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Sterpin E, Widesott L, Poels K, Hoogeman M, Korevaar EW, Lowe M, Molinelli S, Fracchiolla F. Robustness evaluation of pencil beam scanning proton therapy treatment planning: A systematic review. Radiother Oncol 2024; 197:110365. [PMID: 38830538 DOI: 10.1016/j.radonc.2024.110365] [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: 08/09/2023] [Revised: 04/30/2024] [Accepted: 05/29/2024] [Indexed: 06/05/2024]
Abstract
Compared to conventional radiotherapy using X-rays, proton therapy, in principle, allows better conformity of the dose distribution to target volumes, at the cost of greater sensitivity to physical, anatomical, and positioning uncertainties. Robust planning, both in terms of plan optimization and evaluation, has gained high visibility in publications on the subject and is part of clinical practice in many centers. However, there is currently no consensus on the methods and parameters to be used for robust optimization or robustness evaluation. We propose to overcome this deficiency by following the modified Delphi consensus method. This method first requires a systematic review of the literature. We performed this review using the PubMed and Web Of Science databases, via two different experts. Potential conflicts were resolved by a third expert. We then explored the different methods before focusing on clinical studies that evaluate robustness on a significant number of patients. Many robustness assessment methods are proposed in the literature. Some are more successful than others and their implementation varies between centers. Moreover, they are not all statistically or mathematically equivalent. The most sophisticated and rigorous methods have seen more limited application due to the difficulty of their implementation and their lack of widespread availability.
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Affiliation(s)
- E Sterpin
- KU Leuven - Department of Oncology, Laboratory of Experimental Radiotherapy, Leuven, Belgium; UCLouvain - Institution de Recherche Expérimentale et Clinique, Center of Molecular Imaging Radiotherapy and Oncology (MIRO), Brussels, Belgium; Particle Therapy Interuniversity Center Leuven - PARTICLE, Leuven, Belgium.
| | - L Widesott
- Proton Therapy Center - UO Fisica Sanitaria, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - K Poels
- Particle Therapy Interuniversity Center Leuven - PARTICLE, Leuven, Belgium; UZ Leuven, Department of Radiation Oncology, Leuven, Belgium
| | - M Hoogeman
- Erasmus Medical Center, Cancer Institute, Department of Radiotherapy, Rotterdam, the Netherlands; HollandPTC, Delft, the Netherlands
| | - E W Korevaar
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, the Netherlands
| | - M Lowe
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - S Molinelli
- Fondazione CNAO - Medical Physics Unit, Pavia, Italy
| | - F Fracchiolla
- Proton Therapy Center - UO Fisica Sanitaria, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
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Johnson PB, Mamalui M, Brodin P, Janssens G. Secondary cancer risk in six anatomical sites when using PAT, IMPT, and VMAT/IMRT radiotherapy. Radiother Oncol 2024:110421. [PMID: 38997093 DOI: 10.1016/j.radonc.2024.110421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 07/02/2024] [Accepted: 07/05/2024] [Indexed: 07/14/2024]
Abstract
BACKGROUND AND PURPOSE Compared to intensity modulated proton therapy (IMPT), proton arc therapy (PAT) is expected to improve dose conformality, delivery efficiency, and provide a more favorable LET distribution. Alternatively, the low-dose bath is potentially spread over larger volumes, which could impact the likelihood of developing a radiation-induced, secondary cancer (SC). The goal of this study was to evaluate this risk in several anatomical sites using newly developed commercial tools. MATERIALS AND METHODS Treatment plans encompassing six anatomical sites, five patients per site, and three techniques per patient were created using RayStation. Techniques included PAT and IMPT for protons, and either volumetrically modulated radiotherapy (VMAT) or intensity modulated radiotherapy (IMRT) for photons. Risk estimates were based on the organ-equivalent dose (OED) concept using both Schneider's mechanistic dose-response model for carcinoma induction and a linear dose-response model. RESULTS With few exceptions, mean and integral dose were lowest with PAT. For protons, the factor OEDIMPT/OEDPAT ranged from 0.7 to 1.8 with both the mechanistic and linear model, while for photons OEDphoton/OEDPAT ranged from 1.5 to 10 using the mechanistic model and 1.3-9.6 using the linear model. A strong correlation was found between mean dose and OED for organs with significant repopulation/repair (high R value) and less cell death from single hit interactions (low α value). CONCLUSION Based results from both mechanistic and linear risk models, the transition from IMPT to PAT should not substantially affect SC risk in patients treated with proton therapy. Additionally, when using Schneider's model, the shapes of the dose-response curves can be used as a good predictor of how SC risk will respond to shifts from intermediate dose to low dose as anticipated when moving from IMPT to PAT.
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Affiliation(s)
- Perry B Johnson
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, United States; University of Florida College of Medicine, Gainesville, FL, United States.
| | - Maria Mamalui
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, United States; University of Florida College of Medicine, Gainesville, FL, United States
| | - Patrik Brodin
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, United States
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McIntyre M, Wilson P, Gorayski P, Bezak E. A Systematic Review of LET-Guided Treatment Plan Optimisation in Proton Therapy: Identifying the Current State and Future Needs. Cancers (Basel) 2023; 15:4268. [PMID: 37686544 PMCID: PMC10486456 DOI: 10.3390/cancers15174268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/16/2023] [Accepted: 08/17/2023] [Indexed: 09/10/2023] Open
Abstract
The well-known clinical benefits of proton therapy are achieved through higher target-conformality and normal tissue sparing than conventional radiotherapy. However, there is an increased sensitivity to uncertainties in patient motion/setup, proton range and radiobiological effect. Although recent efforts have mitigated some uncertainties, radiobiological effect remains unresolved due to a lack of clinical data for relevant endpoints. Therefore, RBE optimisations may be currently unsuitable for clinical treatment planning. LET optimisation is a novel method that substitutes RBE with LET, shifting LET hotspots outside critical structures. This review outlines the current status of LET optimisation in proton therapy, highlighting knowledge gaps and possible future research. Following the PRISMA 2020 guidelines, a search of the MEDLINE® and Scopus databases was performed in July 2023, identifying 70 relevant articles. Generally, LET optimisation methods achieved their treatment objectives; however, clinical benefit is patient-dependent. Inconsistencies in the reported data suggest further testing is required to identify therapeutically favourable methods. We discuss the methods which are suitable for near-future clinical deployment, with fast computation times and compatibility with existing treatment protocols. Although there is some clinical evidence of a correlation between high LET and adverse effects, further developments are needed to inform future patient selection protocols for widespread application of LET optimisation in proton therapy.
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Affiliation(s)
- Melissa McIntyre
- Allied Health & Human Performance Academic Unit, University of South Australia, Adelaide, SA 5000, Australia
| | - Puthenparampil Wilson
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, SA 5000, Australia
- UniSA STEM, University of South Australia, Adelaide, SA 5000, Australia
| | - Peter Gorayski
- Allied Health & Human Performance Academic Unit, University of South Australia, Adelaide, SA 5000, Australia
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, SA 5000, Australia
- Australian Bragg Centre for Proton Therapy and Research, Adelaide, SA 5000, Australia
| | - Eva Bezak
- Allied Health & Human Performance Academic Unit, University of South Australia, Adelaide, SA 5000, Australia
- Department of Physics, University of Adelaide, Adelaide, SA 5005, Australia
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Rana S, Traneus E, Jackson M, Tran L, Rosenfeld AB. Quantitative analysis of dose-averaged linear energy transfer (LET d ) robustness in pencil beam scanning proton lung plans. Med Phys 2022; 49:3444-3456. [PMID: 35194809 DOI: 10.1002/mp.15569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 02/14/2022] [Accepted: 02/14/2022] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The primary objective of our study was to perform a quantitative robustness analysis of the dose-averaged linear energy transfer (LETd ) and related RBE-weighted dose in robustly optimized (in terms of the range and set up uncertainties) pencil beam scanning (PBS) proton lung cancer plans. METHODS In this study, we utilized the 4DCT data set of six anonymized lung patients. PBS lung plans were generated using a robust optimization technique (range uncertainty: ±3.5% and setup errors: ±5 mm) on the CTV for a total dose of 5000 cGy(RBE) in 5 fractions using RBE of 1.1. For each patient, the LETd distributions were calculated for the nominal plan and three groups. Group 1: two plan robustness scenarios for range uncertainties of ±3.5%; Group 2: twelve plan robustness scenarios (range uncertainty (±3.5%) in conjunction with setup errors (±5 mm)); and Group 3: ten different breathing phases of the 4DCT data set. RBE-weighted dose to the OARs was evaluated for all robustness scenarios and breathing phases. The variation (∆) in the mean LETd and mean RBE-weighted dose from each group was recorded. RESULTS The mean LETd in the CTV of nominal PBS lung plans among six patients ranged from 2.2 to 2.6 keV/μm. On average, for the combined range and setup uncertainties, the ∆ in the mean LETd among 12 scenarios of all six patients was 0.6 keV/μm, which is slightly higher than when only the range uncertainties were considered (0.4 keV/μm). The ∆ in the mean LETd in a patient was ≤1.7 keV/μm in the heart and ≤1.2 keV/μm in the esophagus and total lung. The ∆ in the mean RBE-weighted dose in a patient was up to 79 cGy for the total lung, 165 cGy for the heart, and 258 cGy for the esophagus. For ten breathing phases, the ∆ in the mean LETd in a patient was ≤0.3 keV/μm in the CTV, ≤0.5 keV/μm in the heart, ≤0.4 keV/μm in the esophagus, and ≤0.7 keV/μm in the total lung. CONCLUSION The addition of setup errors to the range uncertainties resulted in slightly less homogeneous LETd distributions. The variations in the mean LETd among ten breathing phases were slightly larger in the total lung than in the heart and esophagus. The combination of setup and range uncertainties had a greater impact than the effect of breathing phases on the variations in the mean RBE-weighted dose to the OARs. Overall, the LETd distributions in the CTV were less sensitive than those in the OARs to setup errors, range uncertainties, and breathing phases for robustly optimized PBS proton lung cancer plans. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Suresh Rana
- Department of Radiation Oncology, Lynn Cancer Institute, Boca Raton Regional Hospital, Baptist Health South Florida, Boca Raton, Florida, USA.,Department of Medical Physics, The Oklahoma Proton Center, Oklahoma City, Oklahoma, USA.,Centre for Medical Radiation Physics (CMRP), University of Wollongong, Wollongong, NSW, Australia
| | - Erik Traneus
- RaySearch Laboratories, Medical Physics, Stockholm, Sweden
| | - Michael Jackson
- Prince of Wales Hospital, Radiation Oncology, Randwick, Australia
| | - Linh Tran
- Centre for Medical Radiation Physics (CMRP), University of Wollongong, Wollongong, NSW, Australia
| | - Anatoly B Rosenfeld
- Centre for Medical Radiation Physics (CMRP), University of Wollongong, Wollongong, NSW, Australia
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Li Y, Li X, Yang J, Wang S, Tang M, Xia J, Gao Y. Flourish of Proton and Carbon Ion Radiotherapy in China. Front Oncol 2022; 12:819905. [PMID: 35237518 PMCID: PMC8882681 DOI: 10.3389/fonc.2022.819905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/24/2022] [Indexed: 11/13/2022] Open
Abstract
Proton and heavy ion therapy offer superior relative biological effectiveness (RBE) in the treatment of deep-seated tumors compared with conventional photon radiotherapy due to its Bragg-peak feature of energy deposition in organs. Many proton and carbon ion therapy centers are active all over the world. At present, five particle radiotherapy institutes have been built and are receiving patient in China, mainly including Wanjie Proton Therapy Center (WPTC), Shanghai Proton Heavy Ion Center (SPHIC), Heavy Ion Cancer Treatment Center (HIMM), Chang Gung Memorial Hospital (CGMH), and Ruijin Hospital affiliated with Jiao Tong University. Many cancer patients have benefited from ion therapy, showing unique advantages over surgery and chemotherapy. By the end of 2020, nearly 8,000 patients had been treated with proton, carbon ion or carbon ion combined with proton therapy. So far, there is no systemic review for proton and carbon ion therapy facility and clinical outcome in China. We reviewed the development of proton and heavy ion therapy, as well as providing the representative clinical data and future directions for particle therapy in China. It has important guiding significance for the design and construction of new particle therapy center and patients’ choice of treatment equipment.
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Affiliation(s)
- Yue Li
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, China
- *Correspondence: Yue Li,
| | - Xiaoman Li
- Department of Radiation Medicine, School of Basic Medical Sciences, Peking University Health Science Center, Beijing, China
| | - Jiancheng Yang
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, China
| | - Sicheng Wang
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, China
| | - Meitang Tang
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, China
| | - Jiawen Xia
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, China
- Huizhou Research Center of Ion Science, Chinese Academy of Sciences, Huizhou, China
| | - Yunzhe Gao
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, China
- School of Nuclear Science and Technology, University of Chinese Academy of Sciences, Beijing, China
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