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Abdelgawad MH, Eldib AA, Elsayed TM, Ma CC. Investigation of the linear accelerator low dose rate mode for pulsed low-dose-rate radiotherapy delivery. Biomed Phys Eng Express 2024; 10:065012. [PMID: 39191263 DOI: 10.1088/2057-1976/ad73dd] [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: 03/22/2024] [Accepted: 08/27/2024] [Indexed: 08/29/2024]
Abstract
Purpose. Pulsed volumetric modulated arc therapy (VMAT) was proposed as an advanced treatment that combines the biological benefits of pulsed low dose rate (PLDR) and the dosimetric benefits of the intensity-modulated beams. In our conventional pulsed VMAT technique, a daily fractional dose of 200 cGy is delivered in 10 arcs with 3 min intervals between the arcs. In this study, we are testing the feasibility of pulsed VMAT that omits the need to split into ten arcs and excludes any beam-off gaps.Methods. The study was conducted using computed tomographic images of 24 patients previously treated at our institution with the conventional PLDR technique. Our newly installed Elekta machine has a low dose rate option on the order of 25 MU min-1. PLDR requires an effective dose rate of 6.7 cGy min-1with attention being paid to the maximum dose received within any point within the target not to exceed 13 cGy min-1. The quality of treatment plans was judged based on dose-volume histograms, isodose distribution, dose conformality to the target, and target dose homogeneity. The dose delivery accuracy was assessed by measurements using theMatriXXEvolution2D array system.Results. All cases were normalized to cover 95% of the target volume with 100% of the prescription dose. The average conformity index was 1.03 ± 0.08 while the average homogeneity index was 1.05 ± 0.02. The maximum reported dose rate at any point within the target was 10.44 cGy min-1. The mean dose rate for all pulsed VMAT plans was 6.88 ± 0.1 cGy min-1. All cases passed our gamma analysis with an average passing rate of 99.00% ± 0.48%.Conclusion. The study showed the applicability of planning pulsed VMAT using Eclipse and its successful delivery on our Elekta linac. Pulsed VMAT using the machine's low dose rate mode is more efficient than our previous pulsed VMAT delivery.
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Affiliation(s)
- Mahmoud H Abdelgawad
- Physics Department, Faculty of Science, Al-Azhar University, Nasr City, Cairo, Egypt
- Fox Chase Cancer Center, Temple University Health System, 333, Cottman Avenue Philadelphia, PA, 19111, United States of America
| | - Ahmed A Eldib
- Fox Chase Cancer Center, Temple University Health System, 333, Cottman Avenue Philadelphia, PA, 19111, United States of America
| | - Tamer M Elsayed
- Physics Department, Faculty of Science, Al-Azhar University, Nasr City, Cairo, Egypt
| | - Cm Charlie Ma
- Fox Chase Cancer Center, Temple University Health System, 333, Cottman Avenue Philadelphia, PA, 19111, United States of America
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Kutuk T, Tolakanahalli R, McAllister NC, Hall MD, Tom MC, Rubens M, Appel H, Gutierrez AN, Odia Y, Mohler A, Ahluwalia MS, Mehta MP, Kotecha R. Pulsed-Reduced Dose Rate (PRDR) Radiotherapy for Recurrent Primary Central Nervous System Malignancies: Dosimetric and Clinical Results. Cancers (Basel) 2022; 14:2946. [PMID: 35740612 PMCID: PMC9221236 DOI: 10.3390/cancers14122946] [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: 05/27/2022] [Revised: 06/07/2022] [Accepted: 06/14/2022] [Indexed: 02/05/2023] Open
Abstract
PURPOSE The objective was to describe PRDR outcomes and report EQD2 OAR toxicity thresholds. METHODS Eighteen patients with recurrent primary CNS tumors treated with PRDR at a single institution between April 2017 and September 2021 were evaluated. The radiotherapy details, cumulative OAR doses, progression-free survival (PFS), overall survival (OS), and toxicities were collected. RESULTS The median PRDR dose was 45 Gy (range: 36-59.4 Gy); the median cumulative EQD2 prescription dose was 102.7 Gy (range: 93.8-120.4 Gy). The median cumulative EQD2 D0.03cc for the brain was 111.4 Gy (range: 82.4-175.2 Gy). Symptomatic radiation necrosis occurred in three patients, for which the median EQD2 brain D0.03cc was 115.9 Gy (110.4-156.7 Gy). The median PFS and OS after PRDR were 6.3 months (95%CI: 0.9-11.6 months) and 8.6 months (95%CI: 4.9-12.3 months), respectively. The systematic review identified five peer-reviewed studies with a median cumulative EQD2 prescription dose of 110.3 Gy. At a median follow-up of 8.7 months, the median PFS and OS were 5.7 months (95%CI: 2.1-15.4 months) and 6.7 months (95%CI: 3.2-14.2 months), respectively. CONCLUSION PRDR re-irradiation is a relatively safe and feasible treatment for recurrent primary CNS tumors. Despite high cumulative dose to OARs, the risk of high-grade, treatment-related toxicity within the first year of follow-up remains acceptable.
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Affiliation(s)
- Tugce Kutuk
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (T.K.); (R.T.); (N.C.M.); (M.D.H.); (M.C.T.); (H.A.); (A.N.G.); (M.P.M.)
| | - Ranjini Tolakanahalli
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (T.K.); (R.T.); (N.C.M.); (M.D.H.); (M.C.T.); (H.A.); (A.N.G.); (M.P.M.)
- Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
| | - Nicole C. McAllister
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (T.K.); (R.T.); (N.C.M.); (M.D.H.); (M.C.T.); (H.A.); (A.N.G.); (M.P.M.)
| | - Matthew D. Hall
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (T.K.); (R.T.); (N.C.M.); (M.D.H.); (M.C.T.); (H.A.); (A.N.G.); (M.P.M.)
- Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
| | - Martin C. Tom
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (T.K.); (R.T.); (N.C.M.); (M.D.H.); (M.C.T.); (H.A.); (A.N.G.); (M.P.M.)
- Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
| | - Muni Rubens
- Department of Clinical Informatics, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA;
| | - Haley Appel
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (T.K.); (R.T.); (N.C.M.); (M.D.H.); (M.C.T.); (H.A.); (A.N.G.); (M.P.M.)
| | - Alonso N. Gutierrez
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (T.K.); (R.T.); (N.C.M.); (M.D.H.); (M.C.T.); (H.A.); (A.N.G.); (M.P.M.)
- Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
| | - Yazmin Odia
- Department of Neuro-Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (Y.O.); (A.M.)
| | - Alexander Mohler
- Department of Neuro-Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (Y.O.); (A.M.)
| | - Manmeet S. Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA;
| | - Minesh P. Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (T.K.); (R.T.); (N.C.M.); (M.D.H.); (M.C.T.); (H.A.); (A.N.G.); (M.P.M.)
- Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (T.K.); (R.T.); (N.C.M.); (M.D.H.); (M.C.T.); (H.A.); (A.N.G.); (M.P.M.)
- Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
- Department of Translational Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
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Ward MC, Koyfman SA, Bakst RL, Margalit DN, Beadle BM, Beitler JJ, Chang SSW, Cooper JS, Galloway TJ, Ridge JA, Robbins JR, Sacco AG, Tsai CJ, Yom SS, Siddiqui F. Retreatment of Recurrent or Second Primary Head and Neck Cancer After Prior Radiation: Executive Summary of the American Radium Society® (ARS) Appropriate Use Criteria (AUC): Expert Panel on Radiation Oncology - Head and Neck Cancer. Int J Radiat Oncol Biol Phys 2022; 113:759-786. [PMID: 35398456 DOI: 10.1016/j.ijrobp.2022.03.034] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 02/16/2022] [Accepted: 03/28/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Re-treatment of recurrent or second primary head and neck cancers occurring in a previously irradiated field is complex. Few guidelines exist to support practice. METHODS We performed an updated literature search of peer-reviewed journals in a systematic fashion. Search terms, key questions, and associated clinical case variants were formed by panel consensus. The literature search informed the committee during a blinded vote on the appropriateness of treatment options via the modified Delphi method. RESULTS The final number of citations retained for review was 274. These informed five key questions, which focused on patient selection, adjuvant re-irradiation, definitive re-irradiation, stereotactic body radiation (SBRT), and re-irradiation to treat non-squamous cancer. Results of the consensus voting are presented along with discussion of the most current evidence. CONCLUSIONS This provides updated evidence-based recommendations and guidelines for the re-treatment of recurrent or second primary cancer of the head and neck.
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Affiliation(s)
- Matthew C Ward
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina; Southeast Radiation Oncology Group, Charlotte, North Carolina.
| | | | | | - Danielle N Margalit
- Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Beth M Beadle
- Stanford University School of Medicine, Palo Alto, California
| | | | | | | | | | - John A Ridge
- Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Jared R Robbins
- University of Arizona College of Medicine Tucson, Tucson, Arizona
| | - Assuntina G Sacco
- University of California San Diego Moores Cancer Center, La Jolla, California
| | - C Jillian Tsai
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sue S Yom
- University of California, San Francisco, California
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Ma CMC. Pulsed low dose-rate radiotherapy: radiobiology and dosimetry. Phys Med Biol 2022; 67. [DOI: 10.1088/1361-6560/ac4c2f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 01/17/2022] [Indexed: 11/12/2022]
Abstract
Abstract
Pulsed low dose-rate radiotherapy (PLDR) relies on two radiobiological findings, the hyper-radiosensitivity of tumor cells at small doses and the reduced normal tissue toxicity at low dose rates. This is achieved by delivering the daily radiation dose of 2 Gy in 10 sub-fractions (pulses) with a 3 min time interval, resulting in an effective low dose rate of 0.067 Gy min−1. In vitro cell studies and in vivo animal experiments demonstrated the therapeutic potential of PLDR treatments and provided useful preclinical data. Various treatment optimization strategies and delivery techniques have been developed for PLDR on existing linear accelerators. Preliminary results from early clinical studies have shown favorable outcomes for various treatment sites especially for recurrent cancers. This paper reviews the experimental findings of PLDR and dosimetric requirements for PLDR treatment planning and delivery, and summarizes major clinical studies on PLDR cancer treatments.
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Price RA, Jin L, Meyer J, Chen L, Lin T, Eldib A, Chen X, Liu J, Veltchev I, Wang L, Ma C. Practical Clinical Implementation of the Special Physics Consultation Process in the Re-irradiation Environment. Adv Radiat Oncol 2020; 6:100594. [PMID: 33490729 PMCID: PMC7811122 DOI: 10.1016/j.adro.2020.09.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 09/30/2020] [Indexed: 11/19/2022] Open
Abstract
Purpose The purpose of this work is to present a practical, structured process allowing for consistent, safe radiation therapy delivery in the re-treatment environment. Methods and materials A process for reirradiation is described with documentation in the form of a special physics consultation. Data acquisition associated with previous treatment is described from highest to lowest quality. Methods are presented for conversion to equieffective dose, as well as our departmental assumptions for tissue repair. The generation of organ-at-risk available physical dose for use in treatment planning is discussed. Results using our methods are compared with published values after conversion to biologically effective dose. Utilization of pulsed-low-dose-rate delivery is described, and data for reirradiation using these methods over the previous 5 years are presented. Results Between 2015 and 2019, the number of patients in our department requiring equieffective dose calculation has doubled. We have developed guidelines for estimation of sublethal damage repair as a function of time between treatment courses ranging from 0% for <6 months to 50% for >1 year. These guidelines were developed based on available spinal cord data because we found that 84% of organs at risk involved nerve-like tissues. The average percent repair used increased from 32% to 37% over this time period. When comparing the results obtained using our methods with published values, 99% of patients had a cumulative biologically effective dose below the limits established for acceptable myelopathy rates. Pulsed-low-dose-rate use over this period tripled with an average prescription dose of 49 Gy. Conclusions The methods described result in safe, effective treatment in the reirradiation setting. Further correlation with patient outcomes and side effects is warranted.
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Abstract
Pulsed low-dose rate radiation therapy has been shown to reduce normal tissue damage while decreasing DNA damage repair in tumor cells. In a cohort of patients treated with palliative or definitive pelvic reirradiation using pulsed low-dose rate radiation therapy, we observed substantial local control and low rates of toxicity.
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Lee CT, Dong Y, Li T, Freedman S, Anaokar J, Galloway TJ, Hallman MA, Weiss SE, Hayes SB, Price RA, Ma CMC, Meyer JE. Local Control and Toxicity of External Beam Reirradiation With a Pulsed Low-dose-rate Technique. Int J Radiat Oncol Biol Phys 2018; 100:959-964. [PMID: 29485075 PMCID: PMC7537409 DOI: 10.1016/j.ijrobp.2017.12.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 11/17/2017] [Accepted: 12/06/2017] [Indexed: 11/28/2022]
Abstract
PURPOSE To evaluate the efficacy and toxicity of external beam reirradiation using a pulsed low-dose-rate (PLDR) technique. METHODS AND MATERIALS We evaluated patients treated with PLDR reirradiation from 2009 to 2016 at a single institution. Toxicity was graded using the Common Terminology Criteria for Adverse Events, version 4.0, and local control was assessed using the Response Evaluation Criteria In Solid Tumors, version 1.1. On univariate analysis (UVA), the χ2 and Fisher exact tests were used to assess the toxicity outcomes. Competing risk analysis using cumulative incidence function estimates were used to assess local progression. RESULTS A total of 39 patients were treated to 41 disease sites with PLDR reirradiation. These patients had a median follow-up time of 8.8 months (range 0.5-64.7). The targets were the thorax, abdomen, and pelvis, including 36 symptomatic sites. The median interval from the first radiation course and reirradiation was 26.2 months; the median dose of the first and second course of radiation was 50.4 Gy and 50 Gy, respectively. Five patients (13%) received concurrent systemic therapy. Of the 39 patients, 9 (23%) developed grade ≥2 acute toxicity, most commonly radiation dermatitis (5 of 9). None developed grade ≥4 acute or subacute toxicity. The only grade ≥2 late toxicity was late skin toxicity in 1 patient. On UVA, toxicity was not significantly associated with the dose of the first course of radiation or reirradiation, the interval to reirradiation, or the reirradiation site. Of the 41 disease sites treated with PLDR reirradiation, 32 had pre- and post-PLDR scans to evaluate for local control. The local progression rate was 16.5% at 6 months and 23.8% at 12 months and was not associated with the dose of reirradiation, the reirradiation site, or concurrent systemic therapy on UVA. Of the 36 symptomatic disease sites, 25 sites (69%) achieved a symptomatic response after PLDR, including 6 (17%) with complete symptomatic relief. CONCLUSION Reirradiation with PLDR is effective and well-tolerated. The risk of late toxicity and the durability of local control were limited by the relatively short follow-up duration in the present cohort.
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Affiliation(s)
- Charles T Lee
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Yanqun Dong
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Tianyu Li
- Biostatistics and Bioinformatics Facility, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Samuel Freedman
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Jordan Anaokar
- Department of Diagnostic Imaging, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Thomas J Galloway
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Mark A Hallman
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Stephanie E Weiss
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Shelly B Hayes
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Robert A Price
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - C M Charlie Ma
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Joshua E Meyer
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania.
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Meyer JE, Finnberg NK, Chen L, Cvetkovic D, Wang B, Zhou L, Dong Y, Hallman MA, Ma CMC, El-Deiry WS. Tissue TGF-β expression following conventional radiotherapy and pulsed low-dose-rate radiation. Cell Cycle 2017; 16:1171-1174. [PMID: 28486014 DOI: 10.1080/15384101.2017.1317418] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
The release of inflammatory cytokines has been implicated in the toxicity of conventional radiotherapy (CRT). Transforming growth factor β (TGF-β) has been suggested to be a risk marker for pulmonary toxicity following radiotherapy. Pulsed low-dose rate radiotherapy (PLDR) is a technique that involves spreading out a conventional radiotherapy dose into short pulses of dose with breaks in between to reduce toxicities. We hypothesized that the more tolerable toxicity profile of PLDR compared with CRT may be related to differential expression of inflammatory cytokines such as TGF-β in normal tissues. To address this, we analyzed tissues from mice that had been subjected to lethal doses of CRT and PLDR by histology and immunohistochemistry (IHC). Equivalent physical doses of CRT triggered more cellular atrophy in the bone marrow, intestine, and pancreas when compared with PLDR as indicated by hematoxylin and eosin staining. IHC data indicates that TGF-β expression is increased in the bone marrow, intestine, and lungs of mice subjected to CRT as compared with tissues from mice subjected to PLDR. Our in vivo data suggest that differential expression of inflammatory cytokines such as TGF-β may play a role in the more favorable normal tissue late response following treatment with PLDR.
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Affiliation(s)
- Joshua E Meyer
- a Radiation Oncology Department , Fox Chase Cancer Center , Philadelphia , PA , USA
| | - Niklas K Finnberg
- b Laboratory of Translational Oncology and Experimental Cancer Therapeutics, Department of Medical Oncology and Molecular Therapeutics Program , Fox Chase Cancer Center , Philadelphia , Pennsylvania
| | - Lili Chen
- a Radiation Oncology Department , Fox Chase Cancer Center , Philadelphia , PA , USA
| | - Dusica Cvetkovic
- a Radiation Oncology Department , Fox Chase Cancer Center , Philadelphia , PA , USA
| | - Bin Wang
- a Radiation Oncology Department , Fox Chase Cancer Center , Philadelphia , PA , USA
| | - Lanlan Zhou
- b Laboratory of Translational Oncology and Experimental Cancer Therapeutics, Department of Medical Oncology and Molecular Therapeutics Program , Fox Chase Cancer Center , Philadelphia , Pennsylvania
| | - Yanqun Dong
- a Radiation Oncology Department , Fox Chase Cancer Center , Philadelphia , PA , USA
| | - Mark A Hallman
- a Radiation Oncology Department , Fox Chase Cancer Center , Philadelphia , PA , USA
| | - Chang-Ming C Ma
- a Radiation Oncology Department , Fox Chase Cancer Center , Philadelphia , PA , USA
| | - Wafik S El-Deiry
- b Laboratory of Translational Oncology and Experimental Cancer Therapeutics, Department of Medical Oncology and Molecular Therapeutics Program , Fox Chase Cancer Center , Philadelphia , Pennsylvania
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Murphy ES, Rogacki K, Godley A, Qi P, Reddy CA, Ahluwalia MS, Peereboom DM, Stevens GH, Yu JS, Kotecha R, Suh JH, Chao ST. Intensity modulated radiation therapy with pulsed reduced dose rate as a reirradiation strategy for recurrent central nervous system tumors: An institutional series and literature review. Pract Radiat Oncol 2017; 7:e391-e399. [PMID: 28666902 DOI: 10.1016/j.prro.2017.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 03/27/2017] [Accepted: 04/10/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Pulsed reduced dose rate (PRDR) is a reirradiation technique that potentially overcomes volume and dose limitations in the setting of previous radiation therapy for recurrent central nervous system (CNS) tumors. Intensity modulated radiation therapy (IMRT) has not yet been reported as a PRDR delivery technique. We reviewed our IMRT PRDR outcomes and toxicity and reviewed the literature of available PRDR series for CNS reirradiation. METHODS AND MATERIALS A total of 24 patients with recurrent brain tumors received PRDR reirradiation between August 2012 and December 2014. Twenty-two patients were planned with IMRT. Linear accelerators delivered an effective dose rate of 0.0667 Gy/minute. Data collected included number of prior interventions, diagnosis, tumor grade, radiation therapy dose and fractionation, normal tissue dose, radiation therapy planning parameters, time to progression, overall survival, and adverse events. RESULTS The median time to PRDR from completion of initial radiation therapy was 47.8 months (range, 11-389.1 months). The median PRDR dose was 54 Gy (range, 38-60 Gy). The mean planning target volume was 369.1 ± 177.9 cm3. The median progression-free survival and 6-month progression-free survival after PRDR treatment was 3.1 months and 31%, respectively. The median overall survival and 6-month overall survival after PRDR treatment was 8.7 months and 71%, respectively. Fifty percent of patients had ≥4 chemotherapy regimens before PRDR. Toxicity was similar to initial treatment, including no cases of radiation necrosis. CONCLUSION IMRT PRDR reirradiation is a feasible and appropriate treatment strategy for large volume recurrent CNS tumors resulting in acceptable overall survival with reasonable toxicity in our patients who were heavily pretreated. Prospective studies are necessary to determine the optimal timing of PRDR reirradiation, the role of concurrent systemic agents, and the ideal patient population who would receive the maximal benefit from this treatment approach. SUMMARY Intensity modulated radiation therapy (IMRT) has not yet been reported as a pulsed reduced dose rate (PRDR) delivery technique for recurrent brain tumors and may allow for safe and comprehensive reirradiation for large volume tumors. We reviewed our IMRT PRDR outcomes and toxicity and reviewed the literature of available PRDR series for recurrent central nervous system tumors. We conclude that IMRT PRDR reirradiation is a feasible and appropriate treatment strategy for large volume recurrent brain tumors resulting in acceptable overall survival with reasonable toxicity in our patients who were heavily pretreated.
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Affiliation(s)
- Erin S Murphy
- Department of Radiation Oncology, Cleveland Clinic Radiation Oncology, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland, Ohio.
| | | | - Andrew Godley
- Department of Radiation Oncology, Cleveland Clinic Radiation Oncology, Cleveland, Ohio
| | - Peng Qi
- Department of Radiation Oncology, Cleveland Clinic Radiation Oncology, Cleveland, Ohio
| | - Chandana A Reddy
- Department of Radiation Oncology, Cleveland Clinic Radiation Oncology, Cleveland, Ohio
| | | | - David M Peereboom
- Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland, Ohio
| | - Glen H Stevens
- Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland, Ohio
| | - Jennifer S Yu
- Department of Radiation Oncology, Cleveland Clinic Radiation Oncology, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland, Ohio
| | - Rupesh Kotecha
- Department of Radiation Oncology, Cleveland Clinic Radiation Oncology, Cleveland, Ohio
| | - John H Suh
- Department of Radiation Oncology, Cleveland Clinic Radiation Oncology, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland, Ohio
| | - Samuel T Chao
- Department of Radiation Oncology, Cleveland Clinic Radiation Oncology, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland, Ohio
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Zilli T, Benz E, Dipasquale G, Rouzaud M, Miralbell R. Reirradiation of Prostate Cancer Local Failures After Previous Curative Radiation Therapy: Long-Term Outcome and Tolerance. Int J Radiat Oncol Biol Phys 2016; 96:318-322. [DOI: 10.1016/j.ijrobp.2016.05.024] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 05/16/2016] [Accepted: 05/23/2016] [Indexed: 10/21/2022]
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Zhang P, Wang B, Chen X, Cvetkovic D, Chen L, Lang J, Ma CM. Local Tumor Control and Normal Tissue Toxicity of Pulsed Low-Dose Rate Radiotherapy for Recurrent Lung Cancer: An In Vivo Animal Study. Dose Response 2015; 13:1559325815588507. [PMID: 26675811 PMCID: PMC4674173 DOI: 10.1177/1559325815588507] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES This study investigates (1) local tumor control and (2) normal tissue toxicity of pulsed low-dose rate radiotherapy (PLDR) for recurrent lung cancer. METHODS For study 1, nude mice were implanted with A549 tumors and divided into the following 3 groups: (1) control (n = 10), (2) conventional radiotherapy (RT; n = 10), and (3) PLDR (n = 10). Tumor-bearing mice received 2 Gy daily dose for 2 consecutive days. Weekly magnetic resonance imaging was used for tumor growth monitoring. For study 2, 20 mice received 8 Gy total body irradiation either continuously (n = 10) or 40 × 0.2 Gy pulses with 3-minute intervals (n = 10). RESULTS For study 1, both conventional RT and PLDR significantly inhibited the growth of A549 xenografts compared with the control group (>35% difference in the mean tumor volume; P < .05). The PLDR results were slightly better than conventional RT (8% difference in the mean tumor volume; P > .05). For study 2, the average weight was 20.94 ± 1.68 g and 25.69 ± 1.27 g and the survival time was 8 days and 12 days for mice treated with conventional RT and PLDR (P < .05), respectively. CONCLUSION This study showed that PLDR could control A549 tumors as effectively as conventional RT, and PLDR induced much less normal tissue toxicity than conventional RT. Thus, PLDR would be a good modality for recurrent lung cancers. ADVANCES IN KNOWLEDGE This article reports our results of an in vivo animal investigation of PLDR for the treatment of recurrent cancers, which may not be eligible for treatment because of the dose limitations on nearby healthy organs that have been irradiated in previous treatments. This was the first in vivo study to quantify the tumor control and normal tissue toxicities of PLDR using mice with implanted tumors, and our findings provided evidence to support the clinical trials that employ PLDR treatment techniques.
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Affiliation(s)
- Peng Zhang
- Department of Radiation Oncology, Sichuan Cancer Hospital, Chengdu, Sichuan, P. R. China
| | - Bin Wang
- Radiation Oncology Department, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Xiaoming Chen
- Radiation Oncology Department, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Dusica Cvetkovic
- Radiation Oncology Department, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Lili Chen
- Radiation Oncology Department, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Jinyi Lang
- Department of Radiation Oncology, Sichuan Cancer Hospital, Chengdu, Sichuan, P. R. China
| | - C-M Ma
- Radiation Oncology Department, Fox Chase Cancer Center, Philadelphia, PA, USA
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Dai X, Zhao Y, Liang Z, Dassarath M, Wang L, Jin L, Chen L, Dong J, Price RA, Ma CM. Volumetric-modulated arc therapy for oropharyngeal carcinoma: a dosimetric and delivery efficiency comparison with static-field IMRT. Phys Med 2014; 31:54-9. [PMID: 25284321 DOI: 10.1016/j.ejmp.2014.09.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 09/04/2014] [Accepted: 09/09/2014] [Indexed: 10/24/2022] Open
Abstract
The purpose of this study is to evaluate the treatment plan adequacy and delivery efficiency among volumetric-modulated arc therapy (VMAT) with one or two arcs and the conventional static-field dynamic multileaf collimator (dMLC) intensity-modulated radiation therapy (IMRT) in patients undergoing oropharyngeal carcinoma. Fifteen patient cases were included in this investigation. Each of the cases was planned using step-and-shoot IMRT, VMAT with a single arc (Arc1) and VMAT with double arcs (Arc2). A two-dose level prescription for planning target volumes (PTVs) was delivered with 70 Gy/56 Gy in 30 fractions. Comparisons were performed of the dose-volume histograms (DVH) for PTVs, the DVH for organs at risk (OARs), the monitor units per fraction (MU/fx), and delivery time. IMRT and Arc2 achieved similar target coverage, but superior to Arc1. Apart from the oral cavity, Arc1 showed no advantage in sparing of OARs compared with IMRT, while Arc2 obtained equivalent or better sparing of OARs among the three techniques. VMAT reduced MU/fx and shortened delivery time remarkably compared with IMRT. Our results demonstrated that for oropharyngeal cases, Arc2 can achieve superior target coverage and normal tissue sparing, as well as a significant reduction in treatment time.
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Affiliation(s)
- Xiaofang Dai
- Cancer Center, Union Hospital, Huazhong University of Sciences and Technology, Wuhan, China
| | - Yingchao Zhao
- Cancer Center, Union Hospital, Huazhong University of Sciences and Technology, Wuhan, China
| | - Zhiwen Liang
- Cancer Center, Union Hospital, Huazhong University of Sciences and Technology, Wuhan, China
| | - Meera Dassarath
- Cancer Center, Union Hospital, Huazhong University of Sciences and Technology, Wuhan, China
| | - Lu Wang
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, USA
| | - Lihui Jin
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, USA
| | - Lili Chen
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, USA
| | - James Dong
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, USA
| | - Robert A Price
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, USA
| | - C-M Ma
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, USA.
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Kang S, Lang J, Wang P, Li J, Lin M, Chen X, Guo M, Chen F, Chen L, Ma CM. Optimization strategies for pulsed low-dose-rate IMRT of recurrent lung and head and neck cancers. J Appl Clin Med Phys 2014; 15:4661. [PMID: 24892337 PMCID: PMC5711051 DOI: 10.1120/jacmp.v15i3.4661] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 01/23/2014] [Accepted: 01/19/2014] [Indexed: 11/23/2022] Open
Abstract
Pulsed low‐dose‐rate radiotherapy (PLDR) has been proven to be a valid method of reirradiation. Previous studies of recurrent cancer radiotherapy were mainly based on conventional 3D CRT and VMAT delivery techniques. There are difficulties in IMRT planning using existing commercial treatment planning systems (TPS) to meet the PLDR protocol. This work focuses on PLDR using ten‐field IMRT and a commercial TPS for two specific sites: recurrent lung cancers and head and neck cancers. Our PLDR protocol requires that the maximum dose to the PTV be less than 0.4 Gy and the mean dose to be 0.2 Gy per field. We investigated various planning strategies to meet the PLDR requirements for 20 lung and head and neck patients. The PTV volume for lung cases ranged from 101.7 to 919.4 cm3 and the maximum dose to the PTV ranged from 0.22 to 0.39 Gy. The PTV volume for head and neck cases ranged from 66.2 to 282.1 cm3 and the maximum dose to the PTV ranged from 0.21 to 0.39 Gy. With special beam arrangements and dosimetry parameters, it is feasible to use a commercial TPS to generate quality PLDR IMRT plans for lung and head and neck reirradiation. PACS number: 87.55.D‐
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