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Toussaint L, Matysiak W, Alapetite C, Aristu J, Bannink-Gawryszuk A, Bolle S, Bolsi A, Calvo F, Cerron Campoo F, Charlwood F, Demoor-Goldschmidt C, Doyen J, Drosik-Rutowicz K, Dutheil P, Embring A, Engellau J, Goedgebeur A, Goudjil F, Harrabi S, Kopec R, Kristensen I, Lægsdmand P, Lütgendorf-Caucig C, Meijers A, Mirandola A, Missohou F, Montero Feijoo M, Muren LP, Ondrova B, Orlandi E, Pettersson E, Pica A, Plaude S, Righetto R, Rombi B, Timmermann B, Van Beek K, Vela A, Vennarini S, Vestergaard A, Vidal M, Vondracek V, Weber DC, Whitfield G, Zimmerman J, Maduro JH, Lassen-Ramshad Y. Clinical practice in European centres treating paediatric posterior fossa tumours with pencil beam scanning proton therapy. Radiother Oncol 2024; 198:110414. [PMID: 38942120 DOI: 10.1016/j.radonc.2024.110414] [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: 10/31/2023] [Revised: 04/17/2024] [Accepted: 06/21/2024] [Indexed: 06/30/2024]
Abstract
BACKGROUND AND PURPOSE As no guidelines for pencil beam scanning (PBS) proton therapy (PT) of paediatric posterior fossa (PF) tumours exist to date, this study investigated planning techniques across European PT centres, with special considerations for brainstem and spinal cord sparing. MATERIALS AND METHODS A survey and a treatment planning comparison were initiated across nineteen European PBS-PT centres treating paediatric patients. The survey assessed all aspects of the treatment chain, including but not limited to delineations, dose constraints and treatment planning. Each centre planned two PF tumour cases for focal irradiation, according to their own clinical practice but based on common delineations. The prescription dose was 54 Gy(RBE) for Case 1 and 59.4 Gy(RBE) for Case 2. For both cases, planning strategies and relevant dose metrics were compared. RESULTS Seventeen (89 %) centres answered the survey, and sixteen (80 %) participated in the treatment planning comparison. In the survey, thirteen (68 %) centres reported using the European Particle Therapy Network definition for brainstem delineation. In the treatment planning study, while most centres used three beam directions, their configurations varied widely across centres. Large variations were also seen in brainstem doses, with a brainstem near maximum dose (D2%) ranging from 52.7 Gy(RBE) to 55.7 Gy(RBE) (Case 1), and from 56.8 Gy(RBE) to 60.9 Gy(RBE) (Case 2). CONCLUSION This study assessed the European PBS-PT planning of paediatric PF tumours. Agreement was achieved in e.g. delineation-practice, while wider variations were observed in planning approach and consequently dose to organs at risk. Collaboration between centres is still ongoing, striving towards common guidelines.
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Affiliation(s)
- Laura Toussaint
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus N, Denmark; Aarhus University, Department of Clinical Medicine, Aarhus N, Denmark.
| | - Witold Matysiak
- University of Groningen, University Medical Centre Groningen, Department of Radiation Oncology, Groningen, the Netherlands
| | - Claire Alapetite
- Institut Curie, Department of Radiation Oncology & Proton Centre, Paris, France
| | - Javier Aristu
- Clínica Universidad de Navarra, Proton Therapy Unit, Madrid, Spain
| | - Agata Bannink-Gawryszuk
- University of Groningen, University Medical Centre Groningen, Department of Radiation Oncology, Groningen, the Netherlands
| | - Stephanie Bolle
- Institut Curie, Department of Radiation Oncology & Proton Centre, Paris, France; Institut Gustave Roussy, Department of Radiation Oncology, Villejuif, France; Centro de Protonterapia Quironsalud, Madrid, Spain
| | - Alessandra Bolsi
- Paul Scherrer Institute, Centre for Proton Therapy, ETH Domain, Villigen, Switzerland
| | - Felipe Calvo
- Clínica Universidad de Navarra, Proton Therapy Unit, Madrid, Spain
| | | | - Frances Charlwood
- University of Manchester, The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Charlotte Demoor-Goldschmidt
- Centre Regional Francois Baclesse, Department of Radiation Oncology, Caen, France; Angers University Hospital, Department of Paediatric Oncology, Angers, France
| | - Jérôme Doyen
- Centre Antoine Lacassagne, Department of Radiation Oncology, Nice, France
| | - Katarzyna Drosik-Rutowicz
- National Research Institute of Oncology Kraków/Gliwice branch, Department of Radiation Oncology, Kraków, Poland
| | - Pauline Dutheil
- Centre Regional Francois Baclesse, Department of Radiation Oncology, Caen, France
| | - Anna Embring
- Karolinska University Hospital, Department of Radiotherapy, Stockholm, Sweden
| | - Jacob Engellau
- Skåne University Hospital, Hematology, Oncology and Radiation Physics, Lund, Sweden
| | - Anneleen Goedgebeur
- PARTICLE Proton Therapy Centre University Hospital Leuven, Department of Radiation Oncology, Leuven, Belgium
| | - Farid Goudjil
- Institut Curie, Department of Radiation Oncology & Proton Centre, Paris, France
| | - Semi Harrabi
- Heidelberg Ion Beam Therapy Centre, University Hospital Heidelberg, Department of Radiation Oncology, Heidelberg, Germany
| | - Renata Kopec
- Institute of Nuclear Physics, Polish Academy of Sciences, Kraków, Poland
| | - Ingrid Kristensen
- Skåne University Hospital, Hematology, Oncology and Radiation Physics, Lund, Sweden
| | - Peter Lægsdmand
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus N, Denmark; Aarhus University, Department of Clinical Medicine, Aarhus N, Denmark
| | | | - Arturs Meijers
- Paul Scherrer Institute, Centre for Proton Therapy, ETH Domain, Villigen, Switzerland
| | - Alfredo Mirandola
- Radiation Oncology Unit, Clinical Department, National Centre for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Fernand Missohou
- Centre Regional Francois Baclesse, Department of Radiation Oncology, Caen, France
| | | | - Ludvig P Muren
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus N, Denmark; Aarhus University, Department of Clinical Medicine, Aarhus N, Denmark
| | - Barbora Ondrova
- Proton Therapy Centre Czech, Department of Radiation Oncology, Prague, Czech Republic
| | - Ester Orlandi
- Radiation Oncology Unit, Clinical Department, National Centre for Oncological Hadrontherapy (CNAO), Pavia, Italy; University of Pavia, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, Pavia, Italy
| | - Erik Pettersson
- Sahlgrenska University Hospital, Department of Therapeutic Radiation Physics, Medical Physics and Biomedical Engineering, Gothenburg, Sweden; Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Department of Medical Radiation Sciences, Gothenburg, Sweden
| | - Alessia Pica
- Paul Scherrer Institute, Centre for Proton Therapy, ETH Domain, Villigen, Switzerland
| | - Sandija Plaude
- West German Proton Therapy Centre Essen (WPE), Essen University Hospital, Essen, Germany
| | | | - Barbara Rombi
- Trento Proton Therapy Centre,epartment of Radiation Oncology, APSS Trento, Italy
| | - Beate Timmermann
- West German Proton Therapy Centre Essen (WPE), Essen University Hospital, Essen, Germany; Department of Particle Therapy, University Hospital Essen, Essen, Germany; West German Cancer Centre (WTZ), German Cancer Consortium (DKTK), Essen, Germany
| | - Karen Van Beek
- PARTICLE Proton Therapy Centre University Hospital Leuven, Department of Radiation Oncology, Leuven, Belgium
| | - Anthony Vela
- Centre Regional Francois Baclesse, Department of Radiation Oncology, Caen, France
| | - Sabina Vennarini
- Paediatric Radiotherapy Unit, IRCCS Foundation Institute of Cancer, Milano, Italy
| | - Anne Vestergaard
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus N, Denmark
| | - Marie Vidal
- Centre Antoine Lacassagne, Department of Radiation Oncology, Nice, France
| | - Vladimir Vondracek
- Proton Therapy Centre Czech, Department of Radiation Oncology, Prague, Czech Republic
| | - Damien C Weber
- Paul Scherrer Institute, Centre for Proton Therapy, ETH Domain, Villigen, Switzerland
| | - Gillian Whitfield
- University of Manchester, The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom; University of Manchester, Royal Manchester Children's Hospital, The Children's Brain Tumour Research Network, Manchester, United Kingdom
| | - Jens Zimmerman
- Karolinska University Hospital, Department of Radiotherapy Physics and Engineering, Stockholm, Sweden
| | - John H Maduro
- University of Groningen, University Medical Centre Groningen, Department of Radiation Oncology, Groningen, the Netherlands
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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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Engeseth GM, Hysing LB, Yepes P, Pettersen HES, Mohan R, Fuller CD, Stokkevåg CH, Wu R, Zhang X, Frank SJ, Gunn GB. Impact of RBE variations on risk estimates of temporal lobe necrosis in patients treated with intensity-modulated proton therapy for head and neck cancer. Acta Oncol 2022; 61:215-222. [PMID: 34534047 PMCID: PMC9969227 DOI: 10.1080/0284186x.2021.1979248] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Temporal lobe necrosis (TLN) is a potential late effect after radiotherapy for skull base head and neck cancer (HNC). Several photon-derived dose constraints and normal tissue complication probability (NTCP) models have been proposed, however variation in relative biological effectiveness (RBE) may challenge the applicability of these dose constraints and models in proton therapy. The purpose of this study was therefore to investigate the influence of RBE variations on risk estimates of TLN after Intensity-Modulated Proton Therapy for HNC. MATERIAL AND METHODS Seventy-five temporal lobes from 45 previously treated patients were included in the analysis. Sixteen temporal lobes had radiation associated Magnetic Resonance image changes (TLIC) suspected to be early signs of TLN. Fixed (RWDFix) and variable RBE-weighed doses (RWDVar) were calculated using RBE = 1.1 and two RBE models, respectively. RWDFix and RWDVar for temporal lobes were compared using Friedman's test. Based on RWDFix, six NTCP models were fitted and internally validated through bootstrapping. Estimated probabilities from RWDFix and RWDVar were compared using paired Wilcoxon test. Seven dose constraints were evaluated separately for RWDFix and RWDVar by calculating the observed proportion of TLIC in temporal lobes meeting the specific dose constraints. RESULTS RWDVar were significantly higher than RWDFix (p < 0.01). NTCP model performance was good (AUC:0.79-0.84). The median difference in estimated probability between RWDFix and RWDVar ranged between 5.3% and 20.0% points (p < 0.01), with V60GyRBE and DMax at the smallest and largest differences, respectively. The proportion of TLIC was higher for RWDFix (4.0%-13.1%) versus RWDVar (1.3%-5.3%). For V65GyRBE ≤ 0.03 cc the proportion of TLIC was less than 5% for both RWDFix and RWDVar. CONCLUSION NTCP estimates were significantly influenced by RBE variations. Dmax as model predictor resulted in the largest deviations in risk estimates between RWDFix and RWDVar. V65GyRBE ≤ 0.03 cc was the most consistent dose constraint for RWDFix and RWDVar.
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Affiliation(s)
- Grete May Engeseth
- University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, USA,Haukeland University Hospital, Department of Oncology and Medical Physics, Bergen, Norway,University of Bergen, Department of Clinical Science, Bergen, Norway,Corresponding author: Grete May Engeseth, , Haukeland University Hospital, Department of Oncology and Medical Physics, Postboks 1400, 5021 Bergen
| | - Liv Bolstad Hysing
- Haukeland University Hospital, Department of Oncology and Medical Physics, Bergen, Norway,University of Bergen, Department of Physics and Technology, Bergen, Norway
| | - Pablo Yepes
- Rice University, Physics and Astronomy Department, Houston, USA
| | | | - Rahde Mohan
- University of Texas MD Anderson Cancer Center, Department of Radiation Physics, Houston, USA
| | - Clifton Dave Fuller
- University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, USA
| | - Camilla Hanquist Stokkevåg
- Haukeland University Hospital, Department of Oncology and Medical Physics, Bergen, Norway,University of Bergen, Department of Physics and Technology, Bergen, Norway
| | - Richard Wu
- University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, USA
| | - Xiaodong Zhang
- University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, USA
| | - Steven Jay Frank
- University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, USA
| | - Gary Brandon Gunn
- University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, USA
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4
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Kubeš J, Haas A, Vondráček V, Andrlík M, Navrátil M, Sláviková S, Vítek P, Dědečková K, Prausová J, Ondrová B, Vinakurau Š, Grebenyuk A, Doležal T, Velacková B, Rosina J. Ultrahypofractionated Proton Radiation Therapy in the Treatment of Low and Intermediate-Risk Prostate Cancer-5-Year Outcomes. Int J Radiat Oncol Biol Phys 2021; 110:1090-1097. [PMID: 33587990 DOI: 10.1016/j.ijrobp.2021.02.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/28/2021] [Accepted: 02/07/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE To analyze the 5-year biochemical disease-free survival (bDFS) and late toxicity profile in patients with prostate cancer treated with pencil beam scanning (PBS) proton radiation therapy. METHODS AND MATERIALS Between January 2013 and March 2016, 284 patients with prostate cancer were treated using intensity modulated proton therapy (IMPT), with an ultrahypofractionated schedule (36.25 GyE in 5 fractions). Five patients were immediately lost from follow-up and thus were excluded from analysis. Data for 279 patients were prospectively collected and analyzed with a median follow-up time of 56.5 (range, 3.4-87.5) months. The mean age at time of treatment was 64.5 (40.1-85.7) years, and the median prostate-specific antigen (PSA) value was 6.35 μg/L (0.67-17.3 μg/L). A total of 121 (43.4%) patients had low-risk, 125 patients (44.8%) had favorable, and 33 (11.8%) unfavorable intermediate-risk cancer. In addition, 49 (17.6%) patients underwent neoadjuvant hormonal therapy, and no patients had adjuvant hormonal therapy. bDFS and late toxicity profiles were evaluated. RESULTS The median treatment time was 9 days (range, 7-18 days). The 5-year bDFS was 96.9%, 91.7%, and 83.5% for the low-, favorable, and unfavorable intermediate-risk group, respectively. Late toxicity (Common Terminology Criteria for Adverse Events v.4) was as follows: gastrointestinal: grade 1, 62 patients (22%), grade 2, 20 patients (7.2%), and grade 3, 1 patient (0.36%); genitourinary: grade 1, 80 patients (28.7%), grade 2, 14 patients (5%), and grade 3, 0 patients. PSA relapse was observed in 17 patients (6.1%), and lymph node or bone recurrence was detected in 11 patients. Four (1.4%) local recurrences were detected. Nine patients (3.2%) died of causes unrelated to prostate cancer. No deaths related to prostate cancer were reported. CONCLUSION Ultrahypofractionated proton beam radiation therapy for prostate cancer is effective with long-term bDFS comparable with other fractionation schedules and with minimal serious long-term GI and GU toxicity.
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Affiliation(s)
- Jiří Kubeš
- Department of Oncology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic; Proton Therapy Center Czech, Prague, Czech Republic; Department of Health Care Disciplines and Population Protection, Faculty of Biomedical Engineering, Czech Technical University in Prague, Kladno, Czech Republic
| | - Alexandra Haas
- Department of Oncology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic; Proton Therapy Center Czech, Prague, Czech Republic
| | - Vladimír Vondráček
- Proton Therapy Center Czech, Prague, Czech Republic; Department of Health Care Disciplines and Population Protection, Faculty of Biomedical Engineering, Czech Technical University in Prague, Kladno, Czech Republic
| | - Michal Andrlík
- Proton Therapy Center Czech, Prague, Czech Republic; Department of Health Care Disciplines and Population Protection, Faculty of Biomedical Engineering, Czech Technical University in Prague, Kladno, Czech Republic.
| | - Matěj Navrátil
- Proton Therapy Center Czech, Prague, Czech Republic; Department of Health Care Disciplines and Population Protection, Faculty of Biomedical Engineering, Czech Technical University in Prague, Kladno, Czech Republic
| | - Silvia Sláviková
- Department of Oncology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic; Proton Therapy Center Czech, Prague, Czech Republic
| | - Pavel Vítek
- Department of Oncology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic; Proton Therapy Center Czech, Prague, Czech Republic
| | - Kateřina Dědečková
- Department of Oncology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic; Proton Therapy Center Czech, Prague, Czech Republic
| | - Jana Prausová
- Department of Oncology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Barbora Ondrová
- Department of Oncology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic; Proton Therapy Center Czech, Prague, Czech Republic
| | - Štěpán Vinakurau
- Department of Oncology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic; Proton Therapy Center Czech, Prague, Czech Republic
| | - Alexander Grebenyuk
- Pavlov First Saint Petersburg State Medical University, Department of Health Protection and Disaster Medicine, Saint Petersburg, Russia
| | | | | | - Jozef Rosina
- Department of Health Care Disciplines and Population Protection, Faculty of Biomedical Engineering, Czech Technical University in Prague, Kladno, Czech Republic; Department of Medical Biophysics and Informatics, 3rd Faculty of Medicine, Charles University, Prague, Czech Republic
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5
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Deng W, Yang Y, Liu C, Bues M, Mohan R, Wong WW, Foote RH, Patel SH, Liu W. A Critical Review of LET-Based Intensity-Modulated Proton Therapy Plan Evaluation and Optimization for Head and Neck Cancer Management. Int J Part Ther 2021; 8:36-49. [PMID: 34285934 PMCID: PMC8270082 DOI: 10.14338/ijpt-20-00049.1] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 10/14/2020] [Indexed: 12/15/2022] Open
Abstract
In this review article, we review the 3 important aspects of linear-energy-transfer (LET) in intensity-modulated proton therapy (IMPT) for head and neck (H&N) cancer management. Accurate LET calculation methods are essential for LET-guided plan evaluation and optimization, which can be calculated either by analytical methods or by Monte Carlo (MC) simulations. Recently, some new 3D analytical approaches to calculate LET accurately and efficiently have been proposed. On the other hand, several fast MC codes have also been developed to speed up the MC simulation by simplifying nonessential physics models and/or using the graphics processor unit (GPU)–acceleration approach. Some concepts related to LET are also briefly summarized including (1) dose-weighted versus fluence-weighted LET; (2) restricted versus unrestricted LET; and (3) microdosimetry versus macrodosimetry. LET-guided plan evaluation has been clinically done in some proton centers. Recently, more and more studies using patient outcomes as the biological endpoint have shown a positive correlation between high LET and adverse events sites, indicating the importance of LET-guided plan evaluation in proton clinics. Various LET-guided plan optimization methods have been proposed to generate proton plans to achieve biologically optimized IMPT plans. Different optimization frameworks were used, including 2-step optimization, 1-step optimization, and worst-case robust optimization. They either indirectly or directly optimize the LET distribution in patients while trying to maintain the same dose distribution and plan robustness. It is important to consider the impact of uncertainties in LET-guided optimization (ie, LET-guided robust optimization) in IMPT, since IMPT is sensitive to uncertainties including both the dose and LET distributions. We believe that the advancement of the LET-guided plan evaluation and optimization will help us exploit the unique biological characteristics of proton beams to improve the therapeutic ratio of IMPT to treat H&N and other cancers.
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Affiliation(s)
- Wei Deng
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Yunze Yang
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Chenbin Liu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, Guangdong, China
| | - Martin Bues
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Radhe Mohan
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William W Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Robert H Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Samir H Patel
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
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6
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Engeseth GM, He R, Mirkovic D, Yepes P, Mohamed ASR, Stieb S, Fuller CD, Wu R, Zhang X, Hysing LB, Pettersen HES, Stokkevåg CH, Mohan R, Frank SJ, Gunn GB. Mixed Effect Modeling of Dose and Linear Energy Transfer Correlations With Brain Image Changes After Intensity Modulated Proton Therapy for Skull Base Head and Neck Cancer. Int J Radiat Oncol Biol Phys 2021; 111:684-692. [PMID: 34153379 PMCID: PMC8855940 DOI: 10.1016/j.ijrobp.2021.06.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/23/2021] [Accepted: 06/10/2021] [Indexed: 11/18/2022]
Abstract
Purpose: Intensity modulated proton therapy (IMPT) could yield high linear energy transfer (LET) in critical structures and increased biological effect. For head and neck cancers at the skull base this could potentially result in radiation-associated brain image change (RAIC). The purpose of the current study was to investigate voxel-wise dose and LET correlations with RAIC after IMPT. Methods and Materials: For 15 patients with RAIC after IMPT, contrast enhancement observed on T1-weighted magnetic resonance imaging was contoured and coregistered to the planning computed tomography. Monte Carlo calculated dose and dose-averaged LET (LETd) distributions were extracted at voxel level and associations with RAIC were modelled using uni- and multivariate mixed effect logistic regression. Model performance was evaluated using the area under the receiver operating characteristic curve and precision-recall curve. Results: An overall statistically significant RAIC association with dose and LETd was found in both the uni- and multivariate analysis. Patient heterogeneity was considerable, with standard deviation of the random effects of 1.81 (1.30–2.72) for dose and 2.68 (1.93–4.93) for LETd, respectively. Area under the receiver operating characteristic curve was 0.93 and 0.95 for the univariate dose-response model and multivariate model, respectively. Analysis of the LETd effect demonstrated increased risk of RAIC with increasing LETd for the majority of patients. Estimated probability of RAIC with LETd = 1 keV/μm was 4% (95% confidence interval, 0%, 0.44%) and 29% (95% confidence interval, 0.01%, 0.92%) for 60 and 70 Gy, respectively. The TD15 were estimated to be 63.6 and 50.1 Gy with LETd equal to 2 and 5 keV/μm, respectively. Conclusions: Our results suggest that the LETd effect could be of clinical significance for some patients; LETd assessment in clinical treatment plans should therefore be taken into consideration.
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Affiliation(s)
- Grete May Engeseth
- The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, Texas; Haukeland University Hospital, Department of Oncology and Medical Physics, Bergen, Norway; The University of Bergen, Department of Clinical Science, Bergen, Norway.
| | - Renjie He
- The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, Texas
| | - Dragan Mirkovic
- The University of Texas MD Anderson Cancer Center, Department of Radiation Physics, Houston, Texas
| | - Pablo Yepes
- Rice University, Physics and Astronomy Department, Houston, Texas
| | | | - Sonja Stieb
- The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, Texas
| | - Clifton Dave Fuller
- The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, Texas
| | - Richard Wu
- The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, Texas
| | - Xiadong Zhang
- The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, Texas
| | - Liv Bolstad Hysing
- Haukeland University Hospital, Department of Oncology and Medical Physics, Bergen, Norway; The University of Bergen, Department of Physics and Technology, Bergen, Norway
| | | | - Camilla Hanquist Stokkevåg
- Haukeland University Hospital, Department of Oncology and Medical Physics, Bergen, Norway; The University of Bergen, Department of Physics and Technology, Bergen, Norway
| | - Radhe Mohan
- The University of Texas MD Anderson Cancer Center, Department of Radiation Physics, Houston, Texas
| | - Steven Jay Frank
- The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, Texas
| | - Gary Brandon Gunn
- The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, Texas
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7
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Kalholm F, Grzanka L, Traneus E, Bassler N. A systematic review on the usage of averaged LET in radiation biology for particle therapy. Radiother Oncol 2021; 161:211-221. [PMID: 33894298 DOI: 10.1016/j.radonc.2021.04.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 04/06/2021] [Accepted: 04/08/2021] [Indexed: 12/20/2022]
Abstract
Linear Energy Transfer (LET) is widely used to express the radiation quality of ion beams, when characterizing the biological effectiveness. However, averaged LET may be defined in multiple ways, and the chosen definition may impact the resulting reported value. We review averaged LET definitions found in the literature, and quantify which impact using these various definitions have for different reference setups. We recorded the averaged LET definitions used in 354 publications quantifying the relative biological effectiveness (RBE) of hadronic beams, and investigated how these various definitions impact the reported averaged LET using a Monte Carlo particle transport code. We find that the kind of averaged LET being applied is, generally, poorly defined. Some definitions of averaged LET may influence the reported averaged LET values up to an order of magnitude. For publications involving protons, most applied dose averaged LET when reporting RBE. The absence of what target medium is used and what secondary particles are included further contributes to an ill-defined averaged LET. We also found evidence of inconsistent usage of averaged LET definitions when deriving LET-based RBE models. To conclude, due to commonly ill-defined averaged LET and to the inherent problems of LET-based RBE models, averaged LET may only be used as a coarse indicator of radiation quality. We propose a more rigorous way of reporting LET values, and suggest that ideally the entire particle fluence spectra should be recorded and provided for future RBE studies, from which any type of averaged LET (or other quantities) may be inferred.
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Affiliation(s)
- Fredrik Kalholm
- Medical Radiation Physics, Dept. of Physics, Stockholm University, Stockholm, Sweden; Department of Oncology and Pathology, Medical Radiation Physics, Karolinska Institutet, Stockholm, Sweden
| | - Leszek Grzanka
- Institute of Nuclear Physics Polish Academy of Sciences, Krakow, Poland
| | | | - Niels Bassler
- Medical Radiation Physics, Dept. of Physics, Stockholm University, Stockholm, Sweden; Department of Oncology and Pathology, Medical Radiation Physics, Karolinska Institutet, Stockholm, Sweden; Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark; Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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8
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Rao AD, Sun K, Zhu M, Mossahebi S, Sabouri P, Houser T, Jatczak J, Zakhary M, Regine WF, Miller RC, Bentzen S, Mishra MV. Plan quality effects of maximum monitor unit constraints in pencil beam scanning proton therapy for central nervous system and skull base tumors. Radiother Oncol 2021; 160:18-24. [PMID: 33753157 DOI: 10.1016/j.radonc.2021.03.016] [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: 10/14/2020] [Revised: 02/08/2021] [Accepted: 03/10/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE/OBJECTIVE(S) With reports of CNS toxicity in patients treated with proton therapy at doses lower than would be expected based on photon data, it has been proposed that heavy monitor unit (MU) weighting of pencil beam scanning (PBS) proton therapy spots may potentially increase the risk of toxicity. We evaluated the impact of maximum MU weighting per spot (maxMU/spot) restrictions on PBS plan quality, prior to implementing clinic-wide maxMU/spot restrictions. MATERIALS/METHODS PBS plans of 11 patients, of which 3 plans included boosts, for a total of 14 PBS sample cases were included. Per sample case, a single dosimetrist created 4 test plans, gradually reducing the maxMU/spot in the plan. Test Plan 1, unrestricted in maxMU/spot, was the reference for all restricted plan comparisons (comparison sets 2 vs. 1; 3 vs. 1; and 4 vs. 1). The impact of MU/spot restrictions on plan quality metrics were analyzed with Wilcoxon signed rank test analyses. Treatment delivery time was modeled for a representative case. RESULTS A total of 14 PBS sample cases, 7 (50%) single-field optimized, 7 (50%) multi-field optimized, 9 (64%) delivering > 3500 cGy, 9 (64%) with 3 beams, and 7 (50%) without a range shifter were included. There were no differences in plan quality metrics of target coverage (V95% and V100% prescription), conformality and gradient indices, hot spot volume (V105% prescription), and dose to normal brain (V10%/30%/50%/70%/90%/100% prescription) with reductions of allowable maxMU/spot across all comparison sets (p > 0.05). Max MU/spot restrictions did not increase treatment delivery time when analyzed for a representative case. CONCLUSION MaxMU/spot restrictions within the thresholds evaluated in this study did not degrade overall plan quality metrics. Future studies should evaluate spot weighting with linear energy transfer/relative biologic effectiveness-informed planning to determine if spot weighting manipulation impacts clinical outcomes and mitigates toxicity.
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Affiliation(s)
- Avani Dholakia Rao
- Department of Radiation Oncology, University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, USA
| | - Kai Sun
- Department of Radiation Oncology, University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, USA; Division of Biostatistics and Bioinformatics, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, USA
| | - Mingyao Zhu
- Department of Radiation Oncology, University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, USA
| | - Sina Mossahebi
- Department of Radiation Oncology, University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, USA
| | - Pouya Sabouri
- Department of Radiation Oncology, University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, USA
| | - Thomas Houser
- Department of Radiation Oncology, University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, USA
| | - Jenna Jatczak
- Department of Radiation Oncology, University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, USA
| | - Mark Zakhary
- Department of Radiation Oncology, University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, USA
| | - William F Regine
- Department of Radiation Oncology, University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, USA.
| | - Robert C Miller
- Department of Radiation Oncology, University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, USA
| | - Søren Bentzen
- Department of Radiation Oncology, University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, USA; Division of Biostatistics and Bioinformatics, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, USA
| | - Mark V Mishra
- Department of Radiation Oncology, University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, USA
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9
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Setianegara J, Mazur TR, Yang D, Li HH. Dual-storage phosphor proton therapy dosimetry: Simultaneous quantification of dose and linear energy transfer. Med Phys 2021; 48:1941-1955. [PMID: 33525050 DOI: 10.1002/mp.14748] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/28/2020] [Accepted: 01/18/2021] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To investigate the feasibility of using the high Zeff storage phosphor material BaFBrI:Eu2+ in conjunction with the low Zeff storage phosphor material KCl:Eu2+ for simultaneous proton dose and linear energy transfer (LET) measurements by (a) measuring the fundamental optical and dosimetric properties of BaFBrI:Eu2+ , (b) evaluating its compatibility in being readout simultaneously with KCl:Eu2+ dosimeters, and (c) modeling and validating its LET dependence under elevated proton LET irradiation. METHODS A commercial BaFBrI:Eu2+ storage phosphor detector (Model ST-VI, Fujifilm) was characterized with energy dispersive x-ray spectroscopy (EDS) analysis to obtain its elemental composition. The dosimeters were irradiated using both a Mevion S250 proton therapy unit (at the center of a spread-out Bragg peak, SOBP) and a Varian Clinac iX linear accelerator with the latter being a low LET irradiation. The photostimulated luminescence (PSL) emission spectra, excitation spectra, and luminescent lifetimes of the detector were measured after proton and photon irradiations. Dosimetric properties including dose linearity, dose rate dependence, radiation hardness, temporal, and readout stabilities were studied using a laboratory optical reader after proton irradiations. In addition, its proton energy dependence was analytically modeled and experimentally validated by irradiating the detectors at various depths within the SOBP (Range: 15.0 g/cm2 , Modulation: 10.0 g/cm2 ). RESULTS The active detector composition for the high Zeff storage phosphor detector was found to be BaFBr0.85 I0.15 :Eu2+ . The BaFBr0.85 I0.15 :Eu2+ material's excitation and emission spectra were in agreement under proton and photon irradiations, with peaks of 586 ± 1 nm and 400 ± 1 nm, respectively, with a full width at half maximum (FWHM) of 119 ± 3 nm and 30 ± 2 nm, respectively. As dosimeter response under photon irradiation is generally believed to be free from LET effect, these results suggest LET independence of charge storage center types resulted from ionizing radiations. There is sufficient spectral overlaps with KCl:Eu2+ dosimeters allowing both dosimeters to be readout under equivalent readout conditions, that is, 594 nm stimulation and 420 nm detection wavelengths. Its PSL characteristic lifetime was found to be less than 5 microseconds which would make it suitable for fast 2D readout post irradiation. Its 420 nm emission band intensity was found to be linear up to 10 Gy absolute proton dose under the same irradiation conditions, dose rate independent, stable in time and under multiple readouts, and with high radiation hardness under cumulative proton dose histories up to 200 Gy as tested in this study. BaFBr0.85 I0.15 :Eu2+ showed significant proton energy-dependent dose under-response in regions of high LET which could be modeled by stopping power ratio calculations with an accuracy of 3% in low LET regions and a distance-to-agreement (DTA) of 1 mm in high LET regions (>5 keV/μm). CONCLUSION We have proven the feasibility of dual-storage phosphor proton dosimetry for simultaneous proton dose and LET measurements. BaFBr0.85 I0.15 :Eu2+ has shown equally excellent dosimetry performance as its low Zeff complement KCl:Eu2+ with distinctive LET dependence merely as a result of its higher Zeff . These promising results pave the way for future studies involving simultaneous proton dose and LET measurements using this novel approach.
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Affiliation(s)
- Jufri Setianegara
- Department of Radiation Oncology, Washington University in St. Louis, MO, 63110, USA.,Department of Physics, Washington University in St. Louis, MO, 63110, USA
| | - Thomas R Mazur
- Department of Radiation Oncology, Washington University in St. Louis, MO, 63110, USA
| | - Deshan Yang
- Department of Radiation Oncology, Washington University in St. Louis, MO, 63110, USA
| | - H Harold Li
- Department of Radiation Oncology, Washington University in St. Louis, MO, 63110, USA.,Department of Biomedical Engineering, Washington University in St. Louis, MO, 63110, USA
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10
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Ytre-Hauge KS, Fjæra LF, Rørvik E, Dahle TJ, Dale JE, Pilskog S, Stokkevåg CH. Inter-patient variations in relative biological effectiveness for cranio-spinal irradiation with protons. Sci Rep 2020; 10:6212. [PMID: 32277106 PMCID: PMC7148381 DOI: 10.1038/s41598-020-63164-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 03/23/2020] [Indexed: 12/30/2022] Open
Abstract
Cranio-spinal irradiation (CSI) using protons has dosimetric advantages compared to photons and is expected to reduce risk of adverse effects. The proton relative biological effectiveness (RBE) varies with linear energy transfer (LET), tissue type and dose, but a variable RBE has not replaced the constant RBE of 1.1 in clinical treatment planning. We examined inter-patient variations in RBE for ten proton CSI patients. Variable RBE models were used to obtain RBE and RBE-weighted doses. RBE was quantified in terms of dose weighted organ-mean RBE ([Formula: see text] = mean RBE-weighted dose/mean physical dose) and effective RBE of the near maximum dose (D2%), i.e. RBED2% = [Formula: see text], where subscripts RBE and phys indicate that the D2% is calculated based on an RBE model and the physical dose, respectively. Compared to the median [Formula: see text] of the patient population, differences up to 15% were observed for the individual [Formula: see text] values found for the thyroid, while more modest variations were seen for the heart (6%), lungs (2%) and brainstem (<1%). Large inter-patient variation in RBE could be correlated to large spread in LET and dose for these organs at risk (OARs). For OARs with small inter-patient variations, the results show that applying a population based RBE in treatment planning may be a step forward compared to using RBE of 1.1. OARs with large inter-patient RBE variations should ideally be selected for patient-specific biological or RBE robustness analysis if the physical doses are close to known dose thresholds.
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Affiliation(s)
| | - Lars Fredrik Fjæra
- Department of Physics and Technology, University of Bergen, Bergen, Norway
| | - Eivind Rørvik
- Department of Medical Physics, Oslo University Hospital, The Radium Hospital, Oslo, Norway
| | - Tordis J Dahle
- Department of Physics and Technology, University of Bergen, Bergen, Norway
| | - Jon Espen Dale
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Sara Pilskog
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Camilla H Stokkevåg
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
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11
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Patient reported outcomes following proton pencil beam scanning vs. passive scatter/uniform scanning for localized prostate cancer: Secondary analysis of PCG 001-09. Clin Transl Radiat Oncol 2020; 22:50-54. [PMID: 32258443 PMCID: PMC7125313 DOI: 10.1016/j.ctro.2020.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 03/01/2020] [Accepted: 03/04/2020] [Indexed: 11/24/2022] Open
Abstract
Data comparing PROs with pencil beam and passive scattering are lacking. We performed a comparison of EPIC domain scores for prostate cancer patients. Results were sensitive to the methods used to compare PROs. Future studies are needed to prospectively compare PROs following protons.
Background Although pencil beam scanning (PBS) is the most conformal method for proton beam therapy (PBT) delivery, it is unknown if outcomes differ compared to treatment with passive scatter/uniform scanning (PS/US). This analysis compares patient reported outcomes (PROs) following PBS and PS/US for prostate cancer (PC) in a prospective multicenter registry study. Methods We evaluated PROs with the Expanded Prostate Cancer Index Composite (EPIC) instrument for men with localized PC enrolled in PCG 001-09 (NCT01255748). PROs were assessed at baseline and through 12 months of follow-up. We compared mean changes in EPIC scores, as well as the proportions of men experiencing a one- and two-fold minimally important difference (MID) in domain scores, between PBS and PS/US. Multivariate analyses (MVAs) were performed to further evaluate the association between proton modality and PRO changes. Results Three-hundred-and-four men completed EPIC at baseline; 72 received PBS and 232 received PS/US. The average quality-of-life (QOL) declines from baseline through 12 months did not significantly differ between the two groups. The proportion of men reporting a 1-MID decline at 12 months for PBS and PS/US was 34.3% and 27.4%, respectively, for urinary QOL (P = 0.27); 40. 1% and 40.9% for bowel QOL (P = 0.36); and 30. 1% and 36.6% for sexual QOL (P = 0.94). Corresponding 2-MID declines for PBS and PS/US were observed in 26.9% and 13.2% of men for urinary QOL (P = 0.01), 35.3% and 29.1% for bowel QOL (P = 0.33); and 16.4% and 18.1% for sexual QOL (P = 0.76). The association between proton modality and 2-MID changes in urinary QOL at 12-months remained significant on MVA (P = 0.007). Conclusions The results of this analysis show differences between PBS and PS/US with regards to two-fold MID changes in urinary function at 12 months, but no differences for average score declines over time. Future studies evaluating PRO measures between the two PBT modalities are warranted.
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12
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Greenberger BA, Yock TI. The role of proton therapy in pediatric malignancies: Recent advances and future directions. Semin Oncol 2020; 47:8-22. [PMID: 32139101 DOI: 10.1053/j.seminoncol.2020.02.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/03/2020] [Accepted: 02/03/2020] [Indexed: 11/11/2022]
Abstract
Proton radiotherapy has promised an advantage in safely treating pediatric malignancies with an increased capability to spare normal tissues, reducing the risk of both acute and late toxicity. The past decade has seen the proliferation of more than 30 proton facilities in the United States, with increased capacity to provide access to approximately 3,000 children per year who will require radiotherapy for their disease. We provide a review of the initial efforts to describe outcomes after proton therapy across the common pediatric disease sites. We discuss the main attempts to assess comparative efficacy between proton and photon radiotherapy concerning toxicity. We also discuss recent efforts of multi-institutional registries aimed at accelerating research to better define the optimal treatment paradigm for children requiring radiotherapy for cure.
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Affiliation(s)
- Benjamin A Greenberger
- Department of Radiation Oncology, Sidney Kimmel Medical College & Cancer Center at Thomas Jefferson University, Philadelphia, PA
| | - Torunn I Yock
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Francis H. Burr Proton Therapy Center, Boston, MA.
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13
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Tommasino F, Widesott L, Fracchiolla F, Lorentini S, Righetto R, Algranati C, Scifoni E, Dionisi F, Scartoni D, Amelio D, Cianchetti M, Schwarz M, Amichetti M, Farace P. Clinical implementation in proton therapy of multi-field optimization by a hybrid method combining conventional PTV with robust optimization. Phys Med Biol 2020; 65:045002. [PMID: 31851957 DOI: 10.1088/1361-6560/ab63b9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
To implement a robust multi-field optimization (MFO) technique compatible with the application of a Monte Carlo (MC) algorithm and to evaluate its robustness. Nine patients (three brain, five head-and-neck, one spine) underwent proton treatment generated by a novel robust MFO technique. A hybrid (hMFO) approach was implemented, planning dose coverage on isotropic PTV compensating for setup errors, whereas range calibration uncertainties are incorporated into PTV robust optimization process. hMFO was compared with single-field optimization (SFO) and full robust multi-field optimization (fMFO), both on the nominal plan and the worst-case scenarios assessed by robustness analysis. The SFO and the fMFO plans were normalized to hMFO on CTV to obtain iso-D95 coverage, and then the organs at risk (OARs) doses were compared. On the same OARs, in the normalized nominal plans the potential impact of variable relative biological effectiveness (RBE) was investigated. hMFO reduces the number of scenarios computed for robust optimization (from twenty-one in fMFO to three), making it practicable with the application of a MC algorithm. After normalizing on D95 CTV coverage, nominal hMFO plans were superior compared to SFO in terms of OARs sparing (p < 0.01), without significant differences compared to fMFO. The improvement in OAR sparing with hMFO with respect to SFO was preserved in worst-case scenarios (p < 0.01), confirming that hMFO is as robust as SFO to physical uncertainties, with no significant differences when compared to the worst case scenarios obtained by fMFO. The dose increase on OARs due to variable RBE was comparable to the increase due to physical uncertainties (i.e. 4-5 Gy(RBE)), but without significant differences between these techniques. hMFO allows improving plan quality with respect to SFO, with no significant differences with fMFO and without affecting robustness to setup, range and RBE uncertainties, making clinically feasible the application of MC-based robust optimization.
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Affiliation(s)
- Francesco Tommasino
- Department of Physics, University of Trento, Via Sommarive, 14-38123 Povo (TN), Italy. Trento Institute for Fundamental Physics and Applications (TIFPA), National Institute for Nuclear Physics, (INFN), Povo, Italy. Author to whom any correspondence should be addressed
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14
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Proton beam therapy delivered using pencil beam scanning vs. passive scattering/uniform scanning for localized prostate cancer: Comparative toxicity analysis of PCG 001-09. Clin Transl Radiat Oncol 2019; 19:80-86. [PMID: 31650043 PMCID: PMC6804653 DOI: 10.1016/j.ctro.2019.08.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 08/29/2019] [Accepted: 08/29/2019] [Indexed: 02/07/2023] Open
Abstract
Background and purpose Patient-level benefits of proton beam therapy (PBT) relative to photon therapy for prostate cancer (PC) continue to be the focus of debate. Although trials comparing the two modalities are underway, most are being conducted using "conventional" PBT (passive scattering/uniform scanning [PS/US]) rather than pencil beam scanning (PBS). The dosimetric benefits of PBS are well-known, but comparative data are limited. This analysis compares PBS toxicity rates with those of PS/US in a prospective multicenter registry. Methods We evaluated acute/late gastrointestinal (GI) and genitourinary (GU) toxicity rates for men with low-to-intermediate risk PC enrolled in PCG 001-09. Acute toxicities with the two techniques were compared using χ2 tests, and the cumulative incidence methods for late toxicity. Multivariable analyses (MVAs) for acute toxicity were performed using logistic regression, and cox proportional hazards models for late toxicity. Results Patients were treated using PS/US (n = 1105) or PBS (n = 238). Acute grade ≥2 GI toxicity in PBS did not significantly differ from that with PS/US (2.9% and 2.1%, respectively; P = 0.47). Acute grade ≥2 GU toxicity was significantly higher with PBS (21.9% and 15.1%; P < 0.01). In MVA, PBS was significantly associated with increased acute grade ≥2 GU toxicity (RR = 1.57, p < 0.001). Late grade ≥2 GI and GU toxicities did not differ significantly between groups. Conclusions This is the first multi-institutional comparative effectiveness evaluation of PBT techniques in PC. Differences in acute GU toxicity warrant further evaluation, and highlight the urgent need for prospective data using PBT.
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Key Words
- CTCAE, Common Terminology Criteria for Adverse Events
- Comparative effectiveness, Toxicity
- GI, gastrointestinal
- GU, genitourinary
- LET, linear energy transfer
- MVA, multivariable analysis
- PARTIQoL, Prostate Advanced Radiation Technologies Investigating Quality of Life
- PBS, pencil beam scanning
- PBT, proton beam therapy
- PC, prostate cancer
- PCG, Proton Collaborative Group
- PS/US, passive scattering/uniform scanning
- Passive scattering, uniform scanning
- Pencil beam scanning
- Prostate cancer
- Proton therapy
- RBE, relative biological effectiveness
- RT, radiation therapy
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Stewart RD, Carlson DJ, Butkus MP, Hawkins R, Friedrich T, Scholz M. A comparison of mechanism-inspired models for particle relative biological effectiveness (RBE). Med Phys 2018; 45:e925-e952. [PMID: 30421808 DOI: 10.1002/mp.13207] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 09/05/2018] [Accepted: 09/13/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND AND SIGNIFICANCE The application of heavy ion beams in cancer therapy must account for the increasing relative biological effectiveness (RBE) with increasing penetration depth when determining dose prescriptions and organ at risk (OAR) constraints in treatment planning. Because RBE depends in a complex manner on factors such as the ion type, energy, cell and tissue radiosensitivity, physical dose, biological endpoint, and position within and outside treatment fields, biophysical models reflecting these dependencies are required for the personalization and optimization of treatment plans. AIM To review and compare three mechanism-inspired models which predict the complexities of particle RBE for various ion types, energies, linear energy transfer (LET) values and tissue radiation sensitivities. METHODS The review of models and mechanisms focuses on the Local Effect Model (LEM), the Microdosimetric-Kinetic (MK) model, and the Repair-Misrepair-Fixation (RMF) model in combination with the Monte Carlo Damage Simulation (MCDS). These models relate the induction of potentially lethal double strand breaks (DSBs) to the subsequent interactions and biological processing of DSB into more lethal forms of damage. A key element to explain the increased biological effectiveness of high LET ions compared to MV x rays is the characterization of the number and local complexity (clustering) of the initial DSB produced within a cell. For high LET ions, the spatial density of DSB induction along an ion's trajectory is much greater than along the path of a low LET electron, such as the secondary electrons produced by the megavoltage (MV) x rays used in conventional radiation therapy. The main aspects of the three models are introduced and the conceptual similarities and differences are critiqued and highlighted. Model predictions are compared in terms of the RBE for DSB induction and for reproductive cell survival. RESULTS AND CONCLUSIONS Comparisons of the RBE for DSB induction and for cell survival are presented for proton (1 H), helium (4 He), and carbon (12 C) ions for the therapeutically most relevant range of ion beam energies. The reviewed models embody mechanisms of action acting over the spatial scales underlying the biological processing of potentially lethal DSB into more lethal forms of damage. Differences among the number and types of input parameters, relevant biological targets, and the computational approaches among the LEM, MK and RMF models are summarized and critiqued. Potential experiments to test some of the seemingly contradictory aspects of the models are discussed.
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Affiliation(s)
- Robert D Stewart
- Department of Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356043, Seattle, WA, 98195, USA
| | - David J Carlson
- Department of Therapeutic Radiology, Yale University, New Haven, CT, USA
| | - Michael P Butkus
- Department of Therapeutic Radiology, Yale University, New Haven, CT, USA
| | - Roland Hawkins
- Radiation Oncology Center, Ochsner Clinic Foundation, New Orleans, LA, 70121, USA
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