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Megahed R, Prabhu AV, Mack DP, Gholami S, Samanta S, Patel M, Lewis GD. Re-irradiation of recurrent head and neck cancers using pulsed reduced dose rate radiotherapy: An institutional series. Oral Oncol 2024; 152:106778. [PMID: 38555751 DOI: 10.1016/j.oraloncology.2024.106778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 04/02/2024]
Abstract
PURPOSE/OBJECTIVE(S) Pulsed reduced dose rate (PRDR) radiation (RT) is a re-irradiation (Re-RT) technique that potentially overcomes dose/volume constraints in the setting of previous RT. There is minimal data for its use for recurrent or secondary primary head and neck squamous cell carcinoma (HNSCC). In this study, we report preliminary data from our institution of a consecutive cohort of HNSCC patients who received PRDR Re-RT. MATERIALS/METHODS Nine patients received PRDR Re-RT from August 2020 to January 2023 and had analyzable data. Intensity modulated RT was used for treatment delivery and a wait time between 20 cGy arc/helical deliveries was used to achieve the effective low dose rate. Data collected included patient demographic information, prior interventions, diagnosis, radiation therapy dose and fractionation, progression free survival, overall survival, and toxicity rates. RESULTS The median time to PRDR-RT from completion of initial RT was 13 months (range, 6-50 months). All but one patient underwent salvage surgery prior to PRDR-RT. The median follow-up after Re-RT was 7 months. The median OS from PRDR-RT was 7 months (range, 1-32 months). Median PFS was 7 months (range, 1-32 months). One patient (11.1 %) had acute grade 3 toxicity, and two patients (22.2 %) had late grade 3 toxicities. There were no grade 4+ toxicities. CONCLUSION PRDR Re-RT is a feasible treatment strategy for patients with recurrent or second primary HNSCC. Initial findings from this retrospective review suggest reasonable survival outcomes and potentially improved toxicity; prospective data is needed to establish the safety and efficacy of this technique.
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Affiliation(s)
- Romy Megahed
- Department of Radiation Oncology, University of Arkansas for Medical Sciences, 4301 W. Markham St., #771, Little Rock, AR 72205-7199, United States
| | - Arpan V Prabhu
- Department of Radiation Oncology, University of Arkansas for Medical Sciences, 4301 W. Markham St., #771, Little Rock, AR 72205-7199, United States
| | - Delanie P Mack
- Department of Radiation Oncology, University of Arkansas for Medical Sciences, 4301 W. Markham St., #771, Little Rock, AR 72205-7199, United States
| | - Somayeh Gholami
- Department of Radiation Oncology, University of Arkansas for Medical Sciences, 4301 W. Markham St., #771, Little Rock, AR 72205-7199, United States
| | - Santanu Samanta
- Department of Radiation Oncology, University of Arkansas for Medical Sciences, 4301 W. Markham St., #771, Little Rock, AR 72205-7199, United States
| | - Mausam Patel
- Department of Radiation Oncology, University of Arkansas for Medical Sciences, 4301 W. Markham St., #771, Little Rock, AR 72205-7199, United States
| | - Gary D Lewis
- Department of Radiation Oncology, University of Arkansas for Medical Sciences, 4301 W. Markham St., #771, Little Rock, AR 72205-7199, United States.
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Khan AU, Radtke J, Hammer C, Malyshev J, Morris B, Glide‐Hurst C, DeWerd L, Culberson W, Bayliss A. Dose-rate dependence and IMRT QA suitability of EBT3 radiochromic films for pulse reduced dose-rate radiotherapy (PRDR) dosimetry. J Appl Clin Med Phys 2024; 25:e14229. [PMID: 38032123 PMCID: PMC10795427 DOI: 10.1002/acm2.14229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/09/2023] [Accepted: 11/18/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Pulsed reduced dose rate (PRDR) is an emerging radiotherapy technique for recurrent diseases. It is pertinent that the linac beam characteristics are evaluated for PRDR dose rates and a suitable dosimeter is employed for IMRT QA. PURPOSE This study sought to investigate the pulse characteristics of a 6 MV photon beam during PRDR irradiations on a commercial linac. The feasibility of using EBT3 radiochromic film for use in IMRT QA was also investigated by comparing its response to a commercial diode array phantom. METHODS A plastic scintillator detector was employed to measure the photon pulse characteristics across nominal repetition rates (NRRs) in the 5-600 MU/min range. Film was irradiated with dose rates in the 0.033-4 Gy/min range to study the dose rate dependence. Five clinical PRDR treatment plans were selected for IMRT QA with the Delta4 phantom and EBT3 film sheets. The planned and measured dose were compared using gamma analysis with a criterion of 3%/3 mm. EBT3 film QA was performed using a cumulative technique and a weighting factor technique. RESULTS Negligible differences were observed in the pulse width and height data between the investigated NRRs. The pulse width was measured to be 3.15 ± 0.01μ s $\mu s$ and the PRF was calculated to be 3-357 Hz for the 5-600 MU/min NRRs. The EBT3 film was found to be dose rate independent within 3%. The gamma pass rates (GPRs) were above 99% and 90% for the Delta4 phantom and the EBT3 film using the cumulative QA method, respectively. GPRs as low as 80% were noted for the weighting factor EBT3 QA method. CONCLUSIONS Altering the NRRs changes the mean dose rate while the instantaneous dose rate remains constant. The EBT3 film was found to be suitable for PRDR dosimetry and IMRT QA with minimal dose rate dependence.
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Affiliation(s)
- Ahtesham Ullah Khan
- Department of Medical Physics, School of Medicine and Public HealthUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Jeff Radtke
- Department of Medical Physics, School of Medicine and Public HealthUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Clifford Hammer
- Department of Medical Physics, School of Medicine and Public HealthUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Julia Malyshev
- Department of Medical Physics, School of Medicine and Public HealthUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Brett Morris
- Department of Human Oncology, School of Medicine and Public HealthUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Carri Glide‐Hurst
- Department of Medical Physics, School of Medicine and Public HealthUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
- Department of Human Oncology, School of Medicine and Public HealthUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Larry DeWerd
- Department of Medical Physics, School of Medicine and Public HealthUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Wesley Culberson
- Department of Medical Physics, School of Medicine and Public HealthUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Adam Bayliss
- Department of Human Oncology, School of Medicine and Public HealthUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
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Harari CM, Burr AR, Morris BA, Tomé WA, Bayliss A, Bhatia A, Grogan PT, Robins HI, Howard SP. Pulsed reduced-dose rate re-irradiation for patients with recurrent grade 2 gliomas. Neurooncol Adv 2024; 6:vdae073. [PMID: 38845694 PMCID: PMC11154132 DOI: 10.1093/noajnl/vdae073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024] Open
Abstract
Background Patients with grade 2 glioma exhibit highly variable survival. Re-irradiation for recurrent disease has limited mature clinical data. We report treatment results of pulsed reduced-dose rate (PRDR) radiation for patients with recurrent grade 2 glioma. Methods A retrospective analysis of 58 patients treated with PRDR from 2000 to 2021 was performed. Radiation was delivered in 0.2 Gy pulses every 3 minutes encompassing tumor plus margin. Survival outcomes and prognostic factors on outcome were Kaplan-Meier and Cox regression analyses. Results The median survival from the date of initial surgery was 8.6 years (95% CI: 5.5-11.8 years). 69% of patients showed malignant transformation to grade 3 (38%) or grade 4 (31%) glioma. Overall survival following PRDR was 12.6 months (95% CI: 8.3-17.0 months) and progression-free survival was 6.2 months (95% CI: 3.8-8.6 months). Overall response rate based on post-PRDR MRI was 36%. In patients who maintained grade 2 histology at recurrence, overall survival from PRDR was 22.0 months with 5 patients remaining disease-free, the longest at 8.2 and 11.4 years. PRDR was generally well tolerated. Conclusions To the best of our knowledge, this is the largest reported series of patients with recurrent grade 2 gliomas treated with PRDR radiation for disease recurrence. We demonstrate promising survival and acceptable toxicity profiles following re-irradiation. In the cohort of patients who maintain grade 2 disease, prolonged survival (>5 years) is observed in selected patients. For the entire cohort, 1p19q codeletion, KPS, and longer time from initial diagnosis to PRDR were associated with improved survival.
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Affiliation(s)
- Colin M Harari
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Carbone Cancer Center, Madison, Wisconsin, USA
| | - Adam R Burr
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Carbone Cancer Center, Madison, Wisconsin, USA
| | - Brett A Morris
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Carbone Cancer Center, Madison, Wisconsin, USA
| | - Wolfgang A Tomé
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, New York, USA
| | - Adam Bayliss
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Carbone Cancer Center, Madison, Wisconsin, USA
| | - Ankush Bhatia
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin, USA
| | | | - H Ian Robins
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Carbone Cancer Center, Madison, Wisconsin, USA
| | - Steven P Howard
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Carbone Cancer Center, Madison, Wisconsin, USA
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Huang R, Li Z, Yang F, Zhang Y, Jiang Y, Li C, Gao H, Li G, Liu Y, Guo W, Yang D, Zhang S, Li J, Wen H, Lang J, Zhang P. Efficacy and safety of PLDR-IMRT for the re-irradiation of recurrent NPC: A prospective, single-arm, multicenter trial. Cancer Sci 2023. [PMID: 36788727 DOI: 10.1111/cas.15759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 02/07/2023] [Accepted: 02/09/2023] [Indexed: 02/16/2023] Open
Abstract
Salvage treatment of locoregionally recurrent nasopharyngeal carcinoma (NPC) requires weighing the benefits of re-irradiation against increased risks of toxicity. Here, we evaluated the outcomes of patients treated with intensity-modulated-based pulsed low-dose-rate radiotherapy (PLDR-IMRT) to enhance the curative effect of salvage treatment and reduce RT-related SAEs. A prospective clinical trial was conducted from March 2018 to March 2020 at multiple institutions. NPC patients who experienced relapse after radical therapy were re-irradiated with a median dose of 60 Gy (50.4-70 Gy)/30 f (28-35 f) using PLDR-IMRT. Thirty-six NPC patients who underwent PLDR-IMRT for locoregional recurrence were identified. With a median follow-up of 26.2 months, the objective response rate (ORR) of the entire cohort was 91.6%. The estimated mPFS duration was 28 months (95% CI: 24.9-31.1), and the estimated mLRFS duration was 30.4 months (95% CI: 25.2-35.5). The overall survival (OS) rate for all patients was 80.6%, the progression-free survival (PFS) rate was 75% and the cancer-specific survival (CSS) rate was 88.9% at 1 year. The LRFS and DMFS rates were 88.9% and 91.7%, respectively, at 1 year. A combination of systematic therapies could provide survival benefits to patients who experience NPC relapse (p < 0.05), and a Karnofsky performance status (KPS) score of ≥90 was a favorable factor for local control (p < 0.05). The incidence of acute SAEs (grade 3+) from PLDR was 22.2%, and the incidence of chronic SAEs was 19.4% among all patients. PLDR-IMRT combined with systematic therapy can effectively treat patients with locoregionally recurrent nasopharyngeal carcinoma and causes fewer adverse events than the rates expected with IMRT.
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Affiliation(s)
- Rui Huang
- Department of Radiation Oncology, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Zhihui Li
- The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Fan Yang
- Department of Oncology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Yu Zhang
- Department of Oncology, MianYang Central Hospital, Mianyang, China
| | - Yanhui Jiang
- Department of Radiotherapy, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Churong Li
- Department of Radiation Oncology, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Hui Gao
- The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Guanghui Li
- Department of Oncology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Yimin Liu
- Department of Radiotherapy, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wenyan Guo
- The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Dingqiang Yang
- Department of Oncology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Shichuan Zhang
- Department of Radiation Oncology, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Jie Li
- Department of Radiation Oncology, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Hao Wen
- Department of Radiation Oncology, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Jinyi Lang
- Department of Radiation Oncology, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Peng Zhang
- Department of Radiation Oncology, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
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Pulsed-Reduced Dose Rate (PRDR) Radiotherapy for Recurrent Primary Central Nervous System Malignancies: Dosimetric and Clinical Results. Cancers (Basel) 2022; 14:cancers14122946. [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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Frosina G. Improving control of high‐grade glioma by ultra‐hyper‐fractionated radiotherapy. J Neurosci Res 2022; 100:933-946. [DOI: 10.1002/jnr.25030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/05/2021] [Accepted: 12/13/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Guido Frosina
- Mutagenesis & Cancer Prevention Unit IRCCS Ospedale Policlinico San Martino Genova Italy
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7
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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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The Effect of High-Dose-Rate Pulsed Radiation on the Survival of Clinically Relevant Radioresistant Cells. Life (Basel) 2021; 11:life11121295. [PMID: 34947826 PMCID: PMC8708735 DOI: 10.3390/life11121295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 11/20/2021] [Accepted: 11/22/2021] [Indexed: 12/20/2022] Open
Abstract
We demonstrated that low dose pulsed radiation (0.25 Gy) at a high-dose-rate, even for very short intervals (10 s), decreases cell survival to a greater extent than single exposure to a similar total dose and dose rate. The objective of this study was to clarify whether high-dose-rate pulsed radiation is effective against SAS-R, a clinically relevant radioresistant cell line. Cell survival following high-dose-rate pulsed radiation was evaluated via a colony assay. Flow cytometry was utilized to evaluate γH2AX, a molecular marker of DNA double-strand breaks and delayed reactive oxygen species (ROS) associated with radiation-induced apoptosis. Increased cytotoxicity was observed in SAS-R and parent SAS cells in response to high dose rate pulsed radiation compared to single dose, as determined by colony assays. Residual γH2AX in both cells subjected to high-dose-rate pulsed radiation showed a tendency to increase, with a significant increase observed in SAS cells at 72 h. In addition, high-dose-rate pulsed radiation increased delayed ROS more than the single exposure did. These results indicate that high-dose-rate pulsed radiation was associated with residual γH2AX and delayed ROS, and high-dose-rate pulsed radiation may be used as an effective radiotherapy procedure against radioresistant cells.
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Wen X, Qiu H, Shao Z, Liu G, Liu N, Chen A, Zhang X, Ding X, Zhang L. Pulsed low-dose rate radiotherapy has an improved therapeutic effect on abdominal and pelvic malignancies. J Zhejiang Univ Sci B 2021; 22:774-781. [PMID: 34514757 DOI: 10.1631/jzus.b2000793] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Until now, there has been a lack of standard and effective treatments for patients with recurrent malignant tumors or abdominal and pelvic malignancies with extensive invasion (Morris, 2000). Generally, these patients face problems such as inability to undergo surgery or chemotherapy resistance (Combs et al., 2016). Re-radiotherapy has achieved a prominent place in the treatment of patients who have received radiotherapy previously and developed in-field recurrences (Straube et al., 2018). However, re-radiotherapy is very complicated, requiring comprehensive consideration of appropriate radiation dose, interval from first radiotherapy, boundary of the radiotherapy target area, and damage to surrounding normal tissues (Straube et al., 2019). In other words, it is necessary to focus on the protection of surrounding normal tissues while maximizing the efficacy of re-radiotherapy in such patients.
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Affiliation(s)
- Xin Wen
- Department of Radiation Oncology, Affiliated Hospital of Xuzhou Medical University, Xuzhou 221000, China
| | - Hui Qiu
- Department of Radiation Oncology, Affiliated Hospital of Xuzhou Medical University, Xuzhou 221000, China
| | - Zhiying Shao
- Department of Interventional Ultrasound, Zhejiang Cancer Hospital, Hangzhou 310000, China
| | - Guihong Liu
- Department of Radiation Oncology, Affiliated Hospital of Xuzhou Medical University, Xuzhou 221000, China
| | - Nianli Liu
- Cancer Institute of Xuzhou Medical University, Xuzhou 221000, China
| | - Aoxing Chen
- Department of Radiation Oncology, Affiliated Hospital of Xuzhou Medical University, Xuzhou 221000, China
| | - Xingying Zhang
- Department of Radiation Oncology, Affiliated Hospital of Xuzhou Medical University, Xuzhou 221000, China
| | - Xin Ding
- Department of Radiation Oncology, Affiliated Hospital of Xuzhou Medical University, Xuzhou 221000, China.
| | - Longzhen Zhang
- Cancer Institute of Xuzhou Medical University, Xuzhou 221000, China. .,Department of Radiation Oncology, Affiliated Hospital of Xuzhou Medical University, Xuzhou 221000, China. .,Jiangsu Center for the Collaboration and Innovation of Cancer Biotherapy, Xuzhou 221000, China.
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Almahariq MF, Quinn TJ, Arden JD, Roskos PT, Wilson GD, Marples B, Grills IS, Chen PY, Krauss DJ, Chinnaiyan P, Dilworth JT. Pulsed radiation therapy for the treatment of newly diagnosed glioblastoma. Neuro Oncol 2021; 23:447-456. [PMID: 32658268 DOI: 10.1093/neuonc/noaa165] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Pulsed radiation therapy (PRT) has shown effective tumor control and superior normal-tissue sparing ability compared with standard radiotherapy (SRT) in preclinical models and retrospective clinical series. This is the first prospective trial to investigate PRT in the treatment of patients with newly diagnosed glioblastoma (GBM). METHODS This is a single-arm, prospective study. Patients with newly diagnosed GBM underwent surgery, followed by 60 Gy of PRT with concurrent temozolomide (TMZ). Each day, a 2-Gy fraction was divided into ten 0.2-Gy pulses, separated by 3-minute intervals. Patients received maintenance TMZ. Neurocognitive function (NCF) and quality of life (QoL) were monitored for 2 years using the Hopkins Verbal Learning Test‒Revised and the European Organisation for Research and Treatment of Cancer QLQ-C30 QoL questionnaire. Change in NCF was evaluated based on a minimal clinically important difference (MCID) threshold of 0.5 standard deviation. RESULTS Twenty patients were enrolled with a median follow-up of 21 months. Median age was 60 years. Forty percent underwent subtotal resection, and 60% underwent gross total resection. One patient had an isocitrate dehydrogenase (IDH)-mutated tumor. Median progression-free survival (PFS) and overall survival (OS) were 10.7 and 20.9 months, respectively. In a post-hoc comparison, median OS for the prospective cohort was longer, compared with a matched cohort receiving SRT (20.9 vs 14 mo, P = 0.042). There was no decline in QoL, and changes in NCF scores did not meet the threshold of an MCID. CONCLUSIONS Treatment of newly diagnosed GBM with PRT is feasible and produces promising effectiveness while maintaining neurocognitive function and QoL. Validation of our results in a larger prospective trial warrants consideration.
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Affiliation(s)
| | - Thomas J Quinn
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Jessica D Arden
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - P T Roskos
- Neuropsychology Services, Department of Physical Medicine and Rehabilitation, Beaumont Health, Dearborn, Michigan
| | - George D Wilson
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont School of Medicine, Auburn Hills, Michigan
| | - Brian Marples
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont School of Medicine, Auburn Hills, Michigan
| | - Peter Y Chen
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont School of Medicine, Auburn Hills, Michigan
| | - Daniel J Krauss
- Oakland University William Beaumont School of Medicine, Auburn Hills, Michigan
| | - Prakash Chinnaiyan
- Oakland University William Beaumont School of Medicine, Auburn Hills, Michigan
| | - Joshua T Dilworth
- Oakland University William Beaumont School of Medicine, Auburn Hills, Michigan
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Outcomes From Whole-Brain Reirradiation Using Pulsed Reduced Dose Rate Radiation Therapy. Adv Radiat Oncol 2020; 5:834-839. [PMID: 33083645 PMCID: PMC7557211 DOI: 10.1016/j.adro.2020.06.021] [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: 05/21/2020] [Revised: 06/23/2020] [Accepted: 06/23/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose Recurrent intracranial metastases after whole-brain irradiation pose a clinical challenge owing to the escalating morbidity associated with their treatment. Although stereotactic radiosurgery is increasingly being used, there are still situations in which whole-brain reirradiation (ReRT) continues to be appropriate. Here, we report our experience using whole-brain pulsed reduced dose rate radiation therapy (PRDR), a method that delivers radiation at a slower rate of 0.067 Gy/min to potentially increase sublethal damage repair and decrease toxicity. Methods and Materials Patients undergoing whole-brain ReRT with PRDR from January 1, 2001 to March 2019 were analyzed. The median PRDR ReRT dose was 26 Gy in 2 Gy fractions, resulting in a median total whole-brain dose of 59.5 Gy. Cox regression analysis was used for multivariate analysis. The Kaplan-Meier method was used for overall survival, progression free survival, and to evaluate the ReRT score. Binary logistic regression was employed to evaluate variables associated with rapid death. Results Seventy-five patients were treated with whole-brain PRDR radiation therapy. The median age was 54 (range, 26-72), the median Karnofsky performance status (KPS) was 80, and 86.7% had recursive partitioning analysis scores of 2. Thirty-two patients had over 10 metastases and 11 had leptomeningeal disease. The median overall survival was 4.1 months (range, 0.29-59.5 months) with a 1 year overall survival of 10.4%. Age, KPS, dexamethasone usage, and intracranial disease volume were significantly correlated with overall survival on multivariate analysis. A KPS ≤70 was associated with rapid death after radiation. The prognostic value of the ReRT score was validated. The most common acute toxicities were fatigue (23.1%) and headache (16.9%). Conclusions In this large cohort of patients with advanced intracranial metastases, PRDR achieves acceptable survival and may decrease toxicity associated with ReRT. PRDR is an easily implemented technique and is a viable treatment option for ReRT of brain metastases.
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Bovi JA, Prah MA, Retzlaff AA, Schmainda KM, Connelly JM, Rand SD, Marszalkowski CS, Mueller WM, Siker ML, Schultz CJ. Pulsed Reduced Dose Rate Radiotherapy in Conjunction With Bevacizumab or Bevacizumab Alone in Recurrent High-grade Glioma: Survival Outcomes. Int J Radiat Oncol Biol Phys 2020; 108:979-986. [PMID: 32599030 PMCID: PMC8655709 DOI: 10.1016/j.ijrobp.2020.06.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 04/07/2020] [Accepted: 06/08/2020] [Indexed: 11/26/2022]
Abstract
Purpose: Dismal prognosis and limited treatment options for recurrent high-grade glioma have provoked interest in various forms of reirradiation. Pulsed reduced dose rate radiation therapy (pRDR) is a promising technique that exploits low-dose hyper-radiosensitivity of proliferating tumor cells while sparing adjacent nonproliferating normal brain tissue. Large radiation treatment volumes can thus be used to target both contrast-enhancing and FLAIR abnormalities thought to harbor recurrent gross and microscopic disease, respectively. The aim of this retrospective study was to determine whether the addition of pRDR to bevacizumab improves survival over bevacizumab alone for recurrent high-grade glioma. Methods and Materials: Eighty patients with recurrent high-grade glioma were included in this study; 47 patients received bevacizumab monotherapy (BEV), and 33 patients received pRDR with bevacizumab (BEV/pRDR). Progression-free survival (PFS) and overall survival were compared between the BEV and BEV/pRDR groups. Regression analysis was performed to identify and control for confounding influences on survival analyses. Results: Significant (P <.05) advantages in PFS (12 vs 4 months; hazard ratio = 2.37) and OS (16 vs. 9 months; hazard ratio = 1.68) were observed with BEV/pRDR compared with BEV alone. Conclusions: This retrospective analysis suggests that treatment with pRDR in addition to bevacizumab could significantly prolong PFS and overall survival compared with bevacizumab alone for recurrent high-grade glioma.
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Affiliation(s)
- Joseph A Bovi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Melissa A Prah
- Department of Biophysics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Amber A Retzlaff
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kathleen M Schmainda
- Department of Biophysics, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Scott D Rand
- Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Wade M Mueller
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Malika L Siker
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Christopher J Schultz
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Pulsed low dose-rate irradiation response in isogenic HNSCC cell lines with different radiosensitivity. Radiol Oncol 2020; 54:168-179. [PMID: 32229678 PMCID: PMC7276640 DOI: 10.2478/raon-2020-0015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 03/01/2020] [Indexed: 12/16/2022] Open
Abstract
Background Management of locoregionally recurrent head and neck squamous cell carcinomas (HNSCC) is challenging due to potential radioresistance. Pulsed low-dose rate (PLDR) irradiation exploits phenomena of increased radiosensitivity, low-dose hyperradiosensitivity (LDHRS), and inverse dose-rate effect. The purpose of this study was to evaluate LDHRS and the effect of PLDR irradiation in isogenic HNSCC cells with different radiosensitivity. Materials and methods Cell survival after different irradiation regimens in isogenic parental FaDu and radioresistant FaDu-RR cells was determined by clonogenic assay; post irradiation cell cycle distribution was studied by flow cytometry; the expression of DNA damage signalling genes was assesed by reverse transcription-quantitative PCR. Results Radioresistant Fadu-RR cells displayed LDHRS and were more sensitive to PLDR irradiation than parental FaDu cells. In both cell lines, cell cycle was arrested in G2/M phase 5 hours after irradiation. It was restored 24 hours after irradiation in parental, but not in the radioresistant cells, which were arrested in G1-phase. DNA damage signalling genes were under-expressed in radioresistant compared to parental cells. Irradiation increased DNA damage signalling gene expression in radioresistant cells, while in parental cells only few genes were under-expressed. Conclusions We demonstrated LDHRS in isogenic radioresistant cells, but not in the parental cells. Survival of LDHRS-positive radioresistant cells after PLDR was significantly reduced. This reduction in cell survival is associated with variations in DNA damage signalling gene expression observed in response to PLDR most likely through different regulation of cell cycle checkpoints.
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14
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Pulsed Reduced Dose Rate for Reirradiation of Recurrent Breast Cancer. Pract Radiat Oncol 2020; 10:e61-e70. [DOI: 10.1016/j.prro.2019.09.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 08/15/2019] [Accepted: 09/06/2019] [Indexed: 11/22/2022]
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Large volume re-irradiation for recurrent meningioma with pulsed reduced dose rate radiotherapy. J Neurooncol 2018; 141:103-109. [PMID: 30392090 DOI: 10.1007/s11060-018-03011-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 09/17/2018] [Indexed: 01/24/2023]
Abstract
PURPOSE Meningiomas comprise up to 30% of primary brain tumors. The majority of meningioma patients enjoy high rates of control after conventional therapies. However, patients with recurrent disease previously treated with radiotherapy have few options for salvage treatment, and systemic interventions have proven largely ineffective. The aim of this study was to determine whether pulsed reduced dose rate radiotherapy (PRDR) was well tolerated in a small cohort of patients with recurrent meningioma. METHODS We retrospectively identified eight patients with recurrent intracranial meningioma treated with PRDR from April 2013 to August of 2017 at a single institution. All patients had radiographic and/or pathologic evidence of progression prior to treatment and had previously completed conventional radiotherapy. Acute and late toxicities were graded based on CTCAE 4.0. RESULTS Of eight patients, six had histologically confirmed atypical meningiomas upon recurrence. All patients were re-treated with IMRT at an apparent dose rate of 0.0667 Gy/min. Median time between radiation courses was 7.7 years. Median PRDR dose was 54 Gy in 27 fractions to a median volume of 261.6 cm3. Two patients (25%) had in field failure with a median follow up of 23.3 months. PFS at 6 months was 100%. All but one (87.5%) patient was still alive at last follow up. No patient experienced grade ≥ 2 acute or late toxicities. CONCLUSIONS PRDR re-irradiation was well tolerated and appeared effective for a small cohort of patients with recurrent meningioma previously treated with radiotherapy. A phase II trial to assess this prospectively is in development.
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Olobatuyi O, de Vries G, Hillen T. Effects of G2-checkpoint dynamics on low-dose hyper-radiosensitivity. J Math Biol 2018; 77:1969-1997. [PMID: 29679122 DOI: 10.1007/s00285-018-1236-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 02/17/2018] [Indexed: 02/03/2023]
Abstract
In experimental studies, it has been found that certain cell lines are more sensitive to low-dose radiation than would be expected from the classical Linear-Quadratic model (LQ model). In fact, it is frequently observed that cells incur more damage at low dose (say 0.3 Gy) than at higher dose (say 1 Gy). This effect has been termed hyper-radiosensitivity (HRS). The effect depends on the type of cells and on their phase in the cell cycle when radiation is applied. Experiments have shown that the G2-checkpoint plays an important role in the HRS effects. Here we design and analyze a differential equation model for the cell cycle that includes G2-checkpoint dynamics and radiation treatment. We fit the model to surviving fraction data for different cell lines including glioma cells, prostate cancer cells, as well as to cell populations that are enriched in certain phases of the cell cycle. The HRS effect is measured in the literature through [Formula: see text], the ratio of slope [Formula: see text] of the surviving fraction curve at zero dose to slope [Formula: see text] of the corresponding LQ model. We derive an explicit formula for this ratio and we show that it corresponds very closely to experimental observations. Finally, we identify the dependence of this ratio on the surviving fraction at 2 Gy. It was speculated in the literature that such dependence exists. Our theoretical analysis will help to more systematically identify the HRS in cell lines, and opens doors to analyze its use in cancer treatment.
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Affiliation(s)
- Oluwole Olobatuyi
- Collaborative Mathematical Biology Group (formerly Center for Mathematical Biology), Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, AB, T6G 2G1, Canada.
| | - Gerda de Vries
- Collaborative Mathematical Biology Group (formerly Center for Mathematical Biology), Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, AB, T6G 2G1, Canada
| | - Thomas Hillen
- Collaborative Mathematical Biology Group (formerly Center for Mathematical Biology), Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, AB, T6G 2G1, Canada
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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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Yan J, Yang J, Yang Y, Ren W, Liu J, Gao S, Li S, Kong W, Zhu L, Yang M, Qian X, Liu B. Use of Pulsed Low-Dose Rate Radiotherapy in Refractory Malignancies. Transl Oncol 2018; 11:175-181. [PMID: 29306203 PMCID: PMC5756059 DOI: 10.1016/j.tranon.2017.12.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 12/07/2017] [Accepted: 12/07/2017] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Most tumor cell lines exhibited low-dose hyperradiosensitivity (LDHRS) to radiation doses lower than 0.3 Gy. Pulsed low-dose rate radiotherapy (PLDR) took advantage of LDHRS and maximized the tumor control process. In this study, we retrospectively analyzed patients receiving PLDR for refractory malignancies. PATIENTS AND METHODS In total, 22 patients were included in our study: 9 females and 13 males. The median age was 61 years old. All the patients previously received multiline treatments and failed with an estimated survival less than 6 months. Thus, palliative PLDR was given. The PLDR was delivered using 10 fractions of 2 Gy/day, with an interval of 3 minutes, for 5 days per week. The dose rate was 6.67 cGy/min. The median follow-up was 1 year (range 8-30 months). Nine patients underwent PLDR for reirradiation due to locally recurrent diseases. The time interval from last irradiation was 11 to 168 months. Ten patients received PLDR due to poor performance status. Three patients were given PLDR for bulky tumor. The irradiated sites included primary disease (seven patients), locally recurrent disease (nine patients), and retroperitoneal adenopathy (six patients). RESULTS Five patients developed grade 3 or 4 toxicities. No grade 5 toxicities occurred. All the toxicities recovered after treatments. In general, the 1-year local-regional control rate was approximately 40%, and almost all the patients developed progression at the second year after PLDR. The 6-month survival rate was 76%, and the 1-year survival rate was 69%. For the three patients given PLDR for bulky tumor, all of them achieved partial remission 1 month after the PLDR, and one patient achieved complete response at the fourth month. CONCLUSION PLDR is an effective and safe option not only for reirradiation but also for patients with poor performance status or bulky tumors. A prospective clinical trial (NCT03061162) is ongoing to validate our results.
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Affiliation(s)
- Jing Yan
- The Comprehensive Cancer Centre of Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Ju Yang
- The Comprehensive Cancer Centre of Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Yang Yang
- The Comprehensive Cancer Centre of Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Wei Ren
- The Comprehensive Cancer Centre of Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Juan Liu
- The Comprehensive Cancer Centre of Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Shanbao Gao
- The Comprehensive Cancer Centre of Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Shuangshuang Li
- The Comprehensive Cancer Centre of Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Weiwei Kong
- The Comprehensive Cancer Centre of Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Lijing Zhu
- The Comprehensive Cancer Centre of Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Mi Yang
- The Comprehensive Cancer Centre of Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Xiaoping Qian
- The Comprehensive Cancer Centre of Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Baorui Liu
- The Comprehensive Cancer Centre of Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China.
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Affiliation(s)
- Steven J Chmura
- a University of Chicago Department of Radiation and Cellular Oncology Ludwig Center for Metastases , Chicago , IL , USA
| | - Ralph R Weichselbaum
- a University of Chicago Department of Radiation and Cellular Oncology Ludwig Center for Metastases , Chicago , IL , USA
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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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The evolving role for re-irradiation in the management of recurrent grade 4 glioma. J Neurooncol 2017; 134:523-530. [PMID: 28386661 DOI: 10.1007/s11060-017-2392-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 02/24/2017] [Indexed: 01/14/2023]
Abstract
Although significant gains have been realized in the management of grade 4 glioma, the majority of these patients will ultimately suffer local recurrence within the prior field of treatment. Clearly, novel local treatment strategies are required to improve patient outcomes. Concerns of toxicity have limited enthusiasm for the utilization of re-irradiation as a treatment option. However, using modern imaging technology and precision radiotherapy delivery techniques re-irradiation has proven a feasible option achieving both a palliative benefit and prolongation of survival with low toxicity rates. The evolution of re-irradiation as a treatment modality for recurrent grade 4 glioma is reviewed. In addition, potential targeted radiosensitizers to be used in conjunction with re-irradiation are also discussed.
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Kainz K, Prah D, Ahunbay E, Li XA. Clinical experience with planning, quality assurance, and delivery of burst-mode modulated arc therapy. J Appl Clin Med Phys 2016; 17:47-59. [PMID: 27685123 PMCID: PMC5874115 DOI: 10.1120/jacmp.v17i5.6253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 03/28/2016] [Accepted: 03/23/2016] [Indexed: 11/29/2022] Open
Abstract
“Burst‐mode” modulated arc therapy (hereafter referred to as “mARC”) is a form of volumetric‐modulated arc therapy characterized by variable gantry rotation speed, static MLCs while the radiation beam is on, and MLC repositioning while the beam is off. We present our clinical experience with the planning techniques and plan quality assurance measurements of mARC delivery. Clinical mARC plans for five representative cases (prostate, low‐dose‐rate brain, brain with partial‐arc vertex fields, pancreas, and liver SBRT) were generated using a Monte Carlo–based treatment planning system. A conventional‐dose‐rate flat 6 MV and a high‐dose‐rate non‐flat 7 MV beam are available for planning and delivery. mARC plans for intact‐prostate cases can typically be created using one 360° arc, and treatment times per fraction seldom exceed 6 min using the flat beam; using the nonflat beam results in slightly higher MU per fraction, but also in delivery times less than 4 min and with reduced mean dose to distal organs at risk. mARC also has utility in low‐dose‐rate brain irradiation; mARC fields can be designed which deliver a uniform 20 cGy dose to the PTV in approximately 3‐minute intervals, making it a viable alternative to conventional 3D CRT. For brain cases using noncoplanar arcs, delivery time is approximately six min using the nonflat beam. For pancreas cases using the nonflat beam, two overlapping 360° arcs are required, and delivery times are approximately 10 min. For liver SBRT, the time to deliver 800 cGy per fraction is at least 12 min. Plan QA measurements indicate that the mARC delivery is consistent with the plan calculation for all cases. mARC has been incorporated into routine practice within our clinic; currently, on average approximately 15 patients per day are treated using mARC; and with the exception of LDR brain cases, all are treated using the nonflat beam. PACS number(s): 87.55.D‐, 87.55.K‐, 87.53.Ay. 87.56.N‐
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Kumar C, Shetake N, Desai S, Kumar A, Samuel G, Pandey BN. Relevance of radiobiological concepts in radionuclide therapy of cancer. Int J Radiat Biol 2016; 92:173-86. [PMID: 26917443 DOI: 10.3109/09553002.2016.1144944] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE Radionuclide therapy (RNT) is a rapidly growing area of clinical nuclear medicine, wherein radionuclides are employed to deliver cytotoxic dose of radiation to the diseased cells/tissues. During RNT, radionuclides are either directly administered or delivered through biomolecules targeting the diseased site. RNT has been clinically used for diverse range of diseases including cancer, which is the focus of the review. CONCLUSIONS The major emphasis in RNT has so far been given towards developing peptides/antibodies and other molecules to conjugate a variety of therapeutic radioisotopes for improved targeting/delivery of radiation dose to the tumor cells. Despite that, many of the RNT approaches have not achieved their desired therapeutic success probably due to poor knowledge about complex and dynamic (i) fate of radiolabeled molecules; (ii) radiation dose delivered; (iii) cellular heterogeneity in tumor mass; and (iv) cellular radiobiological response. Based on understanding gathered during recent years, it may be stated that besides the absorbed dose, the net radiobiological response of tumor/normal cells also determines the clinical response of radiotherapeutic modalities including RNT. The radiosensitivity of tumor/normal cells is governed by radiobiological phenomenon such as radiation-induced bystander effect, genomic instability, adaptive response and low dose hyper-radiosensitivity. These concepts have been well investigated in the context of external beam radiotherapy, but their clinical implications during RNT have received meagre attention. In this direction, a few studies performed using in vitro and in vivo models envisage the possibilities of exploiting the radiobiological knowledge for improved therapeutic outcome of RNT.
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Affiliation(s)
- Chandan Kumar
- a Radiopharmaceutical Chemistry Section , Bhabha Atomic Research Centre , Mumbai
| | - Neena Shetake
- b Radiation Biology and Health Sciences Division , Bhabha Atomic Research Centre , Mumbai
| | - Sejal Desai
- b Radiation Biology and Health Sciences Division , Bhabha Atomic Research Centre , Mumbai ;,d Homi Bhabha National Institute , Mumbai , India
| | - Amit Kumar
- b Radiation Biology and Health Sciences Division , Bhabha Atomic Research Centre , Mumbai ;,d Homi Bhabha National Institute , Mumbai , India
| | - Grace Samuel
- c Isotope Production and Applications Division , Bhabha Atomic Research Centre , Mumbai
| | - Badri N Pandey
- b Radiation Biology and Health Sciences Division , Bhabha Atomic Research Centre , Mumbai ;,d Homi Bhabha National Institute , Mumbai , India
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Khorramizadeh M, Saberi A, Tahmasebi-Birgani M, Shokrani P, Amouhedari A. Effect of Temporal Pattern of Radiation in Intensity Modulated Radiotherapy on Cell Cycle Progression and Apoptosis of ACHN Renal Cell Carcinoma Cell Line. Pak J Biol Sci 2016; 19:315-322. [PMID: 29023017 DOI: 10.3923/pjbs.2016.315.322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND OBJECTIVE The existence of a hypersensitive radiation response to doses below 1 Gy is well established for many normal and tumor cell lines. The aim of this study was to ascertain the impact of temporal pattern modeling IMRT on survival, cell cycle and apoptosis of human RCC cell line ACHN, so as to provide radiobiological basis for optimizing IMRT plans for this disease. MATERIALS AND METHODS The ACHN renal cell carcinoma cell line was used in this study. Impact of the triangle, V, small-large or large-small temporal patterns in the presence and absence of threshold dose of hyper-radiosensitivity at the beginning of patterns were studied using soft agarclonogenic assays. Cell cycle and apoptosis analysis were performed after irradiation with the temporal patterns. RESULTS For triangle and small-large dose sequences, survival fraction was significantly reduced after irradiation with or without threshold dose of hyper-radiosensitivity at the beginning of the patterns. In all of the dose patterns, cell cycle distributions and the percentage of apoptotic cells at 24 h after irradiation with or without priming dose of hyper-radiosensitivity showed no significant difference. However, apoptotic cells were increased when beams with the smallest dose applied at the beginning of dose pattern like triangle and small-large dose sequence. CONCLUSION These data show that the biologic effects of single fraction may differ in clinical settings depending on the size and sequence of the partial fractions. Doses at the beginning but not at the end of sequences may change cytotoxicity effects of radiation.
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Affiliation(s)
- Maryam Khorramizadeh
- Department of Medical Physics, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Alihossein Saberi
- Department of Medical Genetics, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | | | - Parvaneh Shokrani
- Department of Medical Physics and Medical Engineering, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Wobb J, Krueger SA, Kane JL, Galoforo S, Grills IS, Wilson GD, Marples B. The Effects of Pulsed Radiation Therapy on Tumor Oxygenation in 2 Murine Models of Head and Neck Squamous Cell Carcinoma. Int J Radiat Oncol Biol Phys 2015; 92:820-8. [PMID: 26104936 DOI: 10.1016/j.ijrobp.2015.04.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 03/27/2015] [Accepted: 05/31/2015] [Indexed: 01/12/2023]
Abstract
PURPOSE To evaluate the efficacy of low-dose pulsed radiation therapy (PRT) in 2 head and neck squamous cell carcinoma (HNSCC) xenografts and to investigate the mechanism of action of PRT compared with standard radiation therapy (SRT). METHODS AND MATERIALS Subcutaneous radiosensitive UT-SCC-14 and radioresistant UT-SCC-15 xenografts were established in athymic NIH III HO female mice. Tumors were irradiated with 2 Gy/day by continuous standard delivery (SRT: 2 Gy) or discontinuous low-dose pulsed delivery (PRT: 0.2 Gy × 10 with 3-min pulse interval) to total doses of 20 Gy (UT14) or 40 Gy (UT15) using a clinical 5-day on/2-day off schedule. Treatment response was assessed by changes in tumor volume, (18)F-fluorodeoxyglucose (FDG) (tumor metabolism), and (18)F-fluoromisonidazole (FMISO) (hypoxia) positron emission tomography (PET) imaging before, at midpoint, and after treatment. Tumor hypoxia using pimonidazole staining and vascular density (CD34 staining) were assessed by quantitative histopathology. RESULTS UT15 and UT14 tumors responded similarly in terms of growth delay to either SRT or PRT. When compared with UT14 tumors, UT15 tumors demonstrated significantly lower uptake of FDG at all time points after irradiation. UT14 tumors demonstrated higher levels of tumor hypoxia after SRT when compared with PRT as measured by (18)F-FMISO PET. By contrast, no differences were seen in (18)F-FMISO PET imaging between SRT and PRT for UT15 tumors. Histologic analysis of pimonidazole staining mimicked the (18)F-FMISO PET imaging data, showing an increase in hypoxia in SRT-treated UT14 tumors but not PRT-treated tumors. CONCLUSIONS Differences in (18)F-FMISO uptake for UT14 tumors after radiation therapy between PRT and SRT were measurable despite the similar tumor growth delay responses. In UT15 tumors, both SRT and PRT were equally effective at reducing tumor hypoxia to a significant level as measured by (18)F-FMISO and pimonidazole.
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Affiliation(s)
- Jessica Wobb
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Sarah A Krueger
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Jonathan L Kane
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Sandra Galoforo
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - George D Wilson
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Brian Marples
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan.
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Intensity-modulated radiation therapy for pancreatic and prostate cancer using pulsed low-dose rate delivery techniques. Med Dosim 2014; 39:330-6. [PMID: 25087084 DOI: 10.1016/j.meddos.2014.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 03/21/2014] [Accepted: 05/12/2014] [Indexed: 11/22/2022]
Abstract
Reirradiation of patients who were previously treated with radiotherapy is vastly challenging. Pulsed low-dose rate (PLDR) external beam radiotherapy has the potential to reduce normal tissue toxicities while providing significant tumor control for recurrent cancers. This work investigates treatment planning techniques for intensity-modulated radiation therapy (IMRT)-based PLDR treatment of various sites, including cases with pancreatic and prostate cancer. A total of 20 patients with clinical recurrence were selected for this study, including 10 cases with pancreatic cancer and 10 with prostate cancer. Large variations in the target volume were included to test the ability of IMRT using the existing treatment planning system and optimization algorithm to deliver uniform doses in individual gantry angles/fields for PLDR treatments. Treatment plans were generated with 10 gantry angles using the step-and-shoot IMRT delivery technique, which can be delivered in 3-minute intervals to achieve an effective low dose rate of 6.7cGy/min. Instead of dose constraints on critical structures, ring structures were mainly used in PLDR-IMRT optimization. In this study, the PLDR-IMRT plans were compared with the PLDR-3-dimensional conformal radiation therapy (3DCRT) plans and the PLDR-RapidArc plans. For the 10 cases with pancreatic cancer that were investigated, the mean planning target volume (PTV) dose for each gantry angle in the PLDR-IMRT plans ranged from 17.6 to 22.4cGy. The maximum doses ranged between 22.9 and 34.8cGy. The minimum doses ranged from 8.2 to 17.5cGy. For the 10 cases with prostate cancer that were investigated, the mean PTV doses for individual gantry angles ranged from 18.8 to 22.6cGy. The maximum doses per gantry angle were between 24.0 and 34.7cGy. The minimum doses per gantry angle ranged from 4.4 to 17.4cGy. A significant reduction in the organ at risk (OAR) dose was observed with the PLDR-IMRT plan when compared with that using the PLDR-3DCRT plan. The volume receiving an 18-Gy (V18) dose for the left and right kidneys was reduced by 10.6% and 12.5%, respectively, for the pancreatic plans. The volume receiving a 45-Gy (V45) dose for the small bowel decreased from 65.3% to 45.5%. For the cases with prostate cancer, the volume receiving a 40-Gy (V40) dose for the bladder and the rectum was reduced significantly by 25.1% and 51.2%, respectively. When compared with the RapidArc technique, the volume receiving a 30-Gy (V30) dose for the left and the right kidneys was lower in the IMRT plans. For most OARs, no significant differences were observed between the PLDR-IMRT and the PLDR-RapidArc plans. These results clearly demonstrated that the PLDR-IMRT plan was suitable for PLDR pancreatic and prostate cancer treatments in terms of the overall plan quality. A significant reduction in the OAR dose was achieved with the PLDR-IMRT plan when compared with that using the PLDR-3DCRT plan. For most OARs, no significant differences were observed between the PLDR-IMRT and the PLDR-RapidArc plans. When compared with the PLDR-3DCRT plan, the PLDR-IMRT plan could provide superior target coverage and normal tissue sparing for PLDR reirradiation of recurrent pancreatic and prostate cancers. The PLDR-IMRT plan is an effective treatment choice for recurrent cancers in most cancer centers.
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Lin MH, Price RA, Li J, Kang S, Li J, Ma CM. Investigation of pulsed IMRT and VMAT for re-irradiation treatments: dosimetric and delivery feasibilities. Phys Med Biol 2014; 58:8179-96. [PMID: 24200917 DOI: 10.1088/0031-9155/58/22/8179] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Many tumor cells demonstrate hyperradiosensitivity at doses below ~50 cGy. Together with the increased normal tissue repair under low dose rate, the pulsed low dose rate radiotherapy (PLDR), which separates a daily fractional dose of 200 cGy into 10 pulses with 3 min interval between pulses (~20 cGy/pulse and effective dose rate 6.7 cGy min−1), potentially reduces late normal tissue toxicity while still providing significant tumor control for re-irradiation treatments. This work investigates the dosimetric and technical feasibilities of intensity modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT)-based PLDR treatments using Varian Linacs. Twenty one cases (12 real re-irradiation cases) including treatment sites of pancreas, prostate, pelvis, lung, head-and-neck, and breast were recruited for this study. The lowest machine operation dose rate (100 MU min−1) was employed in the plan delivery. Ten-field step-and-shoot IMRT and dual-arc VMAT plans were generated using the Eclipse TPS with routine planning strategies. The dual-arc plans were delivered five times to achieve a 200 cGy daily dose (~20 cGy arc−1). The resulting plan quality was evaluated according to the heterogeneity and conformity indexes (HI and CI) of the planning target volume (PTV). The dosimetric feasibility of retaining the hyperradiosensitivity for PLDR was assessed based on the minimum and maximum dose in the target volume from each pulse. The delivery accuracy of VMAT and IMRT at the 100 MU min−1 machine operation dose rate was verified using a 2D diode array and ion chamber measurements. The delivery reproducibility was further investigated by analyzing the Dynalog files of repeated deliveries. A comparable plan quality was achieved by the IMRT (CI 1.10–1.38; HI 1.04–1.10) and the VMAT (CI 1.08–1.26; HI 1.05–1.10) techniques. The minimum/maximum PTV dose per pulse is 7.9 ± 5.1 cGy/33.7 ± 6.9 cGy for the IMRT and 12.3 ± 4.1 cGy/29.2 ± 4.7 cGy for the VMAT. Six out of the 186 IMRT pulses (fields) were found to exceed 50 cGy maximum PTV dose per pulse while the maximum PTV dose per pulse was within 40 cGy for all the VMAT pulses (arcs). However, for VMAT plans, the dosimetric quality of the entire treatment plan was less superior for the breast cases and large irregular targets. The gamma passing rates for both techniques at the 100 MU min−1 dose rate were at least 94.1% (3%/3 mm) and the point dose measurements agreed with the planned values to within 2.2%. The average root mean square error of the leaf position was 0.93 ± 0.83 mm for IMRT and 0.53 ± 0.48 mm for VMAT based on the Dynalog file analysis. The RMS error of the leaf position was nearly identical for the repeated deliveries of the same plans. In general, both techniques are feasible for PLDR treatments. VMAT was more advantageous for PLDR with more uniform target dose per pulse, especially for centrally located tumors. However, for large, irregular and/or peripheral tumors, IMRT could produce more favorable PLDR plans. By taking the biological benefit of PLDR delivery and the dosimetric benefit of IMRT and VMAT, the proposed methods have a great potential for those previously-irradiated recurrent patients.
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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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Kuperman VY. Effect of radiation protraction on BED in the case of large fraction dose. Med Phys 2013; 40:081716. [DOI: 10.1118/1.4812432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Zhao Y, Cui Y, Han J, Ren J, Wu G, Cheng J. Cell division cycle 25 homolog c effects on low-dose hyper-radiosensitivity and induced radioresistance at elevated dosage in A549 cells. JOURNAL OF RADIATION RESEARCH 2012; 53:686-94. [PMID: 22843362 PMCID: PMC3430412 DOI: 10.1093/jrr/rrs024] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
The underlying mechanisms behind both low-dose hyper-radiosensitivity (HRS) and induced radioresistance (IRR), generally occurring at elevated radiation levels, remain unclear; however, elucidation of the relationship between cell cycle division 25 homolog c (Cdc25c) phosphatase and HRS/IRR may provide important insights into this process. Two cell lines with disparate HRS status, A549 and SiHa cells, were selected as cell models for comparison of dose-dependent Cdc25c phosphatase expression subsequent to low-dose irradiation. Knockdown of Cdc25c in A549 cells was mediated by transfection with a pGCsi-RAN-U6neo vector containing hairpin siRNA sequences. S216-phosphorylated Cdc25c protein [p-Cdc25c (Ser216)], cell survival and mitotic ratio were measured by western blot, colony-forming assay and histone H3 phosphorylation analysis. Variant p-Cdc25c (Ser216) expression was observed in the two cell lines after irradiation. The p-Cdc25c (Ser216) expression noted in SiHa cells after administration of 0-1 Gy radiation was similar to the radioresistance model; however, in A549 cells, the dose response for the phosphorylation of the Cdc25c Ser216 residue overlapped the level required to overcome the HRS response. Furthermore, Cdc25c repression prior to low-dose radiation induced more distinct HRS and prevented the development of IRR. The dose required to overcome the HRS response coincided with the effect of early G2-phase checkpoint arrest in A549 cells (approximately 0.3 Gy), and Cdc25c knockdown in A549 cells (approximately 0.5 Gy) corresponded to the phosphorylation of the Cdc25c Ser216 residue. Resultant data confirmed that dose-dependent Cdc25c phosphatase does effectively act as an early G2-phase checkpoint, thus indicating mechanistic importance in the HRS to IRR transition in A549 cells.
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Affiliation(s)
- Yanxia Zhao
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430023, Hubei, People's Republic of China
| | - Yingshan Cui
- Oncology Department, Jinhua Municipal Center Hospital, Jinhua, 321000, Zhejiang, People's Republic of China
| | - Jun Han
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430023, Hubei, People's Republic of China
| | - Jinghua Ren
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430023, Hubei, People's Republic of China
| | - Gang Wu
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430023, Hubei, People's Republic of China
| | - Jing Cheng
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430023, Hubei, People's Republic of China
- Corresponding author. Tel: +86 (27) 65-650-416; Fax: +86 (27) 65-65-0733;
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Ma CM, Lin MH, Dai XF, Koren S, Klayton T, Wang L, Li JS, Chen L, Price RA. Investigation of pulsed low dose rate radiotherapy using dynamic arc delivery techniques. Phys Med Biol 2012; 57:4613-26. [PMID: 22750648 DOI: 10.1088/0031-9155/57/14/4613] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
There has been no consensus standard of care to treat recurrent cancer patients who have previously been irradiated. Pulsed low dose rate (PLDR) external beam radiotherapy has the potential to reduce normal tissue toxicities while still providing significant tumor control for recurrent cancers. This work investigates the dosimetry feasibility of PLDR treatment using dynamic arc delivery techniques. Five treatment sites were investigated in this study including breast, pancreas, prostate, head and neck, and lung. Dynamic arc plans were generated using the Varian Eclipse system and the RapidArc delivery technique with 6 and 10 MV photon beams. Each RapidArc plan consisted of two full arcs and the plan was delivered five times to achieve a daily dose of 200 cGy. The dosimetry requirement was to deliver approximately 20 cGy/arc with a 3 min interval to achieve an effective dose rate of 6.7 cGy min⁻¹. Monte Carlo simulations were performed to calculate the actual dose delivered to the planning target volume (PTV) per arc taking into account beam attenuation/scattering and intensity modulation. The maximum, minimum and mean doses to the PTV were analyzed together with the dose volume histograms and isodose distributions. The dose delivery for the five plans was validated using solid water phantoms inserted with an ionization chamber and film, and a cylindrical detector array. Two intensity-modulated arcs were used to efficiently deliver the PLDR plans that provided conformal dose distributions for treating complex recurrent cancers. For the five treatment sites, the mean PTV dose ranged from 18.9 to 22.6 cGy/arc. For breast, the minimum and maximum PTV dose was 8.3 and 35.2 cGy/arc, respectively. The PTV dose varied between 12.9 and 27.5 cGy/arc for pancreas, 12.6 and 28.3 cGy/arc for prostate, 12.1 and 30.4 cGy/arc for H&N, and 16.2 and 27.6 cGy/arc for lung. Advanced radiation therapy can provide superior target coverage and normal tissue sparing for PLDR reirradiation of recurrent cancers, which can be delivered using dynamic arc delivery techniques with ten full arcs and an effective dose rate of 6.7 ± 4.0 cGy min⁻¹.
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Affiliation(s)
- C-M Ma
- Radiation Oncology Department, Fox Chase Cancer Center, Philadelphia, PA 19111, USA.
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Semicontinuous Low-Dose-Rate Teletherapy for the Treatment of Recurrent Glial Brain Tumors: Final Report of a Phase I/II Study. Int J Radiat Oncol Biol Phys 2012; 82:765-72. [DOI: 10.1016/j.ijrobp.2010.10.057] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2009] [Revised: 08/25/2010] [Accepted: 10/28/2010] [Indexed: 11/22/2022]
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Ma CMC, Luxton G, Orton CG. Point/counterpoint: pulsed reduced dose rate radiation therapy is likely to become the treatment modality of choice for recurrent cancers. Med Phys 2011; 38:4909-11. [PMID: 21978035 DOI: 10.1118/1.3583794] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- C-M Charlie Ma
- Radiation Oncology Department, Fox Chase Cancer Center, Philadelphia, PA, USA.
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Rong Y, Paliwal B, Howard SP, Welsh J. Treatment Planning for Pulsed Reduced Dose-Rate Radiotherapy in Helical Tomotherapy. Int J Radiat Oncol Biol Phys 2011; 79:934-42. [DOI: 10.1016/j.ijrobp.2010.05.055] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2009] [Revised: 04/12/2010] [Accepted: 05/01/2010] [Indexed: 11/17/2022]
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Leonard BE, Thompson RE, Beecher GC. Human Lung Cancer Risks from Radon - Part III - Evidence of Influence of Combined Bystander and Adaptive Response Effects on Radon Case-Control Studies - A Microdose Analysis. Dose Response 2010; 10:415-61. [PMID: 22942874 DOI: 10.2203/dose-response.09-059.leonard] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Since the publication of the BEIR VI (1999) report on health risks from radon, a significant amount of new data has been published showing various mechanisms that may affect the ultimate assessment of radon as a carcinogen, in particular the potentially deleterious Bystander Effect (BE) and the potentially beneficial Adaptive Response radio-protection (AR). The case-control radon lung cancer risk data of the pooled 13 European countries radon study (Darby et al 2005, 2006) and the 8 North American pooled study (Krewski et al 2005, 2006) have been evaluated. The large variation in the odds ratios of lung cancer from radon risk is reconciled, based on the large variation in geological and ecological conditions and variation in the degree of adaptive response radio-protection against the bystander effect induced lung damage. The analysis clearly shows Bystander Effect radon lung cancer induction and Adaptive Response reduction in lung cancer in some geographical regions. It is estimated that for radon levels up to about 400 Bq m(-3) there is about a 30% probability that no human lung cancer risk from radon will be experienced and a 20% probability that the risk is below the zero-radon, endogenic spontaneous or perhaps even genetically inheritable lung cancer risk rate. The BEIR VI (1999) and EPA (2003) estimates of human lung cancer deaths from radon are most likely significantly excessive. The assumption of linearity of risk, by the Linear No-Threshold Model, with increasing radon exposure is invalid.
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The effects of G2-phase enrichment and checkpoint abrogation on low-dose hyper-radiosensitivity. Int J Radiat Oncol Biol Phys 2010; 77:1509-17. [PMID: 20637979 DOI: 10.1016/j.ijrobp.2010.01.028] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2009] [Revised: 01/19/2010] [Accepted: 01/20/2010] [Indexed: 11/21/2022]
Abstract
PURPOSE An association between low-dose hyper-radiosensitivity (HRS) and the "early" G2/M checkpoint has been established. An improved molecular understanding of the temporal dynamics of this relationship is needed before clinical translation can be considered. This study was conducted to characterize the dose response of the early G2/M checkpoint and then determine whether low-dose radiation sensitivity could be increased by synchronization or chemical inhibition of the cell cycle. METHODS AND MATERIALS Two related cell lines with disparate HRS status were used (MR4 and 3.7 cells). A double-thymidine block technique was developed to enrich the G2-phase population. Clonogenic cell survival, radiation-induced G2-phase cell cycle arrest, and deoxyribonucleic acid double-strand break repair were measured in the presence and absence of inhibitors to G2-phase checkpoint proteins. RESULTS For MR4 cells, the dose required to overcome the HRS response (approximately 0.2 Gy) corresponded with that needed for the activation of the early G2/M checkpoint. As hypothesized, enriching the number of G2-phase cells in the population resulted in an enhanced HRS response, because a greater proportion of radiation-damaged cells evaded the early G2/M checkpoint and entered mitosis with unrepaired deoxyribonucleic acid double-strand breaks. Likewise, abrogation of the checkpoint by inhibition of Chk1 and Chk2 also increased low-dose radiosensitivity. These effects were not evident in 3.7 cells. CONCLUSIONS The data confirm that HRS is linked to the early G2/M checkpoint through the damage response of G2-phase cells. Low-dose radiosensitivity could be increased by manipulating the transition of radiation-damaged G2-phase cells into mitosis. This provides a rationale for combining low-dose radiation therapy with chemical synchronization techniques to improve increased radiosensitivity.
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Adkison JB, Tomé W, Seo S, Richards GM, Robins HI, Rassmussen K, Welsh JS, Mahler PA, Howard SP. Reirradiation of large-volume recurrent glioma with pulsed reduced-dose-rate radiotherapy. Int J Radiat Oncol Biol Phys 2010; 79:835-41. [PMID: 20472350 DOI: 10.1016/j.ijrobp.2009.11.058] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2009] [Revised: 10/09/2009] [Accepted: 11/12/2009] [Indexed: 10/19/2022]
Abstract
PURPOSE Pulsed reduced-dose-rate radiotherapy (PRDR) is a reirradiation technique that reduces the effective dose rate and increases the treatment time, allowing sublethal damage repair during irradiation. PATIENTS AND METHODS A total of 103 patients with recurrent glioma underwent reirradiation using PRDR (86 considered to have Grade 4 at PRDR). PRDR was delivered using a series of 0.2-Gy pulses at 3-min intervals, creating an apparent dose rate of 0.0667 Gy/min to a median dose of 50 Gy (range, 20-60) delivered in 1.8-2.0-Gy fractions. The mean treatment volume was 403.5±189.4 cm3 according to T2-weighted magnetic resonance imaging and a 2-cm margin. RESULTS For the initial or upgraded Grade 4 cohort (n=86), the median interval from the first irradiation to PRDR was 14 months. Patients undergoing PRDR within 14 months of the first irradiation (n=43) had a median survival of 21 weeks. Those treated ≥14 months after radiotherapy had a median survival of 28 weeks (n=43; p=0.004 and HR=1.82 with a 95% CI ranging from 1.25 to 3.10). These data compared favorably to historical data sets, because only 16% of the patients were treated at first relapse (with 46% treated at the second relapse, 32% at the third or fourth relapse, and 4% at the fourth or fifth relapse). The median survival since diagnosis and retreatment was 6.3 years and 11.4 months for low-grade, 4.1 years and 5.6 months for Grade 3, and 1.6 years and 5.1 months for Grade 4 tumors, respectively, according to the initial histologic findings. Multivariate analysis revealed age at the initial diagnosis, initial low-grade disease, and Karnofsky performance score of ≥80 to be significant predictors of survival after initiation of PRDR. CONCLUSION PRDR allowed for safe retreatment of larger volumes to high doses with palliative benefit.
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Affiliation(s)
- Jarrod B Adkison
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA
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Richards GM, Tomé WA, Robins HI, Stewart JA, Welsh JS, Mahler PA, Howard SP. Pulsed reduced dose-rate radiotherapy: a novel locoregional retreatment strategy for breast cancer recurrence in the previously irradiated chest wall, axilla, or supraclavicular region. Breast Cancer Res Treat 2008; 114:307-13. [PMID: 18389365 DOI: 10.1007/s10549-008-9995-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2008] [Accepted: 03/26/2008] [Indexed: 12/29/2022]
Abstract
PURPOSE Reirradiation of breast cancer locoregional recurrence (LRR) in the setting of prior post-mastectomy radiation poses a significant clinical challenge due to the high risk for severe toxicity. In an attempt to reduce these toxicities, we have developed pulsed reduced dose-rate radiotherapy (PRDR), a reirradiation technique in which a series of 0.2 Gy pulses separated by 3-min time intervals is delivered, creating an apparent dose rate of 0.0667 Gy/min. Here we describe our early experience with PRDR. PATIENTS AND METHODS We reirradiated 17 patients with LRR breast cancer to the chest wall, axilla, or supraclavicular region using PRDR. The median prior radiation dose was 60 Gy. We delivered a median PRDR dose of 54 Gy (range 40-66 Gy) in 1.8-2.0 Gy per fraction. Eight patients received concomitant low dose capecitabine for radiosensitization. The median treatment volume was 2,084 cm(3) (range 843-7,881 cm(3)). RESULTS At a median follow-up of 18 months (range 4-75 months) only 2 patients have had tumor failure in the treatment region. Estimated 2-year local control rate is 92%. Treatment was well tolerated with 4 patients experiencing grade 3 acute skin toxicity. Despite a median cumulative dose of 110 Gy (range 80-236 Gy), there has been only one grade 3 and one grade 4 late toxicity. CONCLUSIONS With a median follow-up of 18 months, PRDR appears to be an effective method to reirradiate large volumes of previously irradiated tissue in selected patients with locoregional chest wall, axilla, and supraclavicular recurrences.
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Affiliation(s)
- Gregory M Richards
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA
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Low-Dose Hyper-Radiosensitivity: Past, Present, and Future. Int J Radiat Oncol Biol Phys 2008; 70:1310-8. [DOI: 10.1016/j.ijrobp.2007.11.071] [Citation(s) in RCA: 156] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2007] [Revised: 11/27/2007] [Accepted: 11/30/2007] [Indexed: 01/07/2023]
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Bourgier C, Vozenin-Brotons MC, Arriagada R. Enhanced local control by radiation boost in breast cancer: back side of the coin? J Clin Oncol 2007; 25:5841-3; author reply 5844-5. [PMID: 18089888 DOI: 10.1200/jco.2007.14.6035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Cannon GM, Tomé WA, Robins HI, Howard SP. Pulsed reduced dose-rate radiotherapy: case report : a novel re-treatment strategy in the management of recurrent glioblastoma multiforme. J Neurooncol 2007; 83:307-11. [PMID: 17252184 DOI: 10.1007/s11060-007-9329-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2006] [Accepted: 01/05/2007] [Indexed: 11/28/2022]
Abstract
The initial management of malignant gliomas is multimodality in nature, consisting of surgery, radiation therapy and chemotherapy. However, once progression has occurred, treatment options are limited both in terms of selection and efficacy. We report a case of a 37 year-old male diagnosed with a Grade II astrocytoma initially treated with surgery and external beam radiation therapy consisting of 54 Gy delivered in 1.8 Gy fractions that subsequently progressed to a Grade IV astrocytoma. This was managed with temozolomide chemotherapy until the patient exhibited further progression. Although the patient had received prior full dose radiotherapy, he was re-treated with external beam radiotherapy delivered at a substantially reduced dose-rate. This reduction in dose-rate is obtained by delivering treatment in a series of 0.2 Gy pulses separated by 3 min time intervals, creating an apparent dose rate of 0.0667 Gy/min. The region of recurrence was treated to a dose of 50 Gy delivered using 25 daily fractions of 2.0 Gy. The patient had both a radiographic response and clinical improvement following re-irradiation using pulsed reduced dose-rate radiotherapy with no apparent acute or late neurologic toxicities at a time when other treatment options were not available. Despite delivering 104 Gy to the tumor bed and the surrounding brain parenchyma, at no time was there radiographic evidence of radiation-induced normal tissue necrosis. The radiobiologic basis for the use of pulsed reduced dose-rate external beam radiotherapy in the management of recurrent glioma patients is discussed.
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Affiliation(s)
- George M Cannon
- Department of Human Oncology, School of Medicine and Public Health, University of Wisconsin, K4/350 CSC, 600 Highland Ave., Madison, WI 53792, USA
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Murphy MJ, Lin PS, Ozhasoglu C. Intra-fraction dose delivery timing during stereotactic radiotherapy can influence the radiobiological effect. Med Phys 2007; 34:481-4. [PMID: 17388164 DOI: 10.1118/1.2409750] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The sequence of incremental dose delivery during a radiotherapy fraction can potentially influence the radiobiological effect. This would be most noticeable during the long fractions characteristic of hypo-fractionated stereotactic radiotherapy and radiosurgery. We demonstrate here the spatio-temporal variation of dose delivery by the CyberKnife to a lung tumor and propose strategies to reduce and/or correct for any resultant dose-time cytotoxic effects.
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Affiliation(s)
- Martin J Murphy
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia 23298, USA.
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