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Dalmasso C, Alapetite C, Bolle S, Goudjil F, Lusque A, Desrousseaux J, Claude L, Doyen J, Bernier-Chastagner V, Ducassou A, Sevely A, Roques M, Tensaouti F, Laprie A. Brainstem toxicity after proton or photon therapy in children and young adults with localized intracranial ependymoma: A French retrospective study. Radiother Oncol 2024; 194:110157. [PMID: 38367939 DOI: 10.1016/j.radonc.2024.110157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 02/06/2024] [Accepted: 02/10/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND AND PURPOSE Ependymoma is the third most frequent childhood braintumor. Standard treatment is surgery followed by radiation therapy including proton therapy (PBT). Retrospective studies have reported higher rates of brainstem injury after PBT than after photon therapy (XRT). We report a national multicenter study of the incidence of brainstem injury after XRT versus PBT, and their correlations with dosimetric data. MATERIAL AND METHODS We included all patients aged < 25 years who were treated with PBT or XRT for intracranial ependymoma at five French pediatric oncology reference centers between 2007 and 2020. We reviewed pre-irradiation MRI, follow-up MRIs over the 12 months post-treatment and clinical data. RESULTS Of the 83 patients, 42 were treated with PBT, 37 with XRT, and 4 with both (median dose: 59.4 Gy, range: 53‑60). No new or progressive symptomatic brainstem injury was found. Four patients presented asymptomatic radiographic changes (punctiform brainstem enhancement and FLAIR hypersignal), with median onset at 3.5 months (range: 3.0‑9.4) after radiation therapy, and median offset at 7.6 months (range: 3.7‑7.9). Two had been treated with PBT, one with XRT, and one with mixed XRT-PBT. Prescribed doses were 59.4, 55.8, 59.4 and 54 Gy. CONCLUSION Asymptomatic radiographic changes occurred in 4.8% of patients with ependymoma in a large national series. There was no correlation with dose or technique. No symptomatic brainstem injury was identified.
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Affiliation(s)
- Céline Dalmasso
- Department of Radiation Therapy, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse- Oncopole, Toulouse, France
| | - Claire Alapetite
- Department of Radiation Therapy, Institut Curie, Paris, France; Institut Curie - Centre de Protontherapie d', Orsay, Orsay, France
| | - Stéphanie Bolle
- Institut Curie - Centre de Protontherapie d', Orsay, Orsay, France; Department of Radiation Oncology, Gustave Roussy, Villejuif, France
| | - Farid Goudjil
- Institut Curie - Centre de Protontherapie d', Orsay, Orsay, France
| | - Amélie Lusque
- Department of Biostatistics, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse- Oncopole, Toulouse, France
| | - Jacques Desrousseaux
- Department of Radiation Therapy, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse- Oncopole, Toulouse, France
| | - Line Claude
- Department of Radiation Therapy, Centre Léon Bérard, Lyon, France
| | - Jérome Doyen
- Department of Radiation Therapy, Centre Antoine Lacassagne, Nice, France
| | | | - Anne Ducassou
- Department of Radiation Therapy, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse- Oncopole, Toulouse, France
| | - Annick Sevely
- Department of Radiology, CHU de Toulouse, Toulouse, France
| | - Margaux Roques
- Department of Radiology, CHU de Toulouse, Toulouse, France
| | - Fatima Tensaouti
- Department of Radiation Therapy, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse- Oncopole, Toulouse, France; ToNIC, Toulouse NeuroImaging Center, INSERM, UPS, Toulouse, France
| | - Anne Laprie
- Department of Radiation Therapy, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse- Oncopole, Toulouse, France; ToNIC, Toulouse NeuroImaging Center, INSERM, UPS, Toulouse, France.
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2
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Mohamed AA, Alshaibi R, Faragalla S, Mohamed Y, Lucke-Wold B. Updates on management of gliomas in the molecular age. World J Clin Oncol 2024; 15:178-194. [PMID: 38455131 PMCID: PMC10915945 DOI: 10.5306/wjco.v15.i2.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 01/06/2024] [Accepted: 01/25/2024] [Indexed: 02/20/2024] Open
Abstract
Gliomas are primary brain tumors derived from glial cells of the central nervous system, afflicting both adults and children with distinct characteristics and therapeutic challenges. Recent developments have ushered in novel clinical and molecular prognostic factors, reshaping treatment paradigms based on classification and grading, determined by histological attributes and cellular lineage. This review article delves into the diverse treatment modalities tailored to the specific grades and molecular classifications of gliomas that are currently being discussed and used clinically in the year 2023. For adults, the therapeutic triad typically consists of surgical resection, chemotherapy, and radiotherapy. In contrast, pediatric gliomas, due to their diversity, require a more tailored approach. Although complete tumor excision can be curative based on the location and grade of the glioma, certain non-resectable cases demand a chemotherapy approach usually involving, vincristine and carboplatin. Additionally, if surgery or chemotherapy strategies are unsuccessful, Vinblastine can be used. Despite recent advancements in treatment methodologies, there remains a need of exploration in the literature, particularly concerning the efficacy of treatment regimens for isocitrate dehydrogenase type mutant astrocytomas and fine-tuned therapeutic approaches tailored for pediatric cohorts. This review article explores into the therapeutic modalities employed for both adult and pediatric gliomas in the context of their molecular classification.
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Affiliation(s)
- Ali Ahmed Mohamed
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Rakan Alshaibi
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, United States
| | - Steven Faragalla
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Youssef Mohamed
- College of Osteopathic Medicine, Kansas City University, Joplin, MO 64804, United States
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32611, United States
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Cockle JV, Corley EA, Zebian B, Hettige S, Vaidya SJ, Angelini P, Stone J, Leitch RJ, Albanese A, Mandeville HC, Carceller F, Marshall LV. Novel therapeutic approaches for pediatric diencephalic tumors: improving functional outcomes. Front Oncol 2023; 13:1178553. [PMID: 37886179 PMCID: PMC10598386 DOI: 10.3389/fonc.2023.1178553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 07/06/2023] [Indexed: 10/28/2023] Open
Abstract
Pediatric diencephalic tumors represent a histopathologically and molecularly diverse group of neoplasms arising in the central part of the brain and involving eloquent structures, including the hypothalamic-pituitary axis (HPA), optic pathway, thalamus, and pineal gland. Presenting symptoms can include significant neurological, endocrine, or visual manifestations which may be exacerbated by injudicious intervention. Upfront multidisciplinary assessment and coordinated management is crucial from the outset to ensure best short- and long-term functional outcomes. In this review we discuss the clinical and pathological features of the neoplastic entities arising in this location, and their management. We emphasize a clear move towards 'function preserving' diagnostic and therapeutic approaches with novel toxicity-sparing strategies, including targeted therapies.
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Affiliation(s)
- Julia V. Cockle
- Department of Neuro-oncology, Children and Young People’s Unit, The Royal Marsden National Health Service (NHS) Foundation Trust, London, United Kingdom
- Division of Clinical Studies, The Institute of Cancer Research, London, United Kingdom
| | - Elizabeth A. Corley
- Pediatric and Adolescent Oncology Drug Development Team, Children and Young People’s Unit, The Royal Marsden National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Bassel Zebian
- Department of Neurosurgery, Kings College Hospital National Health Service (NHS) Trust, London, United Kingdom
| | - Samantha Hettige
- Atkinson Morley Neurosurgery Centre, St George’s University Hospital National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Sucheta J. Vaidya
- Department of Neuro-oncology, Children and Young People’s Unit, The Royal Marsden National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Paola Angelini
- Department of Neuro-oncology, Children and Young People’s Unit, The Royal Marsden National Health Service (NHS) Foundation Trust, London, United Kingdom
- Division of Clinical Studies, The Institute of Cancer Research, London, United Kingdom
| | - Joanna Stone
- Department of Neuro-oncology, Children and Young People’s Unit, The Royal Marsden National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - R Jane Leitch
- Department of Ophthalmology, Epsom and St Hellier University Hospitals Trust, Carshalton, United Kingdom
| | - Assunta Albanese
- Department of Neuro-oncology, Children and Young People’s Unit, The Royal Marsden National Health Service (NHS) Foundation Trust, London, United Kingdom
- Department of Pediatric Endocrinology, The Royal Marsden National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Henry C. Mandeville
- Department of Neuro-oncology, Children and Young People’s Unit, The Royal Marsden National Health Service (NHS) Foundation Trust, London, United Kingdom
- Division of Clinical Studies, The Institute of Cancer Research, London, United Kingdom
- Department of Radiotherapy, The Royal Marsden National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Fernando Carceller
- Department of Neuro-oncology, Children and Young People’s Unit, The Royal Marsden National Health Service (NHS) Foundation Trust, London, United Kingdom
- Division of Clinical Studies, The Institute of Cancer Research, London, United Kingdom
- Pediatric and Adolescent Oncology Drug Development Team, Children and Young People’s Unit, The Royal Marsden National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Lynley V. Marshall
- Department of Neuro-oncology, Children and Young People’s Unit, The Royal Marsden National Health Service (NHS) Foundation Trust, London, United Kingdom
- Division of Clinical Studies, The Institute of Cancer Research, London, United Kingdom
- Pediatric and Adolescent Oncology Drug Development Team, Children and Young People’s Unit, The Royal Marsden National Health Service (NHS) Foundation Trust, London, United Kingdom
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4
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Gaito S, Hwang EJ, France A, Aznar MC, Burnet N, Crellin A, Holtzman AL, Indelicato DJ, Timmerman B, Whitfield GA, Smith E. Outcomes of Patients Treated in the UK Proton Overseas Programme: Central Nervous System Group. Clin Oncol (R Coll Radiol) 2023; 35:283-291. [PMID: 36804292 DOI: 10.1016/j.clon.2023.01.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/15/2022] [Accepted: 01/31/2023] [Indexed: 02/11/2023]
Abstract
AIMS In 2008, the UK National Health Service started the Proton Overseas Programme (POP), to provide access for proton beam therapy (PBT) abroad for selected tumour diagnoses while two national centres were being planned. The clinical outcomes for the patient group treated for central nervous system (CNS), base of skull, spinal and paraspinal malignancies are reported here. MATERIALS AND METHODS Since the start of the POP, an agreement between the National Health Service and UK referring centres ensured outcomes data collection, including overall survival, local tumour control and late toxicity data. Clinical and treatment-related data were extracted from this national patient database. Grade ≥3 late toxicities were reported following Common Terminology Criteria for Adverse Events (CTCAE) v 4.0 definition, occurring later than 90 days since the completion of treatment. RESULTS Between 2008 and September 2020, 830 patients were treated within the POP for the above listed malignancies. Overall survival data were available for 815 patients and local control data for 726 patients. Toxicity analysis was carried out on 702 patients, with patients excluded due to short follow-up (<90 days) and/or inadequate toxicity data available. After a median follow-up of 3.34 years (0.06-11.58), the overall survival was 91.2%. The local control rate was 85.9% after a median follow-up of 2.81 years (range 0.04-11.58). The overall grade ≥3 late toxicity incidence was 11.97%, after a median follow-up of 1.72 years (0.04-8.45). The median radiotherapy prescription dose was 54 GyRBE (34.8-79.2). CONCLUSIONS The results of this study indicate the safety of PBT for CNS tumours. Preliminary clinical outcomes following PBT for paediatric/teen and young adult and adult CNS tumours treated within the POP are encouraging, which reflects accurate patient selection and treatment quality. The rate of late effects compares favourably with published cohorts. Clinical outcomes from this patient cohort will be compared with those of UK-treated patients since the start of the national PBT service in 2018.
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Affiliation(s)
- S Gaito
- Proton Clinical Outcomes Unit, The Christie NHS Proton Beam Therapy Centre, Manchester, UK; Division of Clinical Cancer Science, School of Medical Sciences, The University of Manchester, Manchester, UK.
| | - E J Hwang
- Department of Proton Beam Therapy, The Christie Proton Beam Therapy Centre, Manchester, UK; Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, Australia
| | - A France
- Proton Clinical Outcomes Unit, The Christie NHS Proton Beam Therapy Centre, Manchester, UK
| | - M C Aznar
- Division of Clinical Cancer Science, School of Medical Sciences, The University of Manchester, Manchester, UK
| | - N Burnet
- Department of Proton Beam Therapy, The Christie Proton Beam Therapy Centre, Manchester, UK
| | - A Crellin
- Division of Clinical Cancer Science, School of Medical Sciences, The University of Manchester, Manchester, UK; NHS England National Clinical Lead Proton Beam Therapy, UK
| | - A L Holtzman
- Department of Radiation Oncology, University of Florida, Gainesville, Florida, USA
| | - D J Indelicato
- Department of Radiation Oncology, University of Florida, Gainesville, Florida, USA
| | - B Timmerman
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Centre (WTZ), German Cancer Consortium (DKTK), Essen, Germany
| | - G A Whitfield
- Division of Clinical Cancer Science, School of Medical Sciences, The University of Manchester, Manchester, UK; Department of Proton Beam Therapy, The Christie Proton Beam Therapy Centre, Manchester, UK
| | - E Smith
- Proton Clinical Outcomes Unit, The Christie NHS Proton Beam Therapy Centre, Manchester, UK; Division of Clinical Cancer Science, School of Medical Sciences, The University of Manchester, Manchester, UK; Department of Proton Beam Therapy, The Christie Proton Beam Therapy Centre, Manchester, UK
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5
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Grippin AJ, McGovern SL. Proton therapy for pediatric diencephalic tumors. Front Oncol 2023; 13:1123082. [PMID: 37213290 PMCID: PMC10196353 DOI: 10.3389/fonc.2023.1123082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/03/2023] [Indexed: 05/23/2023] Open
Abstract
Diencephalic tumors tend to be low grade tumors located near several critical structures, including the optic nerves, optic chiasm, pituitary, hypothalamus, Circle of Willis, and hippocampi. In children, damage to these structures can impact physical and cognitive development over time. Thus, the goal of radiotherapy is to maximize long term survival while minimizing late effects, including endocrine disruption leading to precocious puberty, height loss, hypogonadotropic hypogonadism, and primary amenorrhea; visual disruption including blindness; and vascular damage resulting in cerebral vasculopathy. Compared to photon therapy, proton therapy offers the potential to decrease unnecessary dose to these critical structures while maintaining adequate dose to the tumor. In this article, we review the acute and chronic toxicities associated with radiation for pediatric diencephalic tumors, focusing on the use of proton therapy to minimize treatment-related morbidity. Emerging strategies to further reduce radiation dose to critical structures will also be considered.
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Peters S, Frisch S, Stock A, Merta J, Bäumer C, Blase C, Schuermann E, Tippelt S, Bison B, Frühwald M, Rutkowski S, Fleischhack G, Timmermann B. Proton Beam Therapy for Pediatric Tumors of the Central Nervous System-Experiences of Clinical Outcome and Feasibility from the KiProReg Study. Cancers (Basel) 2022; 14:cancers14235863. [PMID: 36497345 PMCID: PMC9737072 DOI: 10.3390/cancers14235863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 11/21/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022] Open
Abstract
As radiotherapy is an important part of the treatment in a variety of pediatric tumors of the central nervous system (CNS), proton beam therapy (PBT) plays an evolving role due to its potential benefits attributable to the unique dose distribution, with the possibility to deliver high doses to the target volume while sparing surrounding tissue. Children receiving PBT for an intracranial tumor between August 2013 and October 2017 were enrolled in the prospective registry study KiProReg. Patient's clinical data including treatment, outcome, and follow-up were analyzed using descriptive statistics, Kaplan-Meier, and Cox regression analysis. Adverse events were scored according to the Common Terminology Criteria for Adverse Events (CTCAE) 4.0 before, during, and after PBT. Written reports of follow-up imaging were screened for newly emerged evidence of imaging changes, according to a list of predefined keywords for the first 14 months after PBT. Two hundred and ninety-four patients were enrolled in this study. The 3-year overall survival of the whole cohort was 82.7%, 3-year progression-free survival was 67.3%, and 3-year local control was 79.5%. Seventeen patients developed grade 3 adverse events of the CNS during long-term follow-up (new adverse event n = 7; deterioration n = 10). Two patients developed vision loss (CTCAE 4°). This analysis demonstrates good general outcomes after PBT.
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Affiliation(s)
- Sarah Peters
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, 45147 Essen, Germany
- Clinic for Particle Therapy, University Hospital Essen, 45147 Essen, Germany
- Correspondence: ; Tel.: +49-201-723-8943
| | - Sabine Frisch
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, 45147 Essen, Germany
| | - Annika Stock
- Department of Neuroradiology, University Hospital Wuerzburg, 97080 Wuerzburg, Germany
| | - Julien Merta
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, 45147 Essen, Germany
| | - Christian Bäumer
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, 45147 Essen, Germany
| | - Christoph Blase
- AnästhesieNetz Rhein-Ruhr, Westenfelder Str. 62/64, 44867 Bochum, Germany
| | - Eicke Schuermann
- Department of Pediatric Hematology and Oncology, Pediatrics III, University Hospital Essen, 45147 Essen, Germany
| | - Stephan Tippelt
- Department of Pediatric Hematology and Oncology, Pediatrics III, University Hospital Essen, 45147 Essen, Germany
| | - Brigitte Bison
- Diagnostic and Interventional Neuroradiology, Faculty of Medicine, University of Augsburg, 86156 Augsburg, Germany
- Neuroradiological Reference Center for the Pediatric Brain Tumor (HIT) Studies of the German Society of Pediatric Oncology and Hematology, University Hospital Würzburg, 97080 Würzburg, Germany
| | - Michael Frühwald
- Pediatric and Adolescent Medicine, Swabian Childrens Cancer Center, University Medical Center Augsburg, 86156 Augsburg, Germany
| | - Stefan Rutkowski
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Gudrun Fleischhack
- Department of Pediatric Hematology and Oncology, Pediatrics III, University Hospital Essen, 45147 Essen, Germany
| | - Beate Timmermann
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, 45147 Essen, Germany
- Clinic for Particle Therapy, University Hospital Essen, 45147 Essen, Germany
- West German Cancer Center (WTZ), 45147 Essen, Germany
- German Cancer Consortium (DKTK), 45147 Essen, Germany
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7
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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] [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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8
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Burnet NG, Mee T, Gaito S, Kirkby NF, Aitkenhead AH, Anandadas CN, Aznar MC, Barraclough LH, Borst G, Charlwood FC, Clarke M, Colaco RJ, Crellin AM, Defourney NN, Hague CJ, Harris M, Henthorn NT, Hopkins KI, Hwang E, Ingram SP, Kirkby KJ, Lee LW, Lines D, Lingard Z, Lowe M, Mackay RI, McBain CA, Merchant MJ, Noble DJ, Pan S, Price JM, Radhakrishna G, Reboredo-Gil D, Salem A, Sashidharan S, Sitch P, Smith E, Smith EAK, Taylor MJ, Thomson DJ, Thorp NJ, Underwood TSA, Warmenhoven JW, Wylie JP, Whitfield G. Estimating the percentage of patients who might benefit from proton beam therapy instead of X-ray radiotherapy. Br J Radiol 2022; 95:20211175. [PMID: 35220723 PMCID: PMC10993980 DOI: 10.1259/bjr.20211175] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES High-energy Proton Beam Therapy (PBT) commenced in England in 2018 and NHS England commissions PBT for 1.5% of patients receiving radical radiotherapy. We sought expert opinion on the level of provision. METHODS Invitations were sent to 41 colleagues working in PBT, most at one UK centre, to contribute by completing a spreadsheet. 39 responded: 23 (59%) completed the spreadsheet; 16 (41%) declined, arguing that clinical outcome data are lacking, but joined six additional site-specialist oncologists for two consensus meetings. The spreadsheet was pre-populated with incidence data from Cancer Research UK and radiotherapy use data from the National Cancer Registration and Analysis Service. 'Mechanisms of Benefit' of reduced growth impairment, reduced toxicity, dose escalation and reduced second cancer risk were examined. RESULTS The most reliable figure for percentage of radical radiotherapy patients likely to benefit from PBT was that agreed by 95% of the 23 respondents at 4.3%, slightly larger than current provision. The median was 15% (range 4-92%) and consensus median 13%. The biggest estimated potential benefit was from reducing toxicity, median benefit to 15% (range 4-92%), followed by dose escalation median 3% (range 0 to 47%); consensus values were 12 and 3%. Reduced growth impairment and reduced second cancer risk were calculated to benefit 0.5% and 0.1%. CONCLUSIONS The most secure estimate of percentage benefit was 4.3% but insufficient clinical outcome data exist for confident estimates. The study supports the NHS approach of using the evidence base and developing it through randomised trials, non-randomised studies and outcomes tracking. ADVANCES IN KNOWLEDGE Less is known about the percentage of patients who may benefit from PBT than is generally acknowledged. Expert opinion varies widely. Insufficient clinical outcome data exist to provide robust estimates. Considerable further work is needed to address this, including international collaboration; much is already underway but will take time to provide mature data.
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Affiliation(s)
- Neil G Burnet
- The Christie NHS Foundation Trust, Wilmslow Rd,
Manchester, United Kingdom
| | - Thomas Mee
- Division of Cancer Sciences, University of Manchester,
Manchester Cancer Research Centre, Manchester Academic Health Science
Centre, Manchester, United
Kingdom
| | - Simona Gaito
- The Christie NHS Foundation Trust, Wilmslow Rd,
Manchester, United Kingdom
- Division of Cancer Sciences, University of Manchester,
Manchester Cancer Research Centre, Manchester Academic Health Science
Centre, Manchester, United
Kingdom
| | - Norman F Kirkby
- Division of Cancer Sciences, University of Manchester,
Manchester Cancer Research Centre, Manchester Academic Health Science
Centre, Manchester, United
Kingdom
| | - Adam H Aitkenhead
- Division of Cancer Sciences, University of Manchester,
Manchester Cancer Research Centre, Manchester Academic Health Science
Centre, Manchester, United
Kingdom
- Christie Medical Physics and Engineering, The Christie NHS
Foundation Trust, Wilmslow Road,
Manchester, United Kingdom
| | - Carmel N Anandadas
- The Christie NHS Foundation Trust, Wilmslow Rd,
Manchester, United Kingdom
| | - Marianne C Aznar
- The Christie NHS Foundation Trust, Wilmslow Rd,
Manchester, United Kingdom
- Division of Cancer Sciences, University of Manchester,
Manchester Cancer Research Centre, Manchester Academic Health Science
Centre, Manchester, United
Kingdom
| | - Lisa H Barraclough
- The Christie NHS Foundation Trust, Wilmslow Rd,
Manchester, United Kingdom
| | - Gerben Borst
- The Christie NHS Foundation Trust, Wilmslow Rd,
Manchester, United Kingdom
- Division of Cancer Sciences, University of Manchester,
Manchester Cancer Research Centre, Manchester Academic Health Science
Centre, Manchester, United
Kingdom
| | - Frances C Charlwood
- Christie Medical Physics and Engineering, The Christie NHS
Foundation Trust, Wilmslow Road,
Manchester, United Kingdom
| | - Matthew Clarke
- Christie Medical Physics and Engineering, The Christie NHS
Foundation Trust, Wilmslow Road,
Manchester, United Kingdom
| | - Rovel J Colaco
- The Christie NHS Foundation Trust, Wilmslow Rd,
Manchester, United Kingdom
- Division of Cancer Sciences, University of Manchester,
Manchester Cancer Research Centre, Manchester Academic Health Science
Centre, Manchester, United
Kingdom
| | - Adrian M Crellin
- NHS England National Clinical Lead Proton Beam Therapy, Leeds
Cancer Centre, Leeds Teaching Hospitals NHS Trust, Leeds and St James's
Institute of Oncology, Leeds Teaching Hospitals NHS Trust, Beckett
Street, Leeds, LS9 7TF, UK, Leeds,
United Kingdom
| | - Noemie N Defourney
- Division of Cancer Sciences, University of Manchester,
Manchester Cancer Research Centre, Manchester Academic Health Science
Centre, Manchester, United
Kingdom
| | - Christina J Hague
- The Christie NHS Foundation Trust, Wilmslow Rd,
Manchester, United Kingdom
| | - Margaret Harris
- The Christie NHS Foundation Trust, Wilmslow Rd,
Manchester, United Kingdom
| | - Nicholas T Henthorn
- Division of Cancer Sciences, University of Manchester,
Manchester Cancer Research Centre, Manchester Academic Health Science
Centre, Manchester, United
Kingdom
| | - Kirsten I Hopkins
- International Atomic Energy Agency, Vienna International
Centre, Vienna,
Austria
| | - E Hwang
- The Christie NHS Foundation Trust, Wilmslow Rd,
Manchester, United Kingdom
- Department of Radiation Oncology, Sydney West Radiation
Oncology Network, Crown Princess Mary Cancer Centre,
Sydney, New South Wales, Australia and
Institute of Medical Physics, School of Physics, University of Sydney,
Sydney, New South Wales, Australia
| | - Sam P Ingram
- Division of Cancer Sciences, University of Manchester,
Manchester Cancer Research Centre, Manchester Academic Health Science
Centre, Manchester, United
Kingdom
- Christie Medical Physics and Engineering, The Christie NHS
Foundation Trust, Wilmslow Road,
Manchester, United Kingdom
| | - Karen J Kirkby
- Division of Cancer Sciences, University of Manchester,
Manchester Cancer Research Centre, Manchester Academic Health Science
Centre, Manchester, United
Kingdom
| | - Lip W Lee
- The Christie NHS Foundation Trust, Wilmslow Rd,
Manchester, United Kingdom
| | - David Lines
- Christie Medical Physics and Engineering, The Christie NHS
Foundation Trust, Wilmslow Road,
Manchester, United Kingdom
| | - Zoe Lingard
- Division of Cancer Sciences, University of Manchester,
Manchester Cancer Research Centre, Manchester Academic Health Science
Centre, Manchester, United
Kingdom
| | - Matthew Lowe
- Division of Cancer Sciences, University of Manchester,
Manchester Cancer Research Centre, Manchester Academic Health Science
Centre, Manchester, United
Kingdom
- Christie Medical Physics and Engineering, The Christie NHS
Foundation Trust, Wilmslow Road,
Manchester, United Kingdom
| | - Ranald I Mackay
- Christie Medical Physics and Engineering, The Christie NHS
Foundation Trust, Wilmslow Road,
Manchester, United Kingdom
| | - Catherine A McBain
- The Christie NHS Foundation Trust, Wilmslow Rd,
Manchester, United Kingdom
| | - Michael J Merchant
- Division of Cancer Sciences, University of Manchester,
Manchester Cancer Research Centre, Manchester Academic Health Science
Centre, Manchester, United
Kingdom
| | - David J Noble
- Department of Clinical Oncology, Edinburgh Cancer Centre,
Western General Hospital,
Edinburgh, United Kingdom
| | - Shermaine Pan
- Division of Cancer Sciences, University of Manchester,
Manchester Cancer Research Centre, Manchester Academic Health Science
Centre, Manchester, United
Kingdom
| | - James M Price
- The Christie NHS Foundation Trust, Wilmslow Rd,
Manchester, United Kingdom
- Division of Cancer Sciences, University of Manchester,
Manchester Cancer Research Centre, Manchester Academic Health Science
Centre, Manchester, United
Kingdom
| | | | - David Reboredo-Gil
- Christie Medical Physics and Engineering, The Christie NHS
Foundation Trust, Wilmslow Road,
Manchester, United Kingdom
| | - Ahmed Salem
- The Christie NHS Foundation Trust, Wilmslow Rd,
Manchester, United Kingdom
- Division of Cancer Sciences, University of Manchester,
Manchester Cancer Research Centre, Manchester Academic Health Science
Centre, Manchester, United
Kingdom
| | | | - Peter Sitch
- Christie Medical Physics and Engineering, The Christie NHS
Foundation Trust, Wilmslow Road,
Manchester, United Kingdom
| | - Ed Smith
- The Christie NHS Foundation Trust, Wilmslow Rd,
Manchester, United Kingdom
- Proton Clinical Outcomes Unit, The Christie NHS Foundation
Trust, Manchester, United
Kingdom
| | - Edward AK Smith
- Division of Cancer Sciences, University of Manchester,
Manchester Cancer Research Centre, Manchester Academic Health Science
Centre, Manchester, United
Kingdom
- Christie Medical Physics and Engineering, The Christie NHS
Foundation Trust, Wilmslow Road,
Manchester, United Kingdom
| | - Michael J Taylor
- Division of Cancer Sciences, University of Manchester,
Manchester Cancer Research Centre, Manchester Academic Health Science
Centre, Manchester, United
Kingdom
| | - David J Thomson
- The Christie NHS Foundation Trust, Wilmslow Rd,
Manchester, United Kingdom
- Division of Cancer Sciences, University of Manchester,
Manchester Cancer Research Centre, Manchester Academic Health Science
Centre, Manchester, United
Kingdom
| | - Nicola J Thorp
- The Christie NHS Foundation Trust, Wilmslow Rd,
Manchester, United Kingdom
| | - Tracy SA Underwood
- Division of Cancer Sciences, University of Manchester,
Manchester Cancer Research Centre, Manchester Academic Health Science
Centre, Manchester, United
Kingdom
| | - John W Warmenhoven
- Division of Cancer Sciences, University of Manchester,
Manchester Cancer Research Centre, Manchester Academic Health Science
Centre, Manchester, United
Kingdom
| | - James P Wylie
- The Christie NHS Foundation Trust, Wilmslow Rd,
Manchester, United Kingdom
| | - Gillian Whitfield
- The Christie NHS Foundation Trust, Wilmslow Rd,
Manchester, United Kingdom
- Division of Cancer Sciences, University of Manchester,
Manchester Cancer Research Centre, Manchester Academic Health Science
Centre, Manchester, United
Kingdom
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9
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Lunt N, Fung KW. Scoping the literature on patient travel abroad for cancer screening, diagnosis and treatment. Int J Health Plann Manage 2021; 37:66-77. [PMID: 34523157 DOI: 10.1002/hpm.3315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 06/04/2021] [Accepted: 08/19/2021] [Indexed: 11/11/2022] Open
Abstract
The incidence of cancer is on the rise globally. Under particular circumstances, patients are willing to travel abroad for healthcare treatments. We know relatively little however about patients travelling overseas for cancer-related screening, diagnosis and treatment. Where do patients go, for what treatments, what are their motivations, decision-making processes and treatment experiences? What do we know about patient safety and risk, and outcomes? More broadly, what are the ethical and legal implications? This review presents the first published assessment of what we term 'transnational oncology treatment', defined as patients travelling overseas or across borders for cancer screening, diagnosis and treatment. The review undertakes detailed search and retrieval of the literature, using an accepted scoping review method. We present a narrative review of existing knowledge and themes, identifying coverage and gaps. There is a five-fold agenda for future investigation: trajectories and itineraries; in depth focus on treatment decisions, experiences and outcomes; locating patient travel within wider health system analysis; exploration of professional perspectives and coordination; and situating travel within the context of health trade. Such an agenda is multidisciplinary and wide-ranging, encompassing epidemiology, health economics, health policy ethics, health politics, health management, and health policy.
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Affiliation(s)
- Neil Lunt
- Department of Social Policy and Social Work, University of York, York, UK
| | - Ka-Wo Fung
- Department of Social Work, Soochow University, Taipei, Taiwan
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10
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Niemierko A, Schuemann J, Niyazi M, Giantsoudi D, Maquilan G, Shih HA, Paganetti H. Brain Necrosis in Adult Patients After Proton Therapy: Is There Evidence for Dependency on Linear Energy Transfer? Int J Radiat Oncol Biol Phys 2020; 109:109-119. [PMID: 32911019 DOI: 10.1016/j.ijrobp.2020.08.058] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 08/26/2020] [Accepted: 08/27/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE To investigate if radiographic imaging changes defined as necrosis correlate with regions in the brain with elevated linear energy transfer (LET) for proton radiation therapy treatments with partial brain involvement in central nervous system and patients with head and neck cancer. METHODS AND MATERIALS Fifty patients with head and neck, skull base, or intracranial tumors who underwent proton therapy between 2004 to 2016 with a minimum prescription dose of 59.4 Gy (relative biological effectiveness) and with magnetic resonance imaging changes indicative of brain necrosis after radiation therapy were retrospectively reviewed. Each treatment plan was recalculated using Monte Carlo simulations to provide accurate dose distributions as well as 3-dimensional distributions of LET. To assess the effect of LET on radiographic imaging changes several voxel-based analyses were performed. RESULTS In this patient cohort, LET adjusted for dose was not found to be associated with risk of brain necrosis. CONCLUSIONS A voxel-based analysis of brain necrosis as an endpoint is difficult owing to uncertainties in the origin of necrosis, timing of imaging, variability in patient specific radiosensitivity, and the simultaneous effect of dose and LET. Even though it is expected that the LET and thus relative biological effectiveness increases at the end of range, effects in patients might be small compared with interpatient variability of radiosensitivity and might be obscured by other confounding factors.
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Affiliation(s)
- Andrzej Niemierko
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Jan Schuemann
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Maximilian Niyazi
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany; German Cancer Consortium, partner site Munich, Heidelberg, Germany; German Cancer Research Center, Heidelberg, Germany
| | - Drosoula Giantsoudi
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Genevieve Maquilan
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Helen A Shih
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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11
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Burnet NG, Mackay RI, Smith E, Chadwick AL, Whitfield GA, Thomson DJ, Lowe M, Kirkby NF, Crellin AM, Kirkby KJ. Proton beam therapy: perspectives on the National Health Service England clinical service and research programme. Br J Radiol 2020; 93:20190873. [PMID: 31860337 PMCID: PMC7066938 DOI: 10.1259/bjr.20190873] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 12/05/2019] [Accepted: 12/16/2019] [Indexed: 12/19/2022] Open
Abstract
The UK has an important role in the evaluation of proton beam therapy (PBT) and takes its place on the world stage with the opening of the first National Health Service (NHS) PBT centre in Manchester in 2018, and the second in London coming in 2020. Systematic evaluation of the role of PBT is a key objective. By September 2019, 108 patients had started treatment, 60 paediatric, 19 teenagers and young adults and 29 adults. Obtaining robust outcome data is vital, if we are to understand the strengths and weaknesses of current treatment approaches. This is important in demonstrating when PBT will provide an advantage and when it will not, and in quantifying the magnitude of benefit.The UK also has an important part to play in translational PBT research, and building a research capability has always been the vision. We are perfectly placed to perform translational pre-clinical biological and physical experiments in the dedicated research room in Manchester. The nature of DNA damage from proton irradiation is considerably different from X-rays and this needs to be more fully explored. A better understanding is needed of the relative biological effectiveness (RBE) of protons, especially at the end of the Bragg peak, and of the effects on tumour and normal tissue of PBT combined with conventional chemotherapy, targeted drugs and immunomodulatory agents. These experiments can be enhanced by deterministic mathematical models of the molecular and cellular processes of DNA damage response. The fashion of ultra-high dose rate FLASH irradiation also needs to be explored.
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Affiliation(s)
| | | | - Ed Smith
- The Christie NHS Foundation Trust, Manchester, and University of Manchester, M20 4BX, UK
| | - Amy L Chadwick
- Division of Cancer Sciences, University of Manchester, Manchester Cancer Research Centre, Manchester Academic Health Science Centre, and The Christie NHS Foundation Trust, Manchester, M20 4BX, UK
| | - Gillian A Whitfield
- The Christie NHS Foundation Trust, Manchester, and University of Manchester, M20 4BX, UK
| | - David J Thomson
- The Christie NHS Foundation Trust, Manchester, and University of Manchester, M20 4BX, UK
| | | | - Norman F Kirkby
- Division of Cancer Sciences, University of Manchester, Manchester Cancer Research Centre, Manchester Academic Health Science Centre, and The Christie NHS Foundation Trust, Manchester, M20 4BX, UK
| | | | - Karen J Kirkby
- Division of Cancer Sciences, University of Manchester, Manchester Cancer Research Centre, Manchester Academic Health Science Centre, and The Christie NHS Foundation Trust, Manchester, M20 4BX, UK
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12
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Patient Transfer to Receive Proton Beam Therapy During Intensive Multimodal Therapy is Safe and Feasible for Patients With Newly Diagnosed High-risk Neuroblastoma. J Pediatr Hematol Oncol 2020; 42:e18-e24. [PMID: 31449498 DOI: 10.1097/mph.0000000000001570] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Neuroblastoma (NB) predominantly presents as high-risk disease, requiring intensive multimodal therapy. Proton beam therpy (PBT) is a promising option for many childhood cancers, but is not widely available. Patients with NB hoping to receive PBT may therefore need to be transferred between institutions during intensive multimodal therapy, risking undesirable effects. We evaluated patients with high-risk NB who received PBT at our institute as part of first-line therapy, mainly focusing on the safety and feasibility of mid-treatment patient transfer. Eighteen patients with newly diagnosed high-risk NB who received PBT between April 2010 and June 2016 were retrospectively analyzed for local control, outcomes, and toxicity. Survival (3-y overall survival 71%±11%; 3-y event-free survival 44%±12%) and local control rate (100%) were comparable with previous studies. Few acute adverse events were recorded, and all patients completed PBT without treatment delay. PBT for high-risk NB was safe and feasible for patients requiring mid-treatment interinstitutional transfer.
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13
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Abstract
Radiotherapy is a highly effective anti-cancer treatment commonly used alongside systemic therapies and surgery to achieve long-term cancer-free survival. Conventional radiotherapy uses photon beams to deliver a high dose of radiation to the tumour volume to eradicate cancer cells. This has to be offset against the irradiation of surrounding normal tissues, as increasing this dose causes more treatment-related toxicity. In August 2018, the NHS's first high energy proton beam therapy centre opened at The Christie NHS Foundation Trust in Manchester. A second NHS centre is scheduled to open in 2020 at the University College London Hospitals NHS Trust. Proton beam therapy may offer dosimetric advantages compared to conventional radiotherapy as a result of its characteristic dose deposition - proton beams deliver a comparatively higher proportion of their dose to the target volume relative to normal tissues, without significant exit doses when compared to conventional photon therapy. Therefore proton beam therapy may be indicated for certain tumours situated next to critical organs or in the paediatric population where quality of life and the reduction of secondary effects from radiation are particularly significant. The indications for proton beam therapy and patient outcomes after treatment will be carefully monitored and evaluated in order to provide a robust evidence base for its use.
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Affiliation(s)
- Claire Barker
- Clinical Oncology Registrar, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX
| | - Matthew Lowe
- Principal Clinical Scientist, Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester
| | - Ganesh Radhakrishna
- Clinical Oncology Consultant, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester
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14
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Abstract
Proton beam therapy is a highly conformal form of radiation therapy, which currently represents an important therapeutic component in multidisciplinary management in paediatric oncology. The precise adjustability of protons results in a reduction of radiation-related long-term side-effects and secondary malignancy induction, which is of particular importance for the quality of life. Proton irradiation has been shown to offer significant advantages over conventional photon-based radiotherapy, although the biological effectiveness of both irradiation modalities is comparable. This review evaluates current data from clinical and dosimetric studies on the treatment of tumours of the central nervous system, soft tissue and bone sarcomas of the head and neck region, paraspinal or pelvic region, and retinoblastoma. To date, the clinical results of irradiating childhood tumours with high-precision proton therapy are promising both with regard to tumour cure and the reduction of adverse events. Modern proton therapy techniques such as pencil beam scanning and intensity modulation are increasingly established modern facilities. However, further investigations with larger patient cohorts and longer follow-up periods are required, in order to be able to have clear evidence on clinical benefits.
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Affiliation(s)
- Heike Thomas
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Centre (WTZ), West German, Germany
| | - Beate Timmermann
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Centre (WTZ), West German, Germany.,German Cancer Consortium (DKTK), Essen, Germany
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15
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Are further studies needed to justify the use of proton therapy for paediatric cancers of the central nervous system? A review of current evidence. Radiother Oncol 2019; 133:140-148. [DOI: 10.1016/j.radonc.2019.01.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 12/31/2018] [Accepted: 01/09/2019] [Indexed: 11/21/2022]
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16
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Abstract
PURPOSE OF REVIEW The advent of proton beam therapy (PBT) has initiated a paradigm shift in the field of pediatric radiation oncology, with increasing promise to alleviate both short-term and long-term toxicities. Given the dramatic rise in proton therapy centers in the United States, a discussion of the quality of evidence supporting its use in pediatric cancers is warranted. RECENT FINDINGS Proton radiotherapy appears to decrease the incidence and severity of late effects with the strongest evidence in pediatric brain tumor cohorts that shows benefits in neurocognitive, hearing, and endocrine outcomes. However, emerging data has shown that more conservative brainstem dose limits with protons compared with photons are required to limit brainstem toxicity; these modified recommendations have been incorporated into national cooperative group studies. Decreased toxicity in tumors outside of the CNS for PBT have also been reported in sarcomas, Hodgkin disease and neuroblastoma. Similarly, QoL outcomes are improved in brain tumor and other cohorts of patients treated with PBT. SUMMARY The collective findings demonstrate improved understanding and refinement of PBT in pediatric cancers. Data on QOL, toxicity and disease outcomes with PBT should continue to be collected and reported in order to understand the full extent of the risks and benefits associated with PBT.
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17
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Indelicato DJ, Rotondo RL, Uezono H, Sandler ES, Aldana PR, Ranalli NJ, Beier AD, Morris CG, Bradley JA. Outcomes Following Proton Therapy for Pediatric Low-Grade Glioma. Int J Radiat Oncol Biol Phys 2019; 104:149-156. [PMID: 30684665 DOI: 10.1016/j.ijrobp.2019.01.078] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 01/10/2019] [Accepted: 01/13/2019] [Indexed: 02/03/2023]
Abstract
PURPOSE Dosimetric studies show that proton therapy can reduce the low/intermediate radiation dose to uninvolved tissue in children with low-grade glioma (LGG). For this reason, LGG is the fourth most common pediatric tumor treated with proton therapy, yet clinical outcome data on efficacy and toxicity are limited. METHODS AND MATERIALS We reviewed the medical records of 174 children (≤21 years old) with nonmetastatic LGG enrolled on a prospective protocol and treated with proton therapy between 2007 and 2017. We assessed clinical outcomes and toxicity and analyzed patient, tumor, and treatment-related variables. RESULTS The median age was 10.2 years (range, 2-21). Fifty-eight percent of tumors were World Health Organization grade 1 and 30% were grade 2; 12% were diagnosed on imaging characteristics alone. The most common histology was pilocytic astrocytoma (47%). The most common tumor subsites were diencephalon/optic pathway (52%), caudal brainstem (16%), and cerebellum (13%). Forty-two percent received chemotherapy before radiation therapy. The median follow-up was 4.4 years. The 5-year actuarial rates of local control, progression-free survival, and overall survival were 85% (95% confidence interval [CI], 78%-90%), 84% (95% CI, 77%-89%), and 92% (95% CI, 85%-95%), respectively. On univariate analysis, brainstem/spinal cord tumor location (62% vs 90% elsewhere) and dose <54 GyRBE (67% vs 91% for 54 GyRBE) were associated with inferior local control (P < .01 for both). Twenty-two patients (12.6%) experienced acute nausea or vomiting requiring ondansetron; 2 patients (1.1%) required corticosteroids. Serious toxicities (4% of patients) included brainstem necrosis requiring corticosteroids (n = 2), symptomatic vasculopathy (n = 2), radiation retinopathy (n = 1), epilepsy (n = 1), and death from radiation-induced high-grade glioma (n = 1). Thirty-nine patients (22%) developed new-onset central hormone deficiency. Pseudoprogression was observed in 32.1%. CONCLUSIONS Compared with modern photon series, proton therapy reduces the radiation dose to developing brain tissue, diminishing acute toxicities without compromising disease control.
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Affiliation(s)
- Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida.
| | - Ronny L Rotondo
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Haruka Uezono
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | | | - Philipp R Aldana
- Department of Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Nathan J Ranalli
- Department of Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Alexandra D Beier
- Department of Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
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18
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Steinmeier T, Schulze Schleithoff S, Timmermann B. Evolving Radiotherapy Techniques in Paediatric Oncology. Clin Oncol (R Coll Radiol) 2019; 31:142-150. [PMID: 30639254 DOI: 10.1016/j.clon.2018.12.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 12/06/2018] [Accepted: 12/06/2018] [Indexed: 12/31/2022]
Abstract
AIMS Childhood cancer is rare and survival of childhood cancer has increased up to 80% at 5 years after diagnosis. Radiotherapy is an important element of the multimodal treatment concept. However, due to growing tissue, children are particularly sensitive to radiation-related side-effects and the induction of secondary malignancies. However, radiotherapy techniques have continuously progressed. In addition, modern treatment concepts have been improved in order to minimise long-term effects. Today, radiotherapy is used for various tumour types in childhood, such as sarcomas and tumours of the central nervous system. MATERIALS AND METHODS External beam therapy with either photons or protons and brachytherapy are predominantly used for the treatment of childhood tumours. Technical developments and features, as well as clinical outcomes, for several tumour entities are presented. RESULTS The development of radiotherapy techniques, as well as risk-adapted therapy concepts, resulted in promising outcome regarding tumour control, survival and therapy-related side-effects. It is assumed that proton therapy will be increasingly used for treating children in the future. However, more data have to be collected through multi-institutional registries in order to strengthen the evidence. CONCLUSION The development of radiotherapy techniques is beneficial for children in terms of reducing dose exposure. As compared with other modern and highly conformal techniques, particularly proton therapy may achieve high survival rates and tumour control rates while decreasing the risk for side-effects. However, clinical evidence for modern radiotherapy techniques is still limited today. An optimal patient triaging with the selection of the most appropriate radiation technique for each individual patient will be an important goal for the future.
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Affiliation(s)
- T Steinmeier
- Clinic for Particle Therapy, University Hospital Essen, Essen, Germany; West German Proton Therapy Center Essen (WPE), Essen, Germany; West German Cancer Center (WTZ), Essen, Germany
| | - S Schulze Schleithoff
- Clinic for Particle Therapy, University Hospital Essen, Essen, Germany; West German Proton Therapy Center Essen (WPE), Essen, Germany; West German Cancer Center (WTZ), Essen, Germany
| | - B Timmermann
- Clinic for Particle Therapy, University Hospital Essen, Essen, Germany; West German Proton Therapy Center Essen (WPE), Essen, Germany; West German Cancer Center (WTZ), Essen, Germany; German Cancer Consortium (DKTK), Essen/Düsseldorf, Germany.
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19
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Thorp N, Gandola L. Management of Ependymoma in Children, Adolescents and Young Adults. Clin Oncol (R Coll Radiol) 2019; 31:162-170. [PMID: 30616927 DOI: 10.1016/j.clon.2018.12.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 11/18/2018] [Accepted: 11/22/2018] [Indexed: 12/20/2022]
Abstract
Paediatric ependymomas are rare, malignant tumours arising throughout the central nervous system, but most frequently (in children) the posterior fossa. The standard of care for localised disease is gross total resection and focal radiotherapy, resulting in overall survival rates of up to 85%. Despite improvements in survival, treatment remains challenging, with persistently high rates of (rarely curable) relapse alongside risks of significant tumour and treatment-related toxicity. Systemic therapy is currently used to delay radiotherapy in very young children and in the management of metastatic or recurrent disease. Its use in the adjuvant setting is the subject of ongoing studies. Current research efforts are aimed at eliciting a better understanding of molecular biology, correlating this with tumour behaviour and defining targets for potential new agents. Prognosis seems to be related to the extent of surgical resection and the age at presentation. This article reviews clinical aspects of ependymoma management in children and young people.
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Affiliation(s)
- N Thorp
- Clatterbridge Cancer Centre, Wirral, UK.
| | - L Gandola
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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20
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Ajithkumar T, Taylor R, Kortmann RD. Radiotherapy in the Management of Paediatric Low-Grade Gliomas. Clin Oncol (R Coll Radiol) 2018; 31:151-161. [PMID: 30528521 DOI: 10.1016/j.clon.2018.11.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 11/04/2018] [Indexed: 12/18/2022]
Abstract
Paediatric low-grade (World Health Organization grade I-II) gliomas (LGGs) represent a spectrum of primary central nervous system tumours. Local tumour control is the cornerstone in the general management of childhood gliomas. Surgery is the primary treatment of choice in the majority. Non-surgical treatments are recommended for progressive or symptomatic inoperable disease. Although chemotherapy is increasingly used as first non-surgical treatment, radiotherapy remains standard as salvage treatment or as primary treatment in selected cases in which surrounding normal tissue can be optimally preserved. The role of targeted therapies is currently under investigation in clinical trials. Modern high-precision radiotherapy techniques, including proton therapy, have the potential to improve long-term toxicities. There is therefore an urgent need for prospective studies to compare the efficacy and safety of modern radiotherapy with systemic treatment in children with LGGs. New information on molecular genetic patterns in LGGs may also have an impact on the selection and sequencing of radiotherapy.
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Affiliation(s)
- T Ajithkumar
- Department of Oncology, Cambridge University Hospitals NHS Trust, Cambridge, UK.
| | - R Taylor
- Department of Oncology, Swansea University and South West Wales Cancer Centre, Singleton Hospital, Swansea, UK
| | - R D Kortmann
- Department of Radiation Oncology, University of Leipzig, Leipzig, Germany
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21
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Huynh M, Marcu LG, Giles E, Short M, Matthews D, Bezak E. Current status of proton therapy outcome for paediatric cancers of the central nervous system - Analysis of the published literature. Cancer Treat Rev 2018; 70:272-288. [PMID: 30326423 DOI: 10.1016/j.ctrv.2018.10.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 10/05/2018] [Accepted: 10/06/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION The most common solid tumours that develop in children are cancers of the central nervous system. Due to the increased rate of survival over the past decades, greater focus has been placed on the minimisation of long term side effects. In childhood cancer survivors, over 60% report one or more radiation-related late toxicities while half of these adverse events are graded as life-threatening or severe. Proton therapy enables high conformity with the planning target volume and a reduction in dose to areas beyond the target. Owing to the unique nature of dose delivery with proton therapy a reduction of low doses to normal tissues is achievable, and is believed to allow for a decrease in long-term treatment-related side effects. This paper aims to review the published literature around the effectiveness of proton therapy for the treatment of paediatric cancers of the central nervous system, with a focus on treatment outcomes and treatment-related toxicities. METHODS A search strategy utilising the Medline database was created with the intent of including all articles reporting on proton therapy, paediatric cancers, CNS tumours and treatment outcomes. The final search strategy included the following limitations: limited to humans, English, published from 2000 onwards. The final article count total was 74. RESULTS AND CONCLUSIONS Proton therapy for the treatment of paediatric cancers of the central nervous system was found to provide survival and tumour control outcomes comparable to photon therapy. Reduced incidence of severe acute and late toxicities was also reported with the use of proton therapy. This includes reduced severity of endocrine, neurological, IQ and QoL deficits. Currently, extensive follow-up of proton patient populations still needs to be made to determine incidences of late-onset toxicities and secondary malignancies. Current evidence surrounding proton therapy use in paediatric patients supports its effectiveness and potential benefits in reducing the incidence of severe toxicities in later life.
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Affiliation(s)
- Myxuan Huynh
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia
| | - Loredana Gabriela Marcu
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia; Faculty of Science, University of Oradea, Oradea 410087, Romania
| | - Eileen Giles
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia
| | - Michala Short
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia
| | - Donna Matthews
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia
| | - Eva Bezak
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia; School of Physical Sciences, University of Adelaide, North Terrace, Adelaide, South Australia 5005, Australia.
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22
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Rudà R, Reifenberger G, Frappaz D, Pfister SM, Laprie A, Santarius T, Roth P, Tonn JC, Soffietti R, Weller M, Moyal ECJ. EANO guidelines for the diagnosis and treatment of ependymal tumors. Neuro Oncol 2018; 20:445-456. [PMID: 29194500 PMCID: PMC5909649 DOI: 10.1093/neuonc/nox166] [Citation(s) in RCA: 151] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Ependymal tumors are rare CNS tumors and may occur at any age, but their proportion among primary brain tumors is highest in children and young adults. Thus, the level of evidence of diagnostic and therapeutic interventions is higher in the pediatric compared with the adult patient population.The diagnosis and disease staging is performed by craniospinal MRI. Tumor classification is achieved by histological and molecular diagnostic assessment of tissue specimens according to the World Health Organization (WHO) classification 2016. Surgery is the crucial initial treatment in both children and adults. In pediatric patients with intracranial ependymomas of WHO grades II or III, surgery is followed by local radiotherapy regardless of residual tumor volume. In adults, radiotherapy is employed in patients with anaplastic ependymoma WHO grade III, and in case of incomplete resection of WHO grade II ependymoma. Chemotherapy alone is reserved for young children <12 months and for adults with recurrent disease when further surgery and irradiation are no longer feasible. A gross total resection is the mainstay of treatment in spinal ependymomas, and radiotherapy is reserved for incompletely resected tumors. Nine subgroups of ependymal tumors across different anatomical compartments (supratentorial, posterior fossa, spinal) and patient ages have been identified with distinct genetic and epigenetic alterations, and with distinct outcomes. These findings may lead to more precise diagnostic and prognostic assessments, molecular subgroup-adapted therapies, and eventually new recommendations pending validation in prospective studies.
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Affiliation(s)
- Roberta Rudà
- Department of Neuro-Oncology, University of Turin and City of Health and Science University Hospital, Turin, Italy
| | - Guido Reifenberger
- Institute of Neuropathology, Medical Faculty, Heinrich Heine University Düsseldorf and German Cancer Consortium (DKTK), partner site Essen/Düsseldorf, Düsseldorf, Germany
| | - Didier Frappaz
- Département de Neuro-Oncologie, Centre Léon-Bérard, Institut d’Hématologie et Oncologie Pédiatrique et Adulte, Lyon, France
| | - Stefan M Pfister
- Division of Pediatric Neuro-oncology, German Cancer Research Center, DKTK, Heidelberg, Germany and Department of Pediatric Oncology, Hematology and Immunology, University Hospital Heidelberg, Heidelberg, Germany
| | - Anne Laprie
- Department of Radiation Oncology, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | | | - Patrick Roth
- Department of Neurology and Brain Tumor Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Joerg Christian Tonn
- Department of Neurosurgery Ludwig-Maximilians-Universität and DKTK partner site, University of Munich, Munich, Germany
| | - Riccardo Soffietti
- Department of Neuro-Oncology, University of Turin and City of Health and Science University Hospital, Turin, Italy
| | - Michael Weller
- Department of Neurology and Brain Tumor Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
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23
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Abstract
Proton Beam Therapy is one of the key elements in a major improvement in access to advanced radiotherapy in the UK. An overseas programme has treated significant numbers of children and young adults and skull base tumours since 2008. A major government investment has resulted in building two proton centres in England sited in academic major cancer centres. A weak evidence base for most adult indications means that the NHS will use clinical trials and studies to explore the future role of Protons.
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Affiliation(s)
- A Crellin
- Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
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24
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Bojaxhiu B, Ahlhelm F, Walser M, Placidi L, Kliebsch U, Mikroutsikos L, Morach P, Bolsi A, Lomax T, Pica A, Weber DC. Radiation Necrosis and White Matter Lesions in Pediatric Patients With Brain Tumors Treated With Pencil Beam Scanning Proton Therapy. Int J Radiat Oncol Biol Phys 2018; 100:987-996. [DOI: 10.1016/j.ijrobp.2017.11.037] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 10/11/2017] [Accepted: 11/24/2017] [Indexed: 12/21/2022]
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25
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Lühr A, von Neubeck C, Krause M, Troost EGC. Relative biological effectiveness in proton beam therapy - Current knowledge and future challenges. Clin Transl Radiat Oncol 2018; 9:35-41. [PMID: 29594249 PMCID: PMC5862688 DOI: 10.1016/j.ctro.2018.01.006] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 01/25/2018] [Accepted: 01/27/2018] [Indexed: 12/25/2022] Open
Affiliation(s)
- Armin Lühr
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Cläre von Neubeck
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Mechthild Krause
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Helmholtz Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Esther G C Troost
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Helmholtz Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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