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Wiegreffe S, Sarria GR, Layer JP, Dejonckheere E, Nour Y, Schmeel FC, Anton Giordano F, Schmeel LC, Popp I, Grosu AL, Gkika E, Stefaan Dejonckheere C. Incidence of hippocampal and perihippocampal brain metastases and impact on hippocampal-avoiding radiotherapy: A systematic review and meta-analysis. Radiother Oncol 2024; 197:110331. [PMID: 38772476 DOI: 10.1016/j.radonc.2024.110331] [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: 03/28/2024] [Revised: 04/25/2024] [Accepted: 05/03/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND AND PURPOSE In patients requiring prophylactic cranial irradiation (PCI) or whole-brain radiotherapy (WBRT) for brain metastases (BMs), hippocampal avoidance (HA) has been shown to preserve neurocognitive function and quality of life. Here, we aim to estimate the incidence of hippocampal and perihippocampal BMs and the subsequent risk of local undertreatment in patients undergoing hippocampal sparing radiotherapy. MATERIALS AND METHODS MEDLINE, Embase, and Scopus were searched with the terms "Hippocampus", "Brain Neoplasms", and related terms. Trials reporting on the incidence of hippocampal and/or perihippocampal BMs or hippocampal failure rate after PCI or WBRT were included. RESULTS Forty records were included, encompassing a total of 5,374 patients with over 32,570 BMs. Most trials employed a 5 mm margin to define the HA zone. In trials reporting on BM incidence, 4.4 % (range 0 - 27 %) and 9.2 % (3 - 41 %) of patients had hippocampal and perihippocampal BMs, respectively. The most common risk factor for hippocampal BMs was the total number of BMs. The reported failure rate within the HA zone after HA-PCI or HA-WBRT was 4.5 % (0 - 13 %), salvageable with radiosurgery in most cases. SCLC histology was not associated with a higher risk of hippocampal failure (OR = 2.49; p = 0.23). In trials comparing with a conventional (non-HA) PCI or WBRT group, HA did not increase the hippocampal failure rate (OR = 1.90; p = 0.17). CONCLUSION The overall incidence of hippocampal and perihippocampal BMs is considerably low, with a subsequent low risk of local undertreatment following HA-PCI or HA-WBRT. In patients without involvement, the hippocampus should be spared to preserve neurocognitive function and quality of life.
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Affiliation(s)
- Shari Wiegreffe
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany
| | | | - Julian Philipp Layer
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany; Institute of Experimental Oncology, University Hospital Bonn, 53127 Bonn, Germany
| | - Egon Dejonckheere
- Faculty of Psychology and Educational Sciences, KU Leuven, 3000 Leuven, Belgium; Department of Medical and Clinical Psychology, Tilburg School of Social and Behavioural Sciences, 5037 Tilburg, the Netherlands
| | - Younèss Nour
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany
| | | | - Frank Anton Giordano
- Department of Radiation Oncology, University Medical Center Mannheim, 68167 Mannheim, Germany; DKFZ-Hector Cancer Institute, University Medical Center Mannheim, 68167 Mannheim, Germany
| | | | - Ilinca Popp
- Department of Radiation Oncology, Medical Faculty, University Freiburg, 79106 Freiburg, Germany
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, Medical Faculty, University Freiburg, 79106 Freiburg, Germany
| | - Eleni Gkika
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany
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Matysiak WP, Landeweerd MC, Bannink A, van der Weide HL, Brouwer CL, Langendijk JA, Both S, Maduro JH. Proton PBS Planning Techniques, Robustness Evaluation, and OAR Sparing for the Whole-Brain Part of Craniospinal Axis Irradiation. Cancers (Basel) 2024; 16:892. [PMID: 38473254 DOI: 10.3390/cancers16050892] [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: 12/15/2023] [Revised: 02/06/2024] [Accepted: 02/16/2024] [Indexed: 03/14/2024] Open
Abstract
Proton therapy is a promising modality for craniospinal irradiation (CSI), offering dosimetric advantages over conventional treatments. While significant attention has been paid to spine fields, for the brain fields, only dose reduction to the lens of the eye has been reported. Hence, the objective of this study is to assess the potential gains and feasibility of adopting different treatment planning techniques for the entire brain within the CSI target. To this end, eight previously treated CSI patients underwent retrospective replanning using various techniques: (1) intensity modulated proton therapy (IMPT) optimization, (2) the modification/addition of field directions, and (3) the pre-optimization removal of superficially placed spots. The target coverage robustness was evaluated and dose comparisons for lenses, cochleae, and scalp were conducted, considering potential biological dose increases. The target coverage robustness was maintained across all plans, with minor reductions when superficial spot removal was utilized. Single- and multifield optimization showed comparable target coverage robustness and organ-at-risk sparing. A significant scalp sparing was achieved in adults but only limited in pediatric cases. Superficial spot removal contributed to scalp V30 Gy reduction at the expense of lower coverage robustness in specific cases. Lens sparing benefits from multiple field directions, while cochlear sparing remains impractical. Based on the results, all investigated plan types are deemed clinically adoptable.
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Affiliation(s)
- Witold P Matysiak
- Department of Radiotherapy, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
- Department of Radiotherapy, Mayo Clinic, Rochester, MN 55905, USA
| | - Marieke C Landeweerd
- Department of Radiotherapy, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
| | - Agata Bannink
- Department of Radiotherapy, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
| | - Hiska L van der Weide
- Department of Radiotherapy, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
| | - Charlotte L Brouwer
- Department of Radiotherapy, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
| | - Johannes A Langendijk
- Department of Radiotherapy, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
| | - Stefan Both
- Department of Radiotherapy, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
| | - John H Maduro
- Department of Radiotherapy, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
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Edvardsson A, Gorgisyan J, Andersson KM, Vallhagen Dahlgren C, Dasu A, Gram D, Björk-Eriksson T, Munck af Rosenschöld P. Robustness and dosimetric verification of hippocampal-sparing craniospinal pencil beam scanning proton plans for pediatric medulloblastoma. Phys Imaging Radiat Oncol 2024; 29:100555. [PMID: 38405431 PMCID: PMC10891325 DOI: 10.1016/j.phro.2024.100555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 02/06/2024] [Accepted: 02/08/2024] [Indexed: 02/27/2024] Open
Abstract
Background and Purpose Hippocampal-sparing (HS) is a method that can potentially reduce late cognitive complications for pediatric medulloblastoma (MB) patients treated with craniospinal proton therapy (PT). The aim of this study was to investigate robustness and dosimetric plan verification of pencil beam scanning HS PT. Materials and Methods HS and non-HS PT plans for the whole brain part of craniospinal treatment were created for 15 pediatric MB patients. A robust evaluation of the plans was performed. Plans were recalculated in a water phantom and measured field-by-field using an ion chamber detector at depths corresponding to the central part of hippocampi. All HS and non-HS fields were measured with the standard resolution of the detector and in addition 16 HS fields were measured with high resolution. Measured and planned dose distributions were compared using gamma evaluation. Results The median mean hippocampus dose was reduced from 22.9 Gy (RBE) to 8.9 Gy (RBE), while keeping CTV V95% above 95 % for all nominal HS plans. HS plans were relatively robust regarding hippocampus mean dose, however, less robust regarding target coverage and maximum dose compared to non-HS plans. For standard resolution measurements, median pass rates were 99.7 % for HS and 99.5 % for non-HS plans (p < 0.001). For high-resolution measurements, median pass rates were 100 % in the hippocampus region and 98.2 % in the surrounding region. Conclusions A substantial reduction of dose in the hippocampus region appeared feasible. Dosimetric accuracy of HS plans was comparable to non-HS plans and agreed well with planned dose distribution in the hippocampus region.
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Affiliation(s)
- Anneli Edvardsson
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Sweden
- Medical Radiation Physics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Jenny Gorgisyan
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Sweden
- Medical Radiation Physics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | | | | | - Alexandru Dasu
- The Skandion Clinic, Uppsala, Sweden
- Medical Radiation Sciences, Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Daniel Gram
- Department of Clinical Oncology and Palliative Care, Radiotherapy, Zealand University Hospital, Næstved, Denmark
- Niels Bohr Institute, University of Copenhagen, Copenhagen, Denmark
- Department of Oncology – Section of Radiotherapy, Rigshospitalet, Copenhagen, Denmark
| | - Thomas Björk-Eriksson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Regional Cancer Centre West, Western Sweden Healthcare Region, Gothenburg, Sweden
| | - Per Munck af Rosenschöld
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Sweden
- Medical Radiation Physics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
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Baliga S, Adams JA, Bajaj BVM, Van Benthuysen L, Daartz J, Gallotto SL, Lewy JR, DeNunzio N, Weyman EA, Lawell MP, Palmer JD, Yeap BY, Ebb DH, Huang MS, Perry AF, MacDonald SM, Jones RM, Tarbell NJ, Yock TI. Patterns of failure in pediatric medulloblastoma and implications for hippocampal sparing. Cancer 2023; 129:764-770. [PMID: 36504293 PMCID: PMC10107770 DOI: 10.1002/cncr.34574] [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: 05/20/2022] [Revised: 10/04/2022] [Accepted: 10/10/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hippocampal avoidance (HA) has been shown to preserve cognitive function in adult patients with cancer treated with whole-brain radiation therapy for brain metastases. However, the feasibility of HA in pediatric patients with brain tumors has not been explored because of concerns of increased risk of relapse in the peri-hippocampal region. Our aim was to determine patterns of recurrence and incidence of peri-hippocampal relapse in pediatric patients with medulloblastoma (MB). METHODS AND MATERIALS We identified pediatric patients with MB treated with protons between 2002 and 2016 and who had recurrent disease. To estimate the risk of peri-hippocampal recurrence, three hippocampal zones (HZs) were delineated corresponding to ≤5 mm (HZ-1), 6 to 10 mm (HZ-2), and >10 mm (HZ-3) distance of the recurrence from the contoured hippocampi. To determine the feasibility of HA, three standard-risk patients with MB were planned using either volumetric-modulated arc therapy (VMAT) or intensity-modulated proton therapy (IMPT) plans. RESULTS Thirty-eight patients developed a recurrence at a median of 1.6 years. Of the 25 patients who had magnetic resonance imaging of the recurrence, no patients failed within the hippocampus and only two patients failed within HZ-1. The crude incidence of peri-hippocampal failure was 8%. Both HA-VMAT and HA-IMPT plans were associated with significantly reduced mean dose to the hippocampi (p < .05). HA-VMAT and HA-IMPT plans were associated with decreased percentage of the third and lateral ventricles receiving the prescription craniospinal dose of 23.4 Gy. CONCLUSIONS Peri-hippocampal failures are uncommon in pediatric patients with MB. Hippocampal avoidance should be evaluated in a prospective cohort of pediatric patients with MB. PLAIN LANGUAGE SUMMARY In this study, the patterns of disease recurrence in patients with a pediatric brain tumor known as medulloblastoma treated with proton radiotherapy were examined. The majority of failures occur outside of an important structure related to memory formation called the hippocampus. Hippocampal sparing radiation plans using proton radiotherapy were generated and showed that dose to the hippocampus was able to be significantly reduced. The study provides the rationale to explore hippocampal sparing in pediatric medulloblastoma in a prospective clinical trial.
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Affiliation(s)
- Sujith Baliga
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Judith A Adams
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Benjamin V M Bajaj
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Liam Van Benthuysen
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Juliane Daartz
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Sara L Gallotto
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Jacqueline R Lewy
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Nicholas DeNunzio
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Elizabeth A Weyman
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Miranda P Lawell
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua D Palmer
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Beow Y Yeap
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - David H Ebb
- Department of Pediatric Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mary S Huang
- Department of Pediatric Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Alisa F Perry
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Robin M Jones
- Department of Pediatric Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nancy J Tarbell
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Torunn I Yock
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
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5
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Gram D, Brodin NP, Björk-Eriksson T, Nysom K, Munck Af Rosenschöld P. The risk of radiation-induced neurocognitive impairment and the impact of sparing the hippocampus during pediatric proton cranial irradiation. Acta Oncol 2023; 62:134-140. [PMID: 36847433 DOI: 10.1080/0284186x.2023.2176253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND AND PURPOSE Hippocampus is a central component for neurocognitive function and memory. We investigated the predicted risk of neurocognitive impairment of craniospinal irradiation (CSI) and the deliverability and effects of hippocampal sparing. The risk estimates were derived from published NTCP models. Specifically, we leveraged the estimated benefit of reduced neurocognitive impairment with the risk of reduced tumor control. MATERIAL AND METHODS For this dose planning study, a total of 504 hippocampal sparing intensity modulated proton therapy (HS-IMPT) plans were generated for 24 pediatric patients whom had previously received CSI. Plans were evaluated with respect to target coverage and homogeneity index to target volumes, maximum and mean dose to OARs. Paired t-tests were used to compare hippocampal mean doses and normal tissue complication probability estimates. RESULTS The median mean dose to the hippocampus could be reduced from 31.3 GyRBE to 7.3 GyRBE (p < .001), though 20% of these plans were not considered clinically acceptable as they failed one or more acceptance criterion. Reducing the median mean hippocampus dose to 10.6 GyRBE was possible with all plans considered as clinically acceptable treatment plans. By sparing the hippocampus to the lowest dose level, the risk estimation of neurocognitive impairment could be reduced from 89.6%, 62.1% and 51.1% to 41.0% (p < .001), 20.1% (p < .001) and 29.9% (p < .001) for task efficiency, organization and memory, respectively. Estimated tumor control probability was not adversely affected by HS-IMPT, ranging from 78.5 to 80.5% for all plans. CONCLUSIONS We present estimates of potential clinical benefit in terms of neurocognitive impairment and demonstrate the possibility of considerably reducing neurocognitive adverse effects, minimally compromising target coverage locally using HS-IMPT.
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Affiliation(s)
- Daniel Gram
- Department of Oncology - Section of Radiotherapy, Rigshospitalet, Copenhagen, Denmark.,Niels Bohr Institute, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Oncology and Palliative Care, Radiotherapy, Zealand University Hospital, Næstved, Denmark
| | - N Patrik Brodin
- Institute for Onco-Physics, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Thomas Björk-Eriksson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden.,Regional Cancer Centre West, Gothenburg, Sweden
| | - Karsten Nysom
- Department of Paediatrics and Adolescent Medicine, The Juliane Marie Center, Rigshospitalet, Copenhagen, Denmark
| | - Per Munck Af Rosenschöld
- Niels Bohr Institute, University of Copenhagen, Copenhagen, Denmark.,Radiation Physics - Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden.,Medical Radiation Physics, Department of Clinical Sciences, Lund University, Lund, Sweden
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6
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Al Dahhan NZ, Cox E, Nieman BJ, Mabbott DJ. Cross-translational models of late-onset cognitive sequelae and their treatment in pediatric brain tumor survivors. Neuron 2022; 110:2215-2241. [PMID: 35523175 DOI: 10.1016/j.neuron.2022.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 03/21/2022] [Accepted: 04/08/2022] [Indexed: 10/18/2022]
Abstract
Pediatric brain tumor treatments have a high success rate, but survivors are at risk of cognitive sequelae that impact long-term quality of life. We summarize recent clinical and animal model research addressing pathogenesis or evaluating candidate interventions for treatment-induced cognitive sequelae. Assayed interventions encompass a broad range of approaches, including modifications to radiotherapy, modulation of immune response, prevention of treatment-induced cell loss or promotion of cell renewal, manipulation of neuronal signaling, and lifestyle/environmental adjustments. We further emphasize the potential of neuroimaging as a key component of cross-translation to contextualize laboratory research within broader clinical findings. This cross-translational approach has the potential to accelerate discovery to improve pediatric cancer survivors' long-term quality of life.
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Affiliation(s)
- Noor Z Al Dahhan
- Neurosciences and Mental Health, Hospital for Sick Children, Toronto, ON, Canada
| | - Elizabeth Cox
- Neurosciences and Mental Health, Hospital for Sick Children, Toronto, ON, Canada; Department of Psychology, University of Toronto, Toronto, ON, Canada
| | - Brian J Nieman
- Translational Medicine, Hospital for Sick Children, Toronto, ON, Canada; Mouse Imaging Centre, Hospital for Sick Children, Toronto, ON, Canada; Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada; Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Donald J Mabbott
- Neurosciences and Mental Health, Hospital for Sick Children, Toronto, ON, Canada; Department of Psychology, University of Toronto, Toronto, ON, Canada; Department of Psychology, Hospital for Sick Children, Toronto, ON, Canada.
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Aljabab S, Rana S, Maes S, O'Ryan-Blair A, Castro J, Zheng J, Halasz LM, Taddei PJ. The Advantage of Proton Therapy in Hypothalamic-Pituitary Axis and Hippocampus Avoidance for Children with Medulloblastoma. Int J Part Ther 2021; 8:43-54. [PMID: 35127975 PMCID: PMC8768900 DOI: 10.14338/ijpt-21-00001.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/28/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose Craniospinal irradiation (CSI) improves clinical outcomes at the cost of long-term neuroendocrine and cognitive sequelae. The purpose of this pilot study was to determine whether hypothalamic-pituitary axis (HPA) and hippocampus avoidance (HPA-HA) with intensity-modulated proton therapy (IMPT) can potentially reduce this morbidity compared with standard x-ray CSI. Materials and Methods We retrospectively evaluated 10 patients with medulloblastoma (mean, 7 years; range, 4-14 years). Target volumes and organs at risk were delineated as per our local protocol and the ACNS0331 atlas. An experienced neuroradiologist verified the HPA and hippocampus contours. The primary objective was CSI and boost clinical target volume (CTV) covering 95% of the volume (D95) > 99% coverage with robustness. Described proton therapy doses in grays are prescribed using a biological effectiveness relative to photon therapy of 1.1. The combined prescribed dose in the boost target was 54 Gy. Secondary objectives included the HPA and hippocampus composite average dose (Dmean ≤ 18 Gy). For each patient, volumetric modulated arc radiotherapy (VMAT) and tomotherapy (TOMO) plans existed previously, and a new plan was generated with 3 cranial and 1 or 2 spinal beams for pencil-beam scanning delivery. Statistical comparison was performed with 1-way analysis of variance. Results Compared with standard CSI, HPA-HA CSI had statistically significant decreases in the composite doses received by the HPA (32.2 versus 17.9 Gy; P < .001) and hippocampi (39.8 versus 22.8 Gy; P < .001). The composite HPA Dmean was lower in IMPT plans (17.9 Gy) compared with that of VMAT (21.8 Gy) and TOMO (21.2 Gy) plans (P = .05). Hippocampi composite Dmean was also lower in IMPT plans (21 Gy) compared with that of VMAT (27.5 Gy) and TOMO (27.2 Gy) plans (P = .02). The IMPT CTV D95 coverage was lower in IMPT plans (52.8 Gy) compared with that of VMAT (54.6 Gy) and TOMO (54.6 Gy) plans (P < .001) The spared mean volume was only 1.35% (19.8 cm3) of the whole-brain CTV volume (1476 cm3). Conclusion We found that IMPT has the strong potential to reduce the dose to the HPA and hippocampus, compared with standard x-ray CSI while maintaining target coverage. A prospective clinical trial is required to establish the safety, efficacy, and toxicity of this novel CSI approach.
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Affiliation(s)
- Saif Aljabab
- Radiation Oncology Department, King Saud University, Riyadh, Saudi Arabia
| | - Shushan Rana
- Radiation Oncology Department, University of Washington School of Medicine, Seattle, WA, USA
| | - Shadonna Maes
- Seattle Cancer Care Alliance Proton Therapy Center, Seattle, WA, USA
| | | | - Jackie Castro
- Seattle Cancer Care Alliance Proton Therapy Center, Seattle, WA, USA
| | - Jack Zheng
- Radiation Medicine Program, the Ottawa Hospital Cancer Centre, Ottawa, ON, Canada
| | - Lia M. Halasz
- Radiation Oncology Department, University of Washington School of Medicine, Seattle, WA, USA
| | - Phillip J. Taddei
- Radiation Oncology Department, University of Washington School of Medicine, Seattle, WA, USA
- Seattle Cancer Care Alliance Proton Therapy Center, Seattle, WA, USA
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
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8
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Schmal Z, Hammer B, Müller A, Rübe CE. Fractionated Low-Dose Radiation Induces Long-Lasting Inflammatory Responses in the Hippocampal Stem Cell Niche. Int J Radiat Oncol Biol Phys 2021; 111:1262-1275. [PMID: 34280471 DOI: 10.1016/j.ijrobp.2021.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 12/31/2022]
Abstract
PURPOSE Despite major technical advances in hippocampus-sparing radiation therapy, radiation-induced injury to the neural stem cell compartment may affect neurocognitive functions. In the brain, glial cells modulate neuronal functions and are major mediators of neuroinflammation. In a preclinical mouse model with fractionated low-dose radiation (LDR), the complex response to radiation-induced injury was analyzed in the hippocampal stem cell compartment over a period of 6 months. METHODS AND MATERIALS Adult and juvenile C57BL/6NCrl mice were exposed to low doses of ionizing radiation (IR; 20 fractions of 0.1 Gy, for up to 4 weeks) daily. At 72 hours and 1, 3, and 6 months after fractionated LDR, magnetic resonance imaging (9.4 T) was conducted to detect structural and functional abnormalities in the hippocampal region. Using immunofluorescence and histologic studies, neuroglia cells (astrocytes, microglia, oligodendrocytes) were quantified and neuroinflammatory responses were characterized in the hippocampal dentate gyrus. Using in vivo bromodeoxyuridine labeling, the cell fate of newly generated progenitor cells was tracked in the subgranular zone of the dentate gyrus during fractionated LDR. RESULTS Low doses of IR induced long-lasting inflammatory responses with local increases of activated microglia and reactive astrocytes, which were most pronounced in the juvenile hippocampus within the first months after LDR. Glial activation with the consequent release of proinflammatory mediators increased local blood flow and vascular permeability in the hippocampal region. Cell fate mapping of progenitors located in the subgranular zone revealed a transient shift from neurogenesis to gliogenesis. CONCLUSIONS Glial cell activation and transient neuroinflammation may reflect radiation-induced neuronal damage in the hippocampal stem cell niche. The increased proliferative capacity of the developing brain may explain the enhanced hippocampal radiosensitivity, with stronger inflammatory reactions in the juvenile hippocampus. Thus, limiting the radiation dose to the hippocampal region is an important issue of clinical radiation therapy at all ages to preserve neurocognitive functions.
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Affiliation(s)
| | | | - Andreas Müller
- Department of Diagnostic and Interventional Radiology, Saarland University Medical Center, Homburg/Saar, Germany
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9
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Sethi R, MacDonald S. Hippocampus avoidance in pediatric patients. Neuro Oncol 2019; 21:1093-1094. [DOI: 10.1093/neuonc/noz110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Roshan Sethi
- Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
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10
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Thomas A, Noël G. Medulloblastoma: optimizing care with a multidisciplinary approach. J Multidiscip Healthc 2019; 12:335-347. [PMID: 31118657 PMCID: PMC6498429 DOI: 10.2147/jmdh.s167808] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Medulloblastoma is a malignant tumor of the cerebellum and the most frequent malignant brain tumor in children. The standard of care consists of maximal resection surgery, followed by craniospinal irradiation and chemotherapy. Such treatment allows long-term survival rates of nearly 70%; however, there are wide disparities among patient outcomes, and in any case, major long-term morbidity is observed with conventional treatment. In the last two decades, the molecular understanding of medulloblastoma has improved drastically, allowing us to revolutionize our understanding of medulloblastoma pathophysiological mechanisms. These advances led to an international consensus in 2010 that defined four prognostic molecular subgroups named after their affected signaling pathways, that is, WNT, SHH, Group 3 and Group 4. The molecular understanding of medulloblastoma is starting to translate through to clinical settings due to the development of targeted therapies. Moreover, recent improvements in radiotherapy modalities and the reconsideration of craniospinal irradiation according to the molecular status hold promise for survival preservation and the reduction of radiation-induced morbidity. This review is an overview of the current knowledge of medulloblastoma through a molecular approach, and therapeutic prospects currently being developed in surgery, radiotherapy and targeted therapies to optimize the treatment of medulloblastoma with a multidisciplinary approach will also be discussed.
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Affiliation(s)
- Alice Thomas
- Radiotherapy Department, Centre Paul Strauss, UNICANCER, F-67065 Strasbourg, France,
| | - Georges Noël
- Radiotherapy Department, Centre Paul Strauss, UNICANCER, F-67065 Strasbourg, France, .,Radiobiology Lab, CNRS, IPHC UMR 7178, Centre Paul Strauss, UNICANCER, F-67000 Strasbourg, France,
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Stoker J, Vora S, Patel A, Grosshans D, Brown PD, Vern-Gross T, Bues M, Daniels T, Allred B, Uejo A, Kosiorek H, Bruso M, Keole S. Advantages of intensity modulated proton therapy during hippocampal avoidance whole brain radiation therapy. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2018; 8:28-32. [PMID: 33458413 PMCID: PMC7807533 DOI: 10.1016/j.phro.2018.11.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 10/31/2018] [Accepted: 11/02/2018] [Indexed: 02/07/2023]
Abstract
Whole-brain intensity modulated proton therapy capably spares hippocampal volumes. Hippocampal avoidance whole-brain radiotherapy may benefit pediatric populations. Intensity modulated proton therapy provides superior target-dose homogeneity relative to modulated x-rays.
Background and purpose Intensity modulated proton therapy (IMPT) allows for modulation parameterized for individual beamlets by position, intensity, and depth. This modulation capability is ideally suited for sparing organs at risk intermediate of the radiation target, such as hippocampal volumes within the whole brain. This work compared IMPT relative to volumetric modulated arc therapy (VMAT) during hippocampal avoidance whole brain radiation therapy (HA WBRT). Materials and methods Ten adult and ten pediatric patients previously treated for central nervous system malignancies were identified. IMPT and VMAT treatment plans employing HA WBRT were generated for each patient, delivering 30 GyE (Gray Equivalent) in 10 fractions for adults and 36 GyE in 20 fractions for pediatrics. Dose indices, including dose volume histogram metrics and homogeneity index HI = [D5% − D95%]/[Dmean] × 100, were used to assess plan quality and describe target coverage and normal-tissue sparing. Results IMPT offered significant benefits relative to VMAT for hippocampal sparing. Hippocampal mean dose was reduced from 13.7 ± 0.8 Gy with VMAT to 5.4 ± 0.3 GyE using IMPT for pediatrics, and was reduced from 11.7 ± 0.9 Gy with VMAT to 4.4 ± 0.2 GyE using IMPT for adults. IMPT similarly lowered left hippocampal mean dose. Dose to 95% of the clinical target volume was statistically equivalent for both groups; however IMPT reduced the homogeneity index by roughly half. Conclusion This manuscript demonstrates that HA IMPT can match or exceed dosimetric benefits offered with modulated X-rays. Inclusion of IMPT in future prospective studies is warranted.
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Affiliation(s)
- Joshua Stoker
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
- Corresponding author at: Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ 85054, USA.
| | - Sujay Vora
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Ameet Patel
- Department of Radiology, Division of Neuroradiology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - David Grosshans
- Division of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Paul D. Brown
- Department of Radiation Oncology, Mayo Clinic Rochester, Rochester, MN, USA
| | - Tamara Vern-Gross
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Martin Bues
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Thomas Daniels
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Bryce Allred
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Arielle Uejo
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Heidi Kosiorek
- Department of Research Biostatistics, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Marlene Bruso
- Department of Research Biostatistics, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Sameer Keole
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
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