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Xu P, Wang S, Zhou J, Yuan K, Wang X, Li L, Lang J, Lu S. Spatially fractionated radiotherapy (Lattice SFRT) in the palliative treatment of locally advanced bulky unresectable head and neck cancer. Clin Transl Radiat Oncol 2024; 48:100830. [PMID: 39219705 PMCID: PMC11364051 DOI: 10.1016/j.ctro.2024.100830] [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: 04/23/2024] [Revised: 06/03/2024] [Accepted: 07/29/2024] [Indexed: 09/04/2024] Open
Abstract
Objectives Locally advanced bulky unresectable head neck cancer causes significant tumor mass effects, leading to severe symptoms. This study aims to report the safety and outcomes in patients undergoing Lattice spatially fractionated radiotherapy (Lattice SFRT) for locally advanced bulky unresectable head and neck cancer. Methods Patients with bulky head and neck cancer received Lattice SFRT between June 2022 and June 2023. Lattice SFRT was administered in 2-3 fractions of 12 Gy (Gy) using 6-megavolt (MV) photon beams through a multileaf collimator (MLC) based on VMAT technology. The primary endpoints were symptomatic and tumor response rates. Secondary endpoints were overall survival, local control, and acute and late toxicity rates. Results 19 consecutive patients meeting the study criteria were identified, predominantly with squamous cell carcinoma histology. The median patient age was 62 years (range 39-79 years), and the median tumor volume was 208 cc (cc) (range 48-701 cc). All patients completed radiotherapy. Among all investigated patients, 16 of 19 (84.2 %) patients achieved an objective response, including 10 individuals achieved a partial response (PR), with 3 of them exhibiting regression exceeding 75 %. 17 patients showed symptom improvement to varying degrees. Acute toxicity of Radiation Therapy Oncology Group (RTOG) grade 1 or higher occurred in 5 patients, while no grade 3 adverse events was observed. Conclusions Lattice SFRT proves to be a viable treatment option for the palliative management of bulky head and neck cancer. In the palliative setting, Lattice SFRT offers timely symptom relief, enhancing patient quality of life. Treatment toxicity remains within an acceptable range. Continued optimization of Lattice SFRT delivery and patient selection can benefit from further data on the feasibility and efficacy of this radiation modality.
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Affiliation(s)
- Peng Xu
- Department of Radiation Oncology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Shuo Wang
- Department of Radiation Oncology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Jie Zhou
- Department of Radiation Oncology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Ke Yuan
- Department of Radiation Oncology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Xianliang Wang
- Department of Radiation Oncology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Lintao Li
- Department of Radiation Oncology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Jinyi Lang
- Department of Radiation Oncology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Shun Lu
- Department of Radiation Oncology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
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Li H, Mayr NA, Griffin RJ, Zhang H, Pokhrel D, Grams M, Penagaricano J, Chang S, Spraker MB, Kavanaugh J, Lin L, Sheikh K, Mossahebi S, Simone CB, Roberge D, Snider JW, Sabouri P, Molineu A, Xiao Y, Benedict SH. Overview and Recommendations for Prospective Multi-institutional Spatially Fractionated Radiation Therapy Clinical Trials. Int J Radiat Oncol Biol Phys 2024; 119:737-749. [PMID: 38110104 PMCID: PMC11162930 DOI: 10.1016/j.ijrobp.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 10/30/2023] [Accepted: 12/09/2023] [Indexed: 12/20/2023]
Abstract
PURPOSE The highly heterogeneous dose delivery of spatially fractionated radiation therapy (SFRT) is a profound departure from standard radiation planning and reporting approaches. Early SFRT studies have shown excellent clinical outcomes. However, prospective multi-institutional clinical trials of SFRT are still lacking. This NRG Oncology/American Association of Physicists in Medicine working group consensus aimed to develop recommendations on dosimetric planning, delivery, and SFRT dose reporting to address this current obstacle toward the design of SFRT clinical trials. METHODS AND MATERIALS Working groups consisting of radiation oncologists, radiobiologists, and medical physicists with expertise in SFRT were formed in NRG Oncology and the American Association of Physicists in Medicine to investigate the needs and barriers in SFRT clinical trials. RESULTS Upon reviewing the SFRT technologies and methods, this group identified challenges in several areas, including the availability of SFRT, the lack of treatment planning system support for SFRT, the lack of guidance in the physics and dosimetry of SFRT, the approximated radiobiological modeling of SFRT, and the prescription and combination of SFRT with conventional radiation therapy. CONCLUSIONS Recognizing these challenges, the group further recommended several areas of improvement for the application of SFRT in cancer treatment, including the creation of clinical practice guidance documents, the improvement of treatment planning system support, the generation of treatment planning and dosimetric index reporting templates, and the development of better radiobiological models through preclinical studies and through conducting multi-institution clinical trials.
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Affiliation(s)
- Heng Li
- Department of Radiation Oncology, John Hopkins University, Baltimore, Maryland.
| | - Nina A Mayr
- College of Human Medicine, Michigan State University, East Lansing, Michigan
| | - Robert J Griffin
- Department of Radiation Oncology, University of Arkansas for Medical Science, Little Rock, Arkansas
| | - Hualin Zhang
- Department of Radiation Oncology, University of Southern California, Los Angeles, California
| | - Damodar Pokhrel
- Department of Radiation Medicine, University of Kentucky, Lexington, Kentucky
| | - Michael Grams
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Jose Penagaricano
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Sha Chang
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | | | - James Kavanaugh
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Liyong Lin
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - Khadija Sheikh
- Department of Radiation Oncology, John Hopkins University, Baltimore, Maryland
| | - Sina Mossahebi
- Department of Radiation Oncology, University of Maryland, Baltimore, Maryland
| | - Charles B Simone
- Department of Radiation Oncology, New York Proton Center, New York, New York
| | - David Roberge
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - James W Snider
- South Florida Proton Therapy Institute, 5280 Linton Blvd, Delray Beach, Florida
| | - Pouya Sabouri
- Department of Radiation Oncology, University of Arkansas for Medical Science, Little Rock, Arkansas
| | - Andrea Molineu
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ying Xiao
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stanley H Benedict
- Department of Radiation Oncology, University of California, Davis, Sacramento, California
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Jenkins SV, Johnsrud AJ, Dings RPM, Griffin RJ. Bystander Effects in Spatially Fractionated Radiation Therapy: From Molecule To Organism To Clinical Implications. Semin Radiat Oncol 2024; 34:284-291. [PMID: 38880537 PMCID: PMC11185274 DOI: 10.1016/j.semradonc.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
The standard of care for radiation therapy is numerous, low-dose fractions that are distributed homogeneously throughout the tumor. An alternative strategy under scrutiny is to apply spatially fractionated radiotherapy (high and low doses throughout the tumor) in one or several fractions, either alone or followed by conventional radiation fractionation . Spatial fractionation allows for significant sparing of normal tissue, and the regions of tumor or normal tissue that received sublethal doses can give rise to beneficial bystander effects in both cases. Bystander effects are broadly defined as biological responses that are significantly greater than would be anticipated based on the radiation dose received. Typically these effects are initiated by diffusion of reactive oxygen species and secretion of various cytokines. As demonstrated in the literature, spatial fractionation related bystander effects can occur locally from cell to cell and in what are known as "cohort effects," which tend to take the form of restructuring of the vasculature, enhanced immune infiltration, and development of immunological memory. Other bystander effects can take place at distant sites in what are known as "abscopal effects." While these events are rare, they are mediated by the immune system and can result in the eradication of secondary and metastatic disease. Currently, due to the complexity and variability of these bystander effects, they are not thoroughly understood, but as knowledge improves they may present significant opportunities for improved clinical outcomes.
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Affiliation(s)
- Samir V Jenkins
- Department of Radiation Oncology, University of Arkansas for Medical Sciences, Little Rock, AR..
| | | | - Ruud P M Dings
- Department of Radiation Oncology, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Robert J Griffin
- Department of Radiation Oncology, University of Arkansas for Medical Sciences, Little Rock, AR
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4
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Mossahebi S, Molitoris JK, Poirier Y, Jatczak J, Zhang B, Mohindra P, Ferris M, Regine WF, Yi B. Clinical Implementation and Dosimetric Evaluation of a Robust Proton Lattice Planning Strategy Using Primary and Robust Complementary Beams. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00742-9. [PMID: 38936634 DOI: 10.1016/j.ijrobp.2024.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 05/17/2024] [Accepted: 06/15/2024] [Indexed: 06/29/2024]
Abstract
PURPOSE Pencil-beam scanning proton therapy has been considered a potential modality for the 3D form of spatially fractionated radiation therapy called lattice therapy. However, few practical solutions have been introduced in the clinic. Existing limitations include degradation in plan quality and robustness when using single-field versus multifield lattice plans, respectively. We propose a practical and robust proton lattice (RPL) planning method using multifield and evaluate its dosimetric characteristics compared to clinically acceptable photon lattice plans. METHODS AND MATERIALS Seven cases previously treated with photon lattice therapy were used to evaluate a novel RPL planning technique using 2-orthogonal beams: a primary beam (PB) and a robust complementary beam (RCB) that deliver 67% and 33%, respectively, of the prescribed dose to vertices inside the gross target volume (GTV). Only RCB is robustly optimized for setup and range uncertainties. The number and volume of vertices, peak-to-valley dose ratios (PVDRs), and volume of low dose to GTV of proton and photon plans were compared. The RPL technique was then used in the treatment of 2 patients and their dosimetric parameters were reported. RESULTS The RPL strategy was able to achieve the clinical planning goals. Compared to previously treated photon plans, the average number of vertices increased by 30%, the average vertex volume by 49% (18.2 ± 25.9 cc vs 12.2 ± 14.5 cc, P = .21), and higher PVDR (10.5 ± 4.8 vs 2.5 ± 0.9, P < .005) was achieved. In addition, RPL plans show more conformal dose with less low dose to GTV (V30%, 60.9% ± 7.2% vs 81.6% ± 13.9% and V10%, 88.3% ± 4.5% vs 98.6% ± 3.6% [P < .01]). The RPL plan for 2 treated patients showed PVDRs of 4.61 and 14.85 with vertices-to-GTV ratios of 1.52% and 1.30%, respectively. CONCLUSIONS A novel RPL planning strategy using a pair of orthogonal beams was developed and successfully translated to the clinic. The proposed method can generate better quality plans, a higher number of vertices, and higher PVDRs than currently used photon lattice plans.
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Affiliation(s)
- Sina Mossahebi
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland; Maryland Proton Treatment Center, Baltimore, Maryland.
| | - Jason K Molitoris
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland; Maryland Proton Treatment Center, Baltimore, Maryland
| | - Yannick Poirier
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jenna Jatczak
- Maryland Proton Treatment Center, Baltimore, Maryland
| | - Baoshe Zhang
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland; Maryland Proton Treatment Center, Baltimore, Maryland
| | - Pranshu Mohindra
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Matthew Ferris
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland; Maryland Proton Treatment Center, Baltimore, Maryland
| | - William F Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland; Maryland Proton Treatment Center, Baltimore, Maryland
| | - ByongYong Yi
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland; Maryland Proton Treatment Center, Baltimore, Maryland
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Prezado Y, Grams M, Jouglar E, Martínez-Rovira I, Ortiz R, Seco J, Chang S. Spatially fractionated radiation therapy: a critical review on current status of clinical and preclinical studies and knowledge gaps. Phys Med Biol 2024; 69:10TR02. [PMID: 38648789 DOI: 10.1088/1361-6560/ad4192] [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: 11/27/2023] [Accepted: 04/22/2024] [Indexed: 04/25/2024]
Abstract
Spatially fractionated radiation therapy (SFRT) is a therapeutic approach with the potential to disrupt the classical paradigms of conventional radiation therapy. The high spatial dose modulation in SFRT activates distinct radiobiological mechanisms which lead to a remarkable increase in normal tissue tolerances. Several decades of clinical use and numerous preclinical experiments suggest that SFRT has the potential to increase the therapeutic index, especially in bulky and radioresistant tumors. To unleash the full potential of SFRT a deeper understanding of the underlying biology and its relationship with the complex dosimetry of SFRT is needed. This review provides a critical analysis of the field, discussing not only the main clinical and preclinical findings but also analyzing the main knowledge gaps in a holistic way.
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Affiliation(s)
- Yolanda Prezado
- Institut Curie, Université PSL, CNRS UMR3347, Inserm U1021, Signalisation Radiobiologie et Cancer, F-91400, Orsay, France
- Université Paris-Saclay, CNRS UMR3347, Inserm U1021, Signalisation Radiobiologie et Cancer, F-91400, Orsay, France
- New Approaches in Radiotherapy Lab, Center for Research in Molecular Medicine and Chronic Diseases (CIMUS), Instituto de investigación Sanitaria de Santiago de Compostela (IDIS), University of Santiago de Compostela, Santiago de Compostela, A Coruña, E-15706, Spain
- Oportunius Program, Galician Agency of Innovation (GAIN), Xunta de Galicia, Santiago de Compostela, A Coruña, Spain
| | - Michael Grams
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States of America
| | - Emmanuel Jouglar
- Institut Curie, PSL Research University, Department of Radiation Oncology, F-75005, Paris and Orsay Protontherapy Center, F-91400, Orsay, France
| | - Immaculada Martínez-Rovira
- Physics Department, Universitat Auto`noma de Barcelona, E-08193, Cerdanyola del Valle`s (Barcelona), Spain
| | - Ramon Ortiz
- University of California San Francisco, Department of Radiation Oncology, 1600 Divisadero Street, San Francisco, CA 94143, United States of America
| | - Joao Seco
- Division of Biomedical physics in Radiation Oncology, DKFZ-German Cancer Research Center, Heidelberg, Germany
- Department of Physics and Astronomy, Heidelberg University, Heidelberg, Germany
| | - Sha Chang
- Dept of Radiation Oncology and Department of Biomedical Engineering, University of North Carolina School of Medicine, United States of America
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolin State University, United States of America
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6
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Reaz F, Traneus E, Bassler N. Tuning spatially fractionated radiotherapy dose profiles using the moiré effect. Sci Rep 2024; 14:8468. [PMID: 38605022 PMCID: PMC11009409 DOI: 10.1038/s41598-024-55104-7] [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: 11/03/2023] [Accepted: 02/20/2024] [Indexed: 04/13/2024] Open
Abstract
Spatially Fractionated Radiotherapy (SFRT) has demonstrated promising potential in cancer treatment, combining the advantages of reduced post-radiation effects and enhanced local control rates. Within this paradigm, proton minibeam radiotherapy (pMBRT) was suggested as a new treatment modality, possibly producing superior normal tissue sparing to conventional proton therapy, leading to improvements in patient outcomes. However, an effective and convenient beam generation method for pMBRT, capable of implementing various optimum dose profiles, is essential for its real-world application. Our study investigates the potential of utilizing the moiré effect in a dual collimator system (DCS) to generate pMBRT dose profiles with the flexibility to modify the center-to-center distance (CTC) of the dose distribution in a technically simple way.We employ the Geant4 Monte Carlo simulations tool to demonstrate that the angle between the two collimators of a DCS can significantly impact the dose profile. Varying the DCS angle from 10∘ to 50∘ we could cover CTC ranging from 11.8 mm to 2.4 mm, respectively. Further investigations reveal the substantial influence of the multi-slit collimator's (MSC) physical parameters on the spatially fractionated dose profile, such as period (CTC), throughput, and spacing between MSCs. These findings highlight opportunities for precision dose profile adjustments tailored to specific clinical scenarios.The DCS capacity for rapid angle adjustments during the energy transition stages of a spot scanning system can facilitate dynamic alterations in the irradiation profile, enhancing dose contrast in normal tissues. Furthermore, its unique attribute of spatially fractionated doses in both lateral directions could potentially improve normal tissue sparing by minimizing irradiated volume. Beyond the realm of pMBRT, the dual MSC system exhibits remarkable versatility, showing compatibility with different types of beams (X-rays and electrons) and applicability across various SFRT modalities.Our study illuminates the dual MSC system's potential as an efficient and adaptable tool in the refinement of pMBRT techniques. By enabling meticulous control over irradiation profiles, this system may expedite advancements in clinical and experimental applications, thereby contributing to the evolution of SFRT strategies.
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Affiliation(s)
- Fardous Reaz
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark.
| | | | - Niels Bassler
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
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Deufel C, Dodoo C, Kavanaugh J, Finley R, Lang K, Sorenson K, Spreiter S, Brooks J, Moseley D, Ahmed SK, Haddock MG, Ma D, Park SS, Petersen IA, Owen DW, Grams MP. Automated target placement for VMAT lattice radiation therapy: enhancing efficiency and consistency. Phys Med Biol 2024; 69:075010. [PMID: 38422544 DOI: 10.1088/1361-6560/ad2ee8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 02/29/2024] [Indexed: 03/02/2024]
Abstract
Objective. An algorithm was developed for automated positioning of lattice points within volumetric modulated arc lattice radiation therapy (VMAT LRT) planning. These points are strategically placed within the gross tumor volume (GTV) to receive high doses, adhering to specific separation rules from adjacent organs at risk (OARs). The study goals included enhancing planning safety, consistency, and efficiency while emulating human performance.Approach. A Monte Carlo-based algorithm was designed to optimize the number and arrangement of lattice points within the GTV while considering placement constraints and objectives. These constraints encompassed minimum spacing between points, distance from OARs, and longitudinal separation along thez-axis. Additionally, the algorithm included an objective to permit, at the user's discretion, solutions with more centrally placed lattice points within the GTV. To validate its effectiveness, the automated approach was compared with manually planned treatments for 24 previous patients. Prior to clinical implementation, a failure mode and effects analysis (FMEA) was conducted to identify potential shortcomings.Main results.The automated program successfully met all placement constraints with an average execution time (over 24 plans) of 0.29 ±0.07 min per lattice point. The average lattice point density (# points per 100 c.c. of GTV) was similar for automated (0.725) compared to manual placement (0.704). The dosimetric differences between the automated and manual plans were minimal, with statistically significant differences in certain metrics like minimum dose (1.9% versus 1.4%), D5% (52.8% versus 49.4%), D95% (7.1% versus 6.2%), and Body-GTV V30% (20.7 c.c. versus 19.7 c.c.).Significance.This study underscores the feasibility of employing a straightforward Monte Carlo-based algorithm to automate the creation of spherical target structures for VMAT LRT planning. The automated method yields similar dose metrics, enhances inter-planner consistency for larger targets, and requires fewer resources and less time compared to manual placement. This approach holds promise for standardizing treatment planning in prospective patient trials and facilitating its adoption across centers seeking to implement VMAT LRT techniques.
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Affiliation(s)
- Christopher Deufel
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Christopher Dodoo
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, AZ 85259, United States of America
| | - James Kavanaugh
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Randi Finley
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Karen Lang
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Kasie Sorenson
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Sheri Spreiter
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Jamison Brooks
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Douglas Moseley
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Safia K Ahmed
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, AZ 85259, United States of America
| | - Michael G Haddock
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Daniel Ma
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Ivy A Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Dawn W Owen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Michael P Grams
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
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8
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Ahmed SK, Petersen IA, Grams MP, Finley RR, Haddock MG, Owen D. Spatially Fractionated Radiation Therapy in Sarcomas: A Large Single-Institution Experience. Adv Radiat Oncol 2024; 9:101401. [PMID: 38495033 PMCID: PMC10943518 DOI: 10.1016/j.adro.2023.101401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 10/16/2023] [Indexed: 03/19/2024] Open
Abstract
Purpose Spatially fractionated radiation therapy (SFRT) is a recognized technique for enhancing tumor response in radioresistant and bulky tumors. We analyzed clinical and treatment outcomes in patients with bone and soft tissue sarcomas treated with modern SFRT techniques. Methods and Materials Patients with metastatic or unresectable sarcoma treated with brass collimator, volumetric modulated arc therapy lattice, or proton SFRT from December 2019 to June 2022 were retrospectively reviewed. Consolidative external beam radiation therapy (EBRT) was delivered at the physician's discretion. Patient and treatment characteristics, treatment response (symptom improvement, local control, and imaging response), and toxicity data were collected. Results The cohort consisted of 53 patients treated with 61 SFRT treatments. Median age at treatment was 60.0 years. The primary location was soft tissue in 46 courses (75%) and bone in 15 (25%). Fifty-three courses (87%) were treated for symptom relief. The most used SFRT technique was volumetric modulated arc therapy lattice (n = 52, 85%) to a dose of 20 Gy (n = 48, 79%; range, 16-20 Gy). EBRT was delivered post-SFRT in 55 (90%) treatment courses with a median time interval from SFRT to EBRT of 5 days (range, 0-14 days). Median physical EBRT dose and fractionation was 40 Gy (range, 9-73.5 Gy) and 10 fractions (range, 3-33 fractions). Median follow up was 7.4 months (range, 0.2-30 months). One-year overall survival and local control rates were 53% and 82%. Symptom relief was documented with 32 treatment courses (60%). Stable or partial response was observed with 47 treatment courses (90%). Four grade 3 to 4 acute and subacute toxicities were attributable to SFRT (8%). Conclusions The current series is the largest to date documenting outcomes for SFRT in sarcomas. Our results suggest combined SFRT with EBRT is associated with a favorable toxicity profile and high rates of symptomatic and radiographic responses for metastatic or unresectable sarcomas.
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Affiliation(s)
- Safia K. Ahmed
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Ivy A. Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Michael P. Grams
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Randi R. Finley
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Dawn Owen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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9
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Mayr NA, Mohiuddin M, Snider JW, Zhang H, Griffin RJ, Amendola BE, Hippe DS, Perez NC, Wu X, Lo SS, Regine WF, Simone CB. Practice Patterns of Spatially Fractionated Radiation Therapy: A Clinical Practice Survey. Adv Radiat Oncol 2024; 9:101308. [PMID: 38405319 PMCID: PMC10885580 DOI: 10.1016/j.adro.2023.101308] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 06/26/2023] [Indexed: 02/27/2024] Open
Abstract
Purpose Spatially fractionated radiation therapy (SFRT) is increasingly used for bulky advanced tumors, but specifics of clinical SFRT practice remain elusive. This study aimed to determine practice patterns of GRID and Lattice radiation therapy (LRT)-based SFRT. Methods and Materials A survey was designed to identify radiation oncologists' practice patterns of patient selection for SFRT, dosing/planning, dosimetric parameter use, SFRT platforms/techniques, combinations of SFRT with conventional external beam radiation therapy (cERT) and multimodality therapies, and physicists' technical implementation, delivery, and quality procedures. Data were summarized using descriptive statistics. Group comparisons were analyzed with permutation tests. Results The majority of practicing radiation oncologists (United States, 100%; global, 72.7%) considered SFRT an accepted standard-of-care radiation therapy option for bulky/advanced tumors. Treatment of metastases/recurrences and nonmetastatic primary tumors, predominantly head and neck, lung cancer and sarcoma, was commonly practiced. In palliative SFRT, regimens of 15 to 18 Gy/1 fraction predominated (51.3%), and in curative-intent treatment of nonmetastatic tumors, 15 Gy/1 fraction (28.0%) and fractionated SFRT (24.0%) were most common. SFRT was combined with cERT commonly but not always in palliative (78.6%) and curative-intent (85.7%) treatment. SFRT-cERT time sequencing and cERT dose adjustments were variable. In curative-intent treatment, concurrent chemotherapy and immunotherapy were found acceptable by 54.5% and 28.6%, respectively. Use of SFRT dosimetric parameters was highly variable and differed between GRID and LRT. SFRT heterogeneity dosimetric parameters were more commonly used (P = .008) and more commonly thought to influence local control (peak dose, P = .008) in LRT than in GRID therapy. Conclusions SFRT has already evolved as a clinical practice pattern for advanced/bulky tumors. Major treatment approaches are consistent and follow the literature, but SFRT-cERT combination/sequencing and clinical utilization of dosimetric parameters are variable. These areas may benefit from targeted education and standardization, and knowledge gaps may be filled by incorporating identified inconsistencies into future clinical research.
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Affiliation(s)
- Nina A. Mayr
- College of Human Medicine, Michigan State University, East Lansing, Michigan
| | - Majid Mohiuddin
- Radiation Oncology Consultants and Northwestern Proton Center, Warrenville, Illinois
| | - James W. Snider
- Radiation Oncology, South Florida Proton Therapy Institute, Delray Beach, Florida
| | - Hualin Zhang
- Department of Radiation Oncology, University of Southern California, Los Angeles, California
| | - Robert J. Griffin
- Department of Radiation Oncology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | - Daniel S. Hippe
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | | | - Xiaodong Wu
- Executive Medical Physics Associates, Miami, Florida
| | - Simon S. Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
| | - William F. Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Charles B. Simone
- Department of Radiation Oncology, New York Proton Center, New York, New York
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10
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Medici F, Strolin S, Castellucci P, Cilla S, Laghi V, Galietta E, Vadalà M, Strigari L, Morganti AG, Cammelli S. Complete metabolic response after Partially Ablative Radiotherapy (PAR) for bulky retroperitoneal liposarcoma: A case report. Radiol Case Rep 2024; 19:305-309. [PMID: 38028304 PMCID: PMC10656220 DOI: 10.1016/j.radcr.2023.10.024] [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: 09/26/2023] [Revised: 10/01/2023] [Accepted: 10/08/2023] [Indexed: 12/01/2023] Open
Abstract
In the management of symptomatic inoperable retroperitoneal sarcomas (RPS), palliative radiotherapy (RT) is a potential treatment option. However, the efficacy of low doses used in palliative RT is limited in these radioresistant tumors. Therefore, exploring dose escalation strategies targeting specific regions of the tumor may enhance the therapeutic effect of RT in relieving or preventing symptoms. In this case report, we present the case of an 87-year-old patient with rapidly growing undifferentiated liposarcoma in the retroperitoneum, where surgical and systemic therapies were ruled out due to age and comorbidities. RT was administered using volumetric modulated arc therapy, delivering 20 Gy in 4 fractions twice daily to the macroscopic tumor and 40 Gy in 4 fractions twice daily (simultaneous integrated boost) to the central part of the tumor (Gross Tumor Volume minus 2 cm). An 18F-FDG-PET-CT scan performed after RT demonstrated a complete metabolic response throughout the entire tumor mass. Although the patient eventually succumbed to metastatic spread to the bone, liver, and lung after 9 months, no local disease progression or pain/obstructive symptoms were observed. This case highlights the technical and clinical feasibility of delivering ablative doses of RT to the central region of the tumor and suggests the potential for achieving a complete metabolic response and durable tumor control.
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Affiliation(s)
- Federica Medici
- Department of Medical and Surgical Sciences, DIMEC, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Silvia Strolin
- Department of Medical Physics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Paolo Castellucci
- Nuclear Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Savino Cilla
- Medical Physics Unit, Gemelli Molise Hospital – Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Viola Laghi
- Department of Medical and Surgical Sciences, DIMEC, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Erika Galietta
- Department of Medical and Surgical Sciences, DIMEC, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Maria Vadalà
- Nuclear Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Lidia Strigari
- Department of Medical Physics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alessio Giuseppe Morganti
- Department of Medical and Surgical Sciences, DIMEC, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Silvia Cammelli
- Department of Medical and Surgical Sciences, DIMEC, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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11
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Zhang W, Lin Y, Wang F, Badkul R, Chen RC, Gao H. Lattice position optimization for LATTICE therapy. Med Phys 2023; 50:7359-7367. [PMID: 37357825 PMCID: PMC11058082 DOI: 10.1002/mp.16572] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 05/23/2023] [Accepted: 06/06/2023] [Indexed: 06/27/2023] Open
Abstract
BACKGROUND LATTICE radiation therapy delivers 3D heterogenous dose of high peak-to-valley dose ratio (PVDR) to the tumor target, with peak dose at lattice vertices inside the target and valley dose for the rest of the target. Although the lattice vertex positions can impact PVDR inside the target and sparing of organs-at-risk (OAR), they are fixed as constants and not optimized during treatment planning in current clinical practice. PURPOSE This work proposes a new LATTICE plan optimization method that can optimize lattice vertex positions during LATTICE treatment planning, which is the first lattice position optimization study to the best of our knowledge. METHODS The new LATTICE treatment planning method optimizes lattice vertex positions as well as other plan variables (e.g., photon fluences or proton spot weights), with optimization objectives for target PVDR and OAR sparing. To satisfy mathematical differentiability, the lattice vertices are approximated in sigmoid functions. For geometric feasibility, proper geometry constraints are enforced onto lattice vertex positions. The lattice position optimization problem is solved by iterative convex relaxation (ICR) method and alternating direction method of multipliers (ADMM), and lattice vertex positions and photon/proton plan variables are jointly updated via the Quasi-Newton method. RESULTS Both photon and proton LATTICE RT were considered, and the optimal lattice vertex positions in terms of plan objectives were found by solving all possible combinations on given discrete positions via exhaustive searching based on standard IMRT/IMPT, which served as the ground truth for validating the new LATTICE method. The results show that the new method indeed provided the optimal lattice vertex positions with the smallest optimization objective, the largest target PVDR, and the best OAR sparing. CONCLUSIONS A new LATTICE treatment planning method is proposed and validated that can optimize lattice vertex positions as well as other photon or proton plan variables for improving target PVDR and OAR sparing.
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Affiliation(s)
- Weijie Zhang
- Department of Radiation Oncology, University of Kansas Medical Center, Lawrence, Kansas, USA
| | - Yuting Lin
- Department of Radiation Oncology, University of Kansas Medical Center, Lawrence, Kansas, USA
| | - Fen Wang
- Department of Radiation Oncology, University of Kansas Medical Center, Lawrence, Kansas, USA
| | - Rajeev Badkul
- Department of Radiation Oncology, University of Kansas Medical Center, Lawrence, Kansas, USA
| | - Ronald C Chen
- Department of Radiation Oncology, University of Kansas Medical Center, Lawrence, Kansas, USA
| | - Hao Gao
- Department of Radiation Oncology, University of Kansas Medical Center, Lawrence, Kansas, USA
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12
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Reaz F, Sitarz MK, Traneus E, Bassler N. Parameters for proton minibeam radiotherapy using a clinical scanning beam system. Acta Oncol 2023; 62:1561-1565. [PMID: 37837215 DOI: 10.1080/0284186x.2023.2266125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 09/28/2023] [Indexed: 10/15/2023]
Affiliation(s)
- Fardous Reaz
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Niels Bassler
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
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13
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Grams MP, Deufel CL, Kavanaugh JA, Corbin KS, Ahmed SK, Haddock MG, Lester SC, Ma DJ, Petersen IA, Finley RR, Lang KG, Spreiter SS, Park SS, Owen D. Clinical aspects of spatially fractionated radiation therapy treatments. Phys Med 2023; 111:102616. [PMID: 37311338 DOI: 10.1016/j.ejmp.2023.102616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/06/2023] [Accepted: 05/30/2023] [Indexed: 06/15/2023] Open
Abstract
PURPOSE To provide clinical guidance for centers wishing to implement photon spatially fractionated radiation therapy (SFRT) treatments using either a brass grid or volumetric modulated arc therapy (VMAT) lattice approach. METHODS We describe in detail processes which have been developed over the course of a 3-year period during which our institution treated over 240 SFRT cases. The importance of patient selection, along with aspects of simulation, treatment planning, quality assurance, and treatment delivery are discussed. Illustrative examples involving clinical cases are shown, and we discuss safety implications relevant to the heterogeneous dose distributions. RESULTS SFRT can be an effective modality for tumors which are otherwise challenging to manage with conventional radiation therapy techniques or for patients who have limited treatment options. However, SFRT has several aspects which differ drastically from conventional radiation therapy treatments. Therefore, the successful implementation of an SFRT treatment program requires the multidisciplinary expertise and collaboration of physicians, physicists, dosimetrists, and radiation therapists. CONCLUSIONS We have described methods for patient selection, simulation, treatment planning, quality assurance and delivery of clinical SFRT treatments which were built upon our experience treating a large patient population with both a brass grid and VMAT lattice approach. Preclinical research and patient trials aimed at understanding the mechanism of action are needed to elucidate which patients may benefit most from SFRT, and ultimately expand its use.
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Affiliation(s)
- Michael P Grams
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
| | - Christopher L Deufel
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - James A Kavanaugh
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Kimberly S Corbin
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Safia K Ahmed
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Michael G Haddock
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Scott C Lester
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Daniel J Ma
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Ivy A Petersen
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Randi R Finley
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Karen G Lang
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Sheri S Spreiter
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Dawn Owen
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
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14
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Hatoum GF, Temple HT, Garcia SA, Zheng Y, Kfoury F, Kinley J, Wu X. Neoadjuvant Radiation Therapy with Interdigitated High-Dose LRT for Voluminous High-Grade Soft-Tissue Sarcoma. Cancer Manag Res 2023; 15:113-122. [PMID: 36776730 PMCID: PMC9910204 DOI: 10.2147/cmar.s393934] [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: 10/18/2022] [Accepted: 01/18/2023] [Indexed: 02/05/2023] Open
Abstract
Purpose To report a case of large extremity soft tissue sarcoma (2933 cc), safely treated with a novel approach of interdigitating high-dose LATTICE radiation therapy (LRT) with standard radiation therapy as a neoadjuvant treatment to surgery. Patients and Methods Four sessions of high-dose LRT were delivered in a weekly interval, interdigitated with standard radiation therapy. The LRT plan consisted of 15 high-dose vertices receiving a dose >12 Gy per session, with 2-3 Gy to the peripheral margin of the tumor. The patient underwent surgical excision 2 months after the new regimen of induction radiation therapy. Results and Discussion The patient tolerated the radiation therapy regimen well. The post-operative assessment revealed a negative surgical margin and over 95% necrosis of the total tumor volume. The post-surgical wound complication was mitigated by outpatient wound care. Interdigitating multiple sessions of high-dose LATTICE radiation treatments with standard neoadjuvant radiation therapy as a neoadjuvant therapy for soft tissue sarcoma was feasible and did not incur additional toxicity in this clinical case. A phase-I/II trial will be conducted to further evaluate the toxicity and efficacy of the new treatment strategy with the intent to increase the rate of pathologic necrosis, which has been shown to positively correlate with the overall survival.
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Affiliation(s)
- Georges F Hatoum
- Department of Radiation Oncology, HCA Florida JFK Medical Center Comprehensive Cancer Institute, Lake Worth, FL, USA
| | - H Thomas Temple
- Department of Orthopedic Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Silvio A Garcia
- Department of Radiation Oncology, HCA Florida JFK Medical Center Comprehensive Cancer Institute, Lake Worth, FL, USA
| | - Yi Zheng
- Department of Radiation Oncology, HCA Florida JFK Medical Center Comprehensive Cancer Institute, Lake Worth, FL, USA,Department of Research and Development, Executive Medical Physics Associates, North Miami Beach, FL, USA
| | - Fouad Kfoury
- Pharmacy Department, South Miami Hospital, South Miami, FL, USA
| | - Jill Kinley
- Department of Clinical Research, HCA Florida JFK Medical Center, Atlantis, FL, USA
| | - Xiaodong Wu
- Department of Radiation Oncology, HCA Florida JFK Medical Center Comprehensive Cancer Institute, Lake Worth, FL, USA,Department of Research and Development, Executive Medical Physics Associates, North Miami Beach, FL, USA,Correspondence: Xiaodong Wu, Executive Medical Physics Associates, 19470 NE 22nd Road, North Miami Beach, FL, 33179, USA, Tel +1 305 775 0333, Email
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15
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An International Consensus on the Design of Prospective Clinical–Translational Trials in Spatially Fractionated Radiation Therapy for Advanced Gynecologic Cancer. Cancers (Basel) 2022; 14:cancers14174267. [PMID: 36077802 PMCID: PMC9454841 DOI: 10.3390/cancers14174267] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/22/2022] [Accepted: 08/24/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Spatially fractionated radiation therapy (SFRT) delivers intentionally heterogenous dose to tumors. This is a major departure from current radiation therapy, which strives for uniform dose. Early pilot experience suggests promising treatment outcomes with SFRT in patients with challenging bulky tumors, including gynecologic cancer. Well-conducted prospective multi-institutional clinical trials are now needed to further test SFRT as a treatment modality. However, clinical trial development is hampered by the variabilities in SFRT approach and the overall unfamiliarity with heterogeneous dosing. A broad consensus among SFRT experts, potential investigators, and the wider radiation oncology community is needed so that clinical trials in SFRT can be successfully designed and carried out. We developed an international consensus guideline for the design parameters of clinical/translational trials in SFRT for gynecologic cancer. High-to-moderate consensus was achieved, and harmonized fundamental design parameters for SFRT trials in advanced gynecologic cancer were defined. Abstract Despite the unexpectedly high tumor responses and limited treatment-related toxicities observed with SFRT, prospective multi-institutional clinical trials of SFRT are still lacking. High variability of SFRT technologies and methods, unfamiliar complex dose and prescription concepts for heterogeneous dose and uncertainty regarding systemic therapies present major obstacles towards clinical trial development. To address these challenges, the consensus guideline reported here aimed at facilitating trial development and feasibility through a priori harmonization of treatment approach and the full range of clinical trial design parameters for SFRT trials in gynecologic cancer. Gynecologic cancers were evaluated for the status of SFRT pilot experience. A multi-disciplinary SFRT expert panel for gynecologic cancer was established to develop the consensus through formal panel review/discussions, appropriateness rank voting and public comment solicitation/review. The trial design parameters included eligibility/exclusions, endpoints, SFRT technology/technique, dose/dosimetric parameters, systemic therapies, patient evaluations, and embedded translational science. Cervical cancer was determined as the most suitable gynecologic tumor for an SFRT trial. Consensus emphasized standardization of SFRT dosimetry/physics parameters, biologic dose modeling, and specimen collection for translational/biological endpoints, which may be uniquely feasible in cervical cancer. Incorporation of brachytherapy into the SFRT regimen requires additional pre-trial pilot investigations. Specific consensus recommendations are presented and discussed.
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16
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The Palliative Care in the Metastatic Spinal Tumors. A Systematic Review on the Radiotherapy and Surgical Perspective. Life (Basel) 2022; 12:life12040571. [PMID: 35455062 PMCID: PMC9032747 DOI: 10.3390/life12040571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/18/2022] [Accepted: 04/08/2022] [Indexed: 12/17/2022] Open
Abstract
Spine represents the most common site for metastatic disease involvement. Due to the close relationship between the spinal cord and critical structures, therapeutical management of metastatic spinal cord disease remains challenging. Spinal localization can lead to neurological sequelae, which can significantly affect the quality of life in patients with a limited life expectancy. The authors conducted a systematic literature review according to PRISMA guidelines in order to determine the impact of the most updated palliative care on spinal metastases. The initial literature search retrieved 2526 articles, manually screened based on detailed exclusion criteria. Finally, 65 studies met the inclusion criteria and were finally included in the systematic review. In the wide scenario of palliative care, nowadays, recent medical or surgical treatments represent valuable options for ameliorating pain and improving patients QoL in such this condition.
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17
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Moghaddasi L, Reid P, Bezak E, Marcu LG. Radiobiological and Treatment-Related Aspects of Spatially Fractionated Radiotherapy. Int J Mol Sci 2022; 23:3366. [PMID: 35328787 PMCID: PMC8954016 DOI: 10.3390/ijms23063366] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 03/13/2022] [Accepted: 03/17/2022] [Indexed: 11/17/2022] Open
Abstract
The continuously evolving field of radiotherapy aims to devise and implement techniques that allow for greater tumour control and better sparing of critical organs. Investigations into the complexity of tumour radiobiology confirmed the high heterogeneity of tumours as being responsible for the often poor treatment outcome. Hypoxic subvolumes, a subpopulation of cancer stem cells, as well as the inherent or acquired radioresistance define tumour aggressiveness and metastatic potential, which remain a therapeutic challenge. Non-conventional irradiation techniques, such as spatially fractionated radiotherapy, have been developed to tackle some of these challenges and to offer a high therapeutic index when treating radioresistant tumours. The goal of this article was to highlight the current knowledge on the molecular and radiobiological mechanisms behind spatially fractionated radiotherapy and to present the up-to-date preclinical and clinical evidence towards the therapeutic potential of this technique involving both photon and proton beams.
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Affiliation(s)
- Leyla Moghaddasi
- Department of Medical Physics, Austin Health, Ballarat, VIC 3350, Australia;
- School of Physical Sciences, University of Adelaide, Adelaide, SA 5001, Australia;
| | - Paul Reid
- Radiation Health, Environment Protection Authority, Adelaide, SA 5000, Australia;
| | - Eva Bezak
- School of Physical Sciences, University of Adelaide, Adelaide, SA 5001, Australia;
- Cancer Research Institute, University of South Australia, Adelaide, SA 5001, Australia
| | - Loredana G. Marcu
- Cancer Research Institute, University of South Australia, Adelaide, SA 5001, Australia
- Faculty of Informatics and Science, University of Oradea, 1 Universitatii Str., 410087 Oradea, Romania
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18
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Mayr NA, Snider JW, Regine WF, Mohiuddin M, Hippe DS, Peñagarícano J, Mohiuddin M, Kudrimoti MR, Zhang H, Limoli CL, Le QT, Simone CB. An International Consensus on the Design of Prospective Clinical-Translational Trials in Spatially Fractionated Radiation Therapy. Adv Radiat Oncol 2022; 7:100866. [PMID: 35198833 PMCID: PMC8843999 DOI: 10.1016/j.adro.2021.100866] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 11/12/2021] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Spatially fractionated radiation therapy (SFRT), which delivers highly nonuniform dose distributions instead of conventionally practiced homogeneous tumor dose, has shown high rates of clinical response with minimal toxicities in large-volume primary or metastatic malignancies. However, prospective multi-institutional clinical trials in SFRT are lacking, and SFRT techniques and dose parameters remain variable. Agreement on dose prescription, technical administration, and clinical and translational design parameters for SFRT trials is essential to enable broad participation and successful accrual to rigorously test the SFRT approach. We aimed to develop a consensus for the design of multi-institutional clinical trials in SFRT, tailored to specific primary tumor sites, to help facilitate development and enhance the feasibility of such trials. METHODS AND MATERIALS Primary tumor sites with sufficient pilot experience in SFRT were identified, and fundamental trial design questions were determined. For each tumor site, a comprehensive consensus effort was established through disease-specific expert panels. Clinical trial design criteria included eligibility, SFRT technology and technique, dose and fractionation, target- and normal-tissue dose parameters, systemic therapies, clinical trial endpoints, and translational science considerations. Iterative appropriateness rank voting, expert panel consensus reviews and discussions, and public comment posting were used for consensus development. RESULTS Clinical trial criteria were developed for head and neck cancer and soft-tissue sarcoma. Final consensus among the 22 trial design categories each (a total of 163 criteria) was high to moderate overall. Uniform patient cohorts of advanced bulky disease, standardization of SFRT technologies and dosimetry and physics parameters, and collection of translational correlates were considered essential to trial design. Final guideline recommendations and the degree of agreement are presented and discussed. CONCLUSIONS This consensus provides design guidelines for the development of prospective multi-institutional clinical trials testing SFRT in advanced head and neck cancer and soft-tissue sarcoma through in-advance harmonization of the fundamental clinical trial design among SFRT experts, potential investigators, and the SFRT community.
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Affiliation(s)
- Nina A. Mayr
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
- Tumor Heterogeneity Imaging and Radiomics Laboratory, University of Washington School of Medicine, Seattle, Washington
| | - James W. Snider
- Department of Radiation Oncology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - William F. Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Majid Mohiuddin
- Radiation Oncology Consultants and Northwestern Proton Center, Warrenville, Illinois
| | - Daniel S. Hippe
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | | | - Mahesh R. Kudrimoti
- Department of Radiation Medicine, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Hualin Zhang
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Charles L. Limoli
- Department of Radiation Oncology, University of California School of Medicine, Irvine, Irvine, California
| | - Quynh-Thu Le
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Charles B. Simone
- Department of Radiation Oncology, New York Proton Center, New York, New York
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19
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Zhang X, Griffin RJ, Galhardo EP, Penagaricano J. Feasibility Study of 3D-VMAT-Based GRID Therapy. Technol Cancer Res Treat 2022; 21:15330338221086420. [PMID: 35289202 DOI: 10.1177/15330338221086420] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Spatially fractionated radiotherapy (GRID) could effectively de-bulk tumor volumes for shallow and deep-seated locally advanced tumors. A new treatment planning method using the three-dimensional-volumetric modulated arc therapy (VMAT) technique combined with a novel, software-generated, virtual GRID block (VGB) was developed which allows better conformity plans (VMAT-GRID) and maintain the GRID dosimetric characteristics. The dosimetric metrics calculated via the valley/peak ratio (Dmin/Dmax), D90/D10, gross tumor volume (GTV) mean dose (Dmean), GTV equivalent uniform dose (EUD), and normal tissue maximum dose. Methods: Twenty-five patients with tumor volumes ranging between 71.6 cc and 4683 cc at various tumor sites were retrospectively studied. The prescription was 20 Gy to the maximum point of GTV in a single fraction, and the VMAT-GRID plan was generated using 6 MV/10 MV flattening-filter-free beams. Results: The optimized VGB was designed with the median center-to-center distance of 27 mm, and 9 mm for the median diameter of the opening area in this study. These 2 values can be used to design any optimized VGB, the final VGB may be modified to generate a patient-specific VGB. The median GTV mean dose was 918 (877- 938) cGy, and the median GTV EUD dose was 818 (597-916) cGy. In terms of dose inhomogeneity, the median valley-to-peak dose ratio was 0.07 (0.02-0.26); and the median ratio of D90/D10 was 0.70 (0.38-0.94). For the organ-at-risk doses, there was a rapid dose drop-off in the normal tissue area immediately adjacent to the target, and the maximum global doses were all located inside the GTV. Conclusion: Our results indicated that the VMAT-GRID planning approach could successfully deliver dose with acceptable GRID dose metric while sparing the normal tissue especially in the region near the target due to the rapid dose drop-off and restricting maximum dose inside the target.
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Affiliation(s)
- Xin Zhang
- Department of Radiation Oncology, Boston Medical Center, 1836Boston University School of Medicine, Boston, MA, USA.,Department of Radiation Oncology, 12215University of Arkansas for Medical Science, Little Rock, AR, USA
| | - Robert J Griffin
- Department of Radiation Oncology, 12215University of Arkansas for Medical Science, Little Rock, AR, USA
| | - Edvaldo P Galhardo
- Department of Radiation Oncology, 12215University of Arkansas for Medical Science, Little Rock, AR, USA.,Department of Radiation Oncology, Genesis Care, Bradenton, FL, USA
| | - Jose Penagaricano
- Department of Radiation Oncology, 12215University of Arkansas for Medical Science, Little Rock, AR, USA.,Department of Radiation Oncology, 25301Moffitt Cancer Center, Tampa, FL, USA
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