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Chen Y, Luo H, Liu R, Tan M, Wang Q, Wu X, Du T, Liu Z, Sun S, Zhang Q, Wang X. Efficacy and safety of particle therapy for inoperable stage II-III non-small cell lung cancer: a systematic review and meta-analysis. Radiat Oncol 2023; 18:86. [PMID: 37217970 DOI: 10.1186/s13014-023-02264-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 04/12/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND AND PURPOSE Particle therapy, mainly including carbon-ion radiotherapy (CIRT) and proton beam therapy (PBT), has dose distribution advantages compared to photon radiotherapy. It has been widely reported as a promising treatment method for early non-small cell lung cancer (NSCLC). However, its application in locally advanced non-small cell lung cancer (LA-NSCLC) is relatively rare, and its efficacy and safety are inconclusive. This study aimed to provide systematic evidence for evaluating the efficacy and safety of particle therapy for inoperable LA-NSCLC. METHODS To retrieve published literature, a systematic search was conducted in PubMed, Web of Science, Embase, and Cochrane Library until September 4, 2022. The primary endpoints were local control (LC) rate, overall survival (OS) rate, and progression-free survival (PFS) rate at 2 and 5 years. The secondary endpoint was treatment-related toxicity. The pooled clinical outcomes and 95% confidence intervals (CIs) were calculated by using STATA 15.1. RESULTS Nineteen eligible studies with a total sample size of 851 patients were included. The pooled data demonstrated that the OS, PFS, and LC rates at 2 years of LA-NSCLC treated by particle therapy were 61.3% (95% CI = 54.7-68.7%), 37.9% (95% CI = 33.8-42.6%) and 82.2% (95% CI = 78.7-85.9%), respectively. The pooled 5-year OS, PFS, and LC rates were 41.3% (95% CI = 27.1-63.1%), 25.3% (95% CI = 16.3-39.4%), and 61.5% (95% CI = 50.7-74.6%), respectively. Subgroup analysis stratified by treatment type showed that the concurrent chemoradiotherapy (CCRT, PBT combined with concurrent chemotherapy) group had better survival benefits than the PBT and CIRT groups. The incidence rates of grade 3/4 esophagitis, dermatitis, and pneumonia in LA-NSCLC patients after particle therapy were 2.6% (95% CI = 0.4-6.0%), 2.6% (95% CI = 0.5-5.7%) and 3.4% (95% CI = 1.4-6.0%), respectively. CONCLUSIONS Particle therapy demonstrated promising efficacy and acceptable toxicity in LA-NSCLC patients.
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Affiliation(s)
- Yanliang Chen
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, 730000, Gansu Province, China
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Hongtao Luo
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, 730000, Gansu Province, China
- Department of Postgraduate, University of Chinese Academy of Sciences, Beijing, China
- Heavy Ion Therapy Center, Lanzhou Heavy Ions Hospital, Lanzhou, China
| | - Ruifeng Liu
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, 730000, Gansu Province, China
- Department of Postgraduate, University of Chinese Academy of Sciences, Beijing, China
- Heavy Ion Therapy Center, Lanzhou Heavy Ions Hospital, Lanzhou, China
| | - Mingyu Tan
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, 730000, Gansu Province, China
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Qian Wang
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, 730000, Gansu Province, China
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Xun Wu
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, 730000, Gansu Province, China
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Tianqi Du
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, 730000, Gansu Province, China
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Zhiqiang Liu
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, 730000, Gansu Province, China
- Department of Postgraduate, University of Chinese Academy of Sciences, Beijing, China
- Heavy Ion Therapy Center, Lanzhou Heavy Ions Hospital, Lanzhou, China
| | - Shilong Sun
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, 730000, Gansu Province, China
- Department of Postgraduate, University of Chinese Academy of Sciences, Beijing, China
- Heavy Ion Therapy Center, Lanzhou Heavy Ions Hospital, Lanzhou, China
| | - Qiuning Zhang
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, 730000, Gansu Province, China.
- Department of Postgraduate, University of Chinese Academy of Sciences, Beijing, China.
- Heavy Ion Therapy Center, Lanzhou Heavy Ions Hospital, Lanzhou, China.
| | - Xiaohu Wang
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, 730000, Gansu Province, China.
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China.
- Department of Postgraduate, University of Chinese Academy of Sciences, Beijing, China.
- Heavy Ion Therapy Center, Lanzhou Heavy Ions Hospital, Lanzhou, China.
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Wong SL, Alshaikhi J, Grimes H, Amos RA, Poynter A, Rompokos V, Gulliford S, Royle G, Liao Z, Sharma RA, Mendes R. Retrospective Planning Study of Patients with Superior Sulcus Tumours Comparing Pencil Beam Scanning Protons to Volumetric-Modulated Arc Therapy. Clin Oncol (R Coll Radiol) 2021; 33:e118-e131. [PMID: 32798157 PMCID: PMC7883303 DOI: 10.1016/j.clon.2020.07.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/30/2020] [Accepted: 07/22/2020] [Indexed: 12/25/2022]
Abstract
AIMS Twenty per cent of patients with non-small cell lung cancer present with stage III locally advanced disease. Precision radiotherapy with pencil beam scanning (PBS) protons may improve outcomes. However, stage III is a heterogeneous group and accounting for complex tumour motion is challenging. As yet, it remains unclear as to whom will benefit. In our retrospective planning study, we explored if patients with superior sulcus tumours (SSTs) are a select cohort who might benefit from this treatment. MATERIALS AND METHODS Patients with SSTs treated with radical radiotherapy using four-dimensional planning computed tomography between 2010 and 2015 were identified. Tumour motion was assessed and excluded if greater than 5 mm. Photon volumetric-modulated arc therapy (VMAT) and PBS proton single-field optimisation plans, with and without inhomogeneity corrections, were generated retrospectively. Robustness analysis was assessed for VMAT and PBS plans involving: (i) 5 mm geometric uncertainty, with an additional 3.5% range uncertainty for proton plans; (ii) verification plans at maximal inhalation and exhalation. Comparative dosimetric and robustness analyses were carried out. RESULTS Ten patients were suitable. The mean clinical target volume D95 was 98.1% ± 0.4 (97.5-98.8) and 98.4% ± 0.2 (98.1-98.9) for PBS and VMAT plans, respectively. All normal tissue tolerances were achieved. The same four PBS and VMAT plans failed robustness assessment. Inhomogeneity corrections minimally impacted proton plan robustness and made it worse in one case. The most important factor affecting target coverage and robustness was the clinical target volume entering the spinal canal. Proton plans significantly reduced the mean lung dose (by 21.9%), lung V5, V10, V20 (by 47.9%, 36.4%, 12.1%, respectively), mean heart dose (by 21.4%) and thoracic vertebra dose (by 29.2%) (P < 0.05). CONCLUSIONS In this planning study, robust PBS plans were achievable in carefully selected patients. Considerable dose reductions to the lung, heart and thoracic vertebra were possible without compromising target coverage. Sparing these lymphopenia-related organs may be particularly important in this era of immunotherapy.
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Affiliation(s)
- S-L Wong
- University College London Cancer Institute, London, UK; Department of Clinical Oncology, University College London Hospitals NHS Foundation Trust, London, UK.
| | - J Alshaikhi
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK; Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, UK; Saudi Particle Therapy Centre, Riyadh, Saudi Arabia
| | - H Grimes
- Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, UK
| | - R A Amos
- Department of Clinical Oncology, University College London Hospitals NHS Foundation Trust, London, UK; Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, UK; Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - A Poynter
- Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, UK
| | - V Rompokos
- Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, UK
| | - S Gulliford
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK; Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, UK
| | - G Royle
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Z Liao
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - R A Sharma
- University College London Cancer Institute, London, UK; Department of Clinical Oncology, University College London Hospitals NHS Foundation Trust, London, UK; NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - R Mendes
- Department of Clinical Oncology, University College London Hospitals NHS Foundation Trust, London, UK
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Iwata H, Akita K, Yamaba Y, Kunii E, Takakuwa O, Yoshihara M, Hattori Y, Nakajima K, Hayashi K, Toshito T, Ogino H, Shibamoto Y. Concurrent Chemo-Proton Therapy Using Adaptive Planning for Unresectable Stage 3 Non-Small Cell Lung Cancer: A Phase 2 Study. Int J Radiat Oncol Biol Phys 2020; 109:1359-1367. [PMID: 33227444 DOI: 10.1016/j.ijrobp.2020.11.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 11/05/2020] [Accepted: 11/12/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE This study prospectively evaluated the efficacy and safety of concurrent chemo-proton therapy (CCPT) using adaptive planning for unresectable stage III non-small cell lung cancer (NSCLC). METHODS AND MATERIALS The primary endpoint was overall survival (OS). Secondary endpoints were local control rate (LCR), progression-free survival (PFS), incidence of grade 3 or higher adverse events, and changes in quality of life (QOL). Patients received cisplatin (60 mg/m2) on day 1 and S-1 (∼40 mg/m2 twice daily) on days 1 to 14, q4w, for up to 4 cycles, plus concurrent proton therapy at a total dose of 70 GyRBE for the primary lesion and 66 GyRBE for lymph node metastasis with 2 GyRBE per day. Proton therapy was performed using respiratory-gated and image guided techniques, and adaptive plans were implemented. RESULTS Forty-seven patients were enrolled between August 2013 and August 2018. Four cycles of cisplatin plus S-1 were completed in 34 patients. The mean number of cycles was 4 (range, 1-4). The median follow-up of all and surviving patients was 37 (range, 4-84) and 52 months (range, 26-84), respectively. The mean number of replanning sessions was 2.5 (range, 1-4). The 2- and 5-year OS, LCR, and PFS were 77% (95% confidence interval 64%-89%) and 59% (43%-76%), 84% (73%-95%) and 61% (44%-78%), and 43% (28%-57%) and 37% (22%-51%), respectively. The median OS was not reached. No grade 3 or higher radiation pneumonitis was observed. There was no significant deterioration in the QOL scores after 24 months except for alopecia. CONCLUSIONS CCPT with adaptive planning was well tolerated and yielded remarkable OS for unresectable stage III NSCLC.
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Affiliation(s)
- Hiromitsu Iwata
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City West Medical Center, Nagoya, Japan; Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.
| | - Kenji Akita
- Department of Respiratory Tract Oncology Center, Nagoya City West Medical Center, Nagoya, Japan
| | - Yusuke Yamaba
- Department of Respiratory Tract Oncology Center, Nagoya City West Medical Center, Nagoya, Japan
| | - Eiji Kunii
- Department of Respiratory Tract Oncology Center, Nagoya City West Medical Center, Nagoya, Japan
| | - Osamu Takakuwa
- Department of Respiratory Tract Oncology Center, Nagoya City West Medical Center, Nagoya, Japan
| | - Misuzu Yoshihara
- Department of Respiratory Tract Oncology Center, Nagoya City West Medical Center, Nagoya, Japan
| | - Yukiko Hattori
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City West Medical Center, Nagoya, Japan
| | - Koichiro Nakajima
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City West Medical Center, Nagoya, Japan; Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Kensuke Hayashi
- Department of Proton Therapy Technology, Nagoya Proton Therapy Center, Nagoya, Japan
| | - Toshiyuki Toshito
- Department of Proton Therapy Physics, Nagoya Proton Therapy Center, Nagoya, Japan
| | - Hiroyuki Ogino
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City West Medical Center, Nagoya, Japan; Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yuta Shibamoto
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Iwata H, Shuto T, Kamei S, Omachi K, Moriuchi M, Omachi C, Toshito T, Hashimoto S, Nakajima K, Sugie C, Ogino H, Kai H, Shibamoto Y. Combined effects of cisplatin and photon or proton irradiation in cultured cells: radiosensitization, patterns of cell death and cell cycle distribution. JOURNAL OF RADIATION RESEARCH 2020; 61:832-841. [PMID: 32880637 PMCID: PMC7674701 DOI: 10.1093/jrr/rraa065] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/22/2020] [Accepted: 04/07/2020] [Indexed: 06/11/2023]
Abstract
The purpose of the current study was to investigate the biological effects of protons and photons in combination with cisplatin in cultured cells and elucidate the mechanisms responsible for their combined effects. To evaluate the sensitizing effects of cisplatin against X-rays and proton beams in HSG, EMT6 and V79 cells, the combination index, a simple measure for quantifying synergism, was estimated from cell survival curves using software capable of performing the Monte Carlo calculation. Cell death and apoptosis were assessed using live cell fluorescence imaging. HeLa and HSG cells expressing the fluorescent ubiquitination-based cell cycle indicator system (Fucci) were irradiated with X-rays and protons with cisplatin. Red and green fluorescence in the G1 and S/G2/M phases, respectively, were evaluated and changes in the cell cycle were assessed. The sensitizing effects of ≥1.5 μM cisplatin were observed for both X-ray and proton irradiation (P < 0.05). In the three cell lines, the average combination index was 0.82-1.00 for X-rays and 0.73-0.89 for protons, indicating stronger effects for protons. In time-lapse imaging, apoptosis markedly increased in the groups receiving ≥1.5 μM cisplatin + protons. The percentage of green S/G2/M phase cells at that time was higher when cisplatin was combined with proton beams than with X-rays (P < 0.05), suggesting more significant G2 arrest. Proton therapy plus ≥1.5 μM cisplatin is considered to be very effective. When combined with cisplatin, proton therapy appeared to induce greater apoptotic cell death and G2 arrest, which may partly account for the difference observed in the combined effects.
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Affiliation(s)
- Hiromitsu Iwata
- Corresponding author. Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City West Medical Center, Nagoya, Japan, 1-1-1 Hirate-cho, Kita-ku, Nagoya 462-8508, Japan. Tel.: (+81) 52-991-8577; Fax: (+81) 52-991-8599;
| | - Tsuyoshi Shuto
- Department of Molecular Medicine, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-honmachi, Chuo-ku, Kumamoto, 862-0973, Japan
| | - Shunsuke Kamei
- Department of Molecular Medicine, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-honmachi, Chuo-ku, Kumamoto, 862-0973, Japan
| | - Kohei Omachi
- Department of Molecular Medicine, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-honmachi, Chuo-ku, Kumamoto, 862-0973, Japan
| | - Masataka Moriuchi
- Department of Molecular Medicine, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-honmachi, Chuo-ku, Kumamoto, 862-0973, Japan
| | - Chihiro Omachi
- Department of Proton Therapy Physics, Nagoya Proton Therapy Center, 1-1-1 Hirate-cho, Kita-ku, Nagoya 462-8508, Japan
| | - Toshiyuki Toshito
- Department of Proton Therapy Physics, Nagoya Proton Therapy Center, 1-1-1 Hirate-cho, Kita-ku, Nagoya 462-8508, Japan
| | - Shingo Hashimoto
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
| | - Koichiro Nakajima
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City West Medical Center, 1-1-1 Hirate-cho, Kita-ku, Nagoya 462-8508, Japan
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
| | - Chikao Sugie
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
| | - Hiroyuki Ogino
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City West Medical Center, 1-1-1 Hirate-cho, Kita-ku, Nagoya 462-8508, Japan
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
| | - Hirofumi Kai
- Department of Molecular Medicine, Graduate School of Pharmaceutical Sciences, Kumamoto University, 5-1 Oe-honmachi, Chuo-ku, Kumamoto, 862-0973, Japan
| | - Yuta Shibamoto
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
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Giaj-Levra N, Borghetti P, Bruni A, Ciammella P, Cuccia F, Fozza A, Franceschini D, Scotti V, Vagge S, Alongi F. Current radiotherapy techniques in NSCLC: challenges and potential solutions. Expert Rev Anticancer Ther 2020; 20:387-402. [PMID: 32321330 DOI: 10.1080/14737140.2020.1760094] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Radiotherapy is an important therapeutic strategy in the management of non-small cell lung cancer (NSCLC). In recent decades, technological implementations and the introduction of image guided radiotherapy (IGRT) have significantly increased the accuracy and tolerability of radiation therapy.Area covered: In this review, we provide an overview of technological opportunities and future prospects in NSCLC management.Expert opinion: Stereotactic body radiotherapy (SBRT) is now considered the standard approach in patients ineligible for surgery, while in operable cases, it is still under debate. Additionally, in combination with systemic treatment, SBRT is an innovative option for managing oligometastatic patients and features encouraging initial results in clinical outcomes. To date, in inoperable locally advanced NSCLC, the radical dose prescription has not changed (60 Gy in 30 fractions), despite the median overall survival progressively increasing. These results arise from technological improvements in precisely hitting target treatment volumes and organ at risk sparing, which are associated with better treatment qualities. Finally, for the management of NSCLC, proton and carbon ion therapies and the recent development of MR-Linac are new, intriguing technological approaches under investigation.
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Affiliation(s)
- Niccolò Giaj-Levra
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Italy
| | - Paolo Borghetti
- Dipartimento di Radioterapia Oncologica, Università e ASST Spedali Civili di Brescia, Brescia, Italy
| | - Alessio Bruni
- Radiotherapy Unit, Department of Oncology and Hematology, University Hospital of Modena, Modena, Italy
| | - Patrizia Ciammella
- Radiation Therapy Unit, Department of Oncology and Advanced Technology, AUSL-IRCCS, Reggio, Emilia, Italy
| | - Francesco Cuccia
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Italy
| | - Alessandra Fozza
- Department of Radiation Oncology, SS.Antonio e Biagio e C.Arrigo Hospital Alessandria, Alessandria, Italy
| | - Davide Franceschini
- Department of Radiotherapy and Radiosurgery, Humanitas Clinical and Research Center- IRCCS - Rozzano (MI), Milano, Italy
| | - Vieri Scotti
- Radiation Therapy Unit, Department of Oncology, Careggi University Hospital, Firenze, Italy
| | - Stefano Vagge
- Radiation oncology Department, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Filippo Alongi
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Italy.,University of Brescia, Italy
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Lühr A, von Neubeck C, Pawelke J, Seidlitz A, Peitzsch C, Bentzen SM, Bortfeld T, Debus J, Deutsch E, Langendijk JA, Loeffler JS, Mohan R, Scholz M, Sørensen BS, Weber DC, Baumann M, Krause M. "Radiobiology of Proton Therapy": Results of an international expert workshop. Radiother Oncol 2018; 128:56-67. [PMID: 29861141 DOI: 10.1016/j.radonc.2018.05.018] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 05/17/2018] [Accepted: 05/17/2018] [Indexed: 12/25/2022]
Abstract
The physical properties of proton beams offer the potential to reduce toxicity in tumor-adjacent normal tissues. Toward this end, the number of proton radiotherapy facilities has steeply increased over the last 10-15 years to currently around 70 operational centers worldwide. However, taking full advantage of the opportunities offered by proton radiation for clinical radiotherapy requires a better understanding of the radiobiological effects of protons alone or combined with drugs or immunotherapy on normal tissues and tumors. This report summarizes the main results of the international expert workshop "Radiobiology of Proton Therapy" that was held in November 2016 in Dresden. It addresses the major topics (1) relative biological effectiveness (RBE) in proton beam therapy, (2) interaction of proton radiobiology with radiation physics in current treatment planning, (3) biological effects in proton therapy combined with systemic treatments, and (4) testing biological effects of protons in clinical trials. Finally, important research avenues for improvement of proton radiotherapy based on radiobiological knowledge are identified. The clinical distribution of radiobiological effectiveness of protons alone or in combination with systemic chemo- or immunotherapies as well as patient stratification based on biomarker expressions are key to reach the full potential of proton beam therapy. Dedicated preclinical experiments, innovative clinical trial designs, and large high-quality data repositories will be most important to achieve this goal.
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Affiliation(s)
- Armin Lühr
- Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Germany; OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; German Cancer Consortium (DKTK), Partner Site Dresden and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Cläre von Neubeck
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; German Cancer Consortium (DKTK), Partner Site Dresden and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jörg Pawelke
- Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Germany; OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany
| | - Annekatrin Seidlitz
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; German Cancer Consortium (DKTK), Partner Site Dresden and German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Claudia Peitzsch
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; German Cancer Consortium (DKTK), Partner Site Dresden and German Cancer Research Center (DKFZ), Heidelberg, Germany; National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Germany
| | - Søren M Bentzen
- Division of Biostatistics and Bioinformatics, Department of Epidemiology and Public Health and the Maryland Proton Therapy Center, Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, USA
| | - Thomas Bortfeld
- Physics Division, Department of Radiation Oncology, Massachusetts General Hospital, Boston, USA
| | - Jürgen Debus
- German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Radiation Oncology, University Heidelberg German Consortium for Translational Oncology (DKTK), Germany; National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Eric Deutsch
- Department of Radiation Oncology Gustave Roussy Cancer Campus, INSERM, 1030 Villejuif, France; Université Paris-Sud, Faculté de Medecine du Kremlin Bicetre Paris Sud, Le Kremlin-Bicêtre, France
| | - Johannes A Langendijk
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jay S Loeffler
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, USA; Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, USA
| | - Radhe Mohan
- Department of Radiation Physics, UT MD Anderson Cancer Center, Houston, USA
| | - Michael Scholz
- GSI Helmholtz Center for Heavy Ion Research, Department of Biophysics, Darmstadt, Germany
| | - Brita S Sørensen
- Dept. Experimental Clinical Oncology, Aarhus University Hospital, Denmark
| | - Damien C Weber
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Villigen, Switzerland
| | - Michael Baumann
- Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Germany; OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; German Cancer Consortium (DKTK), Partner Site Dresden and German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Mechthild Krause
- Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Germany; OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; German Cancer Consortium (DKTK), Partner Site Dresden and German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Germany
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Abstract
The finite range of proton beams in tissues offers unique dosimetric advantages that theoretically allow the dose to the target to be escalated while minimizing exposure of surrounding tissues and thereby minimizing radiation-induced toxicity. These theoretical advantages have led to widespread adoption of proton therapy around the world for a wide variety of tumors at different anatomic sites. Many treatment-planning comparisons have shown that proton therapy has substantial dosimetric advantages over conventional photon (X-ray) radiation therapy. However, given the typically significant difference in cost between proton therapy versus conventional photon therapy, strong evidence of proton therapy's clinical benefits in terms of toxicity and survival is warranted. Some findings from retrospective studies, single-arm prospective studies, and a very few randomized clinical trials comparing these modalities are beginning to emerge. In this review, we examine the available data on proton therapy for (non-small cell lung cancer NSCLC). We begin by discussing the unique challenges involved in treating moving targets with significant tissue heterogeneity and the technologic efforts underway to overcome these challenges. We then discuss the rationale for minimizing normal tissue toxicity, particularly pulmonary, cardiac, and hematologic toxicity, within the context of previously unsuccessful attempts at dose escalation for lung cancer. Finally, we explore strategies for accelerating the development of trials aimed at measuring meaningful clinical endpoints and for maximizing the value of proton therapy by personalizing its use for individual patients.
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Affiliation(s)
- Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Charles B Simone
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
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Liao Z, Gandhi SJ, Lin SH, Bradley J. Does Proton Therapy Offer Demonstrable Clinical Advantages for Treating Thoracic Tumors? Semin Radiat Oncol 2018; 28:114-124. [DOI: 10.1016/j.semradonc.2017.11.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Harada H, Murayama S. Proton beam therapy in non-small cell lung cancer: state of the art. LUNG CANCER-TARGETS AND THERAPY 2017; 8:141-145. [PMID: 28883747 PMCID: PMC5574682 DOI: 10.2147/lctt.s117647] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
This review summarizes the past and present status of proton beam therapy (PBT) for lung cancer. PBT has a unique characteristic called the Bragg peak that enables a reduction in the dose of normal tissue around the tumor, but is sensitive to the uncertainties of density changes. The heterogeneity in electron density for thoracic lesions, such as those in the lung and mediastinum, and tumor movement according to respiration necessitates respiratory management for PBT to be applied in lung cancer patients. There are two types of PBT - a passively scattered approach and a scanning approach. Typically, a passively scattered approach is more robust for respiratory movement and a scanning approach could result in a more conformal dose distribution even when the tumor shape is complex. Large tumors of centrally located lung cancer may be more suitably irradiated than with intensity-modulated radiotherapy (IMRT) or stereotactic body radiotherapy (SBRT). For a locally advanced lung cancer, PBT can spare the lung and heart more than photon IMRT. However, no randomized controlled trial has reported differences between PBT and IMRT or SBRT for early-stage and locally advanced lung cancers. Therefore, a well-designed controlled trial is warranted.
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Affiliation(s)
- Hideyuki Harada
- Radiation and Proton Therapy Center, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
| | - Shigeyuki Murayama
- Radiation and Proton Therapy Center, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
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10
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Harada H, Fuji H, Ono A, Kenmotsu H, Naito T, Yamashita H, Asakura H, Nishimura T, Takahashi T, Murayama S. Dose escalation study of proton beam therapy with concurrent chemotherapy for stage III non-small cell lung cancer. Cancer Sci 2016; 107:1018-21. [PMID: 27110950 PMCID: PMC4946725 DOI: 10.1111/cas.12955] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/15/2016] [Accepted: 04/21/2016] [Indexed: 12/25/2022] Open
Abstract
The purpose of this study is to determine the recommended dose (RD) of proton beam therapy (PBT) for inoperable stage III non‐small cell lung cancer (NSCLC). We tested two prescribed doses of PBT: 66 Gy (relative biological effectiveness [RBE]) in 33 fractions and 74 Gy (RBE) in 37 fractions in arms 1 and 2, respectively. The planning target volume (PTV) included the primary tumor and metastatic lymph nodes with adequate margins. Concurrent chemotherapy included intravenous cisplatin (60 mg/m2, day 1) and oral S‐1 (80, 100 or 120 mg based on body surface area, days 1–14), repeated as four cycles every 4 weeks. Dose‐limiting toxicity (DLT) was defined as grade 3 or severe toxicities related to PBT during days 1–90. Each dose level was performed in three patients, and then escalated to the next level if no DLT occurred. When one patient developed a DLT, three additional patients were enrolled. Overall, nine patients (five men, four women; median age, 72 years) were enrolled, including six in arm 1 and three in arm 2. The median follow‐up time was 43 months, and the median progression‐free survival was 15 months. In arm 1, grade 3 infection occurred in one of six patients, but no other DLT was reported. Similarly, no DLT occurred in arm 2. However, one patient in arm 2 developed grade 3 esophageal fistula at 9 months after the initiation of PBT. Therefore, we determined that 66 Gy (RBE) is the RD from a clinical viewpoints. (Clinical trial registration no. UMIN000005585)
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Affiliation(s)
- Hideyuki Harada
- Radiation and Proton Therapy Center, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Hiroshi Fuji
- Radiation and Proton Therapy Center, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Akira Ono
- Division of Thoracic Oncology, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Hirotsugu Kenmotsu
- Division of Thoracic Oncology, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Tateaki Naito
- Division of Thoracic Oncology, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Haruo Yamashita
- Radiation and Proton Therapy Center, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Hirofumi Asakura
- Radiation and Proton Therapy Center, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Tetsuo Nishimura
- Radiation and Proton Therapy Center, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Toshiaki Takahashi
- Division of Thoracic Oncology, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Shigeyuki Murayama
- Radiation and Proton Therapy Center, Shizuoka Cancer Center Hospital, Shizuoka, Japan
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