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Liang X, Liu C, Shen J, Flampouri S, Park JC, Lu B, Yaddanapudi S, Tan J, Furutani KM, Beltran CJ. Impact of proton PBS machine operating parameters on the effectiveness of layer rescanning for interplay effect mitigation in lung SBRT treatment. J Appl Clin Med Phys 2024:e14342. [PMID: 38590112 DOI: 10.1002/acm2.14342] [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: 12/22/2023] [Revised: 02/07/2024] [Accepted: 03/13/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Rescanning is a common technique used in proton pencil beam scanning to mitigate the interplay effect. Advances in machine operating parameters across different generations of particle therapy systems have led to improvements in beam delivery time (BDT). However, the potential impact of these improvements on the effectiveness of rescanning remains an underexplored area in the existing research. METHODS We systematically investigated the impact of proton machine operating parameters on the effectiveness of layer rescanning in mitigating interplay effect during lung SBRT treatment, using the CIRS phantom. Focused on the Hitachi synchrotron particle therapy system, we explored machine operating parameters from our institution's current (2015) and upcoming systems (2025A and 2025B). Accumulated dynamic 4D dose were reconstructed to assess the interplay effect and layer rescanning effectiveness. RESULTS Achieving target coverage and dose homogeneity within 2% deviation required 6, 6, and 20 times layer rescanning for the 2015, 2025A, and 2025B machine parameters, respectively. Beyond this point, further increasing the number of layer rescanning did not further improve the dose distribution. BDTs without rescanning were 50.4, 24.4, and 11.4 s for 2015, 2025A, and 2025B, respectively. However, after incorporating proper number of layer rescanning (six for 2015 and 2025A, 20 for 2025B), BDTs increased to 67.0, 39.6, and 42.3 s for 2015, 2025A, and 2025B machine parameters. Our data also demonstrated the potential problem of false negative and false positive if the randomness of the respiratory phase at which the beam is initiated is not considered in the evaluation of interplay effect. CONCLUSION The effectiveness of layer rescanning for mitigating interplay effect is affected by machine operating parameters. Therefore, past clinical experiences may not be applicable to modern machines.
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Affiliation(s)
- Xiaoying Liang
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - Chunbo Liu
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jiajian Shen
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Stella Flampouri
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, USA
| | - Justin C Park
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - Bo Lu
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Jun Tan
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - Keith M Furutani
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - Chris J Beltran
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
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Abu Qubo A, Numan J, Snijder J, Padilla M, Austin JH, Capaccione KM, Pernia M, Bustamante J, O'Connor T, Salvatore MM. Idiopathic pulmonary fibrosis and lung cancer: future directions and challenges. Breathe (Sheff) 2022; 18:220147. [PMID: 36865932 PMCID: PMC9973524 DOI: 10.1183/20734735.0147-2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 09/14/2022] [Indexed: 01/11/2023] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) is a progressive disease of pulmonary scarring. New treatments slow disease progression and allow pulmonary fibrosis patients to live longer. Persistent pulmonary fibrosis increases a patient's risk of developing lung cancer. Lung cancer in patients with IPF differs from cancers that develop in the non-fibrotic lung. Peripherally located adenocarcinoma is the most frequent cell type in smokers who develop lung cancer, while squamous cell carcinoma is the most frequent in pulmonary fibrosis. Increased fibroblast foci in IPF are associated with more aggressive cancer behaviour and shorter doubling times. Treatment of lung cancer in fibrosis is challenging because of the risk of inducing an exacerbation of fibrosis. In order to improve patient outcomes, modifications of current lung cancer screening guidelines in patients with pulmonary fibrosis will be necessary to avoid delays in treatment. 2-fluoro-2-deoxy-d-glucose (FDG) positron emission tomography (PET) computed tomography (CT) imaging can help identify cancer earlier and more reliably than CT alone. Increased use of wedge resections, proton therapy and immunotherapy may increase survival by decreasing the risk of exacerbation, but further research will be necessary.
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Affiliation(s)
- Ahmad Abu Qubo
- Department of Pathology, Faculty of Medicine, Hashemite University, Zarqa, Jordan
| | - Jamil Numan
- Department of Radiology, Columbia University Medical Center, New York, NY, USA
| | - Juan Snijder
- Department of Pediatrics, Einstein Medical Center, Philadelphia, PA, USA
| | - Maria Padilla
- Department of Pulmonary Medicine, Mount Sinai, New York, NY, USA
| | - John H.M. Austin
- Department of Radiology, Columbia University Medical Center, New York, NY, USA
| | | | - Monica Pernia
- Department of Medicine, Metropolitan Hospital, New York, NY, USA
| | - Jean Bustamante
- Department of Oncology, West Virginia University, Morgantown, WV, USA
| | - Timothy O'Connor
- Department of Radiology, Columbia University Medical Center, New York, NY, USA
| | - Mary M. Salvatore
- Department of Radiology, Columbia University Medical Center, New York, NY, USA,Corresponding author: Mary M. Salvatore ()
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Volpe S, Piperno G, Colombo F, Biffi A, Comi S, Mastroleo F, Maria Camarda A, Casbarra A, Cattani F, Corrao G, de Marinis F, Spaggiari L, Guckenberger M, Orecchia R, Alterio D, Alicja Jereczek-Fossa B. Hypofractionated proton therapy for non-small cell lung cancer: Ready for prime time? A systematic review and meta-analysis. Cancer Treat Rev 2022; 110:102464. [DOI: 10.1016/j.ctrv.2022.102464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/02/2022] [Accepted: 09/14/2022] [Indexed: 11/02/2022]
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The Role of Hypofractionation in Proton Therapy. Cancers (Basel) 2022; 14:cancers14092271. [PMID: 35565400 PMCID: PMC9104796 DOI: 10.3390/cancers14092271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 04/22/2022] [Accepted: 04/27/2022] [Indexed: 12/07/2022] Open
Abstract
Hypofractionated radiotherapy is an attractive approach for minimizing patient burden and treatment cost. Technological advancements in external beam radiotherapy (EBRT) delivery and image guidance have resulted in improved targeting and conformality of the absorbed dose to the disease and a reduction in dose to healthy tissue. These advances in EBRT have led to an increasing adoption and interest in hypofractionation. Furthermore, for many treatment sites, proton beam therapy (PBT) provides an improved absorbed dose distribution compared to X-ray (photon) EBRT. In the past 10 years there has been a notable increase in reported clinical data involving hypofractionation with PBT, reflecting the interest in this treatment approach. This review will discuss the reported clinical data and radiobiology of hypofractionated PBT. Over 50 published manuscripts reporting clinical results involving hypofractionation and PBT were included in this review, ~90% of which were published since 2010. The most common treatment regions reported were prostate, lung and liver, making over 70% of the reported results. Many of the reported clinical data indicate that hypofractionated PBT can be well tolerated, however future clinical trials are still needed to determine the optimal fractionation regime.
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Nogueira LM, Jemal A, Yabroff KR, Efstathiou JA. Assessment of Proton Beam Therapy Use Among Patients With Newly Diagnosed Cancer in the US, 2004-2018. JAMA Netw Open 2022; 5:e229025. [PMID: 35476066 PMCID: PMC9047654 DOI: 10.1001/jamanetworkopen.2022.9025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE Proton beam therapy (PBT) is a potentially superior technology to photon radiotherapy for tumors with complex anatomy, those surrounded by sensitive tissues, and childhood cancers. OBJECTIVE To assess patterns of use of PBT according to the present American Society of Radiation Oncology (ASTRO) clinical indications in the US. DESIGN, SETTING, AND PARTICIPANTS Individuals newly diagnosed with cancer between 2004 and 2018 were selected from the National Cancer Database. Data analysis was performed from October 4, 2021, to February 22, 2022. ASTRO's Model Policies (2017) were used to classify patients into group 1, for which health insurance coverage for PBT treatment is recommended, and group 2, for which coverage is recommended only if additional requirements are met. MAIN OUTCOMES AND MEASURES Use of PBT. RESULTS Of the 5 919 368 patients eligible to receive PBT included in the study, 3 206 902 were female (54.2%), and mean (SD) age at diagnosis was 62.6 (12.3) years. Use of PBT in the US increased from 0.4% in 2004 to 1.2% in 2018 (annual percent change [APC], 8.12%; P < .001) due to increases in group 1 from 0.4% in 2010 to 2.2% in 2018 (APC, 21.97; P < .001) and increases in group 2 from 0.03% in 2014 to 0.1% in 2018 (APC, 30.57; P < .001). From 2010 to 2018, among patients in group 2, PBT targeted to the breast increased from 0.0% to 0.9% (APC, 51.95%), and PBT targeted to the lung increased from 0.1% to 0.7% (APC, 28.06%) (P < .001 for both). Use of PBT targeted to the prostate decreased from 1.4% in 2011 to 0.8% in 2014 (APC, -16.48%; P = .03) then increased to 1.3% in 2018 (APC, 12.45; P < .001). Most patients in group 1 treated with PBT had private insurance coverage in 2018 (1039 [55.4%]); Medicare was the most common insurance type among those in group 2 (1973 [52.5%]). CONCLUSIONS AND RELEVANCE The findings of this study show an increase in the use of PBT in the US between 2004 to 2018; prostate was the only cancer site for which PBT use decreased temporarily between 2011 and 2014, increasing again between 2014 and 2018. These findings may be especially relevant for Medicare radiation oncology coverage policies.
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Affiliation(s)
- Leticia M. Nogueira
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Ahmedin Jemal
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - K. Robin Yabroff
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Jason A. Efstathiou
- Department of Radiation Oncology, Department of Radiation Oncology, Massachusetts General Hospital, Boston
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6
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Dosimetry, Efficacy, Safety, and Cost-Effectiveness of Proton Therapy for Non-Small Cell Lung Cancer. Cancers (Basel) 2021; 13:cancers13184545. [PMID: 34572772 PMCID: PMC8465697 DOI: 10.3390/cancers13184545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 09/04/2021] [Accepted: 09/07/2021] [Indexed: 12/24/2022] Open
Abstract
Non-small cell lung cancer (NSCLC) is the most common malignancy which requires radiotherapy (RT) as an important part of its multimodality treatment. With the advent of the novel irradiation technique, the clinical outcome of NSCLC patients who receive RT has been dramatically improved. The emergence of proton therapy, which allows for a sharper dose of build-up and drop-off compared to photon therapy, has potentially improved clinical outcomes of NSCLC. Dosimetry studies have indicated that proton therapy can significantly reduce the doses for normal organs, especially the lung, heart, and esophagus while maintaining similar robust target volume coverage in both early and advanced NSCLC compared with photon therapy. However, to date, most studies have been single-arm and concluded no significant changes in the efficacy for early-stage NSCLC by proton therapy over stereotactic body radiation therapy (SBRT). The results of proton therapy for advanced NSCLC in these studies were promising, with improved clinical outcomes and reduced toxicities compared with historical photon therapy data. However, these studies were also mainly single-arm and lacked a direct comparison between the two therapies. Currently, there is much emerging evidence focusing on dosimetry, efficacy, safety, and cost-effectiveness of proton therapy for NSCLC that has been published, however, a comprehensive review comparing these therapies is, to date, lacking. Thus, this review focuses on these aspects of proton therapy for NSCLC.
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Vlaskou Badra E, Baumgartl M, Fabiano S, Jongen A, Guckenberger M. Stereotactic radiotherapy for early stage non-small cell lung cancer: current standards and ongoing research. Transl Lung Cancer Res 2021; 10:1930-1949. [PMID: 34012804 PMCID: PMC8107760 DOI: 10.21037/tlcr-20-860] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Stereotactic body radiation therapy (SBRT) allows for the non-invasive and precise delivery of ablative radiation dose. The use and availability of SBRT has increased rapidly over the past decades. SBRT has been proven to be a safe, effective and efficient treatment for early stage non-small cell lung cancer (NSCLC) and is presently considered the standard of care in the treatment of medically or functionally inoperable patients. Evidence from prospective randomized trials on the optimal treatment of patients deemed medically operable remains owing, as three trials comparing SBRT to surgery in this cohort were terminated prematurely due to poor accrual. Yet, SBRT in early stage NSCLC is associated with favorable toxicity profiles and excellent rates of local control, prompting discussion in regard of the treatment of medically operable patients, where the standard of care currently remains surgical resection. Although local control in early stage NSCLC after SBRT is high, distant failure remains an issue, prompting research interest to the combination of SBRT and systemic treatment. Evolving advances in SBRT technology further facilitate the safe treatment of patients with medically or anatomically challenging situations. In this review article, we discuss international guidelines and the current standard of care, ongoing clinical challenges and future directions from the clinical and technical point of view.
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Affiliation(s)
- Eugenia Vlaskou Badra
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Michael Baumgartl
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Silvia Fabiano
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Aurélien Jongen
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Paganetti H, Grassberger C, Sharp GC. Physics of Particle Beam and Hypofractionated Beam Delivery in NSCLC. Semin Radiat Oncol 2021; 31:162-169. [PMID: 33610274 PMCID: PMC7905707 DOI: 10.1016/j.semradonc.2020.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The dosimetric advantages of particle therapy lead to significantly reduced integral dose to normal tissues, making it an attractive treatment option for body sites such as the thorax. With reduced normal tissue dose comes the potential for dose escalation, toxicity reduction, or hypofractionation. While proton and heavy ion therapy have been used extensively for NSCLC, there are challenges in planning and delivery compared with X-ray-based radiation therapy. Particularly, range uncertainties compounded by breathing motion have to be considered. This article summarizes the current state of particle therapy for NSCLC with a specific focus on the impact of dosimetric uncertainties in planning and delivery.
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Affiliation(s)
- Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
| | - Clemens Grassberger
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Gregory C Sharp
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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9
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Chiang JS, Yu NY, Daniels TB, Liu W, Schild SE, Sio TT. Proton beam radiotherapy for patients with early-stage and advanced lung cancer: a narrative review with contemporary clinical recommendations. J Thorac Dis 2021; 13:1270-1285. [PMID: 33717598 PMCID: PMC7947490 DOI: 10.21037/jtd-20-2501] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Although lung cancer rates are decreasing nationally, lung cancer remains the leading cause of cancer related death. Despite advancements in treatment and technology, overall survival (OS) for lung cancer remains poor. Proton beam therapy (PBT) is an advanced radiation therapy (RT) modality for treatment of lung cancer with the potential to achieve dose escalation to tumor while sparing critical structures due to higher target conformality. In early and late-stage non-small cell lung cancer (NSCLC), dosimetric studies demonstrated reduced doses to organs at risk (OARs) such as the lung, spinal cord, and heart, and clinical studies report limited toxicities with PBT, including hypofractionated regimens. In limited-stage SCLC, studies showed that regimens chemo RT including PBT were well tolerated, which may help optimize clinical outcomes. Improved toxicity profiles may be beneficial in post-operative radiotherapy, for which initial dosimetric and clinical data are encouraging. Sparing of OARs may also increase the proportion of patients able to complete reirradiation for recurrent disease. However, there are various challenges of using PBT including a higher financial burden on healthcare and limited data supporting its cost-effectiveness. Further studies are needed to identify subgroups that benefit from PBT based on prognostic factors, and to evaluate PBT combined with immunotherapy, in order to elucidate the benefit that PBT may offer future lung cancer patients.
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Affiliation(s)
- Jennifer S Chiang
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Nathan Y Yu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Thomas B Daniels
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
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Lazarev S, Rosenzweig K, Samstein R, Salgado LR, Hasan S, Press RH, Sharma S, Powell CA, Hirsch FR, Simone CB. Where are we with proton beam therapy for thoracic malignancies? Current status and future perspectives. Lung Cancer 2020; 152:157-164. [PMID: 33421922 DOI: 10.1016/j.lungcan.2020.12.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/12/2020] [Accepted: 12/19/2020] [Indexed: 12/25/2022]
Abstract
Radiation therapy (RT) plays an important role in the curative treatment of a variety of thoracic malignancies. However, delivery of tumoricidal doses with conventional photon-based RT to thoracic tumors often presents unique challenges. Extraneous dose deposited along the entrance and exit paths of the photon beam increases the likelihood of significant acute and delayed toxicities in cardiac, pulmonary, and gastrointestinal structures. Furthermore, safe dose-escalation, delivery of concomitant systemic therapy, or reirradiation of a recurrent disease are frequently not feasible with photon RT. In contrast, protons have distinct physical properties that allow them to deposit a high irradiation dose in the target, while leaving a negligible exit dose in the adjacent organs at risk. Proton beam therapy (PBT), therefore, can reduce toxicities with similar antitumor effect or allow for dose escalation and enhanced antitumor effect with the same or even lower risk of adverse events, thus potentially improving the therapeutic ratio of the treatment. For thoracic malignancies, this favorable dose distribution can translate to decreases in treatment-related morbidities, provide more durable disease control, and potentially prolong survival. This review examines the evolving role of PBT in the treatment of thoracic malignancies and evaluates the data supporting its use.
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Affiliation(s)
- Stanislav Lazarev
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States.
| | - Kenneth Rosenzweig
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Robert Samstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Lucas Resende Salgado
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | | | | | - Sonam Sharma
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Charles A Powell
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Fred R Hirsch
- Center for Thoracic Oncology, The Tisch Cancer Institute at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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Baumann KS, Flatten V, Weber U, Lautenschläger S, Eberle F, Zink K, Engenhart-Cabillic R. Effects of the Bragg peak degradation due to lung tissue in proton therapy of lung cancer patients. Radiat Oncol 2019; 14:183. [PMID: 31653229 PMCID: PMC6814996 DOI: 10.1186/s13014-019-1375-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 09/06/2019] [Indexed: 12/25/2022] Open
Abstract
Purpose To quantify the effects of the Bragg peak degradation due to lung tissue on treatment plans of lung cancer patients with spot scanning proton therapy and to give a conservative approximation of these effects. Methods and materials Treatment plans of five lung cancer patients (tumors of sizes 2.7–46.4 cm3 at different depths in the lung) were optimized without consideration of the Bragg peak degradation. These treatment plans were recalculated with the Monte Carlo code TOPAS in two scenarios: in a first scenario, the treatment plans were calculated without including the Bragg peak degradation to reproduce the dose distribution predicted by the treatment-planning system (TPS). In a second scenario, the treatment plans were calculated while including the Bragg peak degradation. Subsequently, the plans were compared by means of Dmean, D98% and D2% in the clinical target volume (CTV) and organs at risk (OAR). Furthermore, isodose lines were investigated and a gamma index analysis was performed. Results The Bragg peak degradation leads to a lower dose in the CTV and higher doses in OARs distal to the CTV compared to the prediction from the TPS. The reduction of the mean dose in the CTV was − 5% at maximum and − 2% on average. The deeper a tumor was located in the lung and the smaller its volume the bigger was the effect on the CTV. The enhancement of the mean dose in OARs distal to the CTV was negligible for the cases investigated. Conclusions Effects of the Bragg peak degradation due to lung tissue were investigated for lung cancer treatment plans in proton therapy. This study confirms that these effects are clinically tolerable to a certain degree in the current clinical context considering the various more critical dose uncertainties due to motion and range uncertainties in proton therapy.
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Affiliation(s)
- Kilian-Simon Baumann
- University Medical Center Giessen-Marburg, Department of Radiotherapy and Radiooncology, Marburg, Germany. .,University of Applied Sciences, Institute of Medical Physics and Radiation Protection, Giessen, Germany.
| | - Veronika Flatten
- University Medical Center Giessen-Marburg, Department of Radiotherapy and Radiooncology, Marburg, Germany.,University of Applied Sciences, Institute of Medical Physics and Radiation Protection, Giessen, Germany
| | - Uli Weber
- GSI Helmholtzzentrum für Schwerionenforschung, Biophysics Division, Darmstadt, Germany
| | - Stefan Lautenschläger
- University Medical Center Giessen-Marburg, Department of Radiotherapy and Radiooncology, Marburg, Germany.,Marburg Ion-Beam Therapy Center (MIT), Marburg, Germany
| | - Fabian Eberle
- University Medical Center Giessen-Marburg, Department of Radiotherapy and Radiooncology, Marburg, Germany.,Marburg Ion-Beam Therapy Center (MIT), Marburg, Germany
| | - Klemens Zink
- University Medical Center Giessen-Marburg, Department of Radiotherapy and Radiooncology, Marburg, Germany.,University of Applied Sciences, Institute of Medical Physics and Radiation Protection, Giessen, Germany.,Frankfurt Institute of Advanced Studies - FIAS, Frankfurt, Germany
| | - Rita Engenhart-Cabillic
- University Medical Center Giessen-Marburg, Department of Radiotherapy and Radiooncology, Marburg, Germany.,Marburg Ion-Beam Therapy Center (MIT), Marburg, Germany
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12
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Ohnishi K, Nakamura N, Harada H, Tokumaru S, Wada H, Arimura T, Iwata H, Sato Y, Sekino Y, Tamamura H, Mizoe JE, Ogino T, Ishikawa H, Kikuchi Y, Okimoto T, Murayama S, Akimoto T, Sakurai H. Proton Beam Therapy for Histologically or Clinically Diagnosed Stage I Non-Small Cell Lung Cancer (NSCLC): The First Nationwide Retrospective Study in Japan. Int J Radiat Oncol Biol Phys 2019; 106:82-89. [PMID: 31580927 DOI: 10.1016/j.ijrobp.2019.09.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/23/2019] [Accepted: 09/10/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE To investigate the efficacy and safety of proton beam therapy (PBT) for the treatment of stage I non-small cell lung cancer (NSCLC). METHODS AND MATERIALS Six hundred sixty-nine patients with 682 tumors histologically or clinically diagnosed stage I NSCLC according to the seventh edition of Union for International Cancer Control who received passive-scattering PBT from April 2004 and December 2013 in Japan were retrospectively reviewed to analyze survival, local control, and toxicities. RESULTS Of 669 patients, 486 (72.6%) were men, with a median age of 76 years (range, 42-94 years). NSCLC was histologically confirmed in 440 patients (65.7%). Clinical T stages included T1a (n = 265; 38.9%), T1b (n = 216; 31.7%), and T2a (n = 201; 29.4%). The total irradiation doses of PBT ranged from 74.4 to 131.3 biological effective dose GyE (median, 109.6 biological effective dose GyE). The median follow-up period was 38.2 months (range, 0.6-154.5 months) for all patients. The 3-year overall survival and progression-free survival rates for all patients were 79.5% and 64.1%, respectively. For patients with stage IA tumors, the 3-year overall survival and progression-free survival rates were 82.8% and 70.6%, respectively, and the corresponding rates for patients with stage IB tumors were 70.8% and 47.3%, respectively. The 3-year local progression-free rates for all, stage IA, and stage IB patients were 89.8%, 93.5%, and 79.4%, respectively. The incidence of grade 2, 3, 4, and 5 pneumonitis was 9.8%, 1.0%, 0%, and 0.7%, respectively. The incidence of grade ≥3 dermatitis was 0.4%. No grade 4 or severe adverse events, other than pneumonitis, were observed. CONCLUSIONS PBT appears to yield acceptable survival rates, with a low rate of toxicities.
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Affiliation(s)
- Kayoko Ohnishi
- Department of Radiation Oncology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Naoki Nakamura
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Hideyuki Harada
- Proton Therapy Division, Shizuoka Cancer Center, Nagaizumi, Shizuoka, Japan
| | - Sunao Tokumaru
- Department of Radiology, Hyogo Ion Beam Medical Center, Tatsuno, Hyogo, Japan
| | - Hitoshi Wada
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Koriyama, Fukushima, Japan
| | - Takeshi Arimura
- Medipolis Proton Therapy and Research Center, Ibusuki, Kagoshima, Japan
| | - Hiromitsu Iwata
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City West Medical Center, Nagoya, Aichi, Japan
| | - Yoshitaka Sato
- Proton Therapy Center, Fukui Prefecture Hospital, Fukui, Fukui, Japan
| | - Yuta Sekino
- Department of Radiation Oncology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hiroyasu Tamamura
- Proton Therapy Center, Fukui Prefecture Hospital, Fukui, Fukui, Japan
| | - Jun-Etsu Mizoe
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City West Medical Center, Nagoya, Aichi, Japan
| | - Takashi Ogino
- Medipolis Proton Therapy and Research Center, Ibusuki, Kagoshima, Japan
| | - Hitoshi Ishikawa
- Department of Radiation Oncology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yasuhito Kikuchi
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Koriyama, Fukushima, Japan
| | - Tomoaki Okimoto
- Department of Radiology, Hyogo Ion Beam Medical Center, Tatsuno, Hyogo, Japan
| | - Shigeyuki Murayama
- Proton Therapy Division, Shizuoka Cancer Center, Nagaizumi, Shizuoka, Japan
| | - Tetsuo Akimoto
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Hideyuki Sakurai
- Department of Radiation Oncology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan.
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13
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Brooks ED, Ning MS, Verma V, Zhu XR, Chang JY. Proton therapy for non-small cell lung cancer: the road ahead. Transl Lung Cancer Res 2019; 8:S202-S212. [PMID: 31673525 PMCID: PMC6795573 DOI: 10.21037/tlcr.2019.07.08] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 07/17/2019] [Indexed: 12/14/2022]
Abstract
Proton therapy is an evolving radiotherapy modality with indication for numerous cancer types. With the benefits of reducing dose and sparing normal tissue, protons offer a clear physical and dosimetric advantage over photon radiotherapy for many patients. However, its impact on one type of disease, non-small cell lung cancer (NSCLC), is still not fully understood. Our review aims to highlight the data for using proton therapy in NSCLC, with a focus on the clinical data-or lack thereof-supporting proton treatment for early and advanced stage disease. In evaluating these data, we consider how future directions and advances in proton technology give rise for hope in defining a role for protons in improving NSCLC outcomes. We close with considerations for next steps and the challenges ahead in using proton therapy for this unique patient population.
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Affiliation(s)
- Eric D. Brooks
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew S. Ning
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA, USA
| | - X. Ronald Zhu
- Proton Therapy Center, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joe Y. Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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14
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Takei H, Inaniwa T. Effect of Irradiation Time on Biological Effectiveness and Tumor Control Probability in Proton Therapy. Int J Radiat Oncol Biol Phys 2019; 105:222-229. [PMID: 31085286 DOI: 10.1016/j.ijrobp.2019.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 03/16/2019] [Accepted: 05/01/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE The biological effectiveness of proton beams may decrease with irradiation time because of sublethal damage repair (SLDR). The purpose of this study is to systematically evaluate this effect in hypofractionated proton therapy for various target sizes, depths, and prescribed doses per fraction. METHODS AND MATERIALS Plans with a single spread-out Bragg peak beam were created using a constant relative biological effectiveness (RBE) of 1.1 to cover targets of 6 different sizes located at 3 different depths in water. Biological doses of 2, 3, 5, 10, and 20 Gy (RBE) were prescribed to the targets. First, to investigate the depth variation of the biological effectiveness, the biological dose in instantaneous irradiation was recalculated based on the microdosimetric kinetic model. SLDR was then taken into account in the microdosimetric kinetic model during treatments to obtain the irradiation time-dependent biological effectiveness for irradiation time T of 5 to 60 minutes and beam interruption time τ of 0 to 60 minutes. The tumor control probabilities were calculated for single-fraction proton therapy fields of different Ts and τs, and the curative doses were evaluated at a tumor control probability of 90%. RESULTS The biological effectiveness decreased with longer T and τ and higher prescribed dose. The maximum decrease in the biological effectiveness was 21% with a 20 Gy (RBE) prescribed dose. In single-fraction proton therapy, the curative dose increased linearly by approximately 33% to 35% with the increase of T from 0 to 60 minutes. CONCLUSIONS The biological effectiveness varies largely with T and τ because of SLDR during treatments. This effect was pronounced for high prescribed doses per fraction. Thus, the effect of SLDR needs to be considered in hypofractionated and single-fraction proton therapies in relation to size and depth of the target.
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Affiliation(s)
- Hideyuki Takei
- Faculty of Medicine, University of Tsukuba, Ibaraki, Japan.
| | - Taku Inaniwa
- Department of Accelerator and Medical Physics, National Institute of Radiological Sciences, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
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15
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Chen J, Lu JJ, Ma N, Zhao J, Chen C, Fan M, Jiang G, Mao J. Early stage non-small cell lung cancer treated with pencil beam scanning particle therapy: retrospective analysis of early results on safety and efficacy. Radiat Oncol 2019; 14:16. [PMID: 30683133 PMCID: PMC6347845 DOI: 10.1186/s13014-019-1216-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 01/08/2019] [Indexed: 12/17/2022] Open
Abstract
Background To evaluate the safety and efficacy of particle therapy (PT) using pencil beam scanning (PBS) technique for early stage non-small cell lung cancer (NSCLC). Methods From 08/2014 to 03/2018, 31 consecutive patients with sum of the longest diameters of primary tumor and hilar lymph node < 5 cm, N0–1, M0 NSCLC treated with PT were retrospectively analyzed. Gating/active breathing control techniques were used to control tumor motion in 20 and 7 patients. PBS-based proton radiotherapy (PRT) or carbon ion radiotherapy (CIRT) plans were designed via Syngo® planning system. PRT, PRT + CIRT boost, and CIRT were used in 6, 6 and 19 patients, respectively. Prescriptions were categorized to 3 levels: 5–7.5 GyE * 8–10 Fx, 4–5 GyE * 15–16 Fx and 2.25–3.5 GyE * 20–31 Fx. Results Thirty-one patients (20 males and 11 females) with a median age of 71 (50–80) years were enrolled with a median follow-up time of 12.1 (2.9–45.2) months. Fourteen were adenocarcinomas, 7 squamous cell carcinomas, 4 non-specified NSCLC and 6 had no histological diagnosis (4/6 had previous resected lung cancer). The median tumor size was 3.1 (1.1–4.7) cm. No grade 4–5 toxicities were observed. One patient experienced grade 3 (per the Common Terminology Criteria for Adverse Events version 4.03) radiation-induced lung injury (RILI) at 6.7 months from radiation started. Grade 2 acute toxicities included hematological toxicities (5 cases), RILI (2), plural pain (1) and dermatitis (1). Grade 2 late toxicities included RILI (3) and asymptomatic rib fracture (1). Three patients had progressed disease at 4.0~10.6 months after the initiation of PT. One experienced local failure with simultaneous distant failure and died of brain metastasis at 10.8 months; one developed regional and distant failure and died of lung infection at 8.7 months; the other experienced isolated distant failure only and his disease was well controlled after salvage systemic therapy. The estimated rates of progression-free survival, local control, cause-specific survival and overall survival at 1, 2 years were 85.5% and 85.5%, 95.2% and 95.2%, 95.0% and 95.0%, 90.7% and 90.7%, respectively. Conclusions PBS-based PT appears safe and effective for early stage NSCLC. Further follow-up and investigation is warranted. Trial registration ISRCTN, ISRCTN78973763. Registered 14 August 2018- Retrospectively registered, http://www.isrctn.com/ISRCTN78973763.
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Affiliation(s)
- Jian Chen
- Department of Radiation Oncology, Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai Proton and Heavy Ion Center, Shanghai, China
| | - Jiade J Lu
- Department of Radiation Oncology, Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai Proton and Heavy Ion Center, Shanghai, China
| | - Ningyi Ma
- Department of Radiation Oncology, Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai Proton and Heavy Ion Center, Shanghai, China
| | - Jingfang Zhao
- Department of Medical Physics, Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Fudan University, Shanghai, China
| | - Chang Chen
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Min Fan
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, China
| | - Guoliang Jiang
- Department of Radiation Oncology, Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Fudan University, Shanghai, China
| | - Jingfang Mao
- Department of Radiation Oncology, Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Fudan University, Shanghai, China.
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16
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Abstract
Proton therapy is a promising but challenging treatment modality for the management of lung cancer. The technical challenges are due to respiratory motion, low dose tolerance of adjacent normal tissue and tissue density heterogeneity. Different imaging modalities are applied at various steps of lung proton therapy to provide information on target definition, target motion, proton range, patient setup and treatment outcome assessment. Imaging data is used to guide treatment design, treatment delivery, and treatment adaptation to ensure the treatment goal is achieved. This review article will summarize and compare various imaging techniques that can be used in every step of lung proton therapy to address these challenges.
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Affiliation(s)
- Miao Zhang
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Wei Zou
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Boon-Keng Kevin Teo
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
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17
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Nantavithya C, Gomez DR, Wei X, Komaki R, Liao Z, Lin SH, Jeter M, Nguyen QN, Li H, Zhang X, Poenisch F, Zhu XR, Balter PA, Feng L, Choi NC, Mohan R, Chang JY. Phase 2 Study of Stereotactic Body Radiation Therapy and Stereotactic Body Proton Therapy for High-Risk, Medically Inoperable, Early-Stage Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2018; 101:558-563. [PMID: 29680255 DOI: 10.1016/j.ijrobp.2018.02.022] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 01/29/2018] [Accepted: 02/08/2018] [Indexed: 12/12/2022]
Abstract
PURPOSE To report the feasibility of conducting a randomized study to compare the toxicity and efficacy of stereotactic body radiation therapy (SBRT) versus stereotactic body proton therapy (SBPT) for high-risk, medically inoperable, early-stage non-small cell lung cancer (NSCLC). PATIENTS AND METHODS Patients with medically inoperable NSCLC with high-risk features (centrally located or <5 cm T3 tumor or isolated lung parenchymal recurrences) were randomly assigned to SBRT or SBPT. Radiation dose was 50 Gy(relative biological effectiveness [RBE]) in 4 12.5-Gy(RBE) fractions prescribed to the planning target volume. Stereotactic body radiation therapy was given using 3-dimensional conformal radiation therapy or intensity modulated radiation therapy, and SBPT was given using passive scattering. Consistency in patient setup was ensured with on-board cone beam computed tomography for the SBRT group and with orthogonal X rays for the SBPT group. RESULTS The study closed early owing to poor accrual, largely because of insurance coverage and lack of volumetric imaging in the SBPT group. Ultimately, 21 patients were enrolled, and 19 patients who received 50 Gy in 4 fractions were included for analysis (9 SBRT, 10 SBPT). At a median follow-up time of 32 months, median overall survival time was 28 months in the SBRT group and not reached in the SBPT group. Three-year overall survival was 27.8% and 90%, 3-year local control was 87.5% (8 of 9) and 90.0% (9 of 10), and 3-year regional control was 47.6% (5 of 9) and 90% (9 of 10) in the SBRT and SBPT groups, respectively. One patient in the SBPT group developed grade 3 skin fibrosis. No patients experienced grade 4/5 toxicity. CONCLUSION Poor accrual, due to lack of volumetric imaging and insurance coverage for proton therapy, led to early closure of the trial and precluded accurate assessment of efficacy and toxicity. Comparable maturity of 2 radiation therapy modalities, particularly on-board imaging, and better insurance coverage for SBPT should be considered for future studies.
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Affiliation(s)
- Chonnipa Nantavithya
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas; Division of Therapeutic Radiation and Oncology, Department of Radiology, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Daniel R Gomez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Xiong Wei
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ritsuko Komaki
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Melenda Jeter
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Heng Li
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Xiaodong Zhang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Falk Poenisch
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - X Ronald Zhu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Peter A Balter
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lei Feng
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Noah C Choi
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Radhe Mohan
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joe Y Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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18
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Verma V, Simone CB. Approaches to stereotactic body radiation therapy for large (≥5 centimeter) non-small cell lung cancer. Transl Lung Cancer Res 2018; 8:70-77. [PMID: 30788236 DOI: 10.21037/tlcr.2018.06.10] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Although larger (≥5 cm) node-negative non-small cell lung cancer (NSCLC) lesions are altogether uncommon, their incidence may increase following the implementation of lung cancer screening. A rigorous assessment of stereotactic body radiation therapy (SBRT) for these challenging cases is imperative not only owing to concerns of increased risks when delivering ablative doses to large volumes, but also due to lack of prospective data, as these patients were excluded from seminal phase II SBRT trials. In addition to appraising the available institutional or multi-institutional experiences, multiple strategies to reduce toxicities are discussed. These include exploration of several different dose/fractionation schemes and regimens, as well as specialized techniques for SBRT treatment planning and delivery. Because these lesions have a higher rate of occult lymphatic or distant spread, the role of systemic therapies (including chemotherapy and immunotherapy) are also discussed. Altogether, the publication of several key reports, entirely over the last few years, has created a more solid foundation with which to utilize evidence-based management for this unique patient population.
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Affiliation(s)
- Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Charles B Simone
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
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Vyfhuis MA, Onyeuku N, Diwanji T, Mossahebi S, Amin NP, Badiyan SN, Mohindra P, Simone CB. Advances in proton therapy in lung cancer. Ther Adv Respir Dis 2018; 12:1753466618783878. [PMID: 30014783 PMCID: PMC6050808 DOI: 10.1177/1753466618783878] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 05/29/2018] [Indexed: 12/18/2022] Open
Abstract
Lung cancer remains the leading cause of cancer deaths in the United States (US) and worldwide. Radiation therapy is a mainstay in the treatment of locally advanced non-small cell lung cancer (NSCLC) and serves as an excellent alternative for early stage patients who are medically inoperable or who decline surgery. Proton therapy has been shown to offer a significant dosimetric advantage in NSCLC patients over photon therapy, with a decrease in dose to vital organs at risk (OARs) including the heart, lungs and esophagus. This in turn, can lead to a decrease in acute and late toxicities in a population already predisposed to lung and cardiac injury. Here, we present a review on proton treatment techniques, studies, clinical outcomes and toxicities associated with treating both early stage and locally advanced NSCLC.
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Affiliation(s)
- Melissa A.L. Vyfhuis
- Maryland Proton Treatment Center, University of
Maryland School of Medicine, Baltimore, MD, USA
| | - Nasarachi Onyeuku
- Maryland Proton Treatment Center, University of
Maryland School of Medicine, Baltimore, MD, USA
| | - Tejan Diwanji
- Maryland Proton Treatment Center, University of
Maryland School of Medicine, Baltimore, MD, USA
| | - Sina Mossahebi
- Maryland Proton Treatment Center, University of
Maryland School of Medicine, Baltimore, MD, USA
| | - Neha P. Amin
- Maryland Proton Treatment Center, University of
Maryland School of Medicine, Baltimore, MD, USA
| | - Shahed N. Badiyan
- Maryland Proton Treatment Center, University of
Maryland School of Medicine, Baltimore, MD, USA
| | - Pranshu Mohindra
- Maryland Proton Treatment Center, University of
Maryland School of Medicine, Baltimore, MD, USA
| | - Charles B. Simone
- Maryland Proton Treatment Center, University of
Maryland School of Medicine, 850 West Baltimore Street, Baltimore, MD 21201,
USA
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20
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Moriya S, Tachibana H, Hotta K, Nakamura N, Sakae T, Akimoto T. Feasibility of dynamic adaptive passive scattering proton therapy with computed tomography image guidance in the lung. Med Phys 2017; 44:4474-4481. [PMID: 28665491 DOI: 10.1002/mp.12444] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 06/11/2017] [Accepted: 06/23/2017] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Hypo-fractionated proton beam therapy (PBT) is an approach that has been increasingly explored over the past decade. It requires high geometric accuracy for targeting of the PBT beams. However, image-guided PBT is currently commonly performed with kV X-ray images of bony anatomy. A dynamic adaptive passive scattering PBT system using computed tomography-based three-dimensional image guidance was developed, and its effectiveness was then evaluated retrospectively in patients with nonsmall cell lung cancer (NSCLC). METHODS The dynamic adaptive PBT system consisted of computed tomography-based image registration and proton dose calculation using a simplified Monte Carlo algorithm, with a range adaptation system that could adjust the range shifter thickness to alter the dose distribution. Three patients were retrospectively analyzed. All plans, which each had a total dose of 60 Gy (relative biological effectiveness; RBE), were generated using two fields (Gantry angles: 270 degree and 180 degree) in a passive scattering method. Three dose distributions were generated for each patient according to the following different registrations: bone registration, tumor registration, and tumor registration with range adaptation. The following dosimetric parameters were compared with the original plan: target dose coverage at D95% for the clinical target volume (CTV), homogeneity of D5% to D95% for the CTV, and dose distributions in normal tissue (Dmax of Spinal cord and V20 Gy of lung). RESULTS For the bone registration method, the average D95% and D5% to D95% for the CTV showed average differences from the original plan of -3.7 ± 4.1 Gy (mean ± 1SD; RBE) and 3.6 ± 3.9 Gy (RBE) respectively. The tumor registration method achieved better coverage than the bone registration method, although the dosimetric parameters for coverage and homogeneity still showed average differences in -2.0 ± 2.3 Gy (RBE) and 1.9 ± 2.2 Gy (RBE) respectively. The range adaptive plan showed comparable coverage and homogeneity [D95%: -1.0 ± 1.3 Gy (RBE) and D5% to D95%: 0.9 ± 1.0 Gy (RBE) on average] to the original plan, as well as demonstrating similar normal tissue sparing. The approach could be completed in less than 10 min, including CT acquisition, image registration, dose recalculation with range optimization, and the operator's visual verification. CONCLUSIONS The tumor dose coverage in patients with NSCLC may deteriorate as a result of respiratory or body movement if daily proton range adaptation is not performed. Our approach may provide higher geometric accuracy for localization of the tumor, and the dynamic range adaptation enables us to achieve the planned dose distribution for hypo-fractionated PBT in the lung.
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Affiliation(s)
- Shunsuke Moriya
- Doctoral Program in Biomedical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Ibaraki, 305-8577, Japan
| | - Hidenobu Tachibana
- Division of Radiation Oncology and Particle Therapy, Exploratory Oncology Research & Clinical Trial Center, National Cancer Center, Chiba, 277-8577, Japan
| | - Kenji Hotta
- Division of Radiation Oncology and Particle Therapy, Exploratory Oncology Research & Clinical Trial Center, National Cancer Center, Chiba, 277-8577, Japan
| | - Naoki Nakamura
- Division of Radiation Oncology and Particle Therapy, Exploratory Oncology Research & Clinical Trial Center, National Cancer Center, Chiba, 277-8577, Japan
| | - Takeji Sakae
- Doctoral Program in Biomedical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Ibaraki, 305-8577, Japan
| | - Tetsuo Akimoto
- Division of Radiation Oncology and Particle Therapy, Exploratory Oncology Research & Clinical Trial Center, National Cancer Center, Chiba, 277-8577, Japan
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Diwanji TP, Mohindra P, Vyfhuis M, Snider JW, Kalavagunta C, Mossahebi S, Yu J, Feigenberg S, Badiyan SN. Advances in radiotherapy techniques and delivery for non-small cell lung cancer: benefits of intensity-modulated radiation therapy, proton therapy, and stereotactic body radiation therapy. Transl Lung Cancer Res 2017; 6:131-147. [PMID: 28529896 DOI: 10.21037/tlcr.2017.04.04] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The 21st century has seen several paradigm shifts in the treatment of non-small cell lung cancer (NSCLC) in early-stage inoperable disease, definitive locally advanced disease, and the postoperative setting. A key driver in improvement of local disease control has been the significant evolution of radiation therapy techniques in the last three decades, allowing for delivery of definitive radiation doses while limiting exposure of normal tissues. For patients with locally-advanced NSCLC, the advent of volumetric imaging techniques has allowed a shift from 2-dimensional approaches to 3-dimensional conformal radiation therapy (3DCRT). The next generation of 3DCRT, intensity-modulated radiation therapy and volumetric-modulated arc therapy (VMAT), have enabled even more conformal radiation delivery. Clinical evidence has shown that this can improve the quality of life for patients undergoing definitive management of lung cancer. In the early-stage setting, conventional fractionation led to poor outcomes. Evaluation of altered dose fractionation with the previously noted technology advances led to advent of stereotactic body radiation therapy (SBRT). This technique has dramatically improved local control and expanded treatment options for inoperable, early-stage patients. The recent development of proton therapy has opened new avenues for improving conformity and the therapeutic ratio. Evolution of newer proton therapy techniques, such as pencil-beam scanning (PBS), could improve tolerability and possibly allow reexamination of dose escalation. These new progresses, along with significant advances in systemic therapies, have improved survival for lung cancer patients across the spectrum of non-metastatic disease. They have also brought to light new challenges and avenues for further research and improvement.
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Affiliation(s)
- Tejan P Diwanji
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland 21201, USA
| | - Pranshu Mohindra
- University of Maryland School of Medicine, Baltimore, Maryland, 21201, USA
| | - Melissa Vyfhuis
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland 21201, USA
| | - James W Snider
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland 21201, USA
| | - Chaitanya Kalavagunta
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland 21201, USA
| | - Sina Mossahebi
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland 21201, USA
| | - Jen Yu
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland 21201, USA
| | - Steven Feigenberg
- University of Maryland School of Medicine, Baltimore, Maryland, 21201, USA
| | - Shahed N Badiyan
- University of Maryland School of Medicine, Baltimore, Maryland, 21201, USA
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22
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Klapper JA, Hittinger SA, Denlinger CE. Alternatives to Lobectomy for High-Risk Patients With Early-Stage Non-Small Cell Lung Cancer. Ann Thorac Surg 2017; 103:1330-1339. [DOI: 10.1016/j.athoracsur.2016.11.045] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 11/14/2016] [Accepted: 11/16/2016] [Indexed: 12/25/2022]
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23
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Chang JY, Zhang W, Komaki R, Choi NC, Chan S, Gomez D, O'Reilly M, Jeter M, Gillin M, Zhu X, Zhang X, Mohan R, Swisher S, Hahn S, Cox JD. Long-term outcome of phase I/II prospective study of dose-escalated proton therapy for early-stage non-small cell lung cancer. Radiother Oncol 2017; 122:274-280. [PMID: 28139305 PMCID: PMC5319887 DOI: 10.1016/j.radonc.2016.10.022] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 10/12/2016] [Accepted: 10/24/2016] [Indexed: 12/25/2022]
Abstract
PURPOSE The aim of this phase I/II study was to assess the long-term clinical benefits and toxicities of proton beam therapy for medically inoperable early-stage non-small cell lung cancer (NSCLC). PATIENTS AND METHODS From June 2006 to September 2011, 35 patients with medically inoperable T1N0M0 (central or superior location, 12 patients) or T2-3N0M0 (any location, 23 patients) NSCLC were treated with 87.5Gy at 2.5Gy/fraction of proton therapy. Toxicities were scored according to the Common Terminology Criteria for Adverse Events, version 4.0. RESULTS The median follow-up time was 83.1months (95% CI: 69.2-97.1months). For all 35 patients, the 1, 3, and 5-year overall survival rates were 85.7%, 42.9%, and 28.1%, respectively. The 5-year local recurrence-free, regional recurrence-free, and distant metastasis-free survival rates were 85.0%, 89.2%, and 54.4%, respectively. Different T stages had no effect on local and regional recurrence (p=0.499, p=1.00). However, with the increase in T stages, the distant metastasis rate increased significantly (p=0.006). The most common adverse effects were dermatitis (grade 2, 51.4%; grade 3, 2.9%) and radiation pneumonitis (grade 2, 11.4%; grade 3, 2.9%). Other grade 2 toxicities included esophagitis (2.9%), rib fracture (2.9%), heart toxicities (5.7%), and chest wall pain (2.9%). CONCLUSIONS According to our long-term follow-up data, proton therapy with ablative doses is well tolerated and effective in medically inoperable early-stage NSCLC. Systemic therapy should be considered to reduce the rate of distant metastasis in cases of T2 and T3 lesions.
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Affiliation(s)
- Joe Y Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States.
| | - Wencheng Zhang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Ritsuko Komaki
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Noah C Choi
- Department of Radiation Oncology, MGH, Harvard Medical School, United States
| | - Shen Chan
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Daniel Gomez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Michael O'Reilly
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Melenda Jeter
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Michael Gillin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Xiaorong Zhu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Xiaodong Zhang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Radhe Mohan
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Stephen Swisher
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Stephen Hahn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - James D Cox
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
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Hatayama Y, Nakamura T, Suzuki M, Azami Y, Ono T, Yabuuchi T, Hayashi Y, Kimura K, Hirose K, Wada H, Hareyama M, Kikuchi Y, Takai Y. Clinical Outcomes and Prognostic Factors of High-Dose Proton Beam Therapy for Peripheral Stage I Non-Small-Cell Lung Cancer. Clin Lung Cancer 2016; 17:427-432. [DOI: 10.1016/j.cllc.2015.11.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 11/24/2015] [Accepted: 11/24/2015] [Indexed: 12/25/2022]
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Ablative dose proton beam therapy for stage I and recurrent non-small cell lung carcinomas : Ablative dose PBT for NSCLC. Strahlenther Onkol 2016; 192:649-57. [PMID: 27282279 DOI: 10.1007/s00066-016-0985-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 04/21/2016] [Indexed: 12/25/2022]
Abstract
PURPOSE To evaluate the efficacy and safety of ablative dose hypofractionated proton beam therapy (PBT) for patients with stage I and recurrent non-small cell lung carcinoma (NSCLC). PATIENTS AND METHODS A total of 55 patients with stage I (n = 42) and recurrent (n = 13) NSCLC underwent hypofractionated PBT and were retrospectively reviewed. A total dose of 50-72 CGE (cobalt gray equivalent) in 5-12 fractions was delivered. RESULTS The median follow-up duration was 29 months (range 4-95 months). There were 24 deaths (43.6%) during the follow-up period: 11 died of disease progression and 13 from other causes. Kaplan-Meier overall survival rate (OS) at 3 years was 54.9% and the median OS was 48.6 months (range 4-95 months). Local progression was observed in 7 patients and the median time to local progression was 9.3 months (range 5-14 months). Cumulative actuarial local control rate (LCR), lymph node metastasis-free survival, and distant metastasis-free survival rates at 3 years were 85.4, 78.4, and 76.5%, respectively. Larger tumor diameter was significantly associated with poorer LCR (3-year: 94% for ≤3 cm vs. 65% for >3 cm, p = 0.006) on univariate analysis and also an independent prognostic factor for LCR (HR 6.9, 95% CI = 1.3-37.8, p = 0.026) on multivariate analysis. No grade 3 or 4 treatment-related toxicities developed. One grade 5 treatment-related adverse event occurred in a patient with symptomatic idiopathic pulmonary fibrosis. CONCLUSIONS Ablative dose hypofractionated PBT was safe and promising for stage I and recurrent NSCLC.
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Santiago A, Barczyk S, Jelen U, Engenhart-Cabillic R, Wittig A. Challenges in radiobiological modeling: can we decide between LQ and LQ-L models based on reviewed clinical NSCLC treatment outcome data? Radiat Oncol 2016; 11:67. [PMID: 27154064 PMCID: PMC4859978 DOI: 10.1186/s13014-016-0643-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 04/27/2016] [Indexed: 01/31/2023] Open
Abstract
Aim To study the dose-response of stage I non-small-cell lung cancer (NSCLC) in terms of long-term local tumor control (LC) after conventional and hypofractionated photon radiotherapy, modeled with the linear-quadratic (LQ) and linear-quadratic-linear (LQ-L) approaches and to estimate the clinical α/β ratio within the LQ frame. Material and methods We identified studies of curative radiotherapy as single treatment through MedLine search reporting 3-year LC as primary outcome of interest. Logistic models coupled with the biologically effective dose (BED) at isocenter and PTV edge according to both the LQ and LQ-L models with α/β = 10 Gy were fitted. Additionally, α/β was estimated from direct LQ fits. Results Thirty one studies were included reporting outcome of 2319 patients. The LQ-L fit yielded a significant value of 11.0 ± 5.2 Gy for the dose threshold (Dt) for BED10 at the isocenter. The LQ and LQ-L fits did not differ substantially. Concerning the estimation of α/β, the value obtained from the direct LQ fit for the complete fractionation range was 3.9 [68 % CI: 2.2–9.0] Gy (p > 0.05). Conclusion Both LQ and LQ-L fits can model local tumor control after conventionally and hypofractionated irradiation and are robust methods for predicting clinical effects. The observed dose-effect for local control in NSCLC is weaker at high doses due to data dispersion. For BED10 values of 100–150 Gy in ≥3 fractions, the differences in isoeffects predicted by both models can be neglected. Electronic supplementary material The online version of this article (doi:10.1186/s13014-016-0643-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alina Santiago
- Department of Radiotherapy and Radiation Oncology, University Hospital Giessen and Marburg, Philipps-University Marburg, Baldingerstrasse, Marburg, 35043, Germany.
| | - Steffen Barczyk
- Department of Radiotherapy and Radiation Oncology, University Hospital Giessen and Marburg, Philipps-University Marburg, Baldingerstrasse, Marburg, 35043, Germany.,Present address: Gemeinschaftspraxis Strahlentherapie am St. Agnes Hospital, Bocholt, Germany
| | - Urszula Jelen
- Department of Radiotherapy and Radiation Oncology, University Hospital Giessen and Marburg, Philipps-University Marburg, Baldingerstrasse, Marburg, 35043, Germany.,Present address: Marburger Ionenstrahl-Therapiezentrum MIT, Marburg, Germany
| | - Rita Engenhart-Cabillic
- Department of Radiotherapy and Radiation Oncology, University Hospital Giessen and Marburg, Philipps-University Marburg, Baldingerstrasse, Marburg, 35043, Germany
| | - Andrea Wittig
- Department of Radiotherapy and Radiation Oncology, University Hospital Giessen and Marburg, Philipps-University Marburg, Baldingerstrasse, Marburg, 35043, Germany
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Chang JY, Jabbour SK, De Ruysscher D, Schild SE, Simone CB, Rengan R, Feigenberg S, Khan AJ, Choi NC, Bradley JD, Zhu XR, Lomax AJ, Hoppe BS. Consensus Statement on Proton Therapy in Early-Stage and Locally Advanced Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2016; 95:505-516. [PMID: 27084663 PMCID: PMC10868643 DOI: 10.1016/j.ijrobp.2016.01.036] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 12/08/2015] [Accepted: 01/19/2016] [Indexed: 12/25/2022]
Abstract
Radiation dose escalation has been shown to improve local control and survival in patients with non-small cell lung cancer in some studies, but randomized data have not supported this premise, possibly owing to adverse effects. Because of the physical characteristics of the Bragg peak, proton therapy (PT) delivers minimal exit dose distal to the target volume, resulting in better sparing of normal tissues in comparison to photon-based radiation therapy. This is particularly important for lung cancer given the proximity of the lung, heart, esophagus, major airways, large blood vessels, and spinal cord. However, PT is associated with more uncertainty because of the finite range of the proton beam and motion for thoracic cancers. PT is more costly than traditional photon therapy but may reduce side effects and toxicity-related hospitalization, which has its own associated cost. The cost of PT is decreasing over time because of reduced prices for the building, machine, maintenance, and overhead, as well as newer, shorter treatment programs. PT is improving rapidly as more research is performed particularly with the implementation of 4-dimensional computed tomography-based motion management and intensity modulated PT. Given these controversies, there is much debate in the oncology community about which patients with lung cancer benefit significantly from PT. The Particle Therapy Co-operative Group (PTCOG) Thoracic Subcommittee task group intends to address the issues of PT indications, advantages and limitations, cost-effectiveness, technology improvement, clinical trials, and future research directions. This consensus report can be used to guide clinical practice and indications for PT, insurance approval, and clinical or translational research directions.
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Affiliation(s)
- Joe Y Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Salma K Jabbour
- Rutgers Cancer Institute of New Jersey Rutgers, Robert Wood Johnson Medical School, The State University of New Jersey, New Brunswick, New Jersey
| | | | | | - Charles B Simone
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ramesh Rengan
- University of Washington Medical Center, Seattle, Washington
| | | | - Atif J Khan
- Rutgers Cancer Institute of New Jersey Rutgers, Robert Wood Johnson Medical School, The State University of New Jersey, New Brunswick, New Jersey
| | - Noah C Choi
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Xiaorong R Zhu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Bradford S Hoppe
- University of Florida Proton Therapy Institute, Jacksonville, Florida
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Laine AM, Pompos A, Timmerman R, Jiang S, Story MD, Pistenmaa D, Choy H. The Role of Hypofractionated Radiation Therapy with Photons, Protons, and Heavy Ions for Treating Extracranial Lesions. Front Oncol 2016; 5:302. [PMID: 26793619 PMCID: PMC4707221 DOI: 10.3389/fonc.2015.00302] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 12/14/2015] [Indexed: 12/14/2022] Open
Abstract
Traditionally, the ability to deliver large doses of ionizing radiation to a tumor has been limited by radiation-induced toxicity to normal surrounding tissues. This was the initial impetus for the development of conventionally fractionated radiation therapy, where large volumes of healthy tissue received radiation and were allowed the time to repair the radiation damage. However, advances in radiation delivery techniques and image guidance have allowed for more ablative doses of radiation to be delivered in a very accurate, conformal, and safe manner with shortened fractionation schemes. Hypofractionated regimens with photons have already transformed how certain tumor types are treated with radiation therapy. Additionally, hypofractionation is able to deliver a complete course of ablative radiation therapy over a shorter period of time compared to conventional fractionation regimens making treatment more convenient to the patient and potentially more cost-effective. Recently, there has been an increased interest in proton therapy because of the potential further improvement in dose distributions achievable due to their unique physical characteristics. Furthermore, with heavier ions the dose conformality is increased and, in addition, there is potentially a higher biological effectiveness compared to protons and photons. Due to the properties mentioned above, charged particle therapy has already become an attractive modality to further investigate the role of hypofractionation in the treatment of various tumors. This review will discuss the rationale and evolution of hypofractionated radiation therapy, the reported clinical success with initially photon and then charged particle modalities, and further potential implementation into treatment regimens going forward.
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Affiliation(s)
- Aaron Michael Laine
- Department of Radiation Oncology, University of Texas Southwestern Medical Center , Dallas, TX , USA
| | - Arnold Pompos
- Department of Radiation Oncology, University of Texas Southwestern Medical Center , Dallas, TX , USA
| | - Robert Timmerman
- Department of Radiation Oncology, University of Texas Southwestern Medical Center , Dallas, TX , USA
| | - Steve Jiang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center , Dallas, TX , USA
| | - Michael D Story
- Department of Radiation Oncology, University of Texas Southwestern Medical Center , Dallas, TX , USA
| | - David Pistenmaa
- Department of Radiation Oncology, University of Texas Southwestern Medical Center , Dallas, TX , USA
| | - Hak Choy
- Department of Radiation Oncology, University of Texas Southwestern Medical Center , Dallas, TX , USA
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Proton Beam Therapy for Non-Small Cell Lung Cancer: Current Clinical Evidence and Future Directions. Cancers (Basel) 2015; 7:1178-90. [PMID: 26147335 PMCID: PMC4586764 DOI: 10.3390/cancers7030831] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 06/15/2015] [Accepted: 06/15/2015] [Indexed: 11/25/2022] Open
Abstract
Lung cancer is the leading cancer cause of death in the United States. Radiotherapy is an essential component of the definitive treatment of early-stage and locally-advanced lung cancer, and the palliative treatment of metastatic lung cancer. Proton beam therapy (PBT), through its characteristic Bragg peak, has the potential to decrease the toxicity of radiotherapy, and, subsequently improve the therapeutic ratio. Herein, we provide a primer on the physics of proton beam therapy for lung cancer, present the existing data in early-stage and locally-advanced non-small cell lung cancer (NSCLC), as well as in special situations such as re-irradiation and post-operative radiation therapy. We then present the technical challenges, such as anatomic changes and motion management, and future directions for PBT in lung cancer, including pencil beam scanning.
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Ohkawa A, Mizumoto M, Ishikawa H, Abei M, Fukuda K, Hashimoto T, Sakae T, Tsuboi K, Okumura T, Sakurai H. Proton beam therapy for unresectable intrahepatic cholangiocarcinoma. J Gastroenterol Hepatol 2015; 30:957-63. [PMID: 25376272 DOI: 10.1111/jgh.12843] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM Treatment for unresectable intrahepatic cholangiocarcinoma (ICC) has not been established. The aim of the study was to evaluate the outcome of proton beam therapy (PBT) for patients with unresectable ICC. METHODS Up to 2010, 20 patients (11 males, 9 females, median age 63 years old) with unresectable ICC (two, seven, seven, and four in stages II, IIIA, IIIC, and IV, respectively) were treated with PBT. The largest dimensions of the tumors ranged from 15 to 140 mm (median: 50 mm). The intrahepatic region and lymph nodes received median total proton doses of 72.6 GyE in 22 fractions and 56.1 GyE in 17 fractions, respectively. Four patients received concurrent chemotherapy (tegafur, gimeracil, and oteracil; TS-1) during PBT. Twelve patients were treated curatively, and eight were treated palliatively because tumors were present outside the irradiation field. RESULTS In the curative group, nine tumors within the irradiated field were controlled in follow-up of 8.6-62.6 months (median: 20.8 months). Median survival rates in the curative and palliative groups were 27.5 and 9.6 months, respectively, and overall 1- and 3-year survival rates were 82% and 38%, and 50% and 0%, respectively. Eight patients survived for > 2 years, and there was no distant metastasis in five of these patients after 2 years. No severe side-effects occurred. CONCLUSIONS The results suggest that long-term survival can be achieved using PBT for patients with unresectable ICC without distant metastasis. Further studies are required to determine the optimal treatment schedule and best combination of PBT and chemotherapy.
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Affiliation(s)
- Ayako Ohkawa
- Department of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
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GUIDI G, MAFFEI N, CIARMATORI A, MISTRETTA MG, GOTTARDI G, COSTI T, GUIDI G, MAFFEI N, VECCHI C, BALDAZZI G, BERTONI F. REAL-TIME LUNG TUMOUR MOTION MODELING FOR ADAPTIVE RADIATION THERAPY USING LEGO MINDSTORMS. J MECH MED BIOL 2015. [DOI: 10.1142/s0219519415400199] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
An anthropomorphic phantom was built using LEGO Mindstorms® and programmed in LabVIEW® for Adaptive Radiation Therapy (ART) purpose, to simulate the processes of breathing in the lung district during treatments. A thoracic cavity is prototyped by means of an 8 ribs apparatus and 2 artificial tumor masses, driven by intelligent brick LINUX® OS CPU. An optical surface tracking system (VisionRT®) and a QUASAR™ phantom allow correlation between physiological, robotic motion and surrogated signal. Patient's breathing phases are acquired instantaneously by InfraRed/UltraSound sensors. Through 4DCT images, tumor center of mass are individuated and tracked during respiration, to link internal–external organs motion. To quantify the degree of divergences due to dynamics organs deformation, a 4D function was obtained and simulated by our phantom. Sinusoidal signals (6, 10, 12, 15 and 17 Breaths per Minute-BPM) were used for evaluating and commissioning, thereby obtained a correlation coefficient (0.90–0.94) between QUASAR and LEGO. Validated on ideal conditions, phantom was tested in clinical practice. Breaths and CT study of 12 patients were analyzed. Fitting of real breath sinograms returned a mean R value of 0.94 (0.83–0.98) with best model performance achieved in signals with respiratory frequency less than 20 BPM. By using LEGO it is possible to reproduce real patients conditions and simulate normal and even abnormal behavior during the course of therapy, allowing spatial motion estimation.
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Affiliation(s)
- G. GUIDI
- Medical Physics Department, Az.Ospedaliero-Universitaria di Modena, Modena Italy, via del Pozzo 71, 40121 Modena, Italy
| | - N. MAFFEI
- Medical Physics Department, Az.Ospedaliero-Universitaria di Modena, Modena Italy, via del Pozzo 71, 40121 Modena, Italy
| | - A. CIARMATORI
- Medical Physics Department, Az.Ospedaliero-Universitaria di Modena, Modena Italy, via del Pozzo 71, 40121 Modena, Italy
| | - M. G. MISTRETTA
- Medical Physics Department, Az.Ospedaliero-Universitaria di Modena, Modena Italy, via del Pozzo 71, 40121 Modena, Italy
| | - G. GOTTARDI
- Medical Physics Department, Az.Ospedaliero-Universitaria di Modena, Modena Italy, via del Pozzo 71, 40121 Modena, Italy
| | - T. COSTI
- Medical Physics Department, Az.Ospedaliero-Universitaria di Modena, Modena Italy, via del Pozzo 71, 40121 Modena, Italy
| | - G. GUIDI
- Physics Department, University of Bologna, via Berti Pichat 6/2, 40127 Bologna, Italy
| | - N. MAFFEI
- Physics Department, University of Bologna, via Berti Pichat 6/2, 40127 Bologna, Italy
| | - C. VECCHI
- Physics Department, University of Bologna, via Berti Pichat 6/2, 40127 Bologna, Italy
| | - G. BALDAZZI
- Physics Department, University of Bologna, via Berti Pichat 6/2, 40127 Bologna, Italy
| | - F. BERTONI
- Radiation Oncology Department, Az.Ospedaliero-Universitaria di Modena, Modena Italy, via del Pozzo 71, 40121 Modena, Italy
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Makita C, Nakamura T, Takada A, Takayama K, Suzuki M, Azami Y, Kato T, Tsukiyama I, Hareyama M, Kikuchi Y, Daimon T, Hata M, Inoue T, Fuwa N. High-dose proton beam therapy for stage I non-small cell lung cancer: Clinical outcomes and prognostic factors. Acta Oncol 2015; 54:307-14. [PMID: 25291076 DOI: 10.3109/0284186x.2014.948060] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Evidence has suggested that radiation therapy with a lower dose per fraction may be a reasonable option for the treatment of centrally located non-small cell lung cancer (NSCLC). The aim of this study was to evaluate the safety and efficacy of two proton beam therapy (PBT) protocols for stage I NSCLC and to determine prognostic factors. MATERIAL AND METHODS This study included patients clinically diagnosed with stage I NSCLC. Based on the location of the tumor, one of the two PBT protocols was administered. Patients with peripherally located tumors were given 66 Gy relative biological dose effectiveness (RBE) over 10 fractions (Protocol A) while patients with centrally located tumors were given 80 Gy (RBE) over 25 fractions (Protocol B). RESULTS Between January 2009 and May 2012, 56 eligible patients were enrolled (protocol A: 32 patients; protocol B: 24 patients). The three-year overall survival (OS), progression-free survival (PFS), and local control (LC) rates were 81.3% [95% confidence interval (CI) 75.9-86.7%], 73.4% (95% CI 67.2-79.6%), and 96.0% (95% CI 93.2-98.8%), respectively. There were no significant differences in outcomes between the two protocols. Late grade 2 and 3 pulmonary toxicities were observed in nine patients (13.4%) and one patient (1.5%), respectively; no grade 4 or 5 toxicities were observed. Sex, age, performance status, T-stage, operability, and tumor pathology were not associated with OS and PFS. Only maximum standardized uptake value (SUVmax; <5 vs. ≥5) was identified as a significant prognostic factor for OS and PFS. CONCLUSION Both high-dose PBT protocols achieved high LC rates with tolerable toxicities in stage I NSCLC patients, and SUVmax was a significant prognostic factor.
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Affiliation(s)
- Chiyoko Makita
- Department of Radiation Oncology, Aichi Cancer Center Hospital , Chikusaku, Nagoya , Japan
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Wink KCJ, Roelofs E, Solberg T, Lin L, Simone CB, Jakobi A, Richter C, Lambin P, Troost EGC. Particle therapy for non-small cell lung tumors: where do we stand? A systematic review of the literature. Front Oncol 2014; 4:292. [PMID: 25401087 PMCID: PMC4212620 DOI: 10.3389/fonc.2014.00292] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 10/07/2014] [Indexed: 12/25/2022] Open
Abstract
This review article provides a systematic overview of the currently available evidence on the clinical effectiveness of particle therapy for the treatment of non-small cell lung cancer and summarizes findings of in silico comparative planning studies. Furthermore, technical issues and dosimetric uncertainties with respect to thoracic particle therapy are discussed.
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Affiliation(s)
- Krista C J Wink
- Department of Radiation Oncology (MAASTRO Clinic), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre , Maastricht , Netherlands
| | - Erik Roelofs
- Department of Radiation Oncology (MAASTRO Clinic), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre , Maastricht , Netherlands
| | - Timothy Solberg
- Department of Radiation Oncology, Hospital of the University of Pennsylvania , Philadelphia, PA , USA
| | - Liyong Lin
- Department of Radiation Oncology, Hospital of the University of Pennsylvania , Philadelphia, PA , USA
| | - Charles B Simone
- Department of Radiation Oncology, Hospital of the University of Pennsylvania , Philadelphia, PA , USA
| | - Annika Jakobi
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden and Helmholtz-Zentrum Dresden-Rossendorf , Dresden , Germany
| | - Christian Richter
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden and Helmholtz-Zentrum Dresden-Rossendorf , Dresden , Germany ; German Cancer Consortium (DKTK) Dresden and German Cancer Research Center (DKFZ) , Heidelberg , Germany
| | - Philippe Lambin
- Department of Radiation Oncology (MAASTRO Clinic), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre , Maastricht , Netherlands
| | - Esther G C Troost
- Department of Radiation Oncology (MAASTRO Clinic), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre , Maastricht , Netherlands
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Lefebvre L, Doré M, Giraud P. Nouvelles techniques et bénéfices attendus pour la radiothérapie du cancer du poumon. Cancer Radiother 2014; 18:473-9. [DOI: 10.1016/j.canrad.2014.06.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 06/23/2014] [Accepted: 06/27/2014] [Indexed: 12/25/2022]
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Carbon ion therapy for early-stage non-small-cell lung cancer. BIOMED RESEARCH INTERNATIONAL 2014; 2014:727962. [PMID: 25295269 PMCID: PMC4177095 DOI: 10.1155/2014/727962] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2014] [Revised: 08/10/2014] [Accepted: 08/27/2014] [Indexed: 12/25/2022]
Abstract
Carbon ion therapy is a type of radiotherapies that can deliver high-dose radiation to a tumor while minimizing the dose delivered to the organs at risk; this profile differs from that of photon radiotherapy. Moreover, carbon ions are classified as high-linear energy transfer radiation and are expected to be effective for even photon-resistant tumors. Recently, high-precision radiotherapy modalities such as stereotactic body radiotherapy (SBRT), proton therapy, and carbon ion therapy have been used for patients with early-stage non-small-cell lung cancer, and the results are promising, as, for carbon ion therapy, local control and overall survival rates at 5 years are 80-90% and 40-50%, respectively. Carbon ion therapy may be theoretically superior to SBRT and proton therapy, but the literature that is currently available does not show a statistically significant difference among these treatments. Carbon ion therapy demonstrates a better dose distribution than both SBRT and proton therapy in most cases of early-stage lung cancer. Therefore, carbon ion therapy may be safer for treating patients with adverse conditions such as large tumors, central tumors, and poor pulmonary function. Furthermore, carbon ion therapy may also be suitable for dose escalation and hypofractionation.
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Grant JD, Chang JY. Proton-based stereotactic ablative radiotherapy in early-stage non-small-cell lung cancer. BIOMED RESEARCH INTERNATIONAL 2014; 2014:389048. [PMID: 25136582 PMCID: PMC4124720 DOI: 10.1155/2014/389048] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 05/30/2014] [Accepted: 06/21/2014] [Indexed: 12/12/2022]
Abstract
Stereotactic ablative radiotherapy (SABR), a recent implementation in the practice of radiation oncology, has been shown to confer high rates of local control in the treatment of early stage non-small-cell lung cancer (NSCLC). This technique, which involves limited invasive procedures and reduced treatment intervals, offers definitive treatment for patients unable or unwilling to undergo an operation. The use of protons in SABR delivery confers the added physical advantage of normal tissue sparing due to the absence of collateral radiation dose delivered to regions distal to the target. This may translate into clinical benefit and a decreased risk of clinical toxicity in patients with nearby critical structures or limited pulmonary reserve. In this review, we present the rationale for proton-based SABR, principles relating to the delivery and planning of this modality, and a summary of published clinical studies.
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Affiliation(s)
- Jonathan D. Grant
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA
| | - Joe Y. Chang
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA
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Chi A, Nguyen NP, Komaki R. The potential role of respiratory motion management and image guidance in the reduction of severe toxicities following stereotactic ablative radiation therapy for patients with centrally located early stage non-small cell lung cancer or lung metastases. Front Oncol 2014; 4:151. [PMID: 25009800 PMCID: PMC4070060 DOI: 10.3389/fonc.2014.00151] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 05/30/2014] [Indexed: 12/25/2022] Open
Abstract
Image guidance allows delivery of very high doses of radiation over a few fractions, known as stereotactic ablative radiotherapy (SABR). This treatment is associated with excellent outcome for early stage non-small cell lung cancer and metastases to the lungs. In the delivery of SABR, central location constantly poses a challenge due to the difficulty of adequately sparing critical thoracic structures that are immediately adjacent to the tumor if an ablative dose of radiation is to be delivered to the tumor target. As of current, various respiratory motion management and image guidance strategies can be used to ensure accurate tumor target localization prior and/or during daily treatment, which allows for maximal and safe reduction of set up margins. The incorporation of both may lead to the most optimal normal tissue sparing and the most accurate SABR delivery. Here, the clinical outcome, treatment related toxicities, and the pertinent respiratory motion management/image guidance strategies reported in the current literature on SABR for central lung tumors are reviewed.
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Affiliation(s)
- Alexander Chi
- Department of Radiation Oncology, Mary Babb Randolph Cancer Center of West Virginia University , Morgantown, WV , USA
| | | | - Ritsuko Komaki
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center , Houston, TX , USA
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Gomez DR, Chang JY. Accelerated dose escalation with proton beam therapy for non-small cell lung cancer. J Thorac Dis 2014; 6:348-55. [PMID: 24688779 DOI: 10.3978/j.issn.2072-1439.2013.11.07] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 11/07/2013] [Indexed: 11/14/2022]
Abstract
Local tumor control remains challenging in many cases of non-small cell lung cancer (NSCLC), particularly those that involve large or centrally located tumors. Concurrent chemotherapy and radiation can maximize tumor control and survival for patients with locally advanced disease, but a substantial proportion of such patients cannot tolerate this therapy, and sequential chemoradiation regimens or radiation given alone at conventionally fractionated doses produces suboptimal results. An alternative approach is the use of hypofractionated proton beam therapy (PBT). The energy distribution of protons can be exploited to reduce involuntary irradiation of normal tissues, particularly the low-dose irradiation problematic in intensity-modulated (photon) radiation therapy (IMRT). Here we summarize current evidence on the use of hypofractionated PBT for both early-stage and locally advanced NSCLC, and the possibility of using hypofractionated regimens for patients who are not candidates for concurrent chemotherapy.
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Affiliation(s)
- Daniel R Gomez
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joe Y Chang
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Fay M, Poole CM, Pratt G. Recent advances in radiotherapy for thoracic tumours. J Thorac Dis 2014; 5 Suppl 5:S551-5. [PMID: 24163747 DOI: 10.3978/j.issn.2072-1439.2013.08.46] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 08/19/2013] [Indexed: 01/01/2023]
Abstract
Radiation Oncology technology has continued to advance at a rapid rate and is bringing significant benefits to patients. This review outlines some of the advances in technology and radiotherapy treatment of thoracic cancers including brachytherapy, stereotactic radiotherapy, tomotherapy and intensity modulated radiotherapy. The importance of functional imaging with PET and management of movement are highlighted. Most of the discussion relates to non-small cell lung cancer but management of mesothelioma and small cell lung cancer are also covered. This technology has substantial benefits to patients in terms of decreasing toxicity both in the short and longer term.
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Affiliation(s)
- Michael Fay
- Division of Oncology, Royal Brisbane and Women's Hospital, Queensland Health, Brisbane, Australia; ; School of Medicine, University of Queensland, Brisbane, Australia; ; Visiting Scientist, Preclinical Molecular Imaging, Eberhard Karls Universität Tübingen, Germany
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Tarasevych S, Lauwers P, Vandaele F, van Meerbeeck JP. Novel treatment options in stage I non-small-cell lung cancer. Expert Rev Anticancer Ther 2014; 14:1007-20. [PMID: 24930519 DOI: 10.1586/14737140.2014.929500] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
In the last 5 years, the current management of stage I non-small-cell lung cancer has been challenged due to novel surgical approaches and advances in radiation technology. The outcome after a sublobar resection is promising, especially for tumors less than 2 cm. Other treatment opportunities are available for high risk patients with comorbidity and impaired pulmonary function. Stereotactic ablative body radiotherapy is a good alternative treatment to surgery, especially in elderly and comorbid patients. However, randomized evidence comparing sublobar resection and stereotactic radiotherapy is presently lacking. The most recent development in radiotherapy is hadron therapy with a presumed reduced toxicity because of its peculiar physical and biological effects. Promising thermal and microwave ablative techniques are in development and have specific niche indications.
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Affiliation(s)
- Svitlana Tarasevych
- Department of Thoracic Oncology, Multidisciplinary Oncology Center Antwerp University Hospital, Antwerp, Belgium
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Kanemoto A, Okumura T, Ishikawa H, Mizumoto M, Oshiro Y, Kurishima K, Homma S, Hashimoto T, Ohkawa A, Numajiri H, Ohno T, Moritake T, Tsuboi K, Sakae T, Sakurai H. Outcomes and prognostic factors for recurrence after high-dose proton beam therapy for centrally and peripherally located stage I non--small-cell lung cancer. Clin Lung Cancer 2013; 15:e7-12. [PMID: 24365049 DOI: 10.1016/j.cllc.2013.11.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 10/15/2013] [Accepted: 11/08/2013] [Indexed: 12/25/2022]
Abstract
INTRODUCTION This study was conducted to determine disease control rates and prognostic factors associated with recurrence of centrally and peripherally located stage I NSCLC treated using high-dose PBT. PATIENTS AND METHODS Seventy-four patients with 80 centrally or peripherally located stage I NSCLCs were treated with PBT. A protocol using 72.6 Gy (RBE) in 22 fractions was used for centrally located tumors, and 66 Gy (RBE) in 10 or 12 fractions was used for peripherally located tumors. Data were collected and control rates and prognostic factors for recurrence were evaluated retrospectively. RESULTS The median follow-up period was 31.0 months. The overall survival, disease-specific survival, and progression-free survival rates were 76.7%, 83.0%, and 58.6% at 3 years, respectively. Disease recurrence was noted in 30 patients and local recurrence of 11 tumors occurred. The 3-year local control rate was 86.2% for stage IA tumors and 67.0% for stage IB tumors. Radiation dose was identified as a significant prognostic factor for disease recurrence and local recurrence. Tumor diameter and age were only significantly associated with disease recurrence. The 3-year local control rate was 63.9% for centrally located tumors irradiated with 72.6 Gy (RBE) and 88.4% for peripherally located tumors irradiated with 66 Gy (RBE). CONCLUSION Radiation dose was shown to be the most significant prognostic factor for tumor control in stage I NSCLC treated using high-dose PBT. Tumor diameter was not significant for local control. Further evaluation of PBT for centrally located tumors is warranted.
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Affiliation(s)
- Ayae Kanemoto
- Proton Medical Research Center and Department of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan.
| | - Toshiyuki Okumura
- Proton Medical Research Center and Department of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hitoshi Ishikawa
- Proton Medical Research Center and Department of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Masashi Mizumoto
- Proton Medical Research Center and Department of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yoshiko Oshiro
- Proton Medical Research Center and Department of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Koichi Kurishima
- Department of Respiratory Medicine, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Shinsuke Homma
- Department of Respiratory Medicine, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Takayuki Hashimoto
- Proton Medical Research Center and Department of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Ayako Ohkawa
- Proton Medical Research Center and Department of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Haruko Numajiri
- Proton Medical Research Center and Department of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Toshiki Ohno
- Proton Medical Research Center and Department of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Takashi Moritake
- Proton Medical Research Center and Department of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Koji Tsuboi
- Proton Medical Research Center and Department of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Takeji Sakae
- Proton Medical Research Center and Department of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hideyuki Sakurai
- Proton Medical Research Center and Department of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
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Fujii O, Demizu Y, Hashimoto N, Araya M, Takagi M, Terashima K, Mima M, Iwata H, Niwa Y, Jin D, Daimon T, Sasaki R, Hishikawa Y, Abe M, Murakami M, Fuwa N. A retrospective comparison of proton therapy and carbon ion therapy for stage I non-small cell lung cancer. Radiother Oncol 2013; 109:32-7. [DOI: 10.1016/j.radonc.2013.08.038] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Revised: 08/21/2013] [Accepted: 08/25/2013] [Indexed: 12/25/2022]
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Oshiro Y, Sakurai H. The use of proton-beam therapy in the treatment of non-small-cell lung cancer. Expert Rev Med Devices 2013; 10:239-45. [PMID: 23480092 DOI: 10.1586/erd.12.81] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Lung cancer is the most common cause of cancer death worldwide. Surgical resection has played a major role in the treatment of non-small-cell lung cancer (NSCLC); however, the disease is often detected in a progressive and inoperable form. Surgical resection may also be impossible for early-stage NSCLC due to medical conditions, such as pulmonary or cardiovascular disease and old age. Radiotherapy plays an important role for these patients. Proton-beam therapy is a particle radiotherapy with an excellent dose localization that permits treatment of lung cancer by administering a high dose to the tumor while minimizing damage to the surrounding normal tissues. Thus, proton beams are increasingly being used for lung cancer. In this context, the authors review the current knowledge on proton-beam therapy for the treatment of NSCLC.
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Affiliation(s)
- Yoshiko Oshiro
- Department of Radiation Oncology, Tsukuba University, Ibaraki, Japan.
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Shi W, Nichols Jr RC, Flampouri S, Li Z, Hsi W, Huh S, Ho MW, Henderson RH, Mendenhall NP, Hoppe BS. Proton-based chemoradiation for synchronous bilateral non-small-cell lung cancers: A case report. Thorac Cancer 2013; 4:198-202. [DOI: 10.1111/j.1759-7714.2012.00141.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Fan C, Li Y, Liu Q. Advantages of proton therapy in non-small cell lung cancers. Cancer Biother Radiopharm 2013; 28:183-6. [PMID: 23461384 DOI: 10.1089/cbr.2012.1343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The advantage of proton therapy over conventional radiotherapy is enormous, with many clinical advantages. In this review, we summarized the important literature in the advantages of Proton Therapy in Non-small Cell Lung Cancers.
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Zimmermann F, Mosna-Firlejczyk K, Papachristofilou A, Groß M. Results of stereotactic radiotherapy for stage I non-small-cell lung cancer: is there a need for image guidance and highly sophisticated devices? Lung Cancer Manag 2012. [DOI: 10.2217/lmt.12.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY In stage I non-small-cell lung cancer, stereotactic body radiation therapy achieves a local control of 90%, by accurate dose delivery with stereotactic beam navigation and/or image-guided techniques, and extremely dose-escalated hypofractionated radiotherapy. Three-to-ten fractions over 1–2 weeks or one single fraction as radiosurgery are used. A broad spectrum of different techniques have also been introduced, some encouraged by electric companies, and heavily commercialized by institutions and physicians. Although a direct comparison of these techniques has been carried out only in technical and not within clinical trials; clinical data from the few prospective Phase I and II trials and the majority of retrospective evaluations have not shown superiority of either technique. Based on personal experiences, there are nearly no limitations for the use of very simple and cheap techniques, and the broad and increasing disposition of dedicated systems is questionable.
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Affiliation(s)
- Frank Zimmermann
- Clinic of Radiation Oncology, Petersgraben 4, University Hospital, University Basel, 4031 Basel, Switzerland
| | - Katarzyna Mosna-Firlejczyk
- Clinic of Radiation Oncology, Petersgraben 4, University Hospital, University Basel, 4031 Basel, Switzerland
| | - Alexandros Papachristofilou
- Clinic of Radiation Oncology, Petersgraben 4, University Hospital, University Basel, 4031 Basel, Switzerland
| | - Markus Groß
- Clinic of Radiation Oncology, Petersgraben 4, University Hospital, University Basel, 4031 Basel, Switzerland
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Munshi A, Krishnatry R, Banerjee S, Agarwal J. Stereotactic Conformal Radiotherapy in Non-small Cell Lung Cancer — An Overview. Clin Oncol (R Coll Radiol) 2012; 24:556-68. [DOI: 10.1016/j.clon.2012.03.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Revised: 02/07/2012] [Accepted: 03/27/2012] [Indexed: 12/25/2022]
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Results of proton beam therapy without concurrent chemotherapy for patients with unresectable stage III non-small cell lung cancer. J Thorac Oncol 2012; 7:370-5. [PMID: 22157368 DOI: 10.1097/jto.0b013e31823c485f] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION This study was performed retrospectively to evaluate the outcome of patients with stage III non-small cell lung cancer (NSCLC) after proton beam therapy (PBT) alone. METHODS The subjects were 57 patients with histologically confirmed NSCLC (stage IIIA/IIIB: 24/33) who received PBT without concurrent chemotherapy. The cohort included 32 cases of squamous cell carcinoma, 18 adenocarcinoma, and 7 non-small cell carcinoma. Lymph node metastases were N0 7, N1 5, N2 30, and N3 15. Planned total doses ranged from 50 to 84.5 GyE (median, 74 GyE). RESULTS Planned treatment was completed in 51 patients (89%). At the time of analysis, 20 patients were alive, and the median follow-up periods were 16.2 months for all patients and 22.2 months for survivors. The median overall survival period was 21.3 months (95% confidence interval: 14.2-28.4 months), and the 1- and 2-year overall survival rates were 65.5% (52.9-78.0%) and 39.4% (25.3-53.5%), respectively. Disease progression occurred in 38 patients, and the 1- and 2-year progression-free survival rates were 36.2% (23.1-49.4%) and 24.9% (12.7-37.2%), respectively. Local recurrence was observed in 13 patients, and the 1- and 2-year local control rates were 79.1% (66.8-91.3%) and 64.1% (47.5-80.7%), respectively. Grade ≥ 3 lung toxicity was seen in six patients, esophageal toxicity occurred at grade ≤ 2, and there was no cardiac toxicity. CONCLUSION The prognosis of patients with unresectable stage III NSCLC is poor without chemotherapy. Our data suggest that high-dose PBT is beneficial and tolerable for these patients.
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50
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Nichols RC, Henderson RH, Huh S, Flampouri S, Li Z, Bajwa AA, D'Agostino HJ, Pham DC, Mendenhall NP, Hoppe BS. Proton therapy for lung cancer. Thorac Cancer 2012; 3:109-116. [PMID: 28920285 DOI: 10.1111/j.1759-7714.2011.00098.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Proton therapy is an emerging radiotherapy technology with the potential to improve the therapeutic index in the treatment of lung cancer patients. Since charged particles, such as protons, have a penetration length that can be modified by using different energies, protons offer the clinician the ability to modulate radiation dose deposition along the beam path. This facilitates an increase of the dose to the tumor target while minimizing the volume of normal tissue irradiation. Such precise delivery is particularly relevant in the setting of lung cancer where the targeted tissues are in close proximity to moderately radiation-sensitive organs like the spinal cord, heart, and esophagus, but are also effectively surrounded by the normal lung, which is extremely sensitive to radiation damage. Proton therapy has been investigated for the treatment of surgically curable yet medically inoperable patients as well as patients with regionally advanced disease.
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Affiliation(s)
- Romaine C Nichols
- University of Florida Proton Therapy Institute, Jacksonville, FL, USA Department of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Jacksonville, FL, USA Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA Department of Medical Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Randal H Henderson
- University of Florida Proton Therapy Institute, Jacksonville, FL, USA Department of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Jacksonville, FL, USA Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA Department of Medical Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Soon Huh
- University of Florida Proton Therapy Institute, Jacksonville, FL, USA Department of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Jacksonville, FL, USA Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA Department of Medical Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Stella Flampouri
- University of Florida Proton Therapy Institute, Jacksonville, FL, USA Department of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Jacksonville, FL, USA Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA Department of Medical Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Zuofeng Li
- University of Florida Proton Therapy Institute, Jacksonville, FL, USA Department of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Jacksonville, FL, USA Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA Department of Medical Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Abubakr A Bajwa
- University of Florida Proton Therapy Institute, Jacksonville, FL, USA Department of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Jacksonville, FL, USA Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA Department of Medical Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Harry J D'Agostino
- University of Florida Proton Therapy Institute, Jacksonville, FL, USA Department of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Jacksonville, FL, USA Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA Department of Medical Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Dat C Pham
- University of Florida Proton Therapy Institute, Jacksonville, FL, USA Department of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Jacksonville, FL, USA Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA Department of Medical Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Nancy P Mendenhall
- University of Florida Proton Therapy Institute, Jacksonville, FL, USA Department of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Jacksonville, FL, USA Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA Department of Medical Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Bradford S Hoppe
- University of Florida Proton Therapy Institute, Jacksonville, FL, USA Department of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Jacksonville, FL, USA Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA Department of Medical Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
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