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Zhang T, Stengl C, Derksen L, Palskis K, Koritsidis K, Zink K, Adeberg S, Major G, Weishaar D, Theiß U, Jin J, Spadea MF, Theodoridou E, Hesser J, Baumann KS, Seco J. Analysis of hydrogen peroxide production in pure water: Ultrahigh versus conventional dose-rate irradiation and mechanistic insights. Med Phys 2024. [PMID: 39092902 DOI: 10.1002/mp.17335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 07/16/2024] [Accepted: 07/16/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND Ultrahigh dose-rate radiation (UHDR) produces less hydrogen peroxide (H2O2) in pure water, as suggested by some experimental studies, and is used as an argument for the validity of the theory that FLASH spares the normal tissue due to less reactive oxygen species (ROS) production. In contrast, most Monte Carlo simulation studies suggest the opposite. PURPOSE We aim to unveil the effect of UHDR on H2O2 production in pure water and its underlying mechanism, to serve as a benchmark for Monte Carlo simulation. We hypothesized that the reaction of solvated electrons (e aq - ${\mathrm{e}}_{{\mathrm{aq}}}^ - $ ) removing hydroxyl radicals (•OH), the precursor of H2O2, is the reason why UHDR leads to a lower G-value (molecules/100 eV) for H2O2 (G[H2O2]), because: 1, the third-order reaction betweene aq - ${\mathrm{e}}_{{\mathrm{aq}}}^ - $ and •OH is more sensitive to increased instantaneous ROS concentration by UHDR than a two-order reaction of •OH self-reaction producing H2O2; 2,e aq - ${\mathrm{e}}_{{\mathrm{aq}}}^ - $ has two times higher diffusion coefficient and higher reaction rate constant than that of •OH, which meanse aq - ${\mathrm{e}}_{{\mathrm{aq}}}^ - $ would dominate the competition for •OH and benefit more from the inter-track effect of UHDR. Meanwhile, we also experimentally verify the theory of long-lived radicals causing lower G(H2O2) in conventional irradiation, which is mentioned in some simulation studies. METHODS AND MATERIALS H2O2 was measured by Amplex UltraRed assay. 430.1 MeV/u carbon ions (50 and 0.1 Gy/s), 9 MeV electrons (600 and 0.62 Gy/s), and 200 kV x-ray tube (10 and 0.1 Gy/s) were employed. For three kinds of water (real hypoxic: 1% O2; hypoxic: 1% O2 and 5% CO2; and normoxic: 21% O2), unbubbled and bubbled samples with N2O, the scavenger ofe aq - ${\mathrm{e}}_{{\mathrm{aq}}}^ - $ , were irradiated by carbon ions and electrons with conventional and UHDR at different absolute dose levels. Normoxic water dissolved with sodium nitrate (NaNO3), another scavenger ofe aq - ${\mathrm{e}}_{{\mathrm{aq}}}^ - $ , and bubbled with N2O was irradiated by x-ray to verify the results of low-LET electron beam. RESULTS UHDR leads to a lower G(H2O2) than conventional irradiation. O2 and CO2 can both increase G(H2O2). N2O increases G(H2O2) of both UHDR and conventional irradiation and eliminates the difference between them for carbon ions. However, N2O decreases G(H2O2) in electron conventional irradiation but increases G(H2O2) in the case of UHDR, ending up with no dose-rate dependency of G(H2O2). Three-spilled carbon UHDR does not have a lower G(H2O2) than one-spilled UHDR. However, the electron beam shows a lower G(H2O2) for three-spilled UHDR than for one-spilled UHDR. Normoxic water with N2O or NaNO3 can both eliminate the dose rate dependency of H2O2 production for x-ray. CONCLUSIONS UHDR has a lower G(H2O2) than the conventional irradiation for both high LET carbon and low LET electron and x-ray beams. Both scavengers fore aq - ${\mathrm{e}}_{{\mathrm{aq}}}^ - $ , N2O and NaNO3, eliminate the dose-rate dependency of G(H2O2), which suggestse aq - ${\mathrm{e}}_{{\mathrm{aq}}}^ - $ is the reason for decreased G(H2O2) for UHDR. Three-spilled UHDR versus one-spilled UHDR indicates that the assumption of residual radicals reducing G(H2O2) of conventional irradiation may only be valid for low LET electron beam.
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Affiliation(s)
- Tengda Zhang
- Division of Biomedical Physics in Radiation Oncology, German Cancer Research Center, Heidelberg, Germany
- MIISM, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Christina Stengl
- Division of Medical Physics in Radiation Oncology, German Cancer Research Center, Heidelberg, Germany
- Medical Faculty Heidelberg, Heidelberg University, Heidelberg, Germany
| | - Larissa Derksen
- University of Applied Sciences, Institute of Medical Physics and Radiation Protection, Giessen, Germany
| | - Kristaps Palskis
- CERN, Geneva, Switzerland
- Riga Technical University, Riga, Latvia
| | - Konstantinos Koritsidis
- Division of Biomedical Physics in Radiation Oncology, German Cancer Research Center, Heidelberg, Germany
- Faculty of Physics, The Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Klemens Zink
- University of Applied Sciences, Institute of Medical Physics and Radiation Protection, Giessen, Germany
- Department of Radiotherapy and Radiation Oncology, Marburg University Hospital, Marburg, Germany
- Marburg Ion-Beam Therapy Center (MIT), Marburg, Germany
| | - Sebastian Adeberg
- Department of Radiotherapy and Radiation Oncology, Marburg University Hospital, Marburg, Germany
- Marburg Ion-Beam Therapy Center (MIT), Marburg, Germany
- Universitäres Centrum für Tumorerkrankungen (UCT) Frankfurt - Marburg, Marburg, Germany
| | - Gerald Major
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - David Weishaar
- University of Applied Sciences, Institute of Medical Physics and Radiation Protection, Giessen, Germany
| | - Ulrike Theiß
- Marburg Ion-Beam Therapy Center (MIT), Marburg, Germany
- Department of Radiotherapy and Radiation Oncology, Philipps-University, Marburg, Germany
| | - Jing Jin
- State Key Laboratory of Molecular Oncology and Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, China
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, CAMS and PUMC, Shenzhen, China
| | - Maria Francesca Spadea
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany
| | - Elpida Theodoridou
- Division of Biomedical Physics in Radiation Oncology, German Cancer Research Center, Heidelberg, Germany
- Faculty of Physics, The Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Jürgen Hesser
- MIISM, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Interdisciplinary Center for Scientific Computing (IWR), Central Institute for Computer Engineering (ZITI), CZS Heidelberg Center for Model-Based AI, Heidelberg University, Heidelberg, Germany
| | - Kilian-Simon Baumann
- University of Applied Sciences, Institute of Medical Physics and Radiation Protection, Giessen, Germany
- Department of Radiotherapy and Radiation Oncology, Marburg University Hospital, Marburg, Germany
- Marburg Ion-Beam Therapy Center (MIT), Marburg, Germany
| | - Joao Seco
- Division of Biomedical Physics in Radiation Oncology, German Cancer Research Center, Heidelberg, Germany
- Department of Physics and Astronomy, Heidelberg University, Heidelberg, Germany
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Cengel KA, Kim MM, Diffenderfer ES, Busch TM. FLASH Radiotherapy: What Can FLASH's Ultra High Dose Rate Offer to the Treatment of Patients With Sarcoma? Semin Radiat Oncol 2024; 34:218-228. [PMID: 38508786 DOI: 10.1016/j.semradonc.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
FLASH is an emerging treatment paradigm in radiotherapy (RT) that utilizes ultra-high dose rates (UHDR; >40 Gy)/s) of radiation delivery. Developing advances in technology support the delivery of UHDR using electron and proton systems, as well as some ion beam units (eg, carbon ions), while methods to achieve UHDR with photons are under investigation. The major advantage of FLASH RT is its ability to increase the therapeutic index for RT by shifting the dose response curve for normal tissue toxicity to higher doses. Numerous preclinical studies have been conducted to date on FLASH RT for murine sarcomas, alongside the investigation of its effects on relevant normal tissues of skin, muscle, and bone. The tumor control achieved by FLASH RT of sarcoma models is indistinguishable from that attained by treatment with standard RT to the same total dose. FLASH's high dose rates are able to mitigate the severity or incidence of RT side effects on normal tissues as evaluated by endpoints ranging from functional sparing to histological damage. Large animal studies and clinical trials of canine patients show evidence of skin sparing by FLASH vs. standard RT, but also caution against delivery of high single doses with FLASH that exceed those safely applied with standard RT. Also, a human clinical trial has shown that FLASH RT can be delivered safely to bone metastasis. Thus, data to date support continued investigations of clinical translation of FLASH RT for the treatment of patients with sarcoma. Toward this purpose, hypofractionated irradiation schemes are being investigated for FLASH effects on sarcoma and relevant normal tissues.
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Affiliation(s)
- Keith A Cengel
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania..
| | - Michele M Kim
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eric S Diffenderfer
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Theresa M Busch
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Shiraishi Y, Matsuya Y, Fukunaga H. Possible mechanisms and simulation modeling of FLASH radiotherapy. Radiol Phys Technol 2024; 17:11-23. [PMID: 38184508 DOI: 10.1007/s12194-023-00770-x] [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: 05/23/2023] [Revised: 12/01/2023] [Accepted: 12/02/2023] [Indexed: 01/08/2024]
Abstract
FLASH radiotherapy (FLASH-RT) has great potential to improve patient outcomes. It delivers radiation doses at an ultra-high dose rate (UHDR: ≥ 40 Gy/s) in a single instant or a few pulses. Much higher irradiation doses can be administered to tumors with FLASH-RT than with conventional dose rate (0.01-0.40 Gy/s) radiotherapy. UHDR irradiation can suppress toxicity in normal tissues while sustaining antitumor efficiency, which is referred to as the FLASH effect. However, the mechanisms underlying the effects of the FLASH remain unclear. To clarify these mechanisms, the development of simulation models that can contribute to treatment planning for FLASH-RT is still underway. Previous studies indicated that transient oxygen depletion or augmented reactions between secondary reactive species produced by irradiation may be involved in this process. To discuss the possible mechanisms of the FLASH effect and its clinical potential, we summarized the physicochemical, chemical, and biological perspectives as well as the development of simulation modeling for FLASH-RT.
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Affiliation(s)
- Yuta Shiraishi
- Graduate School of Health Sciences, Hokkaido University, N12 W5 Kita-Ku, Sapporo, Hokkaido, 060-0812, Japan
- Faculty of Health Sciences, Japan Healthcare University, 3-11-1-50 Tsukisamu-Higashi, Toyohira-Ku, Sapporo, Hokkaido, 062-0053, Japan
| | - Yusuke Matsuya
- Faculty of Health Sciences, Hokkaido University, N12 W5 Kita-Ku, Sapporo, Hokkaido, 060-0812, Japan
| | - Hisanori Fukunaga
- Faculty of Health Sciences, Hokkaido University, N12 W5 Kita-Ku, Sapporo, Hokkaido, 060-0812, Japan.
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Penabeï S, Sepulveda E, Zakaria AM, Meesungnoen J, Jay-Gerin JP. Effect of Linear Energy Transfer on Cystamine's Radioprotective Activity: A Study Using the Fricke Dosimeter with 6-500 MeV per Nucleon Carbon Ions-Implication for Carbon Ion Hadrontherapy. Molecules 2023; 28:8144. [PMID: 38138632 PMCID: PMC10746108 DOI: 10.3390/molecules28248144] [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: 10/23/2023] [Revised: 12/01/2023] [Accepted: 12/08/2023] [Indexed: 12/24/2023] Open
Abstract
(1) Background: Radioprotective agents have garnered considerable interest due to their prospective applications in radiotherapy, public health medicine, and situations of large-scale accidental radiation exposure or impending radiological emergencies. Cystamine, an organic diamino-disulfide compound, is recognized for its radiation-protective and antioxidant properties. This study aims to utilize the aqueous ferrous sulfate (Fricke) dosimeter to measure the free-radical scavenging capabilities of cystamine during irradiation by fast carbon ions. This analysis spans an energy range from 6 to 500 MeV per nucleon, which correlates with "linear energy transfer" (LET) values ranging from approximately 248 keV/μm down to 9.3 keV/μm. (2) Methods: Monte Carlo track chemistry calculations were used to simulate the radiation-induced chemistry of aerated Fricke-cystamine solutions across a broad spectrum of cystamine concentrations, ranging from 10-6 to 1 M. (3) Results: In irradiated Fricke solutions containing cystamine, cystamine is observed to hinder the oxidation of Fe2+ ions, an effect triggered by oxidizing agents from the radiolysis of acidic water, resulting in reduced Fe3+ ion production. Our simulations, conducted both with and without accounting for the multiple ionization of water, confirm cystamine's ability to capture free radicals, highlighting its strong antioxidant properties. Aligning with prior research, our simulations also indicate that the protective and antioxidant efficiency of cystamine diminishes with increasing LET of the radiation. This result can be attributed to the changes in the geometry of the track structures when transitioning from lower to higher LETs. (4) Conclusions: If we can apply these fundamental research findings to biological systems at a physiological pH, the use of cystamine alongside carbon-ion hadrontherapy could present a promising approach to further improve the therapeutic ratio in cancer treatments.
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Affiliation(s)
| | | | | | | | - Jean-Paul Jay-Gerin
- Département de Médecine Nucléaire et de Radiobiologie, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, 3001, 12ème Avenue Nord, Sherbrooke, QC J1H 5N4, Canada; (S.P.); (E.S.); (A.M.Z.); (J.M.)
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Cho YB, Yoon N, Suh JH, Scott JG. Radio-immune response modelling for spatially fractionated radiotherapy. Phys Med Biol 2023; 68:165010. [PMID: 37459862 PMCID: PMC10409909 DOI: 10.1088/1361-6560/ace819] [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: 05/03/2023] [Revised: 07/06/2023] [Accepted: 07/17/2023] [Indexed: 07/28/2023]
Abstract
Objective.Radiation-induced cell death is a complex process influenced by physical, chemical and biological phenomena. Although consensus on the nature and the mechanism of the bystander effect were not yet made, the immune process presumably plays an important role in many aspects of the radiotherapy including the bystander effect. A mathematical model of immune response during and after radiation therapy is presented.Approach.Immune response of host body and immune suppression of tumor cells are modelled with four compartments in this study; viable tumor cells, T cell lymphocytes, immune triggering cells, and doomed cells. The growth of tumor was analyzed in two distinctive modes of tumor status (immune limited and immune escape) and its bifurcation condition.Main results.Tumors in the immune limited mode can grow only up to a finite size, named as terminal tumor volume analytically calculated from the model. The dynamics of the tumor growth in the immune escape mode is much more complex than the tumors in the immune limited mode especially when the status of tumor is close to the bifurcation condition. Radiation can kill tumor cells not only by radiation damage but also by boosting immune reaction.Significance.The model demonstrated that the highly heterogeneous dose distribution in spatially fractionated radiotherapy (SFRT) can make a drastic difference in tumor cell killing compared to the homogeneous dose distribution. SFRT cannot only enhance but also moderate the cell killing depending on the immune response triggered by many factors such as dose prescription parameters, tumor volume at the time of treatment and tumor characteristics. The model was applied to the lifted data of 67NR tumors on mice and a sarcoma patient treated multiple times over 1200 days for the treatment of tumor recurrence as a demonstration.
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Affiliation(s)
- Young-Bin Cho
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, United States of America
- Department of Radiation Oncology, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, United States of America
- Department of Biomedical Engineering, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, United States of America
| | - Nara Yoon
- Departmentof Mathematics and Computer Science, Adelphi University, New York, United States of America
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, United States of America
- Department of Radiation Oncology, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, United States of America
| | - Jacob G Scott
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, United States of America
- Department of Radiation Oncology, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, United States of America
- Department of Translational Hematology and Oncology Research, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, United States of America
- Department of Physics, Case Western Reserve University, Cleveland, United States of America
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Mali SB, Dahivelkar S. Flash radiotherapy-gateway to promised land or another mirage. Oral Oncol 2023; 139:106342. [PMID: 36821983 DOI: 10.1016/j.oraloncology.2023.106342] [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: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 02/23/2023]
Abstract
Radiation therapy damages cancer cells with ionizing radiation, leading to their death. However, radiation‑induced toxicity limits the dose delivered to the tumor, thereby constraining the control effect of radiotherapy n tumor growth. In addition, the delayed toxicity caused by radiotherapy significantly harms the physical and mental health of patients. FLASH‑RT, an emerging class of radiotherapy, causes a phenomenon known as the 'FLASH effect', which delivers radiotherapy at an ultra‑high dose rate with lower toxicity to normal tissue than conventional radiotherapy to achieve local tumor control.
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Affiliation(s)
- Shrikant B Mali
- MDS Oral and Maxillofacial Surgery Mahatma Gandhi Vidya Mandir's Dental College and Hospital Nashik, India.
| | - Sachinkumar Dahivelkar
- MDS Oral and Maxillofacial Surgery Mahatma Gandhi Vidya Mandir's Dental College and Hospital Nashik, India.
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Thompson SJ, Prise KM, McMahon SJ. Investigating the potential contribution of inter-track interactions within ultra-high dose-rate proton therapy. Phys Med Biol 2023; 68. [PMID: 36731135 DOI: 10.1088/1361-6560/acb88a] [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: 09/15/2022] [Accepted: 02/01/2023] [Indexed: 02/04/2023]
Abstract
Objective. Laser-accelerated protons offer an alternative delivery mechanism for proton therapy. This technique delivers dose-rates of ≥109Gy s-1, many orders of magnitude greater than used clinically. Such ultra-high dose-rates reduce delivery time to nanoseconds, equivalent to the lifetime of reactive chemical species within a biological medium. This leads to the possibility of inter-track interactions between successive protons within a pulse, potentially altering the yields of damaging radicals if they are in sufficient spatial proximity. This work investigates the temporal evolution of chemical species for a range of proton energies and doses to quantify the circumstances required for inter-track interactions, and determine any relevance within ultra-high dose-rate proton therapy.Approach. The TOPAS-nBio Monte Carlo toolkit was used to investigate possible inter-track interactions. Firstly, protons between 0.5 and 100 MeV were simulated to record the radial track dimensions throughout the chemical stage from 1 ps to 1μs. Using the track areas, the geometric probability of track overlap was calculated for various exposures and timescales. A sample of irradiations were then simulated in detail to compare any change in chemical yields for independently and instantaneously delivered tracks, and validate the analytic model.Main results. Track overlap for a clinical 2 Gy dose was negligible for biologically relevant timepoints for all energies. Overlap probability increased with time after irradiation, proton energy and dose, with a minimum 23 Gy dose required before significant track overlap occurred. Simulating chemical interactions confirmed these results with no change in radical yields seen up to 8 Gy for independently and instantaneously delivered tracks.Significance. These observations suggest that the spatial separation between incident protons is too large for physico-chemical inter-track interactions, regardless of the delivery time, indicating such interactions would not play a role in any potential changes in biological response between laser-accelerated and conventional proton therapy.
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Affiliation(s)
- Shannon J Thompson
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, United Kingdom
| | - Kevin M Prise
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, United Kingdom
| | - Stephen J McMahon
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, United Kingdom
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Zhuang Y, Liu K, He Q, Gu X, Jiang C, Wu J. Hypoxia signaling in cancer: Implications for therapeutic interventions. MedComm (Beijing) 2023; 4:e203. [PMID: 36703877 PMCID: PMC9870816 DOI: 10.1002/mco2.203] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 12/14/2022] [Accepted: 12/18/2022] [Indexed: 01/25/2023] Open
Abstract
Hypoxia is a persistent physiological feature of many different solid tumors and a key driver of malignancy, and in recent years, it has been recognized as an important target for cancer therapy. Hypoxia occurs in the majority of solid tumors due to a poor vascular oxygen supply that is not sufficient to meet the needs of rapidly proliferating cancer cells. A hypoxic tumor microenvironment (TME) can reduce the effectiveness of other tumor therapies, such as radiotherapy, chemotherapy, and immunotherapy. In this review, we discuss the critical role of hypoxia in tumor development, including tumor metabolism, tumor immunity, and tumor angiogenesis. The treatment methods for hypoxic TME are summarized, including hypoxia-targeted therapy and improving oxygenation by alleviating tumor hypoxia itself. Hyperoxia therapy can be used to improve tissue oxygen partial pressure and relieve tumor hypoxia. We focus on the underlying mechanisms of hyperoxia and their impact on current cancer therapies and discuss the prospects of hyperoxia therapy in cancer treatment.
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Affiliation(s)
- Yan Zhuang
- State Key Laboratory of Pharmaceutical BiotechnologyNational Institute of Healthcare Data Science at Nanjing UniversityJiangsu Key Laboratory of Molecular MedicineMedicineMedical School of Nanjing UniversityNanjing UniversityNanjingChina
| | - Kua Liu
- State Key Laboratory of Pharmaceutical BiotechnologyNational Institute of Healthcare Data Science at Nanjing UniversityJiangsu Key Laboratory of Molecular MedicineMedicineMedical School of Nanjing UniversityNanjing UniversityNanjingChina
| | - Qinyu He
- State Key Laboratory of Pharmaceutical BiotechnologyNational Institute of Healthcare Data Science at Nanjing UniversityJiangsu Key Laboratory of Molecular MedicineMedicineMedical School of Nanjing UniversityNanjing UniversityNanjingChina
| | - Xiaosong Gu
- Microecological, Regenerative and Microfabrication Technical Platform for Biomedicine and Tissue EngineeringJinan Microecological Biomedicine Shandong LaboratoryJinan CityChina
| | - Chunping Jiang
- State Key Laboratory of Pharmaceutical BiotechnologyNational Institute of Healthcare Data Science at Nanjing UniversityJiangsu Key Laboratory of Molecular MedicineMedicineMedical School of Nanjing UniversityNanjing UniversityNanjingChina,Microecological, Regenerative and Microfabrication Technical Platform for Biomedicine and Tissue EngineeringJinan Microecological Biomedicine Shandong LaboratoryJinan CityChina
| | - Junhua Wu
- State Key Laboratory of Pharmaceutical BiotechnologyNational Institute of Healthcare Data Science at Nanjing UniversityJiangsu Key Laboratory of Molecular MedicineMedicineMedical School of Nanjing UniversityNanjing UniversityNanjingChina,Microecological, Regenerative and Microfabrication Technical Platform for Biomedicine and Tissue EngineeringJinan Microecological Biomedicine Shandong LaboratoryJinan CityChina
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The 'stealth-bomber' paradigm for deciphering the tumour response to carbon-ion irradiation. Br J Cancer 2023; 128:1429-1438. [PMID: 36639527 PMCID: PMC10070470 DOI: 10.1038/s41416-022-02117-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 12/01/2022] [Accepted: 12/08/2022] [Indexed: 01/14/2023] Open
Abstract
Numerous studies have demonstrated the higher biological efficacy of carbon-ion irradiation (C-ions) and their ballistic precision compared with photons. At the nanometre scale, the reactive oxygen species (ROS) produced by radiation and responsible for the indirect effects are differentially distributed according to the type of radiation. Photon irradiation induces a homogeneous ROS distribution, whereas ROS remain condensed in clusters in the C-ions tracks. Based on this linear energy transfer-dependent differential nanometric ROS distribution, we propose that the higher biological efficacy and specificities of the molecular response to C-ions rely on a 'stealth-bomber' effect. When biological targets are on the trajectories of the particles, the clustered radicals in the tracks are responsible for a 'bomber' effect. Furthermore, the low proportion of ROS outside the tracks is not able to trigger the cellular mechanisms of defence and proliferation. The ability of C-ions to deceive the cellular defence of the cancer cells is then categorised as a 'stealth' effect. This review aims to classify the biological arguments supporting the paradigm of the 'stealth-bomber' as responsible for the biological superiority of C-ions compared with photons. It also explains how and why C-ions will always be more efficient for treating patients with radioresistant cancers than conventional radiotherapy.
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Zou W, Kim H, Diffenderfer ES, Carlson DJ, Koch CJ, Xiao Y, Teo BK, Kim MM, Metz JM, Fan Y, Maity A, Koumenis C, Busch TM, Wiersma R, Cengel KA, Dong L. A phenomenological model of proton FLASH oxygen depletion effects depending on tissue vasculature and oxygen supply. Front Oncol 2022; 12:1004121. [PMID: 36518319 PMCID: PMC9742361 DOI: 10.3389/fonc.2022.1004121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/11/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction Radiation-induced oxygen depletion in tissue is assumed as a contributor to the FLASH sparing effects. In this study, we simulated the heterogeneous oxygen depletion in the tissue surrounding the vessels and calculated the proton FLASH effective-dose-modifying factor (FEDMF), which could be used for biology-based treatment planning. Methods The dose and dose-weighted linear energy transfer (LET) of a small animal proton irradiator was simulated with Monte Carlo simulation. We deployed a parabolic partial differential equation to account for the generalized radiation oxygen depletion, tissue oxygen diffusion, and metabolic processes to investigate oxygen distribution in 1D, 2D, and 3D solution space. Dose and dose rates, particle LET, vasculature spacing, and blood oxygen supplies were considered. Using a similar framework for the hypoxic reduction factor (HRF) developed previously, the FEDMF was derived as the ratio of the cumulative normoxic-equivalent dose (CNED) between CONV and UHDR deliveries. Results Dynamic equilibrium between oxygen diffusion and tissue metabolism can result in tissue hypoxia. The hypoxic region displayed enhanced radio-resistance and resulted in lower CNED under UHDR deliveries. In 1D solution, comparing 15 Gy proton dose delivered at CONV 0.5 and UHDR 125 Gy/s, 61.5% of the tissue exhibited ≥20% FEDMF at 175 μm vasculature spacing and 18.9 μM boundary condition. This percentage reduced to 34.5% and 0% for 8 and 2 Gy deliveries, respectively. Similar trends were observed in the 3D solution space. The FLASH versus CONV differential effect remained at larger vasculature spacings. A higher FLASH dose rate showed an increased region with ≥20% FEDMF. A higher LET near the proton Bragg peak region did not appear to alter the FLASH effect. Conclusion We developed 1D, 2D, and 3D oxygen depletion simulation process to obtain the dynamic HRF and derive the proton FEDMF related to the dose delivery parameters and the local tissue vasculature information. The phenomenological model can be used to simulate or predict FLASH effects based on tissue vasculature and oxygen concentration data obtained from other experiments.
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Gonon G, de Toledo SM, Perumal V, Jay-Gerin JP, Azzam EI. Impact of the redox environment on propagation of radiation bystander effects: The modulating effect of oxidative metabolism and oxygen partial pressure. MUTATION RESEARCH. GENETIC TOXICOLOGY AND ENVIRONMENTAL MUTAGENESIS 2022; 883-884:503559. [PMID: 36462795 DOI: 10.1016/j.mrgentox.2022.503559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/09/2022] [Accepted: 11/11/2022] [Indexed: 11/16/2022]
Abstract
Redox modulated pathways play important roles in out-of-field effects of ionizing radiation. We investigated how the redox environment impacts the magnitude of propagation of stressful effects from irradiated to bystander cells. Normal human fibroblasts that have incorporated [3H]-thymidine were intimately co-cultured with bystander cells in a strategy that allowed isolation of bystander cells with high purity. The antioxidant glutathione peroxidase (GPX) was maintained either at wild-type conditions or overexpressed in the bystanders. Following 24 h of coculture, levels of stress-responsive p21Waf1, p-Hdm2, and connexin43 proteins were increased in bystander cells expressing wild-type GPX relative to respective controls. These levels were significantly attenuated when GPX was ectopically overexpressed, demonstrating by direct approach the involvement of a regulator of intracellular redox homeostasis. Evidence of participation of pro-oxidant compounds was generated by exposing confluent cell cultures to low fluences of 3.7 MeV α particles in presence or absence of t-butyl hydroperoxide. By 3 h post-exposure to fluences wherein only ∼2% of cells are traversed through the nucleus by a particle track, increases in chromosomal damage were greater than expected in absence of the drug (p < 0.001) and further enhanced in its presence (p < 0.05). While maintenance and irradiation of cell cultures at low oxygen pressure (pO2 3.8 mm Hg) to mimic in vivo still supported the participation of bystander cells in responses assessed by chromosomal damage and stress-responsive protein levels (p < 0.001), the effects were attenuated compared to ambient pO2 (155 mm Hg) (p < 0.05). Together, the results show that bystander effects are attenuated at below ambient pO2 and when metabolic oxidative stress is reduced but increased when the basal redox environment tilts towards oxidizing conditions. They are consistent with bystander effects being independent of radiation dose rate.
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Affiliation(s)
- Géraldine Gonon
- Institut de Radioprotection et de Sûreté Nucléaire (IRSN), PSE-SANTE/SERAMED/LRAcc, Fontenay-aux-Roses, France; Department of Radiology, Rutgers New Jersey Medical School, Newark, NJ, USA.
| | - Sonia M de Toledo
- Department of Radiology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Venkatachalam Perumal
- Department of Radiology, Rutgers New Jersey Medical School, Newark, NJ, USA; Department of Human Genetics, Sri Ramachandra Institute of Higher Education and Research (Deemed to be University), Chennai, India
| | - Jean-Paul Jay-Gerin
- Département de médecine nucléaire et de radiobiologie, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Edouard I Azzam
- Department of Radiology, Rutgers New Jersey Medical School, Newark, NJ, USA; Radiobiology and Health Branch, Isotopes, Radiobiology & Environment Directorate (IRED), Canadian Nuclear Laboratories (CNL), Chalk River, Ontario, Canada.
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12
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Potential Molecular Mechanisms behind the Ultra-High Dose Rate "FLASH" Effect. Int J Mol Sci 2022; 23:ijms232012109. [PMID: 36292961 PMCID: PMC9602825 DOI: 10.3390/ijms232012109] [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: 08/12/2022] [Revised: 09/26/2022] [Accepted: 10/08/2022] [Indexed: 11/17/2022] Open
Abstract
FLASH radiotherapy, or the delivery of a dose at an ultra-high dose rate (>40 Gy/s), has recently emerged as a promising tool to enhance the therapeutic index in cancer treatment. The remarkable sparing of normal tissues and equivalent tumor control by FLASH irradiation compared to conventional dose rate irradiation—the FLASH effect—has already been demonstrated in several preclinical models and even in a first patient with T-cell cutaneous lymphoma. However, the biological mechanisms responsible for the differential effect produced by FLASH irradiation in normal and cancer cells remain to be elucidated. This is of great importance because a good understanding of the underlying radiobiological mechanisms and characterization of the specific beam parameters is required for a successful clinical translation of FLASH radiotherapy. In this review, we summarize the FLASH investigations performed so far and critically evaluate the current hypotheses explaining the FLASH effect, including oxygen depletion, the production of reactive oxygen species, and an altered immune response. We also propose a new theory that assumes an important role of mitochondria in mediating the normal tissue and tumor response to FLASH dose rates.
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13
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Gao Y, Liu R, Chang C, Charyyev S, Zhou J, Bradley JD, Liu T, Yang X. A potential revolution in cancer treatment: A topical review of FLASH radiotherapy. J Appl Clin Med Phys 2022; 23:e13790. [PMID: 36168677 PMCID: PMC9588273 DOI: 10.1002/acm2.13790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 07/08/2022] [Accepted: 09/01/2022] [Indexed: 11/26/2022] Open
Abstract
FLASH radiotherapy (RT) is a novel technique in which the ultrahigh dose rate (UHDR) (≥40 Gy/s) is delivered to the entire treatment volume. Recent outcomes of in vivo studies show that the UHDR RT has the potential to spare normal tissue without sacrificing tumor control. There is a growing interest in the application of FLASH RT, and the ultrahigh dose irradiation delivery has been achieved by a few experimental and modified linear accelerators. The underlying mechanism of FLASH effect is yet to be fully understood, but the oxygen depletion in normal tissue providing extra protection during FLASH irradiation is a hypothesis that attracts most attention currently. Monte Carlo simulation is playing an important role in FLASH, enabling the understanding of its dosimetry calculations and hardware design. More advanced Monte Carlo simulation tools are under development to fulfill the challenge of reproducing the radiolysis and radiobiology processes in FLASH irradiation. FLASH RT may become one of standard treatment modalities for tumor treatment in the future. This paper presents the history and status of FLASH RT studies with a focus on FLASH irradiation delivery modalities, underlying mechanism of FLASH effect, in vivo and vitro experiments, and simulation studies. Existing challenges and prospects of this novel technique are discussed in this manuscript.
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Affiliation(s)
- Yuan Gao
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Ruirui Liu
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Chih‐Wei Chang
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Serdar Charyyev
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Jun Zhou
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Jeffrey D. Bradley
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Tian Liu
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Xiaofeng Yang
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
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14
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Wei S, Lin H, Shi C, Xiong W, Chen CC, Huang S, Press RH, Hasan S, Chhabra AM, Choi JI, Simone CB, Kang M. Use of single-energy proton pencil beam scanning Bragg peak for intensity-modulated proton therapy FLASH treatment planning in liver hypofractionated radiation therapy. Med Phys 2022; 49:6560-6574. [PMID: 35929404 DOI: 10.1002/mp.15894] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 06/09/2022] [Accepted: 07/20/2022] [Indexed: 11/11/2022] Open
Abstract
PURPOSE The transmission proton FLASH technique delivers high doses to the normal tissue distal to the target, which is less conformal compared to the Bragg peak technique. To investigate FLASH RT planning using single-energy Bragg peak beams with a similar beam arrangement as clinical intensity-modulated proton therapy (IMPT) in liver stereotactic body radiation therapy (SBRT) and to characterize the plan quality, dose sparing of organs-at-risk (OARs), and FLASH dose rate percentage. MATERIALS AND METHODS An in-house platform was developed to enable inverse IMPT-FLASH planning using single-energy Bragg peaks. A universal range shifter and range compensators were utilized to effectively align the Bragg peak to the distal edge of the target. Two different minimum MU settings of 400 and 800 MU/spot (Bragg-400MU and Bragg-800MU) plans were investigated on 10 consecutive hepatocellular carcinoma patients previously treated by IMPT-SBRT to evaluate the FLASH dose and dose rate coverage for OARs. The IMPT-FLASH using single-energy Bragg peaks delivered 50 Gy in 5 fractions with similar or identical beam arrangement to the clinical IMPT-SBRT plans. NRG GI003 dose constraint metrics were used. Three dose rate calculation methods, including average dose rate (ADR), dose threshold dose rate (DTDR), and dose-averaged dose rate (DADR), were all studied. RESULTS The novel spot map optimization can fulfill the inverse planning using single-energy Bragg peaks. All the Bragg peak FLASH plans achieved similar results for the liver-GTV Dmean and heart D0.5cc , compared to SBRT-IMPT. The Bragg-800MU plans resulted in 18.3% higher CTV D2cc compared with SBRT (p < 0.05), and no significant difference was found between Bragg-400MU and SBRT plans. For the CTV Dmax , SBRT plans resulted in 10.3% (p<0.01) less than Bragg-400MU plans and 16.6% (p<0.01) less than Bragg-800MU plans. The Bragg-800MU plans generally achieved higher ADR, DADR, and DTDR dose rates than Bragg-400MU plans, and DADR mostly led to the highest V40Gy/s compared to other dose rate calculation methods, whereas ADR led to the lowest. The lower dose rate portions in certain OARs are related to the lower dose deposited due to the farther distances from targets, especially in the penumbra of the beams. CONCLUSION Single-energy Bragg peak IMPT-FLASH plans eliminate the exit dose in normal tissues, maintaining comparable dose metrics to the conventional IMPT-SBRT plans while achieving a sufficient FLASH dose rate for liver cancers. This study demonstrates the feasibility of and sufficiently high dose rate when applying Bragg peak FLASH treatment for liver cancer hypofractionated FLASH therapy. The advancement of this novel method has the potential to optimize treatment for liver cancer patients. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Shouyi Wei
- New York Proton Center, New York, NY, USA
| | - Haibo Lin
- New York Proton Center, New York, NY, USA
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15
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Mairani A, Mein S, Blakely E, Debus J, Durante M, Ferrari A, Fuchs H, Georg D, Grosshans DR, Guan F, Haberer T, Harrabi S, Horst F, Inaniwa T, Karger CP, Mohan R, Paganetti H, Parodi K, Sala P, Schuy C, Tessonnier T, Titt U, Weber U. Roadmap: helium ion therapy. Phys Med Biol 2022; 67. [PMID: 35395649 DOI: 10.1088/1361-6560/ac65d3] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 04/08/2022] [Indexed: 12/16/2022]
Abstract
Helium ion beam therapy for the treatment of cancer was one of several developed and studied particle treatments in the 1950s, leading to clinical trials beginning in 1975 at the Lawrence Berkeley National Laboratory. The trial shutdown was followed by decades of research and clinical silence on the topic while proton and carbon ion therapy made debuts at research facilities and academic hospitals worldwide. The lack of progression in understanding the principle facets of helium ion beam therapy in terms of physics, biological and clinical findings persists today, mainly attributable to its highly limited availability. Despite this major setback, there is an increasing focus on evaluating and establishing clinical and research programs using helium ion beams, with both therapy and imaging initiatives to supplement the clinical palette of radiotherapy in the treatment of aggressive disease and sensitive clinical cases. Moreover, due its intermediate physical and radio-biological properties between proton and carbon ion beams, helium ions may provide a streamlined economic steppingstone towards an era of widespread use of different particle species in light and heavy ion therapy. With respect to the clinical proton beams, helium ions exhibit superior physical properties such as reduced lateral scattering and range straggling with higher relative biological effectiveness (RBE) and dose-weighted linear energy transfer (LETd) ranging from ∼4 keVμm-1to ∼40 keVμm-1. In the frame of heavy ion therapy using carbon, oxygen or neon ions, where LETdincreases beyond 100 keVμm-1, helium ions exhibit similar physical attributes such as a sharp lateral penumbra, however, with reduced radio-biological uncertainties and without potentially spoiling dose distributions due to excess fragmentation of heavier ion beams, particularly for higher penetration depths. This roadmap presents an overview of the current state-of-the-art and future directions of helium ion therapy: understanding physics and improving modeling, understanding biology and improving modeling, imaging techniques using helium ions and refining and establishing clinical approaches and aims from learned experience with protons. These topics are organized and presented into three main sections, outlining current and future tasks in establishing clinical and research programs using helium ion beams-A. Physics B. Biological and C. Clinical Perspectives.
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Affiliation(s)
- Andrea Mairani
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Centre of Oncological Hadrontherapy (CNAO), Medical Physics, Pavia, Italy.,Division of Molecular and Translational Radiation Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Stewart Mein
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Division of Molecular and Translational Radiation Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,German Cancer Consortium (DKTK) Core-Center Heidelberg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Eleanor Blakely
- Biological Systems and Engineering Division, Lawrence Berkeley National Laboratory, Berkeley, CA, United States of America
| | - Jürgen Debus
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Division of Molecular and Translational Radiation Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,German Cancer Consortium (DKTK) Core-Center Heidelberg, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg University and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Marco Durante
- GSI Helmholtzzentrum für Schwerionenforschung, D-64291 Darmstadt, Germany.,Technische Universität Darmstadt, Institut für Physik Kondensierter Materie, Darmstadt, Germany
| | - Alfredo Ferrari
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Hermann Fuchs
- Division of Medical Physics, Department of Radiation Oncology, Medical University of Vienna, Austria.,MedAustron Ion Therapy Center, Wiener Neustadt, Austria
| | - Dietmar Georg
- Division of Medical Physics, Department of Radiation Oncology, Medical University of Vienna, Austria.,MedAustron Ion Therapy Center, Wiener Neustadt, Austria
| | - David R Grosshans
- The University of Texas MD Anderson cancer Center, Houston, Texas, United States of America
| | - Fada Guan
- The University of Texas MD Anderson cancer Center, Houston, Texas, United States of America.,Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, 06510, United States of America
| | - Thomas Haberer
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Semi Harrabi
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,German Cancer Consortium (DKTK) Core-Center Heidelberg, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg University and German Cancer Research Center (DKFZ), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Felix Horst
- GSI Helmholtzzentrum für Schwerionenforschung, D-64291 Darmstadt, Germany
| | - Taku Inaniwa
- Department of Accelerator and Medical Physics, Institute for Quantum Medical Science, QST, 4-9-1 Anagawa, Inage-ku, Chiba 263-8555, Japan.,Medical Physics Laboratory, Division of Health Science, Graduate School of Medicine, Osaka University, 1-7 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Christian P Karger
- National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,Department of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Radhe Mohan
- The University of Texas MD Anderson cancer Center, Houston, Texas, United States of America
| | - Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, United States of America.,Harvard Medical School, Boston, United States of America
| | - Katia Parodi
- Ludwig-Maximilians-Universität München, Department of Experimental Physics-Medical Physics, Munich, Germany
| | - Paola Sala
- Ludwig-Maximilians-Universität München, Department of Experimental Physics-Medical Physics, Munich, Germany
| | - Christoph Schuy
- GSI Helmholtzzentrum für Schwerionenforschung, D-64291 Darmstadt, Germany
| | - Thomas Tessonnier
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Uwe Titt
- The University of Texas MD Anderson cancer Center, Houston, Texas, United States of America
| | - Ulrich Weber
- GSI Helmholtzzentrum für Schwerionenforschung, D-64291 Darmstadt, Germany
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16
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Alpuim Costa D, Sampaio-Alves M, Netto E, Fernandez G, Oliveira E, Teixeira A, Daniel PM, Bernardo GS, Amaro C. Hyperbaric Oxygen Therapy as a Complementary Treatment in Glioblastoma-A Scoping Review. Front Neurol 2022; 13:886603. [PMID: 35847231 PMCID: PMC9283648 DOI: 10.3389/fneur.2022.886603] [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: 02/28/2022] [Accepted: 05/24/2022] [Indexed: 11/13/2022] Open
Abstract
Glioblastoma (GBM) is the most common and aggressive malignant brain tumor in adults. The mainstay of management for GBM is surgical resection, radiation (RT), and chemotherapy (CT). Even with optimized multimodal treatment, GBM has a high recurrence and poor survival rates ranging from 12 to 24 months in most patients. Recently, relevant advances in understanding GBM pathophysiology have opened new avenues for therapies for recurrent and newly diagnosed diseases. GBM's hypoxic microenvironment has been shown to be highly associated with aggressive biology and resistance to RT and CT. Hyperbaric oxygen therapy (HBOT) may increase anticancer therapy sensitivity by increasing oxygen tension within the hypoxic regions of the neoplastic tissue. Previous data have investigated HBOT in combination with cytostatic compounds, with an improvement of neoplastic tissue oxygenation, inhibition of HIF-1α activity, and a significant reduction in the proliferation of GBM cells. The biological effect of ionizing radiation has been reported to be higher when it is delivered under well-oxygenated rather than anoxic conditions. Several hypoxia-targeting strategies reported that HBOT showed the most significant effect that could potentially improve RT outcomes, with higher response rates and survival and no serious adverse events. However, further prospective and randomized studies are necessary to validate HBOT's effectiveness in the 'real world' GBM clinical practice.
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Affiliation(s)
- Diogo Alpuim Costa
- Haematology and Oncology Department, CUF Oncologia, Lisbon, Portugal
- NOVA Medical School (NMS), Faculdade de Ciências Médicas (FCM), Lisbon, Portugal
- Faculty of Medicine, University of Lisbon, Lisbon, Portugal
- Centro de Medicina Subaquática e Hiperbárica, Azinhaga dos Ulmeiros, Lisbon, Portugal
- Centro Hiperbárico de Cascais, Cascais, Portugal
| | - Mafalda Sampaio-Alves
- Faculty of Medicine, University of Porto, Oporto, Portugal
- PTSurg – Portuguese Surgical Research Collaborative, Lisbon, Portugal
| | - Eduardo Netto
- Radioncology Department, Instituto Português de Oncologia de Lisboa Francisco Gentil (IPOLFG), E.P.E., Lisbon, Portugal
| | | | - Edson Oliveira
- Faculty of Medicine, University of Lisbon, Lisbon, Portugal
- Neurosurgery Department, Cluster CUF Descobertas, Lisbon, Portugal
| | - Andreia Teixeira
- Faculty of Medicine, University of Lisbon, Lisbon, Portugal
- Centro de Medicina Subaquática e Hiperbárica, Azinhaga dos Ulmeiros, Lisbon, Portugal
| | - Pedro Modas Daniel
- Centro de Medicina Subaquática e Hiperbárica, Azinhaga dos Ulmeiros, Lisbon, Portugal
| | - Guilherme Silva Bernardo
- Faculty of Medicine, University of Lisbon, Lisbon, Portugal
- Centro de Medicina Subaquática e Hiperbárica, Azinhaga dos Ulmeiros, Lisbon, Portugal
- Urology Department, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
| | - Carla Amaro
- Centro de Medicina Subaquática e Hiperbárica, Azinhaga dos Ulmeiros, Lisbon, Portugal
- Otorhinolaryngology Department, CUF Descobertas, Lisbon, Portugal
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17
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Bhattacharyya T, Koto M, Windisch P, Ikawa H, Hagiwara Y, Tsuji H, Adeberg S. Emerging Role of Carbon Ion Radiotherapy in Reirradiation of Recurrent Head and Neck Cancers: What Have We Achieved So Far? Front Oncol 2022; 12:888446. [PMID: 35677171 PMCID: PMC9167994 DOI: 10.3389/fonc.2022.888446] [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: 03/02/2022] [Accepted: 04/13/2022] [Indexed: 11/13/2022] Open
Abstract
Administering reirradiation for the treatment of recurrent head and neck cancers is extremely challenging. These tumors are hypoxic and radioresistant and require escalated radiation doses for adequate control. The obstacle to delivering this escalated dose of radiation to the target is its proximity to critical organs at risk (OARs) and possible development of consequent severe late toxicities. With the emergence of highly sophisticated technologies, intensity-modulated radiotherapy (IMRT) and stereotactic body radiotherapy have shown promising outcomes. Proton beam radiotherapy has been used for locally recurrent head and neck cancers because of its excellent physical dose distribution, exploring sharp Bragg peak properties with negligible entrance and exit doses. To further improve these results, carbon ion radiotherapy (CIRT) has been explored in several countries across Europe and Asia because of its favorable physical properties with minimal entrance and exit doses, sharper lateral penumbra, and much higher and variable relative biological efficacy, which cannot be currently achieved with any other form of radiation. Few studies have described the role of CIRT in recurrent head and neck cancers. In this article, we have discussed the different aspects of carbon ions in reirradiation of recurrent head and neck cancers, including European and Asian experiences, different dose schedules, dose constraints of OARs, outcomes, and toxicities, and a brief comparison with proton beam radiotherapy and IMRT.
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Affiliation(s)
- Tapesh Bhattacharyya
- Department of Radiation Oncology, Tata Medical Centre, Kolkata, India
- QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Japan
| | - Masashi Koto
- QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Japan
| | - Paul Windisch
- Department of Radiation Oncology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Hiroaki Ikawa
- QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Japan
| | - Yasuhito Hagiwara
- Department of Radiation Oncology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Hiroshi Tsuji
- QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Japan
| | - Sebastian Adeberg
- National Center for Tumor Diseases (NCT), University Hospital Heidelberg (UKHD) and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Radiation Oncology, University Hospital Heidelberg (UKHD), Heidelberg, Germany
- Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), UKHD and DKFZ, Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
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18
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Tinganelli W, Weber U, Puspitasari A, Simoniello P, Abdollahi A, Oppermann J, Schuy C, Horst F, Helm A, Fournier C, Durante M. FLASH with carbon ions: tumor control, normal tissue sparing, and distal metastasis in a mouse osteosarcoma model. Radiother Oncol 2022; 175:185-190. [DOI: 10.1016/j.radonc.2022.05.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/30/2022] [Accepted: 05/02/2022] [Indexed: 12/30/2022]
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19
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Friedl AA, Prise KM, Butterworth KT, Montay-Gruel P, Favaudon V. Radiobiology of the FLASH effect. Med Phys 2022; 49:1993-2013. [PMID: 34426981 DOI: 10.1002/mp.15184] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 08/03/2021] [Accepted: 08/09/2021] [Indexed: 12/17/2022] Open
Abstract
Radiation exposures at ultrahigh dose rates (UHDRs) at several orders of magnitude greater than in current clinical radiotherapy (RT) have been shown to manifest differential radiobiological responses compared to conventional (CONV) dose rates. This has led to studies investigating the application of UHDR for therapeutic advantage (FLASH-RT) that have gained significant interest since the initial discovery in 2014 that demonstrated reduced lung toxicity with equivalent levels of tumor control compared with conventional dose-rate RT. Many subsequent studies have demonstrated the potential protective role of FLASH-RT in normal tissues, yet the underlying molecular and cellular mechanisms of the FLASH effect remain to be fully elucidated. Here, we summarize the current evidence of the FLASH effect and review FLASH-RT studies performed in preclinical models of normal tissue response. To critically examine the underlying biological mechanisms of responses to UHDR radiation exposures, we evaluate in vitro studies performed with normal and tumor cells. Differential responses to UHDR versus CONV irradiation recurrently involve reduced inflammatory processes and differential expression of pro- and anti-inflammatory genes. In addition, frequently reduced levels of DNA damage or misrepair products are seen after UHDR irradiation. So far, it is not clear what signal elicits these differential responses, but there are indications for involvement of reactive species. Different susceptibility to FLASH effects observed between normal and tumor cells may result from altered metabolic and detoxification pathways and/or repair pathways used by tumor cells. We summarize the current theories that may explain the FLASH effect and highlight important research questions that are key to a better mechanistic understanding and, thus, the future implementation of FLASH-RT in the clinic.
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Affiliation(s)
- Anna A Friedl
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Kevin M Prise
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, UK
| | - Karl T Butterworth
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, UK
| | - Pierre Montay-Gruel
- Department of Radiation Oncology, University of California at Irvine, Irvine, California, USA
| | - Vincent Favaudon
- Institut Curie, Inserm U 1021-CNRS UMR 3347, Université Paris-Saclay, PSL Research University, Centre Universitaire, Orsay, France
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20
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Kim MM, Darafsheh A, Schuemann J, Dokic I, Lundh O, Zhao T, Ramos-Méndez J, Dong L, Petersson K. Development of Ultra-High Dose-Rate (FLASH) Particle Therapy. IEEE TRANSACTIONS ON RADIATION AND PLASMA MEDICAL SCIENCES 2022; 6:252-262. [PMID: 36092270 PMCID: PMC9457346 DOI: 10.1109/trpms.2021.3091406] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Research efforts in FLASH radiotherapy have increased at an accelerated pace recently. FLASH radiotherapy involves ultra-high dose rates and has shown to reduce toxicity to normal tissue while maintaining tumor response in pre-clinical studies when compared to conventional dose rate radiotherapy. The goal of this review is to summarize the studies performed to-date with proton, electron, and heavy ion FLASH radiotherapy, with particular emphasis on the physical aspects of each study and the advantages and disadvantages of each modality. Beam delivery parameters, experimental set-up, and the dosimetry tools used are described for each FLASH modality. In addition, modeling efforts and treatment planning for FLASH radiotherapy is discussed along with potential drawbacks when translated into the clinical setting. The final section concludes with further questions that have yet to be answered before safe clinical implementation of FLASH radiotherapy.
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Affiliation(s)
- Michele M Kim
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Arash Darafsheh
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jan Schuemann
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Ivana Dokic
- Clinical Cooperation Unit Translational Radiation Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital (UKHD) and German Cancer Research Center (DKFZ), Im Neuenheimer Feld 460, Heidelberg, Germany
- Division of Molecular and Translational Radiation Oncology, Department of Radiation Oncology, Heidelberg Faculty of Medicine (MFHD) and Heidelberg University Hospital (UKHD), Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK) Core-Center Heidelberg, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg University and German Cancer Research Center (DKFZ), Im Neuenheimer Feld 222, Heidelberg, Germany
| | - Olle Lundh
- Department of Physics, Lund University, Lund, Sweden
| | - Tianyu Zhao
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - José Ramos-Méndez
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA
| | - Lei Dong
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kristoffer Petersson
- Department of Oncology, The Oxford Institute for Radiation Oncology, University of Oxford, Oxford, United Kingdom
- Radiation Physics, Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
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21
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Yap J, De Franco A, Sheehy S. Future Developments in Charged Particle Therapy: Improving Beam Delivery for Efficiency and Efficacy. Front Oncol 2021; 11:780025. [PMID: 34956897 PMCID: PMC8697351 DOI: 10.3389/fonc.2021.780025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/16/2021] [Indexed: 01/09/2023] Open
Abstract
The physical and clinical benefits of charged particle therapy (CPT) are well recognized. However, the availability of CPT and complete exploitation of dosimetric advantages are still limited by high facility costs and technological challenges. There are extensive ongoing efforts to improve upon these, which will lead to greater accessibility, superior delivery, and therefore better treatment outcomes. Yet, the issue of cost remains a primary hurdle as utility of CPT is largely driven by the affordability, complexity and performance of current technology. Modern delivery techniques are necessary but limited by extended treatment times. Several of these aspects can be addressed by developments in the beam delivery system (BDS) which determines the overall shaping and timing capabilities enabling high quality treatments. The energy layer switching time (ELST) is a limiting constraint of the BDS and a determinant of the beam delivery time (BDT), along with the accelerator and other factors. This review evaluates the delivery process in detail, presenting the limitations and developments for the BDS and related accelerator technology, toward decreasing the BDT. As extended BDT impacts motion and has dosimetric implications for treatment, we discuss avenues to minimize the ELST and overview the clinical benefits and feasibility of a large energy acceptance BDS. These developments support the possibility of advanced modalities and faster delivery for a greater range of treatment indications which could also further reduce costs. Further work to realize methodologies such as volumetric rescanning, FLASH, arc, multi-ion and online image guided therapies are discussed. In this review we examine how increased treatment efficiency and efficacy could be achieved with improvements in beam delivery and how this could lead to faster and higher quality treatments for the future of CPT.
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Affiliation(s)
- Jacinta Yap
- School of Physics, University of Melbourne, Melbourne, VIC, Australia
| | - Andrea De Franco
- IFMIF Accelerator Development Group, Rokkasho Fusion Institute, National Institutes for Quantum Science and Technology, Aomori, Japan
| | - Suzie Sheehy
- School of Physics, University of Melbourne, Melbourne, VIC, Australia
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22
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Durante M, Debus J, Loeffler JS. Physics and biomedical challenges of cancer therapy with accelerated heavy ions. NATURE REVIEWS. PHYSICS 2021; 3:777-790. [PMID: 34870097 PMCID: PMC7612063 DOI: 10.1038/s42254-021-00368-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Radiotherapy should have low toxicity in the entrance channel (normal tissue) and be very effective in cell killing in the target region (tumour). In this regard, ions heavier than protons have both physical and radiobiological advantages over conventional X-rays. Carbon ions represent an excellent combination of physical and biological advantages. There are a dozen carbon-ion clinical centres in Europe and Asia, and more under construction or at the planning stage, including the first in the USA. Clinical results from Japan and Germany are promising, but a heated debate on the cost-effectiveness is ongoing in the clinical community, owing to the larger footprint and greater expense of heavy ion facilities compared with proton therapy centres. We review here the physical basis and the clinical data with carbon ions and the use of different ions, such as helium and oxygen. Research towards smaller and cheaper machines with more effective beam delivery is necessary to make particle therapy affordable. The potential of heavy ions has not been fully exploited in clinics and, rather than there being a single 'silver bullet', different particles and their combination can provide a breakthrough in radiotherapy treatments in specific cases.
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Affiliation(s)
- Marco Durante
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany
- Institute of Condensed Matter Physics, Technische Universität Darmstadt, Darmstadt, Germany
| | - Jürgen Debus
- Department of Radiation Oncology and Heidelberg Ion Beam Therapy Center, Heidelberg University Hospital, Heidelberg, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jay S. Loeffler
- Departments of Radiation Oncology and Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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23
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Averbeck D, Rodriguez-Lafrasse C. Role of Mitochondria in Radiation Responses: Epigenetic, Metabolic, and Signaling Impacts. Int J Mol Sci 2021; 22:ijms222011047. [PMID: 34681703 PMCID: PMC8541263 DOI: 10.3390/ijms222011047] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/24/2021] [Accepted: 10/08/2021] [Indexed: 12/15/2022] Open
Abstract
Until recently, radiation effects have been considered to be mainly due to nuclear DNA damage and their management by repair mechanisms. However, molecular biology studies reveal that the outcomes of exposures to ionizing radiation (IR) highly depend on activation and regulation through other molecular components of organelles that determine cell survival and proliferation capacities. As typical epigenetic-regulated organelles and central power stations of cells, mitochondria play an important pivotal role in those responses. They direct cellular metabolism, energy supply and homeostasis as well as radiation-induced signaling, cell death, and immunological responses. This review is focused on how energy, dose and quality of IR affect mitochondria-dependent epigenetic and functional control at the cellular and tissue level. Low-dose radiation effects on mitochondria appear to be associated with epigenetic and non-targeted effects involved in genomic instability and adaptive responses, whereas high-dose radiation effects (>1 Gy) concern therapeutic effects of radiation and long-term outcomes involving mitochondria-mediated innate and adaptive immune responses. Both effects depend on radiation quality. For example, the increased efficacy of high linear energy transfer particle radiotherapy, e.g., C-ion radiotherapy, relies on the reduction of anastasis, enhanced mitochondria-mediated apoptosis and immunogenic (antitumor) responses.
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Affiliation(s)
- Dietrich Averbeck
- Laboratory of Cellular and Molecular Radiobiology, PRISME, UMR CNRS 5822/IN2P3, IP2I, Lyon-Sud Medical School, University Lyon 1, 69921 Oullins, France;
- Correspondence:
| | - Claire Rodriguez-Lafrasse
- Laboratory of Cellular and Molecular Radiobiology, PRISME, UMR CNRS 5822/IN2P3, IP2I, Lyon-Sud Medical School, University Lyon 1, 69921 Oullins, France;
- Department of Biochemistry and Molecular Biology, Lyon-Sud Hospital, Hospices Civils de Lyon, 69310 Pierre-Bénite, France
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24
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Diffenderfer ES, Sørensen BS, Mazal A, Carlson DJ. The current status of preclinical proton FLASH radiation and future directions. Med Phys 2021; 49:2039-2054. [PMID: 34644403 DOI: 10.1002/mp.15276] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 09/12/2021] [Accepted: 09/17/2021] [Indexed: 11/05/2022] Open
Abstract
We review the current status of proton FLASH experimental systems, including preclinical physical and biological results. Technological limitations on preclinical investigation of FLASH biological mechanisms and determination of clinically relevant parameters are discussed. A review of the biological data reveals no reproduced proton FLASH effect in vitro and a significant in vivo FLASH sparing effect of normal tissue toxicity observed with multiple proton FLASH irradiation systems. Importantly, multiple studies suggest little or no difference in tumor growth delay for proton FLASH when compared to conventional dose rate proton radiation. A discussion follows on future areas of development with a focus on the determination of the optimal parameters for maximizing the therapeutic ratio between tumor and normal tissue response and ultimately clinical translation of proton FLASH radiation.
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Affiliation(s)
- Eric S Diffenderfer
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Brita S Sørensen
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark.,Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Alejandro Mazal
- Department of Medical Physics, Centro de Protonterapia Quironsalud, Madrid, Spain
| | - David J Carlson
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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25
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Zakaria AM, Colangelo NW, Meesungnoen J, Jay-Gerin JP. Transient hypoxia in water irradiated by swift carbon ions at ultra-high dose rates: implication for FLASH carbon-ion therapy. CAN J CHEM 2021. [DOI: 10.1139/cjc-2021-0110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Large doses of ionizing radiation delivered to tumors at ultra-high dose rates (i.e., in a few milliseconds) paradoxically spare the surrounding healthy tissue while preserving anti-tumor activity (compared with conventional radiotherapy delivered at much lower dose rates). This new modality is known as “FLASH radiotherapy” (FLASH-RT). Although the molecular mechanisms underlying FLASH-RT are not yet fully understood, it has been suggested that radiation delivered at high dose rates spares normal tissue via oxygen depletion followed by subsequent radioresistance of the irradiated tissue. To date, FLASH-RT has been studied using electrons, photons, and protons in various basic biological experiments, pre-clinical studies, and recently in a human patient. However, the efficacy of heavy ions, such as energetic carbon ions, under FLASH-RT conditions remains unclear. Given that living cells and tissues consist mainly of water, we set out to study, from a pure radiation chemistry perspective, the effects of ultra-high dose rates on the transient yields and concentrations of radiolytic species formed in water irradiated by 300-MeV per nucleon carbon ions (LET ∼ 11.6 keV/µm). This mimics irradiation in the “plateau” region of the depth–dose distribution of ions, i.e., in the “normal” tissue region in which the LET is rather low. We used Monte Carlo simulations of multiple, simultaneously interacting radiation tracks together with an “instantaneous pulse” irradiation model. Our calculations show a pronounced oxygen depletion around 0.2 μs, strongly suggesting, as with electrons, photons, and protons, that irradiation with energetic carbon ions at ultra-high dose rates is suitable for FLASH-RT.
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Affiliation(s)
- Abdullah Muhammad Zakaria
- Département de médecine nucléaire et de radiobiologie, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, 3001, 12ème Avenue Nord, Sherbrooke, QC J1H 5N4, Canada
| | - Nicholas W. Colangelo
- Department of Radiation Oncology, NYU Grossman School of Medicine, New York, NY, USA
| | - Jintana Meesungnoen
- Département de médecine nucléaire et de radiobiologie, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, 3001, 12ème Avenue Nord, Sherbrooke, QC J1H 5N4, Canada
| | - Jean-Paul Jay-Gerin
- Département de médecine nucléaire et de radiobiologie, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, 3001, 12ème Avenue Nord, Sherbrooke, QC J1H 5N4, Canada
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26
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Weber UA, Scifoni E, Durante M. FLASH radiotherapy with carbon ion beams. Med Phys 2021; 49:1974-1992. [PMID: 34318508 DOI: 10.1002/mp.15135] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 07/19/2021] [Accepted: 07/19/2021] [Indexed: 12/17/2022] Open
Abstract
FLASH radiotherapy is considered a new potential breakthrough in cancer treatment. Ultra-high dose rates (>40 Gy/s) have been shown to reduce toxicity in the normal tissue without compromising tumor control, resulting in a widened therapeutic window. These high dose rates are more easily achievable in the clinic with charged particles, and clinical trials are, indeed, ongoing using electrons or protons. FLASH could be an attractive solution also for heavier ions such as carbon and could even enhance the therapeutic window. However, it is not yet known whether the FLASH effect will be the same as for sparsely ionizing radiation when densely ionizing carbons ions are used. Here we discuss the technical challenges in beam delivery and present a promising solution using 3D range-modulators in order to apply ultra-high dose rates (UHDR) compatible with FLASH with carbon ions. Furthermore, we will discuss the possible outcome of C-ion therapy at UHDR on the level of the radiobiological and radiation chemical effects.
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Affiliation(s)
- Uli Andreas Weber
- Biophysics Department, GSI Helhmoltzzentrum für Schwerionenforschung, Darmstadt, Germany
| | - Emanuele Scifoni
- Istituto Nazionale di Fisica Nucleare (INFN), Trento Institute for Fundamental Physics and Applications (TIFPA), Trento, Italy
| | - Marco Durante
- Biophysics Department, GSI Helhmoltzzentrum für Schwerionenforschung, Darmstadt, Germany.,Institute of Condensed Matter Physics, Technische Universität Darmstadt, Darmstadt, Germany
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27
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Durante M. Failla Memorial Lecture: The Many Facets of Heavy-Ion Science. Radiat Res 2021; 195:403-411. [PMID: 33979440 DOI: 10.1667/rade-21-00029.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 02/22/2021] [Indexed: 11/03/2022]
Abstract
Heavy ions are riveting in radiation biophysics, particularly in the areas of radiotherapy and space radiation protection. Accelerated charged particles can indeed penetrate deeply in the human body to sterilize tumors, exploiting the favorable depth-dose distribution of ions compared to conventional X rays. Conversely, the high biological effectiveness in inducing late effects presents a hazard for manned space exploration. Even after half a century of accelerator-based experiments, clinical applications and flight research, these two topics remain both fascinating and baffling. Heavy-ion therapy is very expensive, and despite the clinical success it remains controversial. Research on late radiation morbidity in spaceflight led to a reduction in uncertainty, but also pointed to new risks previously underestimated, such as possible damage to the central nervous system. Recently, heavy ions have also been used in other, unanticipated biomedical fields, such as treatment of heart arrhythmia or inactivation of viruses for vaccine development. Heavy-ion science nicely merges physics and biology and remains an extraordinary research field for the 21st century.
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Affiliation(s)
- Marco Durante
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung, 64291 Darmstadt, Germany; and Technische Universität Darmstadt, Institute of Condensed Matter Physics, 64289 Darmstadt, Germany
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28
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Lin B, Gao F, Yang Y, Wu D, Zhang Y, Feng G, Dai T, Du X. FLASH Radiotherapy: History and Future. Front Oncol 2021; 11:644400. [PMID: 34113566 PMCID: PMC8185194 DOI: 10.3389/fonc.2021.644400] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 05/04/2021] [Indexed: 12/12/2022] Open
Abstract
The biological effects of radiation dose to organs at risk surrounding tumor target volumes are a major dose-limiting constraint in radiotherapy. This can mean that the tumor cannot be completely destroyed, and the efficacy of radiotherapy will be decreased. Thus, ways to reduce damage to healthy tissue has always been a topic of particular interest in radiotherapy research. Modern radiotherapy technologies such as helical tomotherapy (HT), intensity-modulated radiation therapy (IMRT), and proton radiotherapy can reduce radiation damage to healthy tissues. Recent outcomes of animal experiments show that FLASH radiotherapy (FLASH-RT) can reduce radiation-induced damage in healthy tissue without decreasing antitumor effectiveness. The very short radiotherapy time compared to that of conventional dose-rate radiotherapy is another advantage of FLASH-RT. The first human patient received FLASH-RT in Switzerland in 2018. FLASH-RT may become one of the main radiotherapy technologies in clinical applications in the future. We summarize the history of the development of FLASH-RT, its mechanisms, its influence on radiotherapy, and its future.
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Affiliation(s)
- Binwei Lin
- Department of Oncology, MianYang Central Hospital, Mianyang, China
| | - Feng Gao
- Department of Oncology, MianYang Central Hospital, Mianyang, China
| | - Yiwei Yang
- Institute of Nuclear Physics and Chemistry, China Academy of Engineering Physics, Mianyang, China
| | - Dai Wu
- Institute of Applied Electronics, China Academy of Engineering Physics, Mianyang, China
| | - Yu Zhang
- Department of Oncology, MianYang Central Hospital, Mianyang, China
| | - Gang Feng
- Department of Oncology, MianYang Central Hospital, Mianyang, China
| | - Tangzhi Dai
- Department of Oncology, MianYang Central Hospital, Mianyang, China
| | - Xiaobo Du
- Department of Oncology, MianYang Central Hospital, Mianyang, China
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29
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Rezaee M, Iordachita I, Wong JW. Ultrahigh dose-rate (FLASH) x-ray irradiator for pre-clinical laboratory research. Phys Med Biol 2021; 66. [PMID: 33780922 DOI: 10.1088/1361-6560/abf2fa] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/29/2021] [Indexed: 01/25/2023]
Abstract
FLASH irradiation has been shown to reduce significantly normal tissue toxicity compared to conventional irradiation, while maintaining tumor control probability at similar level. Clinical translation of FLASH irradiation necessitates comprehensive laboratory studies to elucidate biological effects as well as pertinent technological and physical requirements. At present, FLASH research employs complex accelerator technologies of limited accessibilities. Here, we study the feasibility of a novel self-shielded x-ray irradiation cabinet system, as an enabling technology to enhance the preclinical research capabilities. The proposed system employs two commercially available high capacity 150 kVp fluoroscopy x-ray sources with rotating anode technology in a parallel-opposed arrangement. Simulation was performed with the GEANT4 Monte-Carlo platform. Simulated dosimetric properties of the x-ray beam for both FLASH and conventional dose-rate irradiations were characterized. Dose and dose rate from a single kV x-ray fluoroscopy source in solid water phantom were verified with measurements using Gafchromic films. The parallel-opposed x-ray sources can deliver over 50 Gy doses to a 20 mm thick water equivalent medium at ultrahigh dose-rates of 40-240 Gy s-1. A uniform depth-dose rate (±5%) is achieved over 8-12 mm in the central region of the phantom. Mirrored beams minimize heel effect of the source and achieve reasonable cross-beam uniformity (±3%). Conventional dose-rate irradiation (≤0.1 Gy s-1) can also be achieved by reducing the tube current and increasing the distance between the phantom and tubes. The rotating anode x-ray source can be used to deliver both FLASH and conventional dose-rate irradiations with the field dimensions well suitable for small animal and cell-culture irradiations. For FLASH irradiation using parallel-opposed sources, entrance and exit doses can be higher by 30% than the dose at the phantom center. Beam angling can be employed to minimize the high surface doses. Our proposed system is amendable to self-shielding and enhance research in regular laboratory setting.
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Affiliation(s)
- Mohammad Rezaee
- Department of Radiation Oncology and Molecular Radiation Sciences, Faculty of Medicine, Johns Hopkins University, United States of America
| | - Iulian Iordachita
- Department of Mechanical Engineering, Whiting School of Engineering, Johns Hopkins University, United States of America
| | - John W Wong
- Department of Radiation Oncology and Molecular Radiation Sciences, Faculty of Medicine, Johns Hopkins University, United States of America
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30
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Zakaria AM, Lertnaisat P, Islam MM, Meesungnoen J, Katsumura Y, Jay-Gerin JP. Yield of the Fricke dosimeter irradiated with the recoil α and Li ions of the 10B( n, α) 7Li nuclear reaction: effects of multiple ionization and temperature. CAN J CHEM 2021. [DOI: 10.1139/cjc-2020-0381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Monte Carlo track chemistry simulations were used to investigate the effects of multiple ionization (MI) of water on the yields (G values) of the ferrous sulfate (Fricke) dosimeter, which was irradiated with low-energy α and lithium ion recoils from the 10B(n,α)7Li nuclear reaction as a function of temperature from 25 to 350 °C. Calculations were performed individually for 1.47 MeV α-particles and 0.84 MeV lithium nuclei with dose-average linear energy transfer (LET) values of ∼196 and 225 keV/µm at 25 °C, respectively. The total yields were obtained by summing the G values for each recoil α and Li ion weighted with its fraction of the total energy absorbed. At room temperature, our G(Fe3+) values calculated under aerated and deaerated conditions only agreed well with the experimental results, provided the MI of water was incorporated in the simulations. This strongly supports the importance of the role of MI of water in the high-LET radiolysis of water. We also simulated the effects of MI of water on G-values for the primary species of the radiolysis of deaerated 0.4 M H2SO4 aqueous solutions by 10B(n,α)7Li recoils. As with the Fricke dosimeter, the best agreement between experiment and simulation was found at 25 °C when the MI of water was included in the simulations. It was also shown that G(Fe3+) decreases slightly as a function of temperature over the range of 25–350 °C. However, at elevated temperatures, no experimental data were available with which to compare our results.
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Affiliation(s)
- Abdullah Muhammad Zakaria
- Département de Médecine Nucléaire et de Radiobiologie, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, 3001, 12ème Avenue Nord, Sherbrooke, QC J1H 5N4, Canada
| | - Phantira Lertnaisat
- Department of Nuclear Engineering and Management, School of Engineering, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8656, Japan
| | - Muhammad Mainul Islam
- Département de Médecine Nucléaire et de Radiobiologie, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, 3001, 12ème Avenue Nord, Sherbrooke, QC J1H 5N4, Canada
- Baxter Healthcare Corporation, 89 Centre Street South, Alliston, ON L9R 1W7, Canada
| | - Jintana Meesungnoen
- Département de Médecine Nucléaire et de Radiobiologie, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, 3001, 12ème Avenue Nord, Sherbrooke, QC J1H 5N4, Canada
| | - Yosuke Katsumura
- Department of Nuclear Engineering and Management, School of Engineering, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8656, Japan
- Nuclear Professional School, School of Engineering, The University of Tokyo, Shirakata-shirane 2-22, Tokai-mura, Naka-gun, Ibaraki 319-1188, Japan
| | - Jean-Paul Jay-Gerin
- Département de Médecine Nucléaire et de Radiobiologie, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, 3001, 12ème Avenue Nord, Sherbrooke, QC J1H 5N4, Canada
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31
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Carbon Ion Radiobiology. Cancers (Basel) 2020; 12:cancers12103022. [PMID: 33080914 PMCID: PMC7603235 DOI: 10.3390/cancers12103022] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/12/2020] [Accepted: 10/14/2020] [Indexed: 12/15/2022] Open
Abstract
Simple Summary Radiotherapy with carbon ions has been used for over 20 years in Asia and Europe and is now planned in the USA. The physics advantages of carbon ions compared to X-rays are similar to those of protons, but their radiobiological features are quite distinct and may lead to a breakthrough in the treatment of some cancers characterized by high mortality. Abstract Radiotherapy using accelerated charged particles is rapidly growing worldwide. About 85% of the cancer patients receiving particle therapy are irradiated with protons, which have physical advantages compared to X-rays but a similar biological response. In addition to the ballistic advantages, heavy ions present specific radiobiological features that can make them attractive for treating radioresistant, hypoxic tumors. An ideal heavy ion should have lower toxicity in the entrance channel (normal tissue) and be exquisitely effective in the target region (tumor). Carbon ions have been chosen because they represent the best combination in this direction. Normal tissue toxicities and second cancer risk are similar to those observed in conventional radiotherapy. In the target region, they have increased relative biological effectiveness and a reduced oxygen enhancement ratio compared to X-rays. Some radiobiological properties of densely ionizing carbon ions are so distinct from X-rays and protons that they can be considered as a different “drug” in oncology, and may elicit favorable responses such as an increased immune response and reduced angiogenesis and metastatic potential. The radiobiological properties of carbon ions should guide patient selection and treatment protocols to achieve optimal clinical results.
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