Proton therapy special feature: introductory editorial

Proton Therapy in Non-Rhabdomyosarcoma Soft Tissue Sarcomas of Children and Adolescents

This paper provides insights into the use of Proton Beam Therapy (PBT) in pediatric patients with non-rhabdomyosarcoma soft tissue sarcomas (NRSTS). NRSTS are a heterogeneous group of rare and aggressive mesenchymal extraskeletal tumors, presenting complex and challenging clinical management scenarios. The overall survival rate for patients with NRSTS is around 70%, but the outcome is strictly related to the presence of various variables, such as the histological subtype, grade of malignancy and tumor stage at diagnosis. Multimodal therapy is typically considered the preferred treatment for high-grade NRSTS. Radiotherapy plays a key role in the treatment of children and adolescents with NRSTS. However, the potential for radiation-induced side effects partially limits its use. Therefore, PBT represents a very suitable therapeutic option for these patients. The unique depth-dose characteristics of protons can be leveraged to minimize doses to healthy tissue significantly, potentially allowing for increased tumor doses and enhanced preservation of surrounding tissues. These benefits suggest that PBT may improve local control while reducing toxicity and improving quality of life. While clear evidence of therapeutic superiority of PBT over other modern photon techniques in NRSTS is still lacking-partly due to the limited data available-PBT can be an excellent treatment option for young patients with these tumors. A dedicated international comprehensive collaborative approach is essential to better define its role within the multidisciplinary management of NRSTS. Shared guidelines for PBT indications-based on the patient's age, estimated outcome, and tumor location-and centralization in high-level referral centers are needed to optimize the use of resources, since access to PBT remains a challenge due to the limited number of available proton therapy facilities.

Clinical Insight on Proton Therapy for Paediatric Rhabdomyosarcoma

This paper offers an insight into the use of Proton Beam Therapy (PBT) in paediatric patients with rhabdomyosarcoma (RMS). This paper provides a comprehensive analysis of the literature, investigating comparative photon-proton dosimetry, outcome, and toxicity. In the complex and multimodal scenario of the treatment of RMS, clear evidence of the therapeutic superiority of PBT compared to other modern photon techniques has not yet been demonstrated; however, PBT can be considered an excellent treatment option, in particular for young children and patients with specific primary sites, such as the head and neck area (and especially the parameningeal regions), genito-urinary, pelvic, and paravertebral regions. The unique depth-dose characteristics of protons can be exploited to achieve significant reductions in normal tissue doses and may allow an escalation of tumour doses and greater sparing of normal tissues, thus potentially improving local control while at the same time reducing toxicity and improving quality of life. However, access of children with RMS (and more in general with solid tumors) to PBT remains a challenge, due to the limited number of available proton therapy installations.

Clinical Characteristics, Treatment Considerations, and Outcomes of Infants with Rhabdomyosarcoma

RMS most commonly presents in children and adolescents, however a subset of tumors are diagnosed in infants under one year of age. Due to the rarity of infant RMS, utilization of different treatment approaches and goals, and small sample sizes, the published studies of infants with RMS have yielded heterogeneous results. In this review, we discuss the outcomes of infants with RMS treated in various clinical trials and the strategies that various international cooperative groups have employed to reduce the morbidity and mortality related to treatment without compromising the overall survival of this population. This review discusses the unique scenarios of diagnosing and managing congenitals or neonatal RMS, spindle cell RMS and relapsed RMS. This review concludes by exploring novel approaches to diagnosis and management of infants with RMS that are currently being studied by various international cooperative groups.

A Feasibility Study on Proton Range Monitoring Using 13N Peak in Inhomogeneous Targets

Proton irradiations are highly sensitive to spatial variations, mainly due to their high linear energy transfer (LET) and densely ionizing nature. In realistic clinical applications, the targets of ionizing radiation are inhomogeneous in terms of geometry and chemical composition (i.e., organs in the human body). One of the main methods for proton range monitoring is to utilize the production of proton induced positron emitting radionuclides; these could be measured precisely with positron emission tomography (PET) systems. One main positron emitting radionuclide that could be used for proton range monitoring and verification was found to be ¹³N that produces a peak close to the Bragg peak. In the present work, we have employed the Monte Carlo method and Spectral Analysis (SA) technique to investigate the feasibility of utilizing the ¹³N peak for proton range monitoring and verification in inhomogeneous targets. Two different phantom types, namely, (1) ordinary slab and (2) MIRD anthropomorphic phantoms, were used. We have found that the generated ¹³N peak in such highly inhomogeneous targets (ordinary slab and human phantom) is close to the actual Bragg peak, when irradiated by incident proton beam. The feasibility of using the SA technique to estimate the distribution of positron emitter was also investigated. The current findings and the developed tools in the present work would be helpful in proton range monitoring and verification in realistic clinical radiation therapy using proton beams.

Toward automatic beam angle selection for pencil-beam scanning proton liver Treatments: A deep learning-based approach

BACKGROUND

Dose deposition characteristics of proton radiation can be advantageous over photons. Proton treatment planning however poses additional challenges for the planners. Proton therapy is usually delivered with only a small number of beam angles, and the quality of a proton treatment plan is largely determined by the beam angles employed. Finding the optimal beam angles for a proton treatment plan requires time and experience, motivating the investigation of automatic beam angle selection methods.

PURPOSE

A deep learning-based approach to automatic beam angle selection is proposed for proton pencil-beam scanning treatment planning of liver lesions.

METHODS

We cast beam-angle selection as a multi-label classification problem. To account for angular boundary discontinuity, the underlying convolution neural network is trained with the proposed Circular Earth Mover's Distance based regularization and multi-label circular-smooth label technique. Furthermore, an analytical algorithm emulating proton treatment planners' clinical practice is employed in post-processing to improve the output of the model. Forty-nine patients that received proton liver treatments between 2017 and 2020 were randomly divided into training (n = 31), validation (n = 7), and test sets (n = 11). AI-selected beam angles were compared with those angles selected by human planners, and the dosimetric outcome was investigated by creating plans using knowledge-based treatment planning.

RESULTS

For 7 of the 11 cases in the test set, AI-selected beam angles agreed with those chosen by human planners to within 20 degrees (median angle difference = 10°; mean = 18.6°). Moreover, out of the total 22 beam angles predicted by the model, 15 (68%) were within 10 degrees of the human-selected angles. The high correlation in beam angles resulted in comparable dosimetric statistics between proton treatment plans generated using AI- and human-selected angles. For the cases with beam angle differences exceeding 20°, the dosimetric analysis showed similar plan quality although with different emphases on organ-at-risk sparing.

CONCLUSIONS

This pilot study demonstrated the feasibility of a novel deep learning-based beam angle selection technique. Testing on liver cancer patients showed that the resulting plans were clinically viable with comparable dosimetric quality to those using human-selected beam angles. In tandem with auto-contouring and knowledge-based treatment planning tools, the proposed model could represent a pathway for nearly fully automated treatment planning in proton therapy. This article is protected by copyright. All rights reserved.

Proton range monitoring using 13N peak for proton therapy applications

The Monte Carlo method is employed in this study to simulate the proton irradiation of a water-gel phantom. Positron-emitting radionuclides such as ¹¹C, ¹⁵O, and ¹³N are scored using the Particle and Heavy Ion Transport Code System Monte Carlo code package. Previously, it was reported that as a result of ¹⁶O(p,2p2n)¹³N nuclear reaction, whose threshold energy is relatively low (5.660 MeV), a ¹³N peak is formed near the actual Bragg peak. Considering the generated ¹³N peak, we obtain offset distance values between the ¹³N peak and the actual Bragg peak for various incident proton energies ranging from 45 to 250 MeV, with an energy interval of 5 MeV. The offset distances fluctuate between 1.0 and 2.0 mm. For example, the offset distances between the ¹³N peak and the Bragg peak are 2.0, 2.0, and 1.0 mm for incident proton energies of 80, 160, and 240 MeV, respectively. These slight fluctuations for different incident proton energies are due to the relatively stable energy-dependent cross-section data for the ¹⁶O(p,2p2n)¹³N nuclear reaction. Hence, we develop an open-source computer program that performs linear and non-linear interpolations of offset distance data against the incident proton energy, which further reduces the energy interval from 5 to 0.1 MeV. In addition, we perform spectral analysis to reconstruct the ¹³N Bragg peak, and the results are consistent with those predicted from Monte Carlo computations. Hence, the results are used to generate three-dimensional scatter plots of the ¹³N radionuclide distribution in the modeled phantom. The obtained results and the developed methodologies will facilitate future investigations into proton range monitoring for therapeutic applications.

Particle therapy in the future of precision therapy

The first hospital-based treatment facilities for particle therapy started operation about thirty years ago. Since then, the clinical experience with protons and carbon ions has grown continuously and more than 200,000 patients have been treated to date. The promising clinical results led to a rapidly increasing number of treatment facilities and many new facilities are planned or under construction all over the world. An inverted depth-dose profile combined with potential radiobiological advantages make charged particles a precious tool for the treatment of tumours that are particularly radioresistant or located nearby sensitive structures. A rising number of trials have already confirmed the benefits of particle therapy in selected clinical situations and further improvements in beam delivery, image guidance and treatment planning are expected. This review summarises some physical and biological characteristics of accelerated charged particles and gives some examples of their clinical application. Furthermore, challenges and future perspectives of particle therapy will be discussed.