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Zaghloul MS, Hunter A, Mostafa AG, Parkes J. Re-irradiation for recurrent/progressive pediatric brain tumors: from radiobiology to clinical outcomes. Expert Rev Anticancer Ther 2023; 23:709-717. [PMID: 37194207 DOI: 10.1080/14737140.2023.2215439] [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: 01/29/2023] [Accepted: 05/15/2023] [Indexed: 05/18/2023]
Abstract
INTRODUCTION Brain tumors are the most common solid tumors in children. Neurosurgical excision, radiotherapy, and/or chemotherapy represent the standard of care in most histopathological types of pediatric central nervous system (CNS) tumors. Even though the successful cure rate is reasonable, some patients may develop recurrence locally or within the neuroaxis. AREA COVERED The management of these recurrences is not easy; however, significant advances in neurosurgery, radiation techniques, radiobiology, and the introduction of newer biological therapies, have improved the results of their salvage treatment. In many cases, salvage re-irradiation is feasible and has achieved encouraging results. The results of re-irradiation depend upon several factors. These factors include tumor type, extent of the second surgery, tumor volume, location of the recurrence, time that elapses between the initial treatment, the combination with other treatment agents, relapse, and the initial response to radiotherapy. EXPERT OPINION Reviewing the radiobiological basis and clinical outcome of pediatric brain re-irradiation revealed that re-irradiation is safe, feasible, and indicated for recurrent/progressive different tumor types such as; ependymoma, medulloblastoma, diffuse intrinsic pontine glioma (DIPG) and glioblastoma. It is now considered part of the treatment armamentarium for these patients. The challenges and clinical results in treating recurrent pediatric brain tumors were highly documented.
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Affiliation(s)
- Mohamed S Zaghloul
- Radiation Oncology department. National Cancer Institute, Cairo University & Children's Cancer Hospital, Cairo, Egypt
| | - Alistair Hunter
- Division of Radiobiology, Radiation Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Ayatullah G Mostafa
- Department of Radiology, Faculty of Medicine, Egypt and Department of Diagnostic Imaging, Cairo University, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jeannette Parkes
- Radiation Oncology Department, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
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Jones M, Rogers J, Kumar Shrimali R, Hamilton J, Athmanathan S, Jones B. Feasibility and safety of shortened hypofractionated high-dose palliative lung radiotherapy – A retrospective planning study. Phys Med 2023; 108:102559. [PMID: 37004334 DOI: 10.1016/j.ejmp.2023.102559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 02/02/2023] [Accepted: 02/26/2023] [Indexed: 04/03/2023] Open
Abstract
OBJECTIVE Assess the safety and feasibility of shortened hypofractionated high-dose palliative lung radiotherapy in a retrospective planning study. METHODS Fifteen late stage (III or IV) NSCLC lung radiotherapy patients previously treated with the standard palliative 36 Gy in 12 fractions (12F) schedule were non-randomly selected to achieve a representative distribution of tumour sizes, volumes, and location. Plans were produced using 30 Gy in 5 fractions (5F) and 6 fractions (6F) using a 6MV FFF co-planar VMAT technique. Plans were optimised to meet dose-constraints for planning target volumes (PTVs) and organs at risk (OARs) with established OAR constraints expressed as biological equivalent doses (BEDs). The potential safety was assessed using these BEDs and also with reductions of 10% (BED-10%) and 20% (BED-20%) to account for a reduction in tolerance doses from the effects of chemotherapy or surgery. RESULTS Mandatory BED constraints were met for all fifteen 5F and 6F plans; BED-10% constraints were met by all 6F plans and six 5F plans. BED-20% constraints were met by six 6F and three 5F respectively. CONCLUSION It is potentially safe and feasible to deliver high-dose palliative radiotherapy for late stage NSCLC using the 5F or 6F regimes described, when planned to comparable OAR BEDs as standard radical techniques. It appears toxicity from these regimes should be within acceptable limits provided the dose-constraints described are met. A Phase II study is required to fully assess safety and feasibility, the outcomes of which could reduce the number of patient hospital visits for radiotherapy, thereby benefiting patients and optimising resource utilisation.
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Dale RG, Jones B. Radiotherapy treatment interruptions during the Covid-19 pandemic: The UK experience and implications for radiobiology training. Radiat Phys Chem Oxf Engl 1993 2022; 200:110214. [PMID: 35540029 PMCID: PMC9073561 DOI: 10.1016/j.radphyschem.2022.110214] [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: 02/08/2022] [Revised: 04/28/2022] [Accepted: 05/01/2022] [Indexed: 11/25/2022]
Abstract
Unintended treatment interruptions during a course of radiotherapy can lead to extended overall treatment times which can allow increased tumour cell repopulation to occur. Extra dose may therefore be required to offset any loss of tumour control. However, the manner in which the extra dose is delivered requires careful consideration in order to avoid the risk of increased normal tissue toxicity. Radiobiological modelling techniques can allow quantitative examination of such problems and may be used to derive revised pattens of radiation delivery which can help restore a degree of tumour control whilst limiting the likelihood of excess normal tissue morbidity. Unintended treatment interruptions can occur in any radiotherapy department but the rapid spread of the Covid-19 pandemic caused a major increase in the frequency of such interruptions due to staff and patient illness and the consequent self-isolation requirements. This article summarises the radiobiological considerations and caveats involved in assessing treatment interruptions and outlines the UK experience of dealing with the new challenges posed by Covid-19. The world-wide need for more education programmes in cancer radiobiology is highlighted.
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Affiliation(s)
- R G Dale
- Department of Surgery and Cancer, Imperial College, London, UK
| | - B Jones
- Department of Oncology, Oxford University, UK
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Jones B. Risk assessment for proton therapy in the central nervous system by assuming small increments in RBE. Radiat Phys Chem Oxf Engl 1993 2022. [DOI: 10.1016/j.radphyschem.2022.110213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Moore JW, Woolley TE, Hopewell JW, Jones B. Further development of spinal cord retreatment dose estimation: including radiotherapy with protons and light ions. Int J Radiat Biol 2021; 97:1657-1666. [PMID: 34524068 DOI: 10.1080/09553002.2021.1981554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE A graphical user interface (GUI) was developed to aid in the assessment of changes in the radiation tolerance of spinal cord/similar central nervous system tissues with time between two individual treatment courses. METHODS The GUI allows any combination of photons, protons (or ions) to be used as the initial, or retreatment, radiotherapy courses. Allowances for clinical circumstances, of reduced tolerance, can also be made. The radiobiological model was published previously and has been incorporated with additional checks and safety features, to be as safe to use as possible. The proton option includes use of a fixed RBE of 1.1 (set as the default), or a variable RBE, the latter depending on the proton linear energy transfer (LET) for organs at risk. This second LET-based approach can also be used for ions, by changing the LET parameters. RESULTS GUI screenshots are used to show the input and output parameters for different clinical situations used in worked examples. The results from the GUI are in agreement with manual calculations, but the results are now rapidly available without tedious and error-prone manual computations. The software outputs provide a maximum dose limit boundary, which should not be exceeded. Clinicians may also choose to further lower the number of treatment fractions, whilst using the same dose per fraction (or conversely a lower dose per fraction but with the same number of fractions) in order to achieve the intended clinical benefit as safely as possible. CONCLUSIONS The new GUI will allow scientific-based estimations of time related radiation tolerance changes in the spinal cord and similar central nervous tissues (optic chiasm, brainstem), which can be used to guide the choice of retreatment dose fractionation schedules, with either photons, protons or ions.
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Affiliation(s)
- Joshua W Moore
- Cardiff School of Mathematics, Cardiff University, Cardiff, UK
| | | | | | - Bleddyn Jones
- Green Templeton College, University of Oxford, Oxford, UK.,Gray Laboratory, Department of Oncology, University of Oxford, Oxford, UK
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Peyraga G, Ducassou A, Arnaud FX, Lizée T, Pouédras J, Moyal É. [Radiotherapy and spinal toxicity: News and perspectives]. Cancer Radiother 2020; 25:55-61. [PMID: 33303351 DOI: 10.1016/j.canrad.2020.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 04/26/2020] [Accepted: 05/01/2020] [Indexed: 01/21/2023]
Abstract
Radiation-induced myelopathy is a devastating late effect of radiotherapy. Fortunately, this late effect is exceptional. The clinical presentation of radiation myelopathy is aspecific, typically occurring between 6 to 24 months after radiotherapy, and radiation-induced myelopathy remains a diagnosis of exclusion. Magnetic resonance imaging is the most commonly used imaging tool. Radiation oncologists must be extremely cautious to the spinal cord dose, particularly in stereotactic radiotherapy and reirradiation. Conventionally, a maximum dose of 50Gy is tolerated in normofractionated radiotherapy (1.8 to 2Gy per fraction). Repeat radiotherapies lead to consider cumulative doses above this recommendation to offer individualized reirradiation. Several factors increase the risk of radiation-induced myelopathy, such as concomitant or neurotoxic chemotherapy. The development of predictive algorithms to prevent the risk of radiation-induced myelopathy is promising. However, radiotherapy prescription should be cautious, regarding to ALARA principle (as low as reasonably achievable). As the advent of immunotherapy has improved patient survival data and the concept of oligometastatic cancer is increasing in daily practice, stereotactic treatments and reirradiations will be increasingly frequent indications. Predict the risk of radiation-induced myelopathy is therefore a major issue in the following years, and remains a daily challenge for radiation oncologists.
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Affiliation(s)
- G Peyraga
- Service de radiothérapie, groupe de radiothérapie et d'oncologie des Pyrénées (Grop), chemin de l'Ormeau, 65000 Tarbes, France.
| | - A Ducassou
- Service de radiothérapie, Institut universitaire du cancer de Toulouse (Oncopole), 1, avenue Irène-Joliot-Curie, 31000 Toulouse, France
| | - F-X Arnaud
- Service de radiothérapie, Institut universitaire du cancer de Toulouse (Oncopole), 1, avenue Irène-Joliot-Curie, 31000 Toulouse, France
| | - T Lizée
- Service de radiothérapie, Institut cancérologique de l'ouest, centre Paul-Papin, 15, rue André-Bocquel, 49055 Angers, France
| | - J Pouédras
- Service de radiothérapie, Institut universitaire du cancer de Toulouse (Oncopole), 1, avenue Irène-Joliot-Curie, 31000 Toulouse, France
| | - É Moyal
- Service de radiothérapie, Institut universitaire du cancer de Toulouse (Oncopole), 1, avenue Irène-Joliot-Curie, 31000 Toulouse, France
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Jones B, Klinge T, Hopewell JW. The influence of the α/β ratio on treatment time iso-effect relationships in the central nervous system. Int J Radiat Biol 2020; 96:903-909. [PMID: 32243225 DOI: 10.1080/09553002.2020.1748736] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Purpose: To investigate the influence of changes in α/β ratio (range 1.5-3 Gy) on iso-effective doses, with varying treatment time, in spinal cord and central nervous system tissues with comparable radio-sensitivity. It is important to establish if an α/β ratio of 2 Gy, the accepted norm for neuro-oncology iso-effect estimations, can be used.Methods: The rat spinal cord irradiation data of Pop et al. provided ED50 values for radiation myelopathy for treatment times that varied from minutes to ∼6 days. Analysis using biphasic repair kinetics, allowing for variable dose-rates, provided the best fit with repair half-times of 0.19 and 2.16 hr, each providing ∼50% of overall repair; with an α/β ratio 2.47 Gy (CI 1.5-3.95 Gy). Using the above data set, graphical methods were used to investigate changes in the repair parameters for differing fixed α/β ratios between 1.5 and 3.0 Gy. Two different intermittent dose delivery equations were used to evaluate the implications in a radiosurgery setting.Results: Changes in the α/β ratio (1.5-3.0 Gy) have a minor effect on equivalent doses for radiation myelopathy for treatment durations of a few hours. Changing the α/β value from 2 Gy to 2.47 Gy, modified equivalent single doses by < 1% when overall treatment times ranged from 0.1 to 5.0 hr. Significant changes were only found for treatment times longer than 5-10 hr. These two α/β ratios were also compared in a practical radiosurgery situation, using two different models for estimating BED, again there was no significant loss of accuracy.Conclusions: It is reasonable to use an α/β ratio of 2 Gy for CNS tissue, with the same repair half-times as published in the original publication by Pop et al., in situations where the assessment of the BED in radiosurgery is used with other form of radiotherapy. In radiosurgery, the variation in BED with treatment duration (for a fixed physical dose) is very similar, but absolute BED values depend on the α/β value. In radiosurgery, clinical recommendations obtained using BED calculations using the originally proposed α/β ratio of 2.47 Gy are still appropriate. For calculations involving a combination of radiosurgery and other modalities, such as fractionated radiotherapy, it would be appropriate in all cases to apply a value of 2 Gy, the accepted norm in neuro-oncology, without significant loss of accuracy in the radio-surgical component. This may have important applications in retreatment situations.
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Affiliation(s)
- Bleddyn Jones
- Gray Laboratory, Department of Oncology, University of Oxford, Oxford, UK.,Green Templeton College, University of Oxford, Oxford, UK
| | - Thomas Klinge
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, Department Medical Physics and Biomedical Engineering, University College London, London, UK.,Centre for Medical Image Computing, Department Medical Physics and Biomedical Engineering, University College London, London, UK.,School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
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Budia I, Alvarez-Arenas A, Woolley TE, Calvo GF, Belmonte-Beitia J. Radiation protraction schedules for low-grade gliomas: a comparison between different mathematical models. J R Soc Interface 2019; 16:20190665. [PMID: 31822220 DOI: 10.1098/rsif.2019.0665] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
We optimize radiotherapy (RT) administration strategies for treating low-grade gliomas. Specifically, we consider different tumour growth laws, both with and without spatial effects. In each scenario, we find the optimal treatment in the sense of maximizing the overall survival time of a virtual low-grade glioma patient, whose tumour progresses according to the examined growth laws. We discover that an extreme protraction therapeutic strategy, which amounts to substantially extending the time interval between RT sessions, may lead to better tumour control. The clinical implications of our results are also presented.
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Affiliation(s)
- I Budia
- Department of Mathematics and MôLAB-Mathematical Oncology Laboratory, University of Castilla-La Mancha, 13071 Ciudad Real, Spain
| | - A Alvarez-Arenas
- Department of Mathematics and MôLAB-Mathematical Oncology Laboratory, University of Castilla-La Mancha, 13071 Ciudad Real, Spain
| | - T E Woolley
- School of Mathematics, Cardiff University, Senghennydd Road, Cardiff CF24 4AG, UK
| | - G F Calvo
- Department of Mathematics and MôLAB-Mathematical Oncology Laboratory, University of Castilla-La Mancha, 13071 Ciudad Real, Spain
| | - J Belmonte-Beitia
- Department of Mathematics and MôLAB-Mathematical Oncology Laboratory, University of Castilla-La Mancha, 13071 Ciudad Real, Spain
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Palma G, Monti S, Conson M, Pacelli R, Cella L. Normal tissue complication probability (NTCP) models for modern radiation therapy. Semin Oncol 2019; 46:210-218. [PMID: 31506196 DOI: 10.1053/j.seminoncol.2019.07.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/31/2019] [Indexed: 02/07/2023]
Abstract
Mathematical models of normal tissue complication probability (NTCP) able to robustly predict radiation-induced morbidities (RIM) play an essential role in the identification of a personalized optimal plan, and represent the key to maximizing the benefits of technological advances in radiation therapy (RT). Most modern RT techniques pose, however, new challenges in estimating the risk of RIM. The aim of this report is to schematically review NTCP models in the framework of advanced radiation therapy techniques. Issues relevant to hypofractionated stereotactic body RT and ion beam therapy are critically reviewed. Reirradiation scenarios for new or recurrent malignances and NTCP are also illustrated. A new phenomenological approach to predict RIM is suggested.
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Affiliation(s)
- Giuseppe Palma
- National Research Council, Institute of Biostructures and Bioimaging, Napoli, Italy
| | - Serena Monti
- National Research Council, Institute of Biostructures and Bioimaging, Napoli, Italy
| | - Manuel Conson
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy
| | - Roberto Pacelli
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy
| | - Laura Cella
- National Research Council, Institute of Biostructures and Bioimaging, Napoli, Italy.
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Jones B, Hopewell J. Spinal cord re-treatments using photon and proton based radiotherapy: LQ-derived tolerance doses. Phys Med 2019; 64:304-310. [DOI: 10.1016/j.ejmp.2019.04.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 03/27/2019] [Accepted: 04/08/2019] [Indexed: 10/27/2022] Open
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