The case for particle therapy

Whole-Body 12C Irradiation Transiently Decreases Mouse Hippocampal Dentate Gyrus Proliferation and Immature Neuron Number, but Does Not Change New Neuron Survival Rate

High-charge and -energy (HZE) particles comprise space radiation and they pose a challenge to astronauts on deep space missions. While exposure to most HZE particles decreases neurogenesis in the hippocampus—a brain structure important in memory—prior work suggests that ¹²C does not. However, much about ¹²C’s influence on neurogenesis remains unknown, including the time course of its impact on neurogenesis. To address this knowledge gap, male mice (9–11 weeks of age) were exposed to whole-body ¹²C irradiation 100 cGy (IRR; 1000 MeV/n; 8 kEV/µm) or Sham treatment. To birthdate dividing cells, mice received BrdU i.p. 22 h post-irradiation and brains were harvested 2 h (Short-Term) or three months (Long-Term) later for stereological analysis indices of dentate gyrus neurogenesis. For the Short-Term time point, IRR mice had fewer Ki67, BrdU, and doublecortin (DCX) immunoreactive (+) cells versus Sham mice, indicating decreased proliferation (Ki67, BrdU) and immature neurons (DCX). For the Long-Term time point, IRR and Sham mice had similar Ki67+ and DCX+ cell numbers, suggesting restoration of proliferation and immature neurons 3 months post-¹²C irradiation. IRR mice had fewer surviving BrdU+ cells versus Sham mice, suggesting decreased cell survival, but there was no difference in BrdU+ cell survival rate when compared within treatment and across time point. These data underscore the ability of neurogenesis in the mouse brain to recover from the detrimental effect of ¹²C exposure.

Evaluation of the premature chromosome condensation scoring protocol after proton and X-ray irradiation of human peripheral blood lymphocytes at high doses range

PURPOSE OF THE STUDY

One of the main difficulties in radiation dose assessment is cells inability to reach mitosis after exposure to acute radiation. Premature chromosome condensation (PCC) has become an important method used in biological dosimetry in case of exposure to high doses. Various ways to induce PCC including mitotic cells fusion, chemical stimulation with calyculin A or okadaic acid give wide spectrum of application. The main goal of this study was to evaluate the utility of drug-induced PCC scoring procedure by testing 2 experimental modes where 150 and 75 G2/M-PCC phase cells were analyzed after exposure to high dose proton and X-ray radiation. Another aim is to determine the differences in cellular response induced by proton and photon radiation using a HPBL in vitro model as a further extension of our previous studies involving doses up to 4.0 Gy.

MATERIALS AND METHODS

Total body exposure was simulated by irradiating whole blood collected from a healthy donor. Whole blood samples were exposed to two radiation types: 60 MeV protons and 250 kVp X-rays in the dose range of 5.0-20.0 Gy, the dose rate for protons was 0.075 and 0.15 Gy/s for X-rays. Post 48 h of human peripheral blood lymphocytes (HPBL) culture, calyculin A was added. After Giemsa staining, chromosome spreads were photographed and manually analyzed by scorers in the G2/M-PCC phase. In order to check the consistency of obtained results all scorers followed identical scoring criteria. Additionally, PCC index kinetics was evaluated for first 500 cells scored.

CONCLUSIONS

Here we provide a different method of results analysis. Presented dose-response curves were obtained by calculating the value of counted excess chromosome fragments. The results indicated that obtained dose estimates as adequate in the high dose range till 18.0 Gy for both studied radiation types, giving an opportunity to further improve PCC assay procedure and shorten the analysis time i.e. in case of partial-body exposure. Moreover, the study presents preliminary results of HPBL cellular response after proton irradiation at high doses range showing differences of PCC index kinetics for different cell classes and cell distribution.

Proton radiobiology and its clinical implications

Denser ionisation clustering and complex DNA damage in proton Bragg peaks far exceeds that seen with conventional X-rays. This results in more efficient cell sterilisation, quantified by the relative biological effectiveness (RBE). Currently, a 1.1 RBE is used to determine the clinical proton doses by dividing the usual X-rays dose by this amount. This number, derived from short-term experiments, has been criticised as being irrelevant to late normal tissue (NT) effects following radiotherapy and included many control irradiations using lower voltage X-rays (with elevated RBE values) than those used in the clinic. In principle, an increased RBE could be used for each organ at risk, by using extensions of the clinically successful linear quadratic model.

Protons undoubtedly reduce or eliminate NT radiation dose in tissues distantly located from a tumour, but the necessity to include NT margins around a tumour can result in a higher volume of NT than tumour being irradiated. Deleterious side-effects can follow if the NT RBE exceeds 1.1, including in tissue very close to these margins and which are only partially spared.

Use of a constant 1.1 RBE can ‘overdose’ NT, which may require a greater dose reduction such as 1.2 in the brain; some tumours may be ‘under-dosed’ (since they might require a lesser or no reduction in dose). More sophisticated proton experiments show that RBE values of 1.1–1.5 and higher occur in some situations. There are now mathematical models of varying degrees of complexity that can estimate the RBE from the dose, LET and the low-LET radiosensitivities. True multidisciplinary cooperation is required to implement such new ideas in proton therapy in order to improve safety and effectiveness.

Clinical and Research Activities at the CATANA Facility of INFN-LNS: From the Conventional Hadrontherapy to the Laser-Driven Approach

The CATANA proton therapy center was the first Italian clinical facility making use of energetic (62 MeV) proton beams for the radioactive treatment of solid tumors. Since the date of the first patient treatment in 2002, 294 patients have been successful treated whose majority was affected by choroidal and iris melanomas. In this paper, we report on the current clinical and physical status of the CATANA facility describing the last dosimetric studies and reporting on the last patient follow-up results. The last part of the paper is dedicated to the description of the INFN-LNS ongoing activities on the realization of a beamline for the transport of laser-accelerated ion beams for future applications. The ELIMED (ELI-Beamlines MEDical and multidisciplinary applications) project is introduced and the main scientific aspects will be described.

A new silicon tracker for proton imaging and dosimetry

For many years, silicon micro-strip detectors have been successfully used as tracking detectors for particle and nuclear physics experiments. A new application of this technology is to the field of particle therapy where radiotherapy is carried out by use of charged particles such as protons or carbon ions. Such a treatment has been shown to have advantages over standard x-ray radiotherapy and as a result of this, many new centres offering particle therapy are currently under construction around the world today. The Proton Radiotherapy, Verification and Dosimetry Applications (PRaVDA) consortium are developing instrumentation for particle therapy based upon technology from high-energy physics. The characteristics of a new silicon micro-strip tracker for particle therapy will be presented. The array uses specifically designed, large area sensors with technology choices that follow closely those taken for the ATLAS experiment at the HL-LHC. These detectors will be arranged into four units each with three layers in an x-u-v configuration to be suitable for fast proton tracking with minimal ambiguities. The sensors will form a tracker capable of tracing the path of ~200 MeV protons entering and exiting a patient allowing a new mode of imaging known as proton computed tomography (pCT). This will aid the accurate delivery of treatment doses and in addition, the tracker will also be used to monitor the beam profile and total dose delivered during the high fluences used for treatment. We present here details of the design, construction and assembly of one of the four units that will make up the complete tracker along with its characterisation using radiation tests carried out using a 90Sr source in the laboratory and a 60 MeV proton beam at the Clatterbridge Cancer Centre.

Evaluation of the relative biological effectiveness of spot-scanning proton irradiation in vitro

Variations in relative biological effectiveness (RBE) from a fixed value of 1.1 are critical in proton beam therapy. To date, studies estimating RBE at multiple positions relative to the spread-out Bragg peak (SOBP) have been predominantly performed using passive scattering methods, and limited data are available for spot-scanning beams. Thus, to investigate the RBE of spot-scanning beams, Chinese hamster fibroblast V79 cells were irradiated using the beam line at the Hokkaido University Hospital Proton Therapy Center. Cells were placed at six different depths, including the entrance of the proton beam and the proximal and distal part of the SOBP. Surviving cell fractions were analyzed using colony formation assay, and cell survival curves were obtained by the curve fitted using a linear-quadratic model. RBE10 and RBE37 were 1.15 and 1.21 at the center of the SOBP, respectively. In contrast, the distal region showed higher RBE values (1.50 for RBE10 and 1.85 for RBE37). These results are in line with those of previous studies conducted using passive scattering proton beams. Taken together, these data strongly suggest that variations in RBE should be considered during treatment planning for spot-scanning beams as well as for passive scattering proton beams.

Variations in the Processing of DNA Double-Strand Breaks Along 60-MeV Therapeutic Proton Beams

Purpose

To investigate the variations in induction and repair of DNA damage along the proton path, after a previous report on the increasing biological effectiveness along clinically modulated 60-MeV proton beams.

Methods and Materials

Human skin fibroblast (AG01522) cells were irradiated along a monoenergetic and a modulated spread-out Bragg peak (SOBP) proton beam used for treating ocular melanoma at the Douglas Cyclotron, Clatterbridge Centre for Oncology, Wirral, Liverpool, United Kingdom. The DNA damage response was studied using the 53BP1 foci formation assay. The linear energy transfer (LET) dependence was studied by irradiating the cells at depths corresponding to entrance, proximal, middle, and distal positions of SOBP and the entrance and peak position for the pristine beam.

Results

A significant amount of persistent foci was observed at the distal end of the SOBP, suggesting complex residual DNA double-strand break damage induction corresponding to the highest LET values achievable by modulated proton beams. Unlike the directly irradiated, medium-sharing bystander cells did not show any significant increase in residual foci.

Conclusions

The DNA damage response along the proton beam path was similar to the response of X rays, confirming the low-LET quality of the proton exposure. However, at the distal end of SOBP our data indicate an increased complexity of DNA lesions and slower repair kinetics. A lack of significant induction of 53BP1 foci in the bystander cells suggests a minor role of cell signaling for DNA damage under these conditions.

Commissioning and Quality Assurance of an Integrated System for Patient Positioning and Setup Verification in Particle Therapy

In an increasing number of clinical indications, radiotherapy with accelerated particles shows relevant advantages when compared with high energy X-ray irradiation. However, due to the finite range of ions, particle therapy can be severely compromised by setup errors and geometric uncertainties. The purpose of this work is to describe the commissioning and the design of the quality assurance procedures for patient positioning and setup verification systems at the Italian National Center for Oncological Hadrontherapy (CNAO). The accuracy of systems installed in CNAO and devoted to patient positioning and setup verification have been assessed using a laser tracking device. The accuracy in calibration and image based setup verification relying on in room X-ray imaging system was also quantified. Quality assurance tests to check the integration among all patient setup systems were designed, and records of daily QA tests since the start of clinical operation (2011) are presented. The overall accuracy of the patient positioning system and the patient verification system motion was proved to be below 0.5 mm under all the examined conditions, with median values below the 0.3 mm threshold. Image based registration in phantom studies exhibited sub-millimetric accuracy in setup verification at both cranial and extra-cranial sites. The calibration residuals of the OTS were found consistent with the expectations, with peak values below 0.3 mm. Quality assurance tests, daily performed before clinical operation, confirm adequate integration and sub-millimetric setup accuracy. Robotic patient positioning was successfully integrated with optical tracking and stereoscopic X-ray verification for patient setup in particle therapy. Sub-millimetric setup accuracy was achieved and consistently verified in daily clinical operation.

The effects of radiation on angiogenesis

The average human body contains tens of thousands of miles of vessels that permeate every tissue down to the microscopic level. This makes the human vasculature a prime target for an agent like radiation that originates from a source and passes through the body. Exposure to radiation released during nuclear accidents and explosions, or during cancer radiotherapy, is well known to cause vascular pathologies because of the ionizing effects of electromagnetic radiations (photons) such as gamma rays. There is however, another type of less well-known radiation - charged ion particles, and these atoms stripped of electrons, have different physical properties to the photons of electromagnetic radiation. They are either found in space or created on earth by particle collider facilities, and are of significant recent interest due to their enhanced effectiveness and increasing use in cancer radiotherapy, as well as a health risk to the growing number of people spending time in the space environment. Although there is to date, relatively few studies on the effects of charged particles on the vascular system, a very different picture of the biological effects of these particles compared to photons is beginning to emerge. These under researched biological effects of ion particles have a large impact on the health consequences of exposure. In this short review, we will discuss the effects of charged particles on an important biological process of the vascular system, angiogenesis, which creates and maintains the vasculature and is highly important in tumor vasculogenesis.

[From the carbon track to therapeutic efficiency of hadrontherapy]

Carbon ions, thanks to their relative biological effectiveness much higher than that of photons and protons and their ballistic characteristics similar to those of protons, can effectively treat radioresistant tumours. The reasons for this increased efficiency are found in the microdosimetric and radiobiological features of ions. The energy deposit or linear energy transfer increases along the range and reaches a very high level at the end producing the Bragg peak, where the linear energy transfer is about hundred times higher than that of photons. These massive energy deposits create multiple DNA lesions that are difficult to repair. DNA repair is associated with longer blockage of the cell cycle and more frequent chromosomal aberrations that are lethal to cells. The types of cell death are identical to those triggered in response to photon irradiation, but the response is earlier and more important at equivalent physical dose. Radiobiological differences between carbon ions and photons have been studied for some years and many aspects remain to be explored. In general, these phenomena tend to reduce the differences of radiosensitivity among different tissues. It is therefore in situation where tumours are relatively radioresistant compared to healthy tissue, that carbon ions must be used and not in the opposite situations where the fractionation of low linear energy transfer radiation is sufficient to provide the necessary differential effect to cure the tumour.

[Particle therapy: carbon ions]

Carbon ion therapy is an innovative radiation therapy. It has been first proposed in the forties by Robert Wilson, however the first dedicated centres for human care have been build up only recently in Japan and Germany. The interest of carbon ion is twofold: 1) the very sharp targeting of the tumour with the so called spread out Bragg peak that delivers most of the beam energy in the tumour and nothing beyond it, sparing very efficiently the healthy tissues; 2) the higher relative biological efficiency compared to X rays or protons, able to kill radioresistant tumour cells. Both properties make carbon ions the elective therapy for non resectable radioresistant tumours loco-regionally threatening. The technical and clinical experience accumulated during the recent decades is summarized in this paper along with a detailed presentation of the elective indications. A short comparison between conventional radiotherapy and hadrontherapy is proposed for the indications which are considered as priority for carbon ions.

Do we have enough evidence to implement particle therapy as standard treatment in lung cancer? A systematic literature review

BACKGROUND

The societal burden of lung cancer is high because of its high incidence and high lethality. From a theoretical point of view, radiotherapy with beams of protons and heavier charged particles, for example, carbon ions (C-ions), should lead to superior results, compared with photon beams. In this review, we searched for clinical evidence to justify implementation of particle therapy as standard treatment in lung cancer.

METHODS

A systematic literature review based on an earlier published comprehensive review was performed and updated through November 2009.

RESULTS

Eleven fully published studies, all dealing with non-small cell lung cancer (NSCLC), mainly stage I, were identified. No phase III trials were found. For proton therapy, 2- to 5-year local tumor control rates varied in the range of 57%-87%. The 2- and 5-year overall survival (OS) and 2- and 5-year cause-specific survival (CSS) rates were 31%-74% and 23% and 58%-86% and 46%, respectively. Radiation-induced pneumonitis was observed in about 10% of patients. For C-ion therapy, the overall local tumor control rate was 77%, but it was 95% when using a hypofractionated radiation schedule. The 5-year OS and CSS rates were 42% and 60%, respectively. Slightly better results were reported when using hypofractionation, 50% and 76%, respectively.

CONCLUSION

The present results with protons and heavier charged particles are promising. However, the current lack of evidence on the clinical (cost-)effectiveness of particle therapy emphasizes the need to investigate the efficiency of particle therapy in an adequate manner. Until these results are available for lung cancer, charged particle therapy should be considered experimental.

The apparent increase in the {beta}-parameter of the linear quadratic model with increased linear energy transfer during fast neutron irradiation

The issue of whether the beta-parameter of the linear quadratic model changes with linear energy transfer (LET) remains controversial. Retrospective analysis of UK fast neutron experimental data using human cell lines at Clatterbridge shows that the beta-parameter of the linear quadratic model probably does increase with LET during neutron irradiation. For cells without a deficiency in DNA damage repair and for experiments in which beta-parameter estimates were considered to be unreliably low, a provisional relationship of beta(H) = 1.82 beta(L) was found (where the suffixes refer to high and low LET exposures, respectively). This implies that radicalbeta increases by around 1.35 in the specific case of 62.5 MeV neutrons relative to 4 MeV X-rays. Increments in the beta-parameter with LET influence the relative biological effect (RBE), especially at high doses per fraction. Large fractions are being used in experimental carbon ion therapy, in which broadly similar RBE values to fast neutrons are found. These interesting findings after fast neutron exposure need to be studied further for applications in charged particle beam therapy using light ions, which is presently undergoing a worldwide expansion.

Charged particles in radiation oncology

Radiotherapy is one of the most common and effective therapies for cancer. Generally, patients are treated with X-rays produced by electron accelerators. Many years ago, researchers proposed that high-energy charged particles could be used for this purpose, owing to their physical and radiobiological advantages compared with X-rays. Particle therapy is an emerging technique in radiotherapy. Protons and carbon ions have been used for treating many different solid cancers, and several new centers with large accelerators are under construction. Debate continues on the cost:benefit ratio of this technique, that is, on whether the high costs of accelerators and beam delivery in particle therapy are justified by a clear clinical advantage. This Review considers the present clinical results in the field, and identifies and discusses the research questions that have resulted with this technique.

Joint symposium 2009 on carbon ion radiotherapy

The clinical results of carbon ion therapy pioneered in Japan remain promising, especially in a wide range of cancers that are difficult to treat using X-rays. As well as producing impressive tumour control rates, there appears to be a marked reduction in radiation-related toxicity, as would be expected from the advantageous dose distributions. There remain some controversial research-related issues, such as the radiobiological conversion methods, dose fractionation, and which form of accelerator systems and treatment delivery systems should be used. Cost is a major issue, which is being addressed by the use of far fewer treatments than with X-ray therapy. The expansion of this form of treatment in Japan and mainland Europe will provide opportunities for a large research portfolio, which is necessary to optimise this kinder form of radiotherapy.

DNA damage by low-energy ions

Ion-beam irradiation provides a promising treatment for some types of cancer. This promise is due mainly to the selective deposition of energy into a relatively small volume (the Bragg peak), thus reducing damage to healthy tissue. Recent observations that electrons with energies below the ionization potential of DNA can cause covalent damage to the bases and backbone have led to investigations into the ability of low-energy (<1 keV·Da−1) ion beams to damage double-stranded DNA. It has been clearly demonstrated that these low-energy ions induce a mixture of single- and double-strand breaks to dried DNA in vacuo. These effects depend upon the number of ions incident upon the DNA, the kinetic energy of the ions and on their charge state. This DNA damage may be important, as all radiotherapies will result in the production of low-energy secondary ions as radiation passes through tissues. Currently, their effects are neglected in treatment planning, and thus more work is required to quantify and understand DNA damage by low-energy ions.

Radiation therapy for children: evolving technologies in the era of ALARA

The evolution of ever more sophisticated oncologic imaging and technologies providing far more precise radiation therapy have combined to increase the utilization of sophisticated radiation therapy in childhood cancer. For a majority of children with common central nervous system, soft tissue, bone, and dysontogenic neoplasms, local irradiation is fundamental to successful multi-disciplinary management. Along with more precise target volume definition and radiation delivery, new technologies provide added certainty of patient positioning (electronic portal imaging, cone beam CT) and conformality of dose delivery (3-D conformal irradiation, intensity modulated radiation therapy, proton beam therapy). Each of the major areas of technology development are able to better confine the high-dose region to the intended target, but they are also associated with the potential for larger volumes of uninvolved tissues being exposed to low radiation doses. The latter issue plays a role in documented levels of secondary carcinogenesis, sometimes with greater anticipated incidence than that seen in conventional radiation therapy. Parameters related to carcinogenesis, such as dose-volume relationships and neutron contamination that accompanies high-energy photon irradiation and proton therapy, can be identified, sometimes modulated, and accepted as part of the clinical decision process in fine tuning radiation therapy in this more vulnerable age group.

Why more needs to be known about RBE effects in modern radiotherapy

Radiation therapy remains a very effective tool in the clinical management and cure of cancer and new techniques of radiation delivery continue to be developed. Of particular note is the growing world-wide interest in particle beam therapy (PBT) using protons or light ions. Such beams (particularly light ions) are associated with an increased relative biological effectiveness (RBE) which, when viewed alongside the more favourable physical distributions of radiation dose available with all forms of particle beams, makes them especially attractive for treating tumours which are associated with disappointing outcomes following conventional X-ray therapy. Although the large body of clinical experience already gained with conventional X-ray therapy will be of paramount importance in guiding the development of treatment programmes using particle beams, understanding and quantification of the RBE effects which are unique to the latter will also be essential. This is because the magnitude of RBE effect is not fixed for any one radiation/tissue combination but is subject to a number of other radiobiological influences. Such relationships may be quantified within the linear-quadratic radiobiological model, within which the associated concept of biologically effective dose (BED) provides a way of inter-comparing the overall biological impact of existing and projected treatments. This paper summarises the main features of RBE and BED, discusses the main quantitative implications for PBT and highlights why clear understanding of RBE effects will be essential to make best use of PBT. It also summarises other clinical applications where knowledge of and allowance for RBE effects is important and suggests that more needs to be done to allow safer practical applications.

The potential clinical advantages of charged particle radiotherapy using protons or light ions

The increasing use of charged particle radiotherapy (CPT) in many countries will require British oncologists to establish their personal viewpoints on this subject in order to advise their patients regarding the merits or otherwise of obtaining such treatment abroad. This paper covers the advantages and some disadvantages of CPT in many anatomical locations on the basis of the achievable dose distributions as a consequence of the Bragg peak effect. The advantages in terms of normal tissue effects should follow the reduction of tissue volumes exposed to low/moderate dose: significant reductions in acute tissue effects are expected and experienced. For late reacting tissues, the predicted benefits are in the reduction of chronic low-grade symptoms and so improving the quality of life. For tumour control, dose escalation beyond what is achievable with X-ray therapy is possible only for some tumour types. Also, some tumours not presently treated by X-rays can be treated by CPT instead of radical surgery. Many of the available publications about CPT are at 'proof of principle' stage, as the treatment technique continues to be optimised: this is a similar situation to mega-voltage radiotherapy around 50 years ago. Oncologists in the UK need to familiarise themselves with CPT dose distributions, continually educate themselves by following the results of clinical studies as these emerge with time and hopefully visit CPT centres for direct experience.

What are the potential benefits and limitations of particle therapy in the treatment of paediatric malignancies?

The reduction in dose received by normal tissue is essential in radiotherapy to reduce the chance of late side-effects. This is especially true in paediatric radiotherapy as any late-effects can seriously impair the future quality of life experienced by the treated child.

Particle therapy uses high-energy particles to deliver a surgically precise beam of energy to a pre-determined position in the body. Common side-effects associated with conventional radiotherapy (CRT) are considerably reduced, often virtually eliminated, owing to the reduction in dose received by neighbouring healthy tissues, improving future quality of life. The superior accuracy of particles also means the dose can be escalated improving control rates.

Clinical trials, reviews and planning studies have been reviewed to assess the benefits and limitations offered by particle therapy in paediatric treatments. The reduced integral dose and improved conformity is clearly highlighted throughout these studies, demonstrating the potential advantages available with particles when treating paediatric patients.

The data suggest that the advantages experienced with particle therapy result in a significant reduction in the side-effects experienced and therefore an improvement in quality of life when compared with conventional therapy. Owing to the reduction of subsequent sequelae, paediatric patients need to be considered when designing and constructing a particle centre in the UK.

A systematic literature review of the clinical and cost-effectiveness of hadron therapy in cancer

BACKGROUND

In view of the continued increase in the number of hadron (i.e. neutron, proton and light or heavy ion) therapy (HT) centres we performed a systematic literature review to identify reports of the efficacy of HT.

METHODS

Eleven databases were searched systematically. No limit was applied to language or study design. Established experts were contacted for unpublished data. Data on outcomes were extracted and summarised in tabular form.

RESULTS

Seven hundred and seventy three papers were identified. For proton and heavy ion therapy, the number of RCTs was too small to draw firm conclusions. Based on prospective and retrospective studies, proton irradiation emerges as the treatment of choice for some ocular and skull base tumours. For prostate cancer, the results were comparable with those from the best photon therapy series. Heavy ion therapy is still in an experimental phase.

CONCLUSION

Existing data do not suggest that the rapid expansion of HT as a major treatment modality would be appropriate. Further research into the clinical and cost-effectiveness of HT is needed. The formation of a European Hadron Therapy Register would offer a straightforward way of accelerating the rate at which we obtain high-quality evidence that could be used in assessing the role of HT in the management of cancer.

Current status of radiotherapy with proton and light ion beams

Several model studies have shown potential clinical advantages with charged particles (protons and light ions) compared with 3D-conformal radiotherapy (3D-CRT) and intensity-modulated radiotherapy (IMRT) in many disease sites. The newly developed intensity-modulated proton therapy (IMPT) often yields superior dose distributions to photon IMRT, with the added advantage of a significant reduction in the volume of healthy normal tissues exposed to low-to-medium doses. Initially, the major emphasis in clinical research for proton and light ion therapy was dose escalation for inherently radioresistant tumors, or for lesions adjacent to critical normal structures that constrained the dose that could be safely delivered with conventional x-ray therapy. Since the advent of IMRT the interest in particle therapy has gradually shifted toward protocols aimed at morbidity reduction. Lately the emphasis has mostly been placed on the potential for reduced risk of radiation-induced carcinogenesis with protons. Compared with 3D-CRT, a 2-fold increase has been theoretically estimated with the use of IMRT due to the larger integral volumes. In the pediatric setting, due to a higher inherent susceptibility of tissues, the risk could be significant, and the benefits of protons have been strongly emphasized in the literature. There is a significant expansion of particle therapy facilities around the world. Increasing public awareness of the potential benefits of particle therapy and wider accessibility for patients require that treating physicians stay abreast of the clinical indications of this radiotherapy modality. The article reviews the available literature for various disease sites in which particle therapy has traditionally been considered to offer clinical advantages and to highlight current lines of clinical research. The issue of radiation-induced second malignancies is examined in the light of the controversial epidemiological evidence available. The cost-effectiveness of particle therapy is also discussed.

Association of left renal vein variations and pelvic varices in abdominal MDCT

The aim of this study was to determine whether left renal vein (LRV) variation is associated with pelvic varices and left ovarian vein (LOV) reflux. Routine abdominal multidetector-row computed tomography scans of 324 women without symptoms of pelvic congestion syndrome were analyzed. Presence and type of LRV variants (circumaortic [CLRV] or retroaortic [RLRV]) were recorded. Diameters of the LRV, ovarian veins (OVs), and parauterine veins were measured and a specific LRV diameter ratio was calculated for each patient. Presence and severity of pelvic varices and LOV reflux were noted. Pelvic varices were detected in 59 (18%) of the total of 324 women, in 7 (37%) of the 19 women with RLRVs, in 7 (29%) of the 24 women with CLRVs, and in 45 (16%) of the 281 women with normal LRVs. The frequency of pelvic varices in the women with LRV variation was significantly higher than that in the group with normal LRV anatomy (33 vs. 16%; p=0.009). The frequency of pelvic varices in the women with RLRVs was also significantly higher than that in the group with normal LRV anatomy (p=0.02). LRV diameter ratio was correlated with presence of pelvic varices and presence of LOV reflux (p=0.0001 for both). This study revealed an association between pelvic varices and LRV variations in a population of predominantly multiparous women.