Precautions in the Use of Intensity-Modulated Radiation Therapy

Cardio-oncology concerns in radiotherapy: heart and cardiac substructure toxicities from modern delivery techniques

Cardio-oncology is lately gaining more attention due to radiation-induced cardiac events reported by a very large number of studies. In view of this, the current overview of the literature aimed to encompass all studies from the past 15 years to assess changes in cardiac dose due to treatment evolution, as well as the changes in treatment planning customs to incorporate not only the heart as a whole but also cardiac substructures. Modern treatment techniques, particularly proton therapy, offers superior cardiac sparing compared to more established radiotherapy, for all evaluated tumor sites. Intensity modulation, particularly coupled with respiratory gating shows significant improvement in dose-volume parameters pertaining to the heart. While past studies considered mean heart dose as the only reference for cardiac toxicities, recommendations for the other cardiac substructures to be dosimetrically assessed during planning are becoming more common.

Radiation-induced angiosarcoma of the breast: retrospective analysis at a regional treatment centre

BACKGROUND

Radiation-induced angiosarcoma (RIA) is an uncommon but morbid complication after radiotherapy for breast cancer.

METHODS

Retrospective analysis of breast RIA patients at Cambridge University Hospital (CUH), a regional treatment centre in the East of England.

RESULTS

22 patients were identified between 2010 and 2022. Median age of diagnosis was 65 years (range 41-78). Median time from breast radiotherapy to RIA diagnosis was 6.5 years (range 2.4-16.0)-this interval has decreased over the last 24 years (r2 = 0.6601). 9% had metastasis at presentation. All patients underwent surgery (55% at CUH, 45% at local hospitals). 27% received peri-operative pegylated liposomal doxorubicin in the first-line setting. 62% relapsed following their primary curative-intent treatments after a median of 28 months. Metastases occurred in 36%, the commonest sites being lung (100%) and lymph node (50%). 2-year and 5-year overall survival (OS) rates for all patients were 73% and 60%, respectively. No correlation between progression-free survival (PFS) and OS was found with tumour size, margin, peri-operative chemotherapy, and whether surgery was performed at CUH. Patients with multifocal disease on their breasts had shorter PFS following surgery compared to single-lesion disease (median 10 vs 65 months; HR = 4.359 [95% CI 1.342-14.16]; P = 0.0143). Patients aged > 72 years had a median OS of 45 months vs 102 months for those ≤ 72 years (HR = 7.129 [95% CI 1.646-30.88]; P = 0.0086).

CONCLUSION

RIA has high rates of recurrence and mortality and appears to be occurring sooner after breast radiotherapy. Further studies on its pathogenesis and effective treatment are warranted.

Impact of tumor size and location on lung dose difference between stereotactic body radiation therapy techniques for non-small cell lung cancer

Background

To evaluate the lung dose differences between three‐dimensional conformal radiotherapy (3D‐CRT) and intensity‐modulated radiation therapy (IMRT) techniques for lung stereotactic body radiation therapy (SBRT) and the correlations with tumor characteristics, such as size and location.

Methods

Dosimetric comparisons between the two SBRT techniques in high‐ and low‐ to intermediate‐dose regions were retrospectively performed using four planning indices and lung‐dose parameters in 31 lung tumors. The magnitude of differences in these parameters was analyzed with relation to the planning target volume (PTV) and location‐related parameters.

Results

The absolute differences between the two techniques in lung‐dose parameters were small in both ipsilateral and bilateral lungs. The dosimetric differences were mainly correlated with the PTV rather than location‐related parameters, with positive and negative correlations with the high‐dose and intermediate‐dose parameters, respectively. The distances from the ipsilateral lung centroid to the PTV center were not correlated with the differences in any of the lung‐dose parameters. Additionally, the negative correlations with the MLD and V20 differences disappeared after applying a more rapid dose fall‐off in the IMRT plans for tumors with small PTVs of ≤15 cc.

Conclusions

Lung dose differences between the 3D‐CRT and IMRT techniques for lung SBRT were mainly correlated with the PTV rather than location‐related parameters. Together with the dosimetric benefit in high‐dose lung regions of IMRT for larger tumors, the relative increases in the MLD and V20 for small‐sized tumors could be reduced by applying a more rapid dose fall‐off outside the PTV.

Intensity Modulated Radiation Therapy: A Review of Current Practice and Future Directions

The use of intensity modulated radiation therapy (IMRT) has been rapidly growing in the United States. This technology is now being used in a multitude of academic and community centers throughout the country and is being incorporated into the treatment of cancers in almost every anatomical site, most commonly head and neck cancer, central nervous system tumors, and prostate cancer. In addition, current protocols are investigating the use of IMRT for the treatment of breast cancer, lung cancer, abdominal/retroperitoneal malignancies, and gynecological diseases. This article presents a brief technical review of IMRT and addresses specific clinical concerns and caveats that radiation oncologists should be aware of when utilizing this technology.

In vitro evaluation of Cordyceps militaris as a potential radioprotective agent

Radiation is an important component of therapy for a wide range of malignant conditions. However, it triggers DNA damage and cell death in normal cells and results in adverse side-effects. Cordyceps militaris (C. militaris), a traditional medicinal mushroom, produces the bioactive compound, cordycepin (3'-deoxyadenosine) and has multiple pharmacological activities, such as antitumor, antimetastatic, antioxidant and immunomodulatory effects. The present study was undertaken to investigate whether CM-AE, an extract obtained from C. militaris exerts protective effects against radiation-induced DNA damage. The protective effects of CM-AE were compared with those of cordycepin. CM-AE effectively increased free radical scavenging activity and decreased radiation-induced plasmid DNA strand breaks in in vitro assays. CM-AE significantly inhibited the generation of reactive oxygen species (ROS) and cellular DNA damage in 2 Gy irradiated Chinese hamster ovary (CHO)-K1 cells. Moreover, treatment with CM-AE induced similar levels of phosphorylated H2AX in the cells, which reflects the initial DNA double-strand breaks in the irradiated cells compared with the non-irradiated CHO-K1 cells. However, cordycepin did not show free radical scavenging activity and did not protect against radiation-induced plasmid DNA or cellular DNA damage. These results suggest that the free radical scavenging activity of CM-AE contributes towards its DNA radioprotective effects and that the protective effects of CM-AE are much more potent to those of cordycepin. The data presented in this study may provide useful information for the screening of potent radioprotective materials.

Geraniin down regulates gamma radiation-induced apoptosis by suppressing DNA damage

Gamma ray irradiation triggers DNA damage and apoptosis of proliferating stem cells and peripheral immune cells, resulting in the destruction of intestinal crypts and lymphoid system. Geraniin is a natural compound extracts from an aquatic plant Nymphaea tetragona and possesses good antioxidant property. In this study, we demonstrate that geraniin rescues radiosensitive splenocytes and jejunal crypt cells from radiation-induced DNA damage and apoptosis. Isolated splenocytes from C57BL/6 mice treated with geraniin were protected against radiation injury of 2 Gy irradiation through the enhancement of the proliferation and attenuation of DNA damage. Also, geraniin inhibited apoptosis in radiosensitive splenocytes by reducing the expression level and immunoreactivity of proapoptotic p53 and Bax and increasing those of anti-apoptotic Bcl-2. In mice exposed to radiation, geraniin treatment protected splenocytes and intestinal crypt cells from radiation-induced cell death. Our results suggest that geraniin presents radioprotective effects by regulating DNA damage on splenocytes, exerting immunostimulatory capacities and inhibiting apoptosis of radiosensitive immune cells and jejunal crypt cells. Therefore, geraniin can be a radioprotective agent against γ-irradiation exposure.

Effect of radiotherapy techniques (IMRT vs. 3D-CRT) on outcome in patients with intermediate-risk rhabdomyosarcoma enrolled in COG D9803--a report from the Children's Oncology Group

PURPOSE

To compare the dosimetric parameters of intensity-modulated radiotherapy (IMRT) and three-dimensional conformal radiotherapy (3D-CRT) in patients with intermediate-risk rhabdomyosarcoma and to analyze their effect on locoregional control and failure-free survival (FFS).

METHODS AND MATERIALS

The study population consisted of 375 patients enrolled in the Children's Oncology Group protocol D9803 study, receiving IMRT or 3D-CRT. Dosimetric data were collected from 179 patients with an available composite plan. The chi-square test or Fisher's exact test was used to compare the patient characteristics and radiotherapy parameters between the two groups. The interval-to-event outcomes were estimated using the Kaplan-Meier method and compared using log-rank tests. Cox proportional hazards regression analysis was used to examine the effect of the treatment technique on FFS after adjusting for primary site and risk group.

RESULTS

The median follow-up time was 5.7 and 4.2 years for patients receiving 3D-CRT and IMRT, respectively. No differences in the 5-year failure of locoregional control (18% vs. 15%) or FFS (72% vs. 76%) rates were noted between the two groups. Multivariate analysis revealed no association between the two techniques and FFS. Patients with primary tumors in parameningeal sites were more likely to receive IMRT than 3D-CRT. IMRT became more common during the later years of the study. Patients receiving IMRT were more likely to receive >50 Gy, photon energy of ≤6 MV, and >5 radiation fields than those who received 3D-CRT. The coverage of the IMRT planning target volume by the prescription dose was improved compared with the coverage using 3D-CRT with similar target dose heterogeneity.

CONCLUSIONS

IMRT improved the target dose coverage compared with 3D-CRT, although an improvement in locoregional control or FFS could not be demonstrated in this population. Future studies comparing the integral dose to nontarget tissue and late radiation toxicity between the two groups are warranted.

Intensity modulated radiotherapy (IMRT) in the treatment of children and adolescents--a single institution's experience and a review of the literature

Background

While IMRT is widely used in treating complex oncological cases in adults, it is not commonly used in pediatric radiation oncology for a variety of reasons. This report evaluates our 9 year experience using stereotactic-guided, inverse planned intensity-modulated radiotherapy (IMRT) in children and adolescents in the context of the current literature.

Methods

Between 1999 and 2008 thirty-one children and adolescents with a mean age of 14.2 years (1.5 - 20.5) were treated with IMRT in our department. This heterogeneous group of patients consisted of 20 different tumor entities, with Ewing's sarcoma being the largest (5 patients), followed by juvenile nasopharyngeal fibroma, esthesioneuroblastoma and rhabdomyosarcoma (3 patients each). In addition a review of the available literature reporting on technology, quality, toxicity, outcome and concerns of IMRT was performed.

Results

With IMRT individualized dose distributions and excellent sparing of organs at risk were obtained in the most challenging cases. This was achieved at the cost of an increased volume of normal tissue receiving low radiation doses. Local control was achieved in 21 patients. 5 patients died due to progressive distant metastases. No severe acute or chronic toxicity was observed.

Conclusion

IMRT in the treatment of children and adolescents is feasible and was applied safely within the last 9 years at our institution. Several reports in literature show the excellent possibilities of IMRT in selective sparing of organs at risk and achieving local control. In selected cases the quality of IMRT plans increases the therapeutic ratio and outweighs the risk of potentially increased rates of secondary malignancies by the augmented low dose exposure.

Transition in survival from low-dose hyper-radiosensitivity to increased radioresistance is independent of activation of ATM Ser1981 activity

PURPOSE

The molecular basis of low-dose hyper-radiosensitivity (HRS) is only partially understood. The aim of this study was to define the roles of ataxia telangiectasia mutated (ATM) activity and the downstream ATM-dependent G(2)-phase cell cycle checkpoint in overcoming HRS and triggering radiation resistance.

METHODS AND MATERIALS

Survival was measured using a high-resolution clonogenic assay. ATM Ser1981 activation was measured by Western blotting. The role of ATM was determined in survival experiments after molecular (siRNA) and chemical (0.4 mM caffeine) inhibition and chemical (20 microg/mL chloroquine, 15 microM genistein) activation 4-6 h before irradiation. Checkpoint responsiveness was assessed in eight cell lines of differing HRS status using flow cytometry to quantify the progression of irradiated (0-2 Gy) G(2)-phase cells entering mitosis, using histone H3 phosphorylation analysis.

RESULTS

The dose-response pattern of ATM activation was concordant with the transition from HRS to radioresistance. However, ATM activation did not play a primary role in initiating increased radioresistance. Rather, a relationship was discovered between the function of the downstream ATM-dependent early G(2)-phase checkpoint and the prevalence and overcoming of HRS. Four cell lines that exhibited HRS failed to show low-dose (<0.3-Gy) checkpoint function. In contrast, four HRS-negative cell lines exhibited immediate cell cycle arrest for the entire 0-2-Gy dose range.

CONCLUSION

Overcoming HRS is reliant on the function of the early G(2)-phase checkpoint. These data suggest that clinical exploitation of HRS could be achieved by combining radiotherapy with chemotherapeutic agents that modulate this cell cycle checkpoint.