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Nesteruk KP, Bradley SG, Kooy HM, Clasie BM. Beam Position Projection Algorithms in Proton Pencil Beam Scanning. Cancers (Basel) 2024; 16:2098. [PMID: 38893217 PMCID: PMC11171160 DOI: 10.3390/cancers16112098] [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: 04/24/2024] [Revised: 05/24/2024] [Accepted: 05/29/2024] [Indexed: 06/21/2024] Open
Abstract
Beam position uncertainties along the beam trajectory arise from the accelerator, beamline, and scanning magnets (SMs). They can be monitored in real time, e.g., through strip ionization chambers (ICs), and treatments can be paused if needed. Delivery is more reliable and accurate if the beam position is projected from monitored nozzle parameters to the isocenter, allowing for accurate online corrections to be performed. Beam position projection algorithms are also used in post-delivery log file analyses. In this paper, we investigate the four potential algorithms that can be applied to all pencil beam scanning (PBS) nozzles. For some combinations of nozzle configurations and algorithms, however, the projection uses beam properties determined offline (e.g., through beam tuning or technical commissioning). The best algorithm minimizes either the total uncertainty (i.e., offline and online) or the total offline uncertainty in the projection. Four beam position algorithms are analyzed (A1-A4). Two nozzle lengths are used as examples: a large nozzle (1.5 m length) and a small nozzle (0.4 m length). Three nozzle configurations are considered: IC after SM, IC before SM, and ICs on both sides. Default uncertainties are selected for ion chamber measurements, nozzle entrance beam position and angle, and scanning magnet angle. The results for other uncertainties can be determined by scaling these results or repeating the error propagation. We show the propagation of errors from two locations and the SM angle to the isocenter for all the algorithms. The best choice of algorithm depends on the nozzle length and is A1 and A3 for the large and small nozzles, respectively. If the total offline uncertainty is to be minimized (a better choice if the offline uncertainty is not stable), the best choice of algorithm changes to A1 for the small nozzle for some hardware configurations. Reducing the nozzle length can help to reduce the gantry size and make proton therapy more accessible. This work is important for designing smaller nozzles and, consequently, smaller gantries. This work is also important for log file analyses.
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Affiliation(s)
- Konrad P. Nesteruk
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, USA; (K.P.N.); (S.G.B.); (H.M.K.)
- Harvard Medical School, Boston, MA 02115, USA
| | - Stephen G. Bradley
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, USA; (K.P.N.); (S.G.B.); (H.M.K.)
| | - Hanne M. Kooy
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, USA; (K.P.N.); (S.G.B.); (H.M.K.)
- Harvard Medical School, Boston, MA 02115, USA
| | - Benjamin M. Clasie
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, USA; (K.P.N.); (S.G.B.); (H.M.K.)
- Harvard Medical School, Boston, MA 02115, USA
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Fjellanger K, Heijmen BJ, Breedveld S, Sandvik IM, Hysing LB. Comparison of deep inspiration breath hold and free breathing intensity modulated proton therapy of locally advanced lung cancer. Phys Imaging Radiat Oncol 2024; 30:100590. [PMID: 38827886 PMCID: PMC11140793 DOI: 10.1016/j.phro.2024.100590] [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: 02/02/2024] [Revised: 05/14/2024] [Accepted: 05/14/2024] [Indexed: 06/05/2024] Open
Abstract
Background and purpose For locally advanced non-small cell lung cancer (LA-NSCLC), intensity-modulated proton therapy (IMPT) can reduce organ at risk (OAR) doses compared to intensity-modulated radiotherapy (IMRT). Deep inspiration breath hold (DIBH) reduces OAR doses compared to free breathing (FB) in IMRT. In IMPT, differences in dose distributions and robustness between DIBH and FB are unclear. In this study, we compare DIBH to FB in IMPT, and IMPT to IMRT. Materials and methods Fortyone LA-NSCLC patients were prospectively included. 4D computed tomography images (4DCTs) and DIBH CTs were acquired for treatment planning and during weeks 1 and 3 of treatment. A new system for automated robust planning was developed and used to generate a FB and a DIBH IMPT plan for each patient. Plans were compared in terms of dose-volume parameters and normal tissue complication probabilities (NTCPs). Dose recalculations on repeat CTs were used to compare inter-fraction plan robustness. Results In IMPT, DIBH reduced median lungs Dmean from 9.3 Gy(RBE) to 8.0 Gy(RBE) compared to FB, and radiation pneumonitis NTCP from 10.9 % to 9.4 % (p < 0.001). Inter-fraction plan robustness for DIBH and FB was similar. Median NTCPs for radiation pneumonitis and mortality were around 9 percentage points lower with IMPT than IMRT (p < 0.001). These differences were much larger than between FB and DIBH within each modality. Conclusion DIBH IMPT resulted in reduced lung dose and radiation pneumonitis NTCP compared to FB IMPT. Inter-fraction robustness was comparable. OAR doses were far lower in IMPT than IMRT.
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Affiliation(s)
- Kristine Fjellanger
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
- Institute of Physics and Technology, University of Bergen, Bergen, Norway
| | - Ben J.M. Heijmen
- Department of Radiotherapy, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sebastiaan Breedveld
- Department of Radiotherapy, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Inger Marie Sandvik
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Liv B. Hysing
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
- Institute of Physics and Technology, University of Bergen, Bergen, Norway
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Weiß A, Löck S, Xu T, Liao Z, Hoffmann AL, Troost EGC. Prediction of radiation pneumonitis using the effective α/β of lungs and heart in NSCLC patients treated with proton beam therapy. Radiother Oncol 2024; 190:110013. [PMID: 37972734 DOI: 10.1016/j.radonc.2023.110013] [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: 09/27/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE Radiation pneumonitis (RP) remains a major complication in non-small cell lung cancer (NSCLC) patients undergoing radiochemotherapy (RCHT). Traditionally, the mean lung dose (MLD) and the volume of the total lung receiving at least 20 Gy (V20Gy) are used to predict RP in patients treated with normo-fractionated photon therapy. However, other models, including the actual dose-distribution in the lungs using the effective α/β model or a combination of radiation doses to the lungs and heart, have been proposed for predicting RP. Moreover, the models established for photons may not hold for patients treated with passively-scattered proton therapy (PSPT). Therefore, we here tested and validated novel predictive parameters for RP in NSCLC patient treated with PSPT. METHODS Data on the occurrence of RP, structure files and dose-volume histogram parameters for lungs and heart of 96 NSCLC patients, treated with PSPT and concurrent chemotherapy, was retrospectively retrieved from prospective clinical studies of two international centers. Data was randomly split into a training set (64 patients) and a validation set (32 patients). Statistical analyses were performed using binomial logistic regression. RESULTS The biologically effective dose (BED) of the'lungs - GTV' significantly predicted RP ≥ grade 2 in the training-set using both a univariate model (p = 0.019, AUCtrain = 0.72) and a multivariate model in combination with the effective α/β parameter of the heart (pBED = 0.006, [Formula: see text] = 0.043, AUCtrain = 0.74). However, these results did not hold in the validation-set (AUCval = 0.52 andAUCval = 0.50, respectively). Moreover, these models were found to neither outperform a model built with the MLD (p = 0.015, AUCtrain = 0.73, AUCval = 0.51), nor a multivariate model additionally including the V20Gy of the heart (pMLD = 0.039, pV20Gy,heart = 0.58, AUCtrain = 0.74, AUCval = 0.53). CONCLUSION Using the effective α/β parameter of the lungs and heart we achieved similar performance to commonly used models built for photon therapy, such as MLD, in predicting RP ≥ grade 2. Therefore, prediction models developed for photon RCHT still hold for patients treated with PSPT.
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Affiliation(s)
- Albrecht Weiß
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
| | - Steffen Löck
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Ting Xu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Aswin L Hoffmann
- OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology-OncoRay, Dresden, Germany
| | - Esther G C Troost
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, Helmholtz Association/Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany; Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology-OncoRay, Dresden, Germany.
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Jin Y, Shimizu S, Li Y, Yao Y, Liu X, Si H, Sakurai H, Xiao W. Proton therapy (PT) combined with concurrent chemotherapy for locally advanced non-small cell lung cancer with negative driver genes. Radiat Oncol 2023; 18:189. [PMID: 37974211 PMCID: PMC10652584 DOI: 10.1186/s13014-023-02372-8] [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: 10/06/2023] [Accepted: 10/30/2023] [Indexed: 11/19/2023] Open
Abstract
PURPOSE To discuss the optimal treatment modality for inoperable locally advanced Non-Small Cell Lung Cancer patients with poor physical status, impaired cardio-pulmonary function, and negative driver genes, and provide clinical evidence. MATERIALS AND METHODS Retrospective analysis of 62 cases of locally advanced non-small cell lung cancer patients with negative driver genes treated at Tsukuba University Hospital(Japan) and Qingdao University Affiliated Hospital(China).The former received proton therapy with concurrent chemotherapy, referred to as the proton group, with 25 cases included; while the latter underwent X-ray therapy with concurrent chemoradiotherapy followed by 1 year of sequential immunomodulatory maintenance therapy, referred to as the X-ray group, with 37 cases included.The treatment response and adverse reactions were assessed using RECIST v1.1 criteria and CTCAE v3.0, and radiotherapy planning and evaluation of organs at risk were performed using the CB-CHOP method.All data were subjected to statistical analysis using GraphPad Prism v9.0, with a T-test using P < 0.05 considered statistically significant. RESULTS (1)Target dose distribution: compared to the X-ray group, the proton group exhibited smaller CTV and field sizes, with a more pronounced bragg peak.(2)Organs at risk dose: When comparing the proton group to the X-ray group, lung doses (V5, V20, MLD) and heart doses (V40, Dmax) were lower, with statistical significance (P < 0.05), while spinal cord and esophagus doses showed no significant differences between the two groups (P > 0.05).(3)Treatment-related toxicities: The incidence of grade 3 or higher adverse events in the proton group and X-ray group was 28.6% and 4.2%, respectively, with a statistically significant difference (P < 0.05). In terms of the types of adverse events, the proton group primarily experienced esophagitis and pneumonia, while the X-ray group primarily experienced pneumonia, esophagitis, and myocarditis. Both groups did not experience radiation myelitis or esophagotracheal fistula.(4)Efficacy evaluation: The RR in the proton group and X-ray group was 68.1% and 70.2%, respectively (P > 0.05), and the DCR was 92.2% and 86.4%, respectively (P > 0.05), indicating no significant difference in short-term efficacy between the two treatment modalities.(5)Survival status: The PFS in the proton group and X-ray group was 31.6 ± 3.5 months (95% CI: 24.7 ~ 38.5) and 24.9 ± 1.55 months (95% CI: 21.9 ~ 27.9), respectively (P > 0.05), while the OS was 51.6 ± 4.62 months (95% CI: 42.5 ~ 60.7) and 33.1 ± 1.99 months (95% CI: 29.2 ~ 37.1), respectively (P < 0.05).According to the annual-specific analysis, the PFS rates for the first to third years in both groups were as follows: 100%, 56.1% and 32.5% for the proton group vs. 100%, 54.3% and 26.3% for the X-ray group. No statistical differences were observed at each time point (P > 0.05).The OS rates for the first to third years in both groups were as follows: 100%, 88.2%, 76.4% for the proton group vs. 100%, 91.4%, 46.3% for the X-ray group. There was no significant difference in the first to second years (P > 0.05), but the third year showed a significant difference (P < 0.05). Survival curve graphs also depicted a similar trend. CONCLUSION There were no significant statistical differences observed between the two groups in terms of PFS and OS within the first two years. However, the proton group demonstrated a clear advantage over the X-ray group in terms of adverse reactions and OS in the third year. This suggests a more suitable treatment modality and clinical evidence for populations with frail health, compromised cardio-pulmonary function, post-COVID-19 sequelae, and underlying comorbidities.
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Affiliation(s)
- Yonglong Jin
- Department of Radiotherapy, The Affiliated Hospital of Qingdao University, Qingdao, China
- School of Public Health, Qingdao University, Qingdao, China
| | - Shosei Shimizu
- Department of Radiation Oncology, University of Tsukuba Hospital, Tsukuba, Japan
- Department of Radiotherapy, YIZHOU Cancer Hospital, Qingdao, China
| | - Yinuo Li
- Department of Radiation Oncology, University of Tsukuba Hospital, Tsukuba, Japan
| | - Yuan Yao
- Graduate School of Environmental Science, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Xiguang Liu
- Department of Radiotherapy, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Hongzong Si
- School of Public Health, Qingdao University, Qingdao, China
| | - Hideyuki Sakurai
- Department of Radiation Oncology, University of Tsukuba Hospital, Tsukuba, Japan.
| | - Wenjing Xiao
- Department of Radiotherapy, The Affiliated Hospital of Qingdao University, Qingdao, China.
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Xiang L, Ren PR, Li HX, Ye H, Pang HW, Wen QL, Zhang JW, He LJH, Shang CL, Yang BY, Lin SL, Wu JBW. Effect of 3-Dimensional Interstitial High-Dose-Rate Brachytherapy With Regional Metastatic Lymph Node Intensity-Modulated Radiation Therapy in Locally Advanced Peripheral Non-Small Cell Lung Cancer: 5-Year Follow-up of a Phase 2 Clinical Trial. Int J Radiat Oncol Biol Phys 2023; 115:347-355. [PMID: 35901979 DOI: 10.1016/j.ijrobp.2022.07.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/29/2022] [Accepted: 07/16/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE We aimed to reveal the 5-year clinical outcomes of 3-dimensional (3D) interstitial high-dose-rate (HDR) brachytherapy with regional metastatic lymph node intensity modulated radiation therapy (IMRT) for locally advanced peripheral non-small cell lung cancer (NSCLC), which has been shown to have low toxicity and improved 2-year survival rates in patients with this disease. METHODS AND MATERIALS In this phase 2, single-arm, open-label clinical trial, 83 patients with locally advanced peripheral NSCLC were enrolled (median follow-up [range], 53.7 [4.3-120.4] months). All eligible patients received 3D interstitial HDR brachytherapy with regional metastatic lymph node IMRT. The primary endpoint was overall survival (OS). Secondary endpoints were local recurrence-free survival, regional recurrence-free survival, progression-free survival, distant metastasis-free survival, toxicities, and quality of life. RESULTS The final analysis included 75 patients (19 [25.3%] females, 56 [74.7%] males; median [range] age, 64 [44-80] years; stage IIIA, 34 [45.3%]; stage IIIB, 41 [54.7%]). At the latest follow-up, 32 (42.7%) patients had survived. The median OS was 38.0 months (5-year OS, 44.5%; 95% confidence interval [CI], 33.8%-58.6%). Local recurrence-free survival, recurrence-free survival, and distant metastasis-free survival at 5 years were 79.2% (95% CI, 68.5%-91.5%), 73.6% (95% CI, 61.5%-88.1%), and 50.3% (95% CI, 38.3%-66.1%), respectively. The dominant failure pattern was distant disease, corresponding to 40% (30 of 75) of patients and 65.2% (30 of 46) of all failures. Two (2.7%) patients developed grade 1 acute pneumonitis. Grade 2 and 3 acute esophagitis occurred in 11 (14.7%) and 4 (5.3%) patients, respectively. No late radiation-related grade ≥2 late adverse events were observed. CONCLUSIONS 3D interstitial HDR brachytherapy with regional metastatic lymph node IMRT for locally advanced peripheral NSCLC shows significant OS and has a low toxicity rate. Additional evaluation in a phase 3 trial is recommended to substantiate these findings.
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Affiliation(s)
- Li Xiang
- Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Pei-Rong Ren
- Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Hong-Xia Li
- Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Hua Ye
- Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Hao-Wen Pang
- Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Qing-Lian Wen
- Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jian-Wen Zhang
- Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Li-Jia He He
- Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Chang-Ling Shang
- Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Bo Yang Yang
- Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Sheng Lin Lin
- Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, China.
| | - Jing-Bo Wu Wu
- Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, China.
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Cunningham C, Bolcaen J, Bisio A, Genis A, Strijdom H, Vandevoorde C. Recombinant Endostatin as a Potential Radiosensitizer in the Treatment of Non-Small Cell Lung Cancer. Pharmaceuticals (Basel) 2023; 16:219. [PMID: 37259367 PMCID: PMC9961924 DOI: 10.3390/ph16020219] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/22/2023] [Accepted: 01/24/2023] [Indexed: 11/03/2023] Open
Abstract
Non-small cell lung cancer (NSCLC) is the most prevalent type of lung cancer, which is the leading cause of cancer-related deaths worldwide. Over the past decades, tumour angiogenesis has been intensely studied in the treatment of NSCLC due to its fundamental role in cancer progression. Several anti-angiogenic drugs, such as recombinant endostatin (RE), have been evaluated in several preclinical and clinical trials, with mixed and often disappointing results. However, there is currently an emerging interest in RE due to its ability to create a vascular normalization window, which could further improve treatment efficacy of the standard NSCLC treatment. This review provides an overview of preclinical and clinical studies that combined RE and radiotherapy for NSCLC treatment. Furthermore, it highlights the ongoing challenges that have to be overcome in order to maximize the benefit; as well as the potential advantage of combinations with particle therapy and immunotherapy, which are rapidly gaining momentum in the treatment landscape of NSCLC. Different angiogenic and immunosuppressive effects are observed between particle therapy and conventional X-ray radiotherapy. The combination of RE, particle therapy and immunotherapy presents a promising future therapeutic triad for NSCLC.
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Affiliation(s)
- Charnay Cunningham
- Centre for Cardio-Metabolic Research in Africa (CARMA), Division of Medical Physiology, Stellenbosch University, Cape Town 7602, South Africa
- Radiation Biophysics Division, SSC Laboratory, NRF Ithemba LABS, Cape Town 7131, South Africa
| | - Julie Bolcaen
- Radiation Biophysics Division, SSC Laboratory, NRF Ithemba LABS, Cape Town 7131, South Africa
| | - Alessandra Bisio
- Department of Cellular, Computational and Integrative Biology—CIBIO, University of Trento, 38123 Trento, Italy
| | - Amanda Genis
- Centre for Cardio-Metabolic Research in Africa (CARMA), Division of Medical Physiology, Stellenbosch University, Cape Town 7602, South Africa
| | - Hans Strijdom
- Centre for Cardio-Metabolic Research in Africa (CARMA), Division of Medical Physiology, Stellenbosch University, Cape Town 7602, South Africa
| | - Charlot Vandevoorde
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung, Planckstr. 1, 64291 Darmstadt, Germany
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Current Landscape of Therapeutic Resistance in Lung Cancer and Promising Strategies to Overcome Resistance. Cancers (Basel) 2022; 14:cancers14194562. [PMID: 36230484 PMCID: PMC9558974 DOI: 10.3390/cancers14194562] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/12/2022] [Accepted: 09/15/2022] [Indexed: 02/06/2023] Open
Abstract
Simple Summary Despite an initial response to therapy, many lung cancer patients inevitably develop resistance to therapy leading to decreased duration of response and success of treatment. Recent research aims to elucidate mechanisms of resistance in order to improve drug response and treatment outcomes. By utilizing multidisciplinary approaches that target various resistance mechanism, it may be possible to delay development of treatment resistance or even resensitize cancers. This review aims to discuss novel approaches to improve clinical outcomes, delay the occurrence of resistance, and overcome resistance. Abstract Lung cancer is one of the leading causes of cancer-related deaths worldwide with a 5-year survival rate of less than 18%. Current treatment modalities include surgery, chemotherapy, radiation therapy, targeted therapy, and immunotherapy. Despite advances in therapeutic options, resistance to therapy remains a major obstacle to the effectiveness of long-term treatment, eventually leading to therapeutic insensitivity, poor progression-free survival, and disease relapse. Resistance mechanisms stem from genetic mutations and/or epigenetic changes, unregulated drug efflux, tumor hypoxia, alterations in the tumor microenvironment, and several other cellular and molecular alterations. A better understanding of these mechanisms is crucial for targeting factors involved in therapeutic resistance, establishing novel antitumor targets, and developing therapeutic strategies to resensitize cancer cells towards treatment. In this review, we summarize diverse mechanisms driving resistance to chemotherapy, radiotherapy, targeted therapy, and immunotherapy, and promising strategies to help overcome this therapeutic resistance.
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Substantial Sparing of Organs at Risk with Modern Proton Therapy in Lung Cancer, but Altered Breathing Patterns Can Jeopardize Target Coverage. Cancers (Basel) 2022; 14:cancers14061365. [PMID: 35326516 PMCID: PMC8945974 DOI: 10.3390/cancers14061365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/01/2022] [Accepted: 03/04/2022] [Indexed: 02/06/2023] Open
Abstract
Simple Summary Treatment of locally advanced non-small cell lung cancer (LA-NSCLC) is a fine balance between toxicity and cure. Modern proton therapy might offer a more gentle radiation treatment compared to state-of-the-art photon radiotherapy, but is also more susceptible to the influence of breathing motion and anatomical changes. In this study, the influence of such uncertainties on treatment delivery was thoroughly investigated. Modern proton therapy did indeed show potential to reduce the risk of toxicity for the heart and lungs. This potential was maintained under the influence of anatomical and delivery uncertainties. However, changes in breathing motion jeopardized the target dose distribution in a subset of patients. We therefore recommend imaging at onset or early in treatment to recognize these patients and adapt the treatment. Abstract Enhancing treatment of locally advanced non-small cell lung cancer (LA-NSCLC) by using pencil beam scanning proton therapy (PBS-PT) is attractive, but little knowledge exists on the effects of uncertainties occurring between the planning (Plan) and the start of treatment (Start). In this prospective simulation study, we investigated the clinical potential for PBS-PT under the influence of such uncertainties. Imaging with 4DCT at Plan and Start was carried out for 15 patients that received state-of-the-art intensity-modulated radiotherapy (IMRT). Three PBS-PT plans were created per patient: 3D robust single-field uniform dose (SFUD), 3D robust intensity-modulated proton therapy (IMPT), and 4D robust IMPT (4DIMPT). These were exposed to setup and range uncertainties and breathing motion at Plan, and changes in breathing motion and anatomy at Start. Target coverage and dose-volume parameters relevant for toxicity were compared. The organ at risk sparing at Plan was greatest with IMPT, followed by 4DIMPT, SFUD and IMRT, and persisted at Start. All plans met the preset criteria for target robustness at Plan. At Start, three patients had a lack of CTV coverage with PBS-PT. In conclusion, the clinical potential for heart and lung toxicity reduction with PBS-PT was substantial and persistent. Altered breathing patterns between Plan and Start jeopardized target coverage for all PBS-PT techniques.
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Bainbridge H, Dunlop A, McQuaid D, Gulliford S, Gunapala R, Ahmed M, Locke I, Nill S, Oelfke U, McDonald F. A Comparison of Isotoxic Dose-escalated Radiotherapy in Lung Cancer with Moderate Deep Inspiration Breath Hold, Mid-ventilation and Internal Target Volume Techniques. Clin Oncol (R Coll Radiol) 2022; 34:151-159. [PMID: 34503896 DOI: 10.1016/j.clon.2021.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 07/31/2021] [Accepted: 08/23/2021] [Indexed: 12/25/2022]
Abstract
AIMS With interest in normal tissue sparing and dose-escalated radiotherapy in the treatment of inoperable locally advanced non-small cell lung cancer, this study investigated the impact of motion-managed moderate deep inspiration breath hold (mDIBH) on normal tissue sparing and dose-escalation potential and compared this to planning with a four-dimensional motion-encompassing internal target volume or motion-compensating mid-ventilation approach. MATERIALS AND METHODS Twenty-one patients underwent four-dimensional and mDIBH planning computed tomography scans. Internal and mid-ventilation target volumes were generated on the four-dimensional scan, with mDIBH target volumes generated on the mDIBH scan. Isotoxic target dose-escalation guidelines were used to generate six plans per patient: three with a target dose cap and three without. Target dose-escalation potential, normal tissue complication probability and differences in pre-specified dose-volume metrics were evaluated for the three motion-management techniques. RESULTS The mean total lung volume was significantly greater with mDIBH compared with four-dimensional scans. Lung dose (mean and V21 Gy) and mean heart dose were significantly reduced with mDIBH in comparison with four-dimensional-based approaches, and this translated to a significant reduction in heart and lung normal tissue complication probability with mDIBH. In 20/21 patients, the trial target prescription dose cap of 79.2 Gy was achievable with all motion-management techniques. CONCLUSION mDIBH aids lung and heart dose sparing in isotoxic dose-escalated radiotherapy compared with four-dimensional planning techniques. Given concerns about lung and cardiac toxicity, particularly in an era of consolidation immunotherapy, reduced normal tissue doses may be advantageous for treatment tolerance and outcome.
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Affiliation(s)
- H Bainbridge
- Department of Radiotherapy at The Royal Marsden NHS Foundation Trust, Sutton, UK; The Institute of Cancer Research, London, UK
| | - A Dunlop
- Joint Department of Physics at The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, UK
| | - D McQuaid
- Joint Department of Physics at The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, UK
| | - S Gulliford
- Joint Department of Physics at The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, UK
| | - R Gunapala
- Department of Statistics at The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - M Ahmed
- Department of Radiotherapy at The Royal Marsden NHS Foundation Trust, Sutton, UK; The Institute of Cancer Research, London, UK
| | - I Locke
- Department of Radiotherapy at The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - S Nill
- Joint Department of Physics at The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, UK
| | - U Oelfke
- Joint Department of Physics at The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, UK
| | - F McDonald
- Department of Radiotherapy at The Royal Marsden NHS Foundation Trust, Sutton, UK; The Institute of Cancer Research, London, UK.
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10
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Loap P, Tkatchenko N, Goudjil F, Ribeiro M, Baron B, Fourquet A, Kirova Y. Cardiac substructure exposure in breast radiotherapy: a comparison between intensity modulated proton therapy and volumetric modulated arc therapy. Acta Oncol 2021; 60:1038-1044. [PMID: 33788665 DOI: 10.1080/0284186x.2021.1907860] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Proton therapy for breast cancer treatment reduces cardiac radiation exposure. Left-sided breast cancer patients with indication for internal mammary chain (IMC) irradiation are most at risk of radiation-induced cardiotoxicity. This study aims to evaluate in this situation the potential dosimetric benefit of intensity modulated proton therapy (IMPT) over volumetric modulated arc therapy (VMAT) at the cardiac substructure level. MATERIALS AND METHODS Cardiac substructures were retrospectively delineated according to ESTRO guidelines on the simulation CT scans of fourteen left-sided breast cancer patients having undergone conserving surgery and adjuvant locoregional free-breathing (FB-) or deep inspiration breath-hold (DIBH-) VMAT with internal mammary chain irradiation. IMPT treatment was re-planned on the simulation CT scans. Mean doses to cardiac substructures were retrieved and compared between VMAT treatment plans and IMPT simulation plans. Pearson correlation coefficients were calculated between mean doses delivered to cardiac substructures using these two techniques. RESULTS Mean doses to all cardiac substructures were significantly lower with IMPT than with VMAT. Regardless of the irradiation technique, the most exposed cardiac substructure was the mid segment of the left anterior descending coronary artery (LADCA). Pearson correlation coefficients between mean doses to cardiac substructures were usually weak and statistically non-significant for IMPT; mean heart dose (MHD) only correlated with mean doses delivered to the right ventricle, to the mid segment of the right coronary artery (RCA) and, to a lesser extent, to the LADCA. CONCLUSION The dosimetric benefit of IMPT over conformal photon therapy was consistently observed for all cardiac substructures. MHD may not be a reliable dosimetric parameter for precise cardiac exposure evaluation when planning IMPT.
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Affiliation(s)
- Pierre Loap
- Institut Curie, Department of Radiation Oncology, Paris, France
| | | | - Farid Goudjil
- Institut Curie, Department of Radiation Oncology, Paris, France
| | - Madison Ribeiro
- Institut Curie, Department of Radiation Oncology, Paris, France
| | - Brian Baron
- Institut Curie, Department of Radiation Oncology, Paris, France
| | - Alain Fourquet
- Institut Curie, Department of Radiation Oncology, Paris, France
| | - Youlia Kirova
- Institut Curie, Department of Radiation Oncology, Paris, France
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11
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Flatten V, Burg JM, Witt M, Derksen L, Fragoso Costa P, Wulff J, Bäumer C, Timmermann B, Weber U, Vorwerk H, Engenhart-Cabillic R, Zink K, Baumann KS. Estimating the modulating effect of lung tissue in particle therapy using a clinical CT voxel histogram analysis. Phys Med Biol 2021; 66. [PMID: 34298533 DOI: 10.1088/1361-6560/ac176e] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 07/23/2021] [Indexed: 11/12/2022]
Abstract
To treat lung tumours with particle therapy, different additional tasks and challenges in treatment planning and application have to be addressed thoroughly. One of these tasks is the quantification and consideration of the Bragg peak degradation due to lung tissue: As lung is an heterogeneous tissue, the Bragg peak is broadened when particles traverse the microscopic alveoli. These are not fully resolved in clinical CT images and thus, the effect is not considered in the dose calculation. In this work, a correlation between the CT histograms of heterogeneous material and the impact on the Bragg peak curve is presented. Different inorganic materials were scanned with a conventional CT scanner and additionally, the Bragg peak degradation was measured in a proton beam and was then quantified. A model is proposed that allows an estimation of the modulation power by performing a histogram analysis on the CT scan. To validate the model for organic samples, a second measurement series was performed with frozen porcine lunge samples. This allows to investigate the possible limits of the proposed model in a set-up closer to clinical conditions. For lung substitutes, the agreement between model and measurement is within ±0.05 mm and for the organic lung samples, within ±0.15 mm. This work presents a novel, simple and efficient method to estimate if and how much a material or a distinct region (within the lung) is degrading the Bragg peak on the basis of a common clinical CT image. Up until now, only a direct in-beam measurement of the region or material of interest could answer this question.
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Affiliation(s)
- Veronika Flatten
- Department of Radiotherapy and Radiooncology, University Hospital of Giessen and Marburg Campus Marburg, Marburg, GERMANY
| | - Jan Michael Burg
- , University of Applied Sciences, Institute of Medical Physics and Radiation Protection, Giessen, GERMANY
| | - Matthias Witt
- Department of Radiotherapy and Radiooncology, University Hospital of Giessen and Marburg Campus Marburg, Marburg, GERMANY
| | - Larissa Derksen
- , University of Applied Sciences, Institute of Medical Physics and Radiation Protection, Giessen, GERMANY
| | | | - Jörg Wulff
- Medical Physics, Westdeutsches Protonentherapiezentrum Essen gGmbH, Essen, GERMANY
| | | | - Beate Timmermann
- Deparment of Particle Therapy, University Hospital Essen, Essen, GERMANY
| | - Uli Weber
- , GSI Helmholtzzentrum fur Schwerionenforschung GmbH, Darmstadt, Hessen, GERMANY
| | - Hilke Vorwerk
- Department of Radiotherapy and Radiooncology, University Medical Center Giessen-Marburg, Marburg, GERMANY
| | - Rita Engenhart-Cabillic
- University Medical Center Giessen-Marburg, Department of Radiotherapy and Radiooncology, Marburg, GERMANY
| | - Klemens Zink
- University Medical Center Giessen-Marburg, Department of Radiotherapy and Radiooncology, Marburg, GERMANY
| | - Kilian-Simon Baumann
- Department of Radiotherapy and Radiooncology, University Medical Center Giessen-Marburg, Marburg, GERMANY
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12
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Paganetti H, Grassberger C, Sharp GC. Physics of Particle Beam and Hypofractionated Beam Delivery in NSCLC. Semin Radiat Oncol 2021; 31:162-169. [PMID: 33610274 PMCID: PMC7905707 DOI: 10.1016/j.semradonc.2020.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The dosimetric advantages of particle therapy lead to significantly reduced integral dose to normal tissues, making it an attractive treatment option for body sites such as the thorax. With reduced normal tissue dose comes the potential for dose escalation, toxicity reduction, or hypofractionation. While proton and heavy ion therapy have been used extensively for NSCLC, there are challenges in planning and delivery compared with X-ray-based radiation therapy. Particularly, range uncertainties compounded by breathing motion have to be considered. This article summarizes the current state of particle therapy for NSCLC with a specific focus on the impact of dosimetric uncertainties in planning and delivery.
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Affiliation(s)
- Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
| | - Clemens Grassberger
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Gregory C Sharp
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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13
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Nenoff L, Matter M, Amaya EJ, Josipovic M, Knopf AC, Lomax AJ, Persson GF, Ribeiro CO, Visser S, Walser M, Weber DC, Zhang Y, Albertini F. Dosimetric influence of deformable image registration uncertainties on propagated structures for online daily adaptive proton therapy of lung cancer patients. Radiother Oncol 2021; 159:136-143. [PMID: 33771576 DOI: 10.1016/j.radonc.2021.03.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 03/14/2021] [Accepted: 03/15/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE A major burden of introducing an online daily adaptive proton therapy (DAPT) workflow is the time and resources needed to correct the daily propagated contours. In this study, we evaluated the dosimetric impact of neglecting the online correction of the propagated contours in a DAPT workflow. MATERIAL AND METHODS For five NSCLC patients with nine repeated deep-inspiration breath-hold CTs, proton therapy plans were optimised on the planning CT to deliver 60 Gy-RBE in 30 fractions. All repeated CTs were registered with six different clinically used deformable image registration (DIR) algorithms to the corresponding planning CT. Structures were propagated rigidly and with each DIR algorithm and reference structures were contoured on each repeated CT. DAPT plans were optimised with the uncorrected, propagated structures (propagated DAPT doses) and on the reference structures (ideal DAPT doses), non-adapted doses were recalculated on all repeated CTs. RESULTS Due to anatomical changes occurring during the therapy, the clinical target volume (CTV) coverage of the non-adapted doses reduces on average by 9.7% (V95) compared to an ideal DAPT doses. For the propagated DAPT doses, the CTV coverage was always restored (average differences in the CTV V95 < 1% compared to the ideal DAPT doses). Hotspots were always reduced with any DAPT approach. CONCLUSION For the patients presented here, a benefit of online DAPT was shown, even if the daily optimisation is based on propagated structures with some residual uncertainties. However, a careful (offline) structure review is necessary and corrections can be included in an offline adaption.
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Affiliation(s)
- Lena Nenoff
- Paul Scherrer Institute, Center for Proton Therapy, Switzerland; Department of Physics, ETH Zurich, Switzerland.
| | - Michael Matter
- Paul Scherrer Institute, Center for Proton Therapy, Switzerland; Department of Physics, ETH Zurich, Switzerland
| | | | - Mirjana Josipovic
- Department of Oncology, Rigshospitalet Copenhagen University Hospital, Denmark
| | - Antje-Christin Knopf
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Antony John Lomax
- Paul Scherrer Institute, Center for Proton Therapy, Switzerland; Department of Physics, ETH Zurich, Switzerland
| | - Gitte F Persson
- Department of Oncology, Rigshospitalet Copenhagen University Hospital, Denmark; Department of Oncology, Herlev-Gentofte Hospital Copenhagen University Hospital, Denmark; Department of Clinical Medicine, Faculty of Medical Sciences, University of Copenhagen, Denmark
| | - Cássia O Ribeiro
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Sabine Visser
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Marc Walser
- Paul Scherrer Institute, Center for Proton Therapy, Switzerland
| | - Damien Charles Weber
- Paul Scherrer Institute, Center for Proton Therapy, Switzerland; Department of Radiation Oncology, University Hospital Zurich, Switzerland; Department of Radiation Oncology, University Hospital Bern, Switzerland
| | - Ye Zhang
- Paul Scherrer Institute, Center for Proton Therapy, Switzerland
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14
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Gjyshi O, Xu T, Elhammali A, Boyce-Fappiano D, Chun SG, Gandhi S, Lee P, Chen AB, Lin SH, Chang JY, Tsao A, Gay CM, Zhu XR, Zhang X, Heymach JV, Fossella FV, Lu C, Nguyen QN, Liao Z. Toxicity and Survival After Intensity-Modulated Proton Therapy Versus Passive Scattering Proton Therapy for NSCLC. J Thorac Oncol 2021; 16:269-277. [PMID: 33198942 PMCID: PMC7855203 DOI: 10.1016/j.jtho.2020.10.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/07/2020] [Accepted: 10/09/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Although intensity-modulated radiation therapy (IMPT) is dosimetrically superior to passive scattering proton therapy (PSPT) for locally advanced NSCLC (LA-NSCLC), direct comparisons of clinical outcomes are lacking. Here, we compare toxicity profiles and clinical outcomes after IMPT versus PSPT for LA-NSCLC. METHODS This is a nonrandomized, comparative study of two independent cohorts with LA-NSCLC (stage II-IIIB, stage IV with solitary brain metastasis) treated with concurrent chemotherapy and proton beam therapy. Toxicity (Common Terminology Criteria for Adverse Events version 4.0) and outcomes were prospectively collected as part of a clinical trial (ClinicalTrials.gov identifier NCT00915005) or prospective registry (ClinicalTrials.gov identifier NCT00991094). RESULTS Of 139 patients, 86 (62%) received PSPT and 53 (38%) IMPT; median follow-up times were 23.9 and 29.0 months, respectively. IMPT delivered lower mean radiation doses to the lungs (PSPT 16.0 Gy versus IMPT 13.0 Gy, p < 0.001), heart (10.7 Gy versus 6.6 Gy, p = 0.004), and esophagus (27.4 Gy versus 21.8 Gy, p = 0.005). Consequently, the IMPT cohort had lower rates of grade 3 or higher pulmonary (17% versus 2%, p = 0.005) and cardiac (11% versus 0%, p = 0.01) toxicities. Six patients (7%) with PSPT and zero patients (0%) with IMPT experienced grade 4 or 5 toxicity. Lower rates of pulmonary (28% versus 3%, p = 0.006) and cardiac (14% versus 0%, p = 0.05) toxicities were observed in the IMPT cohort even after propensity score matching for baseline imbalances. There was also a trend toward longer median overall survival in the IMPT group (23.9 mo versus 36.2 mo, p = 0.09). No difference was found in the 3-year rates of local (25% versus 20%, p = 0.44), local-regional (29% versus 36%, p = 0.56) and distant (52% versus 51%, p = 0.71) recurrences. CONCLUSIONS IMPT is associated with lower radiation doses to the lung, heart, and esophagus, and lower rates of grade 3 or higher cardiopulmonary toxicity; additional clinical studies will be needed to assess the potential differences in survival between the two techniques.
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Affiliation(s)
- Olsi Gjyshi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ting Xu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Adnan Elhammali
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David Boyce-Fappiano
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stephen G Chun
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Saumil Gandhi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Percy Lee
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Aileen B Chen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joe Y Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Anne Tsao
- Department of Thoracic-Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Carl M Gay
- Department of Thoracic-Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - X Ronald Zhu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Xiaodong Zhang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - John V Heymach
- Department of Thoracic-Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Frank V Fossella
- Department of Thoracic-Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Charles Lu
- Department of Thoracic-Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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15
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Held KD, Lomax AJ, Troost EGC. Proton therapy special feature: introductory editorial. Br J Radiol 2020; 93:20209004. [PMID: 32081045 DOI: 10.1259/bjr.20209004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Kathryn D Held
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Antony J Lomax
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland.,Department of Physics, ETH Zürich, Zürich, Switzerland
| | - Esther G C Troost
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,OncoRay - National Center for Radiation Research in Oncology, Dresden, Germany
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