemic, as well as the uncertainties that may arise from their combination. Abstract Approximately 20% patients with non-small cell lung cancer (NSCLC) present with CNS spread at the time of diagnosis and 25–50% are found to have brain metastases (BMs) during the course of the disease. The improvement in the diagnostic tools and screening, as well as the use of new systemic therapies have contributed to a more precise diagnosis and prolonged survival of lung cancer patients with more time for BMs development. In the past, most of the systemic therapies failed intracranially because of the inability to effectively cross the blood brain barrier. Some of the new targeted therapies, especially the group of tyrosine kinase inhibitors (TKIs) have shown durable CNS response. However, the use of ionizing radiation remains vital in the management of metastatic brain disease. Although a decrease in CNS-related deaths has been achieved over the past decade, many challenges arise from the need of multiple and repeated brain radiation treatments, which carry along not insignificant risks and toxicity. The combination of stereotactic radiotherapy and systemic treatments in terms of effectiveness and adverse effects, such as radionecrosis, remains a subject of ongoing investigation. This review discusses the challenges of the use of radiation therapy in NSCLC BMs in view of different systemic treatments such as chemotherapy, TKIs and immunotherapy. It also outlines the future perspectives and strategies for personalized BMs management.
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Affiliation(s)
- Paola Anna Jablonska
- Brain Metastases and CNS Oncology Radiation Medicine Program, Princess Margaret Cancer Center, Toronto, ON M5G 2M9, Canada
- Department of Radiation Oncology, Clinica Universidad de Navarra, 31008 Pamplona, Spain
- Correspondence: ; Tel.: +1-416-946-2000
| | - Joaquim Bosch-Barrera
- Department of Medical Oncology, Catalan Institute of Oncology, Doctor Josep Trueta University Hospital, 17007 Girona, Spain;
- Girona Biomedical Research Institute (IDIBGI), Salt, 17190 Girona, Spain
- Department of Medical Sciences, Medical School, University of Girona, 17071 Girona, Spain
| | - Diego Serrano
- IDISNA and Program in Solid Tumors, Center for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain; (D.S.); (A.C.)
- Department of Pathology, Anatomy and Physiology, School of Medicine, University of Navarra, 31008 Pamplona, Spain
| | | | - Alfonso Calvo
- IDISNA and Program in Solid Tumors, Center for Applied Medical Research (CIMA), University of Navarra, 31008 Pamplona, Spain; (D.S.); (A.C.)
- Department of Pathology, Anatomy and Physiology, School of Medicine, University of Navarra, 31008 Pamplona, Spain
- CIBERONC, ISCIII, 28029 Madrid, Spain
| | - Javier Aristu
- Department of Radiation Oncology and Protontherapy Unit, Clinica Universidad de Navarra, 28027 Madrid, Spain;
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Barcellini A, Ditto A, Mirandola A, Roccio M, Imparato S, Raspagliesi F, Orlandi E. Is a tailored strategy using proton beam radiotherapy for reirradiation advantageous for elderly women? A case report. TUMORI JOURNAL 2021; 107:NP67-NP72. [PMID: 33896256 DOI: 10.1177/03008916211007930] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The management of primary or recurrent vaginal tumours in an aging population is challenging for gynecologic and radiation oncologists. In patients unsuited for surgery and already irradiated on the pelvis, proton beam radiotherapy may be worthwhile due to its ballistic advantages. CASE REPORT We report the case of an 80-year-old woman with a squamous cell carcinoma of the vagina after a history of pelvic radiation and vaginal brachytherapy delivered for a previous endometrial adenocarcinoma. She received proton beam radiotherapy with a complete response after 12 months and mild toxicity. CONCLUSIONS The complexity of reirradiation management in the frail and elderly population requires attention. Efforts should be focused on maintaining autonomy and quality of life in order to improve adherence and clinical compliance to the treatment. In the era of the tailored approach, hadrontherapy can play an important role to minimize toxicity, obtain good local control, and reduce the overall treatment time.
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Affiliation(s)
- Amelia Barcellini
- Radiation Oncology, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Antonino Ditto
- Gynecologic Oncology Unit, IRCCS National Cancer Institute Foundation, Milan, Italy
| | - Alfredo Mirandola
- Medical Physics, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Marianna Roccio
- Department of Obstetrics and Gynecology, IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia, Italy
| | - Sara Imparato
- Diagnostic Imaging Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | | | - Ester Orlandi
- Radiation Oncology, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
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Dutz A, Lühr A, Troost EGC, Agolli L, Bütof R, Valentini C, Baumann M, Vermeren X, Geismar D, Timmermann B, Krause M, Löck S. Identification of patient benefit from proton beam therapy in brain tumour patients based on dosimetric and NTCP analyses. Radiother Oncol 2021; 160:69-77. [PMID: 33872640 DOI: 10.1016/j.radonc.2021.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 03/17/2021] [Accepted: 04/08/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND The limited availability of proton beam therapy (PBT) requires individual treatment selection strategies, such as the model-based approach. In this study, we assessed the dosimetric benefit of PBT compared to photon therapy (XRT), analysed the corresponding changes in normal tissue complication probability (NTCP) on a variety of available models, and illustrated model-based patient selection in an in-silico study for patients with brain tumours. METHODS For 92 patients treated at two PBT centres, volumetric modulated arc therapy treatment plans were retrospectively created for comparison with the clinically applied PBT plans. Several dosimetric parameters for the brain excluding tumour and margins, cerebellum, brain stem, frontal and temporal lobes, hippocampi, cochleae, chiasm, optic nerves, lacrimal glands, lenses, pituitary gland, and skin were compared between both modalities using Wilcoxon signed-rank tests. NTCP differences (ΔNTCP) were calculated for 11 models predicting brain necrosis, delayed recall, temporal lobe injury, hearing loss, tinnitus, blindness, ocular toxicity, cataract, endocrine dysfunction, alopecia, and erythema. A patient was assumed to be selected for PBT if ΔNTCP exceeded a threshold of 10 percentage points for at least one of the side-effects. RESULTS PBT substantially reduced the dose in almost all investigated OARs, especially in the low and intermediate dose ranges and for contralateral organs. In general, NTCP predictions were significantly lower for PBT compared to XRT, in particular in ipsilateral organs. Considering ΔNTCP of all models, 80 patients (87.0%) would have been selected for PBT in this in-silico study, mainly due to predictions of a model on delayed recall (51 patients). CONCLUSION In this study, substantial dose reductions for PBT were observed, mainly in contralateral organs. However, due to the sigmoidal dose response, NTCP was particularly reduced in ipsilateral organs. This underlines that physical dose-volume parameters alone may not be sufficient to describe the clinical relevance between different treatment techniques and highlights potential benefits of NTCP models. Further NTCP models for different modern treatment techniques are mandatory and existing models have to be externally validated in order to implement the model-based approach in clinical practice for cranial radiotherapy.
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Affiliation(s)
- Almut Dutz
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Armin Lühr
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; Medical Physics and Radiotherapy, Faculty of Physics, TU Dortmund University, Germany
| | - Esther G C Troost
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Linda Agolli
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Rebecca Bütof
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Chiara Valentini
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Michael Baumann
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany; Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany
| | - Xavier Vermeren
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, Germany
| | - Dirk Geismar
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, Germany; Department of Particle Therapy, University Hospital Essen, Germany; West German Cancer Center (WTZ), University Hospital Essen, Germany
| | - Beate Timmermann
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, Germany; Department of Particle Therapy, University Hospital Essen, Germany; West German Cancer Center (WTZ), University Hospital Essen, Germany; German Cancer Consortium (DKTK), partner site Essen, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Mechthild Krause
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Steffen Löck
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
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Dutz A, Lühr A, Agolli L, Bütof R, Valentini C, Troost EG, Baumann M, Vermeren X, Geismar D, Lamba N, Lebow ES, Bussière M, Daly JE, Bussière MR, Krause M, Timmermann B, Shih HA, Löck S. Modelling of late side-effects following cranial proton beam therapy. Radiother Oncol 2021; 157:15-23. [DOI: 10.1016/j.radonc.2021.01.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 01/04/2021] [Accepted: 01/05/2021] [Indexed: 02/06/2023]
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Dohm A, Sanchez J, Stotsky-Himelfarb E, Willingham FF, Hoffe S. Strategies to Minimize Late Effects From Pelvic Radiotherapy. Am Soc Clin Oncol Educ Book 2021; 41:158-168. [PMID: 34010045 DOI: 10.1200/edbk_320999] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
During the past 30 years, radiation treatment techniques have significantly improved, from conventional external-beam radiation therapy, to three-dimensional conformal radiation therapy, to current intensity-modulated radiation therapy, benefiting patients who undergo treatment of pelvic malignancies. Modern treatment options also include proton beam irradiation as well as low and high dose rate brachytherapy. Although the acute adverse effects of these modalities are well documented in clinical trials, less well known are the true incidence and optimal management of those late adverse effects that can occur months to years later. In a population of survivors of cancer that is steadily increasing, with many such patients receiving radiotherapy at some time during their disease course, these late effects can become a considerable management and quality-of-life issue. This review will examine the range of late toxicities that can occur from pelvic radiotherapy and explore strategies to prevent and mitigate them.
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Bauer J, Bahn E, Harrabi S, Herfarth K, Debus J, Alber M. How can scanned proton beam treatment planning for low-grade glioma cope with increased distal RBE and locally increased radiosensitivity for late MR-detected brain lesions? Med Phys 2021; 48:1497-1507. [PMID: 33506555 DOI: 10.1002/mp.14739] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 12/10/2020] [Accepted: 01/16/2021] [Indexed: 11/06/2022] Open
Abstract
A novel risk model has recently been proposed for the occurrence of late contrast-enhancing brain lesions (CEBLs) after proton irradiation of low-grade glioma (LGG) patients. It predicts a strong dependence on dose-weighted linear-energy transfer (LETd effect) and an increased radiosensitivity of the ventricular proximity, a 4-mm fringe surrounding the ventricular system (VP4mm effect). On this basis, we investigated (A) how these two risk factors and patient-specific anatomical and treatment plan (TP) features contribute to normal tissue complication probability (NTCP) and (B) if conventional LETd -reduction techniques like multiple-field TP are able to reduce NTCP. (A) The LGG model cohort (N = 110) was stratified with respect to prescribed dose, tumor grade, and treatment field configuration. NTCP predictions and CEBL occurrence rates per strata were analyzed. (B) The effect of multiple-field TP was investigated in two patient groups: (i) nine high-risk subjects with extended lateral target volumes who had developed CEBLs after single-beam treatments were retrospectively replanned with a clinical standard two-field setting using almost orthogonal fields and strictly opposing fields, (ii) single-field treatments were simulated for seven low-risk patients with small central target volumes clinically treated with two strictly opposing fields. (A) In the model cohort, we identified the exposure of the radiosensitive VP4mm fringe with proton field components of increased biological effectiveness as dominant NTCP driving factor. We observed that larger target volumes and location lateral to the main ventricles, both being characteristic for WHO°II tumors, presented with the highest complication risks. Among subjects of an equal dose prescription of 54 Gy(RBE), the highest median NTCP was obtained for the WHO°II group treated with two fields using sharp angles. (B) Regarding the effect of multiple-field plans, we found that an NTCP reduction was only achievable in the low-risk group where the LETd effect dominates and the VP4mm effect is small. NTCP of the single-field plans was 23% higher compared to the clinical opposing field plan. In the high-risk group, where the VP4mm effect dominates the risk, both two-field scenarios yielded 44% higher NTCP predictions compared to the clinical single-field plans. The interplay of an increased radiosensitivity in the VP4mm fringe with proton field components of increased biological effectiveness creates a geometric complexity that can hardly be managed by current clinical TP. Our results underline that advanced biologically guided TP approaches become crucial for an effective risk minimization in proton therapy of LGG.
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Affiliation(s)
- Julia Bauer
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor diseases (NCT), Heidelberg, Germany
| | - Emanuel Bahn
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor diseases (NCT), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Semi Harrabi
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor diseases (NCT), Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Klaus Herfarth
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor diseases (NCT), Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor diseases (NCT), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus Alber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor diseases (NCT), Heidelberg, Germany
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Marcu LG, Bezak E, Peukert DD, Wilson P. Translational Research in FLASH Radiotherapy-From Radiobiological Mechanisms to In Vivo Results. Biomedicines 2021; 9:181. [PMID: 33670409 PMCID: PMC7918545 DOI: 10.3390/biomedicines9020181] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 01/18/2023] Open
Abstract
FLASH radiotherapy, or the administration of ultra-high dose rate radiotherapy, is a new radiation delivery method that aims to widen the therapeutic window in radiotherapy. Thus far, most in vitro and in vivo results show a real potential of FLASH to offer superior normal tissue sparing compared to conventionally delivered radiation. While there are several postulations behind the differential behaviour among normal and cancer cells under FLASH, the full spectra of radiobiological mechanisms are yet to be clarified. Currently the number of devices delivering FLASH dose rate is few and is mainly limited to experimental and modified linear accelerators. Nevertheless, FLASH research is increasing with new developments in all the main areas: radiobiology, technology and clinical research. This paper presents the current status of FLASH radiotherapy with the aforementioned aspects in mind, but also to highlight the existing challenges and future prospects to overcome them.
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Affiliation(s)
- Loredana G Marcu
- Faculty of Informatics & Science, Department of Physics, University of Oradea, 410087 Oradea, Romania
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia
| | - Eva Bezak
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia
- School of Physical Sciences, Department of Physics, University of Adelaide, North Terrace, Adelaide, SA 5005, Australia
| | - Dylan D Peukert
- School of Civil, Environmental & Mining Engineering, University of Adelaide, North Terrace, Adelaide, SA 5005, Australia
- STEM, University of South Australia, Adelaide, SA 5001, Australia
| | - Puthenparampil Wilson
- STEM, University of South Australia, Adelaide, SA 5001, Australia
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, SA 5000, Australia
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Otterlei OM, Indelicato DJ, Toussaint L, Ytre-Hauge KS, Pilskog S, Fjaera LF, Rørvik E, Pettersen HES, Muren LP, Lassen-Ramshad Y, Di Pinto M, Stokkevåg CH. Variation in relative biological effectiveness for cognitive structures in proton therapy of pediatric brain tumors. Acta Oncol 2021; 60:267-274. [PMID: 33131367 DOI: 10.1080/0284186x.2020.1840626] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Clinically, a constant value of 1.1 is used for the relative biological effectiveness (RBE) of protons, whereas in vitro the RBE has been shown to vary depending on physical dose, tissue type, and linear energy transfer (LET). As the LET increases at the distal end of the proton beam, concerns exist for an elevated RBE in normal tissues. The aim of this study was therefore to investigate the heterogeneity of RBE to brain structures associated with cognition (BSCs) in pediatric suprasellar tumors. MATERIAL AND METHODS Intensity-modulated proton therapy (IMPT) plans for 10 pediatric craniopharyngioma patients were re-calculated using 11 phenomenological and two plan-based variable RBE models. Based on LET, tissue dependence and number of data points used to fit the models, the three RBE models considered the most relevant for the studied endpoint were selected. Thirty BSCs were investigated in terms of RBE and dose/volume parameters. RESULTS For a representative patient, the median (range) dose-weighted mean RBE (RBEd) across all BSCs from the plan-based models was among the lowest (1.09 (1.02-1.52) vs. the phenomenological models at 1.21 (0.78-2.24)). Omitting tissue dependency resulted in RBEd at 1.21 (1.04-2.24). Across all patients, the narrower RBE model selection gave median RBEd values from 1.22 to 1.30. CONCLUSION For all BSCs, there was a systematic model-dependent variation in RBEd, mirroring the uncertainty in biological effects of protons. According to a refined selection of in vitro models, the RBE variation across BSCs was in effect underestimated when using a fixed RBE of 1.1.
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Affiliation(s)
| | | | - Laura Toussaint
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | | | - Sara Pilskog
- Department of Physics and Technology, University of Bergen, Bergen, Norway
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | | | - Eivind Rørvik
- Department of Physics and Technology, University of Bergen, Bergen, Norway
| | | | - Ludvig P. Muren
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | | | - Marcos Di Pinto
- Department of Radiation Oncology, University of Florida, Jacksonville, FL, USA
| | - Camilla H. Stokkevåg
- Department of Physics and Technology, University of Bergen, Bergen, Norway
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
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Suckert T, Beyreuther E, Müller J, Azadegan B, Meinhardt M, Raschke F, Bodenstein E, von Neubeck C, Lühr A, Krause M, Dietrich A. Late Side Effects in Normal Mouse Brain Tissue After Proton Irradiation. Front Oncol 2021; 10:598360. [PMID: 33520710 PMCID: PMC7842140 DOI: 10.3389/fonc.2020.598360] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 11/16/2020] [Indexed: 12/16/2022] Open
Abstract
Radiation-induced late side effects such as cognitive decline and normal tissue complications can severely affect quality of life and outcome in long-term survivors of brain tumors. Proton therapy offers a favorable depth-dose deposition with the potential to spare tumor-surrounding normal tissue, thus potentially reducing such side effects. In this study, we describe a preclinical model to reveal underlying biological mechanisms caused by precise high-dose proton irradiation of a brain subvolume. We studied the dose- and time-dependent radiation response of mouse brain tissue, using a high-precision image-guided proton irradiation setup for small animals established at the University Proton Therapy Dresden (UPTD). The right hippocampal area of ten C57BL/6 and ten C3H/He mice was irradiated. Both strains contained four groups (nirradiated = 3, ncontrol = 1) treated with increasing doses (0 Gy, 45 Gy, 65 Gy or 85 Gy and 0 Gy, 40 Gy, 60 Gy or 80 Gy, respectively). Follow-up examinations were performed for up to six months, including longitudinal monitoring of general health status and regular contrast-enhanced magnetic resonance imaging (MRI) of mouse brains. These findings were related to comprehensive histological analysis. In all mice of the highest dose group, first symptoms of blood-brain barrier (BBB) damage appeared one week after irradiation, while a dose-dependent delay in onset was observed for lower doses. MRI contrast agent leakage occurred in the irradiated brain areas and was progressive in the higher dose groups. Mouse health status and survival corresponded to the extent of contrast agent leakage. Histological analysis revealed tissue changes such as vessel abnormalities, gliosis, and granule cell dispersion, which also partly affected the non-irradiated contralateral hippocampus in the higher dose groups. All observed effects depended strongly on the prescribed radiation dose and the outcome, i.e. survival, image changes, and tissue alterations, were very consistent within an experimental dose cohort. The derived dose–response model will determine endpoint-specific dose levels for future experiments and may support generating clinical hypotheses on brain toxicity after proton therapy.
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Affiliation(s)
- Theresa Suckert
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
| | - Elke Beyreuther
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiation Physics, Dresden, Germany
| | - Johannes Müller
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Behnam Azadegan
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,Department of Physics, Hakim Sabzevari University, Sabzevar, Iran
| | - Matthias Meinhardt
- Neuropathology, Institute of Pathology, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Felix Raschke
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Elisabeth Bodenstein
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
| | - Cläre von Neubeck
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,Department of Particle Therapy, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Armin Lühr
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany.,Department of Medical Physics and Radiotherapy, Faculty of Physics, TU Dortmund University, Dortmund, Germany
| | - Mechthild Krause
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Antje Dietrich
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
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Otazo R, Lambin P, Pignol JP, Ladd ME, Schlemmer HP, Baumann M, Hricak H. MRI-guided Radiation Therapy: An Emerging Paradigm in Adaptive Radiation Oncology. Radiology 2020; 298:248-260. [PMID: 33350894 DOI: 10.1148/radiol.2020202747] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Radiation therapy (RT) continues to be one of the mainstays of cancer treatment. Considerable efforts have been recently devoted to integrating MRI into clinical RT planning and monitoring. This integration, known as MRI-guided RT, has been motivated by the superior soft-tissue contrast, organ motion visualization, and ability to monitor tumor and tissue physiologic changes provided by MRI compared with CT. Offline MRI is already used for treatment planning at many institutions. Furthermore, MRI-guided linear accelerator systems, allowing use of MRI during treatment, enable improved adaptation to anatomic changes between RT fractions compared with CT guidance. Efforts are underway to develop real-time MRI-guided intrafraction adaptive RT of tumors affected by motion and MRI-derived biomarkers to monitor treatment response and potentially adapt treatment to physiologic changes. These developments in MRI guidance provide the basis for a paradigm change in treatment planning, monitoring, and adaptation. Key challenges to advancing MRI-guided RT include real-time volumetric anatomic imaging, addressing image distortion because of magnetic field inhomogeneities, reproducible quantitative imaging across different MRI systems, and biologic validation of quantitative imaging. This review describes emerging innovations in offline and online MRI-guided RT, exciting opportunities they offer for advancing research and clinical care, hurdles to be overcome, and the need for multidisciplinary collaboration.
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Affiliation(s)
- Ricardo Otazo
- From the Departments of Medical Physics (R.O.) and Radiology (R.O., H.H.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065; The D-Lab, Department of Precision Medicine, Department of Radiology & Nuclear Medicine, GROW-School for Oncology, Maastricht University Medical Centre, Maastricht, the Netherlands (P.L.); Department of Radiation Oncology, Dalhousie University, Halifax, Canada (J.P.P.); Divisions of Medical Physics in Radiology (M.E.L.), Radiology (H.P.S.), and Radiation Oncology/Radiobiology (M.B.), German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Physics and Astronomy (M.E.L.) and Faculty of Medicine (M.E.L., M.B.), Heidelberg University, Heidelberg, Germany; and OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany (M.B.)
| | - Philippe Lambin
- From the Departments of Medical Physics (R.O.) and Radiology (R.O., H.H.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065; The D-Lab, Department of Precision Medicine, Department of Radiology & Nuclear Medicine, GROW-School for Oncology, Maastricht University Medical Centre, Maastricht, the Netherlands (P.L.); Department of Radiation Oncology, Dalhousie University, Halifax, Canada (J.P.P.); Divisions of Medical Physics in Radiology (M.E.L.), Radiology (H.P.S.), and Radiation Oncology/Radiobiology (M.B.), German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Physics and Astronomy (M.E.L.) and Faculty of Medicine (M.E.L., M.B.), Heidelberg University, Heidelberg, Germany; and OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany (M.B.)
| | - Jean-Philippe Pignol
- From the Departments of Medical Physics (R.O.) and Radiology (R.O., H.H.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065; The D-Lab, Department of Precision Medicine, Department of Radiology & Nuclear Medicine, GROW-School for Oncology, Maastricht University Medical Centre, Maastricht, the Netherlands (P.L.); Department of Radiation Oncology, Dalhousie University, Halifax, Canada (J.P.P.); Divisions of Medical Physics in Radiology (M.E.L.), Radiology (H.P.S.), and Radiation Oncology/Radiobiology (M.B.), German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Physics and Astronomy (M.E.L.) and Faculty of Medicine (M.E.L., M.B.), Heidelberg University, Heidelberg, Germany; and OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany (M.B.)
| | - Mark E Ladd
- From the Departments of Medical Physics (R.O.) and Radiology (R.O., H.H.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065; The D-Lab, Department of Precision Medicine, Department of Radiology & Nuclear Medicine, GROW-School for Oncology, Maastricht University Medical Centre, Maastricht, the Netherlands (P.L.); Department of Radiation Oncology, Dalhousie University, Halifax, Canada (J.P.P.); Divisions of Medical Physics in Radiology (M.E.L.), Radiology (H.P.S.), and Radiation Oncology/Radiobiology (M.B.), German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Physics and Astronomy (M.E.L.) and Faculty of Medicine (M.E.L., M.B.), Heidelberg University, Heidelberg, Germany; and OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany (M.B.)
| | - Heinz-Peter Schlemmer
- From the Departments of Medical Physics (R.O.) and Radiology (R.O., H.H.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065; The D-Lab, Department of Precision Medicine, Department of Radiology & Nuclear Medicine, GROW-School for Oncology, Maastricht University Medical Centre, Maastricht, the Netherlands (P.L.); Department of Radiation Oncology, Dalhousie University, Halifax, Canada (J.P.P.); Divisions of Medical Physics in Radiology (M.E.L.), Radiology (H.P.S.), and Radiation Oncology/Radiobiology (M.B.), German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Physics and Astronomy (M.E.L.) and Faculty of Medicine (M.E.L., M.B.), Heidelberg University, Heidelberg, Germany; and OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany (M.B.)
| | - Michael Baumann
- From the Departments of Medical Physics (R.O.) and Radiology (R.O., H.H.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065; The D-Lab, Department of Precision Medicine, Department of Radiology & Nuclear Medicine, GROW-School for Oncology, Maastricht University Medical Centre, Maastricht, the Netherlands (P.L.); Department of Radiation Oncology, Dalhousie University, Halifax, Canada (J.P.P.); Divisions of Medical Physics in Radiology (M.E.L.), Radiology (H.P.S.), and Radiation Oncology/Radiobiology (M.B.), German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Physics and Astronomy (M.E.L.) and Faculty of Medicine (M.E.L., M.B.), Heidelberg University, Heidelberg, Germany; and OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany (M.B.)
| | - Hedvig Hricak
- From the Departments of Medical Physics (R.O.) and Radiology (R.O., H.H.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065; The D-Lab, Department of Precision Medicine, Department of Radiology & Nuclear Medicine, GROW-School for Oncology, Maastricht University Medical Centre, Maastricht, the Netherlands (P.L.); Department of Radiation Oncology, Dalhousie University, Halifax, Canada (J.P.P.); Divisions of Medical Physics in Radiology (M.E.L.), Radiology (H.P.S.), and Radiation Oncology/Radiobiology (M.B.), German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Physics and Astronomy (M.E.L.) and Faculty of Medicine (M.E.L., M.B.), Heidelberg University, Heidelberg, Germany; and OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany (M.B.)
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Hofmaier J, Dedes G, Carlson DJ, Parodi K, Belka C, Kamp F. Variance-based sensitivity analysis for uncertainties in proton therapy: A framework to assess the effect of simultaneous uncertainties in range, positioning, and RBE model predictions on RBE-weighted dose distributions. Med Phys 2020; 48:805-818. [PMID: 33210739 DOI: 10.1002/mp.14596] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 10/20/2020] [Accepted: 11/11/2020] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Treatment plans in proton therapy are more sensitive to uncertainties than in conventional photon therapy. In addition to setup uncertainties, proton therapy is affected by uncertainties in proton range and relative biological effectiveness (RBE). While to date a constant RBE of 1.1 is commonly assumed, the actual RBE is known to increase toward the distal end of the spread-out Bragg peak. Several models for variable RBE predictions exist. We present a framework to evaluate the combined impact and interactions of setup, range, and RBE uncertainties in a comprehensive, variance-based sensitivity analysis (SA). MATERIAL AND METHODS The variance-based SA requires a large number (104 -105 ) of RBE-weighted dose (RWD) calculations. Based on a particle therapy extension of the research treatment planning system CERR we implemented a fast, graphics processing unit (GPU) accelerated pencil beam modeling of patient and range shifts. For RBE predictions, two biological models were included: The mechanistic repair-misrepair-fixation (RMF) model and the phenomenological Wedenberg model. All input parameters (patient position, proton range, RBE model parameters) are sampled simultaneously within their assumed probability distributions. Statistical formalisms rank the input parameters according to their influence on the overall uncertainty of RBE-weighted dose-volume histogram (RW-DVH) quantiles and the RWD in every voxel, resulting in relative, normalized sensitivity indices (S = 0: noninfluential input, S = 1: only influential input). Results are visualized as RW-DVHs with error bars and sensitivity maps. RESULTS AND CONCLUSIONS The approach is demonstrated for two representative brain tumor cases and a prostate case. The full SA including ∼ 3 × 10 4 RWD calculations took 39, 11, and 55 min, respectively. Range uncertainty was an important contribution to overall uncertainty at the distal end of the target, while the relatively smaller uncertainty inside the target was governed by biological uncertainties. Consequently, the uncertainty of the RW-DVH quantile D98 for the target was governed by range uncertainty while the uncertainty of the mean target dose was dominated by the biological parameters. The SA framework is a powerful and flexible tool to evaluate uncertainty in RWD distributions and DVH quantiles, taking into account physical and RBE uncertainties and their interactions. The additional information might help to prioritize research efforts to reduce physical and RBE uncertainties and could also have implications for future approaches to biologically robust planning and optimization.
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Affiliation(s)
- Jan Hofmaier
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, 81377, Germany
| | - George Dedes
- Department of Medical Physics, Faculty of Physics, LMU Munich, Garching b. Munich, 85748, Germany
| | - David J Carlson
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Katia Parodi
- Department of Medical Physics, Faculty of Physics, LMU Munich, Garching b. Munich, 85748, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, 81377, Germany.,German Cancer Consortium (DKTK), Munich, 81377, Germany
| | - Florian Kamp
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, 81377, Germany
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Iwata H, Shuto T, Kamei S, Omachi K, Moriuchi M, Omachi C, Toshito T, Hashimoto S, Nakajima K, Sugie C, Ogino H, Kai H, Shibamoto Y. Combined effects of cisplatin and photon or proton irradiation in cultured cells: radiosensitization, patterns of cell death and cell cycle distribution. JOURNAL OF RADIATION RESEARCH 2020; 61:832-841. [PMID: 32880637 PMCID: PMC7674701 DOI: 10.1093/jrr/rraa065] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/22/2020] [Accepted: 04/07/2020] [Indexed: 06/11/2023]
Abstract
The purpose of the current study was to investigate the biological effects of protons and photons in combination with cisplatin in cultured cells and elucidate the mechanisms responsible for their combined effects. To evaluate the sensitizing effects of cisplatin against X-rays and proton beams in HSG, EMT6 and V79 cells, the combination index, a simple measure for quantifying synergism, was estimated from cell survival curves using software capable of performing the Monte Carlo calculation. Cell death and apoptosis were assessed using live cell fluorescence imaging. HeLa and HSG cells expressing the fluorescent ubiquitination-based cell cycle indicator system (Fucci) were irradiated with X-rays and protons with cisplatin. Red and green fluorescence in the G1 and S/G2/M phases, respectively, were evaluated and changes in the cell cycle were assessed. The sensitizing effects of ≥1.5 μM cisplatin were observed for both X-ray and proton irradiation (P < 0.05). In the three cell lines, the average combination index was 0.82-1.00 for X-rays and 0.73-0.89 for protons, indicating stronger effects for protons. In time-lapse imaging, apoptosis markedly increased in the groups receiving ≥1.5 μM cisplatin + protons. The percentage of green S/G2/M phase cells at that time was higher when cisplatin was combined with proton beams than with X-rays (P < 0.05), suggesting more significant G2 arrest. Proton therapy plus ≥1.5 μM cisplatin is considered to be very effective. When combined with cisplatin, proton therapy appeared to induce greater apoptotic cell death and G2 arrest, which may partly account for the difference observed in the combined effects.
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Affiliation(s)
- Hiromitsu Iwata
- Corresponding author. Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City West Medical Center, Nagoya, Japan, 1-1-1 Hirate-cho, Kita-ku, Nagoya 462-8508, Japan. Tel.: (+81) 52-991-8577; Fax: (+81) 52-991-8599;
| | - Tsuyoshi Shuto
- Department of Molecular Medicine, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-honmachi, Chuo-ku, Kumamoto, 862-0973, Japan
| | - Shunsuke Kamei
- Department of Molecular Medicine, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-honmachi, Chuo-ku, Kumamoto, 862-0973, Japan
| | - Kohei Omachi
- Department of Molecular Medicine, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-honmachi, Chuo-ku, Kumamoto, 862-0973, Japan
| | - Masataka Moriuchi
- Department of Molecular Medicine, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-honmachi, Chuo-ku, Kumamoto, 862-0973, Japan
| | - Chihiro Omachi
- Department of Proton Therapy Physics, Nagoya Proton Therapy Center, 1-1-1 Hirate-cho, Kita-ku, Nagoya 462-8508, Japan
| | - Toshiyuki Toshito
- Department of Proton Therapy Physics, Nagoya Proton Therapy Center, 1-1-1 Hirate-cho, Kita-ku, Nagoya 462-8508, Japan
| | - Shingo Hashimoto
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
| | - Koichiro Nakajima
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City West Medical Center, 1-1-1 Hirate-cho, Kita-ku, Nagoya 462-8508, Japan
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
| | - Chikao Sugie
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
| | - Hiroyuki Ogino
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City West Medical Center, 1-1-1 Hirate-cho, Kita-ku, Nagoya 462-8508, Japan
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
| | - Hirofumi Kai
- Department of Molecular Medicine, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-honmachi, Chuo-ku, Kumamoto, 862-0973, Japan
| | - Yuta Shibamoto
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
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45
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Hahn C, Eulitz J, Peters N, Wohlfahrt P, Enghardt W, Richter C, Lühr A. Impact of range uncertainty on clinical distributions of linear energy transfer and biological effectiveness in proton therapy. Med Phys 2020; 47:6151-6162. [PMID: 33118161 DOI: 10.1002/mp.14560] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/01/2020] [Accepted: 10/20/2020] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Increased radiation response after proton irradiation, such as late radiation-induced toxicity, is determined by high dose and elevated linear energy transfer (LET). Steep dose-averaged LET (LETd ) gradients and elevated LETd occur at the end of proton range and might be particularly sensitive to uncertainties in range prediction. Therefore, this study quantified LETd distributions and the impact of range uncertainty in robust dose-optimized proton treatment plans and assessed the biological effect in normal tissues and tumors of patients. METHODS For each of six cancer patients (two brain, head-and-neck, and prostate), two nominal treatment plans were robustly dose optimized using single- and multi-field optimization, respectively. For each plan, two additional scenarios with ±3.5% range deviation relative to the nominal plan were derived by global rescaling of stopping-power ratios. Dose and LETd distributions were calculated for each scenario using the beam parameters of the corresponding nominal plan. The variability in relative biological effectiveness (RBE) and probability of late radiation-induced brain toxicity (PIC ) was assessed. RESULTS The optimization technique (single- vs multi-field) had a negligible impact on the LETd distributions in the clinical target volume (CTV) and in most organs at risk (OARs). LETd distributions in the CTV were rather homogeneous with arithmetic mean of LETd below 3.2 keV/µm and robust against range deviations. The RBE variability within the CTV induced by range uncertainty was small (≤0.05, 95% confidence interval). In OARs, LETd hotspots (>7 keV/µm) occurred and LETd distributions were inhomogeneous and sensitive to range deviations. LETd hotspots and the impact of range deviations were most prominent in OARs of brain tumor patients which translated in RBE values exceeding 1.1 in all brain OARs. The near-maximum predicted PIC in healthy brain tissue of brain tumor patients was smaller than 5% and occurred adjacent to the CTV. Range deviations induced absolute differences in PIC up to 1.2%. CONCLUSIONS Robust dose optimization generates LETd distributions in the target volume robust against range deviations. The current findings support using a constant RBE within the CTV. The impact of range deviations on the considered probability of late radiation-induced toxicity in brain tissue was limited for robust dose-optimized treatment plans. Incorporation of LETd in robust optimization frameworks may further reduce uncertainty related to the RBE-weighted dose estimation in normal tissues.
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Affiliation(s)
- Christian Hahn
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Department of Medical Physics and Radiotherapy, Faculty of Physics, TU Dortmund University, Dortmund, Germany
| | - Jan Eulitz
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Nils Peters
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Patrick Wohlfahrt
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Wolfgang Enghardt
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany.,German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Christian Richter
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany.,German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Armin Lühr
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,Department of Medical Physics and Radiotherapy, Faculty of Physics, TU Dortmund University, Dortmund, Germany.,Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany.,German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
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Obrador E, Salvador R, Villaescusa JI, Soriano JM, Estrela JM, Montoro A. Radioprotection and Radiomitigation: From the Bench to Clinical Practice. Biomedicines 2020; 8:E461. [PMID: 33142986 PMCID: PMC7692399 DOI: 10.3390/biomedicines8110461] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 10/27/2020] [Accepted: 10/29/2020] [Indexed: 02/07/2023] Open
Abstract
The development of protective agents against harmful radiations has been a subject of investigation for decades. However, effective (ideal) radioprotectors and radiomitigators remain an unsolved problem. Because ionizing radiation-induced cellular damage is primarily attributed to free radicals, radical scavengers are promising as potential radioprotectors. Early development of such agents focused on thiol synthetic compounds, e.g., amifostine (2-(3-aminopropylamino) ethylsulfanylphosphonic acid), approved as a radioprotector by the Food and Drug Administration (FDA, USA) but for limited clinical indications and not for nonclinical uses. To date, no new chemical entity has been approved by the FDA as a radiation countermeasure for acute radiation syndrome (ARS). All FDA-approved radiation countermeasures (filgrastim, a recombinant DNA form of the naturally occurring granulocyte colony-stimulating factor, G-CSF; pegfilgrastim, a PEGylated form of the recombinant human G-CSF; sargramostim, a recombinant granulocyte macrophage colony-stimulating factor, GM-CSF) are classified as radiomitigators. No radioprotector that can be administered prior to exposure has been approved for ARS. This differentiates radioprotectors (reduce direct damage caused by radiation) and radiomitigators (minimize toxicity even after radiation has been delivered). Molecules under development with the aim of reaching clinical practice and other nonclinical applications are discussed. Assays to evaluate the biological effects of ionizing radiations are also analyzed.
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Affiliation(s)
- Elena Obrador
- Department of Physiology, Faculty of Medicine and Odontology, University of Valencia, 46010 Valencia, Spain; (E.O.); (R.S.); (J.M.E.)
| | - Rosario Salvador
- Department of Physiology, Faculty of Medicine and Odontology, University of Valencia, 46010 Valencia, Spain; (E.O.); (R.S.); (J.M.E.)
| | - Juan I. Villaescusa
- Service of Radiological Protection, Clinical Area of Medical Image, La Fe University Hospital, 46026 Valencia, Spain;
- Biomedical Imaging Research Group GIBI230, Health Research Institute (IISLaFe), La Fe University Hospital, 46026 Valencia, Spain
| | - José M. Soriano
- Food & Health Lab, Institute of Materials Science, University of Valencia, 46980 Valencia, Spain;
- Joint Research Unit in Endocrinology, Nutrition and Clinical Dietetics, University of Valencia-Health Research Institute IISLaFe, 46026 Valencia, Spain
| | - José M. Estrela
- Department of Physiology, Faculty of Medicine and Odontology, University of Valencia, 46010 Valencia, Spain; (E.O.); (R.S.); (J.M.E.)
| | - Alegría Montoro
- Service of Radiological Protection, Clinical Area of Medical Image, La Fe University Hospital, 46026 Valencia, Spain;
- Biomedical Imaging Research Group GIBI230, Health Research Institute (IISLaFe), La Fe University Hospital, 46026 Valencia, Spain
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47
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Sertorio M, Nowrouzi A, Akbarpour M, Chetal K, Salomonis N, Brons S, Mascia A, Ionascu D, McCauley S, Kupneski T, Köthe A, Debus J, Perentesis JP, Abdollahi A, Zheng Y, Wells SI. Differential transcriptome response to proton versus X-ray radiation reveals novel candidate targets for combinatorial PT therapy in lymphoma. Radiother Oncol 2020; 155:293-303. [PMID: 33096164 DOI: 10.1016/j.radonc.2020.10.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 10/09/2020] [Accepted: 10/15/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Knowledge of biological responses to proton therapy (PT) in comparison to X-ray remains in its infancy. Identification of PT specific molecular signals is an important opportunity for the discovery of biomarkers and synergistic drugs to advance clinical application. Since PT is used for the treatment of lymphoma, we report here transcriptomic responses of lymphoma cell lines to PT vs X-ray and identify potential therapeutic targets. MATERIALS AND METHODS Two lymphoma cell lines of human (BL41) and murine (J3D) origin were irradiated by X-ray and PT. Differential transcriptome regulation was quantified by RNA sequencing for each radiation type at 12 hours post irradiation. Gene-set enrichment analysis revealed deregulated molecular pathways and putative targets for lymphoma cell sensitization to PT. RESULTS Transcriptomic gene set enrichment analyses uncovered pathways that contribute to the unfolded protein response (UPR) and mitochondrial transport. Functional validation at multiple time points demonstrated increased UPR activation and decreased protein translation, perhaps due to increased oxidative stress and oxidative protein damage after PT. PPARgamma was identified as a potential regulator of the PT transcriptomic response. Inhibition of PPARgamma by two compounds, T0070907 and SR2595, sensitized lymphoma cells to PT. CONCLUSIONS Proton vs X-ray radiation leads to the transcriptional regulation of a specific subset of genes in line with diminished protein translation and UPR activation that may be due to oxidative stress. This study demonstrates that different radiation qualities trigger distinct cellular responses in lymphoma cells, and identifies PPARgamma inhibition as a potential strategy for the sensitization of lymphoma to PT.
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Affiliation(s)
- Mathieu Sertorio
- Division of Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA.
| | - Ali Nowrouzi
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital (UKHD), Germany; German Cancer Consortium (DKTK) Core Center, Clinical Cooperation Units (CCU) Translational Radiation Oncology and Radiation Oncology, National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), German Cancer Research Center (DKFZ) and Heidelberg University Hospital (UKHD), Germany; Division of Molecular and Translational Radiation Oncology, Heidelberg Medical Faculty (HDMF), Heidelberg University, Germany
| | - Mahdi Akbarpour
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital (UKHD), Germany; German Cancer Consortium (DKTK) Core Center, Clinical Cooperation Units (CCU) Translational Radiation Oncology and Radiation Oncology, National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), German Cancer Research Center (DKFZ) and Heidelberg University Hospital (UKHD), Germany; Division of Molecular and Translational Radiation Oncology, Heidelberg Medical Faculty (HDMF), Heidelberg University, Germany
| | - Kashish Chetal
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Nathan Salomonis
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA
| | - Stephan Brons
- Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), German Cancer Research Center (DKFZ) and Heidelberg University Hospital (UKHD), Germany
| | - Anthony Mascia
- Department of Radiation Oncology, University of Cincinnati College of Medicine, USA
| | - Dan Ionascu
- Department of Radiation Oncology, University of Cincinnati College of Medicine, USA
| | - Shelby McCauley
- Division of Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Taylor Kupneski
- Division of Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Andreas Köthe
- Division of Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Jürgen Debus
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital (UKHD), Germany; German Cancer Consortium (DKTK) Core Center, Clinical Cooperation Units (CCU) Translational Radiation Oncology and Radiation Oncology, National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), German Cancer Research Center (DKFZ) and Heidelberg University Hospital (UKHD), Germany; Division of Molecular and Translational Radiation Oncology, Heidelberg Medical Faculty (HDMF), Heidelberg University, Germany
| | - John P Perentesis
- Division of Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA
| | - Amir Abdollahi
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital (UKHD), Germany; German Cancer Consortium (DKTK) Core Center, Clinical Cooperation Units (CCU) Translational Radiation Oncology and Radiation Oncology, National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), German Cancer Research Center (DKFZ) and Heidelberg University Hospital (UKHD), Germany; Division of Molecular and Translational Radiation Oncology, Heidelberg Medical Faculty (HDMF), Heidelberg University, Germany
| | - Yi Zheng
- Division of Experimental Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA.
| | - Susanne I Wells
- Division of Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA.
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Abstract
Objective Particle radiobiology has contributed new understanding of radiation safety and underlying mechanisms of action to radiation oncology for the treatment of cancer, and to planning of radiation protection for space travel. This manuscript will highlight the significance of precise physical and biologically effective dosimetry to this translational research for the benefit of human health. This review provides a brief snapshot of the evolving scientific basis for, and the complex current global status, and remaining challenges of hadron therapy for the treatment of cancer. The need for particle radiobiology for risk planning in return missions to the Moon, and exploratory deep-space missions to Mars and beyond are also discussed. Methods Key lessons learned are summarized from an impressive collective literature published by an international cadre of multidisciplinary experts in particle physics, radiation chemistry, medical physics of imaging and treatment planning, molecular, cellular, tissue radiobiology, biology of microgravity and other stressors, theoretical modeling of biophysical data, and clinical results with accelerator-produced particle beams. Results Research pioneers, many of whom were Nobel laureates, led the world in the discovery of ionizing radiations originating from the Earth and the Cosmos. Six radiation pioneers led the way to hadron therapy and the study of charged particles encountered in outer space travel. Worldwide about 250,000 patients have been treated for cancer, or other lesions such as arteriovenous malformations in the brain between 1954 and 2019 with charged particle radiotherapy, also known as hadron therapy. The majority of these patients (213,000) were treated with proton beams, but approximately 32,000 were treated with carbon ion radiotherapy. There are 3500 patients who have been treated with helium, pions, neon or other ions. There are currently 82 facilities operating to provide ion beam clinical treatments. Of these, only 13 facilities located in Asia and Europe are providing carbon ion beams for preclinical, clinical, and space research. There are also numerous particle physics accelerators worldwide capable of producing ion beams for research, but not currently focused on treating patients with ion beam therapy but are potentially available for preclinical and space research. Approximately, more than 550 individuals have traveled into Lower Earth Orbit (LEO) and beyond and returned to Earth. Conclusion Charged particle therapy with controlled beams of protons and carbon ions have significantly impacted targeted cancer therapy, eradicated tumors while sparing normal tissue toxicities, and reduced human suffering. These modalities still require further optimization and technical refinements to reduce cost but should be made available to everyone in need worldwide. The exploration of our Universe in space travel poses the potential risk of exposure to uncontrolled charged particles. However, approaches to shield and provide countermeasures to these potential radiation hazards in LEO have allowed an amazing number of discoveries currently without significant life-threatening medical consequences. More basic research with components of the Galactic Cosmic Radiation field are still required to assure safety involving space radiations and combined stressors with microgravity for exploratory deep space travel. Advances in knowledge The collective knowledge garnered from the wealth of available published evidence obtained prior to particle radiation therapy, or to space flight, and the additional data gleaned from implementing both endeavors has provided many opportunities for heavy ions to promote human health.
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Baumann M, Ebert N, Kurth I, Bacchus C, Overgaard J. What will radiation oncology look like in 2050? A look at a changing professional landscape in Europe and beyond. Mol Oncol 2020; 14:1577-1585. [PMID: 32463984 PMCID: PMC7332208 DOI: 10.1002/1878-0261.12731] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 05/25/2020] [Indexed: 12/28/2022] Open
Abstract
The number of newly diagnosed cancers per year is predicted to almost double in the next two decades worldwide, and it remains unclear if and when this alarming trend will level off or even reverse. As such, cancer is very likely to continue to pose a major threat to human health. Radiation oncology is an indispensable pillar of cancer treatment and a well‐developed discipline. Nevertheless, key trends in cancer research and care, including improved primary prevention, early detection, integrated multidisciplinary approaches, personalized strategies at all levels of care, value‐based assessments of healthcare systems, and global health perspectives, will all shape the future of radiation oncology. Broader scientific advances, such as rapid progress in digitization, automation, and in our biological understanding of cancer, as well as the wider societal view of healthcare systems will also influence radiation oncology and how it is practiced. To stimulate a proactive discussion on how to adapt and reshape our discipline, this review provides some predictions on what the role and practice of radiation oncology might look like in 30 years’ time.
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Affiliation(s)
- Michael Baumann
- German Cancer Research Center (DKFZ), Heidelberg, Germany.,OncoRay-National Center for Radiation Research in Oncology, Medical Faculty and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany.,Ruprecht-Karls-University, Heidelberg, Germany
| | - Nadja Ebert
- German Cancer Research Center (DKFZ), Heidelberg, Germany.,OncoRay-National Center for Radiation Research in Oncology, Medical Faculty and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Ina Kurth
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Carol Bacchus
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
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van de Water S, Belosi MF, Albertini F, Winterhalter C, Weber DC, Lomax AJ. Shortening delivery times for intensity-modulated proton therapy by reducing the number of proton spots: an experimental verification. Phys Med Biol 2020; 65:095008. [PMID: 32155594 DOI: 10.1088/1361-6560/ab7e7c] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Delivery times of intensity-modulated proton therapy (IMPT) can be shortened by reducing the number of spots in the treatment plan, but this may affect clinical plan delivery. Here, we assess the experimental deliverability, accuracy and time reduction of spot-reduced treatment planning for a clinical case, as well as its robustness. For a single head-and-neck cancer patient, a spot-reduced plan was generated and compared with the conventional clinical plan. The number of proton spots was reduced using the iterative 'pencil beam resampling' technique. This involves repeated inverse optimization, while adding in each iteration a small sample of randomly selected spots and subsequently excluding low-weighted spots until plan quality deteriorates. Field setup was identical for both plans and comparable dosimetric quality was a prerequisite. Both IMPT plans were delivered on PSI Gantry 2 and measured in water, while delivery log-files were used to extract delivery times and reconstruct the delivered dose via Monte-Carlo dose calculations. In addition, robustness simulations were performed to assess sensitivity to machine inaccuracies and errors in patient setup and proton range. The number of spots was reduced by 96% (from 33 855 to 1510 in total) without compromising plan quality. The spot-reduced plan was deliverable on our gantry in standard clinical mode and resulted in average delivery times per field being shortened by 46% (from 51.2 to 27.6 s). For both plans, differences between measured and calculated dose were within clinical tolerance for patient-specific verifications and Monte-Carlo dose reconstructions were in accordance with clinical experience. The spot-reduced plan was slightly more sensitive to machine inaccuracies, but more robust against setup and range errors. In conclusion, for an example head-and-neck case, spot-reduced IMPT planning provided a deliverable treatment plan and enabled considerable shortening of the delivery time (∼50%) without compromising plan quality or delivery accuracy, and without substantially affecting robustness.
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Affiliation(s)
- Steven van de Water
- Center for Proton Therapy, Paul Scherrer Institute, Villigen PSI, Switzerland
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