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Borghini A, Labate L, Piccinini S, Panaino CMV, Andreassi MG, Gizzi LA. FLASH Radiotherapy: Expectations, Challenges, and Current Knowledge. Int J Mol Sci 2024; 25:2546. [PMID: 38473799 DOI: 10.3390/ijms25052546] [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] [Received: 11/18/2023] [Revised: 02/12/2024] [Accepted: 02/19/2024] [Indexed: 03/14/2024] Open
Abstract
Major strides have been made in the development of FLASH radiotherapy (FLASH RT) in the last ten years, but there are still many obstacles to overcome for transfer to the clinic to become a reality. Although preclinical and first-in-human clinical evidence suggests that ultra-high dose rates (UHDRs) induce a sparing effect in normal tissue without modifying the therapeutic effect on the tumor, successful clinical translation of FLASH-RT depends on a better understanding of the biological mechanisms underpinning the sparing effect. Suitable in vitro studies are required to fully understand the radiobiological mechanisms associated with UHDRs. From a technical point of view, it is also crucial to develop optimal technologies in terms of beam irradiation parameters for producing FLASH conditions. This review provides an overview of the research progress of FLASH RT and discusses the potential challenges to be faced before its clinical application. We critically summarize the preclinical evidence and in vitro studies on DNA damage following UHDR irradiation. We also highlight the ongoing developments of technologies for delivering FLASH-compliant beams, with a focus on laser-driven plasma accelerators suitable for performing basic radiobiological research on the UHDR effects.
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Affiliation(s)
| | - Luca Labate
- Intense Laser Irradiation Laboratory (ILIL), CNR Istituto Nazionale di Ottica, 56124 Pisa, Italy
| | - Simona Piccinini
- Intense Laser Irradiation Laboratory (ILIL), CNR Istituto Nazionale di Ottica, 56124 Pisa, Italy
| | | | | | - Leonida Antonio Gizzi
- Intense Laser Irradiation Laboratory (ILIL), CNR Istituto Nazionale di Ottica, 56124 Pisa, Italy
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Böhlen TT, Germond JF, Traneus E, Vallet V, Desorgher L, Ozsahin EM, Bochud F, Bourhis J, Moeckli R. 3D-conformal very-high energy electron therapy as candidate modality for FLASH-RT: A treatment planning study for glioblastoma and lung cancer. Med Phys 2023; 50:5745-5756. [PMID: 37427669 DOI: 10.1002/mp.16586] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/27/2023] [Indexed: 07/11/2023] Open
Abstract
BACKGROUND Pre-clinical ultra-high dose rate (UHDR) electron irradiations on time scales of 100 ms have demonstrated a remarkable sparing of brain and lung tissues while retaining tumor efficacy when compared to conventional dose rate irradiations. While clinically-used gantries and intensity modulation techniques are too slow to match such time scales, novel very-high energy electron (VHEE, 50-250 MeV) radiotherapy (RT) devices using 3D-conformed broad VHEE beams are designed to deliver UHDR treatments that fulfill these timing requirements. PURPOSE To assess the dosimetric plan quality obtained using VHEE-based 3D-conformal RT (3D-CRT) for treatments of glioblastoma and lung cancer patients and compare the resulting treatment plans to those delivered by standard-of-care intensity modulated photon RT (IMRT) techniques. METHODS Seven glioblastoma patients and seven lung cancer patients were planned with VHEE-based 3D-CRT using 3 to 16 coplanar beams with equidistant angular spacing and energies of 100 and 200 MeV using a forward planning approach. Dose distributions, dose-volume histograms, coverage (V95% ) and homogeneity (HI98% ) for the planning target volume (PTV), as well as near-maximum doses (D2% ) and mean doses (Dmean ) for organs-at-risk (OAR) were evaluated and compared to clinical IMRT plans. RESULTS Mean differences of V95% and HI98% of all VHEE plans were within 2% or better of the IMRT reference plans. Glioblastoma plan dose metrics obtained with VHEE configurations of 200 MeV and 3-16 beams were either not significantly different or were significantly improved compared to the clinical IMRT reference plans. All OAR plan dose metrics evaluated for VHEE plans created using 5 beams of 100 MeV were either not significantly different or within 3% on average, except for Dmean for the body, Dmean for the brain, D2% for the brain stem, and D2% for the chiasm, which were significantly increased by 1, 2, 6, and 8 Gy, respectively (however below clinical constraints). Similarly, the dose metrics for lung cancer patients were also either not significantly different or were significantly improved compared to the reference plans for VHEE configurations with 200 MeV and 5 to 16 beams with the exception of D2% and Dmean to the spinal canal (however below clinical constraints). For the lung cancer cases, the VHEE configurations using 100 MeV or only 3 beams resulted in significantly worse dose metrics for some OAR. Differences in dose metrics were, however, strongly patient-specific and similar for some patient cases. CONCLUSIONS VHEE-based 3D-CRT may deliver conformal treatments to simple, mostly convex target shapes in the brain and the thorax with a limited number of critical adjacent OAR using a limited number of beams (as low as 3 to 7). Using such treatment techniques, a dosimetric plan quality comparable to that of standard-of-care IMRT can be achieved. Hence, from a treatment planning perspective, 3D-conformal UHDR VHEE treatments delivered on time scales of 100 ms represent a promising candidate technique for the clinical transfer of the FLASH effect.
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Affiliation(s)
- Till Tobias Böhlen
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Jean-François Germond
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | | | - Veronique Vallet
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Laurent Desorgher
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Esat Mahmut Ozsahin
- Department of Radiation Oncology, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - François Bochud
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Jean Bourhis
- Department of Radiation Oncology, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Raphaël Moeckli
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
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Tan HS, Teo KBK, Dong L, Friberg A, Koumenis C, Diffenderfer E, Zou JW. Modeling ultra-high dose rate electron and proton FLASH effect with the physicochemical approach. Phys Med Biol 2023; 68:10.1088/1361-6560/ace14d. [PMID: 37352867 PMCID: PMC10472835 DOI: 10.1088/1361-6560/ace14d] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 06/23/2023] [Indexed: 06/25/2023]
Abstract
Objective. A physicochemical model built on the radiochemical kinetic theory was recently proposed in (Labarbeet al2020) to explain the FLASH effect. We performed extensive simulations to scrutinize its applicability for oxygen depletion studies and FLASH-related experiments involving both proton and electron beams.Approach. Using the dose and beam delivery parameters for each FLASH experiment, we numerically solved the radiochemical rate equations comprised of a set of coupled nonlinear ordinary differential equations to obtain the area under the curve (AUC) of radical concentrations.Main results. The modeled differences in AUC induced by ultra-high dose rates appeared to correlate well with the FLASH effect. (i) For the whole brain irradiation of mice performed in (Montay-Gruelet al2017), the threshold dose rate values for memory preservation coincided with those at which AUC started to decrease much less rapidly. (ii) For the proton pencil beam scanning FLASH of (Cunninghamet al2021), we found linear correlations between radicals' AUC and the biological endpoints: TGF-β1, leg contracture and plasma level of cytokine IL-6. (iii) Compatible with the findings of the proton FLASH experiment in (Kimet al2021), we found that radicals' AUC at the entrance and mid-Spread-Out Bragg peak regions were highly similar. In addition, our model also predicted ratios of oxygen depletionG-values between normal and UHDR irradiation similar to those observed in (Caoet al2021) and (El Khatibet al2022).Significance. Collectively, our results suggest that the normal tissue sparing conferred by UHDR irradiation may be due to the lower degree of exposure to peroxyl and superoxide radicals. We also found that the differential effect of dose rate on the radicals' AUC was less pronounced at lower initial oxygen levels, a trait that appears to align with the FLASH differential effect on normal versus tumor tissues.
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Affiliation(s)
- Hai Siong Tan
- University of Pennsylvania, Perelman School of Medicine, Department of Radiation Oncology, Philadelphia, United States of America
| | - Kevin Boon Keng Teo
- University of Pennsylvania, Perelman School of Medicine, Department of Radiation Oncology, Philadelphia, United States of America
| | - Lei Dong
- University of Pennsylvania, Perelman School of Medicine, Department of Radiation Oncology, Philadelphia, United States of America
| | - Andrew Friberg
- University of Pennsylvania, Perelman School of Medicine, Department of Radiation Oncology, Philadelphia, United States of America
| | - Constantinos Koumenis
- University of Pennsylvania, Perelman School of Medicine, Department of Radiation Oncology, Philadelphia, United States of America
| | - Eric Diffenderfer
- University of Pennsylvania, Perelman School of Medicine, Department of Radiation Oncology, Philadelphia, United States of America
| | - Jennifer Wei Zou
- University of Pennsylvania, Perelman School of Medicine, Department of Radiation Oncology, Philadelphia, United States of America
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Zhang Q, Gerweck LE, Cascio E, Gu L, Yang Q, Dong X, Huang P, Bertolet A, Nesteruk KP, Sung W, McNamara AL, Schuemann J. Absence of Tissue-Sparing Effects in Partial Proton FLASH Irradiation in Murine Intestine. Cancers (Basel) 2023; 15:cancers15082269. [PMID: 37190197 DOI: 10.3390/cancers15082269] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/07/2023] [Accepted: 04/11/2023] [Indexed: 05/17/2023] Open
Abstract
Ultra-high dose rate irradiation has been reported to protect normal tissues more than conventional dose rate irradiation. This tissue sparing has been termed the FLASH effect. We investigated the FLASH effect of proton irradiation on the intestine as well as the hypothesis that lymphocyte depletion is a cause of the FLASH effect. A 16 × 12 mm2 elliptical field with a dose rate of ~120 Gy/s was provided by a 228 MeV proton pencil beam. Partial abdominal irradiation was delivered to C57BL/6j and immunodeficient Rag1-/-/C57 mice. Proliferating crypt cells were counted at 2 days post exposure, and the thickness of the muscularis externa was measured at 280 days following irradiation. FLASH irradiation did not reduce the morbidity or mortality of conventional irradiation in either strain of mice; in fact, a tendency for worse survival in FLASH-irradiated mice was observed. There were no significant differences in lymphocyte numbers between FLASH and conventional-dose-rate mice. A similar number of proliferating crypt cells and a similar thickness of the muscularis externa following FLASH and conventional dose rate irradiation were observed. Partial abdominal FLASH proton irradiation at 120 Gy/s did not spare normal intestinal tissue, and no difference in lymphocyte depletion was observed. This study suggests that the effect of FLASH irradiation may depend on multiple factors, and in some cases dose rates of over 100 Gy/s do not induce a FLASH effect and can even result in worse outcomes.
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Affiliation(s)
- Qixian Zhang
- Physics Division, Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, MA 02129, USA
| | - Leo E Gerweck
- Physics Division, Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, MA 02129, USA
| | - Ethan Cascio
- Physics Division, Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, MA 02129, USA
| | - Liqun Gu
- Physics Division, Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, MA 02129, USA
| | - Qingyuan Yang
- Physics Division, Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, MA 02129, USA
| | - Xinyue Dong
- Physics Division, Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, MA 02129, USA
| | - Peigen Huang
- Physics Division, Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, MA 02129, USA
| | - Alejandro Bertolet
- Physics Division, Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, MA 02129, USA
| | - Konrad Pawel Nesteruk
- Physics Division, Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, MA 02129, USA
| | - Wonmo Sung
- Physics Division, Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, MA 02129, USA
| | - Aimee L McNamara
- Physics Division, Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, MA 02129, USA
| | - Jan Schuemann
- Physics Division, Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, MA 02129, USA
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Schulte R, Johnstone C, Boucher S, Esarey E, Geddes CGR, Kravchenko M, Kutsaev S, Loo BW, Méot F, Mustapha B, Nakamura K, Nanni EA, Obst-Huebl L, Sampayan SE, Schroeder CB, Sheng K, Snijders AM, Snively E, Tantawi SG, Van Tilborg J. Transformative Technology for FLASH Radiation Therapy. Appl Sci (Basel) 2023; 13:5021. [PMID: 38240007 PMCID: PMC10795821 DOI: 10.3390/app13085021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/22/2024]
Abstract
The general concept of radiation therapy used in conventional cancer treatment is to increase the therapeutic index by creating a physical dose differential between tumors and normal tissues through precision dose targeting, image guidance, and radiation beams that deliver a radiation dose with high conformality, e.g., protons and ions. However, the treatment and cure are still limited by normal tissue radiation toxicity, with the corresponding side effects. A fundamentally different paradigm for increasing the therapeutic index of radiation therapy has emerged recently, supported by preclinical research, and based on the FLASH radiation effect. FLASH radiation therapy (FLASH-RT) is an ultra-high-dose-rate delivery of a therapeutic radiation dose within a fraction of a second. Experimental studies have shown that normal tissues seem to be universally spared at these high dose rates, whereas tumors are not. While dose delivery conditions to achieve a FLASH effect are not yet fully characterized, it is currently estimated that doses delivered in less than 200 ms produce normal-tissue-sparing effects, yet effectively kill tumor cells. Despite a great opportunity, there are many technical challenges for the accelerator community to create the required dose rates with novel compact accelerators to ensure the safe delivery of FLASH radiation beams.
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Affiliation(s)
- Reinhard Schulte
- Division of Biomedical Engineering Sciences, Loma Linda University, Loma Linda, CA 92350, USA
| | - Carol Johnstone
- Fermi National Accelerator Laboratory, Batavia, IL 60510, USA
| | - Salime Boucher
- RadiaBeam Technologies, LLC, Santa Monica, CA 90404, USA
| | - Eric Esarey
- Lawrence Berkeley National Laboratory, Berkeley, CA 94720, USA
| | | | | | - Sergey Kutsaev
- RadiaBeam Technologies, LLC, Santa Monica, CA 90404, USA
| | - Billy W. Loo
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - François Méot
- Brookhaven National Laboratory, Upton, NY 11973, USA
| | | | - Kei Nakamura
- Lawrence Berkeley National Laboratory, Berkeley, CA 94720, USA
| | - Emilio A. Nanni
- SLAC National Accelerator Laboratory, Menlo Park, CA 94025, USA
| | | | - Stephen E. Sampayan
- Lawrence Livermore National Laboratory, Livermore, CA 94551, USA
- Opcondys, Inc., Manteca, CA 95336, USA
| | | | - Ke Sheng
- Department of Radiation Oncology, University of California, San Francisco, CA 94115, USA
| | | | - Emma Snively
- SLAC National Accelerator Laboratory, Menlo Park, CA 94025, USA
| | - Sami G. Tantawi
- SLAC National Accelerator Laboratory, Menlo Park, CA 94025, USA
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Dai Y, Liang R, Wang J, Zhang J, Wu D, Zhao R, Liu Z, Chen F. Fractionated FLASH radiation in xenografted lung tumors induced FLASH effect at a split dose of 2 Gy. Int J Radiat Biol 2023; 99:1542-1549. [PMID: 36952604 DOI: 10.1080/09553002.2023.2194403] [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: 06/07/2022] [Accepted: 03/16/2023] [Indexed: 03/25/2023]
Abstract
PURPOSE To explore the minimum split dose of FLASH radiotherapy (FLASH). MATERIAL AND METHODS Lungs of nude mice were used to verify the capacity of normal tissue sparing of FLASH, while tumor-bearing nude mice were used to evaluate the curative power. Xenografted tumor models were established in Balb/c-nu mice using A549 cells at a concentration of 5 × 10 6 / 100 μ L . With the same total dose (20 Gy), the dose rate of FLASH was 200 Gy/s when conventional radiotherapy(CONV) was 0.033 Gy/s. Two schemes of FLASH irradiations were applied: single pulse (FLASH1) and ten pulses (FLASH10). Then, according to the different tissue types and irradiation schemes, mice were divided into eight groups: Control-T, CONV-T, FLASH1-T, FLASH10-T (T for tumor) and Control-L, CONV-L, FLASH1-L, FLASH10-L (L for lung). Evaluation of FLASH effect was based on the changes in tumor volume and pathological analysis of tumor and lung tissues before and after irradiation. RESULTS Compared to control group, the mean volume of tumors in nude mice increased slowly or decreased after irradiation with both FLASH and CONV (Control-T: 233.6± 55.19 mm3, CONV-T: 146.1± 50.62 mm3, FLASH1-T: 148± 18.83 mm3, FLASH10-T: 119.1± 50.62 mm3, p ≤ . 05) . Tumor cells of irradiated groups had similar degrees of dissolution damage and inflammation, while the acute radiation pneumonia induced by FLASH was less severe. The pulmonary pathology of FLASH1-L and FLASH10-L were similar, and only a few neutrophils were observed. In addition to inflammatory cells, slight thickening of alveolar septum and obvious interstitial hemorrhage were also observed in the CONV-L group. CONCLUSION The FLASH effect was successfully reproduced in both single and fractionated irradiation, with 2 Gy being the minimum split dose to achieve the FLASH effect in existing experiments. It is suggested that the transient oxygen depletion might not be the only mechanism behind the FLASH effect.
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Affiliation(s)
- Yuling Dai
- Nuclear and Radiation Frontier Technology Research Center, China Institute for Radiation Protection, Taiyuan, China
- Shanxi Provincial Key Laboratory for Translational Nuclear Medicine and Precision Protection, Taiyuan, China
| | - Runcheng Liang
- Nuclear and Radiation Frontier Technology Research Center, China Institute for Radiation Protection, Taiyuan, China
- Shanxi Provincial Key Laboratory for Translational Nuclear Medicine and Precision Protection, Taiyuan, China
| | - Jianxin Wang
- Institute of Applied Electronics, China Academy of Engineering Physics, Mianyang, China
| | - Jing Zhang
- Nuclear and Radiation Frontier Technology Research Center, China Institute for Radiation Protection, Taiyuan, China
- Shanxi Provincial Key Laboratory for Translational Nuclear Medicine and Precision Protection, Taiyuan, China
| | - Dai Wu
- Institute of Applied Electronics, China Academy of Engineering Physics, Mianyang, China
| | - Ri Zhao
- Nuclear and Radiation Frontier Technology Research Center, China Institute for Radiation Protection, Taiyuan, China
- Shanxi Provincial Key Laboratory for Translational Nuclear Medicine and Precision Protection, Taiyuan, China
| | - Zhaoxing Liu
- Nuclear and Radiation Frontier Technology Research Center, China Institute for Radiation Protection, Taiyuan, China
- Shanxi Provincial Key Laboratory for Translational Nuclear Medicine and Precision Protection, Taiyuan, China
| | - Faguo Chen
- Nuclear and Radiation Frontier Technology Research Center, China Institute for Radiation Protection, Taiyuan, China
- Shanxi Provincial Key Laboratory for Translational Nuclear Medicine and Precision Protection, Taiyuan, China
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Chappuis F, Grilj V, Tran HN, Zein SA, Bochud F, Bailat C, Incerti S, Desorgher L. Modeling of scavenging systems in water radiolysis with Geant4-DNA. Phys Med 2023; 108:102549. [PMID: 36921424 DOI: 10.1016/j.ejmp.2023.102549] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 01/11/2023] [Accepted: 02/13/2023] [Indexed: 03/16/2023] Open
Abstract
PURPOSE This paper presents the capabilities of the Geant4-DNA Monte Carlo toolkit to simulate water radiolysis with scavengers using the step-by-step (SBS) or the independent reaction times (IRT) methods. It features two examples of application areas: (1) computing the escape yield of H2O2 following a 60Co γ-irradiation and (2) computing the oxygen depletion in water irradiated with 1 MeV electrons. METHODS To ease the implementation of the chemical stage in Geant4-DNA, we developed a user interface that helps define the chemical reactions and set the concentration of scavengers. The first application area example required two computational steps to perform water radiolysis using NO2- and NO3- as scavengers and a 60Co irradiation. The oxygen depletion computation technique for the second application area example consisted of simulating track segments of 1 MeV electrons and determining the radio-induced loss and gain of oxygen molecules. RESULTS The production of H2O2 under variable scavenging levels is consistent with the literature; the mean relative difference between the SBS and IRT methods is 7.2 % ± 0.5 %. For the oxygen depletion 1 µs post-irradiation, the mean relative difference between both methods is equal to 9.8 % ± 0.3 %. The results in the microsecond scale depend on the initial partial pressure of oxygen in water. In addition, the computed oxygen depletions agree well with the literature. CONCLUSIONS The Geant4-DNA toolkit makes it possible to simulate water radiolysis in the presence of scavengers. This feature offers perspectives in radiobiology, with the possibility of simulating cell-relevant scavenging mechanisms.
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Affiliation(s)
- Flore Chappuis
- Institute of Radiation Physics (IRA), Lausanne University Hospital and University of Lausanne, CH-1007 Lausanne, Switzerland
| | - Veljko Grilj
- Institute of Radiation Physics (IRA), Lausanne University Hospital and University of Lausanne, CH-1007 Lausanne, Switzerland
| | - Hoang Ngoc Tran
- Univ. Bordeaux, CNRS, LP2I Bordeaux, UMR 5797, F-33170 Gradignan, France
| | - Sara A Zein
- Univ. Bordeaux, CNRS, LP2I Bordeaux, UMR 5797, F-33170 Gradignan, France
| | - François Bochud
- Institute of Radiation Physics (IRA), Lausanne University Hospital and University of Lausanne, CH-1007 Lausanne, Switzerland
| | - Claude Bailat
- Institute of Radiation Physics (IRA), Lausanne University Hospital and University of Lausanne, CH-1007 Lausanne, Switzerland
| | - Sébastien Incerti
- Univ. Bordeaux, CNRS, LP2I Bordeaux, UMR 5797, F-33170 Gradignan, France
| | - Laurent Desorgher
- Institute of Radiation Physics (IRA), Lausanne University Hospital and University of Lausanne, CH-1007 Lausanne, Switzerland.
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Böhlen TT, Germond JF, Bourhis J, Bailat C, Bochud F, Moeckli R. The minimal FLASH sparing effect needed to compensate the increase of radiobiological damage due to hypofractionation for late-reacting tissues. Med Phys 2022; 49:7672-7682. [PMID: 35933554 PMCID: PMC10087769 DOI: 10.1002/mp.15911] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 07/06/2022] [Accepted: 07/28/2022] [Indexed: 12/27/2022] Open
Abstract
PURPOSE Normal tissue (NT) sparing by ultra-high dose rate (UHDR) irradiations compared to conventional dose rate (CONV) irradiations while being isotoxic to the tumor has been termed "FLASH effect" and has been observed when large doses per fraction (d ≳ 5 Gy) have been delivered. Since hypofractionated treatment schedules are known to increase toxicities of late-reacting tissues compared to normofractionated schedules for many clinical scenarios at CONV dose rates, we developed a formalism based on the biologically effective dose (BED) to assess the minimum magnitude of the FLASH effect needed to compensate the loss of late-reacting NT sparing when reducing the number of fractions compared to a normofractionated CONV treatment schedule while remaining isoeffective to the tumor. METHODS By requiring the same BED for the tumor, we derived the "break-even NT sparing weighting factor" WBE for the linear-quadratic (LQ) and LQ-linear (LQ-L) models for an NT region irradiated at a relative dose r (relative to the prescribed dose per fraction d to the tumor). WBE was evaluated numerically for multiple values of d and r, and for different tumor and NT α/β-ratios. WBE was compared against currently available experimental data on the magnitude of the NT sparing provided by the FLASH effect for single fraction doses. RESULTS For many clinically relevant scenarios, WBE decreases steeply initially for d > 2 Gy for late-reacting tissues with (α/β)NT ≈ 3 Gy, implying that a significant NT sparing by the FLASH effect (between 15% and 30%) is required to counteract the increased radiobiological damage experienced by late-reacting NT for hypofractionated treatments with d < 10 Gy compared to normofractionated treatments that are equieffective to the tumor. When using the LQ model with generic α/β-ratios for tumor and late-reacting NT of (α/β)T = 10 Gy and (α/β)NT = 3 Gy, respectively, most currently available experimental evidence about the magnitude of NT sparing by the FLASH effect suggests no net NT sparing benefit for hypofractionated FLASH radiotherapy (RT) in the high-dose region when compared with WBE . Instead, clinical indications with more similar α/β-ratios of the tumor and dose-limiting NT toxicities [i.e., (α/β)T ≈ (α/β)NT ], such as prostate treatments, are generally less penalized by hypofractionated treatments and need consequently smaller magnitudes of NT sparing by the FLASH effect to achieve a net benefit. For strongly hypofractionated treatments (>10-15 Gy/fraction), the LQ-L model predicts, unlike the LQ model, a larger WBE suggesting a possible benefit of strongly hypofractionated FLASH RT, even for generic α/β-ratios of (α/β)T = 10 Gy and (α/β)NT = 3 Gy. However, knowledge on the isoeffect scaling for high doses per fraction (≳10 Gy/fraction) and its modeling is currently limited and impedes accurate and reliable predictions for such strongly hypofractionated treatments. CONCLUSIONS We developed a formalism that quantifies the minimal NT sparing by the FLASH effect needed to compensate for hypofractionation, based on the LQ and LQ-L models. For a given hypofractionated UHDR treatment scenario and magnitude of the FLASH effect, the formalism predicts if a net NT sparing benefit is expected compared to a respective normofractionated CONV treatment.
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Affiliation(s)
- Till Tobias Böhlen
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Jean-François Germond
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Jean Bourhis
- Department of Radiation Oncology, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Claude Bailat
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - François Bochud
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Raphaël Moeckli
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
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Faillace L, Alesini D, Bisogni G, Bosco F, Carillo M, Cirrone P, Cuttone G, De Arcangelis D, De Gregorio A, Di Martino F, Favaudon V, Ficcadenti L, Francescone D, Franciosini G, Gallo A, Heinrich S, Migliorati M, Mostacci A, Palumbo L, Patera V, Patriarca A, Pensavalle J, Perondi F, Remetti R, Sarti A, Spataro B, Torrisi G, Vannozzi A, Giuliano L. Perspectives in linear accelerator for FLASH VHEE: Study of a compact C-band system. Phys Med 2022; 104:149-159. [PMID: 36427487 DOI: 10.1016/j.ejmp.2022.10.018] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 10/10/2022] [Accepted: 10/23/2022] [Indexed: 11/24/2022] Open
Abstract
PURPOSE In order to translate the FLASH effect in clinical use and to treat deep tumors, Very High Electron Energy irradiations could represent a valid technique. Here, we address the main issues in the design of a VHEE FLASH machine. We present preliminary results for a compact C-band system aiming to reach a high accelerating gradient and high current necessary to deliver a Ultra High Dose Rate with a beam pulse duration of 3μs. METHODS The proposed system is composed by low energy high current injector linac followed by a high acceleration gradient structure able to reach 60-160 MeV energy range. To obtain the maximum energy, an energy pulse compressor options is considered. CST code was used to define the specifications RF parameters of the linac. To optimize the accelerated current and therefore the delivered dose, beam dynamics simulations was performed using TSTEP and ASTRA codes. RESULTS The VHEE parameters Linac suitable to satisfy FLASH criteria were simulated. Preliminary results allow to obtain a maximum energy of 160 MeV, with a peak current of 200 mA, which corresponds to a charge of 600 nC. CONCLUSIONS A promising preliminary design of VHEE linac for FLASH RT has been performed. Supplementary studies are on going to complete the characterization of the machine and to manufacture and test the RF prototypes.
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Affiliation(s)
- L Faillace
- INFN Laboratori Nazionali di Frascati, Italy.
| | - D Alesini
- INFN Laboratori Nazionali di Frascati, Italy
| | - G Bisogni
- INFN Sezione di Pisa, Italy; Department of Physics, University of Pisa, 56127 Pisa, Italy
| | - F Bosco
- SBAI Department, Sapienza University of Rome, Italy; INFN Sezione di Roma, Italy
| | - M Carillo
- SBAI Department, Sapienza University of Rome, Italy; INFN Sezione di Roma, Italy
| | - P Cirrone
- INFN Laboratori Nazionali del Sud, Catania, Italy
| | - G Cuttone
- INFN Laboratori Nazionali del Sud, Catania, Italy
| | - D De Arcangelis
- SBAI Department, Sapienza University of Rome, Italy; INFN Sezione di Roma, Italy
| | - A De Gregorio
- INFN Sezione di Roma, Italy; Department of Physics, Sapienza University, Piazzale Aldo Moro 2, 00185 Rome, Italy
| | - F Di Martino
- U.O. Fisica Sanitaria, Azienda Universitaria Ospedaliera Pisana, Pisa, Italy
| | - V Favaudon
- Institut Curie, Paris-Saclay University, PSL Research University, INSERM U1021/UMR3347, Orsay, France
| | - L Ficcadenti
- SBAI Department, Sapienza University of Rome, Italy; INFN Sezione di Roma, Italy
| | - D Francescone
- SBAI Department, Sapienza University of Rome, Italy; INFN Sezione di Roma, Italy
| | - G Franciosini
- INFN Sezione di Roma, Italy; Department of Physics, Sapienza University, Piazzale Aldo Moro 2, 00185 Rome, Italy
| | - A Gallo
- INFN Laboratori Nazionali di Frascati, Italy
| | - S Heinrich
- Institut Curie, Paris-Saclay University, PSL Research University, INSERM U1021/UMR3347, Orsay, France
| | - M Migliorati
- SBAI Department, Sapienza University of Rome, Italy; INFN Sezione di Roma, Italy
| | - A Mostacci
- SBAI Department, Sapienza University of Rome, Italy; INFN Sezione di Roma, Italy
| | - L Palumbo
- SBAI Department, Sapienza University of Rome, Italy; INFN Sezione di Roma, Italy
| | - V Patera
- SBAI Department, Sapienza University of Rome, Italy; INFN Sezione di Roma, Italy
| | - A Patriarca
- Institut Curie, PSL Research University, Proton Therapy Centre, Centre Universitaire, Orsay, France
| | - J Pensavalle
- INFN Sezione di Pisa, Italy; Department of Physics, University of Pisa, 56127 Pisa, Italy
| | - F Perondi
- SBAI Department, Sapienza University of Rome, Italy
| | - R Remetti
- SBAI Department, Sapienza University of Rome, Italy
| | - A Sarti
- SBAI Department, Sapienza University of Rome, Italy; INFN Sezione di Roma, Italy
| | - B Spataro
- INFN Laboratori Nazionali di Frascati, Italy
| | - G Torrisi
- INFN Laboratori Nazionali del Sud, Catania, Italy
| | - A Vannozzi
- INFN Laboratori Nazionali di Frascati, Italy
| | - L Giuliano
- SBAI Department, Sapienza University of Rome, Italy; INFN Sezione di Roma, Italy
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10
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Zou W, Kim H, Diffenderfer ES, Carlson DJ, Koch CJ, Xiao Y, Teo BK, Kim MM, Metz JM, Fan Y, Maity A, Koumenis C, Busch TM, Wiersma R, Cengel KA, Dong L. A phenomenological model of proton FLASH oxygen depletion effects depending on tissue vasculature and oxygen supply. Front Oncol 2022; 12:1004121. [PMID: 36518319 PMCID: PMC9742361 DOI: 10.3389/fonc.2022.1004121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/11/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction Radiation-induced oxygen depletion in tissue is assumed as a contributor to the FLASH sparing effects. In this study, we simulated the heterogeneous oxygen depletion in the tissue surrounding the vessels and calculated the proton FLASH effective-dose-modifying factor (FEDMF), which could be used for biology-based treatment planning. Methods The dose and dose-weighted linear energy transfer (LET) of a small animal proton irradiator was simulated with Monte Carlo simulation. We deployed a parabolic partial differential equation to account for the generalized radiation oxygen depletion, tissue oxygen diffusion, and metabolic processes to investigate oxygen distribution in 1D, 2D, and 3D solution space. Dose and dose rates, particle LET, vasculature spacing, and blood oxygen supplies were considered. Using a similar framework for the hypoxic reduction factor (HRF) developed previously, the FEDMF was derived as the ratio of the cumulative normoxic-equivalent dose (CNED) between CONV and UHDR deliveries. Results Dynamic equilibrium between oxygen diffusion and tissue metabolism can result in tissue hypoxia. The hypoxic region displayed enhanced radio-resistance and resulted in lower CNED under UHDR deliveries. In 1D solution, comparing 15 Gy proton dose delivered at CONV 0.5 and UHDR 125 Gy/s, 61.5% of the tissue exhibited ≥20% FEDMF at 175 μm vasculature spacing and 18.9 μM boundary condition. This percentage reduced to 34.5% and 0% for 8 and 2 Gy deliveries, respectively. Similar trends were observed in the 3D solution space. The FLASH versus CONV differential effect remained at larger vasculature spacings. A higher FLASH dose rate showed an increased region with ≥20% FEDMF. A higher LET near the proton Bragg peak region did not appear to alter the FLASH effect. Conclusion We developed 1D, 2D, and 3D oxygen depletion simulation process to obtain the dynamic HRF and derive the proton FEDMF related to the dose delivery parameters and the local tissue vasculature information. The phenomenological model can be used to simulate or predict FLASH effects based on tissue vasculature and oxygen concentration data obtained from other experiments.
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11
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Jansen J, Beyreuther E, García-Calderón D, Karsch L, Knoll J, Pawelke J, Schürer M, Seco J. oChanges in Radical Levels as a Cause for the FLASH effect: Impact of beam structure parameters at ultra-high dose rates on oxygen depletion in water. Radiother Oncol 2022; 175:193-196. [PMID: 36030933 DOI: 10.1016/j.radonc.2022.08.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 01/15/2023]
Abstract
The influence of different average and bunch dose rates in electron beams on the FLASH effect was investigated. The present study measures O2 content in water at different beam pulse patterns and finds strong correlation with biological data, strengthening the hypothesis of radical-related mechanisms as a reason for the FLASH effect.
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Affiliation(s)
- Jeannette Jansen
- Division of Biomedical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Elke Beyreuther
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden and Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Institute of Radiation Physics, Dresden, Germany
| | - Daniel García-Calderón
- Division of Biomedical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Physics and Astronomy, Ruprecht-Karls-University, Heidelberg, Germany
| | - Leonhard Karsch
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden and Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Jan Knoll
- Division of Biomedical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Physics and Astronomy, Ruprecht-Karls-University, Heidelberg, Germany
| | - Jörg Pawelke
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden and Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Michael Schürer
- National Center for Tumor Diseases Dresden (NCT/UCC), Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
| | - Joao Seco
- Division of Biomedical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Physics and Astronomy, Ruprecht-Karls-University, Heidelberg, Germany.
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12
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Böhlen TT, Germond JF, Bourhis J, Vozenin MC, Ozsahin EM, Bochud F, Bailat C, Moeckli R. Normal tissue sparing by FLASH as a function of single fraction dose: A quantitative analysis. Int J Radiat Oncol Biol Phys 2022; 114:1032-1044. [PMID: 35810988 DOI: 10.1016/j.ijrobp.2022.05.038] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [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: 02/02/2022] [Revised: 04/26/2022] [Accepted: 05/24/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE The FLASH effect designates normal tissue sparing by ultra-high dose rate (UHDR) compared to conventional dose rate (CONV) irradiation without compromising tumor control. Understanding the magnitude of this effect and its dependency on dose are essential requirements for an optimized clinical translation of FLASH radiation therapy. In this context, we evaluated available experimental data on the magnitudes of normal tissue sparing provided by the FLASH effect as a function of dose, and followed a phenomenological data-driven approach for its parameterization. METHODS We gathered available in vivo data of the normal tissue sparing of CONV compared to UHDR single fraction doses and converted it to a common scale using isoeffect dose ratios, hereafter referred to as FLASH modifying factors (FMF). We then evaluated the suitability of a piecewise linear function with two pieces to parametrize FMF × D as a function of dose D. RESULTS We found that the magnitude of FMF generally decreases (i.e., sparing increases) as function of single fraction dose and that individual data series can be described by the piecewise linear function. The sparing magnitude appears organ specific. Pooled skin reaction data followed a consistent trend as a function of dose. Average FMF values and their standard deviations were 0.95±0.11 for all data below 10 Gy, 0.92±0.06 for mouse gut data between 10-25 Gy, and 0.96±0.07 and 0.71±0.06 for mammalian skin reaction data between 10-25 Gy and >25 Gy, respectively. CONCLUSIONS The magnitude of normal tissue sparing by FLASH is increasing with dose and is dependent on the irradiated tissue. A piecewise linear function can parameterize currently available individual data series.
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Affiliation(s)
- Till Tobias Böhlen
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Jean-François Germond
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Jean Bourhis
- Department of Radiation Oncology, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Marie-Catherine Vozenin
- Department of Radiation Oncology, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Esat Mahmut Ozsahin
- Department of Radiation Oncology, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - François Bochud
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Claude Bailat
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Raphaël Moeckli
- Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland..
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13
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Schüler E, Acharya M, Montay-Gruel P, Loo BW, Vozenin MC, Maxim PG. Ultra-high dose rate electron beams and the FLASH effect: From preclinical evidence to a new radiotherapy paradigm. Med Phys 2022; 49:2082-2095. [PMID: 34997969 PMCID: PMC9032195 DOI: 10.1002/mp.15442] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [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: 08/03/2021] [Revised: 11/14/2021] [Accepted: 12/17/2021] [Indexed: 12/30/2022] Open
Abstract
In their seminal paper from 2014, Fauvadon et al. coined the term FLASH irradiation to describe ultra-high-dose rate irradiation with dose rates greater than 40 Gy/s, which results in delivery times of fractions of a second. The experiments presented in that paper were performed with a high-dose-per-pulse 4.5 MeV electron beam, and the results served as the basis for the modern-day field of FLASH radiation therapy (RT). In this article, we review the studies that have been published after those early experiments, demonstrating the robust effects of FLASH RT on normal tissue sparing in preclinical models. We also outline the various irradiation parameters that have been used. Although the robustness of the biological response has been established, the mechanisms behind the FLASH effect are currently under investigation in a number of laboratories. However, differences in the magnitude of the FLASH effect between experiments in different labs have been reported. Reasons for these differences even within the same animal model are currently unknown, but likely has to do with the marked differences in irradiation parameter settings used. Here, we show that these parameters are often not reported, which complicates large multistudy comparisons. For this reason, we propose a new standard for beam parameter reporting and discuss a systematic path to the clinical translation of FLASH RT.
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Affiliation(s)
- Emil Schüler
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030 USA,Graduate School of Biomedical Sciences, The University of Texas, Houston, TX 77030 USA
| | - Munjal Acharya
- Department of Anatomy and Neurobiology, University of California Irvine, Irvine, CA, USA
| | - Pierre Montay-Gruel
- Department of Radiation Oncology, University of California Irvine, Irvine, CA, USA
| | - Billy W. Loo
- Department of Radiation Oncology and Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Marie-Catherine Vozenin
- Laboratory of Radiation Oncology/DO/Radio-Oncology/CHUV, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland,Corresponding authors: Peter G. Maxim, PhD, Department of Radiation Oncology, University of California, Irvine, Irvine, CA 713-563-4019, , Marie-Catherine Vozenin, PhD, Laboratory of Radiation Oncology/DO/Radio-Oncology/CHUV, Lausanne University Hospital and University of Lausanne, Switzerland. +41 216925901,
| | - Peter G. Maxim
- Department of Radiation Oncology, University of California Irvine, Irvine, CA, USA,Corresponding authors: Peter G. Maxim, PhD, Department of Radiation Oncology, University of California, Irvine, Irvine, CA 713-563-4019, , Marie-Catherine Vozenin, PhD, Laboratory of Radiation Oncology/DO/Radio-Oncology/CHUV, Lausanne University Hospital and University of Lausanne, Switzerland. +41 216925901,
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14
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Okoro CM, Schüler E, Taniguchi CM. The Therapeutic Potential of FLASH-RT for Pancreatic Cancer. Cancers (Basel) 2022; 14:cancers14051167. [PMID: 35267474 PMCID: PMC8909276 DOI: 10.3390/cancers14051167] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/21/2022] [Accepted: 02/22/2022] [Indexed: 11/21/2022] Open
Abstract
Simple Summary Ultra-high dose rate radiation, widely nicknamed FLASH-RT, kills tumors without significantly damaging nearby normal tissues. This selective sparing of normal tissue by FLASH-RT tissue is called the FLASH effect. This review explores some of the proposed mechanisms of the FLASH effect and the current data that might support its use in pancreatic cancer. Since radiation for pancreatic cancer treatment is limited by GI toxicity issues and is a disease with one of the lowest five-year survival rates, FLASH-RT could have a large impact in the treatment of this disease with further study. Abstract Recent preclinical evidence has shown that ionizing radiation given at an ultra-high dose rate (UHDR), also known as FLASH radiation therapy (FLASH-RT), can selectively reduce radiation injury to normal tissue while remaining isoeffective to conventional radiation therapy (CONV-RT) with respect to tumor killing. Unresectable pancreatic cancer is challenging to control without ablative doses of radiation, but this is difficult to achieve without significant gastrointestinal toxicity. In this review article, we explore the propsed mechanisms of FLASH-RT and its tissue-sparing effect, as well as its relevance and suitability for the treatment of pancreatic cancer. We also briefly discuss the challenges with regard to dosimetry, dose rate, and fractionation for using FLASH-RT to treat this disease.
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Affiliation(s)
- Chidi M. Okoro
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Emil Schüler
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Correspondence: (E.S.); (C.M.T.)
| | - Cullen M. Taniguchi
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Correspondence: (E.S.); (C.M.T.)
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15
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Sarti A, De Maria P, Battistoni G, De Simoni M, Di Felice C, Dong Y, Fischetti M, Franciosini G, Marafini M, Marampon F, Mattei I, Mirabelli R, Muraro S, Pacilio M, Palumbo L, Rocca L, Rubeca D, Schiavi A, Sciubba A, Tombolini V, Toppi M, Traini G, Trigilio A, Patera V. Deep Seated Tumour Treatments With Electrons of High Energy Delivered at FLASH Rates: The Example of Prostate Cancer. Front Oncol 2022; 11:777852. [PMID: 35024354 PMCID: PMC8744000 DOI: 10.3389/fonc.2021.777852] [Citation(s) in RCA: 3] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/19/2021] [Indexed: 12/25/2022] Open
Abstract
Different therapies are adopted for the treatment of deep seated tumours in combination or as an alternative to surgical removal or chemotherapy: radiotherapy with photons (RT), particle therapy (PT) with protons or even heavier ions like 12C, are now available in clinical centres. In addition to these irradiation modalities, the use of Very High Energy Electron (VHEE) beams (100–200 MeV) has been suggested in the past, but the diffusion of that technique was delayed due to the needed space and budget, with respect to standard photon devices. These disadvantages were not paired by an increased therapeutic efficacy, at least when comparing to proton or carbon ion beams. In this contribution we investigate how recent developments in electron beam therapy could reshape the treatments of deep seated tumours. In this respect we carefully explored the application of VHEE beams to the prostate cancer, a well-known and studied example of deep seated tumour currently treated with high efficacy both using RT and PT. The VHEE Treatment Planning System was obtained by means of an accurate Monte Carlo (MC) simulation of the electrons interactions with the patient body. A simple model of the FLASH effect (healthy tissues sparing at ultra-high dose rates), has been introduced and the results have been compared with conventional RT. The study demonstrates that VHEE beams, even in absence of a significant FLASH effect and with a reduced energy range (70–130 MeV) with respect to implementations already explored in literature, could be a good alternative to standard RT, even in the framework of technological developments that are nowadays affordable.
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Affiliation(s)
- Alessio Sarti
- Dipartimento di Scienze di Base e Applicate per l'Ingegneria, Sapienza Università di Roma, Roma, Italy.,Istituto Nazionale di Fisica Nucleare (INFN) Sezione di Roma I, Roma, Italy
| | - Patrizia De Maria
- Scuola post-laurea in Fisica Medica, Dipartimento di Scienze e Biotecnologie medico-chirurgiche, Sapienza Università di Roma, Roma, Italy
| | - Giuseppe Battistoni
- Istituto Nazionale di Fisica Nucleare (INFN) Sezione di Milano, Milano, Italy
| | - Micol De Simoni
- Istituto Nazionale di Fisica Nucleare (INFN) Sezione di Roma I, Roma, Italy.,Dipartimento di Fisica, Sapienza Università di Roma, Roma, Italy
| | - Cinzia Di Felice
- Unità di Fisica Sanitaria, Azienda Ospedaliero-Universitaria Policlinico Umberto I, Roma, Italy
| | - Yunsheng Dong
- Istituto Nazionale di Fisica Nucleare (INFN) Sezione di Milano, Milano, Italy
| | - Marta Fischetti
- Dipartimento di Scienze di Base e Applicate per l'Ingegneria, Sapienza Università di Roma, Roma, Italy.,Istituto Nazionale di Fisica Nucleare (INFN) Sezione di Roma I, Roma, Italy
| | - Gaia Franciosini
- Istituto Nazionale di Fisica Nucleare (INFN) Sezione di Roma I, Roma, Italy.,Dipartimento di Fisica, Sapienza Università di Roma, Roma, Italy
| | - Michela Marafini
- Istituto Nazionale di Fisica Nucleare (INFN) Sezione di Roma I, Roma, Italy.,Museo Storico della Fisica e Centro Studi e Ricerche "E. Fermi", Roma, Italy
| | - Francesco Marampon
- Dipartimento di Scienze Radiologiche, Oncologiche e Anatomo Patologiche, Sapienza Università di Roma, Roma, Italy
| | - Ilaria Mattei
- Istituto Nazionale di Fisica Nucleare (INFN) Sezione di Milano, Milano, Italy
| | - Riccardo Mirabelli
- Istituto Nazionale di Fisica Nucleare (INFN) Sezione di Roma I, Roma, Italy.,Dipartimento di Fisica, Sapienza Università di Roma, Roma, Italy
| | - Silvia Muraro
- Istituto Nazionale di Fisica Nucleare (INFN) Sezione di Milano, Milano, Italy
| | - Massimiliano Pacilio
- Unità di Fisica Sanitaria, Azienda Ospedaliero-Universitaria Policlinico Umberto I, Roma, Italy
| | - Luigi Palumbo
- Dipartimento di Scienze di Base e Applicate per l'Ingegneria, Sapienza Università di Roma, Roma, Italy.,Istituto Nazionale di Fisica Nucleare (INFN) Sezione di Roma I, Roma, Italy
| | - Loredana Rocca
- Dipartimento di Scienze di Base e Applicate per l'Ingegneria, Sapienza Università di Roma, Roma, Italy
| | - Damiana Rubeca
- Dipartimento di Scienze di Base e Applicate per l'Ingegneria, Sapienza Università di Roma, Roma, Italy
| | - Angelo Schiavi
- Dipartimento di Scienze di Base e Applicate per l'Ingegneria, Sapienza Università di Roma, Roma, Italy.,Istituto Nazionale di Fisica Nucleare (INFN) Sezione di Roma I, Roma, Italy
| | - Adalberto Sciubba
- Dipartimento di Scienze di Base e Applicate per l'Ingegneria, Sapienza Università di Roma, Roma, Italy.,Istituto Nazionale di Fisica Nucleare (INFN) Sezione dei Laboratori di Frascati, Roma, Italy
| | - Vincenzo Tombolini
- Dipartimento di Scienze Radiologiche, Oncologiche e Anatomo Patologiche, Sapienza Università di Roma, Roma, Italy
| | - Marco Toppi
- Dipartimento di Scienze di Base e Applicate per l'Ingegneria, Sapienza Università di Roma, Roma, Italy.,Istituto Nazionale di Fisica Nucleare (INFN) Sezione dei Laboratori di Frascati, Roma, Italy
| | - Giacomo Traini
- Istituto Nazionale di Fisica Nucleare (INFN) Sezione di Roma I, Roma, Italy
| | - Antonio Trigilio
- Istituto Nazionale di Fisica Nucleare (INFN) Sezione di Roma I, Roma, Italy.,Dipartimento di Fisica, Sapienza Università di Roma, Roma, Italy
| | - Vincenzo Patera
- Dipartimento di Scienze di Base e Applicate per l'Ingegneria, Sapienza Università di Roma, Roma, Italy.,Istituto Nazionale di Fisica Nucleare (INFN) Sezione di Roma I, Roma, Italy
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16
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Borghini A, Vecoli C, Labate L, Panetta D, Andreassi MG, Gizzi LA. FLASH ultra-high dose rates in radiotherapy: preclinical and radiobiological evidence. Int J Radiat Biol 2021; 98:127-135. [PMID: 34913413 DOI: 10.1080/09553002.2022.2009143] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE Flash radiotherapy (FLASH-RT) is currently being regarded as the next breakthrough in radiation treatment of cancer, delivering ultrahigh radiation doses in a very short time, and sparing normal tissues from detrimental injury. Here we review the current evidence on the preclinical findings as well as the radiobiological mechanisms underlying the FLASH effect. We also briefly examine the scenario of available technologies for delivering FLASH dose-rates for research and their implications for future clinical use. CONCLUSIONS Preclinical studies report that the FLASH-RT reduces radiation-induced toxicity whilst maintaining an equivalent tumor response across different animal models. However, the molecular radiobiology underlying FLASH effect is not fully understood and further experiments are necessary to understand the biological response. Future studies also includes the design of a FLASH delivery system able to produce beams appropriate for treatment of tumors with ultra-high dose rates. All these research activities will greatly benefit from a multidisciplinary collaboration across biology, physics and clinical oncology, increasing the potential of a rapid clinical translation of FLASH-RT.
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Affiliation(s)
| | | | - Luca Labate
- CNR National Institute of Optics, Pisa, Italy
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Gao F, Yang Y, Zhu H, Wang J, Xiao D, Zhou Z, Dai T, Zhang Y, Feng G, Li J, Lin B, Xie G, Ke Q, Zhou K, Li P, Shen X, Wang H, Yan L, Lao C, Shan L, Li M, Lu Y, Chen M, Feng S, Zhao J, Wu D, Du X. First demonstration of the FLASH effect with ultrahigh dose rate high-energy X-rays. Radiother Oncol 2021; 166:44-50. [PMID: 34774651 DOI: 10.1016/j.radonc.2021.11.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [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: 05/03/2021] [Revised: 10/02/2021] [Accepted: 11/01/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE This study aimed to evaluate whether high-energy X-rays (HEXs) of the PARTER (platform for advanced radiotherapy research) platform built on CTFEL (Chengdu THz Free Electron Laser facility) can produce ultrahigh dose rate (FLASH) X-rays and trigger the FLASH effect. MATERIALS AND METHODS EBT3 radiochromic film and fast current transformer (FCT) devices were used to measure absolute dose and pulsed beam current of HEXs. Subcutaneous tumor-bearing mice and healthy mice were treated with sham, FLASH, and conventional dose rate radiotherapy (CONV), respectively to observe the tumor control efficiency and normal tissue damage. RESULTS The maximum dose rate of HEXs of PARTER was up to over 1000 Gy/s. Tumor-bearing mice experiment showed a good result on tumor control (p < 0.0001) and significant difference in survival curves (p < 0.005) among the three groups. In the thorax-irradiated healthy mice experiment, there was a significant difference (p = 0.038) in survival among the three groups, with the risk of death decreased by 81% in the FLASH group compared to that in the CONV group. The survival time of healthy mice irradiated in the abdomen in the FLASH group was undoubtedly higher (62.5% of mice were still alive when we stopped observation) than that in the CONV group (7 days). CONCLUSION This study confirmed that HEXs of the PARTER system can produce ultrahigh dose rate X-rays and trigger a FLASH effect, which provides a basis for future scientific research and clinical application of HEX in FLASH radiotherapy.
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Affiliation(s)
- Feng Gao
- Departmant of Oncology, Nuclear Medicine Laboratory of Mianyang Central Hospital, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
| | - Yiwei Yang
- Institute of Nuclear Physics and Chemistry, China Academy of Engineering Physics, Mianyang, China
| | - Hongyu Zhu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Jianxin Wang
- Institute of Applied Electronics, China Academy of Engineering Physics, Mianyang, China
| | - Dexin Xiao
- Institute of Applied Electronics, China Academy of Engineering Physics, Mianyang, China
| | - Zheng Zhou
- Institute of Applied Electronics, China Academy of Engineering Physics, Mianyang, China
| | - Tangzhi Dai
- Departmant of Oncology, Nuclear Medicine Laboratory of Mianyang Central Hospital, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
| | - Yu Zhang
- Departmant of Oncology, Nuclear Medicine Laboratory of Mianyang Central Hospital, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
| | - Gang Feng
- Departmant of Oncology, Nuclear Medicine Laboratory of Mianyang Central Hospital, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
| | - Jie Li
- Departmant of Oncology, Nuclear Medicine Laboratory of Mianyang Central Hospital, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
| | - Binwei Lin
- Departmant of Oncology, Nuclear Medicine Laboratory of Mianyang Central Hospital, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
| | - Gang Xie
- Department of Pathology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
| | - Qi Ke
- Department of Pathology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
| | - Kui Zhou
- Institute of Applied Electronics, China Academy of Engineering Physics, Mianyang, China
| | - Peng Li
- Institute of Applied Electronics, China Academy of Engineering Physics, Mianyang, China
| | - Xuming Shen
- Institute of Applied Electronics, China Academy of Engineering Physics, Mianyang, China
| | - Hanbin Wang
- Institute of Applied Electronics, China Academy of Engineering Physics, Mianyang, China
| | - Longgang Yan
- Institute of Applied Electronics, China Academy of Engineering Physics, Mianyang, China
| | - Chenglong Lao
- Institute of Applied Electronics, China Academy of Engineering Physics, Mianyang, China
| | - Lijun Shan
- Institute of Applied Electronics, China Academy of Engineering Physics, Mianyang, China
| | - Ming Li
- Institute of Applied Electronics, China Academy of Engineering Physics, Mianyang, China
| | - Yanhua Lu
- Institute of Applied Electronics, China Academy of Engineering Physics, Mianyang, China
| | - Menxue Chen
- Institute of Applied Electronics, China Academy of Engineering Physics, Mianyang, China
| | - Song Feng
- School of Nuclear Science and Technology, University of South China, Hengyang, China
| | - Jianheng Zhao
- Institute of Applied Electronics, China Academy of Engineering Physics, Mianyang, China
| | - Dai Wu
- Institute of Applied Electronics, China Academy of Engineering Physics, Mianyang, China.
| | - Xiaobo Du
- Departmant of Oncology, Nuclear Medicine Laboratory of Mianyang Central Hospital, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China.
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