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Bontempi P, Rozzanigo U, Marangoni S, Fogazzi E, Ravanelli D, Cazzoletti L, Giometto B, Farace P. Non-lesional white matter in relapsing-remitting multiple sclerosis assessed by multicomponent T2 relaxation. Brain Behav 2023; 13:e3334. [PMID: 38041516 PMCID: PMC10726908 DOI: 10.1002/brb3.3334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/31/2023] [Accepted: 11/02/2023] [Indexed: 12/03/2023] Open
Abstract
INTRODUCTION The purpose of the study is to investigate, by T2 relaxation, non-lesional white matter (WM) in relapsing-remitting (RR) multiple sclerosis (MS). METHODS Twenty stable RR MS patients underwent 1.5T Magnetic Resonance Imaging (MRI) with 3D Fluid-Attenuated Inversion-Recovery (FLAIR), 3D-T1-weighted, and T2-relaxation multi-echo sequences. The Lesion Segmentation Tool processed FLAIR images to identify focal lesions (FLs), whereas T1 images were segmented to identify WM and FL sub-volumes with T1 hypo-intensity. Non-lesional WM was obtained as the segmented WM, excluding FL volumes. The multi-echo sequence allowed decomposition into myelin water, intra-extracellular water, and free water (Fw), which were evaluated on the segmented non-lesional WM. Correlation analysis was performed between the non-lesional WM relaxation parameters and Expanded Disability Status Scale (EDSS), disease duration, patient age, and T1 hypo-intense FL volumes. RESULTS The T1 hypo-intense FL volumes correlated with EDSS. On the non-lesional WM, the median Fw correlated with EDSS, disease duration, age, and T1 hypo-intense FL volumes. Bivariate EDSS correlation of FL volumes and WM T2-relaxation parameters did not improve significance. CONCLUSION T2 relaxation allowed identifying subtle WM alterations, which significantly correlated with EDSS, disease duration, and age but do not seem to be EDSS-predictors independent from FL sub-volumes in stable RR patients. Particularly, the increase in the Fw component is suggestive of an uninvestigated prodromal phenomenon in brain degeneration.
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Affiliation(s)
- Pietro Bontempi
- Department of Engineering for Innovation MedicineUniversity of VeronaVeronaItaly
| | - Umberto Rozzanigo
- Neuro‐radiology Unit, Hospital of TrentoAzienda Provinciale per i Servizi Sanitari (APSS)TrentoItaly
| | - Sabrina Marangoni
- Neurology Unit, Hospital of TrentoAzienda Provinciale per i Servizi Sanitari (APSS)TrentoItaly
| | - Elena Fogazzi
- Physics departmentUniversity of TrentoPovoTrentoItaly
| | - Daniele Ravanelli
- Medical Physics Department, Hospital of TrentoAzienda Provinciale per i Servizi Sanitari (APSS)TrentoItaly
| | - Lucia Cazzoletti
- Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public HealthUniversity of VeronaVeronaItaly
| | - Bruno Giometto
- Neurology Unit, Hospital of TrentoAzienda Provinciale per i Servizi Sanitari (APSS)TrentoItaly
| | - Paolo Farace
- Medical Physics Department, Hospital of TrentoAzienda Provinciale per i Servizi Sanitari (APSS)TrentoItaly
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Scaringella M, Bruzzi M, Farace P, Fogazzi E, Righetto R, Rit S, Tommasino F, Verroi E, Civinini C. The INFN proton computed tomography system for relative stopping power measurements: calibration and verification. Phys Med Biol 2023; 68:154001. [PMID: 37379855 DOI: 10.1088/1361-6560/ace2a8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 06/28/2023] [Indexed: 06/30/2023]
Abstract
Objective. This paper describes the procedure to calibrate the three-dimensional (3D) proton stopping power relative to water (SPR) maps measured by the proton computed tomography (pCT) apparatus of the Istituto Nazionale di Fisica Nucleare (INFN, Italy). Measurements performed on water phantoms are used to validate the method. The calibration allowed for achieving measurement accuracy and reproducibility to levels below 1%.Approach. The INFN pCT system is made of a silicon tracker for proton trajectory determination followed by a YAG:Ce calorimeter for energy measurement. To perform the calibration, the apparatus has been exposed to protons of energies ranging from 83 to 210 MeV. Using the tracker, a position-dependent calibration has been implemented to keep the energy response uniform across the calorimeter. Moreover, correction algorithms have been developed to reconstruct the proton energy when this is shared in more than one crystal and to consider the energy loss in the non-uniform apparatus material. To verify the calibration and its reproducibility, water phantoms have been imaged with the pCT system during two data-taking sessions.Main results. The energy resolution of the pCT calorimeter resulted to beσEE≅0.9%at 196.5 MeV. The average values of the water SPR in fiducial volumes of the control phantoms have been calculated to be 0.995±0.002. The image non-uniformities were below 1%. No appreciable variation of the SPR and uniformity values between the two data-taking sessions could be identified.Significance. This work demonstrates the accuracy and reproducibility of the calibration of the INFN pCT system at a level below 1%. Moreover, the uniformity of the energy response keeps the image artifacts at a low level even in the presence of calorimeter segmentation and tracker material non-uniformities. The implemented calibration technique allows the INFN-pCT system to face applications where the precision of the SPR 3D maps is of paramount importance.
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Affiliation(s)
- Monica Scaringella
- Istituto Nazionale di Fisica Nucleare sezione di Firenze, Via G. Sansone 1, Sesto Fiorentino (Fi), Italy
| | - Mara Bruzzi
- Istituto Nazionale di Fisica Nucleare sezione di Firenze, Via G. Sansone 1, Sesto Fiorentino (Fi), Italy
- Dipartimento di Fisica e Astronomia, Università degli Studi di Firenze, via G. Sansone 1, Sesto Fiorentino (Fi), Italy
| | - Paolo Farace
- Medical Physics Department, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), Via Paolo Orsi, 1, Trento, Italy
- Istituto Nazionale di Fisica Nucleare TIFPA, via Sommarive, 14, Povo (Tn), Italy
| | - Elena Fogazzi
- Istituto Nazionale di Fisica Nucleare TIFPA, via Sommarive, 14, Povo (Tn), Italy
- Dipartimento di Fisica Università di Trento, via Sommarive 14, Povo (Tn), Italy
| | - Roberto Righetto
- Medical Physics Department, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), Via Paolo Orsi, 1, Trento, Italy
- Istituto Nazionale di Fisica Nucleare TIFPA, via Sommarive, 14, Povo (Tn), Italy
| | - Simon Rit
- University of Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS, UMR 5220, U1294 F-69373, Lyon, France
| | - Francesco Tommasino
- Istituto Nazionale di Fisica Nucleare TIFPA, via Sommarive, 14, Povo (Tn), Italy
- Dipartimento di Fisica Università di Trento, via Sommarive 14, Povo (Tn), Italy
| | - Enrico Verroi
- Istituto Nazionale di Fisica Nucleare TIFPA, via Sommarive, 14, Povo (Tn), Italy
| | - Carlo Civinini
- Istituto Nazionale di Fisica Nucleare sezione di Firenze, Via G. Sansone 1, Sesto Fiorentino (Fi), Italy
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Fogazzi E, Trevisan D, Farace P, Righetto R, Rit S, Scaringella M, Bruzzi M, Tommasino F, Civinini C. Characterization of the INFN proton CT scanner for cross-calibration of x-ray CT. Phys Med Biol 2023. [PMID: 37201529 DOI: 10.1088/1361-6560/acd6d3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
OBJECTIVE The goal of this study was to assess the imaging performances of the pCT system developed in the framework of INFN-funded (Italian National Institute of Nuclear Physics) research projects. The spatial resolution, noise power spectrum and RSP accuracy has been investigated, as a preliminary step to implement a new cross-calibration method for x-ray CT (xCT). 
Approach: The INFN pCT apparatus, made of four planes of silicon micro-strip detectors and a YAG:Ce scintillating calorimeter, reconstructs 3D RSP maps by a filtered-back projection algorithm. The imaging performances (i.e. spatial resolution, noise power spectrum and RSP accuracy) of the pCT system were assessed on a custom-made phantom, made of plastic materials with different densities ([0.66, 2.18] g/cm3). For comparison, the same phantom was acquired with a clinical xCT system.
Main results: The spatial resolution analysis revealed the non-linearity of the imaging system, showing different imaging responses in air or water phantom background. Applying the Hann filter in the pCT reconstruction, it was possible to investigate the imaging potential of the system. Matching the spatial resolution value of the xCT (0.54 lp/mm) and acquiring both with the same dose level (11.6 mGy), the pCT appeared to be less noisy than xCT, with an RSP standard deviation of 0.0063. Concerning the RSP accuracy, the measured Mean Absolute Percentage Errors were (0.23+-0.09)% in air and (0.21+-0.07)% in water.
Significance: The obtained performances confirm that the INFN pCT system provides a very accurate RSP estimation, appearing to be a feasible clinical tool for verification and correction of xCT calibration in proton treatment planning.
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Affiliation(s)
- Elena Fogazzi
- Dipartimento di Fisica, Università degli Studi di Trento, Via Sommarive, 14, Povo (TN), 38122, ITALY
| | - Diego Trevisan
- Medical Physics Unit, , Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), via Paolo Orsi, 1, Trento, 38122, ITALY
| | - Paolo Farace
- Medical Physics Unit, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), via Paolo Orsi, 1, Trento, 38122, ITALY
| | - Roberto Righetto
- Medical Physics Unit, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), via Paolo Orsi, 1, Trento, Trento, 38122, ITALY
| | - Simon Rit
- Université de Lyon, CREATIS ; CNRS UMR5220 ; Inserm U1206 ; INSA-Lyon ; Université Lyon 1, CREATIS, Centre Léon Bérard, Lyon, 69373, FRANCE
| | - Monica Scaringella
- Istituto Nazionale di Fisica Nucleare Sezione di Firenze, Via G. Sansone 1, Sesto Fiorentino, 50019, ITALY
| | - Mara Bruzzi
- Dipartimento di Fisica e Astronomia, Universita di Firenze, Via G. Sansone, 1, Sesto Fiorentino, 50019, ITALY
| | - Francesco Tommasino
- Physics, University of Trento, via Sommarive, 14, Trento, Trentino-Alto Adige, 38122, ITALY
| | - Carlo Civinini
- Istituto Nazionale di Fisica Nucleare Sezione di Firenze, Via G. Sansone, 1, Sesto Fiorentino, 50019, ITALY
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Tommasino F, Cartechini G, Righetto R, Farace P, Cianchetti M. Does variable RBE affect toxicity risks for mediastinal lymphoma patients? NTCP-based evaluation after proton therapy treatment. Phys Med 2023; 108:102569. [PMID: 36989976 DOI: 10.1016/j.ejmp.2023.102569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 02/04/2023] [Accepted: 03/18/2023] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION Mediastinal lymphoma (ML) is a solid malignancy affecting young patients. Modern combined treatments allow obtaining good survival probability, together with a long life expectancy, and therefore with the need to minimize treatment-related toxicities. We quantified the expected toxicity risk for different organs and endpoints in ML patients treated with intensity-modulated proton therapy (IMPT) at our centre, accounting also for uncertainties related to variable RBE. METHODS Treatment plans for ten ML patients were recalculated with a TOPAS-based Monte Carlo code, thus retrieving information on LET and allowing the estimation of variable RBE. Published NTCP models were adopted to calculate the toxicity risk for hypothyroidism, heart valve defects, coronary heart disease and lung fibrosis. NTCP was calculated assuming both constant (i.e. 1.1) and variable RBE. The uncertainty associated with individual radiosensitivity was estimated by random sampling α/β values before RBE evaluation. RESULTS Variable RBE had a minor impact on hypothyroidism risk for 7 patients, while it led to significant increase for the remaining three (+24% risk maximum increase). Lung fibrosis was slightly affected by variable RBE, with a maximum increase of ≅ 1%. This was similar for heart valve dysfunction, with the exception of one patient showing an about 10% risk increase, which could be explained by means of large heart volume and D1 increase. DISCUSSION The use of NTCP models allows for identifying those patients associated with a higher toxicity risk. For those patients, it might be worth including variable RBE in plan evaluation.
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Ruggi A, Melchionda F, Sardi I, Pavone R, Meneghello L, Kitanovski L, Zaletel LZ, Farace P, Zucchelli M, Scagnet M, Toni F, Righetto R, Cianchetti M, Prete A, Greto D, Cammelli S, Morganti AG, Rombi B. Toxicity and Clinical Results after Proton Therapy for Pediatric Medulloblastoma: A Multi-Centric Retrospective Study. Cancers (Basel) 2022; 14:2747. [PMID: 35681727 PMCID: PMC9179586 DOI: 10.3390/cancers14112747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 05/28/2022] [Accepted: 05/30/2022] [Indexed: 02/04/2023] Open
Abstract
Medulloblastoma is the most common malignant brain tumor in children. Even if current treatment dramatically improves the prognosis, survivors often develop long-term treatment-related sequelae. The current radiotherapy standard for medulloblastoma is craniospinal irradiation with a boost to the primary tumor site and to any metastatic sites. Proton therapy (PT) has similar efficacy compared to traditional photon-based radiotherapy but might achieve lower toxicity rates. We report on our multi-centric experience with 43 children with medulloblastoma (median age at diagnosis 8.7 years, IQR 6.6, M/F 23/20; 26 high-risk, 14 standard-risk, 3 ex-infant), who received active scanning PT between 2015 and 2021, with a focus on PT-related acute-subacute toxicity, as well as some preliminary data on late toxicity. Most acute toxicities were mild and manageable with supportive therapy. Hematological toxicity was limited, even among HR patients who underwent hematopoietic stem-cell transplantation before PT. Preliminary data on late sequelae were also encouraging, although a longer follow-up is needed.
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Affiliation(s)
- Alessandro Ruggi
- Specialty School of Paediatrics-Alma Mater Studiorum, Università di Bologna, 40138 Bologna, Italy;
| | - Fraia Melchionda
- Pediatric Onco-Hematology, IRCCS Sant’Orsola SSD, University Hospital of Bologna, 40138 Bologna, Italy; (F.M.); (A.P.)
| | - Iacopo Sardi
- Neuro-Oncology Unit, Department of Pediatric Oncology, Meyer Children’s Hospital, 50139 Florence, Italy; (I.S.); (R.P.)
| | - Rossana Pavone
- Neuro-Oncology Unit, Department of Pediatric Oncology, Meyer Children’s Hospital, 50139 Florence, Italy; (I.S.); (R.P.)
| | - Linda Meneghello
- Pediatric Onco-Hematology Service, Pediatric Unit, Santa Chiara Hospital, 38123 Trento, Italy;
| | - Lidija Kitanovski
- Department of Oncology and Haematology, University Children’s Hospital, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia;
| | | | - Paolo Farace
- Proton Therapy Unit, Santa Chiara Hospital, Azienda Provinciale per i Servizi Sanitari (APSS), 38123 Trento, Italy; (P.F.); (R.R.); (M.C.)
| | - Mino Zucchelli
- Pediatric Neurosurgery, Institute of Neurological Science, IRCCS Bellaria Hospital, 40139 Bologna, Italy;
| | - Mirko Scagnet
- Department of Neurosurgery, Meyer Children’s Hospital, 50139 Florence, Italy;
| | - Francesco Toni
- Neuroradiology Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy;
| | - Roberto Righetto
- Proton Therapy Unit, Santa Chiara Hospital, Azienda Provinciale per i Servizi Sanitari (APSS), 38123 Trento, Italy; (P.F.); (R.R.); (M.C.)
| | - Marco Cianchetti
- Proton Therapy Unit, Santa Chiara Hospital, Azienda Provinciale per i Servizi Sanitari (APSS), 38123 Trento, Italy; (P.F.); (R.R.); (M.C.)
| | - Arcangelo Prete
- Pediatric Onco-Hematology, IRCCS Sant’Orsola SSD, University Hospital of Bologna, 40138 Bologna, Italy; (F.M.); (A.P.)
| | - Daniela Greto
- Azienda Ospedaliero-Universitaria Careggi, 50134 Florence, Italy;
| | - Silvia Cammelli
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (S.C.); (A.G.M.)
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy
| | - Alessio Giuseppe Morganti
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (S.C.); (A.G.M.)
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy
| | - Barbara Rombi
- Proton Therapy Unit, Santa Chiara Hospital, Azienda Provinciale per i Servizi Sanitari (APSS), 38123 Trento, Italy; (P.F.); (R.R.); (M.C.)
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Dionisi F, Scartoni D, Rombi B, Vennarini S, Righetto R, Farace P, Lorentini S, Schwarz M, Di Murro L, Demofonti C, D'Angelillo RM, Petrongari MG, Sanguineti G, Amichetti M. Consolidative active scanning proton therapy for mediastinal lymphoma: selection criteria, treatment implementation and clinical feasibility. Strahlenther Onkol 2022; 198:558-565. [PMID: 35394144 DOI: 10.1007/s00066-022-01918-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 02/22/2022] [Indexed: 11/27/2022]
Abstract
AIMS Proton therapy (PT) represents an advanced form of radiotherapy with unique physical properties which could be of great advantage in reducing long-term radiation morbidity for cancer survivors. Here, we aim to describe the whole process leading to the clinical implementation of consolidative active scanning proton therapy treatment (PT) for mediastinal lymphoma. METHODS The process included administrative, technical and clinical issues. Authorization of PT is required in all cases as mediastinal lymphoma is currently not on the list of diseases reimbursable by the Italian National Health Service. Technically, active scanning PT treatment for mediastinal lymphoma is complex, due to the interaction between actively scanned protons and the usually irregular and large volumes to be irradiated, the nearby healthy tissues and the target motion caused by breathing. A road map to implement the technical procedures was prepared. The clinical selection of patients was of utmost importance and took into account both patient and tumor characteristics. RESULTS The first mediastinal lymphoma was treated at our PT center in 2018, four years after the start of the clinical activities. The treatment technique implementation included mechanical deep inspiration breath-hold simulation computed tomography (CT), clinical target volume (CTV)-based multifield optimization planning and plan robustness analysis. The ultimate authorization rate was 93%. In 4 cases a proton-photon plan comparison was required. Between May 2018 and February, 2021, 14 patients were treated with consolidative PT. The main clinical reasons for choosing PT over photons was a bulky disease in 8 patients (57%), patient's age in 11 patients (78%) and the proximity of the lymphoma to cardiac structures in 10 patients (71%). With a median follow-up of 15 months (range, 1-33 months) all patients but one (out-of-field relapse) are without evidence of disease, all are alive and no late toxicities were observed during the follow-up period. CONCLUSIONS The clinical implementation of consolidative active scanning PT for mediastinal lymphoma required specific technical procedures and a prolonged experience with PT treatments. An accurate selection of patients for which PT could be of advantage in comparison with photons is mandatory.
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Affiliation(s)
- F Dionisi
- Department of Radiation Oncology, IRCSS Regina Elena National Cancer Institute, Rome, Italy.
| | - D Scartoni
- Proton Therapy unit, APSS, Trento, Italy
| | - B Rombi
- Proton Therapy unit, APSS, Trento, Italy
| | | | - R Righetto
- Proton Therapy unit, APSS, Trento, Italy
| | - P Farace
- Proton Therapy unit, APSS, Trento, Italy
| | | | - M Schwarz
- Proton Therapy unit, APSS, Trento, Italy
| | - L Di Murro
- Department of Radiotherapy, University of Tor Vergata, Rome, Italy
| | - C Demofonti
- Department of Radiotherapy, University of Tor Vergata, Rome, Italy
| | - R M D'Angelillo
- Department of Radiotherapy, University of Tor Vergata, Rome, Italy
| | - M G Petrongari
- Department of Radiation Oncology, IRCSS Regina Elena National Cancer Institute, Rome, Italy
| | - G Sanguineti
- Department of Radiation Oncology, IRCSS Regina Elena National Cancer Institute, Rome, Italy
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Righetto R, Fellin F, Scartoni D, Amichetti M, Schwarz M, Amelio D, Farace P. Is it beneficial to use apertures in proton radiosurgery with a scanning beam? A dosimetric comparison in neurinoma and meningioma patients. J Appl Clin Med Phys 2021; 23:e13459. [PMID: 34751499 PMCID: PMC8833271 DOI: 10.1002/acm2.13459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 10/07/2021] [Accepted: 10/08/2021] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To assess the dosimetric advantages of apertures in intracranial single fraction proton radiosurgery. MATERIALS AND METHODS Six neuroma and 10 meningioma patients were investigated. For each patient, six plans were computed, with two spot spacing and three aperture settings (no apertures, 5 and 8 mm margin between aperture and clinical target volume [CTV]). All plans were optimized on the CTV with the same beam arrangement and the same single-field robust optimization (2 mm setup errors, 3.5% range uncertainties). Robustness analysis was performed with 0.5 and 1.0 mm systematic setup errors and 3.5% range uncertainties. CTV coverage in the perturbed scenarios and healthy brain tissue sparing in the surrounding of the CTV were compared. RESULTS Meningiomas were larger and at a shallow depth than neuromas. In neuromas, spot spacing did not affect OAR doses or the robustness of CTV coverage and the apertures reduced brain dose without any significant impact on CTV robustness. In meningiomas, smaller spot spacing produced a reduction in brain V5Gy and improved robustness of CTV coverage; in addition, an 8 mm margin aperture reduced low and medium brain tissue doses without affecting robustness in the 0.5 mm perturbed scenario. A 5 mm margin aperture caused a reduction of plan robustness. CONCLUSION The optimal use of apertures is a trade-off between sparing of low and medium dose to the healthy brain and robustness of target coverage, also depending on size and depth of the lesion.
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Affiliation(s)
- Roberto Righetto
- Proton Therapy Unit, S. Chiara Hospital-Azienda Provinciale per I Servizi Sanitari (APSS), Trento, Italy
| | - Francesco Fellin
- Proton Therapy Unit, S. Chiara Hospital-Azienda Provinciale per I Servizi Sanitari (APSS), Trento, Italy
| | - Daniele Scartoni
- Proton Therapy Unit, S. Chiara Hospital-Azienda Provinciale per I Servizi Sanitari (APSS), Trento, Italy
| | - Maurizio Amichetti
- Proton Therapy Unit, S. Chiara Hospital-Azienda Provinciale per I Servizi Sanitari (APSS), Trento, Italy
| | - Marco Schwarz
- Proton Therapy Unit, S. Chiara Hospital-Azienda Provinciale per I Servizi Sanitari (APSS), Trento, Italy.,Trento Institute for Fundamental Physics and Applications (TIFPA), National Institute for Nuclear Physics, (INFN), Povo, Italy
| | - Dante Amelio
- Proton Therapy Unit, S. Chiara Hospital-Azienda Provinciale per I Servizi Sanitari (APSS), Trento, Italy
| | - Paolo Farace
- Proton Therapy Unit, S. Chiara Hospital-Azienda Provinciale per I Servizi Sanitari (APSS), Trento, Italy
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Farace P, Tamburin S. Combining Low-Dose Radiation Therapy and Magnetic Resonance Guided Focused Ultrasound to Reduce Amyloid-β Deposition in Alzheimer's Disease. J Alzheimers Dis 2021; 84:69-72. [PMID: 34487049 DOI: 10.3233/jad-215041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Amyloid-β deposition is one of the neuropathological hallmarks of Alzheimer's disease (AD), but pharmacological strategies toward its reduction are poorly effective.Preclinical studies indicate that low-dose radiation therapy (LD-RT) may reduce brain amyloid-β. Animal models and proof-of-concept preliminary data in humans have shown that magnetic resonance guided focused ultrasound (MRgFUS) can reversibly open the blood-brain-barrier and facilitate the delivery of targeted therapeutics to the hippocampus, to reduce amyloid-β and promote neurogenesis in AD. Ongoing clinical trials on AD are exploring whole-brain LD-RT, which may damage radio-sensitive structures, i.e., hippocampus and white matter, thus contributing to reduced neurogenesis and radiation-induced cognitive decline. However, selective irradiation of cortical amyloid-β plaques through advanced LD-RT techniques might spare the hippocampus and white matter. We propose combined use of advanced LD-RT and targeted drug delivery through MRgFUS for future clinical trials to reduce amyloid-β deposition in AD since its preclinical stages.
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Affiliation(s)
- Paolo Farace
- Protontherapy Unit, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Stefano Tamburin
- Department of Neurosciences, Biomedicine & Movement Sciences, University of Verona, Verona, Italy.,Verona University Hospital, Verona, Italy
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Fracchiolla F, Engwall E, Janson M, Tamm F, Lorentini S, Fellin F, Bertolini M, Algranati C, Righetto R, Farace P, Amichetti M, Schwarz M. PO-1609 Clinical validation of a GPU-based MC dose engine of a commercial TPS for PBS proton therapy. Radiother Oncol 2021. [DOI: 10.1016/s0167-8140(21)08060-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Bontempi P, Scartoni D, Amelio D, Cianchetti M, Turkaj A, Amichetti M, Farace P. Multicomponent T 2 relaxometry reveals early myelin white matter changes induced by proton radiation treatment. Magn Reson Med 2021; 86:3236-3245. [PMID: 34268786 DOI: 10.1002/mrm.28913] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/21/2021] [Accepted: 06/14/2021] [Indexed: 11/11/2022]
Abstract
PURPOSE To investigate MRI myelin water imaging (MWI) by multicomponent T2 relaxometry as a quantitative imaging biomarker for brain radiation-induced changes and to compare it with DTI. METHODS Sixteen patients underwent fractionated proton therapy (PT) receiving dose to the healthy tissue because of direct or indirect (base skull tumors) irradiation. MWI was performed by a multi-echo sequence with 32 equally spaced echoes (10-320 ms). Decay data were processed to identify 3 T2 compartments: myelin water (Mw) below 40 ms, intra-extracellular water (IEw) between 40 and 250 ms, and free water (CSFw) above 250 ms. Both MWI and DTI scans were acquired pre (pre)-treatment and immediately at the end (end) of PT. After image registration, voxel-wise difference maps, obtained by subtracting MWI and DTI pre from those acquired at the end of PT, were compared with the corresponding biological equivalent dose (BED). RESULTS Mw difference showed a positive correlation and IEw difference showed a negative correlation with BED considering end-pre changes (P < .01). The changes in CSFw were not significantly correlated with the delivered BED. The changes in DTI data, considering end-pre acquisitions, showed a positive correlation between fractional anisotropy and the delivered BED. CONCLUSION MWI might detect early white matter radiation-induced alterations, providing additional information to DTI, which might improve the understanding of the pathogenesis of the radiation damage.
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Affiliation(s)
- Pietro Bontempi
- Proton Therapy Unit, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Daniele Scartoni
- Proton Therapy Unit, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Dante Amelio
- Proton Therapy Unit, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Marco Cianchetti
- Proton Therapy Unit, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Ana Turkaj
- Proton Therapy Unit, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Maurizio Amichetti
- Proton Therapy Unit, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Paolo Farace
- Proton Therapy Unit, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
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Bontempi P, Rozzanigo U, Amelio D, Scartoni D, Amichetti M, Farace P. Quantitative Multicomponent T2 Relaxation Showed Greater Sensitivity Than Flair Imaging to Detect Subtle Alterations at the Periphery of Lower Grade Gliomas. Front Oncol 2021; 11:651137. [PMID: 33828992 PMCID: PMC8019971 DOI: 10.3389/fonc.2021.651137] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/02/2021] [Indexed: 02/02/2023] Open
Abstract
Purpose To demonstrate that quantitative multicomponent T2 relaxation can be more sensitive than conventional FLAIR imaging for detecting cerebral tissue abnormalities. Methods Six patients affected by lower-grade non-enhancing gliomas underwent T2 relaxation and FLAIR imaging before a radiation treatment by proton therapy (PT) and were examined at follow-up. The T2 decay signal obtained by a thirty-two-echo sequence was decomposed into three main components, attributing to each component a different T2 range: water trapped in the lipid bilayer membrane of myelin, intra/extracellular water and cerebrospinal fluid. The T2 quantitative map of the intra/extracellular water was compared with FLAIR images. Results Before PT, in five patients a mismatch was observed between the intra/extracellular water T2 map and FLAIR images, with peri-tumoral areas of high T2 that typically extended outside the area of abnormal FLAIR hyper-intensity. Such mismatch regions evolved into two different types of patterns. The first type, observed in three patients, was a reduced extension of the abnormal regions on T2 map with respect to FLAIR images (T2 decrease pattern). The second type, observed in two patients, was the appearance of new areas of abnormal hyper-intensity on FLAIR images matching the anomalous T2 map extension (FLAIR increase pattern), that was considered as asymptomatic radiation induced damage. Conclusion Our preliminarily results suggest that quantitative T2 mapping of the intra/extracellular water component was more sensitive than conventional FLAIR imaging to subtle cerebral tissue abnormalities, deserving to be further investigated in future clinical studies.
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Affiliation(s)
- Pietro Bontempi
- Proton Therapy Unit, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Umberto Rozzanigo
- Radiology Department, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Dante Amelio
- Proton Therapy Unit, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Daniele Scartoni
- Proton Therapy Unit, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Maurizio Amichetti
- Proton Therapy Unit, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Paolo Farace
- Proton Therapy Unit, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
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Farace P, Tommasino F, Righetto R, Fracchiolla F, Scaringella M, Bruzzi M, Civinini C. Technical Note: CT calibration for proton treatment planning by cross-calibration with proton CT data. Med Phys 2021; 48:1349-1355. [PMID: 33382083 DOI: 10.1002/mp.14698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/30/2020] [Accepted: 12/23/2020] [Indexed: 12/31/2022] Open
Abstract
PURPOSE This study explores the possibility of a new method for x-ray computed tomography (CT) calibration by means of cross-calibration with proton CT (pCT) data. The proposed method aims at a more accurate conversion of CT Hounsfield Units (HU) into proton stopping power ratio (SPR) relative to water to be used in proton-therapy treatment planning. METHODS X-ray CT scan was acquired on a synthetic anthropomorphic phantom, composed of different tissue equivalent materials (TEMs). A pCT apparatus was instead adopted to obtain a reference three-dimensional distribution of the phantom's SPR values. After rigid registration, the x-ray CT was artificially blurred to the same resolution of pCT. Then a scatter plot showing voxel-by-voxel SPR values as a function of HU was employed to link the two measurements and thus obtaining a cross-calibrated x-ray CT calibration curve. The cross-calibration was tested at treatment planning system and then compared with a conventional calibration based on exactly the same TEMs constituting the anthropomorphic phantom. RESULTS Cross-calibration provided an accurate SPR mapping, better than by conventional TEMs calibration. The dose distribution of single beams optimized on the reference SPR map was recomputed on cross-calibrated CT, showing, with respect to conventional calibration, minor deviation at the dose fall-off (lower than 1%). CONCLUSIONS The presented data demonstrated that, by means of reference pCT data, a heterogeneous phantom can be used for CT calibration, paving the way to the use of biological samples, with their accurate description of patients' tissues. This overcomes the limitations of conventional CT calibration requiring homogenous samples, only available by synthetic TEMs, which fail in accurately mimicking the properties of biological tissues. Once a heterogeneous biological sample is provided with its corresponding reference SPR maps, a cross-calibration procedure could be adopted by other PT centers, even when not equipped with a pCT system.
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Affiliation(s)
- Paolo Farace
- Protontherapy Unit, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy.,Istituto Nazionale di Fisica Nucleare TIFPA, via Sommarive, 14, Trento, Italy
| | - Francesco Tommasino
- Istituto Nazionale di Fisica Nucleare TIFPA, via Sommarive, 14, Trento, Italy.,Department of Physics, University of Trento, via Sommarive, 14, Trento, Italy
| | - Roberto Righetto
- Protontherapy Unit, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy.,Istituto Nazionale di Fisica Nucleare TIFPA, via Sommarive, 14, Trento, Italy
| | - Francesco Fracchiolla
- Protontherapy Unit, Hospital of Trento, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy.,Istituto Nazionale di Fisica Nucleare TIFPA, via Sommarive, 14, Trento, Italy
| | - Monica Scaringella
- Istituto Nazionale di Fisica Nucleare sezione di Firenze, Via G. Sansone 1, Sesto Fiorentino, Italy
| | - Mara Bruzzi
- Istituto Nazionale di Fisica Nucleare sezione di Firenze, Via G. Sansone 1, Sesto Fiorentino, Italy.,Dipartimento di Fisica e Astronomia, Università degli Studi di Firenze, via G. Sansone 1, Sesto Fiorentino, Italy
| | - Carlo Civinini
- Istituto Nazionale di Fisica Nucleare sezione di Firenze, Via G. Sansone 1, Sesto Fiorentino, Italy
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Fracchiolla F, Dionisi F, Righetto R, Widesott L, Giacomelli I, Cartechini G, Farace P, Bertolini M, Amichetti M, Schwarz M. PO-1611: Clinical implementation of liver cancer treatments with pencil beam scanning proton therapy. Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(21)01629-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Tommasino F, Cartechini G, Fracchiolla F, Menegotti L, Scifoni E, La Tessa C, Schwarz M, Farace P. PO-1425: Secondary cancer risk in breast cancer patients treated with protons compared to 3D-CRT and VMAT. Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(21)01443-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Fracchiolla F, Dionisi F, Righetto R, Widesott L, Giacomelli I, Cartechini G, Farace P, Bertolini M, Amichetti M, Schwarz M. Clinical implementation of pencil beam scanning proton therapy for liver cancer with forced deep expiration breath hold. Radiother Oncol 2020; 154:137-144. [PMID: 32976870 DOI: 10.1016/j.radonc.2020.09.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 09/16/2020] [Accepted: 09/17/2020] [Indexed: 01/04/2023]
Abstract
PURPOSE To present our technique for liver cancer treatments with proton therapy in pencil beam scanning mode and to evaluate the impact of uncertainties on plan quality. MATERIALS AND METHODS Seventeen patients affected by liver cancer were included in this study. Patients were imaged and treated in forced breath-hold using the Active Breathing Coordinator system and monitored with an optical tracking system. Three simulation CTs were acquired to estimate the anatomical variability between breath-holds and generate an internal target volume (ITV). The treatment plans were optimized with a Single Field Optimization technique aimed at minimizing the use of range shifter. Plan robustness was tested simulating systematic range and setup uncertainties, as well as the interplay effect between breath-holds. The appropriateness of margin was further verified based on the actual positioning data acquired during treatment. RESULTS The dose distributions of the nominal plans achieved a satisfactory target coverage in 11 out of 17 patients, while in the remaining 6 D95 to the PTV was affected by the constraint on mean liver dose. The constraints for all other organs at risk were always within tolerances. The interplay effect had a limited impact on the dose distributions: the worst case scenario showed a D95 reduction in the ITV < 3.9 GyRBE and no OAR with D1 > 105% of the prescription dose. The robustness analysis showed that for 13 out of 17 patients the ITV coverage in terms of D95 was better than D95 of the PTV in the nominal plan. For the remaining 4 patients, the maximum difference between ITV D95 and PTV D95 was ≤0.7% even for the largest simulated setup error and it was deemed clinically acceptable. Hot spots in the OARs were always lower than 105% of the prescription dose. Positioning images confirmed that the breath hold technique and the PTV margin were adequate to compensate for inter- and intra-breath-hold variations in liver position. CONCLUSION We designed and clinically applied a technique for the treatment of liver cancer with proton pencil beam scanning in forced deep expiration breath-hold. The initial data on plan robustness and patient positioning suggest that the choices in terms of planning technique and treatment margins are able to reach the desired balance between target coverage and organ at risk sparing.
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Affiliation(s)
- Francesco Fracchiolla
- Azienda Provinciale per i Servizi Sanitari (APSS) Protontherapy Department, Trento, Italy.
| | - Francesco Dionisi
- Azienda Provinciale per i Servizi Sanitari (APSS) Protontherapy Department, Trento, Italy
| | - Roberto Righetto
- Azienda Provinciale per i Servizi Sanitari (APSS) Protontherapy Department, Trento, Italy
| | - Lamberto Widesott
- Azienda Provinciale per i Servizi Sanitari (APSS) Protontherapy Department, Trento, Italy
| | - Irene Giacomelli
- Azienda Provinciale per i Servizi Sanitari (APSS) Protontherapy Department, Trento, Italy
| | | | - Paolo Farace
- Azienda Provinciale per i Servizi Sanitari (APSS) Protontherapy Department, Trento, Italy
| | - Mattia Bertolini
- Azienda Provinciale per i Servizi Sanitari (APSS) Protontherapy Department, Trento, Italy
| | - Maurizio Amichetti
- Azienda Provinciale per i Servizi Sanitari (APSS) Protontherapy Department, Trento, Italy
| | - Marco Schwarz
- Azienda Provinciale per i Servizi Sanitari (APSS) Protontherapy Department, Trento, Italy; TIFPA Trento Institute for Fundamental Physics and Applications, Italy
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Fellin F, Artoni M, Righetto R, Bellinzona VE, Widesott L, Dionisi F, Farace P. An avoidance method to minimize dose perturbation effects in proton pencil beam scanning treatment of patients with small high-Z implants. Phys Med Biol 2020; 65:14NT01. [PMID: 32464619 DOI: 10.1088/1361-6560/ab9775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
To implement a multi-field-optimization (MFO) technique for treating patients with high-Z implants in pencil beam scanning proton-therapy and generate treatment plans that avoids small implants. Two main issues were addressed: (i) the assessment of the optimal CT acquisition and segmentation technique to define the dimension of the implant and (ii) the distance of pencil beams from the implant (avoidance margin) to assure that it does not affect dose distribution. Different CT reconstruction protocols (by O-MAR or standard reconstruction and by 12 bit or 16 bit dynamic range) followed by thresholding segmentation were tested on a phantom with lead spheres of different sizes. The proper avoidance margin was assessed on a dedicated phantoms of different materials (copper/tantalum and lead), shape (square slabs and spheres) and detectors (two-dimensional array chamber and radio-chromic films). The method was then demonstrated on a head-and-neck carcinoma patient, who underwent carotid artery embolization with a platinum coil close to the target. Regardless the application of O-MAR reconstruction, the CT protocol with a full 16 bit dynamic range allowed better estimation of the sphere volumes, with maximal error around -5% in the greater sphere only. Except the configuration with a shallow target (which required a pre-absorber), particularly with a retracted snout, an avoidance margin of around 0.9-1.3 cm allowed to keep the difference between planned and measured dose below 5-10%. The patient plan analysis showed adequate plan quality and confirmed effective implant avoidance. Potential target under-dosage can be produced by patient misalignment, which could be minimized by daily alignment on the implant, identifiable on orthogonal kilovolt images. By implant avoidance MFO it was possible to minimize potential dose perturbation effects produced by small high-Z implants. An advantage of such approach lies in its potential applicability for any type of implant, regardless the precise knowledge of its composition.
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Tommasino F, Widesott L, Fracchiolla F, Lorentini S, Righetto R, Algranati C, Scifoni E, Dionisi F, Scartoni D, Amelio D, Cianchetti M, Schwarz M, Amichetti M, Farace P. Clinical implementation in proton therapy of multi-field optimization by a hybrid method combining conventional PTV with robust optimization. Phys Med Biol 2020; 65:045002. [PMID: 31851957 DOI: 10.1088/1361-6560/ab63b9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
To implement a robust multi-field optimization (MFO) technique compatible with the application of a Monte Carlo (MC) algorithm and to evaluate its robustness. Nine patients (three brain, five head-and-neck, one spine) underwent proton treatment generated by a novel robust MFO technique. A hybrid (hMFO) approach was implemented, planning dose coverage on isotropic PTV compensating for setup errors, whereas range calibration uncertainties are incorporated into PTV robust optimization process. hMFO was compared with single-field optimization (SFO) and full robust multi-field optimization (fMFO), both on the nominal plan and the worst-case scenarios assessed by robustness analysis. The SFO and the fMFO plans were normalized to hMFO on CTV to obtain iso-D95 coverage, and then the organs at risk (OARs) doses were compared. On the same OARs, in the normalized nominal plans the potential impact of variable relative biological effectiveness (RBE) was investigated. hMFO reduces the number of scenarios computed for robust optimization (from twenty-one in fMFO to three), making it practicable with the application of a MC algorithm. After normalizing on D95 CTV coverage, nominal hMFO plans were superior compared to SFO in terms of OARs sparing (p < 0.01), without significant differences compared to fMFO. The improvement in OAR sparing with hMFO with respect to SFO was preserved in worst-case scenarios (p < 0.01), confirming that hMFO is as robust as SFO to physical uncertainties, with no significant differences when compared to the worst case scenarios obtained by fMFO. The dose increase on OARs due to variable RBE was comparable to the increase due to physical uncertainties (i.e. 4-5 Gy(RBE)), but without significant differences between these techniques. hMFO allows improving plan quality with respect to SFO, with no significant differences with fMFO and without affecting robustness to setup, range and RBE uncertainties, making clinically feasible the application of MC-based robust optimization.
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Affiliation(s)
- Francesco Tommasino
- Department of Physics, University of Trento, Via Sommarive, 14-38123 Povo (TN), Italy. Trento Institute for Fundamental Physics and Applications (TIFPA), National Institute for Nuclear Physics, (INFN), Povo, Italy. Author to whom any correspondence should be addressed
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Righetto R, Clemens LP, Lorentini S, Fracchiolla F, Algranati C, Tommasino F, Dionisi F, Cianchetti M, Schwarz M, Farace P. Accurate proton treatment planning for pencil beam crossing titanium fixation implants. Phys Med 2020; 70:28-38. [PMID: 31954210 DOI: 10.1016/j.ejmp.2020.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 01/02/2020] [Accepted: 01/03/2020] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To present a planning strategy for proton pencil-beam scanning when titanium implants need to be crossed by the beam. METHODS We addressed three issues: the implementation of a CT calibration curve to assign to titanium the correct stopping power; the effect of artefacts on CT images and their reduction by a dedicated algorithm; the differences in dose computation depending on the dose engine, pencil-beam vs Monte-Carlo algorithms. We performed measurement tests on a simple cylinder phantom and on a real implant. These phantoms were irradiated with three geometries (single spots, uniform mono-energetic layer and uniform box), measuring the exit dose either by radio-chromic film or multi-layer ionization chamber. The procedure was then applied on two patients treated for chordoma. RESULTS We had to set in the calibration curve a mass density equal to 4.37 g/cm3 to saturated Hounsfield Units, in order to have the correct stopping power assigned to titanium in TPS. CT artefact reduction algorithm allowed a better reconstruction of the shape and size of the implant. Monte-Carlo resulted accurate in computing the dose distribution whereas the pencil-beam algorithm failed due to sharp density interfaces between titanium and the surrounding material. Finally, the treatment plans obtained on two patients showed the impact of the dose engine algorithm, with 10-20% differences between pencil-beam and Monte-Carlo in small regions distally to the titanium screws. CONCLUSION The described combination of CT calibration, artefacts reduction and Monte-Carlo computation provides a reliable methodology to compute dose in patients with titanium implants.
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Affiliation(s)
- Roberto Righetto
- Proton Therapy Department, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy.
| | | | - Stefano Lorentini
- Proton Therapy Department, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Francesco Fracchiolla
- Proton Therapy Department, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Carlo Algranati
- Proton Therapy Department, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Francesco Tommasino
- Department of Physics, University of Trento, Povo, Italy; Trento Institute for Fundamental Physics and Applications (TIFPA), National Institute for Nuclear Physics, (INFN), Povo, Italy
| | - Francesco Dionisi
- Proton Therapy Department, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Marco Cianchetti
- Proton Therapy Department, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Marco Schwarz
- Proton Therapy Department, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy; Trento Institute for Fundamental Physics and Applications (TIFPA), National Institute for Nuclear Physics, (INFN), Povo, Italy
| | - Paolo Farace
- Proton Therapy Department, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
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Deffet S, Farace P, Macq B. Sparse deconvolution of proton radiography data to estimate water equivalent thickness maps. Med Phys 2019; 47:509-517. [DOI: 10.1002/mp.13917] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 09/30/2019] [Accepted: 11/04/2019] [Indexed: 11/06/2022] Open
Affiliation(s)
- Sylvain Deffet
- Institute of Information and Communication Technologies Université catholique de Louvain Louvain‐La‐Neuve 1348Belgium
| | - Paolo Farace
- Proton Therapy Unit Hospital of Trento Trento 38100Italy
| | - Benoît Macq
- Institute of Information and Communication Technologies Université catholique de Louvain Louvain‐La‐Neuve 1348Belgium
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Tommasino F, Cella L, Farace P. In Regard to DeCesaris et al. Int J Radiat Oncol Biol Phys 2019; 105:676-677. [PMID: 31540598 DOI: 10.1016/j.ijrobp.2019.06.2547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 05/22/2019] [Accepted: 06/25/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Francesco Tommasino
- University of Trento, Department of Physics, Trento, Italy; Istituto Nazionale di Fisica Nucleare, Trento Institute for Fundamental Physics and Applications, Trento, Italy
| | - Laura Cella
- National Research Council Institute of Biostructures and Bioimaging, Napoli, Italy
| | - Paolo Farace
- Protontherapy Department, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
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Dionisi F, Croci S, Giacomelli I, Cianchetti M, Caldara A, Bertolin M, Vanoni V, Pertile R, Widesott L, Farace P, Schwarz M, Amichetti M. Clinical results of proton therapy reirradiation for recurrent nasopharyngeal carcinoma. Acta Oncol 2019; 58:1238-1245. [PMID: 31155998 DOI: 10.1080/0284186x.2019.1622772] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background and purpose: Recurrent nasopharyngeal carcinoma (NPC) has limited curative treatment options. Reirradiation is the only potential definitive treatment in advanced stages at a cost of substantial severe and often life-threatening toxicity. Proton therapy (PT) reduces irradiated volume compared with X-ray radiotherapy and could be advantageous in terms of safety and efficacy in a population of heavily pretreated patients. We report the retrospective results of PT reirradiation in recurrent NPC patients treated at our Institution Methods: All recurrent NPC patients treated since the beginning of clinical activity entered the present analysis. Clinical target volume consisted of Gross Tumor volume plus a patient-specific margin depending on disease behavior, tumor location, proximity of organs at risk, previous radiation dose. No elective nodal irradiation was performed. Active scanning technique with the use of Single Field Optimization (SFO) or Multifield Optimization (MFO) was adopted. Cumulative X-ray -PT doses were calculated for all patients using a dose accumulation tool since 2016. Treatment toxicity was retrospectively collected. Results: Between February 2015, and October 2018, 17 recurrent NPC patients were treated. Median follow-up (FUP) was 10 months (range 2-41). Median PT reirradiation dose was 60 Gy RBE (range 30.6-66). The majority of patients (53%) underwent concomitant chemotherapy. Acute toxicity was low with no ≥ G3 adverse events. Late events ≥ G3 occurred in 23.5% of patients. Most frequent late toxicity was hearing impairment (17,6%). G2 soft tissue necrosis occurred in two patients. Fatal bleeding of uncertain cause (either tumor recurrence or G5 carotid blowout) occurred in one patient. Kaplan-Meier 18 months Overall Survival (OS) and Local control (LC) rates were 54.4% and 66.6%, respectively. Conclusions: Our initial results with the use of modern PT for reirradiation of recurrent NPC patients are encouraging. Favorable LC and OS rates were obtained at the cost of acceptable severe late toxicity.
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Affiliation(s)
- F. Dionisi
- Proton Therapy Unit, APSS, Trento, Italy
| | - S. Croci
- Radiation Oncology Unit, University of Siena, Siena, Italy
| | | | | | | | | | - V. Vanoni
- Radiation Oncology Unit, APSS, Trento, Italy
| | | | | | - P. Farace
- Medical Physics Unit, APSS, Trento, Italy
| | - M. Schwarz
- Medical Physics Unit, APSS, Trento, Italy
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Fellin F, Iacco M, D'Avino V, Tommasino F, Farace P, Palma G, Conson M, Giacomelli I, Zucchetti C, Falcinelli L, Amichetti M, Aristei C, Cella L. Potential skin morbidity reduction with intensity-modulated proton therapy for breast cancer with nodal involvement. Acta Oncol 2019; 58:934-942. [PMID: 30938217 DOI: 10.1080/0284186x.2019.1591638] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background: Different modern radiation therapy treatment solutions for breast cancer (BC) and regional nodal irradiation (RNI) have been proposed. In this study, we evaluate the potential reduction in radiation-induced skin morbidity obtained by intensity modulated proton therapy (IMPT) compared with intensity modulated photon therapy (IMXT) for left-side BC and RNI. Material and Methods: Using CT scans from 10 left-side BC patients, treatment plans were generated using IMXT and IMPT techniques. A dose of 50 Gy (or Gy [RBE] for IMPT) was prescribed to the target volume (involved breast, the internal mammary, supraclavicular, and infraclavicular nodes). Two single filed optimization IMPT (IMPT1 and IMPT2) plans were calculated without and with skin optimization. For each technique, skin dose-metrics were extracted and normal tissue complication probability (NTCP) models from the literature were employed to estimate the risk of radiation-induced skin morbidity. NTCPs for relevant organs-at-risk (OARs) were also considered for reference. The non-parametric Anova (Friedman matched-pairs signed-rank test) was used for comparative analyses. Results: IMPT improved target coverage and dose homogeneity even if the skin was included into optimization strategy (HIIMPT2 = 0.11 vs. HIIMXT = 0.22 and CIIMPT2 = 0.96 vs. CIIMXT = 0.82, p < .05). A significant relative skin risk reduction (RR = NTCPIMPT/NTCPIMXT) was obtained with IMPT2 including the skin in the optimization with a RR reduction ranging from 0.3 to 0.9 depending on the analyzed skin toxicity endpoint/model. Both IMPT plans attained significant OARs dose sparing compared with IMXT. As expected, the heart and lung doses were significantly reduced using IMPT. Accordingly, IMPT always provided lower NTCP values. Conclusions: IMPT guarantees optimal target coverage, OARs sparing, and simultaneously minimizes the risk of skin morbidity. The applied model-based approach supports the potential clinical relevance of IMPT for left-side BC and RNI and might be relevant for the setup of cost-effectiveness evaluation strategies based on NTCP predictions, as well as for establishing patient selection criteria.
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Affiliation(s)
- Francesco Fellin
- Protontherapy Department, Azienda Provinciale per I Servizi Sanitari (APSS), Trento, Italy
| | - Martina Iacco
- Perugia General Hospital, Medical Physics Unit, Perugia, Italy
| | - Vittoria D'Avino
- Institute of Biostructures and Bioimaging, National Research Council (CNR), Naples, Italy
| | - Francesco Tommasino
- Department of Physics, University of Trento, Povo, Italy
- Trento Institute for Fundamental Physics and Applications (TIFPA), National Institute for Nuclear Physics (INFN), Povo, Italy
| | - Paolo Farace
- Protontherapy Department, Azienda Provinciale per I Servizi Sanitari (APSS), Trento, Italy
| | - Giuseppe Palma
- Institute of Biostructures and Bioimaging, National Research Council (CNR), Naples, Italy
| | - Manuel Conson
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy
| | - Irene Giacomelli
- Protontherapy Department, Azienda Provinciale per I Servizi Sanitari (APSS), Trento, Italy
| | | | | | - Maurizio Amichetti
- Protontherapy Department, Azienda Provinciale per I Servizi Sanitari (APSS), Trento, Italy
| | - Cynthia Aristei
- Radiation Oncology Section, Perugia General Hospital, Perugia, Italy
- Department of Surgical and Biomedical Science, University of Perugia, Perugia, Italy
| | - Laura Cella
- Institute of Biostructures and Bioimaging, National Research Council (CNR), Naples, Italy
- National Institute for Nuclear Physics (INFN), Naples, Italy
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Tommasino F, Widesott L, Fracchiolla F, Lorentini S, Righetto R, Algranati C, Scifoni E, Dionisi F, Scartoni D, Amelio D, Cianchetti M, Schwarz M, Amichetti M, Farace P. EP-1837 A new hybrid approach to allow robust Monte Carlo-based multi-field optimization in proton therapy. Radiother Oncol 2019. [DOI: 10.1016/s0167-8140(19)32257-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Widesott L, Lorentini S, Fracchiolla F, Farace P, Schwarz M. EP-1777 Improvements in pencil beam algorithm in proton therapy: do we still need Monte Carlo in brain? Radiother Oncol 2019. [DOI: 10.1016/s0167-8140(19)32197-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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25
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Fellin F, Fracchiolla F, Rombi B, Lipparini M, Vennarini S, Farace P. An advanced junction concept in pediatric craniospinal irradiation by proton pencil beam scanning. Phys Med 2019; 60:168-173. [DOI: 10.1016/j.ejmp.2019.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 04/03/2019] [Accepted: 04/06/2019] [Indexed: 11/24/2022] Open
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Amelio D, Scartoni D, Farace P, Widesott L, Vennarini S, Fellin F, Brugnara S, Pagone R, Schwarz M, Amichetti M. P01.084 Re-irradiation in recurrent glioblastoma: proton therapy with or without chemotherapy. Neuro Oncol 2018. [DOI: 10.1093/neuonc/noy139.126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- D Amelio
- Proton Therapy Center - Trento Hospital, Trento, Italy
| | - D Scartoni
- Proton Therapy Center - Trento Hospital, Trento, Italy
| | - P Farace
- Proton Therapy Center - Trento Hospital, Trento, Italy
| | - L Widesott
- Proton Therapy Center - Trento Hospital, Trento, Italy
| | - S Vennarini
- Proton Therapy Center - Trento Hospital, Trento, Italy
| | - F Fellin
- Proton Therapy Center - Trento Hospital, Trento, Italy
| | - S Brugnara
- Medical Oncology Dept. - Trento Hospital, Trento, Italy
| | - R Pagone
- Medical Oncology Dept. - Trento Hospital, Trento, Italy
| | - M Schwarz
- Proton Therapy Center - Trento Hospital, Trento, Italy
| | - M Amichetti
- Proton Therapy Center - Trento Hospital, Trento, Italy
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Widesott L, Lorentini S, Fracchiolla F, Farace P, Schwarz M. Improvements in pencil beam scanning proton therapy dose calculation accuracy in brain tumor cases with a commercial Monte Carlo algorithm. Phys Med Biol 2018; 63:145016. [PMID: 29726402 DOI: 10.1088/1361-6560/aac279] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
A commercial Monte Carlo (MC) algorithm (RayStation version 6.0.024) for the treatment of brain tumors with pencil beam scanning (PBS) proton therapy is validated and compared via measurements and analytical calculations in clinically realistic scenarios. For the measurements a 2D ion chamber array detector (MatriXX PT) was placed underneath the following targets: (1) an anthropomorphic head phantom (with two different thicknesses) and (2) a biological sample (i.e. half a lamb's head). In addition, we compared the MC dose engine versus the RayStation pencil beam (PB) algorithm clinically implemented so far, in critical conditions such as superficial targets (i.e. in need of a range shifter (RS)), different air gaps, and gantry angles to simulate both orthogonal and tangential beam arrangements. For every plan the PB and MC dose calculations were compared to measurements using a gamma analysis metrics (3%, 3 mm). For the head phantom the gamma passing rate (GPR) was always >96% and on average >99% for the MC algorithm; the PB algorithm had a GPR of ⩽90% for all the delivery configurations with a single slab (apart 95% GPR from the gantry of 0° and small air gap) and in the case of two slabs of the head phantom the GPR was >95% only in the case of small air gaps for all three (0°, 45°, and 70°) simulated beam gantry angles. Overall the PB algorithm tends to overestimate the dose to the target (up to 25%) and underestimate the dose to the organ at risk (up to 30%). We found similar results (but a bit worse for the PB algorithm) for the two targets of the lamb's head where only two beam gantry angles were simulated. Our results suggest that in PBS proton therapy a range shifter (RS) needs to be used with caution when planning a treatment with an analytical algorithm due to potentially great discrepancies between the planned dose and the dose delivered to the patient, including in the case of brain tumors where this issue could be underestimated. Our results also suggest that a MC evaluation of the dose has to be performed every time the RS is used and, mostly, when it is used with large air gaps and beam directions tangential to the patient surface.
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Affiliation(s)
- Lamberto Widesott
- Proton Therapy Department, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
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28
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Tommasino F, Lorentini S, Schwarz M, Fellin F, Farace P. PV-0137: Dosimetric uncertainties in pencil beam proton therapy for breast cancer. Radiother Oncol 2018. [DOI: 10.1016/s0167-8140(18)30447-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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29
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Righetto R, Farace P, Bonani W, Cianchetti M, Schwarz M. PO-0884: Validation of computed dose distribution in the presence of titanium implants. Radiother Oncol 2018. [DOI: 10.1016/s0167-8140(18)31194-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cristani M, Daducci A, Farace P, Marzola P, Murino V, Sbarbati A, Castellani U. DCE-MRI Data Analysis for Cancer Area Classification. Methods Inf Med 2018; 48:248-53. [DOI: 10.3414/me9224] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Summary
Objectives: The paper aims at improving the support of medical researchers in the context of in-vivo cancer imaging. Morphological and functional parameters obtained by dynamic contrast-enhanced MRI (DCE-MRI) techniques are analyzed, which aim at investigating the development of tumor microvessels. The main contribution consists in proposing a machine learning methodology to segment automatically these MRI data, by isolating tumor areas with different meaning, in a histological sense.
Methods: The proposed approach is based on a three-step procedure: i) robust feature extraction from raw time-intensity curves, ii) voxel segmentation, and iii) voxel classification based on a learning-by-example approach. In the first step, few robust features that compactly represent the response of the tissue to the DCE-MRI analysis are computed. The second step provides a segmentation based on the mean shift (MS) paradigm, which has recently shown to be robust and useful for different and heterogeneous clustering tasks. Finally, in the third step, a support vector machine (SVM) is trained to classify voxels according to the labels obtained by the clustering phase (i.e., each class corresponds to a cluster). Indeed, the SVM is able to classify new unseen subjects with the same kind of tumor.
Results: Experiments on different subjects affected by the same kind of tumor evidence that the extracted regions by both the MS clustering and the SVM classifier exhibit a precise medical meaning, as carefully validated by the medical researchers. Moreover, our approach is more stable and robust than methods based on quantification of DCE-MRI data by means of pharmacokinetic models.
Conclusions: The proposed method allows to analyze the DCE-MRI data more precisely and faster than previous automated or manual approaches.
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Traneus E, Bizzocchi N, Fellin F, Rombi B, Farace P. Universal field matching in craniospinal irradiation by a background-dose gradient-optimized method. J Appl Clin Med Phys 2017; 19:46-49. [PMID: 29115059 PMCID: PMC5768013 DOI: 10.1002/acm2.12204] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 09/13/2017] [Accepted: 09/27/2017] [Indexed: 12/28/2022] Open
Abstract
Purpose The gradient‐optimized methods are overcoming the traditional feathering methods to plan field junctions in craniospinal irradiation. In this note, a new gradient‐optimized technique, based on the use of a background dose, is described. Methods Treatment planning was performed by RayStation (RaySearch Laboratories, Stockholm, Sweden) on the CT scans of a pediatric patient. Both proton (by pencil beam scanning) and photon (by volumetric modulated arc therapy) treatments were planned with three isocenters. An ‘in silico’ ideal background dose was created first to cover the upper‐spinal target and to produce a perfect dose gradient along the upper and lower junction regions. Using it as background, the cranial and the lower‐spinal beams were planned by inverse optimization to obtain dose coverage of their relevant targets and of the junction volumes. Finally, the upper‐spinal beam was inversely planned after removal of the background dose and with the previously optimized beams switched on. Results In both proton and photon plans, the optimized cranial and the lower‐spinal beams produced a perfect linear gradient in the junction regions, complementary to that produced by the optimized upper‐spinal beam. The final dose distributions showed a homogeneous coverage of the targets. Discussion Our simple technique allowed to obtain high‐quality gradients in the junction region. Such technique universally works for photons as well as protons and could be applicable to the TPSs that allow to manage a background dose.
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Affiliation(s)
| | | | | | | | - Paolo Farace
- Proton therapy UnitHospital of TrentoTrentoItaly
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Amelio D, Scartoni D, Farace P, Widesott L, Lorentini S, Vennarini S, Fellin F, Brugnara S, Maines F, Schwarz M, Amichetti M. Proton Therapy Reirradiation in Difficult-to-Treat Recurrent Glioblastoma. Int J Radiat Oncol Biol Phys 2017. [DOI: 10.1016/j.ijrobp.2017.06.741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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33
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Deffet S, Macq B, Righetto R, Vander Stappen F, Farace P. Registration of pencil beam proton radiography data with X-ray CT. Med Phys 2017; 44:5393-5401. [DOI: 10.1002/mp.12497] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 07/14/2017] [Accepted: 07/21/2017] [Indexed: 11/08/2022] Open
Affiliation(s)
- Sylvain Deffet
- Institute of Information and Communication Technologies; Université catholique de Louvain; Louvain-La-Neuve 1348 Belgium
| | - Benoît Macq
- Institute of Information and Communication Technologies; Université catholique de Louvain; Louvain-La-Neuve 1348 Belgium
| | | | - François Vander Stappen
- Medical Accelerators Solutions - R&D; Ion Beam Applications (IBA); Louvain-La-Neuve 1348 Belgium
| | - Paolo Farace
- Proton Therapy Unit; Hospital of Trento; Trento 38122 Italy
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Tommasino F, Durante M, D'Avino V, Liuzzi R, Conson M, Farace P, Palma G, Schwarz M, Cella L, Pacelli R. Model-based approach for quantitative estimates of skin, heart, and lung toxicity risk for left-side photon and proton irradiation after breast-conserving surgery. Acta Oncol 2017; 56:730-736. [PMID: 28281862 DOI: 10.1080/0284186x.2017.1299218] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Proton beam therapy represents a promising modality for left-side breast cancer (BC) treatment, but concerns have been raised about skin toxicity and poor cosmesis. The aim of this study is to apply skin normal tissue complication probability (NTCP) model for intensity modulated proton therapy (IMPT) optimization in left-side BC. MATERIAL AND METHODS Ten left-side BC patients undergoing photon irradiation after breast-conserving surgery were randomly selected from our clinical database. Intensity modulated photon (IMRT) and IMPT plans were calculated with iso-tumor-coverage criteria and according to RTOG 1005 guidelines. Proton plans were computed with and without skin optimization. Published NTCP models were employed to estimate the risk of different toxicity endpoints for skin, lung, heart and its substructures. RESULTS Acute skin NTCP evaluation suggests a lower toxicity level with IMPT compared to IMRT when the skin is included in proton optimization strategy (0.1% versus 1.7%, p < 0.001). Dosimetric results show that, with the same level of tumor coverage, IMPT attains significant heart and lung dose sparing compared with IMRT. By NTCP model-based analysis, an overall reduction in the cardiopulmonary toxicity risk prediction can be observed for all IMPT compared to IMRT plans: the relative risk reduction from protons varies between 0.1 and 0.7 depending on the considered toxicity endpoint. CONCLUSIONS Our analysis suggests that IMPT might be safely applied without increasing the risk of severe acute radiation induced skin toxicity. The quantitative risk estimates also support the potential clinical benefits of IMPT for left-side BC irradiation due to lower risk of cardiac and pulmonary morbidity. The applied approach might be relevant on the long term for the setup of cost-effectiveness evaluation strategies based on NTCP predictions.
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Affiliation(s)
- Francesco Tommasino
- Department of Physics, University of Trento, Povo, Italy
- Trento Institute for Fundamental Physics and Applications (TIFPA), National Institute for Nuclear Physics, (INFN), Povo, Italy
| | - Marco Durante
- Trento Institute for Fundamental Physics and Applications (TIFPA), National Institute for Nuclear Physics, (INFN), Povo, Italy
| | - Vittoria D'Avino
- Institute of Biostructures and Bioimaging, National Research Council (CNR), Naples, Italy
- Department of Naples, National Institute for Nuclear physics (INFN), Naples, Italy
| | - Raffaele Liuzzi
- Institute of Biostructures and Bioimaging, National Research Council (CNR), Naples, Italy
| | - Manuel Conson
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy
| | - Paolo Farace
- Department of Protontherapy, Azienda Provinciale per I Servizi Sanitari (APSS), Trento, Italy
| | - Giuseppe Palma
- Institute of Biostructures and Bioimaging, National Research Council (CNR), Naples, Italy
- Department of Naples, National Institute for Nuclear physics (INFN), Naples, Italy
| | - Marco Schwarz
- Trento Institute for Fundamental Physics and Applications (TIFPA), National Institute for Nuclear Physics, (INFN), Povo, Italy
- Department of Protontherapy, Azienda Provinciale per I Servizi Sanitari (APSS), Trento, Italy
| | - Laura Cella
- Institute of Biostructures and Bioimaging, National Research Council (CNR), Naples, Italy
- Department of Naples, National Institute for Nuclear physics (INFN), Naples, Italy
| | - Roberto Pacelli
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy
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Miori G, WIdesott L, Fracchiolla F, Lorentini S, Farace P, Righetto R, Algranati C, Schwarz M. PO-0875: Dosimetric effects of anatomical changes in proton therapy of head and neck (H&N) cancer. Radiother Oncol 2017. [DOI: 10.1016/s0167-8140(17)31312-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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36
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Farace P, Bizzocchi N, Righetto R, Fellin F, Fracchiolla F, Lorentini S, Widesott L, Algranati C, Rombi B, Vennarini S, Amichetti M, Schwarz M. Supine craniospinal irradiation in pediatric patients by proton pencil beam scanning. Radiother Oncol 2017; 123:112-118. [DOI: 10.1016/j.radonc.2017.02.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 01/19/2017] [Accepted: 02/12/2017] [Indexed: 10/20/2022]
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Amelio D, Scartoni D, Palucci A, Vennarini S, Giacomelli I, Lemoine S, Donner D, Farace P, Chierichetti F, Amichetti M. P04.02 Analysis of 18F-DOPA PET imaging for target volume definition in patients with recurrent glioblastoma treated with proton therapy. Neuro Oncol 2017. [DOI: 10.1093/neuonc/nox036.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Fellin F, Righetto R, Fava G, Trevisan D, Amelio D, Farace P. Water equivalent thickness of immobilization devices in proton therapy planning – Modelling at treatment planning and validation by measurements with a multi-layer ionization chamber. Phys Med 2017; 35:31-38. [DOI: 10.1016/j.ejmp.2017.02.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 01/12/2017] [Accepted: 02/14/2017] [Indexed: 11/16/2022] Open
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Farace P, Righetto R, Deffet S, Meijers A, Vander Stappen F. Technical Note: A direct ray-tracing method to compute integral depth dose in pencil beam proton radiography with a multilayer ionization chamber. Med Phys 2016; 43:6405. [DOI: 10.1118/1.4966703] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Amelio D, Widesott L, Vennarini S, Fellin F, Maines F, Righetto R, Lorentini S, Farace P, Schwarz M, Amichetti M. P08.52 Proton therapy re-Irradiation in large-volume recurrent glioblastoma. Neuro Oncol 2016. [DOI: 10.1093/neuonc/now188.185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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41
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Bizzocchi N, Rombi B, Farace P, Vennarini S, Righetto R, Schwarz M, Amichetti M. RO-20A PLANNING APPROACH FOR LENS SPARING PROTON CRANIOSPINAL IRRADIATION IN A PEDIATRIC PATIENT. Neuro Oncol 2016. [DOI: 10.1093/neuonc/now082.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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42
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Deffet S, Farace P, Righetto R, Macq B, Vander Stappen F. SU-G-TeP2-13: Patient-Specific Reduction of Range Uncertainties in Proton Therapy by Proton Radiography with a Multi-Layer Ionization Chamber. Med Phys 2016. [DOI: 10.1118/1.4957048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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43
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Rombi B, Fellin F, Vennarini S, Bizzocchi N, Farace P, Cammelli S, Paone G, Prete A, Schwarz M, Amichetti M. RO-18PROTON PENCIL BEAM SCANNING VS VMAT FOR CRANIOSPINAL IRRADIATION IN FULLY GROWN PEDIATRIC PATIENT: A CASE REPORT. Neuro Oncol 2016. [DOI: 10.1093/neuonc/now082.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Bizzocchi N, Rombi B, Farace P, Algranati C, Righetto R, Schwarz M, Amichetti M. EP-1691: A planning approach for lens sparing proton craniospinal irradiation in pediatric patients. Radiother Oncol 2016. [DOI: 10.1016/s0167-8140(16)32942-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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46
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Righetto R, Meijers A, Vander Stappen F, Farace P. PO-0914: Adjustment of CT calibration in presence of titanium implants by pencil beam proton radiography. Radiother Oncol 2016. [DOI: 10.1016/s0167-8140(16)32164-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
In this note, an intensity modulated proton therapy (IMPT) technique, based on the use of high single-energy (SE-IMPT) pencil beams, is described.The method uses only the highest system energy (226 MeV) and only lateral penumbra to produce dose gradient, as in photon therapy. In the study, after a preliminary analysis of the width of proton pencil beam penumbras at different depths, SE-IMPT was compared with conventional IMPT in a phantom containing titanium inserts and in a patient, affected by a spinal chordoma with fixation rods.It was shown that SE-IMPT has the potential to produce a sharp dose gradient and that it is not affected by the uncertainties produced by metal implants crossed by the proton beams. Moreover, in the chordoma patient, target coverage and organ at risk sparing of the SE-IMPT plan resulted comparable to that of the less reliable conventional IMPT technique. Robustness analysis confirmed that SE-IMPT was not affected by range errors, which can drastically affect the IMPT plan.When accepting a low-dose spread as in modern photon techniques, SE-IMPT could be an option for the treatment of lesions (e.g. cervical bone tumours) where steep dose gradient could improve curability, and where range uncertainty, due for example to the presence of metal implants, hampers conventional IMPT.
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Affiliation(s)
- Paolo Farace
- Proton Therapy Unit, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
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Farace P, Deidda MA, Amichetti M. Axillary irradiation omitting axillary dissection in breast cancer: is there a role for shoulder-sparing proton therapy? Br J Radiol 2015; 88:20150274. [PMID: 26153903 DOI: 10.1259/bjr.20150274] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The recent EORTC 10981-22023 AMAROS trial showed that axillary radiotherapy and axillary lymph node dissection provide comparable local control and reduced lymphoedema in the irradiated group. However, no significant differences between the two groups in range of motion and quality of life were reported. It has been acknowledged that axillary irradiation could have induced some toxicity, particularly shoulder function impairment. In fact, conventional breast irradiation by tangential beams has to be modified to achieve full-dose coverage of the axillary nodes, including in the treatment field a larger portion of the shoulder structures. In this scenario, alternative irradiation techniques were discussed. Compared with modern photon techniques, axillary irradiation by proton therapy has the potential for sparing the shoulder without detrimental increase of the medium-to-low doses to the other normal tissues.
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Affiliation(s)
- P Farace
- 1 Proton Therapy Centre, Azienda Provinciale per i Servizi Sanitari, Trento, Italy
| | - M A Deidda
- 2 Radiotherapy Department, Regional Oncological Hospital, Cagliari, Italy
| | - M Amichetti
- 1 Proton Therapy Centre, Azienda Provinciale per i Servizi Sanitari, Trento, Italy
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Farace P, Vinante L, Ravanelli D, Bizzocchi N, Vennarini S. Planning field-junction in proton cranio-spinal irradiation - the ancillary-beam technique. Acta Oncol 2015; 54:1075-8. [PMID: 25350525 DOI: 10.3109/0284186x.2014.970667] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Paolo Farace
- Proton Therapy Unit, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Lorenzo Vinante
- Proton Therapy Unit, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Daniele Ravanelli
- Proton Therapy Unit, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Nicola Bizzocchi
- Proton Therapy Unit, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Sabina Vennarini
- Proton Therapy Unit, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
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Fracchiolla F, Lorentini S, Widesott L, Farace P, Schwarz M. OC-0161: 'End to end' validation of a Monte Carlo code for independent dose calculation in a proton pencil beam scanning system. Radiother Oncol 2015. [DOI: 10.1016/s0167-8140(15)40159-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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