Long-term outcomes after carbon-ion radiotherapy for oral mucosal malignant melanoma

Challenges in the Diagnosis and Treatment of Oral Amelanotic Malignant Melanoma: A Case Report

Oral malignant melanoma (OMM) is extremely rare and usually has a poor prognosis. Early diagnosis is very important and can improve survival but it is usually difficult due to a lack of symptomatology. We present the first case of a 39-year-old East European woman with oral amelanotic melanoma, who underwent surgery and adjuvant immunotherapy; however, after six months, she developed local recurrence. The patient continued immunotherapy with external radiotherapy targeting the oral tumor recurrence. During therapy, imagistic reevaluation brought evidence of bones, lungs, liver, endotracheal, and brain metastases. Histological differential diagnosis between amelanotic OMM and leiomyosarcoma was necessary to establish the right course of treatment. A series of complications further delayed chemotherapy administration, making the treatment in this case very challenging. The patient had a significant, although late response to immunotherapy, and maintained a good performance status during disease progression with a survival of 15 months until present.

Curative carbon ion radiotherapy in a head and neck mucosal melanoma series: Facing the future within multidisciplinarity

PURPOSE

To evaluate efficacy and toxicity of carbon ion radiotherapy (CIRT) in locally advanced head and neck mucosal melanoma (HNMM) patients treated at our Institute.

MATERIALS AND METHODS

Between June 2013 and June 2020, 40 HNMM patients were treated with CIRT. Prescription dose was 65.6-68.8 Gy relative biological effectiveness [RBE] in 16 fractions. Twelve (30%) patients received only biopsy, 28 (70%) surgical resection before CIRT. Immunotherapy was administered before and/or after CIRT in 45% of patients, mainly for distant progression (89%).

RESULTS

Median follow-up was 18 months. 2-year Local Relapse Free Survival (LRFS), Overall Survival (OS), Progression Free Survival (PFS) and Distant Metastasis Free Survival (DMFS) were 84.5%, 58.6%, 33.2% and 37.3%, respectively. At univariate analysis, LRFS was significantly better for non-recurrent status, < 2 surgeries before CIRT and treatment started < 9 months from the initial diagnosis, with no significant differences for operated versus unresected patients. After relapse, immunotherapy provided longer median OS (17 months vs 3.6, p-value<0.001). Late toxicity ≥ G3 (graded with CTCAE 5.0 scale) was reported in 10% of patients.

CONCLUSION

CIRT in advanced HNMM patients is safe and locally effective. Prospective trials are warranted to assess the role of targeted/immune- systemic therapy to improve OS.

Simulation study of comparative dosimetric analysis of coplanar horizontal-port scanned carbon-ion beam therapy in the head and neck

OBJECTIVE

Carbon-ion radiotherapy (CIRT) has demonstrated success in treating radioresistant disease within the head and neck, owing to its unique physical and radiobiological properties. Construction cost remains prohibitive; a center offering only a horizontal port may bridge this difficulty, but removal of the vertical port may prohibit treatment of disease near critical organs-at-risk. Building a center only containing a horizontal treatment port has been proposed as one method for cost savings.

METHODS

20 complex cases of head and neck cancer previously treated with conventional CIRT were retrospectively planned using horizontal-port-only treatment incorporating non-coplanar treatment angles to achieve greater degrees of freedom. These were dosimetrically compared with the previous plans.

RESULTS

Comparable D95 coverage of both planning target volume and gross tumor volume with ability to meet organ-at-risk constraints were feasible with horizontal-port-only treatment. Collectively differences were noted in PTV D95, brain stem Dmax, contralateral eye Dmax and V10 Gy (RBE); further qualitative differences were noted on a plan-by-plan basis dependent on disease location.

CONCLUSION

Horizontal-port-only treatment employing non-coplanar angles was feasible for complicated head and neck disease typically treated with CIRT, though careful consideration is necessary on a plan-by-plan basis.

ADVANCES IN KNOWLEDGE

It is worth noting that non-coplanar approaches are not typically used with the current treatment gantry and may extend further the difference between horizontal port planning and a gantry-based gold-standard.

Basic and translational research on carbon-ion radiobiology

Carbon-ion beam irradiation (IR) has evident advantages over the conventional photon beams in treating tumors. It releases enormous amount of energy in a well-defined range with insignificant scatter in surrounding tissues based on well-localized energy deposition. Over the past 28 years, more than 14,000 patients with various types of cancer have been treated by carbon ion radiotherapy (CIRT) with promising results at QST. I have provided an overview of the basic and translational research on carbon-ion radiobiology including mechanisms underlying high linear energy transfer (LET) carbon-ion IR-induced cell death (apoptosis, autophagy, senescence, mitotic catastrophe etc.) and high radiocurability produced by carbon-ion beams in combination with DNA damaging drugs or with molecular-targeted drugs, micro-RNA therapeutics and immunotherapy. Additionally, I have focused on the application of these treatment in human cancer cells, especially cancer stem cells (CSCs). Finally, I have summarized the current studies on the application of basic carbon-ion beam IR according to the cancer types and clinical outcomes.

A cross-sectional analysis of registered clinical trials on the use of particle beam radiation therapy in head and neck cancers

Background

To present and analyze the current status of registered clinical trials on particle beam (including proton and carbon ion beam) radiation therapy (PBRT) for head and neck (H&N) malignancies, and to provide insights for future clinical research, we designed the cross-sectional analysis.

Methods

We identified and analyzed all clinical trials of interest registered on ClinicalTrials.gov and PTCOG.ch until March 22, 2020.

Results

We identified 57 registered clinical trials related to the use of proton therapy or carbon ion radiation therapy (CIRT) in H&N malignancies. There were 20, 27, and 5 trials focused on CIRT, proton therapy, and both ions, respectively. The eligible trials were registered between 2007 and 2020, mainly focused on adenoid cystic carcinoma (ACC), squamous cell carcinoma (SCC), sinonasal malignancies (SNM), skull base tumors, locally advanced, and recurrent tumors. The nature of 23 (40%) trials were not stated and could not be identified. A total of 25 (44%) registered trials were phase II, including randomized controlled trials (RCTs). There were 14 RCTs (7 phase II, 2 phase II/III, 2 phase III, 1 phase I/II, and 2 phase not applicable), and 25 studies including RCTs were registered before the first enrolment. There were 11 completed clinical trials among the eligible trials, including 7 with published trial-related results.

Conclusions

Less than 10% of the countries with PBRT treatment facilities in operation have initiated clinical trials on H&N cancer. Furthermore, among all registered trials, less than 10% have been completed with results published. More clinical trials, especially high quality trials, are needed for optimizing and standardizing treatment techniques of PBRT for H&N malignancies.

Oral mucosal melanoma - A systematic review

Oral mucosal melanoma (OMM) is the subject of few studies, resulting in a lack of understanding. The aim of this study is to review the current literature on OMM. The term searched was "oral mucosal melanoma" between 01/01/2000 and 03/15/2021 in the PubMed Database (MEDLINE). Patients presenting with OMM and treated in our center between January 2009 and January 2020 were included in a case series. Demographics, location, risk factors, genetic mutations, treatment performed, and overall survival (OS) rates were evaluated. The PubMed database search yielded a total of 513 results, thirty-eight articles were finally included, which amounted to 2230 cases of OMM. 13 patients were included in the case series. A male-to-female ratio of 1.28:1.00 was found with a mean age at first diagnosis of 58.2 years old. Hard palate (1060 cases) and then gingiva (794 cases) were the two main locations. No risk factors could be identified. OMM were staged III or IV at diagnosis. Mutations were described as such: KIT in 14.6% of cases, BRAF in 7%, and NRAS in 5.6%. Treatment protocols varied but radical surgery was the cornerstone treatment associated with adjuvant therapies. Immunotherapy has not been evaluated for OMM. OS rates were 43.4% at 3 years, 33.1% at 5 year and 15.4% at 10 years. OMM show distinct features from cutaneous melanoma (CM): typical locations, no identified risk factors, different mutations profile, worse prognosis with advanced stage at diagnosis. Targeted therapies are still underused compared to CM.

Dosimetric and Clinical Risk Factors for the Development of Maxillary Osteoradionecrosis in Adenoid Cystic Carcinoma (ACC) Patients Treated With Carbon Ion Radiotherapy

Background

The present study aims to evaluate dosimetric and clinical risk factors for the development of maxillary osteoradionecrosis (ORN) in head and neck adenoid cystic carcinoma (ACC) patients treated with carbon ion radiotherapy (CIRT).

Methods

Clinical data and treatment plans of ACC patients, consecutively treated from January 2013 to September 2016 within the phase II clinical trial CNAO S9/2012/C, were retrospectively reviewed. ORN and other treatment-related toxicity were graded according to the Common Terminology Criteria for Adverse Events (CTACE), version 4.0. The maxillary bone was contoured on the planning CT, and only patients receiving more than 10% of the prescription dose at their maxilla were considered for the analysis (67 patients). The volumes of maxilla receiving doses from 10 Gy (RBE) to 60 Gy (RBE) (V_D), with an increment of 10 Gy (RBE), and additional clinical factors were correlated to the incidence of ORN with univariate analysis (Chi-square test). The logistic regression model was subsequently applied for multivariate analysis. Treatment plans calculated with a local effect model (LEM)-based optimization were recalculated with the modified microdosimetric kinetic model (MKM), and compared with literature data from the Japanese experience.

Results

The median time interval from the start of CIRT to ORN appearance was 24 months (range, 8–54 months). Maxillary ORN was observed in 11 patients (16.4%). Grade 1 ORN was observed in 2 patients (18.1%), G2 in 4 (36.3%), G3 in 4 (36.3%) and G4 in 1 (9.3%). From univariate analysis, the site of the tumor, the presence of teeth within the PTV and acute mucositis correlated with the development of maxillary ORN. V_D were significantly higher for all the dose levels tested in patients with maxillary ORN than patients without necrosis, according to both radiobiological models. The multivariate analysis showed that V60 significantly correlated with ORN risk.

Conclusion

The volume of maxilla irradiated with high dose values was relevant for ORN development in our cohort of ACC patients. These results are in line with previously published data obtained with a different radiobiological model. Our findings might be helpful to prevent the risk of ORN in patients receiving CIRT.

Accurate delineation of mucosal lesions in treatment planning computed tomography using iodine paste markers for oral mucosal melanoma

We introduce the utility of iodine paste markers using endodontic materials for the accurate contouring of mucosal lesions of oral mucosal melanoma (OMM), which are difficult to delineate on imaging during the planning of carbon-ion radiation therapy (CIRT). The patient had a primary OMM located in the palatal mucosa without palatal or maxillary bone invasion. A dental root canal filling material, which is a calcium hydroxide/iodoform non-hardenable paste, was used as a marker. We first performed treatment planning computed tomography (CT) without an iodine paste marker for mucosal lesions. Subsequently, we placed an iodine paste marker on the palatal mucosal lesion to accurately delineate the mucosal lesions of the palate. Finally, we took reference CT with an iodine paste marker. CT without the marker was fused to the reference CT with markers during treatment planning, and the gross tumor volume (GTV) was contoured. Thereafter, CIRT was delivered without markers. During CIRT, expected acute mucositis was observed in the area of the planning target volume (PTV), including melanosis, in accordance with the dose distribution. The use of iodine paste markers for localized mucosal lesions, which are difficult to delineate on CT and MRI, may be useful for contouring GTVs on treatment planning CT accurately.

Who Will Benefit from Charged-Particle Therapy?

Charged-particle therapy (CPT) such as proton beam therapy (PBT) and carbon-ion radiotherapy (CIRT) exhibit substantial physical and biological advantages compared to conventional photon radiotherapy. As it can reduce the amount of radiation irradiated in the normal organ, CPT has been mainly applied to pediatric cancer and radioresistent tumors in the eloquent area. Although there is a possibility of greater benefits, high set-up cost and dearth of high level of clinical evidence hinder wide applications of CPT. This review aims to present recent clinical results of PBT and CIRT in selected diseases focusing on possible indications of CPT. We also discussed how clinical studies are conducted to increase the number of patients who can benefit from CPT despite its high cost.

The Role of Particle Therapy in Adenoid Cystic Carcinoma and Mucosal Melanoma of the Head and Neck

Particle irradiation is suitable for resistant histologies owing to a combination of improved dose delivery with potential radiobiologic advantages in high linear energy transfer radiation. Within the head and neck, adenoid cystic carcinoma and mucosal melanoma are two such histologies, being radioresistant and lying closely proximal to critical structures. Here, we review the use of particle irradiation for adenoid cystic carcinoma and mucosal melanoma of the head and neck.

Carbon Ion Dose Constraints in the Head and Neck and Skull Base: Review of MedAustron Institutional Protocols

Background

Dose constraints are of paramount importance for the outcome of any radiotherapy treatment. In this article, we report dose-volume constraints as well as currently used fractionation schedules for carbon ion radiotherapy as applied in MedAustron (Wiener Neustadt, Austria).

Materials and Methods

For fractionation schedules, both German and Japanese regimes were used. From the clinical experience of National Institute of Radiological Sciences (Chiba, Japan) and Heidelberg Ion Therapy (Heidelberg, Germany; formerly GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany) and the work by colleagues in Centro Nazionale Adroterapia Oncologica (Pavia, Italy) recalculating the dose from the microdosimetric kinetic model to the local effect model, we have set the dose constraints for critical organs of the head and neck area. Where no clinical data was available, an educated guess was made, based on data available from photon and proton series.

Results

We report the constraints for the optic nerve and chiasm, brainstem, spinal cord, cochlea, brain parenchyma, salivary gland, eye and adnexa, and mandibular/maxillary bone; constraints are grouped based on a fractionation scheme (German versus Japanese) and the risk of toxicity (safe, low to middle, and middle to high).

Conclusion

We think validation of dose constraints should present a relevant part of the activity of any carbon ion radiotherapy facility, and we anticipate future multicentric, joint evaluations.

Clinical features and dosimetric evaluation of carbon ion radiation-induced osteoradionecrosis of mandible in head and neck tumors

BACKGROUND AND PURPOSE

Osteoradionecrosis (ORN) affects the patient's quality of life by making eating and maintaining oral hygiene painful. This study aimed to analyze carbon ion radiotherapy (C-ion RT)-induced ORN of the mandible.

MATERIALS AND METHODS

A retrospective study of 199 patients with head and neck tumors treated with C-ion RT was performed from 2010 to 2019. Only 11 patients with tumors located in the oropharynx and floor of the mouth were analyzed. C-ion RT consisted of 57.6 Gy or 64.0 Gy (relative biological effectiveness) in 16 fractions. The mandible was analyzed for magnetic resonance imaging (MRI) changes and bone exposure. The relationship between the radiation dose and ORN of the mandible was analyzed.

RESULTS

Five patients (45.5%) had ORN of the mandible. The median follow-up time was 68 months. The median onset times based on MRI changes and bone exposure were 9 and 15 months, respectively. Doses of 30 Gy (relative biological effectiveness) to the mandible and teeth showed the most significant effect, causing ORN at 29.5 ± 6.7 cc and 3.9 ± 1.8 cc, respectively, with cut-off values at 16.5 cc (p = 0.002) and 1.8 cc (p = 0.0059), respectively.

CONCLUSION

This is the first study reporting the incidence, onset time, and risk-predictive dosimetry parameters of C-ion RT-induced ORN of the mandible. Our study will be useful for establishing clinical strategies for C-ion RT to the head and neck near the mandible.

Safety and Efficacy of Salvage Neck Dissection Following Carbon-ion Radiotherapy with Chemotherapy for a Patient with Mucosal Malignant Melanoma of Head and Neck

Mucosal malignant melanoma of the head and neck is a rare diagnosis. The safety and efficacy of salvage neck dissection following carbon–ion radiotherapy with concurrent chemotherapy are not well described, and carbon–ion radiation protocols have not been fully developed. A 77 year old woman with crT0N1M0 mucosal melanoma of the head and neck achieved a complete response following initial treatment with carbon–ion radiotherapy and concurrent chemotherapy. She was treated with salvage neck dissection for as a cervical lymph node metastasis 16 months after initial treatment. She experienced neither Clavien-Dindo Grade 3 or 4 postoperative complications nor subsequent recurrence of disease at 3 months following salvage neck dissection. Surgical specimens may be useful for future precision oncology based on the molecular biology of recurrence melanoma with poor prognosis.

Multicenter study of carbon-ion radiation therapy for nonsquamous cell carcinomas of the oral cavity

Background

The aim of this study was to evaluate the efficacy and safety of carbon‐ion radiation therapy for nonsquamous cell carcinomas of the oral cavity in a multicenter study.

Methods

Retrospective analysis of the clinicopathological features and outcomes of 76 patients with oral nonsquamous cell carcinomas with N0‐1 M0 status and were treated with carbon‐ion radiation therapy at four institutions in Japan between November 2003 and December 2014 was performed.

Results

Salivary gland carcinoma, mucosal melanoma, and three other carcinomas were found in 46, 27, and 3 patients, respectively. T1‐3, T4a, and T4b disease was diagnosed in 27, 18, and 31 patients, respectively. Median follow‐up period was 31.1 months (range, 3‐118 months). Three‐year local control, progression‐free survival, and overall survival of all patients were 86.8%, 63.1%, and 78.4%, respectively. Multivariate analysis showed T classification (T4) to be a significant independent poor prognostic factor for local control. Acute grade 3 mucositis was observed in 38 patients. Grades 3 and 4 late morbidities were observed in 9 and 4 patients, respectively. No grade 5 late toxicity was observed.

Conclusions

Oral nonsquamous cell carcinomas could be treated effectively, with acceptable toxicity, by carbon‐ion radiation therapy.

Modern radiotherapy for head and neck cancer

Radiation therapy (RT) plays a key role in curative-intent treatments for head and neck cancers. Its use is indicated as a sole therapy in early stage tumors or in combination with surgery or concurrent chemotherapy in advanced stages. Recent technologic advances have resulted in both improved oncologic results and expansion of the indications for RT in clinical practice. Despite this, RT administered to the head and neck region is still burdened by a high rate of acute and late side effects. Moreover, about 50% of patients with high-risk disease experience loco-regional recurrence within 3 years of follow-up. Therefore, in recent decades, efforts have been dedicated to optimize the cost/benefit ratio of RT in this subset of patients. The aim of the present review was to highlight modern concepts of RT for head and neck cancers considering both the technological advances that have been achieved and recent knowledge that has informed the biological interaction between radiation and both tumor and healthy tissues.

Overexpression of Ras-Related C3 Botulinum Toxin Substrate 2 Radiosensitizes Melanoma Cells In Vitro and In Vivo

Radioresistance is the major obstacle in the radiotherapy of the malignant melanoma. Thus, it is of importance to increase the radiosensitivity of melanoma cells. In the present study, the radioresistant melanoma cell line OCM-1 with inducible overexpression of Ras-related C3 botulinum toxin substrate 2 was established based on a radiation-inducible early growth response gene (Egr-1) promoter. The effects of Ras-related C3 botulinum toxin substrate 2 overexpression on the radiosensitivity of melanoma cells exposed to either X-rays or carbon ion beams were evaluated in cultured cells as well as xenograft tumor models. In addition, both reactive oxygen species yield and the NADPH oxidase activity were measured in the irradiated melanoma cells. It was found that the radiation-inducible overexpression of Ras-related C3 botulinum toxin substrate 2 sensitized the melanoma cells to both X-rays and carbon ion irradiation by enhancing the NADPH oxidase activity and the subsequent reactive oxygen species production. Besides, the overexpression of Ras-related C3 botulinum toxin substrate 2 enhanced the tumor-killing effect of radiotherapy in xenograft tumors significantly. The results of this study indicate that Ras-related C3 botulinum toxin substrate 2 is promising in increasing the radiosensitivity of melanoma cells, which provides experimental evidence and theoretical basis for clinical radiosensitization of the malignant melanoma.

Prevalence of malignant melanoma in anatomical sites of the oral cavity: A meta-analysis

Oral malignant melanoma (OMM) is a very rare disease entity accounting <1% of all other melanomas. Till date, no comprehensive meta-analysis has been conducted regarding the prevalence of malignant melanoma in the oral cavity. Therefore, the present meta-analysis was conducted to update on the prevalence of malignant melanoma in anatomical sites of the oral cavity. Literature search was performed to congregate reports of last 10 years using databases, such as PubMed and ScienceDirect. The search strings used were "palate," "buccal," "gingiva," "gum," "maxillary," "mandibular," "lip," "tongue," "melanoma," "oral melanoma," "malignant melanoma," "prognosis," "risk factors," "noncutaneous" and "diagnosis" of OMM by combining terms using the Boolean operators. MedCalc 16.4.3 software was used for the analysis. "Random effects model" was used in the analysis due to significant heterogeneity in the studies. Proportion method was used to analyze the prevalence. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed to report the analysis. Out of 130 studies screened, 19 were included in the meta-analysis and a total of 1323 patients were included. The median age of the patients was found to be 61.87 ± 7.78 years (confidence interval 53.8-67 years). All the screened studies showed significant heterogeneity in gender as well as tumor sites (P < 0.0001). Palate (34.29%) was the most commonly affected site in OMM patients. Overall, the results of the meta-analysis suggest that palate is the most prevalent site in OMM. Furthermore, OMM is high in patients between the fifth and sixth decade of life with a male predominance.

Feasibility of carbon-ion radiotherapy for oral non-squamous cell carcinomas

Background

This study evaluated carbon‐ion radiotherapy (C‐ion RT) for oral non‐squamous cell carcinomas (non‐SCC).

Methods

We retrospectively obtained data from 74 patients who underwent C‐ion RT for oral malignancies between April 1997 and March 2016. The C‐ion RT was administered in 16 fractions at a total dose of 57.6 or 64.0 Gy (relative biological effectiveness).

Results

Forty‐three patients had salivary gland carcinomas, 29 patients had mucosal melanoma, and 2 patients had other types of pathologies. The tumors were classified as T1‐T3 (24 cases), T4a (21 cases), or T4b (29 cases). The median follow‐up was 49 months. The 5‐year rates were 78.8% for local control, 36.2% for progression‐free survival, and 58.3% for overall survival. Although 10 patients developed grade 3 osteoradionecrosis after C‐ion RT, all patients maintained their mastication and deglutition functions after sequestrectomy and prosthesis placement.

Conclusion

C‐ion RT was effective for oral non‐SCC and had acceptable toxicities.

Transplantable Melanomas in Hamsters and Gerbils as Models for Human Melanoma. Sensitization in Melanoma Radiotherapy-From Animal Models to Clinical Trials

The focus of the present review is to investigate the role of melanin in the radioprotection of melanoma and attempts to sensitize tumors to radiation by inhibiting melanogenesis. Early studies showed radical scavenging, oxygen consumption and adsorption as mechanisms of melanin radioprotection. Experimental models of melanoma in hamsters and in gerbils are described as well as their use in biochemical and radiobiological studies, including a spontaneously metastasizing ocular model. Some results from in vitro studies on the inhibition of melanogenesis are presented as well as radio-chelation therapy in experimental and clinical settings. In contrast to cutaneous melanoma, uveal melanoma is very successfully treated with radiation, both using photon and proton beams. We point out that the presence or lack of melanin pigmentation should be considered, when choosing therapeutic options, and that both the experimental and clinical data suggest that melanin could be a target for radiosensitizing melanoma cells to increase efficacy of radiotherapy against melanoma.

Palatal Melanoma: "The Silent Killer"

Primary melanoma of the oral cavity is extremely uncommon tumour consisting approximately 0.2 - 8.0% of all melanoma cases and 0.5% of all oral malignancies. It has an aggressive behaviour and poor prognosis, with 5 - year - survival rate between 5 - 20%. The initial symptoms are often unnoticed, which lead to late diagnosis and worsening of the prognosis. Because of its infrequent occurrence, there is no well - defined classification and therapeutic protocol, in contrast to melanomas of another side. Early diagnosis and treatment are essentially linked to survival rate. We present a case of palatal melanoma in a 76 - year - old female patient, as we want to emphasise the importance of the early detection and accurate diagnosis of melanoma of oral cavity, to its influence of the therapeutic outcome.

The 150 most important questions in cancer research and clinical oncology series: questions 67-75 : Edited by Chinese Journal of Cancer

Since the beginning of 2017, Chinese Journal of Cancer has published a series of important questions in cancer research and clinical oncology, which sparkle diverse thoughts, interesting communications, and potential collaborations among researchers all over the world. In this article, 9 more questions are presented as followed. Question 67. How could we overcome the resistance of hepatocellular carcinoma against chemotherapeutics? Question 68. Is pursuit of non-covalent small-molecule binders of RAS proteins viable as a strategy of cancer drug discovery? Question 69. In what oligomeric structures do RAS proteins signal? Question 70. How can we achieve non-invasive early detection and diagnosis of lung cancer? Question 71. Does genetic information influence the volatolome enabling diagnosis of lung cancer with genetic mutations via cell headspace or breath analysis? Question 72. Is heavy ion beam radiotherapy effective to kill cancer stem cells? Question 73. Is there any diversity among different types of cancer in terms of sensitivity to heavy ion beam radiotherapy? Question 74. Can targeted alpha-particle therapy augment the effect of carbon ion radiotherapy on malignancies? Question 75. How does chromosomal instability drive tumor progression?