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Eichkorn T, Lischalk JW, Schwarz R, Bauer L, Deng M, Regnery S, Jungk C, Hörner-Rieber J, Herfarth K, König L, Debus J. Radiation-Induced Cerebral Contrast Enhancements Strongly Share Ischemic Stroke Risk Factors. Int J Radiat Oncol Biol Phys 2024; 118:1192-1205. [PMID: 38237810 DOI: 10.1016/j.ijrobp.2023.12.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 12/12/2023] [Accepted: 12/31/2023] [Indexed: 03/18/2024]
Abstract
PURPOSE Radiation-induced cerebral contrast enhancements (RICE) are frequent after photon and particularly proton radiation therapy and are associated with a significant risk for neurologic morbidity. Nevertheless, risk factors are poorly understood. A more robust understanding of RICE risk factors is crucial to improve management and offer adaptive therapy at the outset and during follow-up. METHODS AND MATERIALS We analyzed the comorbidities in detail of 190 consecutive adult patients treated at a single European national comprehensive cancer center with proton radiation therapy (54 Gy relative biological effectiveness) for LGG from 2010 to 2020 who were followed with serial clinical examinations and magnetic resonance imaging for a median 5.6 years. RESULTS Classical vascular risk factors including age (≥50 vs <50 years: 1.6-fold; P = .0024), hypertension (2.7-fold; P = .00012), and diabetes (11.7-fold; P = .0066) were observed more frequently in the cohort that developed RICE. Dyslipidemia (2.1-fold), being overweight (2.0-fold), and smoking (2.6-fold), as well as history of previous stroke (1.7-fold), were also more frequently observed in the RICE cohort, although these factors did not reach the threshold for significance. Multivariable regression modeling supported the influence of age (P = .05), arterial hypertension (P = .01), and potentially male sex (P = .02), diabetes (P = .0008), and smoking (P = .001) on RICE occurrence over time, independent of each other and further vascular risk factors. If RICE occurred, bevacizumab treatment was 2-fold more frequently needed in the cohort with vascular risk factors, but RICE long-term prognosis did not differ between the RICE subcohorts with and without vascular risk factors. CONCLUSIONS This is the first report in the literature demonstrating that RICE strongly shares vascular risk factors with ischemic stroke, which further enhances the nebulous understanding of the multifactorial pathophysiology of RICE. Classical vascular risk factors, especially age, hypertension, and diabetes, clearly correlated independently with RICE risk. Risk-adapted screening and management for RICE can be directly derived from these data to assist in clinical management.
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Affiliation(s)
- Tanja Eichkorn
- 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.
| | - Jonathan W Lischalk
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University Langone Health at Long Island, New York, New York
| | - Robert Schwarz
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Lena Bauer
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Maximilian Deng
- 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
| | - Sebastian Regnery
- 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
| | - Christine Jungk
- National Center for Tumor Diseases (NCT), Heidelberg, Germany; Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Juliane Hörner-Rieber
- 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; Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 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
| | - Laila König
- 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; Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany; German Cancer Consortium (DKTK), Partner Site Heidelberg, Heidelberg, Germany
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Quashie EE, Li XA, Prior P, Awan M, Schultz C, Tai A. Obtaining organ-specific radiobiological parameters from clinical data for radiation therapy planning of head and neck cancers. Phys Med Biol 2023; 68:245015. [PMID: 37903437 DOI: 10.1088/1361-6560/ad07f5] [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: 06/20/2023] [Accepted: 10/30/2023] [Indexed: 11/01/2023]
Abstract
Objective.Different radiation therapy (RT) strategies, e.g. conventional fractionation RT (CFRT), hypofractionation RT (HFRT), stereotactic body RT (SBRT), adaptive RT, and re-irradiation are often used to treat head and neck (HN) cancers. Combining and/or comparing these strategies requires calculating biological effective dose (BED). The purpose of this study is to develop a practical process to estimate organ-specific radiobiologic model parameters that may be used for BED calculations in individualized RT planning for HN cancers.Approach.Clinical dose constraint data for CFRT, HFRT and SBRT for 5 organs at risk (OARs) namely spinal cord, brainstem, brachial plexus, optic pathway, and esophagus obtained from literature were analyzed. These clinical data correspond to a particular endpoint. The linear-quadratic (LQ) and linear-quadratic-linear (LQ-L) models were used to fit these clinical data and extract relevant model parameters (alpha/beta ratio, gamma/alpha,dTand BED) from the iso-effective curve. The dose constraints in terms of equivalent physical dose in 2 Gy-fraction (EQD2) were calculated using the obtained parameters.Main results.The LQ-L and LQ models fitted clinical data well from the CFRT to SBRT with the LQ-L representing a better fit for most of the OARs. The alpha/beta values for LQ-L (LQ) were found to be 2.72 (2.11) Gy, 0.55 (0.30) Gy, 2.82 (2.90) Gy, 6.57 (3.86) Gy, 5.38 (4.71) Gy, and the dose constraint EQD2 were 55.91 (54.90) Gy, 57.35 (56.79) Gy, 57.54 (56.35) Gy, 60.13 (59.72) Gy and 65.66 (64.50) Gy for spinal cord, optic pathway, brainstem, brachial plexus, and esophagus, respectively. Additional two LQ-L parametersdTwere 5.24 Gy, 5.09 Gy, 7.00 Gy, 5.23 Gy, and 6.16 Gy, and gamma/alpha were 7.91, 34.02, 8.67, 5.62 and 4.95.Significance.A practical process was developed to extract organ-specific radiobiological model parameters from clinical data. The obtained parameters can be used for biologically based radiation planning such as calculating dose constraints of different fractionation regimens.
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Affiliation(s)
- Edwin E Quashie
- Department of Radiation Oncology, Medical College of Wisconsin, WI 53226, United States of America
- Department of Radiation Oncology, Brown University School of Medicine, Providence, RI 02903, United States of America
- Department of Radiation Oncology, Rhode Island Hospital, Providence, RI 02903, United States of America
| | - X Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, WI 53226, United States of America
| | - Phillip Prior
- Department of Radiation Oncology, Medical College of Wisconsin, WI 53226, United States of America
| | - Musaddiq Awan
- Department of Radiation Oncology, Medical College of Wisconsin, WI 53226, United States of America
| | - Christopher Schultz
- Department of Radiation Oncology, Medical College of Wisconsin, WI 53226, United States of America
| | - An Tai
- Department of Radiation Oncology, Medical College of Wisconsin, WI 53226, United States of America
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3
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Holtzman AL, Dagan R, Mendenhall WM. Proton Radiotherapy for Skull-Base Malignancies. Oral Maxillofac Surg Clin North Am 2023:S1042-3699(23)00005-5. [PMID: 37005171 DOI: 10.1016/j.coms.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Abstract
Proton therapy (PT) is a form of highly conformal external-beam radiotherapy used to mitigate acute and late effects following radiotherapy. Indications for treatment include both benign and malignant skull-base and central nervous system pathologies. Studies have demonstrated that PT shows promising results in minimizing neurocognitive decline and reducing second malignancies with low rates of central nervous system necrosis. Future directions and advances in biologic optimization may provide additional benefits beyond the physical properties of particle dosimetry.
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Affiliation(s)
- Adam L Holtzman
- Department of Radiation Oncology, University of Florida College of Medicine, 2015 North Jefferson Street, Jacksonville, FL 32206, USA.
| | - Roi Dagan
- Department of Radiation Oncology, University of Florida College of Medicine, 2015 North Jefferson Street, Jacksonville, FL 32206, USA
| | - William M Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, 2015 North Jefferson Street, Jacksonville, FL 32206, USA
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Dumot C, Pikis S, Mantziaris G, Xu Z, Dayawansa S, Anand RK, Nabeel AM, Sheehan D, Sheehan K, Reda WA, Tawadros SR, Karim KA, El-Shehaby AMN, Eldin RME, Peker S, Samanci Y, Kaisman-Elbaz T, Speckter H, Hernández W, Isidor J, Tripathi M, Madan R, Zacharia BE, Daggubati LC, Moreno NM, Álvarez RM, Langlois AM, Mathieu D, Deibert CP, Sudhakar VR, Cifarelli CP, Icaza DA, Cifarelli DT, Wei Z, Niranjan A, Barnett GH, Lunsford LD, Bowden GN, Sheehan JP. Stereotactic radiosurgery for Koos grade IV vestibular schwannoma in patients ≥ 65 years old: a multi-institutional retrospective study. Acta Neurochir (Wien) 2023; 165:211-220. [PMID: 36543963 DOI: 10.1007/s00701-022-05454-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Surgery is the preferred treatment for large vestibular schwannomas (VS). Good tumor control and cranial nerve outcomes were described in selected Koos IV VS after single-session stereotactic radiosurgery (SRS), but outcomes in elderly patients have never been specifically studied. The aim of this study is to report clinical and radiological outcomes after single-session SRS for Koos IV VS in patients ≥ 65 years old. METHOD This multicenter, retrospective study included patients ≥ 65 years old, treated with primary, single-session SRS for a Koos IV VS, and at least 12 months of follow-up. Patients with life-threatening or incapacitating symptoms were excluded. Tumor control rate, hearing, trigeminal, and facial nerve function were studied at last follow-up. RESULTS One-hundred and fifty patients (median age of 71.0 (IQR 9.0) years old with a median tumor volume of 8.3 cc (IQR 4.4)) were included. The median prescription dose was 12.0 Gy (IQR 1.4). The local tumor control rate was 96.0% and 86.2% at 5 and 10 years, respectively. Early tumor expansion occurred in 6.7% and was symptomatic in 40% of cases. A serviceable hearing was present in 16.1% prior to SRS and in 7.4% at a last follow-up of 46.5 months (IQR 55.8). The actuarial serviceable hearing preservation rate was 69.3% and 50.9% at 5 and 10 years, respectively. Facial nerve function preservation or improvement rates at 5 and 10 years were 98.7% and 91.0%, respectively. At last follow-up, the trigeminal nerve function was improved in 14.0%, stable in 80.7%, and worsened in 5.3% of the patients. ARE were noted in 12.7%. New hydrocephalus was seen in 8.0% of patients. CONCLUSION SRS can be a safe alternative to surgery for selected Koos IV VS in patients ≥ 65 years old. Further follow-up is warranted.
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Affiliation(s)
- Chloe Dumot
- Department of Neurological Surgery, University of Virginia Health System, 1215 Leet Street, P.O. Box 800742, Charlottesville, VA, 22908-0742, USA.,Department of Neurological Surgery, Hospices Civils de Lyon, Lyon, France
| | - Stylianos Pikis
- Department of Neurological Surgery, University of Virginia Health System, 1215 Leet Street, P.O. Box 800742, Charlottesville, VA, 22908-0742, USA
| | - Georgios Mantziaris
- Department of Neurological Surgery, University of Virginia Health System, 1215 Leet Street, P.O. Box 800742, Charlottesville, VA, 22908-0742, USA
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia Health System, 1215 Leet Street, P.O. Box 800742, Charlottesville, VA, 22908-0742, USA
| | - Sam Dayawansa
- Department of Neurological Surgery, University of Virginia Health System, 1215 Leet Street, P.O. Box 800742, Charlottesville, VA, 22908-0742, USA
| | - Rithika Kormath Anand
- Department of Neurological Surgery, University of Virginia Health System, 1215 Leet Street, P.O. Box 800742, Charlottesville, VA, 22908-0742, USA
| | - Ahmed M Nabeel
- Gamma Knife Center Cairo, Nasser Institute Cairo, Cairo, Egypt.,Neurosurgery Department, Faculty of Medecine, Benha University, Qalubya, Egypt
| | - Darrah Sheehan
- Department of Neurological Surgery, University of Virginia Health System, 1215 Leet Street, P.O. Box 800742, Charlottesville, VA, 22908-0742, USA
| | - Kimball Sheehan
- Department of Neurological Surgery, University of Virginia Health System, 1215 Leet Street, P.O. Box 800742, Charlottesville, VA, 22908-0742, USA
| | - Wael A Reda
- Gamma Knife Center Cairo, Nasser Institute Cairo, Cairo, Egypt.,Departments of Neurosurgery and Clinical Oncology, Faculty of Medeine, Ain Shams University, Cairo, Egypt
| | - Sameh R Tawadros
- Gamma Knife Center Cairo, Nasser Institute Cairo, Cairo, Egypt.,Departments of Neurosurgery and Clinical Oncology, Faculty of Medeine, Ain Shams University, Cairo, Egypt
| | - Khaled Abdel Karim
- Gamma Knife Center Cairo, Nasser Institute Cairo, Cairo, Egypt.,Departments of Neurosurgery and Clinical Oncology, Faculty of Medeine, Ain Shams University, Cairo, Egypt
| | - Amr M N El-Shehaby
- Gamma Knife Center Cairo, Nasser Institute Cairo, Cairo, Egypt.,Departments of Neurosurgery and Clinical Oncology, Faculty of Medeine, Ain Shams University, Cairo, Egypt
| | - Reem M Emad Eldin
- Gamma Knife Center Cairo, Nasser Institute Cairo, Cairo, Egypt.,Department of Radiation Oncology, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Selcuk Peker
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Yavuz Samanci
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Tehila Kaisman-Elbaz
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Herwin Speckter
- Department of Radiology and Dominican Gamma Knife Center, CEDIMAT, Santo Domingo, Dominican Republic
| | - Wenceslao Hernández
- Department of Radiology and Dominican Gamma Knife Center, CEDIMAT, Santo Domingo, Dominican Republic
| | - Julio Isidor
- Department of Radiology and Dominican Gamma Knife Center, CEDIMAT, Santo Domingo, Dominican Republic
| | - Manjul Tripathi
- Departments of Neurosurgery and Radiation Therapy, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Renu Madan
- Departments of Neurosurgery and Radiation Therapy, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Brad E Zacharia
- Department of Neurosurgery, Penn State Health-Hershey Medical Center, Hershey, PA, USA
| | - Lekhaj C Daggubati
- Department of Neurosurgery, Penn State Health-Hershey Medical Center, Hershey, PA, USA
| | - Nuria Martínez Moreno
- Department of Neurosurgery, Penn State Health-Hershey Medical Center, Hershey, PA, USA
| | | | - Anne-Marie Langlois
- Division of Neurosurgery, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, QC, Canada
| | - David Mathieu
- Division of Neurosurgery, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, QC, Canada
| | | | - Vivek R Sudhakar
- Departments of Neurosurgery and Radiation Oncology, West Virginia University, Morgantown, WV, USA
| | - Christopher P Cifarelli
- Departments of Neurosurgery and Radiation Oncology, West Virginia University, Morgantown, WV, USA
| | - Denisse Arteaga Icaza
- Departments of Neurosurgery and Radiation Oncology, West Virginia University, Morgantown, WV, USA
| | - Daniel T Cifarelli
- Departments of Neurosurgery and Radiation Oncology, West Virginia University, Morgantown, WV, USA
| | - Zhishuo Wei
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ajay Niranjan
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Gene H Barnett
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - L Dade Lunsford
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Greg N Bowden
- Department of Neurosurgery, University of Alberta, Edmonton, AB, Canada
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, 1215 Leet Street, P.O. Box 800742, Charlottesville, VA, 22908-0742, USA.
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5
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Holtzman AL, Rutenberg MS, De Leo AN, Rao D, Patel J, Morris CG, Indelicato DJ, Mendenhall WM. The incidence of brainstem toxicity following high-dose conformal proton therapy for adult skull-base malignancies. Acta Oncol 2022; 61:1026-1031. [PMID: 35897132 DOI: 10.1080/0284186x.2022.2101900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Dose escalation for skull-based malignancies often presents risks to critical adjacent neural structures, including the brainstem. We report the incidence of brainstem toxicity following fractionated high-dose conformal proton therapy and associated dosimetric parameters. MATERIAL AND METHODS We performed a single-institution review of patients with skull-base chordoma or chondrosarcoma who were treated with proton therapy between February 2007 and January 2020 on a prospective outcomes-tracking protocol. The primary endpoint was grade ≥2 brainstem toxicity. No patients received concurrent chemotherapy, and brainstem toxicity was censored for analysis if it coincided with local disease progression. RESULTS We analyzed 163 patients who received a minimum of 45 GyRBE to 0.03 cm3 of the brainstem. Patients were treated to a median total dose of 73.8 (range 64.5-74.4) GyRBE at 1.8 GyRBE per fraction with 17 patients undergoing twice-daily treatment at 1.2 GyRBE per fraction. With a median follow-up of 4 years, the 5-year cumulative incidence of grade ≥2 brainstem injury was 1.3% (95% CI 0.25-4.3%). There was one grade 2, one grade 3, and no grade 4 or 5 events, with all patients recovering function with medical management. CONCLUSION In delivering curative-intent radiotherapy for skull-base chordoma and chondrosarcoma in adults, small volumes of the brainstem can safely receive at least 64 GyRBE with minimal risk of serious brainstem injury.
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Affiliation(s)
- Adam L Holtzman
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | | | - Alexandra N De Leo
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Dinesh Rao
- Department of Radiology, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Jeet Patel
- Department of Radiology, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - William M Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
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Chondrosarcoma of the sella turcica: Case report and review. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Chen YH, Molenaar D, Uyl-de Groot CA, van Vulpen M, Blommestein HM. Medical Resource Use and Medical Costs for Radiotherapy-Related Adverse Effects: A Systematic Review. Cancers (Basel) 2022; 14:2444. [PMID: 35626049 PMCID: PMC9139402 DOI: 10.3390/cancers14102444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/09/2022] [Accepted: 05/11/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Despite the need for a proper economic evaluation of new radiotherapies, the economic burden of radiotherapy-induced adverse effects remains unclear. A systematic review has been conducted to identify the existing evidence of healthcare resource use and costs related to radiotherapy-induced adverse effects and also to provide recommendations for including this evidence in economic evaluations. METHODS This systematic review of healthcare resource use and/or medical costs related to radiotherapy-induced adverse effects was performed up until 2020, focusing on patients with head and neck cancer, brain cancer, prostate cancer, eye cancer and breast cancer. RESULTS Resource use for treating the same adverse effects varied considerably across studies; for instance, the cost for mucositis ranged from USD 2949 to USD 17,244. This broad range could be related to differences in (1) severity of adverse effects in the study population, (2) study design, (3) cost estimation approach and (4) country and clinical practice. CONCLUSIONS Our findings revealed unignorable differences for the same adverse effects, which implied that the potential for the economic burden of adverse effects was being overestimated or underestimated in economic evaluation for radiotherapy.
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Affiliation(s)
- Yi Hsuan Chen
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, 3062 PA Rotterdam, The Netherlands; (C.A.U.-d.G.); (H.M.B.)
| | - Dominique Molenaar
- Department of Otolaryngology-Head and Neck Surgery, Amsterdam University Medical Center (UMC), Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands;
| | - Carin A. Uyl-de Groot
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, 3062 PA Rotterdam, The Netherlands; (C.A.U.-d.G.); (H.M.B.)
| | | | - Hedwig M. Blommestein
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, 3062 PA Rotterdam, The Netherlands; (C.A.U.-d.G.); (H.M.B.)
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Mohan R. A review of proton therapy – Current status and future directions. PRECISION RADIATION ONCOLOGY 2022; 6:164-176. [DOI: 10.1002/pro6.1149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Radhe Mohan
- Department of Radiation Physics, MD Anderson Cancer Center Houston Texas USA
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9
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Fan X, Huang Y, Xu P, Min Y, Li J, Feng M, Xu G, Lang J. Dosimetric analysis of radiation-induced brainstem necrosis for nasopharyngeal carcinoma treated with IMRT. BMC Cancer 2022; 22:178. [PMID: 35177030 PMCID: PMC8851808 DOI: 10.1186/s12885-022-09213-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 01/19/2022] [Indexed: 11/10/2022] Open
Abstract
Background Radiation-induced brainstem necrosis (RIBN) is a late life-threatening complication that can appear after treatment in patients with nasopharyngeal carcinoma (NPC). However, the relationship between RIBN and radiation dose is not still well-defined. Methods During January 2013 and December 2017, a total of 1063 patients with NPC were treated at Sichuan cancer hospital with IMRT. A total of 479 patients were eligible for dosimetric analysis. Dosimetric parameters of the RIBN, Dmax(the maximum dose), D0.1c (maximum average dose delivered to a 0.1-cc volume), D1cc, D2cc, D3cc, D5cc, D10cc and Dmean (mean does) were evaluated and recorded. ROC curve was used to analyze the area under curve (AUC) and cutoff points. Logistic regression for screening dose-volume parameter and logistic dose response model were used to predict the incidence of brainstem necrosis. Results Among the 479 patients with NPC, 6 patients were diagnosed with RIBN, the incidence of RIBN was 1.25% (6/479), and the median time to RIBN after treatment was 28.5 months (range 18–48 months). The dose of the brainstem in patients with RIBN were higher than that in patients without necrosis. ROC curve showed that the area under the curve (AUC) of Dmax was the largest (0.987). Moreover, logistic stepwise regression indicated that Dmax was the most important dose factor. The RIBN incidence at 5% over 5 years (TD5/5) and 50% incidence over 5 years (TD50/5) was 69.59 Gy and76.45 Gy, respectively. Conclusions Brainstem necrosis is associated with high dose irritation. Dmax is the most significant predictive dosimetric factor for RIBN. Dmax of brainstem should be considered as the dose limitation parameter. We suggest that the limitation dose for brainstem was Dmax < 69.59 Gy.
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Affiliation(s)
- Xigang Fan
- Department of Oncology, People's Hospital of Deyang City, Deyang, Sichuan, China.,Department of Radiation Oncology, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Chengdu, Sichuan, China
| | - Yecai Huang
- Department of Radiation Oncology, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Chengdu, Sichuan, China.,School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Peng Xu
- Department of Radiation Oncology, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Chengdu, Sichuan, China
| | - Yanmei Min
- Department of Oncology, The Third Hospital of Mianyang, Mianyang, Sichuan, China
| | - Jie Li
- Department of Radiation Oncology, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Chengdu, Sichuan, China
| | - Mei Feng
- Department of Radiation Oncology, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Chengdu, Sichuan, China
| | - Guohui Xu
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China.,Department of Interventional Radiology, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, Chengdu, Sichuan, China
| | - Jinyi Lang
- Department of Radiation Oncology, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Chengdu, Sichuan, China. .,School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China.
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Soule E, Baig S, Fiester P, Holtzman A, Rutenberg M, Tavanaiepour D, Rao D. Current Management and Image Review of Skull Base Chordoma: What the Radiologist Needs to Know. J Clin Imaging Sci 2021; 11:46. [PMID: 34513210 PMCID: PMC8422542 DOI: 10.25259/jcis_139_2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 08/14/2021] [Indexed: 11/04/2022] Open
Abstract
Chordomas of the skull-base are typically slow-growing, notochord-derived tumors that most commonly originate along the clivus. Skull base chordoma is treated with surgery and radiotherapy. Local recurrence approaches 50% at 10 years. Radiologists play a critical role in diagnosis, treatment planning, and follow-up. Surgeons and radiation oncologists rely on radiologists for pre-operative delineation of tumor and adjacent anatomy, identification of post-treatment changes and disease recurrence, and radiation treatment effects. This review provides an overview of clinical characteristics, surgical anatomy, indications for radiotherapy, identification of treatment complications, and patterns of disease recurrence for radiologists to provide value in the management of these lesions.
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Affiliation(s)
- Erik Soule
- Department of Neuroradiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Saif Baig
- Department of Radiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Peter Fiester
- Department of Neuroradiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Adam Holtzman
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Michael Rutenberg
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Daryoush Tavanaiepour
- Department of Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Dinesh Rao
- Department of Neuroradiology, University of Florida College of Medicine, Jacksonville, Florida, United States
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11
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Particle Radiotherapy for Skull Base Chondrosarcoma: A Clinical Series from Italian National Center for Oncological Hadrontherapy. Cancers (Basel) 2021; 13:cancers13174423. [PMID: 34503233 PMCID: PMC8430859 DOI: 10.3390/cancers13174423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/09/2021] [Accepted: 08/27/2021] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Skull-base chondrosarcoma is a rare locally aggressive or malignant group of cartilaginous neoplasm. The standard of care consists of surgery and high-dose radiation therapy, better if with particle, due to their radioresistance and proximity to organs at risk such as brainstem and optic pathways. Due to the rarity of the tumor and its site, outcomes in terms of local control and toxicity of patients with this malignancy after receiving particle therapy has been documented only in a limited number of series with a restricted number of patients, in particular with regard to carbon ions. The aim of our retrospective study is to assess the role of particle therapy (protons and carbon ions) after surgery in our Institute in skull-base chondrosarcomas. Abstract Background: The standard treatment for skull base chondrosarcoma (SB-CHS) consists of surgery and high-dose radiation therapy. Our aim was to evaluate outcome in terms of local control (LC) and toxicity of proton therapy (PT) and carbon ion (CIRT) after surgery. Materials and methods: From September 2011 to July 2020, 48 patients underwent particle therapy (67% PT, 33% CIRT) for SB-CHS. PT and CIRT total dose was 70 GyRBE (relative biological effectiveness) in 35 fractions and 70.4 GyRBE in 16 fractions, respectively. Toxicity was assessed using the Common Terminology Criteria for Adverse Events (CTCAE v5). Results: After a median follow-up time of 38 months, one local failure (2%) was documented and the patient died for progressive disease. Overall, 3-year LC was 98%. One (2%) and 4 (8%) patients experienced G3 acute and late toxicity, respectively. White-matter brain changes were documented in 22 (46%) patients, but only 7 needed steroids (G2). No patients had G3 brain toxicity. No G4–5 complications were reported. We did not find any correlation between high-grade toxicity or white-matter changes and characteristics of patients, disease and surgery. Conclusions: PT and CIRT appeared to be effective and safe treatments for patients with SB-CHS, resulting in high LC rates and an acceptable toxicity profile.
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12
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Munari S, Colangeli R, Ramacciotti G, Zanoletti E. Clivus Chordoma: Case Report and Current Considerations on Treatment Strategies. J Int Adv Otol 2021; 16:286-290. [PMID: 32784169 DOI: 10.5152/iao.2020.7494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Chordomas are the rare malignant bone lesions derived from the embryonic notochord. They are slow-growing tumors with a locally aggressive behavior. The clival chordomas are extradural, exophytic, and lytic lesions centered on the clivus, and are managed differently from those arising elsewhere because of the emphasis on preserving the neurological function. The gold standard for therapy is the complete resection followed by radiation therapy for a better local control of the tumor. This case report concerns a 20-year old girl with an incidental diagnosis of the clival chordoma, which was first treated via an endoscopic anterior approach to remove the exophytic portion of the tumor. The adjuvant radiation therapy was not feasible because of the macroscopic intradural residual tumor being at the level of jugular foramen. The girl was referred to our institute for the removal of the intradural residual tumor via a petro-occipital trans-sigmoid (POTS) approach followed by adjuvant proton beam therapy. The choice of the surgical approach depends on the size of the tumor, its location, and its anatomical distribution, but should also be balanced against the morbidity, considering the patient's age, and the feasibility of postoperative rehabilitation.
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Affiliation(s)
- Sara Munari
- Division of Otolaryngology, Department of Neurosciences DNS, Padova University, Padova, Italy
| | - Roberta Colangeli
- Division of Otolaryngology, Department of Neurosciences DNS, Padova University, Padova, Italy
| | - Giulia Ramacciotti
- Division of Otolaryngology, Department of Neurosciences DNS, Padova University, Padova, Italy
| | - Elisabetta Zanoletti
- Division of Otolaryngology, Department of Neurosciences DNS, Padova University, Padova, Italy
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13
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Iannalfi A, D'Ippolito E, Riva G, Molinelli S, Gandini S, Viselner G, Fiore MR, Vischioni B, Vitolo V, Bonora M, Ronchi S, Petrucci R, Barcellini A, Mirandola A, Russo S, Vai A, Mastella E, Magro G, Maestri D, Ciocca M, Preda L, Valvo F, Orecchia R. Proton and carbon ion radiotherapy in skull base chordomas: a prospective study based on a dual particle and a patient-customized treatment strategy. Neuro Oncol 2021; 22:1348-1358. [PMID: 32193546 DOI: 10.1093/neuonc/noaa067] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The aim of this study is to evaluate results in terms of local control (LC), overall survival (OS), and toxicity profile and to better identify factors influencing clinical outcome of skull base chordoma treated with proton therapy (PT) and carbon ion radiotherapy (CIRT). METHODS We prospectively collected and analyzed data of 135 patients treated between November 2011 and December 2018. Total prescription dose in the PT group (70 patients) and CIRT group (65 patients) was 74 Gy relative biological effectiveness (RBE) delivered in 37 fractions and 70.4 Gy(RBE) delivered in 16 fractions, respectively (CIRT in unfavorable patients). LC and OS were evaluated using the Kaplan-Meier method. Univariate and multivariate analyses were performed, to identify prognostic factors on clinical outcomes. RESULTS After a median follow-up of 44 (range, 6-87) months, 14 (21%) and 8 (11%) local failures were observed in CIRT and PT group, respectively. Five-year LC rate was 71% in CIRT cohort and 84% in PT cohort. The estimated 5-year OS rate in the CIRT and PT group was 82% and 83%, respectively. On multivariate analysis, gross tumor volume (GTV), optic pathways, and/or brainstem compression and dose coverage are independent prognostic factors of local failure risk. High rate toxicity grade ≥3 was reported in 11% of patients. CONCLUSIONS Particle radiotherapy is an effective treatment for skull base chordoma with acceptable late toxicity. GTV, optic pathways, and/or brainstem compression and target coverage were independent prognostic factors for LC. KEY POINTS • Proton and carbon ion therapy are effective and safe in skull base chordoma.• Prognostic factors are GTV, organs at risk compression, and dose coverage.• Dual particle therapy and customized strategy was adopted.
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Affiliation(s)
- Alberto Iannalfi
- Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Emma D'Ippolito
- Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Giulia Riva
- Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Silvia Molinelli
- Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Sara Gandini
- Department of Experimental Oncology, European Institute of Oncology, IRCCS, Milan, Italy
| | | | - Maria Rosaria Fiore
- Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Barbara Vischioni
- Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Viviana Vitolo
- Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Maria Bonora
- Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Sara Ronchi
- Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Rachele Petrucci
- Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Amelia Barcellini
- Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Alfredo Mirandola
- Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Stefania Russo
- Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Alessandro Vai
- Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Edoardo Mastella
- Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Giuseppe Magro
- Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Davide Maestri
- Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Mario Ciocca
- Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Lorenzo Preda
- Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Francesca Valvo
- Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Roberto Orecchia
- Scientific Directorate, European Institute of Oncology, IRCCS, Milan, Italy
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14
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Weber DC, Bizzocchi N, Bolsi A, Jenkinson MD. Proton Therapy for Intracranial Meningioma for the Treatment of Primary/Recurrent Disease Including Re-Irradiation. Front Oncol 2020; 10:558845. [PMID: 33381447 PMCID: PMC7769250 DOI: 10.3389/fonc.2020.558845] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 10/28/2020] [Indexed: 01/14/2023] Open
Abstract
Meningeal tumors represent approximately 10-25% of primary brain tumors and occur usually in elderly female patients. Most meningiomas are benign (80-85%) and for symptomatic and/or large tumors, surgery, with or without radiation therapy (RT), has been long established as an effective means of local tumor control. RT can be delivered to inoperable lesions or to those with non-benign histology and for Simpson I-III and IV-V resection. RT can be delivered with photons or particles (protons or carbon ions) in stereotactic or non-stereotactic conditions. Particle therapy delivered for these tumors uses the physical properties of charged carbon ions or protons to spare normal brain tissue (i.e. Bragg peak), with or without or a dose-escalation paradigm for non-benign lesions. PT can substantially decrease the dose delivered to the non-target brain tissues, including but not limited to the hippocampi, optic apparatus or cochlea. Only a limited number of meningioma patients have been treated with PT in the adjuvant or recurrent setting, as well as for inoperable lesions with pencil beam scanning and with protons only. Approximately 500 patients with image-defined or WHO grade I meningioma have been treated with protons. The reported outcome, usually 5-year local tumor control, ranges from 85 to 99% (median, 96%). For WHO grade II or III patients, the outcome of only 97 patients has been published, reporting a median tumor local control rate of 52% (range, 38-71.1). Only 24 recurring patients treated previously with photon radiotherapy and re-treated with PT were reported. The clinical outcome of these challenging patients seems interesting, provided that they presented initially with benign tumors, are not in the elderly category and have been treated previously with conventional radiation dose of photons. Overall, the number of meningioma patients treated or-re-irradiated with this treatment modality is small and the clinical evidence level is somewhat low (i.e. 3b-5). In this review, we detail the results of upfront PT delivered to patients with meningioma in the adjuvant setting and for inoperable tumors. The outcome of meningioma patients treated with this radiation modality for recurrent tumors, with or without previous RT, will also be reviewed.
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Affiliation(s)
- Damien C Weber
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Villigen, Switzerland.,Radiation Oncology Department, University Hospital Zürich, Zürich, Switzerland.,Radiation Oncology Department, University Hospital of Bern, Inselspital, Bern, Switzerland
| | - Nicola Bizzocchi
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Villigen, Switzerland
| | - Alessandra Bolsi
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Villigen, Switzerland
| | - Michael D Jenkinson
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom.,Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
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15
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Research progress on mechanism and dosimetry of brainstem injury induced by intensity-modulated radiotherapy, proton therapy, and heavy ion radiotherapy. Eur Radiol 2020; 30:5011-5020. [PMID: 32318844 DOI: 10.1007/s00330-020-06843-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 03/11/2020] [Accepted: 03/30/2020] [Indexed: 10/24/2022]
Abstract
Radiotherapy (RT) is an effective method for treating head and neck cancer (HNC). However, RT may cause side effects during and after treatment. Radiation-induced brainstem injury (BSI) is often neglected due to its low incidence and short survival time and because it is indistinguishable from intracranial tumor progression. It is currently believed that the possible mechanism of radiation-induced BSI includes increased expression of vascular endothelial growth factor and damage of vascular endothelial cells, neurons, and glial cells as well as an inflammatory response and oxidative stress. At present, it is still difficult to avoid BSI even with several advanced RT techniques. Intensity-modulated radiotherapy (IMRT) is the most commonly used therapeutic technique in the field of RT. Compared with early conformal therapy, it has greatly reduced the injury to normal tissues. Proton beam radiotherapy (PBT) and heavy ion radiotherapy (HIT) have good dose distribution due to the presence of a Bragg peak, which not only results in better control of the tumor but also minimizes the dose to the surrounding normal tissues. There are many clinical studies on BSI caused by IMRT, PBT, and HIT. In this paper, we review the mechanism, dosimetry, and other aspects of BSI caused by IMRT, PBT, and HIT.Key Points• Enhanced MRI imaging can better detect radiation-induced BSI early.• This article summarized the dose constraints of brainstem toxicity in clinical studies using different techniques including IMRT, PBT, and HIT and recommended better dose constraints pattern to clinicians.• The latest pathological mechanism of radiation-induced BSI and the corresponding advanced treatment methods will be discussed.
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16
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Vogel J, Carmona R, Ainsley CG, Lustig RA. The Promise of Proton Therapy for Central Nervous System Malignancies. Neurosurgery 2020; 84:1000-1010. [PMID: 30476191 DOI: 10.1093/neuros/nyy454] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 08/28/2018] [Indexed: 11/15/2022] Open
Abstract
Radiation therapy plays a significant role in management of benign and malignant diseases of the central nervous system. Patients may be at risk of acute and late toxicity from radiation therapy due to dose deposition in critical normal structures. In contrast to conventional photon delivery techniques, proton therapy is characterized by Bragg peak dose deposition which results in decreased exit dose beyond the target and greater sparing of normal structure which may reduce the rate of late toxicities from treatment. Dosimetric studies have demonstrated reduced dose to normal structures using proton therapy as compared to photon therapy. In addition, clinical studies are being reported demonstrating safety, feasibility, and low rates of acute toxicity. Technical challenges in proton therapy remain, including full understanding of depth of proton penetration and the biological activity in the distal Bragg peak. In addition, longer clinical follow-up is required to demonstrate reduction in late toxicities as compared to conventional photon-based radiation techniques. In this review, we summarize the current clinical literature and areas of active investigation in proton therapy for adult central nervous system malignancies.
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Affiliation(s)
- Jennifer Vogel
- Department of Rad-iation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ruben Carmona
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania
| | - Christopher G Ainsley
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania
| | - Robert A Lustig
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania
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17
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Lu VM, O'Connor KP, Mahajan A, Carlson ML, Van Gompel JJ. Carbon ion radiotherapy for skull base chordomas and chondrosarcomas: a systematic review and meta-analysis of local control, survival, and toxicity outcomes. J Neurooncol 2020; 147:503-513. [PMID: 32206977 DOI: 10.1007/s11060-020-03464-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 03/18/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Carbon ion radiotherapy (CIRT) is an emerging radiation therapy to treat skull base chordomas and chondrosarcomas. To date, its use is limited to a few centers around the world, and there has been no attempt to systematically evaluate survival and toxicity outcomes reported in the literature. Correspondingly, the aim of this study was to qualitatively and quantitatively assess these outcomes. METHODS A systematic search of seven electronic databases from inception to November 2019 was conducted following PRISMA guidelines. Articles were screened against pre-specified criteria. Outcomes were then pooled by random-effects meta-analyses of proportions. RESULTS A total of nine studies provided unique metadata for assessment, with six originating from Heidelberg, Germany. The surveyed cohort size was 632 patients, with 389 (62%) chordomas and 243 (38%) chondrosarcomas of the skull base. Across all studies, median cohort age at therapy and female proportion were 46 years and 51% respectively. Estimates of local control incidence at 1-, 5-, and 10-years in chordoma-only studies were 99%, 80%, and 56%, and in chondrosarcoma-only studies were 99%, 89%, and 88%. Estimates of overall survival probability at 1-, 5-, and 10-years in chordoma-only studies were 100%, 94%, and 78%, and in chondrosarcoma-only studies were 99%, 95%, and 79%. The incidence of early and late toxicity (Grade ≥ 3) ranged from 0 to 4% across all study groups. CONCLUSIONS The emerging use of CIRT to treat skull base chordomas and chondrosarcomas appear promising with regard to tumor control, overall survival, and risk profile of early and late toxicity. The current literature suffers from the fact only a few centers in the world currently employ this technology.
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Affiliation(s)
- Victor M Lu
- Department of Neurologic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA.
| | - Kyle P O'Connor
- Department of Neurosurgery, University of Oklahoma, Oklahoma City, OK, USA
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Matthew L Carlson
- Department of Neurologic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, MN, USA
| | - Jamie J Van Gompel
- Department of Neurologic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA.
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, MN, USA.
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18
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Albano L, Losa M, Flickinger J, Mortini P, Minniti G. Radiotherapy of Parasellar Tumours. Neuroendocrinology 2020; 110:848-858. [PMID: 32126559 DOI: 10.1159/000506902] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 03/02/2020] [Indexed: 11/19/2022]
Abstract
Parasellar tumours represent a wide group of intracranial lesions, both benign and malignant. They may arise from several structures located within the parasellar area or they may infiltrate or metastasize this region. The treatment of the tumours located in these areas is challenging because of their complex anatomical location and their heterogenous histology. It often requires a multimodal approach, including surgery, radiation therapy (RT), and medical therapy. Due to the proximity of critical structures and the risks of side effects related to the procedure, a successful surgical resection is often not achievable. Thus, RT plays a crucial role in the treatment of several parasellar tumours. Conventional fractionated RT and modern radiation techniques, like stereotactic radiosurgery and proton beam RT, have become a standard management option, in particular for cases with residual or recurrent tumours after surgery and for those cases where surgery is contraindicated. This review examines the role of RT in parasellar tumours analysing several techniques, outcomes and side effects.
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Affiliation(s)
- Luigi Albano
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
- Neuroimaging Research Unit, Division of Neuroscience, Institute of Experimental Neurology, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Marco Losa
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - John Flickinger
- Department of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Giuseppe Minniti
- Radiation Oncology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy,
- UPMC Hillman Cancer Center San Pietro Hospital, Rome, Italy,
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19
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Brahimi Y, Antoni D, Srour R, Proust F, Thiery A, Wagner P, Noel G. Efficacy and Tolerance of Intensity Modulated Radiation Therapy for Skull Base Meningioma. Adv Radiat Oncol 2019; 4:587-595. [PMID: 31673652 PMCID: PMC6817551 DOI: 10.1016/j.adro.2019.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 07/06/2019] [Accepted: 07/11/2019] [Indexed: 11/29/2022] Open
Abstract
Purpose The purpose of this study was to evaluate the efficacy and tolerance of normofractionated stereotactic radiation therapy (RT) and intensity modulated RT with helical tomotherapy for skull base meningioma. Methods and Materials Between January 2009 and 2014, 46 patients with skull base meningioma were treated with normofractionated intensity modulated RT in stereotactic conditions (50%) or with helical tomotherapy (50%). Most of the lesions were localized in the cavernous sinus (59%). The mean planning target volume was 47.2 mL (range, 1.1-223 mL). Results After treatment, 5 lesions exhibited a partial response radiologically and 39 lesions were stable. At the time of treatment, 35 patients were symptomatic with a mean of 2 symptoms per patient. The most frequent symptoms were visual impairment (41%), cranial nerve dysfunction (20%), and headache (16%). The median follow-up time was 42 months (range, 10-76 months). After RT, 71% of patients exhibited an improvement of at least 1 symptom with a median interval of 15.6 months (range, 5.3-30.5 months). The most frequent improved symptoms were cranial nerve deficits (47%), visual impairment (45%), and headache (42%).The clinical response was correlated with the clinical target volume (CTV) margin (P = .06), extended clinical follow-up time (P = .004), and larger planning target volume (P = .05) by univariate analysis. Taking in account correlation factors, in the multivariate analysis, only CTV was a favorable significant factor of clinical improvement (P = .049; hazard ratio: 5 95%; confidence interval, 1.1-28). We observed 3 cases of trigeminal nerve dysfunction at 4.2, 5.7, and 24.6 months; 2 cases of visual disturbance at 10.1 and 24 months; 2 cases of neurocognitive disorders at 12.9 and 35.2 months; and 1 case of stroke at 20.3 months. Conclusions RT for skull base meningiomas is an effective and safe treatment, leading in most cases to clinical improvement. The addition of a CTV margin to meningioma volume improved the symptoms of patients.
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Affiliation(s)
- Youssef Brahimi
- University Radiation Oncology Department, Comprehensive Cancer Center Paul Strauss, Strasbourg, France
| | - Delphine Antoni
- University Radiation Oncology Department, Comprehensive Cancer Center Paul Strauss, Strasbourg, France.,Laboratory of Radiobiology, Federation of Translational Medicine, Strasbourg University, Strasbourg, France
| | - Robin Srour
- Neurosurgery Department, Hôpital Pasteur, Colmar, France
| | - François Proust
- Neurosurgery Department, University Hospital of Strasbourg, Strasbourg, France
| | - Alicia Thiery
- Epidemiology and Biostatistics Department, Comprehensive Cancer Center Paul Strauss, Strasbourg, France
| | - Pierre Wagner
- Radiology Department, Comprehensive Cancer Center Paul Strauss, Strasbourg, France
| | - Georges Noel
- University Radiation Oncology Department, Comprehensive Cancer Center Paul Strauss, Strasbourg, France.,Laboratory of Radiobiology, Federation of Translational Medicine, Strasbourg University, Strasbourg, France
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20
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Lee AW, Ng WT, Pan JJ, Chiang CL, Poh SS, Choi HC, Ahn YC, AlHussain H, Corry J, Grau C, Grégoire V, Harrington KJ, Hu CS, Kwong DL, Langendijk JA, Le QT, Lee NY, Lin JC, Lu TX, Mendenhall WM, O'Sullivan B, Ozyar E, Peters LJ, Rosenthal DI, Sanguineti G, Soong YL, Tao Y, Yom SS, Wee JT. International Guideline on Dose Prioritization and Acceptance Criteria in Radiation Therapy Planning for Nasopharyngeal Carcinoma. Int J Radiat Oncol Biol Phys 2019; 105:567-580. [PMID: 31276776 DOI: 10.1016/j.ijrobp.2019.06.2540] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 06/12/2019] [Accepted: 06/25/2019] [Indexed: 12/09/2022]
Abstract
PURPOSE The treatment of nasopharyngeal carcinoma requires high radiation doses. The balance of the risks of local recurrence owing to inadequate tumor coverage versus the potential damage to the adjacent organs at risk (OARs) is of critical importance. With advancements in technology, high target conformality is possible. Nonetheless, to achieve the best possible dose distribution, optimal setting of dose targets and dose prioritization for tumor volumes and various OARs is fundamental. Radiation doses should always be guided by the As Low As Reasonably Practicable principle. There are marked variations in practice. This study aimed to develop a guideline to serve as a global practical reference. METHODS AND MATERIALS A literature search on dose tolerances and normal-tissue complications after treatment for nasopharyngeal carcinoma was conducted. In addition, published guidelines and protocols on dose prioritization and constraints were reviewed. A text document and preliminary set of variants was circulated to a panel of international experts with publications or extensive experience in the field. An anonymized voting process was conducted to rank the proposed variants. A summary of the initial voting and different opinions expressed by members were then recirculated to the whole panel for review and reconsideration. Based on the comments of the panel, a refined second proposal was recirculated to the same panel. The current guideline was based on majority voting after repeated iteration for final agreement. RESULTS Variation in opinion among international experts was repeatedly iterated to develop a guideline describing appropriate dose prioritization and constraints. The percentage of final agreement on the recommended parameters and alternative views is shown. The rationale for the recommendations and the limitations of current evidence are discussed. CONCLUSIONS Through this comprehensive review of available evidence and interactive exchange of vast experience by international experts, a guideline was developed to provide a practical reference for setting dose prioritization and acceptance criteria for tumor volumes and OARs. The final decision on the treatment prescription should be based on the individual clinical situation and the patient's acceptance of optimal balance of risk.
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Affiliation(s)
- Anne W Lee
- Department of Clinical Oncology, University of Hong Kong Shenzhen Hospital and University of Hong Kong, China
| | - Wai Tong Ng
- Department of Clinical Oncology, Pamela Youde Nethersole Eastern Hospital, Hong Kong
| | - Jian Ji Pan
- Department of Radiation Oncology, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Chi-Leung Chiang
- Department of Clinical Oncology, University of Hong Kong Shenzhen Hospital and University of Hong Kong, China
| | - Sharon S Poh
- Division of Radiation Oncology, National Cancer Centre Singapore, Oncology ACP, Duke-NUS Medical School, Singapore
| | - Horace C Choi
- Department of Clinical Oncology, University of Hong Kong, Hong Kong
| | - Yong Chan Ahn
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hussain AlHussain
- Department of Radiation Oncology, Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - June Corry
- Radiation Oncology, GenesisCare, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - Cai Grau
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Vincent Grégoire
- Center for Molecular Imaging, Oncology and Radiotherapy, Université Catholique de Louvain, Brussels, Belgium and Department of Radiation Oncology, Centre Léon Bérard, Lyon, France
| | - Kevin J Harrington
- The Royal Marsden/The Institute of Cancer Research National Institute for Health Research Biomedical Research Centre, London, UK
| | - Chao Su Hu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Dora L Kwong
- Department of Clinical Oncology, University of Hong Kong and Queen Mary Hospital, Hong Kong
| | - Johannes A Langendijk
- Department of Radiotherapy, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Quynh Thu Le
- Department of Radiation Oncology, Stanford University, NRG Oncology and Head and Neck Cancer International Group, California
| | - Nancy Y Lee
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York
| | - Jin Ching Lin
- Department of Radiation Oncology, Taichung Veterans General Hospital, National Yang-Ming University, Taipei, Taiwan
| | - Tai Xiang Lu
- Department of Radiation Oncology, Cancer Center of Sun Yat-Sen University, Guangzhou, China
| | - William M Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Brian O'Sullivan
- Department of Radiation Oncology, University of Toronto, Princess Margaret Cancer Centre, Toronto, Canada
| | - Enis Ozyar
- Department of Radiation Oncology, Acibadem University School of Medicine, Istanbul, Turkey
| | - Lester J Peters
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Giuseppe Sanguineti
- Department of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Yoke Lim Soong
- Division of Radiation Oncology, National Cancer Centre Singapore, Oncology ACP, Duke-NUS Medical School, Singapore
| | - Yungan Tao
- Department of Radiation Oncology, Institut Gustave Roussy, Paris-Saclay University, Villejuif, France
| | - Sue S Yom
- Department of Radiation Oncology, University of California-San Francisco, San Francisco, California
| | - Joseph T Wee
- Division of Radiation Oncology, National Cancer Centre Singapore, Oncology ACP, Duke-NUS Medical School, Singapore.
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21
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Huang XD, Li YC, Chen FP, Zheng WH, Zhou GQ, Lin L, Hu J, He WJ, Zhang LL, Kou J, Ma J, Zhang WD, Qi ZY, Sun Y. Evolution and Dosimetric Analysis of Magnetic Resonance Imaging–Detected Brain Stem Injury After Intensity Modulated Radiation Therapy in Nasopharyngeal Carcinoma. Int J Radiat Oncol Biol Phys 2019; 105:124-131. [DOI: 10.1016/j.ijrobp.2019.04.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 04/03/2019] [Accepted: 04/27/2019] [Indexed: 12/25/2022]
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22
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Dionisi F, Croci S, Giacomelli I, Cianchetti M, Caldara A, Bertolin M, Vanoni V, Pertile R, Widesott L, Farace P, Schwarz M, Amichetti M. Clinical results of proton therapy reirradiation for recurrent nasopharyngeal carcinoma. Acta Oncol 2019; 58:1238-1245. [PMID: 31155998 DOI: 10.1080/0284186x.2019.1622772] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background and purpose: Recurrent nasopharyngeal carcinoma (NPC) has limited curative treatment options. Reirradiation is the only potential definitive treatment in advanced stages at a cost of substantial severe and often life-threatening toxicity. Proton therapy (PT) reduces irradiated volume compared with X-ray radiotherapy and could be advantageous in terms of safety and efficacy in a population of heavily pretreated patients. We report the retrospective results of PT reirradiation in recurrent NPC patients treated at our Institution Methods: All recurrent NPC patients treated since the beginning of clinical activity entered the present analysis. Clinical target volume consisted of Gross Tumor volume plus a patient-specific margin depending on disease behavior, tumor location, proximity of organs at risk, previous radiation dose. No elective nodal irradiation was performed. Active scanning technique with the use of Single Field Optimization (SFO) or Multifield Optimization (MFO) was adopted. Cumulative X-ray -PT doses were calculated for all patients using a dose accumulation tool since 2016. Treatment toxicity was retrospectively collected. Results: Between February 2015, and October 2018, 17 recurrent NPC patients were treated. Median follow-up (FUP) was 10 months (range 2-41). Median PT reirradiation dose was 60 Gy RBE (range 30.6-66). The majority of patients (53%) underwent concomitant chemotherapy. Acute toxicity was low with no ≥ G3 adverse events. Late events ≥ G3 occurred in 23.5% of patients. Most frequent late toxicity was hearing impairment (17,6%). G2 soft tissue necrosis occurred in two patients. Fatal bleeding of uncertain cause (either tumor recurrence or G5 carotid blowout) occurred in one patient. Kaplan-Meier 18 months Overall Survival (OS) and Local control (LC) rates were 54.4% and 66.6%, respectively. Conclusions: Our initial results with the use of modern PT for reirradiation of recurrent NPC patients are encouraging. Favorable LC and OS rates were obtained at the cost of acceptable severe late toxicity.
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Affiliation(s)
- F. Dionisi
- Proton Therapy Unit, APSS, Trento, Italy
| | - S. Croci
- Radiation Oncology Unit, University of Siena, Siena, Italy
| | | | | | | | | | - V. Vanoni
- Radiation Oncology Unit, APSS, Trento, Italy
| | | | | | - P. Farace
- Medical Physics Unit, APSS, Trento, Italy
| | - M. Schwarz
- Medical Physics Unit, APSS, Trento, Italy
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23
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Brainstem Injury in Pediatric Patients Receiving Posterior Fossa Photon Radiation. Int J Radiat Oncol Biol Phys 2019; 105:1034-1042. [PMID: 31472183 DOI: 10.1016/j.ijrobp.2019.08.039] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 08/09/2019] [Accepted: 08/15/2019] [Indexed: 01/23/2023]
Abstract
PURPOSE Brainstem necrosis is a rare, but dreaded complication of radiation therapy; however, data on the incidence of brainstem injury for tumors involving the posterior fossa in photon-treated patient cohorts are still needed. METHODS AND MATERIALS Clinical characteristics and dosimetric parameters were recorded for 107 pediatric patients who received photon radiation for posterior fossa tumors without brainstem involvement from 2000 to 2016. Patients were excluded if they received a prescription dose <50.4 Gy, a brainstem maximum dose <50.4 Gy, or had fewer than 2 magnetic resonance imaging scans within 18 months after radiation. Post-radiation therapy magnetic resonance imaging findings were recorded, and brainstem toxicity was graded using National Cancer Institute Common Terminology Criteria for Adverse Events, version 5. RESULTS The most common histologies were medulloblastoma (61.7%) and ependymoma (15.9%), and median age at diagnosis was 8.3 years (range, 0.8-20.7). Sixty-seven patients (62.6%) received craniospinal irradiation (median, 23.4 Gy; range, 18.0-39.6) as a component of their radiation therapy, and 39.3% and 40.2% of patients received an additional involved field or whole posterior fossa boost, respectively. Median prescribed dose was 55.8 Gy (range, 50.4-60.0). Median clinical and imaging follow-up were 4.7 years (range, 0.1-17.5) and 4.2 years (range, 0.1-17.3), respectively. No grade ≥2 toxicities were observed. The incidence of grade 1 brainstem necrosis was 1.9% (2 of 107). These patients were by definition asymptomatic and experienced resolution of imaging abnormality after 5.3 months and 2.1 years, respectively. CONCLUSIONS Risk of brainstem necrosis was minimal in this multi-institutional study of pediatric patients treated with photon radiation therapy for tumors involving the posterior fossa with no cases of symptomatic brainstem injury, suggesting that brainstem injury risk is minimal in patients treated with photon therapy.
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24
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Weber DC, Lim PS, Tran S, Walser M, Bolsi A, Kliebsch U, Beer J, Bachtiary B, Lomax T, Pica A. Proton therapy for brain tumours in the area of evidence-based medicine. Br J Radiol 2019; 93:20190237. [PMID: 31067074 DOI: 10.1259/bjr.20190237] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
ADVANCES IN KNOWLEDGE This review details the indication of brain tumors for proton therapy and give a list of the open prospective trials for these challenging tumors.
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Affiliation(s)
- Damien C Weber
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland.,University of Bern, Bern, Switzerland.,University of Zürich, Zürich, Switzerland
| | - Pei S Lim
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Sebastien Tran
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Marc Walser
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Alessandra Bolsi
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Ulrike Kliebsch
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Jürgen Beer
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Barbara Bachtiary
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Tony Lomax
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland.,Department of Physics, ETH, Zürich, Switzerland
| | - Alessia Pica
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
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25
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Salvage Carbon-Ion Radiation Therapy For Locoregionally Recurrent Head and Neck Malignancies. Sci Rep 2019; 9:4259. [PMID: 30862843 PMCID: PMC6414648 DOI: 10.1038/s41598-019-39241-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 01/11/2019] [Indexed: 12/25/2022] Open
Abstract
To investigate the safety and efficacy of salvage carbon-ion radiation therapy (CIRT) in patients with locoregionally recurrent head and neck malignancies. One hundred and forty-one patients with locally recurrent head and neck malignancies previously treated with radiotherapy were salvaged using intensity-modulated carbon-ion radiation therapy (CIRT). The median dose was 60 Gray-Equivalent (GyE) (range 50–69 GyE, 2.0~3.5 GyE/daily fraction). All patients completed planned CIRT except for one. With a median follow-up time of 14.7 (range 1.6–36.4) months, the 1-year overall survival rate was 95.9%. Local, regional, and distant progression free survival rates were 84.9% and 97.7%, and 96%, respectively. Grade 3 or higher acute and late toxicities were observed in 7.1% of the patients. Ten patients developed mucosal necrosis and 4 of these patients deceased. Due to its physical and biological characteristics, CIRT appeared to be an acceptable treatment option for patients with locoregionally recurrent head and neck malignancies after previous radiotherapy. Treatment-induced adverse effects and early response to CIRT were both favorable. Longer follow-up is needed to evaluate the long-term outcome in terms of disease control, survival, as well as potential late effects.
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26
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Sinclair G, Benmakhlouf H, Martin H, Maeurer M, Dodoo E. Adaptive hypofractionated gamma knife radiosurgery in the acute management of brainstem metastases. Surg Neurol Int 2019; 10:14. [PMID: 30783544 PMCID: PMC6367951 DOI: 10.4103/sni.sni_53_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 10/29/2018] [Indexed: 12/15/2022] Open
Abstract
Background: Intrinsic brainstem metastases are life-threatening neoplasms requiring rapid, effective intervention. Microsurgery is considered not feasible in most cases and systemic treatment seldom provides a successful outcome. In this context, radiation therapy remains the best option but adverse radiation effects (ARE) remain a major concern. A dose-adaptive gamma knife procedure coined as Rapid Rescue Radiosurgery (3R) offers the possibility to treat these lesions whilst reducing the risk of ARE evolvement. We report the results of 3R applied to a group of patients with brainstem metastases. Methods: Eight patients with nine brainstem metastases, having undergone three separate, dose-adapted gamma knife radiosurgery (GKRS) procedures over 7 days, were retrospectively analyzed in terms of tumor volume reduction, local control rates, and ARE-development under the period of treatment and at least 6 months after treatment completion. Results: Mean peripheral doses at GKRS 1, GKRS 2, and GKRS 3 were 7.4, 7.7, and 8.2 Gy (range 6–9 Gy) set at the 35–50% isodose lines. Mean tumor volume reduction between GKRS 1 and GKRS 3 was −15% and −56% at first follow-up. Four patients developed radiologic signs of ARE but remained clinically asymptomatic. One patient developed a local recurrence at 34 months. Mean survival from GKRS 1 was 13 months. Two patients were still alive at the time of paper submission (10 and 23 months from GKRS 1). Conclusions: In this study, 3R proved effective in terms of tumor volume reduction, rescue/preservation of neurological function, and limited ARE evolvement.
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Affiliation(s)
- Georges Sinclair
- Department of Neurosurgery, Karolinska University Hospital, Solna, Sweden
| | - Hamza Benmakhlouf
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Solna, Sweden
| | - Heather Martin
- Department of Neuroradiology, Karolinska University Hospital, Solna, Sweden
| | - Markus Maeurer
- Department of Laboratory Medicine (LABMED), Therapeutic Immunology Unit (TIM), Karolinska Institutet, Stockholm, Sweden.,Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institute, Centre for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Solna, Sweden
| | - Ernest Dodoo
- Department of Neurosurgery, Karolinska University Hospital, Solna, Sweden
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27
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A retrospective dosimetry study of intensity-modulated radiotherapy for nasopharyngeal carcinoma: radiation-induced brainstem injury and dose-volume analysis. Radiat Oncol 2018; 13:194. [PMID: 30285884 PMCID: PMC6171220 DOI: 10.1186/s13014-018-1105-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 08/20/2018] [Indexed: 01/19/2023] Open
Abstract
Background Radiation therapy is the standard radical treatment for nasopharyngeal carcinoma (NPC) but also causes transient as well as long-term complications. Patients who develop severe radiation-induced brainstem injuries have a poor prognosis due to the lack of effective medical therapies. However, the relationship between brainstem injury and radiation volume dose is unknown. In this study, we found that radiation-induced brainstem injury was significantly associated with brainstem dose per unit volume. Methods A retrospective analysis was performed on a consecutive cohort of 327 patients with NPC receiving IMRT from May 2005 to December 2014. Dose-volume data and long-term outcome were analyzed. Results The median follow-up duration was 56 months (range, 3–141 months), and six with T4 and two with T3 patients had radiation-induced brainstem injuries. The 3-year and 5-year incidences were 2.2% and 2.8%, respectively. The latency period of brainstem injury ranged from 9 to 58 months, with a median period of 21 months. The Cox regression analysis showed that brainstem radiation toxicity was associated with the T4 stage, D2% of gross tumor volume of nasopharyngeal primary lesions and their direct extensions (GTVnx), Dmax (the maximum point dose), D1%, D0.1cc (the top dose delivered to a 0.1-ml volume), and D1cc (the top dose delivered to a 1-ml volume) of the brainstem (p < 0.05). Receiver operating characteristic (ROC) curves showed that GTVnx D2% and the Dmax, D1%, D0.1cc, and D1cc of the brainstem were significant predictors of brainstem injury. The area under the ROC curve for these five parameters was 0.724, 0.813, 0.818, 0.818, and 0.798, respectively (p < 0.001), and the cutoff points 77.26 Gy, 67.85 Gy, 60.13 Gy, 60.75 Gy, and 54.58 Gy, respectively, were deemed as the radiation dose limit. Conclusions Radiotherapy-induced brainstem injury was uncommon in patients with NPC who received definitive IMRT. Multiple dose-volume data may be the dose tolerance of radiation-induced brainstem injury.
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28
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Brahimi Y, Antoni D, Srour R, Proust F, Cebula H, Labani A, Noël G. [Base of the skull meningioma: Efficacy, clinical tolerance and radiological evaluation after radiotherapy]. Cancer Radiother 2018; 22:264-286. [PMID: 29773473 DOI: 10.1016/j.canrad.2017.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 09/15/2017] [Accepted: 09/20/2017] [Indexed: 11/29/2022]
Abstract
Skull base meningioma leads to functional disturbances, which can significantly alter the quality of life. The optimal management of these lesions, whose goals are neurological preservation and tumour local control, is not yet clearly established. It is widely recognized that the goal of a radical excision should be abandoned despite the advances in the field of microsurgery of skull base lesions. Although less morbid, partial tumour excision would be associated with increased risk of local tumour recurrence. Although discussed both exclusive and adjuvant have proven to be highly successful in terms of clinical improvement and local control. Various radiation techniques have demonstrated their efficacy in the management of this pathology. However, high rates of clinical improvement are in contrast with low rates of radiological improvement. The notion of clinical and radiological dissociation appeared. However, in most of these studies, the analysis of the radiological response could be subject of legitimate criticism. This work proposes to review the local control, the efficacy and the clinical tolerance and the radiological response of the various radiation techniques for the meningioma of the base of the skull and to demonstrate the interest of quantitative volumetric analyses in the follow-up of meningioma after radiotherapy.
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Affiliation(s)
- Y Brahimi
- Département universitaire de radiothérapie, centre Paul-Strauss, Unicancer, 3, rue de la Porte-de-l'Hôpital, 67065 Strasbourg cedex, France
| | - D Antoni
- Département universitaire de radiothérapie, centre Paul-Strauss, Unicancer, 3, rue de la Porte-de-l'Hôpital, 67065 Strasbourg cedex, France; Laboratoire de radiobiologie, UMR 7178 institut pluridisciplinaire Hubert-Curien (IPHC), université de Strasbourg, 67000 Strasbourg, France; CNRS, IPHC UMR 7178, 67000 Strasbourg, France
| | - R Srour
- Service de neurochirurgie, hôpital Pasteur, 39, avenue de la Liberté, 68024 Colmar cedex, France
| | - F Proust
- Service de neurochirurgie, hôpital universitaire de Strasbourg, 1, rue Molière, 67000 Strasbourg, France
| | - H Cebula
- Service de neurochirurgie, hôpital universitaire de Strasbourg, 1, rue Molière, 67000 Strasbourg, France
| | - A Labani
- Service de radiologie, hôpital universitaire de Strasbourg, 1, place de l'Hôpital, 67000 Strasbourg, France
| | - G Noël
- Département universitaire de radiothérapie, centre Paul-Strauss, Unicancer, 3, rue de la Porte-de-l'Hôpital, 67065 Strasbourg cedex, France; Laboratoire de radiobiologie, UMR 7178 institut pluridisciplinaire Hubert-Curien (IPHC), université de Strasbourg, 67000 Strasbourg, France; CNRS, IPHC UMR 7178, 67000 Strasbourg, France.
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Radiation dose constraints for organs at risk in neuro-oncology; the European Particle Therapy Network consensus. Radiother Oncol 2018; 128:26-36. [PMID: 29779919 DOI: 10.1016/j.radonc.2018.05.001] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 04/16/2018] [Accepted: 05/01/2018] [Indexed: 12/25/2022]
Abstract
PURPOSE For unbiased comparison of different radiation modalities and techniques, consensus on delineation of radiation sensitive organs at risk (OARs) and on their dose constraints is warranted. Following the publication of a digital, online atlas for OAR delineation in neuro-oncology by the same group, we assessed the brain OAR-dose constraints in a follow-up study. METHODS We performed a comprehensive search to identify the current papers on OAR dose constraints for normofractionated photon and particle therapy in PubMed, Ovid Medline, Cochrane Library, Embase and Web of Science. Moreover, the included articles' reference lists were cross-checked for potential studies that met the inclusion criteria. Consensus was reached among 20 radiation oncology experts in the field of neuro-oncology. RESULTS For the OARs published in the neuro-oncology literature, we summarized the available literature and recommended dose constraints associated with certain levels of normal tissue complication probability (NTCP) according to the recent ICRU recommendations. For those OARs with lacking or insufficient NTCP data, a proposal for effective and efficient data collection is given. CONCLUSION The use of the European Particle Therapy Network-consensus OAR dose constraints summarized in this article is recommended for the model-based approach comparing photon and proton beam irradiation as well as for prospective clinical trials including novel radiation techniques and/or modalities.
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30
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Mattke M, Vogt K, Bougatf N, Welzel T, Oelmann-Avendano J, Hauswald H, Jensen A, Ellerbrock M, Jäkel O, Haberer T, Herfarth K, Debus J, Uhl M. High control rates of proton- and carbon-ion-beam treatment with intensity-modulated active raster scanning in 101 patients with skull base chondrosarcoma at the Heidelberg Ion Beam Therapy Center. Cancer 2018; 124:2036-2044. [PMID: 29469932 DOI: 10.1002/cncr.31298] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 01/07/2018] [Accepted: 01/23/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND The current study compares the results of irradiation with protons and irradiation with carbon ions via a raster scan technique in patients with G1 and G2 skull base chondrosarcomas. METHODS Between 2009 and 2014, a total of 101 patients (40 men and 61 women) with a median age of 44 years (range, 19-77 years) were irradiated with carbon ions (79 patients) or protons (22 patients) via a raster scan technique at the Heidelberg Ion Beam Therapy Center. The median total dose was 60 Gy (relative biological effectiveness [RBE]) at 3 Gy per fraction for carbon ions and 70 Gy (RBE) at 2 Gy per fraction for protons. The median boost planning target volume was 38 cm3 (range, 8-133 cm3 ). Overall survival (OS) and local control (LC) were evaluated with the Kaplan-Meier method. RESULTS The median follow-up period was 40 months (range, 0.8-78.1 months). At the start of the irradiation, all patients had residual macroscopic tumors. Five patients (5%) developed a local recurrence during the follow-up. The 1-, 2-, and 4-year LC rates were 100%, 100%, and 100%, respectively, for protons and 98.6%, 97.2%, and 90.5%, respectively, for carbon ions. The OS rates during the same periods of time were 100%, 100%, and 100%, respectively, for protons and 100%, 98.5%, and 92.9%, respectively, for carbon ions. An age ≤ 44 years was associated with a trend for a better outcome. No toxicity worse than Common Toxicity Criteria grade 3 was observed after treatment. CONCLUSIONS No significant difference between carbon ions and protons in the therapy of skull base chondrosarcoma could be detected in these initial retrospective results. Cancer 2018;124:2036-44. © 2018 American Cancer Society.
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Affiliation(s)
- Matthias Mattke
- Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology, National Center for Radiation Research in Oncology, Heidelberg, Germany
| | - Kira Vogt
- Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology, National Center for Radiation Research in Oncology, Heidelberg, Germany
| | - Nina Bougatf
- Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology, National Center for Radiation Research in Oncology, Heidelberg, Germany.,Heidelberg Ion Beam Therapy Center, Heidelberg, Germany.,German Cancer Research Center, Heidelberg, Germany
| | - Thomas Welzel
- Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology, National Center for Radiation Research in Oncology, Heidelberg, Germany
| | - Jan Oelmann-Avendano
- Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology, National Center for Radiation Research in Oncology, Heidelberg, Germany
| | - Henrik Hauswald
- Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology, National Center for Radiation Research in Oncology, Heidelberg, Germany.,Heidelberg Ion Beam Therapy Center, Heidelberg, Germany.,German Cancer Research Center, Heidelberg, Germany
| | - Alexandra Jensen
- Department of Radiation Oncology, Ludwig Maximilian University of Munich, Munich, Germany
| | - Malte Ellerbrock
- Heidelberg Institute for Radiation Oncology, National Center for Radiation Research in Oncology, Heidelberg, Germany.,Heidelberg Ion Beam Therapy Center, Heidelberg, Germany
| | - Oliver Jäkel
- Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology, National Center for Radiation Research in Oncology, Heidelberg, Germany.,Heidelberg Ion Beam Therapy Center, Heidelberg, Germany.,German Cancer Research Center, Heidelberg, Germany
| | - Thomas Haberer
- Heidelberg Institute for Radiation Oncology, National Center for Radiation Research in Oncology, Heidelberg, Germany.,Heidelberg Ion Beam Therapy Center, Heidelberg, Germany
| | - Klaus Herfarth
- Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology, National Center for Radiation Research in Oncology, Heidelberg, Germany.,Heidelberg Ion Beam Therapy Center, Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology, National Center for Radiation Research in Oncology, Heidelberg, Germany.,Heidelberg Ion Beam Therapy Center, Heidelberg, Germany.,German Cancer Research Center, Heidelberg, Germany
| | - Matthias Uhl
- Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology, National Center for Radiation Research in Oncology, Heidelberg, Germany.,Heidelberg Ion Beam Therapy Center, Heidelberg, Germany
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Combs SE, Sterzing F, Uhl M, Habl G, Schubert K, Debus J, Herfarth K. Helical tomotherapy for meningiomas of the skull base and in paraspinal regions with complex anatomy and/or multiple lesions. TUMORI JOURNAL 2018; 97:484-91. [DOI: 10.1177/030089161109700412] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aim To evaluate helical tomotherapy for the treatment of complex-shaped uni- or multifocal meningiomas. Methods and materials Between 2007 and 2009, 12 patients with complex-shaped meningiomas and/or multiple meningioma lesions were treated with helical tomotherapy. Histologic classification according to the most recent WHO classification for brain tumors was WHO grade I meningioma in 5 patients, atypical WHO grade II meningioma in 5 patients, and anaplastic WHO grade III meningioma in 2 patients. Eight patients were treated with primary radiotherapy, and in 4 patients tomotherapy was performed as re-irradiation for recurrent tumors. Results All patients were alive at the time of this analysis. Treatment was well tolerated by all patients. No severe side effects were observed. Four of 12 patients developed progression during follow-up at 2, 4, 17 and 29 months after radiotherapy. Of these, 2 patients were diagnosed with anaplastic meningiomas, and 2 patients suffered from atypical meningioma. Tumor progression developed after primary radiotherapy in 2 patients, and 2 recurrences developed after re-irradiation. Conclusions Helical tomotherapy can help meet the challenge of treating complex-shaped meningiomas in critical locations with one or multiple lesions due to the excellent dose distributions and the favorable clinical results.
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Affiliation(s)
- Stephanie E Combs
- University Hospital of Heidelberg, Department of Radiation Oncology, Im Neuenheimer Feld, Heidelberg, Germany
| | - Florian Sterzing
- University Hospital of Heidelberg, Department of Radiation Oncology, Im Neuenheimer Feld, Heidelberg, Germany
| | - Matthias Uhl
- University Hospital of Heidelberg, Department of Radiation Oncology, Im Neuenheimer Feld, Heidelberg, Germany
| | - Gregor Habl
- University Hospital of Heidelberg, Department of Radiation Oncology, Im Neuenheimer Feld, Heidelberg, Germany
| | - Kai Schubert
- University Hospital of Heidelberg, Department of Radiation Oncology, Im Neuenheimer Feld, Heidelberg, Germany
| | - Jürgen Debus
- University Hospital of Heidelberg, Department of Radiation Oncology, Im Neuenheimer Feld, Heidelberg, Germany
| | - Klaus Herfarth
- University Hospital of Heidelberg, Department of Radiation Oncology, Im Neuenheimer Feld, Heidelberg, Germany
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Austin AM, Douglass MJ, Nguyen GT, Penfold SN. A radiobiological Markov simulation tool for aiding decision making in proton therapy referral. Phys Med 2017; 44:72-82. [DOI: 10.1016/j.ejmp.2017.11.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 11/07/2017] [Accepted: 11/15/2017] [Indexed: 12/26/2022] Open
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Li YC, Chen FP, Zhou GQ, Zhu JH, Hu J, Kang DH, Wu CF, Lin L, Wang XJ, Ma J, Sun Y. Incidence and dosimetric parameters for brainstem necrosis following intensity modulated radiation therapy in nasopharyngeal carcinoma. Oral Oncol 2017; 73:97-104. [DOI: 10.1016/j.oraloncology.2017.08.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 08/11/2017] [Accepted: 08/16/2017] [Indexed: 12/25/2022]
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Quantification of the uncertainties of a biological model and their impact on variable RBE proton treatment plan optimization. Phys Med 2017; 36:91-102. [PMID: 28410691 DOI: 10.1016/j.ejmp.2017.03.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 03/14/2017] [Accepted: 03/20/2017] [Indexed: 01/12/2023] Open
Abstract
PURPOSE In proton radiation therapy, a relative biological effectiveness (RBE) equal to 1.1 is currently assumed, although biological experiments show that it is not constant. The purpose of this study was to quantify the uncertainties of a published biological model and explore their impact on variable RBE treatment plan (TP) optimization. METHODS Two patient cases with a high and a low (α/β)x tumor were investigated. Firstly, intensity modulated proton therapy TPs assuming constant RBE were derived, and subsequently the variable RBE weighted dose (RWD), including the uncertainty originating in the fit to the experimental data and the uncertainty of the (α/β)x, were calculated. Secondly, TPs optimized for uniform biological effect assuming a variable RBE were created using the worst case tissue specific (α/β)x. RESULTS For the nasopharyngeal cancer patient, the uncertainty of (α/β)x corresponded to a CTV D98 confidence interval (CI) of (-2, +4)% while for the fit parameter CI was (-2,+1)%. For the standard fractionation prostate case the (α/β)x CI was (-7,+5)% and the fit parameter CI was (-3,+3)%. For the hypofractionated case both CIs were (-1,+1)%. In both patient cases, the RBE in most organs at risk (OARs) was significantly underestimated by the constant RBE approximation, whereas the situation was not as definite in the target volumes. Overdosage of OARs was reduced by using the biological effect optimization. CONCLUSION For the two patient cases, the RWD uncertainty from the fit parameter in the biological model contributed non-negligibly to the total uncertainty, depending on the patient case and the organ. The presented optimization strategy is a basic method for robust biological effect optimization to reduce potential consequences caused by the (α/β)x uncertainty.
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Mohan R, Grosshans D. Proton therapy - Present and future. Adv Drug Deliv Rev 2017; 109:26-44. [PMID: 27919760 PMCID: PMC5303653 DOI: 10.1016/j.addr.2016.11.006] [Citation(s) in RCA: 239] [Impact Index Per Article: 34.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 11/28/2016] [Accepted: 11/30/2016] [Indexed: 12/13/2022]
Abstract
In principle, proton therapy offers a substantial clinical advantage over conventional photon therapy. This is because of the unique depth-dose characteristics of protons, which can be exploited to achieve significant reductions in normal tissue doses proximal and distal to the target volume. These may, in turn, allow escalation of tumor doses and greater sparing of normal tissues, thus potentially improving local control and survival while at the same time reducing toxicity and improving quality of life. Protons, accelerated to therapeutic energies ranging from 70 to 250MeV, typically with a cyclotron or a synchrotron, are transported to the treatment room where they enter the treatment head mounted on a rotating gantry. The initial thin beams of protons are spread laterally and longitudinally and shaped appropriately to deliver treatments. Spreading and shaping can be achieved by electro-mechanical means to treat the patients with "passively-scattered proton therapy" (PSPT) or using magnetic scanning of thin "beamlets" of protons of a sequence of initial energies. The latter technique can be used to treat patients with optimized intensity modulated proton therapy (IMPT), the most powerful proton modality. Despite the high potential of proton therapy, the clinical evidence supporting the broad use of protons is mixed. It is generally acknowledged that proton therapy is safe, effective and recommended for many types of pediatric cancers, ocular melanomas, chordomas and chondrosarcomas. Although promising results have been and continue to be reported for many other types of cancers, they are based on small studies. Considering the high cost of establishing and operating proton therapy centers, questions have been raised about their cost effectiveness. General consensus is that there is a need to conduct randomized trials and/or collect outcomes data in multi-institutional registries to unequivocally demonstrate the advantage of protons. Treatment planning and plan evaluation of PSPT and IMPT require special considerations compared to the processes used for photon treatment planning. The differences in techniques arise from the unique physical properties of protons but are also necessary because of the greater vulnerability of protons to uncertainties, especially from inter- and intra-fractional variations in anatomy. These factors must be considered in designing as well as evaluating treatment plans. In addition to anatomy variations, other sources of uncertainty in dose delivered to the patient include the approximations and assumptions of models used for computing dose distributions for planning of treatments. Furthermore, the relative biological effectiveness (RBE) of protons is simplistically assumed to have a constant value of 1.1. In reality, the RBE is variable and a complex function of the energy of protons, dose per fraction, tissue and cell type, end point, etc. These uncertainties, approximations and current technological limitations of proton therapy may limit the achievement of its true potential. Ongoing research is aimed at better understanding the consequences of the various uncertainties on proton therapy and reducing the uncertainties through image-guidance, adaptive radiotherapy, further study of biological properties of protons and the development of novel dose computation and optimization methods. However, residual uncertainties will remain in spite of the best efforts. To increase the resilience of dose distributions in the face of uncertainties and improve our confidence in dose distributions seen on treatment plans, robust optimization techniques are being developed and implemented. We assert that, with such research, proton therapy will be a commonly applied radiotherapy modality for most types of solid cancers in the near future.
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Affiliation(s)
- Radhe Mohan
- Department of Radiation Physics, MD Anderson Cancer Center, Houston, TX 77030, United States.
| | - David Grosshans
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX 77030, United States
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Treggiari E, Maddox TW, Gonçalves R, Benoit J, Buchholz J, Blackwood L. RETROSPECTIVE COMPARISON OF THREE-DIMENSIONAL CONFORMAL RADIATION THERAPY VS. PREDNISOLONE ALONE IN 30 CASES OF CANINE INFRATENTORIAL BRAIN TUMORS. Vet Radiol Ultrasound 2016; 58:106-116. [PMID: 27859957 DOI: 10.1111/vru.12440] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 09/20/2016] [Indexed: 01/24/2023] Open
Abstract
Infratentorial tumors are relatively infrequent in dogs and a lack of data makes it difficult to offer prognostic information. Untreated, dogs with these neoplasms have shorter survival times than those with supratentorial tumors. The role of radiation therapy (RT) in the management of infratentorial tumors is poorly defined and tumoral/peritumoral swelling in this site is a potential cause of serious acute side effects. The aim of this retrospective, cohort study was to describe cases of infratentorial tumors treated with fractionated three-dimensional conformal RT (3D CRT) and glucocorticoids (GC), and compare outcomes and survival with dogs affected by tumors in the same location that received GC alone. Thirty patients with a MRI diagnosis of infratentorial tumors were recruited (15 received RT and GC and 15 GC alone). None had mentation changes at presentation. For both groups, MRI and medical records were reviewed; and factors associated with survival were evaluated with Kaplan-Meier product limit survival and Cox regression analysis. Overall median survival time (MST) was 294 days (95% CI 42-545). The MST in the RT group was 756 days (95% CI 209-1302) vs. 89 days (95% CI 34.7-143.3 days) for those dogs treated palliatively with GC alone. This difference was statistically significant (P = 0.001). No other factors (including neurological signs, MRI features, tumor volume and total RT dose) were statistically associated with survival in the RT group. This study suggests that 3D CRT offers a survival advantage for dogs with infratentorial tumors compared to GC alone, and significant complications are uncommon.
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Affiliation(s)
- Elisabetta Treggiari
- School of Veterinary Science, Small Animal Teaching Hospital, University of Liverpool, CH64 7TE, Neston, Cheshire, UK
| | - Thomas W Maddox
- School of Veterinary Science, Small Animal Teaching Hospital, University of Liverpool, CH64 7TE, Neston, Cheshire, UK
| | - Rita Gonçalves
- School of Veterinary Science, Small Animal Teaching Hospital, University of Liverpool, CH64 7TE, Neston, Cheshire, UK
| | - Jerome Benoit
- Veterinary Referrals Cancer and Critical Care (VRCC Ltd.), SS15 6TP, Laindon, Essex, UK
| | - Julia Buchholz
- Animal Oncology and Imaging Centre (AOI), 6331, Hünenberg, Switzerland
| | - Laura Blackwood
- School of Veterinary Science, Small Animal Teaching Hospital, University of Liverpool, CH64 7TE, Neston, Cheshire, UK
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Guimas V, Thariat J, Graff-Cailleau P, Boisselier P, Pointreau Y, Pommier P, Montbarbon X, Laude C, Racadot S. Radiothérapie conformationnelle avec modulation d’intensité des cancers des voies aérodigestives supérieures, dose de tolérance des tissus sains : appareil cochléovestibulaire et tronc cérébral. Cancer Radiother 2016; 20:475-83. [DOI: 10.1016/j.canrad.2016.07.077] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 07/09/2016] [Accepted: 07/11/2016] [Indexed: 12/25/2022]
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Woodward WA, Amos RA. Proton Radiation Biology Considerations for Radiation Oncologists. Int J Radiat Oncol Biol Phys 2016; 95:59-61. [PMID: 27084628 DOI: 10.1016/j.ijrobp.2015.10.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 10/12/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Wendy A Woodward
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Richard A Amos
- Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, United Kingdom; Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
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Noël G, Antoni D, Barillot I, Chauvet B. Délinéation des organes à risque et contraintes dosimétriques. Cancer Radiother 2016; 20 Suppl:S36-60. [DOI: 10.1016/j.canrad.2016.07.032] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Matloob SA, Nasir HA, Choi D. Proton beam therapy in the management of skull base chordomas: systematic review of indications, outcomes, and implications for neurosurgeons. Br J Neurosurg 2016; 30:382-7. [PMID: 27173123 DOI: 10.1080/02688697.2016.1181154] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Chordomas are rare tumours affecting the skull base. There is currently no clear consensus on the post-surgical radiation treatments that should be used after maximal tumour resection. However, high-dose proton beam therapy is an accepted option for post-operative radiotherapy to maximise local control, and in the UK, National Health Service approval for funding abroad is granted for specific patient criteria. OBJECTIVES To review the indications and efficacy of proton beam therapy in the management of skull base chordomas. The primary outcome measure for review was the efficacy of proton beam therapy in the prevention of local occurrence. METHODS A systematic review of English and non-English articles using MEDLINE (1946-present) and EMBASE (1974-present) databases was performed. Additional studies were reviewed when referenced in other studies and not available on these databases. Search terms included chordoma or chordomas. The PRISMA guidelines were followed for reporting our findings as a systematic review. RESULTS A total of 76 articles met the inclusion and exclusion criteria for this review. Limitations included the lack of documentation of the extent of primary surgery, tumour size, and lack of standardised outcome measures. Level IIb/III evidence suggests proton beam therapy given post operatively for skull base chordomas results in better survival with less damage to surrounding tissue. CONCLUSIONS Proton beam therapy is a grade B/C recommended treatment modality for post-operative radiation therapy to skull base chordomas. In comparison to other treatment modalities long-term local control and survival is probably improved with proton beam therapy. Further, studies are required to directly compare proton beam therapy to other treatment modalities in selected patients.
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Affiliation(s)
- Samir A Matloob
- a Victor Horsley Department of Neurosurgery , National Hospital for Neurology and Neurosurgery , Queen Square, London , UK
| | - Haleema A Nasir
- a Victor Horsley Department of Neurosurgery , National Hospital for Neurology and Neurosurgery , Queen Square, London , UK
| | - David Choi
- a Victor Horsley Department of Neurosurgery , National Hospital for Neurology and Neurosurgery , Queen Square, London , UK
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Pencil beam scanning proton therapy for pediatric intracranial ependymoma. J Neurooncol 2016; 128:137-145. [DOI: 10.1007/s11060-016-2090-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 02/25/2016] [Indexed: 10/22/2022]
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Sinclair G, Bartek J, Martin H, Barsoum P, Dodoo E. Adaptive hypofractionated gamma knife radiosurgery for a large brainstem metastasis. Surg Neurol Int 2016; 7:S130-8. [PMID: 26958430 PMCID: PMC4765246 DOI: 10.4103/2152-7806.176138] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 12/28/2015] [Indexed: 11/24/2022] Open
Abstract
Background: To demonstrate how adaptive hypofractionated radiosurgery by gamma knife (GK) can be successfully utilized to treat a large brainstem metastasis - a novel approach to a challenging clinical situation. Case Description: A 42-year-old woman, diagnosed with metastatic nonsmall cell lung cancer in July 2011, initially treated with chemotherapy and tyrosine kinase inhibitors, developed multiple brain metastases March 2013, with subsequent whole brain radiotherapy, after which a magnetic resonance imaging (MRI) showed a significant volume regression of all brain metastases. A follow-up MRI in October 2013 revealed a growing brainstem lesion of 26 mm. Linear accelerator-based radiotherapy and microsurgery were judged contraindicated, why the decision was made to treat the patient with three separate radiosurgical sessions during the course of 1 week, with an 18% tumor volume reduction demonstrated after the last treatment. Follow-up MRI 2.5 months after her radiosurgical treatment showed a tumor volume reduction of 67% compared to the 1st day of treatment. Later on, the patient developed a radiation-induced perilesional edema although without major clinical implications. An MRI at 12 months and 18-fluoro-deoxyglucose positron emission tomography of the brain at 13 months showed decreased edema with no signs of tumor recurrence. Despite disease progression during the last months of her life, the patient's condition remained overall acceptable. Conclusion: GK-based stereotactic adaptive hypofractionation proved to be effective to achieve tumor control while limiting local adverse reactions. This surgical modality should be considered when managing larger brain lesions in critical areas.
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Affiliation(s)
- Georges Sinclair
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Jiri Bartek
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden; Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Heather Martin
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Pierre Barsoum
- Department of Medical Physics, Karolinska University Hospital, Stockholm, Sweden
| | - Ernest Dodoo
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
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Maranzano E, Draghini L, Casale M, Arcidiacono F, Anselmo P, Trippa F, Giorgi C. Long-term outcome of moderate hypofractionated stereotactic radiotherapy for meningiomas. Strahlenther Onkol 2015; 191:953-60. [PMID: 26490452 DOI: 10.1007/s00066-015-0915-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 10/07/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE The aim of this work was to evaluate long-term results of moderate hypofractionated stereotactic radiotherapy (hFSRT) for intracranial meningiomas. PATIENTS AND METHODS In all, 77 consecutive patients with 80 lesions were included. Median age was 65 years (range 23-82 years), male/female ratio was 21/56, and the median Karnofsky performance status was 90 (range 60-100). In 31 lesions (39 %), diagnosis was based upon clinical and radiological data; 37 lesions were histologically proven as World Health Organization (WHO) grade I and 12 grade II meningiomas. Median treatment volume was 23 cc. Prescribed doses were 45 Gy in 15 fractions of 3 Gy (15 × 3 Gy) or 42 Gy in 14 fractions of 3 Gy (14 × 3 Gy). RESULTS After a median follow-up of 56 months, 49 (61 %) lesions received 14 × 3 Gy and 31 (39 %) 15 × 3 Gy. Local control (LC) rate remained unchanged at 84 % at 5 and 10 years. Overall survival and disease-specific survival (DSS) were 76 and 93 % at 5 years, 72 and 89 % at 10 years, respectively. With univariate analysis, previous surgery and WHO grade II tumor were negative prognostic factors for LC and DSS. With multivariate analysis only tumor grade was an independent prognostic factor for LC. No clinically significant acute and/or late toxicities were observed. CONCLUSION Moderate hFSRT was effective and safe with an excellent tolerance profile. It can be an alternative treatment option for patients with recurrent or inoperable large meningiomas. The low number of fractions administered with hFSRT led to reduce treatment-related discomfort for patients. Grade II tumor and previous surgery were negative prognosis factors.
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Affiliation(s)
- Ernesto Maranzano
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Via T. di Joannuccio, 1, 05100, Terni, Italy.
| | - Lorena Draghini
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Via T. di Joannuccio, 1, 05100, Terni, Italy
| | - Michelina Casale
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Via T. di Joannuccio, 1, 05100, Terni, Italy
| | - Fabio Arcidiacono
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Via T. di Joannuccio, 1, 05100, Terni, Italy
| | - Paola Anselmo
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Via T. di Joannuccio, 1, 05100, Terni, Italy
| | - Fabio Trippa
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Via T. di Joannuccio, 1, 05100, Terni, Italy
| | - Cesare Giorgi
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Via T. di Joannuccio, 1, 05100, Terni, Italy
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Iyer A, Kano H, Kondziolka D, Liu X, Flickinger JC, Lunsford LD. Postsurgical management strategies in patients with skull base chondrosarcomas. CNS Oncol 2015; 2:203-8. [PMID: 25057979 DOI: 10.2217/cns.13.3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Chondrosarcomas of the skull base are rare, slow-growing tumors that are often lethal and remain a management quandary. A systematic review was performed to understand postsurgical management options for patients with these tumors. The current standard of care includes surgical resection followed by either adjuvant radiation therapy and/or early radiosurgery. The role of chemotherapy has been limited, but remains under investigation. Overall survival and progression-free survival range between 70 and 100% at 5 years when multimodality approaches are used. Overall survival may be greater for patients who have a shorter interval (<6 months) between diagnosis and radiosurgery, an older age, and either a single or no prior resection. Progression-free survival may be increased for patients older than 40 years of age, who have not had prior radiation therapy, and for those with smaller tumors that do not compress the brainstem.
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Affiliation(s)
- Aditya Iyer
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Liu W, Mohan R, Park P, Liu Z, Li H, Li X, Li Y, Wu R, Sahoo N, Dong L, Zhu XR, Grosshans DR. Dosimetric benefits of robust treatment planning for intensity modulated proton therapy for base-of-skull cancers. Pract Radiat Oncol 2014; 4:384-91. [PMID: 25407859 PMCID: PMC4238033 DOI: 10.1016/j.prro.2013.12.001] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Revised: 11/14/2013] [Accepted: 12/02/2013] [Indexed: 11/15/2022]
Abstract
PURPOSE The clinical advantage of intensity modulated proton therapy (IMPT) may be diminished by range and patient setup uncertainties. We evaluated the effectiveness of robust optimization that incorporates uncertainties into the treatment planning optimization algorithm for treatment of base of skull cancers. METHODS AND MATERIALS We compared 2 IMPT planning methods for 10 patients with base of skull chordomas and chondrosarcomas: (1) conventional optimization, in which uncertainties are dealt with by creating a planning target volume (PTV); and (2) robust optimization, in which uncertainties are dealt with by optimizing individual spot weights without a PTV. We calculated root-mean-square deviation doses (RMSDs) for every voxel to generate RMSD volume histograms (RVHs). The area under the RVH curve was used for relative comparison of the 2 methods' plan robustness. Potential benefits of robust planning, in terms of target dose coverage and homogeneity and sparing of organs at risk (OARs) were evaluated using established clinical metrics. Then the plan evaluation metrics were averaged and compared with 2-sided paired t tests. The impact of tumor volume on the effectiveness of robust optimization was also analyzed. RESULTS Relative to conventionally optimized plans, robustly optimized plans were less sensitive for both targets and OARs. In the nominal scenario, robust and conventional optimization resulted in similar D95% doses (D95% clinical target volume [CTV]: 63.3 and 64.8 Gy relative biologic effectiveness [RBE]), P <.01]) and D5%-D95% (D5%-D95% CTV: 8.0 and 7.1 Gy[RBE], [P <.01); irradiation of OARs was less with robust optimization (brainstem V60: 0.076 vs 0.26 cm(3) [P <.01], left temporal lobe V70: 0.22 vs 0.41 cm(3), [P = .068], right temporal lobe V70: 0.016 vs 0.11 cm(3), [P = .096], left cochlea Dmean: 28.1 vs 30.1 Gy[RBE], [P = .023], right cochlea Dmean: 23.7 vs 25.2 Gy[RBE], [P = .059]). Results in the worst-case scenario were analogous. CONCLUSIONS Robust optimization is effective for creating clinically feasible IMPT plans for tumors of the base of skull.
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Affiliation(s)
- Wei Liu
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona.
| | - Radhe Mohan
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Peter Park
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - Zhong Liu
- School of Business Administration, Southwestern University of Finance and Economics, Chengdu, China
| | - Heng Li
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Xiaoqiang Li
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yupeng Li
- Varian Medical Systems, Inc, Palo Alto, California
| | - Richard Wu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Narayan Sahoo
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lei Dong
- Scripps Proton Center, San Diego, California
| | - X Ronald Zhu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David R Grosshans
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Fukumitsu N, Ishikawa H, Ohnishi K, Terunuma T, Mizumoto M, Numajiri H, Aihara T, Okumura T, Tsuboi K, Sakae T, Sakurai H. Dose distribution resulting from changes in aeration of nasal cavity or paranasal sinus cancer in the proton therapy. Radiother Oncol 2014; 113:72-6. [DOI: 10.1016/j.radonc.2014.08.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 08/18/2014] [Accepted: 08/18/2014] [Indexed: 10/24/2022]
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Yock TI, Constine LS, Mahajan A. Protons, the brainstem, and toxicity: ingredients for an emerging dialectic. Acta Oncol 2014; 53:1279-82. [PMID: 25327262 DOI: 10.3109/0284186x.2014.957415] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Torunn I Yock
- Massachusetts General Hospital, Francis H. Burr Proton Therapy Center , Boston , USA
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Indelicato DJ, Flampouri S, Rotondo RL, Bradley JA, Morris CG, Aldana PR, Sandler E, Mendenhall NP. Incidence and dosimetric parameters of pediatric brainstem toxicity following proton therapy. Acta Oncol 2014; 53:1298-304. [PMID: 25279957 DOI: 10.3109/0284186x.2014.957414] [Citation(s) in RCA: 141] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Proton therapy offers superior low and intermediate radiation dose distribution compared with photon-based radiation for brain and skull base tumors; yet tissue within and adjacent to the target volume may receive a comparable radiation dose. We investigated the tolerance of the pediatric brainstem to proton therapy and identified prognostic variables. MATERIAL AND METHODS All patients < 18 years old with tumors of the brain or skull base treated from 2007 to 2013 were reviewed; 313 who received > 50.4 CGE to the brainstem were included in this study. Brainstem toxicity was graded according to the NCI Common Terminology Criteria for Adverse Events v4.0. RESULTS The three most common histologies were ependymoma, craniopharyngioma, and low-grade glioma. Median patient age was 5.9 years (range 0.5-17.9 years) and median prescribed dose was 54 CGE (range 48.6-75.6 CGE). The two-year cumulative incidence of toxicity was 3.8% ± 1.1%. The two-year cumulative incidence of grade 3 + toxicity was 2.1% ± 0.9%. Univariate analysis identified age < 5 years, posterior fossa tumor location and specific dosimetric parameters as factors associated with an increased risk of toxicity. CONCLUSION Utilization of current national brainstem dose guidelines is associated with a low risk of brainstem toxicity in pediatric patients. For young patients with posterior fossa tumors, particularly those who undergo aggressive surgery, our data suggest more conservative dosimetric guidelines should be considered.
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Affiliation(s)
- Daniel J Indelicato
- Department of Radiation Oncology, University of Florida , Jacksonville, Florida , USA
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50
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Grosshans DR, Zhu XR, Melancon A, Allen PK, Poenisch F, Palmer M, McAleer MF, McGovern SL, Gillin M, DeMonte F, Chang EL, Brown PD, Mahajan A. Spot scanning proton therapy for malignancies of the base of skull: treatment planning, acute toxicities, and preliminary clinical outcomes. Int J Radiat Oncol Biol Phys 2014; 90:540-6. [PMID: 25304948 DOI: 10.1016/j.ijrobp.2014.07.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 06/30/2014] [Accepted: 07/03/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE To describe treatment planning techniques and early clinical outcomes in patients treated with spot scanning proton therapy for chordoma or chondrosarcoma of the skull base. METHODS AND MATERIALS From June 2010 through August 2011, 15 patients were treated with spot scanning proton therapy for chordoma (n=10) or chondrosarcoma (n=5) at a single institution. Toxicity was prospectively evaluated and scored weekly and at all follow-up visits according to Common Terminology Criteria for Adverse Events, version 3.0. Treatment planning techniques and dosimetric data were recorded and compared with those of passive scattering plans created with clinically applicable dose constraints. RESULTS Ten patients were treated with single-field-optimized scanning beam plans and 5 with multifield-optimized intensity modulated proton therapy. All but 2 patients received a simultaneous integrated boost as well. The mean prescribed radiation doses were 69.8 Gy (relative biological effectiveness [RBE]; range, 68-70 Gy [RBE]) for chordoma and 68.4 Gy (RBE) (range, 66-70) for chondrosarcoma. In comparison with passive scattering plans, spot scanning plans demonstrated improved high-dose conformality and sparing of temporal lobes and brainstem. Clinically, the most common acute toxicities included fatigue (grade 2 for 2 patients, grade 1 for 8 patients) and nausea (grade 2 for 2 patients, grade 1 for 6 patients). No toxicities of grades 3 to 5 were recorded. At a median follow-up time of 27 months (range, 13-42 months), 1 patient had experienced local recurrence and a second developed distant metastatic disease. Two patients had magnetic resonance imaging-documented temporal lobe changes, and a third patient developed facial numbness. No other subacute or late effects were recorded. CONCLUSIONS In comparison to passive scattering, treatment plans for spot scanning proton therapy displayed improved high-dose conformality. Clinically, the treatment was well tolerated, and with short-term follow-up, disease control rates and toxicity profiles were favorable.
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Affiliation(s)
- David R Grosshans
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - X Ronald Zhu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Adam Melancon
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Pamela K Allen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Falk Poenisch
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew Palmer
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Susan L McGovern
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael Gillin
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Franco DeMonte
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eric L Chang
- Department of Radiation Oncology, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Paul D Brown
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Anita Mahajan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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