Paving the Road for Modern Particle Therapy - What Can We Learn from the Experience Gained with Fast Neutron Therapy in Munich?

Pencil beam kernel-based dose calculations on CT data for a mixed neutron-gamma fission field applying tissue correction factors

Objective.For fast neutron therapy with mixed neutron and gamma radiation at the fission neutron therapy facility MEDAPP at the research reactor FRM II in Garching, no clinical dose calculation software was available in the past. Here, we present a customized solution for research purposes to overcome this lack of three-dimensional dose calculation.Approach.The applied dose calculation method is based on two sets of decomposed pencil beam kernels for neutron and gamma radiation. The decomposition was performed using measured output factors and simulated depth dose curves and beam profiles in water as reference medium. While measurements were performed by applying the two-chamber dosimetry method, simulated data was generated using the Monte Carlo code MCNP. For the calculation of neutron dose deposition on CT data, tissue-specific correction factors were generated for soft tissue, bone, and lung tissue for the MEDAPP neutron spectrum. The pencil beam calculations were evaluated with reference to Monte Carlo calculations regarding accuracy and time efficiency.Main results.In water, dose distributions calculated using the pencil beam approach reproduced the input from Monte Carlo simulations. For heterogeneous media, an assessment of the tissue-specific correction factors with reference to Monte Carlo simulations for different tissue configurations showed promising results. Especially for scenarios where no lung tissue is present, the dose calculation could be highly improved by the applied correction method.Significance.With the presented approach, time-efficient dose calculations on CT data and treatment plan evaluations for research purposes are now available for MEDAPP.

Radiotherapy for salivary gland cancer: REFCOR recommendations by the formal consensus method

OBJECTIVE

To determine the indications for radiotherapy in salivary gland cancer and to specify the modalities and target radiation volumes.

MATERIAL AND METHODS

The French Network of Rare Head and Neck Tumors (REFCOR) formed a steering group which drafted a narrative review of the literature published on Medline and proposed recommendations. The level of adherence to the recommendations was then assessed by a rating group, according to the formal consensus method.

RESULTS

Postoperatively, radiotherapy to the primary tumor site±to the lymph nodes is indicated if one or more of the following adverse histoprognostic factors are present (risk>10% of locoregional recurrence): T3-T4 category, lymph node invasion, extraglandular invasion, close or positive surgical margins, high tumor grade, perineural invasion, vascular emboli, and/or bone invasion. Intensity-modulated radiation therapy (IMRT) is the gold standard. For unresectable cancers or inoperable patients, carbon ion hadrontherapy may be considered.

CONCLUSION

Radiotherapy in salivary gland cancer is indicated in postoperative situations in case of adverse histoprognostic factors and for inoperable tumors.

Neutron brachytherapy in the modern era: Indications and evidence

Hadrontherapy is a form of radiation therapy (RT) that relies on heavy particles, such as proton, heavy ions, or neutrons, to enhance anti-tumoral efficacy based on their specific dosimetric and radio-biological properties. Neutrons are characterized by specific radiobiological properties that might deserve greater consideration, including the high linear energy transfer and the low oxygen enhancement ratio. Neutron brachytherapy, relying on interstitial or intracavitary neutron sources, has been developed since the 1950s using Californium-252 (252Cf) as a mixed emitter of fission fast neutrons and γ-photos. However, the place of NBT in the era of modern radiation therapy is yet to be precisely defined. In this systematic review, we aim to provide an up-to-date analysis of current experience and clinical evidence of NBT in the XXI ^th century, by answering the following clinical questions: How is NBT currently delivered? What are the current efficacy data and tolerance profiles of NBT?

Particle radiotherapy and molecular therapies: mechanisms and strategies towards clinical applications

Immunotherapy and targeted therapy are now commonly used in clinical trials in combination with radiotherapy for several cancers. While results are promising and encouraging, the molecular mechanisms of the interaction between the drugs and radiation remain largely unknown. This is especially important when switching from conventional photon therapy to particle therapy using protons or heavier ions. Different dose deposition patterns and molecular radiobiology can in fact modify the interaction with drugs and their effectiveness. We will show here that whilst the main molecular players are the same after low and high linear energy transfer radiation exposure, significant differences are observed in post-exposure signalling pathways that may lead to different effects of the drugs. We will also emphasise that the problem of the timing between drug administration and radiation and the fractionation regime are critical issues that need to be addressed urgently to achieve optimal results in combined treatments with particle therapy.

Hadrontherapy techniques for breast cancer

Radiotherapy plays a key role in breast cancer treatment, and recent technical advances have been made to improve the therapeutic window by limiting the risk of radiation-induced toxicity or by increasing tumor control. Hadrontherapy is a form a radiotherapy relying on particle beams; compared with photon beams, particle beams have specific physical, radiobiological and immunological properties, which can be valuable in diverse clinical situations. To date, available hadrontherapy techniques for breast cancer irradiation include proton therapy, carbon ion radiation therapy, fast neutron therapy and boron neutron capture therapy. This review analyzes the current rationale and level of evidence for each hadrontherapy technique for breast cancer.

Biomedical Research Programs at Present and Future High-Energy Particle Accelerators

Biomedical applications at high-energy particle accelerators have always been an important section of the applied nuclear physics research. Several new facilities are now under constructions or undergoing major upgrades. While the main goal of these facilities is often basic research in nuclear physics, they acknowledge the importance of including biomedical research programs and of interacting with other medical accelerator facilities providing patient treatments. To harmonize the programs, avoid duplications, and foster collaboration and synergism, the International Biophysics Collaboration is providing a platform to several accelerator centers with interest in biomedical research. In this paper, we summarize the programs of various facilities in the running, upgrade, or construction phase.

Particle therapy in Europe

Particle therapy using protons or heavier ions is currently the most advanced form of radiotherapy and offers new opportunities for improving cancer care and research. Ions deposit the dose with a sharp maximum – the Bragg peak – and normal tissue receives a much lower dose than what is delivered by X‐ray therapy. Particle therapy has also biological advantages due to the high linear energy transfer of the charged particles around the Bragg peak. The introduction of particle therapy has been slow in Europe, but within the last decade, more than 20 clinical facilities have opened and facilitated access to this frontline therapy. In this review article, the basic concepts of particle therapy are reviewed along with a presentation of the current clinical indications, the European clinical research, and the established networks.

A Unique Prototypic Device for Radiation Therapy: The p53-Independent Antiproliferative Effect of Neutron Radiation

Radiation therapy with heavy particles including neutrons, an otherwise therapeutically perspective because of its high tissue penetration and efficient tumor damage, is currently limited by the lack of adequate equipment. An NG-24 generator (140 kg, 42 × 110 cm, ~1011 particles/s, > 14 MeV) has been designed and engineered to replace the huge and environmentally harmful neutron reactors, cyclotrons, and accelerators with a compact, portable, safe, and potent source of high-energy neutrons. We demonstrate that the neutron beam produced by NG-24 causes a significant antiproliferative effect on human tumor cell lines regardless of the status of the anti-apoptotic p53 protein. Phosphorylation of histone 2A and increased amounts of p21, cyclin D, and phospho-p53 were detectable in HCT116 colon carcinoma cells (wild-type p53) irradiated with 4 Gy several days post-treatment, accompanied by G2/M phase arrest. These treatments dramatically reduced the ability of single cells to form colonies. In the HCT116p53KO subline (p53 -/-), the G2/M arrest was independent of the aforementioned mechanisms. Hence, the NG-24 generator is a source of a powerful, therapeutically relevant neutron flux that triggers a p53-independent antiproliferative response in tumor cells.

Neutrons are forever! Historical perspectives

Purpose: Neutrons were an active field of radiobiology at the time of publication of the first issues of the International Journal of Radiation Biology in 1959. Three back-to-back papers published by Neary and his colleagues contain key elements of interest at the time. The present article aims to put these papers into context with the discovery of the neutron 27 years previously and then give a feel for how the field has progressed to the present day. It does not intend to provide a comprehensive review of this enormous field, but rather to provide selective summaries of main driving forces and developments. Conclusions: Neutron radiobiology has continued as a vigorous field of study throughout the past 84 years. Main driving forces have included concern for protection from the harmful effects of neutrons, exploitation and optimization for cancer therapy (fast beam therapy, brachytherapy and boron capture therapy), and scientific curiosity about the mechanisms of radiation action. Effort has fluctuated as the emphasis has shifted from time to time, but all three areas remain active today. Whatever the future holds for the various types of neutron therapy, the health protection aspects will remain with us permanently because of natural environmental exposure to neutrons as well as increased additional exposures from a variety of human activities.

A novel vertebrate system for the examination and direct comparison of the relative biological effectiveness for different radiation qualities and sources

PURPOSE

The recent rapid increase of hadron therapy applications requires the development of high performance, reliable in vivo models for preclinical research on the biological effects of high linear energy transfer (LET) particle radiation.

AIM

The aim of this paper was to test the relative biological effectiveness (RBE) of the zebrafish embryo system at two neutron facilities.

MATERIAL AND METHODS

Series of viable zebrafish embryos at 24-hour post-fertilization (hpf) were exposed to single fraction, whole-body, photon and neutron (reactor fission neutrons (<En = 1 MeV>) and (p (18 MeV)+Be, <En> = 3.5 MeV) fast neutron) irradiation. The survival and morphologic abnormalities of each embryo were assessed at 24-hour intervals from the point of fertilization up to 192 hpf and then compared to conventional 6 MV photon beam irradiation results.

RESULTS

The higher energy of the fast neutron beams represents lower RBE (ref. source LINAC 6 MV photon). The lethality rate in the zebrafish embryo model was 10 times higher for 1 MeV fission neutrons and 2.5 times greater for p (18 MeV)+Be cyclotron generated fast neutron beam when compared to photon irradiation results. Dose-dependent organ perturbations (shortening of the body length, spine curvature, microcephaly, micro-ophthalmia, pericardial edema and inhibition of yolk sac resorption) and microscopic (marked cellular changes in eyes, brain, liver, muscle and the gastrointestinal system) changes scale together with the dose response.

CONCLUSION

The zebrafish embryo system is a powerful and versatile model for assessing the effect of ionizing radiation with different LET values on viability, organ and tissue development.

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Neutron Therapy: An Experimental System in Radiooncology. The history of the use of neutrons in radiotherapy will be revisited by focusing on the ideas, theories and experiments that led to first clinical studies. For addressing epistemological questions regarding biological effects of fast neutrons, the notion of an "experimental system" is employed and its evolution over time discussed. Taking up the analytical framework of Hans-Jörg Rheinberger, biological effects and the physical instrument "cyclotron" are conceptualized in terms of epistemic and technical objects. It is shown that the epistemic object "biological effects of neutrons" could never reach the status of a technical object and - more strikingly - that the cyclotron itself returned to being an epistemic object in the context of medicine. So there is a misunderstanding of the different roles epistemic and technical objects have to play in the framework of an experimental system. This misunderstanding led to today's highly controversial discussions about the application of neutrons in radiotherapy.