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Li H, Mayr NA, Griffin RJ, Zhang H, Pokhrel D, Grams M, Penagaricano J, Chang S, Spraker MB, Kavanaugh J, Lin L, Sheikh K, Mossahebi S, Simone CB, Roberge D, Snider JW, Sabouri P, Molineu A, Xiao Y, Benedict SH. Overview and Recommendations for Prospective Multi-institutional Spatially Fractionated Radiation Therapy Clinical Trials. Int J Radiat Oncol Biol Phys 2024; 119:737-749. [PMID: 38110104 PMCID: PMC11162930 DOI: 10.1016/j.ijrobp.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 10/30/2023] [Accepted: 12/09/2023] [Indexed: 12/20/2023]
Abstract
PURPOSE The highly heterogeneous dose delivery of spatially fractionated radiation therapy (SFRT) is a profound departure from standard radiation planning and reporting approaches. Early SFRT studies have shown excellent clinical outcomes. However, prospective multi-institutional clinical trials of SFRT are still lacking. This NRG Oncology/American Association of Physicists in Medicine working group consensus aimed to develop recommendations on dosimetric planning, delivery, and SFRT dose reporting to address this current obstacle toward the design of SFRT clinical trials. METHODS AND MATERIALS Working groups consisting of radiation oncologists, radiobiologists, and medical physicists with expertise in SFRT were formed in NRG Oncology and the American Association of Physicists in Medicine to investigate the needs and barriers in SFRT clinical trials. RESULTS Upon reviewing the SFRT technologies and methods, this group identified challenges in several areas, including the availability of SFRT, the lack of treatment planning system support for SFRT, the lack of guidance in the physics and dosimetry of SFRT, the approximated radiobiological modeling of SFRT, and the prescription and combination of SFRT with conventional radiation therapy. CONCLUSIONS Recognizing these challenges, the group further recommended several areas of improvement for the application of SFRT in cancer treatment, including the creation of clinical practice guidance documents, the improvement of treatment planning system support, the generation of treatment planning and dosimetric index reporting templates, and the development of better radiobiological models through preclinical studies and through conducting multi-institution clinical trials.
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Affiliation(s)
- Heng Li
- Department of Radiation Oncology, John Hopkins University, Baltimore, Maryland.
| | - Nina A Mayr
- College of Human Medicine, Michigan State University, East Lansing, Michigan
| | - Robert J Griffin
- Department of Radiation Oncology, University of Arkansas for Medical Science, Little Rock, Arkansas
| | - Hualin Zhang
- Department of Radiation Oncology, University of Southern California, Los Angeles, California
| | - Damodar Pokhrel
- Department of Radiation Medicine, University of Kentucky, Lexington, Kentucky
| | - Michael Grams
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Jose Penagaricano
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Sha Chang
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | | | - James Kavanaugh
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Liyong Lin
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - Khadija Sheikh
- Department of Radiation Oncology, John Hopkins University, Baltimore, Maryland
| | - Sina Mossahebi
- Department of Radiation Oncology, University of Maryland, Baltimore, Maryland
| | - Charles B Simone
- Department of Radiation Oncology, New York Proton Center, New York, New York
| | - David Roberge
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - James W Snider
- South Florida Proton Therapy Institute, 5280 Linton Blvd, Delray Beach, Florida
| | - Pouya Sabouri
- Department of Radiation Oncology, University of Arkansas for Medical Science, Little Rock, Arkansas
| | - Andrea Molineu
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ying Xiao
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stanley H Benedict
- Department of Radiation Oncology, University of California, Davis, Sacramento, California
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Tsai P, Yang Y, Wu M, Chen CC, Yu F, Simone CB, Choi JI, Tomé WA, Lin H. A comprehensive pre-clinical treatment quality assurance program using unique spot patterns for proton pencil beam scanning FLASH radiotherapy. J Appl Clin Med Phys 2024:e14400. [PMID: 38831639 DOI: 10.1002/acm2.14400] [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: 01/03/2024] [Revised: 03/14/2024] [Accepted: 05/07/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND Quality assurance (QA) for ultra-high dose rate (UHDR) irradiation is a crucial aspect in the emerging field of FLASH radiotherapy (FLASH-RT). This innovative treatment approach delivers radiation at UHDR, demanding careful adoption of QA protocols and procedures. A comprehensive understanding of beam properties and dosimetry consistency is vital to ensure the safe and effective delivery of FLASH-RT. PURPOSE To develop a comprehensive pre-treatment QA program for cyclotron-based proton pencil beam scanning (PBS) FLASH-RT. Establish appropriate tolerances for QA items based on this study's outcomes and TG-224 recommendations. METHODS A 250 MeV proton spot pattern was designed and implemented using UHDR with a 215nA nozzle beam current. The QA pattern that covers a central uniform field area, various spot spacings, spot delivery modes and scanning directions, and enabling the assessment of absolute, relative and temporal dosimetry QA parameters. A strip ionization chamber array (SICA) and an Advanced Markus chamber were utilized in conjunction with a 2 cm polyethylene slab and a range (R80) verification wedge. The data have been monitored for over 3 months. RESULTS The relative dosimetries were compliant with TG-224. The variations of temporal dosimetry for scanning speed, spot dwell time, and spot transition time were within ± 1 mm/ms, ± 0.2 ms, and ± 0.2 ms, respectively. While the beam-to-beam absolute output on the same day reached up to 2.14%, the day-to-day variation was as high as 9.69%. High correlation between the absolute dose and dose rate fluctuations were identified. The dose rate of the central 5 × 5 cm2 field exhibited variations within 5% of the baseline value (155 Gy/s) during an experimental session. CONCLUSIONS A comprehensive QA program for FLASH-RT was developed and effectively assesses the performance of a UHDR delivery system. Establishing tolerances to unify standards and offering direction for future advancements in the evolving FLASH-RT field.
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Affiliation(s)
| | - Yunjie Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Mengjou Wu
- New York Proton Center, New York, New York, USA
| | | | - Francis Yu
- New York Proton Center, New York, New York, USA
| | | | | | - Wolfgang A Tomé
- Department of Radiation Oncology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| | - Haibo Lin
- New York Proton Center, New York, New York, USA
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Radiation Oncology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
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Lin Y, Li W, Johnson D, Prezado Y, Gan GN, Gao H. Development and characterization of the first proton minibeam system for single-gantry proton facility. Med Phys 2024; 51:3995-4006. [PMID: 38642468 DOI: 10.1002/mp.17074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 03/28/2024] [Accepted: 03/28/2024] [Indexed: 04/22/2024] Open
Abstract
BACKGROUND Minibeam represents a preclinical spatially fractionated radiotherapy modality with great translational potential. The advantage lies in its high therapeutic index (compared to GRID and LATTICE) and ability to treat at greater depth (compared to microbeam). Proton minibeam radiotherapy (pMBRT) is a synergy of proton and minibeam. While the single-gantry proton facility has gained popularity due to its affordability and compact design, it often has limited beam time available for research purposes. Conversely, given the current requirement of pMBRT on specific minibeam hardware collimators, necessitates a reproducible and fast setup to minimize pMBRT treatment time and streamline the switching time between pMBRT and conventional treatment for clinically translation. PURPOSE The contribution of this work is the development and characterization of the first pMBRT system tailored for single-gantry proton facility. The system allows for efficient and reproducible plug-and-play setup, achievable within minutes. METHODS The single room pMBRT system is constructed based on IBA ProteusONE proton machine. The end of nozzle is attached with beam modifying accessories though an accessory drawer. A small snout is attached to the accessory drawer and used to hold apertures and range shifters. The minibeam aperture consists of two components: a fitting ring and an aperture body. Three minibeam apertures were manufactured. The first-generation apertures underwent qualitatively analysis with film, and the second generation aperture underwent more comprehensive quantitative measurement. The reproducibility of the setup is accessed, and the film measurements are performed to characterize the pMBRT system in cross validation with Monte Carlo (MC) simulations. RESULTS We presented initial results of large field pMBRT aperture and the film measurements indicates the effect of source-to-isocenter distance = 930 cm in Y proton scanning direction. Consistent with TOPAS MC simulation, the dose uniformity of pMBRT field <2 cm is demonstrated to be better than 2%, rendering its suitability for pre-clinical studies. Subsequently, we developed the second generation of aperture with five slits and characterized the aperture with film dosimetry studies and compared the results to the benchmark MC. Comprehensive film measurements were also performed to evaluate the effect of divergence, air gap and gantry-angle dependency and repeatability and revealing a consistent performance within 5%. Furthermore, the 2D gamma analysis indicated a passing rate exceeding 99% using 3% dose difference and 0.2 mm distance agreement criteria. We also establish the peak valley dose ratio and the depth dose profile measurements, and the results are within 10% from MC simulation. CONCLUSIONS We have developed the first pMBRT system tailored for a single-gantry proton facility, which has demonstrated accuracy in benchmark with MC simulations, and allows for efficient plug-and-play setup, emphasizing efficiency.
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Affiliation(s)
- Yuting Lin
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Wangyao Li
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Daniel Johnson
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Yolanda Prezado
- Institut Curie, University PSL, CNRS UMR3347, INSERM U1021, Orsay, France
| | - Gregory N Gan
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Hao Gao
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, Kansas, USA
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Chow JCL, Ruda HE. Mechanisms of Action in FLASH Radiotherapy: A Comprehensive Review of Physicochemical and Biological Processes on Cancerous and Normal Cells. Cells 2024; 13:835. [PMID: 38786057 PMCID: PMC11120005 DOI: 10.3390/cells13100835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 05/09/2024] [Accepted: 05/11/2024] [Indexed: 05/25/2024] Open
Abstract
The advent of FLASH radiotherapy (FLASH-RT) has brought forth a paradigm shift in cancer treatment, showcasing remarkable normal cell sparing effects with ultra-high dose rates (>40 Gy/s). This review delves into the multifaceted mechanisms underpinning the efficacy of FLASH effect, examining both physicochemical and biological hypotheses in cell biophysics. The physicochemical process encompasses oxygen depletion, reactive oxygen species, and free radical recombination. In parallel, the biological process explores the FLASH effect on the immune system and on blood vessels in treatment sites such as the brain, lung, gastrointestinal tract, skin, and subcutaneous tissue. This review investigated the selective targeting of cancer cells and the modulation of the tumor microenvironment through FLASH-RT. Examining these mechanisms, we explore the implications and challenges of integrating FLASH-RT into cancer treatment. The potential to spare normal cells, boost the immune response, and modify the tumor vasculature offers new therapeutic strategies. Despite progress in understanding FLASH-RT, this review highlights knowledge gaps, emphasizing the need for further research to optimize its clinical applications. The synthesis of physicochemical and biological insights serves as a comprehensive resource for cell biology, molecular biology, and biophysics researchers and clinicians navigating the evolution of FLASH-RT in cancer therapy.
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Affiliation(s)
- James C. L. Chow
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 1X6, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Harry E. Ruda
- Centre of Advance Nanotechnology, Faculty of Applied Science and Engineering, University of Toronto, Toronto, ON M5S 3E4, Canada;
- Department of Materials Science and Engineering, University of Toronto, Toronto, ON M5S 3E4, Canada
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Garba NN, Aliyu AS, Rabiu N, Kankara UM, Vatsa AM, Ismaila A, Musa J, Onuh E. Investigation of natural radionuclides and radiation shielding potential of some commonly used building materials in Northwestern Nigeria. Sci Rep 2024; 14:9696. [PMID: 38678147 PMCID: PMC11055895 DOI: 10.1038/s41598-024-60541-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 04/24/2024] [Indexed: 04/29/2024] Open
Abstract
This study assessed the gamma-ray shielding potential of clay, sand, gypsum and kaolin commonly used as a building material in Northwestern, Nigeria. The radiological status of the samples was first evaluated by determining the activity concentrations of 238U, 232Th and 40K using NaI (Tl) detector after which elemental composition and mass density were determined using Neutron Activation Analytical Technique. After which the mass attenuation coefficients (MAC), linear attenuation coefficients (LAC), half value layer (HVL), tenth value layer (TVL), and effective atomic number (Zeff) were determined experimentally and theoretically using standard point sources of 137Cs and 60Co photon peaks (0.662 and 1.332, 1.173) MeV and Py-MLBUF software. The activity concentrations were found to range from 51 to 59 Bq kg-1 with a mean value of 59 Bq kg-1 for 238U, 24 to 27 Bq kg-1 with a mean value of 29 Bq kg-1 for 232Th, and 219 to 247 Bq kg-1 with a mean value of 247 Bq kg-1 for 40K which were about within the world recommended values of 33, 45 and 420 Bq kg-1 respectively. The results of the elemental compositions show that Si, Al, K, Fe, and Ba in clay and sand samples have concentrations in the range of 36.83-78.48%, 1.92-26.05%, 6.33-21.96%, 2.39-19.09%, and 0.09-1.44%, respectively, while in kaolin and gypsum, results revealed that Si, Al, K, Fe, and Ca range between 0.34 and 65.52%, 1.14-35.82%, 0.00-12.12%, 0.00-5.77%, and 0.00-96.6%, respectively. However, the concentrations of other elements such as Mg, Ti, Mn, Zn, Na, and Ba varied significantly with the samples. The results showed that clay has an average density of 1.96 g/cm3, sand has 2.32 g/cm3, kaolin has 2.63 g/cm3, and gypsum has the highest density with a value of 2.66 g/cm3 compared to other samples. During the measurements, a thallium-activated sodium-iodide NaI (TI) detector was used. A narrow beam transmission geometry condition was adopted for the measurements to ensure minimal scattered radiation. Absorption and attenuation of gamma beams as a function of sample thickness against gamma energy generally exhibit an increasing gamma ray behaviour as the sample thickness increases from 1 to 3 cm. The results showed that the gypsum, kaolin, sand, and clay were capable of attenuating 63.5%, 61.5%, 58.4%, and 44.2 of gamma-ray photons of energy 0.662 MeV at 3 cm thickness %, respectively, and 40.6%, 32.9%, 30.6%, and 27.3% of gamma energy 1.332 MeV at 3 cm thickness, respectively. The results showed that MAC, LAC, and Zeff of all the samples decreased with an increase in photon energy, while those of HVL and TVL increased. The experimental results for all the gamma-ray shielding parameters were found to be in good agreement with the theoretical values obtained using Py-MLBUF. The results have shown that all the samples have similar photon attenuation behaviours; however, gypsum has the best shielding potential than kaolin and this is attributed due to its highest density value.
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Affiliation(s)
- N N Garba
- Department of Physics, Ahmadu Bello University, Zaria, Nigeria.
| | - A S Aliyu
- Department of Physics, Ahmadu Bello University, Zaria, Nigeria
| | - N Rabiu
- Department of Physics, Ahmadu Bello University, Zaria, Nigeria
| | - U M Kankara
- Department of Physics, Ahmadu Bello University, Zaria, Nigeria
| | - A M Vatsa
- Department of Physics, Ahmadu Bello University, Zaria, Nigeria
| | - A Ismaila
- Department of Physics, Ahmadu Bello University, Zaria, Nigeria
| | - J Musa
- Department of Physics, Ahmadu Bello University, Zaria, Nigeria
| | - E Onuh
- Department of Physics, Ahmadu Bello University, Zaria, Nigeria
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Chong LM, Wang P, Lee VV, Vijayakumar S, Tan HQ, Wang FQ, Yeoh TDYY, Truong ATL, Tan LWJ, Tan SB, Senthil Kumar K, Hau E, Vellayappan BA, Blasiak A, Ho D. Radiation therapy with phenotypic medicine: towards N-of-1 personalization. Br J Cancer 2024:10.1038/s41416-024-02653-3. [PMID: 38514762 DOI: 10.1038/s41416-024-02653-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/29/2024] [Accepted: 03/04/2024] [Indexed: 03/23/2024] Open
Abstract
In current clinical practice, radiotherapy (RT) is prescribed as a pre-determined total dose divided over daily doses (fractions) given over several weeks. The treatment response is typically assessed months after the end of RT. However, the conventional one-dose-fits-all strategy may not achieve the desired outcome, owing to patient and tumor heterogeneity. Therefore, a treatment strategy that allows for RT dose personalization based on each individual response is preferred. Multiple strategies have been adopted to address this challenge. As an alternative to current known strategies, artificial intelligence (AI)-derived mechanism-independent small data phenotypic medicine (PM) platforms may be utilized for N-of-1 RT personalization. Unlike existing big data approaches, PM does not engage in model refining, training, and validation, and guides treatment by utilizing prospectively collected patient's own small datasets. With PM, clinicians may guide patients' RT dose recommendations using their responses in real-time and potentially avoid over-treatment in good responders and under-treatment in poor responders. In this paper, we discuss the potential of engaging PM to guide clinicians on upfront dose selections and ongoing adaptations during RT, as well as considerations and limitations for implementation. For practicing oncologists, clinical trialists, and researchers, PM can either be implemented as a standalone strategy or in complement with other existing RT personalizations. In addition, PM can either be used for monotherapeutic RT personalization, or in combination with other therapeutics (e.g. chemotherapy, targeted therapy). The potential of N-of-1 RT personalization with drugs will also be presented.
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Affiliation(s)
- Li Ming Chong
- Department of Biomedical Engineering, College of Design and Engineering, National University of Singapore, Singapore, 117583, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore, 117456, Singapore
- The Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117456, Singapore
| | - Peter Wang
- Department of Biomedical Engineering, College of Design and Engineering, National University of Singapore, Singapore, 117583, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore, 117456, Singapore
- The Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117456, Singapore
| | - V Vien Lee
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore, 117456, Singapore
| | - Smrithi Vijayakumar
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore, 117456, Singapore
| | - Hong Qi Tan
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore, 168583, Singapore
| | - Fu Qiang Wang
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore, 168583, Singapore
| | | | - Anh T L Truong
- Department of Biomedical Engineering, College of Design and Engineering, National University of Singapore, Singapore, 117583, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore, 117456, Singapore
- The Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117456, Singapore
| | - Lester Wen Jeit Tan
- Department of Biomedical Engineering, College of Design and Engineering, National University of Singapore, Singapore, 117583, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore, 117456, Singapore
- The Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117456, Singapore
| | - Shi Bei Tan
- Department of Biomedical Engineering, College of Design and Engineering, National University of Singapore, Singapore, 117583, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore, 117456, Singapore
- The Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117456, Singapore
| | - Kirthika Senthil Kumar
- Department of Biomedical Engineering, College of Design and Engineering, National University of Singapore, Singapore, 117583, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore, 117456, Singapore
| | - Eric Hau
- Department of Radiation Oncology, Westmead Hospital, Sydney, NSW, Australia
- Department of Radiation Oncology, Blacktown Haematology and Cancer Care Centre, Sydney, NSW, Australia
- Westmead Medical School, The University of Sydney, Sydney, NSW, Australia
- Centre for Cancer Research, Westmead Institute of Medical Research, Sydney, NSW, Australia
| | - Balamurugan A Vellayappan
- Department of Radiation Oncology, National University Cancer Institute, Singapore, 119074, Singapore.
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 119228, Singapore.
| | - Agata Blasiak
- Department of Biomedical Engineering, College of Design and Engineering, National University of Singapore, Singapore, 117583, Singapore.
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore, 117456, Singapore.
- The Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117456, Singapore.
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117600, Singapore.
| | - Dean Ho
- Department of Biomedical Engineering, College of Design and Engineering, National University of Singapore, Singapore, 117583, Singapore.
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore, 117456, Singapore.
- The Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117456, Singapore.
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117600, Singapore.
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Mayr NA, Mohiuddin M, Snider JW, Zhang H, Griffin RJ, Amendola BE, Hippe DS, Perez NC, Wu X, Lo SS, Regine WF, Simone CB. Practice Patterns of Spatially Fractionated Radiation Therapy: A Clinical Practice Survey. Adv Radiat Oncol 2024; 9:101308. [PMID: 38405319 PMCID: PMC10885580 DOI: 10.1016/j.adro.2023.101308] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 06/26/2023] [Indexed: 02/27/2024] Open
Abstract
Purpose Spatially fractionated radiation therapy (SFRT) is increasingly used for bulky advanced tumors, but specifics of clinical SFRT practice remain elusive. This study aimed to determine practice patterns of GRID and Lattice radiation therapy (LRT)-based SFRT. Methods and Materials A survey was designed to identify radiation oncologists' practice patterns of patient selection for SFRT, dosing/planning, dosimetric parameter use, SFRT platforms/techniques, combinations of SFRT with conventional external beam radiation therapy (cERT) and multimodality therapies, and physicists' technical implementation, delivery, and quality procedures. Data were summarized using descriptive statistics. Group comparisons were analyzed with permutation tests. Results The majority of practicing radiation oncologists (United States, 100%; global, 72.7%) considered SFRT an accepted standard-of-care radiation therapy option for bulky/advanced tumors. Treatment of metastases/recurrences and nonmetastatic primary tumors, predominantly head and neck, lung cancer and sarcoma, was commonly practiced. In palliative SFRT, regimens of 15 to 18 Gy/1 fraction predominated (51.3%), and in curative-intent treatment of nonmetastatic tumors, 15 Gy/1 fraction (28.0%) and fractionated SFRT (24.0%) were most common. SFRT was combined with cERT commonly but not always in palliative (78.6%) and curative-intent (85.7%) treatment. SFRT-cERT time sequencing and cERT dose adjustments were variable. In curative-intent treatment, concurrent chemotherapy and immunotherapy were found acceptable by 54.5% and 28.6%, respectively. Use of SFRT dosimetric parameters was highly variable and differed between GRID and LRT. SFRT heterogeneity dosimetric parameters were more commonly used (P = .008) and more commonly thought to influence local control (peak dose, P = .008) in LRT than in GRID therapy. Conclusions SFRT has already evolved as a clinical practice pattern for advanced/bulky tumors. Major treatment approaches are consistent and follow the literature, but SFRT-cERT combination/sequencing and clinical utilization of dosimetric parameters are variable. These areas may benefit from targeted education and standardization, and knowledge gaps may be filled by incorporating identified inconsistencies into future clinical research.
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Affiliation(s)
- Nina A. Mayr
- College of Human Medicine, Michigan State University, East Lansing, Michigan
| | - Majid Mohiuddin
- Radiation Oncology Consultants and Northwestern Proton Center, Warrenville, Illinois
| | - James W. Snider
- Radiation Oncology, South Florida Proton Therapy Institute, Delray Beach, Florida
| | - Hualin Zhang
- Department of Radiation Oncology, University of Southern California, Los Angeles, California
| | - Robert J. Griffin
- Department of Radiation Oncology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | - Daniel S. Hippe
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | | | - Xiaodong Wu
- Executive Medical Physics Associates, Miami, Florida
| | - Simon S. Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
| | - William F. Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Charles B. Simone
- Department of Radiation Oncology, New York Proton Center, New York, New York
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At B, Velayudham R. Assessing dosimetric advancements in spatially fractionated radiotherapy: From grids to lattices. Med Dosim 2024:S0958-3947(23)00116-4. [PMID: 38290896 DOI: 10.1016/j.meddos.2023.12.003] [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: 08/17/2023] [Revised: 12/05/2023] [Accepted: 12/21/2023] [Indexed: 02/01/2024]
Abstract
Spatially fractionated radiotherapy (SFRT) techniques have undergone transformative evolution, encompassing physical GRID therapy, MLC-based grids, virtual TOMO GRIDs, and 3-dimensional high-dose lattices. Historical roots trace back to Alban Köhler's pioneering Spatially fractionated grid therapy (SFGRT), utilizing physical grids for dose modulation. Technological innovations introduced multi-leaf collimators (MLCs), enabling adaptable spatial fractionation and a shift to the broader term "SFRT." Physics and dosimetry-based studies have demonstrated the feasibility of computerized treatment planning and identified the potential to minimize the peripheral dose while using such high-dose therapy. Meanwhile, 3-dimensional high-dose lattices showed enhanced precision. The meticulous placement of high-dose volumetric spheres enables a reduction in the volume of high-dose spills. Advancements in 3-dimensional lattices through intensity-modulated radiotherapy and volumetric modulated arc therapy (VMAT) techniques offer enhanced therapeutic options. A database of SFRT studies identified 723 articles. This review shows the trajectory of SFRT from traditional grids to MLC-based approaches, virtual TOMO GRIDs, and innovative 3-dimensional lattices. Technological innovations, dosimetric advancements, and clinical feasibility have underscored the continual progress in refining spatially fractionated radiotherapy. The integration of MLCs and lattice techniques has demonstrated improved therapeutic outcomes, solidifying their relevance in modern radiation therapy protocols. Research has yet to reveal a clear correlation between treatment outcomes and dosimetric parameters. Additional investigations are necessary to assess the impact of various dosimetric parameters, such as EUD, peak-to-valley ratio (PVDR), D5%, D10%, D20%, D90%, etc., on the effectiveness of treatments.
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Affiliation(s)
- Bhagyalakshmi At
- Vellore Institute of Technology, Vellore Campus, Katpadi, Tamil Nadu 500036, India; American Oncology Institute at Baby Memorial Hospital, Kozhikode, Kerala 673004, India
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Cordoni FG. A spatial measure-valued model for radiation-induced DNA damage kinetics and repair under protracted irradiation condition. J Math Biol 2024; 88:21. [PMID: 38285219 PMCID: PMC10824812 DOI: 10.1007/s00285-024-02046-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 10/01/2023] [Accepted: 12/27/2023] [Indexed: 01/30/2024]
Abstract
In the present work, we develop a general spatial stochastic model to describe the formation and repair of radiation-induced DNA damage. The model is described mathematically as a measure-valued particle-based stochastic system and extends in several directions the model developed in Cordoni et al. (Phys Rev E 103:012412, 2021; Int J Radiat Biol 1-16, 2022a; Radiat Res 197:218-232, 2022b). In this new spatial formulation, radiation-induced DNA damage in the cell nucleus can undergo different pathways to either repair or lead to cell inactivation. The main novelty of the work is to rigorously define a spatial model that considers the pairwise interaction of lesions and continuous protracted irradiation. The former is relevant from a biological point of view as clustered lesions are less likely to be repaired, leading to cell inactivation. The latter instead describes the effects of a continuous radiation field on biological tissue. We prove the existence and uniqueness of a solution to the above stochastic systems, characterizing its probabilistic properties. We further couple the model describing the biological system to a set of reaction-diffusion equations with random discontinuity that model the chemical environment. At last, we study the large system limit of the process. The developed model can be applied to different contexts, with radiotherapy and space radioprotection being the most relevant. Further, the biochemical system derived can play a crucial role in understanding an extremely promising novel radiotherapy treatment modality, named in the community FLASH radiotherapy, whose mechanism is today largely unknown.
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10
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Gaudreault M, Chang D, Kron T, Siva S, Chander S, Hardcastle N, Yeo A. Development of an automated treatment planning approach for lattice radiation therapy. Med Phys 2024; 51:682-693. [PMID: 37797078 DOI: 10.1002/mp.16761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 08/29/2023] [Accepted: 09/14/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Lattice radiation therapy (LRT) alternates regions of high and low doses within the target. The heterogeneous dose distribution is delivered to a geometrical structure of vertices segmented inside the tumor. LRT is typically used to treat patients with large tumor volumes with cytoreduction intent. Due to the geometric complexity of the target volume and the required dose distribution, LRT treatment planning demands additional resources, which may limit clinical integration. PURPOSE We introduce a fully automated method to (1) generate an ordered lattice of vertices with various sizes and center-to-center distances and (2) perform dose optimization and calculation. We aim to report the dosimetry associated with these lattices to help clinical decision-making. METHODS Sarcoma cancer patients with tumor volume between 100 cm3 and 1500 cm3 who received radiotherapy treatment between 2010 and 2018 at our institution were considered for inclusion. Automated segmentation and dose optimization/calculation were performed by using the Eclipse Scripting Application Programming Interface (ESAPI, v16, Varian Medical Systems, Palo Alto, USA). Vertices were modeled by spheres segmented within the gross tumor volume (GTV) with 1 cm/1.5 cm/2 cm diameters (LRT-1 cm/1.5 cm/2 cm) and 2 to 5 cm center-to-center distance on square lattices alternating along the superior-inferior direction. Organs at risk were modeled by subtracting the GTV from the body structure (body-GTV). The prescription dose was that 50% of the vertice volume should receive at least 20 Gy in one fraction. The automated dose optimization included three stages. The vertices optimization objectives were refined during optimization according to their values at the end of the first and second stages. Lattices were classified according to a score based on the minimization of body-GTV max dose and the maximization of GTV dose uniformity (measured with the equivalent uniform dose [EUD]), GTV dose heterogeneity (measured with the GTV D90%/D10% ratio), and the number of patients with more than one vertex inserted in the GTV. Plan complexity was measured with the modulation complexity score (MCS). Correlations were assessed with the Spearman correlation coefficient (r) and its associated p-value. RESULTS Thirty-three patients with GTV volumes between 150 and 1350 cm3 (median GTV volume = 494 cm3 , IQR = 272-779 cm3 were included. The median time required for segmentation/planning was 1 min/21 min. The number of vertices was strongly correlated with GTV volume in each LRT lattice for each center-to-center distance (r > 0.85, p-values < 0.001 in each case). Lattices with center-to-center distance = 2.5 cm/3 cm/3.5 cm in LRT-1.5 cm and center-to-center distance = 4 cm in LRT-1 cm had the best scores. These lattices were characterized by high heterogeneity (median GTV D90%/D10% between 0.06 and 0.19). The generated plans were moderately complex (median MCS ranged between 0.19 and 0.40). CONCLUSIONS The automated LRT planning method allows for the efficacious generation of vertices arranged in an ordered lattice and the refinement of planning objectives during dose optimization, enabling the systematic evaluation of LRT dosimetry from various lattice geometries.
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Affiliation(s)
- Mathieu Gaudreault
- Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia
| | - David Chang
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Tomas Kron
- Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia
- Centre for Medical Radiation Physics, University of Wollongong, Sydney, New South Wales, Australia
| | - Shankar Siva
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Sarat Chander
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Nicholas Hardcastle
- Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia
- Centre for Medical Radiation Physics, University of Wollongong, Sydney, New South Wales, Australia
| | - Adam Yeo
- Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia
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11
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Gicobi JK, Mao Z, DeFranco G, Hirdler JB, Li Y, Vianzon VV, Dellacecca ER, Hsu MA, Barham W, Yan Y, Mansfield AS, Lin Y, Wu X, Hitosugi T, Owen D, Grams MP, Orme JJ, Lucien F, Zeng H, Park SS, Dong H. Salvage therapy expands highly cytotoxic and metabolically fit resilient CD8 + T cells via ME1 up-regulation. SCIENCE ADVANCES 2023; 9:eadi2414. [PMID: 37967193 PMCID: PMC10651128 DOI: 10.1126/sciadv.adi2414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 10/16/2023] [Indexed: 11/17/2023]
Abstract
Patients with advanced cancers who either do not experience initial response to or progress while on immune checkpoint inhibitors (ICIs) receive salvage radiotherapy to reduce tumor burden and tumor-related symptoms. Occasionally, some patients experience substantial global tumor regression with a rebound of cytotoxic CD8+ T cells. We have termed the rebound of cytotoxic CD8+ T cells in response to salvage therapy as T cell resilience and examined the underlying mechanisms of resilience. Resilient T cells are enriched for CX3CR1+ CD8+ T cells with low mitochondrial membrane potential, accumulate less reactive oxygen species (ROS), and express more malic enzyme 1 (ME1). ME1 overexpression enhanced the cytotoxicity and expansion of effector CD8+ T cells partially via the type I interferon pathway. ME1 also increased mitochondrial respiration while maintaining the redox state balance. ME1 increased the cytotoxicity of peripheral lymphocytes from patients with advanced cancers. Thus, preserved resilient T cells in patients rebound after salvage therapy and ME1 enhances their resiliency.
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Affiliation(s)
- Joanina K. Gicobi
- Department of Immunology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Zhiming Mao
- Department of Immunology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Grace DeFranco
- Department of Immunology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | | | - Ying Li
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL, USA
| | - Vianca V. Vianzon
- Department of Immunology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Emilia R. Dellacecca
- Department of Immunology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Michelle A. Hsu
- Department of Immunology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Whitney Barham
- Department of Immunology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Yiyi Yan
- Division of Medical Oncology, Mayo Clinic, Jacksonville, FL, USA
| | | | - Yi Lin
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Xiaosheng Wu
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Taro Hitosugi
- Department of Oncology, Mayo Clinic, Rochester, MN, USA
| | - Dawn Owen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Michael P. Grams
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Jacob J. Orme
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Hu Zeng
- Department of Immunology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
- Department of Rheumatology, Mayo Clinic, Rochester, MN, USA
| | - Sean S. Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Haidong Dong
- Department of Immunology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
- Department of Urology, Mayo Clinic, Rochester, MN, USA
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12
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Rosenstrom A, Santana-Leitner M, Rokni S, Shumail M, Tantawi S, Kwofie J, Dewji S, Loo BW. Shielding Analysis of a Preclinical Bremsstrahlung X-ray FLASH Radiotherapy System within a Clinical Radiation Therapy Vault. HEALTH PHYSICS 2023; 125:281-288. [PMID: 37459481 PMCID: PMC10502918 DOI: 10.1097/hp.0000000000001718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
ABSTRACT A preclinical radiotherapy system producing FLASH dose rates with 12 MV bremsstrahlung x rays is being developed at Stanford University and SLAC National Accelerator Laboratory. Because of the high expected workload of 6,800 Gy w -1 at the isocenter, an efficient shielding methodology is needed to protect operators and the public while the preclinical system is operated in a radiation therapy vault designed for 6 MV x rays. In this study, an analysis is performed to assess the shielding of the local treatment head and radiation vault using the Monte Carlo code FLUKA and the empirical methodology given in the National Council on Radiation Protection and Measurements Report 151. Two different treatment head shielding designs were created to compare single-layer and multilayer shielding methodologies using high-Z and low-Z materials. The multilayered shielding methodology produced designs with a 17% reduction in neutron fluence leaking from the treatment head compared to the single layered design of the same size, resulting in a decreased effective dose to operators and the public. The conservative assumptions used in the empirical methods can lead to over-shielding when treatment heads use polyethylene or multilayered shielding. High-Z/Low-Z multilayered shielding optimized via Monte Carlo is shown to be effective in the case of treatment head shielding and provide more effective shielding design for external beam radiotherapy systems that use 12 MV bremsstrahlung photons. Modifications to empirical methods used in the assessment of MV radiotherapy systems may be warranted to capture the effects of polyethylene in treatment head shielding.
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Affiliation(s)
| | - Mario Santana-Leitner
- Radiation Protection Department, SLAC, MS 48, 2575 Sand Hill Road, Menlo Park, CA 94025
| | - Sayed Rokni
- Radiation Protection Department, SLAC, MS 48, 2575 Sand Hill Road, Menlo Park, CA 94025
| | - Muhammad Shumail
- Technology Innovation Department, SLAC, MS 48, 2575 Sand Hill Road, Menlo Park, CA 94025
| | - Sami Tantawi
- Technology Innovation Department, SLAC, MS 48, 2575 Sand Hill Road, Menlo Park, CA 94025
| | - John Kwofie
- Occupational Health Center, Stanford University ESF-480 Oak Rd, Stanford, CA 94305
| | - Shaheen Dewji
- Nuclear & Radiological Engineering & Medical Physics Programs Georgia Institute of Technology, North Ave NW, Atlanta, GA 30332
| | - Billy W Loo
- Department of Radiation Oncology and Stanford Cancer Institute, Stanford University School of Medicine, 875 Blake Wilbur Drive, Stanford CA 94305
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13
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Grams MP, Deufel CL, Kavanaugh JA, Corbin KS, Ahmed SK, Haddock MG, Lester SC, Ma DJ, Petersen IA, Finley RR, Lang KG, Spreiter SS, Park SS, Owen D. Clinical aspects of spatially fractionated radiation therapy treatments. Phys Med 2023; 111:102616. [PMID: 37311338 DOI: 10.1016/j.ejmp.2023.102616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/06/2023] [Accepted: 05/30/2023] [Indexed: 06/15/2023] Open
Abstract
PURPOSE To provide clinical guidance for centers wishing to implement photon spatially fractionated radiation therapy (SFRT) treatments using either a brass grid or volumetric modulated arc therapy (VMAT) lattice approach. METHODS We describe in detail processes which have been developed over the course of a 3-year period during which our institution treated over 240 SFRT cases. The importance of patient selection, along with aspects of simulation, treatment planning, quality assurance, and treatment delivery are discussed. Illustrative examples involving clinical cases are shown, and we discuss safety implications relevant to the heterogeneous dose distributions. RESULTS SFRT can be an effective modality for tumors which are otherwise challenging to manage with conventional radiation therapy techniques or for patients who have limited treatment options. However, SFRT has several aspects which differ drastically from conventional radiation therapy treatments. Therefore, the successful implementation of an SFRT treatment program requires the multidisciplinary expertise and collaboration of physicians, physicists, dosimetrists, and radiation therapists. CONCLUSIONS We have described methods for patient selection, simulation, treatment planning, quality assurance and delivery of clinical SFRT treatments which were built upon our experience treating a large patient population with both a brass grid and VMAT lattice approach. Preclinical research and patient trials aimed at understanding the mechanism of action are needed to elucidate which patients may benefit most from SFRT, and ultimately expand its use.
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Affiliation(s)
- Michael P Grams
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
| | - Christopher L Deufel
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - James A Kavanaugh
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Kimberly S Corbin
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Safia K Ahmed
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Michael G Haddock
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Scott C Lester
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Daniel J Ma
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Ivy A Petersen
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Randi R Finley
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Karen G Lang
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Sheri S Spreiter
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Dawn Owen
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
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14
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Galluzzi L, Aryankalayil MJ, Coleman CN, Formenti SC. Emerging evidence for adapting radiotherapy to immunotherapy. Nat Rev Clin Oncol 2023:10.1038/s41571-023-00782-x. [PMID: 37280366 DOI: 10.1038/s41571-023-00782-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 06/08/2023]
Abstract
Immunotherapy has revolutionized the clinical management of many malignancies but is infrequently associated with durable objective responses when used as a standalone treatment approach, calling for the development of combinatorial regimens with superior efficacy and acceptable toxicity. Radiotherapy, the most commonly used oncological treatment, has attracted considerable attention as a combination partner for immunotherapy owing to its well-known and predictable safety profile, widespread clinical availability, and potential for immunostimulatory effects. However, numerous randomized clinical trials investigating radiotherapy-immunotherapy combinations have failed to demonstrate a therapeutic benefit compared with either modality alone. Such a lack of interaction might reflect suboptimal study design, choice of end points and/or administration of radiotherapy according to standard schedules and target volumes. Indeed, radiotherapy has empirically evolved towards radiation doses and fields that enable maximal cancer cell killing with manageable toxicity to healthy tissues, without much consideration of potential radiation-induced immunostimulatory effects. Herein, we propose the concept that successful radiotherapy-immunotherapy combinations might require modifications of standard radiotherapy regimens and target volumes to optimally sustain immune fitness and enhance the antitumour immune response in support of meaningful clinical benefits.
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Affiliation(s)
- Lorenzo Galluzzi
- Department of Radiation Oncology, Weill Cornell Medical College, New York, NY, USA
- Sandra and Edward Meyer Cancer Center, New York, NY, USA
- Caryl and Israel Englander Institute for Precision Medicine, New York, NY, USA
| | - Molykutty J Aryankalayil
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - C Norman Coleman
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Silvia C Formenti
- Department of Radiation Oncology, Weill Cornell Medical College, New York, NY, USA.
- Sandra and Edward Meyer Cancer Center, New York, NY, USA.
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA.
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15
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Rosenstrom A, Leitner MS, Rokni SH, Shumail M, Tantawi S, Dewji S, Loo BW. Monte Carlo simulation of shielding designs for a cabinet form factor preclinical MV-energy photon FLASH radiotherapy system. Med Phys 2023; 50:3055-3065. [PMID: 36780153 DOI: 10.1002/mp.16290] [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: 02/08/2022] [Revised: 01/03/2023] [Accepted: 01/26/2023] [Indexed: 02/14/2023] Open
Abstract
PURPOSE A preclinical MV-energy photon FLASH radiotherapy system is being designed at Stanford and SLAC National Accelerator Laboratory. Because of the higher energy and dose rate compared to conventional kV-energy photon laboratory-scale irradiators, adequate shielding in a stand-alone cabinet form factor is more challenging to achieve. We present a Monte Carlo simulation of multilayered shielding for a compact self-shielding system without the need for a radiation therapy vault. METHODS A multilayered shielding approach using multiple alternating layers of high-Z and low-Z materials is applied to the self-shielded cabinet to effectively mitigate the secondary radiation produced and to allow the device to be housed in a Controlled Radiation Area outside of a radiation vault. The multilayered shielding approach takes advantage of the properties of high-Z and low-Z radiation shielding materials such as density, cross-section, atomic number of the shielding elements, and products of radiation interactions within each layer. The Monte Carlo radiation transport code, FLUKA, is used to simulate the total effective dose produced by the operation. RESULTS The multilayered shielding designs proposed and simulated produced effective dose rates significantly lower than monolayer designs with the same total material thickness at the regulatory boundary; this is accomplished through the manipulation of the locations where secondary radiation is produced and reactions due to material properties such as neutron back reflection in hydrogen. Borated polyethylene at five weight percent significantly increased the shielding performance as compared to regular polyethylene, with the magnitude of the reduction depending upon the order of the shielding material. CONCLUSIONS The multilayered shielding provides a path for shielding preclinical FLASH systems that deliver MV-energy bremsstrahlung photons. This approach promises to be more efficient with respect to the shielding material mass and space claim as compared to shielded vaults typically required for clinical radiation therapy with MV photons. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Andrew Rosenstrom
- Nuclear & Radiological Engineering & Medical Physics Programs, Georgia Institute of Technology, North Ave NW, Atlanta, GA, United States Of America.,Radiation Protection Department, SLAC, Menlo Park, CA, United States Of America
| | | | - Sayed H Rokni
- Radiation Protection Department, SLAC, Menlo Park, CA, United States Of America
| | - Muhammad Shumail
- Technology Innovation Department, SLAC, Menlo Park, CA, United States Of America
| | - Sami Tantawi
- Technology Innovation Department, SLAC, Menlo Park, CA, United States Of America
| | - Shaheen Dewji
- Nuclear & Radiological Engineering & Medical Physics Programs, Georgia Institute of Technology, North Ave NW, Atlanta, GA, United States Of America
| | - Billy W Loo
- Department of Radiation Oncology and Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, United States Of America
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16
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Hatoum GF, Temple HT, Garcia SA, Zheng Y, Kfoury F, Kinley J, Wu X. Neoadjuvant Radiation Therapy with Interdigitated High-Dose LRT for Voluminous High-Grade Soft-Tissue Sarcoma. Cancer Manag Res 2023; 15:113-122. [PMID: 36776730 PMCID: PMC9910204 DOI: 10.2147/cmar.s393934] [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: 10/18/2022] [Accepted: 01/18/2023] [Indexed: 02/05/2023] Open
Abstract
Purpose To report a case of large extremity soft tissue sarcoma (2933 cc), safely treated with a novel approach of interdigitating high-dose LATTICE radiation therapy (LRT) with standard radiation therapy as a neoadjuvant treatment to surgery. Patients and Methods Four sessions of high-dose LRT were delivered in a weekly interval, interdigitated with standard radiation therapy. The LRT plan consisted of 15 high-dose vertices receiving a dose >12 Gy per session, with 2-3 Gy to the peripheral margin of the tumor. The patient underwent surgical excision 2 months after the new regimen of induction radiation therapy. Results and Discussion The patient tolerated the radiation therapy regimen well. The post-operative assessment revealed a negative surgical margin and over 95% necrosis of the total tumor volume. The post-surgical wound complication was mitigated by outpatient wound care. Interdigitating multiple sessions of high-dose LATTICE radiation treatments with standard neoadjuvant radiation therapy as a neoadjuvant therapy for soft tissue sarcoma was feasible and did not incur additional toxicity in this clinical case. A phase-I/II trial will be conducted to further evaluate the toxicity and efficacy of the new treatment strategy with the intent to increase the rate of pathologic necrosis, which has been shown to positively correlate with the overall survival.
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Affiliation(s)
- Georges F Hatoum
- Department of Radiation Oncology, HCA Florida JFK Medical Center Comprehensive Cancer Institute, Lake Worth, FL, USA
| | - H Thomas Temple
- Department of Orthopedic Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Silvio A Garcia
- Department of Radiation Oncology, HCA Florida JFK Medical Center Comprehensive Cancer Institute, Lake Worth, FL, USA
| | - Yi Zheng
- Department of Radiation Oncology, HCA Florida JFK Medical Center Comprehensive Cancer Institute, Lake Worth, FL, USA,Department of Research and Development, Executive Medical Physics Associates, North Miami Beach, FL, USA
| | - Fouad Kfoury
- Pharmacy Department, South Miami Hospital, South Miami, FL, USA
| | - Jill Kinley
- Department of Clinical Research, HCA Florida JFK Medical Center, Atlantis, FL, USA
| | - Xiaodong Wu
- Department of Radiation Oncology, HCA Florida JFK Medical Center Comprehensive Cancer Institute, Lake Worth, FL, USA,Department of Research and Development, Executive Medical Physics Associates, North Miami Beach, FL, USA,Correspondence: Xiaodong Wu, Executive Medical Physics Associates, 19470 NE 22nd Road, North Miami Beach, FL, 33179, USA, Tel +1 305 775 0333, Email
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17
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Ji X, Jiang W, Wang J, Zhou B, Ding W, Liu S, Huang H, Chen G, Sun X. Application of individualized multimodal radiotherapy combined with immunotherapy in metastatic tumors. Front Immunol 2023; 13:1106644. [PMID: 36713375 PMCID: PMC9877461 DOI: 10.3389/fimmu.2022.1106644] [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: 11/24/2022] [Accepted: 12/22/2022] [Indexed: 01/14/2023] Open
Abstract
Radiotherapy is one of the mainstays of cancer treatment. More than half of cancer patients receive radiation therapy. In addition to the well-known direct tumoricidal effect, radiotherapy has immunomodulatory properties. When combined with immunotherapy, radiotherapy, especially high-dose radiotherapy (HDRT), exert superior systemic effects on distal and unirradiated tumors, which is called abscopal effect. However, these effects are not always effective for cancer patients. Therefore, many studies have focused on exploring the optimized radiotherapy regimens to further enhance the antitumor immunity of HDRT and reduce its immunosuppressive effect. Several studies have shown that low-dose radiotherapy (LDRT) can effectively reprogram the tumor microenvironment, thereby potentially overcoming the immunosuppressive stroma induced by HDRT. However, bridging the gap between preclinical commitment and effective clinical delivery is challenging. In this review, we summarized the existing studies supporting the combined use of HDRT and LDRT to synergistically enhance antitumor immunity, and provided ideas for the individualized clinical application of multimodal radiotherapy (HDRT+LDRT) combined with immunotherapy.
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18
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Li H, Luo Q, Zhang H, Ma X, Gu Z, Gong Q, Luo K. Nanomedicine embraces cancer radio-immunotherapy: mechanism, design, recent advances, and clinical translation. Chem Soc Rev 2023; 52:47-96. [PMID: 36427082 DOI: 10.1039/d2cs00437b] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Cancer radio-immunotherapy, integrating external/internal radiation therapy with immuno-oncology treatments, emerges in the current management of cancer. A growing number of pre-clinical studies and clinical trials have recently validated the synergistic antitumor effect of radio-immunotherapy, far beyond the "abscopal effect", but it suffers from a low response rate and toxicity issues. To this end, nanomedicines with an optimized design have been introduced to improve cancer radio-immunotherapy. Specifically, these nanomedicines are elegantly prepared by incorporating tumor antigens, immuno- or radio-regulators, or biomarker-specific imaging agents into the corresponding optimized nanoformulations. Moreover, they contribute to inducing various biological effects, such as generating in situ vaccination, promoting immunogenic cell death, overcoming radiation resistance, reversing immunosuppression, as well as pre-stratifying patients and assessing therapeutic response or therapy-induced toxicity. Overall, this review aims to provide a comprehensive landscape of nanomedicine-assisted radio-immunotherapy. The underlying working principles and the corresponding design strategies for these nanomedicines are elaborated by following the concept of "from bench to clinic". Their state-of-the-art applications, concerns over their clinical translation, along with perspectives are covered.
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Affiliation(s)
- Haonan Li
- Department of Radiology, Department of Biotherapy, Huaxi MR Research Center (HMRRC), Cancer Center, Frontiers Science Center for Disease-Related Molecular Network, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu 610041, China.
| | - Qiang Luo
- Department of Radiology, Department of Biotherapy, Huaxi MR Research Center (HMRRC), Cancer Center, Frontiers Science Center for Disease-Related Molecular Network, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu 610041, China.
| | - Hu Zhang
- Amgen Bioprocessing Centre, Keck Graduate Institute, Claremont, CA 91711, USA
| | - Xuelei Ma
- Department of Radiology, Department of Biotherapy, Huaxi MR Research Center (HMRRC), Cancer Center, Frontiers Science Center for Disease-Related Molecular Network, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu 610041, China.
| | - Zhongwei Gu
- Department of Radiology, Department of Biotherapy, Huaxi MR Research Center (HMRRC), Cancer Center, Frontiers Science Center for Disease-Related Molecular Network, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu 610041, China.
| | - Qiyong Gong
- Department of Radiology, Department of Biotherapy, Huaxi MR Research Center (HMRRC), Cancer Center, Frontiers Science Center for Disease-Related Molecular Network, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu 610041, China. .,Functional and Molecular Imaging Key Laboratory of Sichuan Province and Research Unit of Psychoradiology, Chinese Academy of Medical Sciences, Chengdu 610041, China
| | - Kui Luo
- Department of Radiology, Department of Biotherapy, Huaxi MR Research Center (HMRRC), Cancer Center, Frontiers Science Center for Disease-Related Molecular Network, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu 610041, China. .,Functional and Molecular Imaging Key Laboratory of Sichuan Province and Research Unit of Psychoradiology, Chinese Academy of Medical Sciences, Chengdu 610041, China
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19
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Hara D, Tao W, Schmidt RM, Yang YP, Daunert S, Dogan N, Ford JC, Pollack A, Shi J. Boosted Radiation Bystander Effect of PSMA-Targeted Gold Nanoparticles in Prostate Cancer Radiosensitization. NANOMATERIALS (BASEL, SWITZERLAND) 2022; 12:4440. [PMID: 36558293 PMCID: PMC9784958 DOI: 10.3390/nano12244440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/05/2022] [Accepted: 12/09/2022] [Indexed: 06/17/2023]
Abstract
Metal nanoparticles are effective radiosensitizers that locally enhance radiation doses in targeted cancer cells. Compared with other metal nanoparticles, gold nanoparticles (GNPs) exhibit high biocompatibility, low toxicity, and they increase secondary electron scatter. Herein, we investigated the effects of active-targeting GNPs on the radiation-induced bystander effect (RIBE) in prostate cancer cells. The impact of GNPs on the RIBE presents implications for secondary cancers or spatially fractionated radiotherapy treatments. Anti-prostate-specific membrane antigen (PSMA) antibodies were conjugated with PEGylated GNPs through EDC-NHS chemistry. The media transfer technique was performed to induce the RIBE on the non-irradiated bystander cells. This study focused on the LNCaP cell line, because it can model a wide range of stages relating to prostate cancer progression, including the transition from androgen dependence to castration resistance and bone metastasis. First, LNCaP cells were pretreated with phosphate buffered saline (PBS) or PSMA-targeted GNPs (PGNPs) for 24 h and irradiated with 160 kVp X-rays (0-8 Gy). Following that, the collected culture media were filtered (sterile 0.45 µm polyethersulfone) in order to acquire PBS- and PGNP- conditioned media (CM). Then, PBS- and PGNP-CM were transferred to the bystander cells that were loaded with/without PGNPs. MTT, γ-H2AX, clonogenic assays and reactive oxygen species assessments were performed to compare RIBE responses under different treatments. Compared with 2 Gy-PBS-CM, 8 Gy-PBS-CM demonstrated a much higher RIBE response, thus validating the dose dependence of RIBE in LNCaP cells. Compared with PBS-CM, PGNP-CM exhibited lower cell viability, higher DNA damage, and a smaller survival fraction. In the presence of PBS-CM, bystander cells loaded with PGNPs showed increased cell death compared with cells that did not have PGNPs. These results demonstrate the PGNP-boosted expression and sensitivity of RIBE in prostate cancer cells.
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Affiliation(s)
- Daiki Hara
- Department of Radiation Oncology, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
- Department of Biomedical Engineering, College of Engineering, University of Miami, Miami, FL 33146, USA
| | - Wensi Tao
- Department of Radiation Oncology, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | - Ryder M. Schmidt
- Department of Radiation Oncology, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
- Department of Biomedical Engineering, College of Engineering, University of Miami, Miami, FL 33146, USA
| | - Yu-Ping Yang
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
- Department of Biochemistry and Molecular Biology, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | - Sylvia Daunert
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
- Department of Biochemistry and Molecular Biology, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | - Nesrin Dogan
- Department of Radiation Oncology, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
- Department of Biomedical Engineering, College of Engineering, University of Miami, Miami, FL 33146, USA
| | - John Chetley Ford
- Department of Radiation Oncology, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
- Department of Biomedical Engineering, College of Engineering, University of Miami, Miami, FL 33146, USA
| | - Alan Pollack
- Department of Radiation Oncology, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | - Junwei Shi
- Department of Radiation Oncology, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
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20
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Whelan B, Trovati S, Wang J, Fahrig R, Maxim PG, Hanuka A, Shumail M, Tantawi S, Merrick J, Perl J, Keall P, Loo BW. Bayesian optimization to design a novel x-ray shaping device. Med Phys 2022; 49:7623-7637. [PMID: 35904020 DOI: 10.1002/mp.15887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 06/23/2022] [Accepted: 07/12/2022] [Indexed: 12/27/2022] Open
Abstract
PURPOSE In radiation therapy, x-ray dose must be precisely sculpted to the tumor, while simultaneously avoiding surrounding organs at risk. This requires modulation of x-ray intensity in space and/or time. Typically, this is achieved using a multi leaf collimator (MLC)-a complex mechatronic device comprising over one hundred individually powered tungsten 'leaves' that move in or out of the radiation field as required. Here, an all-electronic x-ray collimation concept with no moving parts is presented, termed "SPHINX": Scanning Pencil-beam High-speed Intensity-modulated X-ray source. SPHINX utilizes a spatially distributed bremsstrahlung target and collimator array in conjunction with magnetic scanning of a high energy electron beam to generate a plurality of small x-ray "beamlets." METHODS A simulation framework was developed in Topas Monte Carlo incorporating a phase space electron source, transport through user defined magnetic fields, bremsstrahlung x-ray production, transport through a SPHINX collimator, and dose in water. This framework was completely parametric, meaning a simulation could be built and run for any supplied geometric parameters. This functionality was coupled with Bayesian optimization to find the best parameter set based on an objective function which included terms to maximize dose rate for a user defined beamlet width while constraining inter-channel cross talk and electron contamination. Designs for beamlet widths of 5, 7, and 10 mm2 were generated. Each optimization was run for 300 iterations and took approximately 40 h on a 24-core computer. For the optimized 7-mm model, a simulation of all beamlets in water was carried out including a linear scanning magnet calibration simulation. Finally, a back-of-envelope dose rate formalism was developed and used to estimate dose rate under various conditions. RESULTS The optimized 5-, 7-, and 10-mm models had beamlet widths of 5.1 , 7.2 , and 10.1 mm2 and dose rates of 3574, 6351, and 10 015 Gy/C, respectively. The reduction in dose rate for smaller beamlet widths is a result of both increased collimation and source occlusion. For the simulation of all beamlets in water, the scanning magnet calibration reduced the offset between the collimator channels and beam centroids from 2.9 ±1.9 mm to 0.01 ±0.03 mm. A slight reduction in dose rate of approximately 2% per degree of scanning angle was observed. Based on a back-of-envelope dose rate formalism, SPHINX in conjunction with next-generation linear accelerators has the potential to achieve substantially higher dose rates than conventional MLC-based delivery, with delivery of an intensity modulated 100 × 100 mm2 field achievable in 0.9 to 10.6 s depending on the beamlet widths used. CONCLUSIONS Bayesian optimization was coupled with Monte Carlo modeling to generate SPHINX geometries for various beamlet widths. A complete Monte Carlo simulation for one of these designs was developed, including electron beam transport of all beamlets through scanning magnets, x-ray production and collimation, and dose in water. These results demonstrate that SPHINX is a promising candidate for sculpting radiation dose with no moving parts, and has the potential to vastly improve both the speed and robustness of radiotherapy delivery. A multi-beam SPHINX system may be a candidate for delivering magavoltage FLASH RT in humans.
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Affiliation(s)
- Brendan Whelan
- ACRF Image-X Institute, School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.,Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California, USA
| | - Stefania Trovati
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California, USA.,Lawrence Berkeley National Laboratory, Berkeley, California, USA
| | - Jinghui Wang
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California, USA.,Varian Medical Systems, Palo Alto, California, USA
| | - Rebecca Fahrig
- Innovation, Advanced Therapies, Siemens Healthineers, Forchheim, Germany.,Department of Computer Science 5, Friedrich-Alexander Universitat, Erlangen, Germany
| | - Peter G Maxim
- Department of Radiation Oncology, University of California, Irvine, California, USA
| | - Adi Hanuka
- SLAC National Accelerator Laboratory, Menlo Park, California, USA
| | - Muhammad Shumail
- SLAC National Accelerator Laboratory, Menlo Park, California, USA
| | - Sami Tantawi
- SLAC National Accelerator Laboratory, Menlo Park, California, USA.,Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California, USA
| | - Julian Merrick
- SLAC National Accelerator Laboratory, Menlo Park, California, USA
| | - Joseph Perl
- SLAC National Accelerator Laboratory, Menlo Park, California, USA
| | - Paul Keall
- ACRF Image-X Institute, School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Billy W Loo
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California, USA.,Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California, USA
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21
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Xu C, Shang Z, Najafi M. Lung Pneumonitis and Fibrosis in Cancer Therapy: A Review on Cellular and Molecular Mechanisms. Curr Drug Targets 2022; 23:1505-1525. [PMID: 36082868 DOI: 10.2174/1389450123666220907144131] [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: 06/09/2022] [Revised: 07/05/2022] [Accepted: 08/02/2022] [Indexed: 01/25/2023]
Abstract
Fibrosis and pneumonitis are the most important side effects of lung tissue following cancer therapy. Radiotherapy and chemotherapy by some drugs, such as bleomycin, can induce pneumonitis and fibrosis. Targeted therapy and immunotherapy also may induce pneumonitis and fibrosis to a lesser extent compared to chemotherapy and radiotherapy. Activation of lymphocytes by immunotherapy or infiltration of inflammatory cells such as macrophages, lymphocytes, neutrophils, and mast cells following chemo/radiation therapy can induce pneumonitis. Furthermore, the polarization of macrophages toward M2 cells and the release of anti-inflammatory cytokines stimulate fibrosis. Lung fibrosis and pneumonitis may also be potentiated by some other changes such as epithelial-mesenchymal transition (EMT), oxidative stress, reduction/oxidation (redox) responses, renin-angiotensin system, and the upregulation of some inflammatory mediators such as a nuclear factor of kappa B (NF-κB), inflammasome, cyclooxygenase-2 (COX-2), and inducible nitric oxide synthase (iNOS). Damages to the lung vascular system and the induction of hypoxia also can induce pulmonary injury following chemo/radiation therapy. This review explains various mechanisms of the induction of pneumonitis and lung fibrosis following cancer therapy. Furthermore, the targets and promising agents to mitigate lung fibrosis and pneumonitis will be discussed.
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Affiliation(s)
- Chaofeng Xu
- Zhuji People's Hospital of Zhejiang Province, Zhuji Affiliated Hospital of Shaoxing University, Zhuji, Zhejiang, 311800, China
| | - Zhongtu Shang
- Zhuji People's Hospital of Zhejiang Province, Zhuji Affiliated Hospital of Shaoxing University, Zhuji, Zhejiang, 311800, China
| | - Masoud Najafi
- Medical Technology Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran.,Radiology and Nuclear Medicine Department, School of Paramedical Sciences, Kermanshah University of Medical Sciences, Kermanshah, Iran
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22
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Xiao Z, Zhang Y, Speth J, Lee E, Mascia A, Lamba M. Evaluation of a conventionally shielded proton treatment room for FLASH radiotherapy. Med Phys 2022; 49:6765-6773. [PMID: 36114793 PMCID: PMC10091931 DOI: 10.1002/mp.15964] [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: 05/05/2022] [Revised: 07/27/2022] [Accepted: 08/28/2022] [Indexed: 12/13/2022] Open
Abstract
PURPOSE FLASH radiotherapy (FLASH-RT) is the potential for a major breakthrough in cancer care, as preclinical results have shown significantly reduced toxicities to healthy tissues while maintaining excellent tumor control. However, FLASH conditions were not considered in the current proton facilities' shielding designs. The purpose of this study is to validate the adequacy of conventionally shielded proton rooms used for FLASH-RT. METHODS Clinical FLASH irradiations typically take place in a few 100 ms, orders of magnitude shorter than the response time of the wide-energy neutron detector (WENDI-II). The nozzle beam current (representing the dose rate) dependence of the WENDI-II detector response was empirically determined to stabilize with a beam current of ≤10 nA at the measurement point with the highest dose rate. A large, predefined proton transmission FLASH plan (250 MeV, 7 × 20 cm2 , 8 Gy at isocenter) was commissioned as part of a FLASH clinical trial. For purpose of this study, that field was adjusted from 250 to 244 MeV, allowing a lower beam current of 10 nA to provide reliable detector response. Radiation surveys were performed for the proton beams with/without extra beam stopper (30 × 30 × 40-cm3 solid water slabs) at 0°, 90°, 180°, and 270° gantry angles. RESULTS Ambient doses were recorded at seven different locations. A 170-nA beam current, commonly used for clinical FLASH plans, was chosen to normalize the average ambient dose rate to FLASH conditions. Assuming 200-Gy/h workload (25 FLASH beams, 8 Gy/beam), annual occupational dose at controlled areas was calculated. For all gantry angles, ≤0.4 mSv/year is expected at treatment room door. The highest ambient dose, 2.46 mSv/year, ∼5% of the maximum annual permissible occupational dose, was identified at the isocenter of the adjacent treatment room with 90° gantry. CONCLUSION These survey results indicate that our conventionally shielded proton rotating gantry rooms result in acceptable occupational and public doses when the transmission FLASH beams delivered at four cardinal gantry angles based on 200-Gy/h workload assumption. These findings support that FLASH clinical trials in our conventionally shielded proton facilities can be safely implemented.
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Affiliation(s)
- Zhiyan Xiao
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Yongbin Zhang
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Joseph Speth
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Eunsin Lee
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Anthony Mascia
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Michael Lamba
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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23
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Validation of Monte Carlo-based calculations for megavolt electron beams for IORT and FLASH-IORT. Heliyon 2022; 8:e10682. [PMID: 36185136 PMCID: PMC9519483 DOI: 10.1016/j.heliyon.2022.e10682] [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: 03/23/2022] [Revised: 05/18/2022] [Accepted: 09/13/2022] [Indexed: 11/20/2022] Open
Abstract
In Intra-Operative Radiation Therapy (IORT) the tumour site is surgically exposed and normal tissue located around the tumour may be avoided. Electron applicators would require large surgical incisions; therefore, the preferred mechanism for beam collimation is the IORT cone system. FLASH radiotherapy (FLASH-RT) involves the treatment of tumours at ultra-high dose rates and the IORT cone system can also be used. This study validates the Monte Carlo-based calculations for these small electron beams to accurately determine the dose characteristics of each possible cone-energy combination as well as custom-built alloy cutouts attached to the end of the IORT cone. This will contribute to accurate dose distribution and output factor calculations that are essential to all radiation therapy treatments. A Monte Carlo (MC) model was modelled for electron beams produced by a Siemens Primus LINAC and the IORT cones. The accelerator was built with the component modules available in the BEAMnrc code. The phase-space file generated by the BEAM simulation was used as the source input for the subsequent DOSXYZnrc simulations. Percentage Depth Dose (PDD) data and profiles were extracted from the dose distributions obtained with the DOSXYZnrc simulations. These beam characteristics were compared with measured data for 6, 12, and 18 MeV electron beams for the IORT open cones of diameters 19, 45, and 64 mm and irregularly shaped cutouts. The MC simulations could replicate electron beams within a criterion of 3%/3 mm. Applicator factors were within 0.7%, and cone factors showed good agreement, except for the 9 mm cone size. Based on the successful comparisons between measurement and MC-calculated dose distributions, output factors for the open cones and for small irregularly shaped IORT beams, it may be concluded that the Monte Carlo based dose calculation could replicate electron beams used for IORT and FLASH-IORT.
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24
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An International Consensus on the Design of Prospective Clinical–Translational Trials in Spatially Fractionated Radiation Therapy for Advanced Gynecologic Cancer. Cancers (Basel) 2022; 14:cancers14174267. [PMID: 36077802 PMCID: PMC9454841 DOI: 10.3390/cancers14174267] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/22/2022] [Accepted: 08/24/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Spatially fractionated radiation therapy (SFRT) delivers intentionally heterogenous dose to tumors. This is a major departure from current radiation therapy, which strives for uniform dose. Early pilot experience suggests promising treatment outcomes with SFRT in patients with challenging bulky tumors, including gynecologic cancer. Well-conducted prospective multi-institutional clinical trials are now needed to further test SFRT as a treatment modality. However, clinical trial development is hampered by the variabilities in SFRT approach and the overall unfamiliarity with heterogeneous dosing. A broad consensus among SFRT experts, potential investigators, and the wider radiation oncology community is needed so that clinical trials in SFRT can be successfully designed and carried out. We developed an international consensus guideline for the design parameters of clinical/translational trials in SFRT for gynecologic cancer. High-to-moderate consensus was achieved, and harmonized fundamental design parameters for SFRT trials in advanced gynecologic cancer were defined. Abstract Despite the unexpectedly high tumor responses and limited treatment-related toxicities observed with SFRT, prospective multi-institutional clinical trials of SFRT are still lacking. High variability of SFRT technologies and methods, unfamiliar complex dose and prescription concepts for heterogeneous dose and uncertainty regarding systemic therapies present major obstacles towards clinical trial development. To address these challenges, the consensus guideline reported here aimed at facilitating trial development and feasibility through a priori harmonization of treatment approach and the full range of clinical trial design parameters for SFRT trials in gynecologic cancer. Gynecologic cancers were evaluated for the status of SFRT pilot experience. A multi-disciplinary SFRT expert panel for gynecologic cancer was established to develop the consensus through formal panel review/discussions, appropriateness rank voting and public comment solicitation/review. The trial design parameters included eligibility/exclusions, endpoints, SFRT technology/technique, dose/dosimetric parameters, systemic therapies, patient evaluations, and embedded translational science. Cervical cancer was determined as the most suitable gynecologic tumor for an SFRT trial. Consensus emphasized standardization of SFRT dosimetry/physics parameters, biologic dose modeling, and specimen collection for translational/biological endpoints, which may be uniquely feasible in cervical cancer. Incorporation of brachytherapy into the SFRT regimen requires additional pre-trial pilot investigations. Specific consensus recommendations are presented and discussed.
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25
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Impressive Results after "Metabolism-Guided" Lattice Irradiation in Patients Submitted to Palliative Radiation Therapy: Preliminary Results of LATTICE_01 Multicenter Study. Cancers (Basel) 2022; 14:cancers14163909. [PMID: 36010902 PMCID: PMC9406022 DOI: 10.3390/cancers14163909] [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: 07/09/2022] [Revised: 08/05/2022] [Accepted: 08/11/2022] [Indexed: 11/17/2022] Open
Abstract
Purpose: To evaluate feasibility, toxicities, and clinical response in Stage IV patients treated with palliative “metabolism-guided” lattice technique. Patients and Methods: From June 2020 to December 2021, 30 consecutive clinical stage IV patients with 31 bulky lesions were included in this study. All patients received palliative irradiation consisting of a spatially fractionated high radiation dose delivered in spherical deposits (vertices, Vs) within the bulky disease. The Vs were placed at the edges of tumor areas with different metabolisms at the PET exam following a non-geometric arrangement. Precisely, the Vs overlapped the interfaces between the tumor areas of higher 18F-FDG uptake (>75% SUV max) and areas with lower 18F-FDG uptake. A median dose of 15 Gy/1 fraction (range 10−27 Gy in 1/3 fractions) was delivered to the Vs. Within 7 days after the Vs boost, all the gross tumor volume (GTV) was homogeneously treated with hypo-fractionated radiation therapy (RT). Results: The rate of symptomatic response was 100%, and it was observed immediately after lattice RT delivery in 3/30 patients, while 27/30 patients had a symptomatic response within 8 days from the end of GTV irradiation. Radiation-related acute grade ≥1 toxicities were observed in 6/30 (20%) patients. The rate of overall clinical response was 89%, including 23% of complete remission. The 1-year overall survival rate was 86.4%. Conclusions: “Metabolism-guided” lattice radiotherapy is feasible and well-tolerated, being able to yield very impressive results both in terms of symptom relief and overall clinical response rate in stage IV bulky disease patients. These preliminary results seem to indicate that this kind of therapy could emerge as the best therapeutic option for this patient setting.
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26
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Schneider T, Fernandez-Palomo C, Bertho A, Fazzari J, Iturri L, Martin OA, Trappetti V, Djonov V, Prezado Y. Combining FLASH and spatially fractionated radiation therapy: The best of both worlds. Radiother Oncol 2022; 175:169-177. [PMID: 35952978 DOI: 10.1016/j.radonc.2022.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 07/23/2022] [Accepted: 08/03/2022] [Indexed: 11/16/2022]
Abstract
FLASH radiotherapy (FLASH-RT) and spatially fractionated radiation therapy (SFRT) are two new therapeutical strategies that use non-standard dose delivery methods to reduce normal tissue toxicity and increase the therapeutic index. Although likely based on different mechanisms, both FLASH-RT and SFRT have shown to elicit radiobiological effects that significantly differ from those induced by conventional radiotherapy. With the therapeutic potential having been established separately for each technique, the combination of FLASH-RT and SFRT could therefore represent a winning alliance. In this review, we discuss the state of the art, advantages and current limitations, potential synergies, and where a combination of these two techniques could be implemented today or in the near future.
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Affiliation(s)
- Tim Schneider
- Institut Curie, Université PSL, CNRS UMR3347, Inserm U1021, Signalisation Radiobiologie et Cancer, 91400 Orsay, France; Université Paris-Saclay, CNRS UMR3347, Inserm U1021, Signalisation Radiobiologie et Cancer, 91400 Orsay, France
| | | | - Annaïg Bertho
- Institut Curie, Université PSL, CNRS UMR3347, Inserm U1021, Signalisation Radiobiologie et Cancer, 91400 Orsay, France; Université Paris-Saclay, CNRS UMR3347, Inserm U1021, Signalisation Radiobiologie et Cancer, 91400 Orsay, France
| | - Jennifer Fazzari
- Institute of Anatomy, University of Bern, Baltzerstrasse 2, 3012 Bern, Switzerland
| | - Lorea Iturri
- Institut Curie, Université PSL, CNRS UMR3347, Inserm U1021, Signalisation Radiobiologie et Cancer, 91400 Orsay, France; Université Paris-Saclay, CNRS UMR3347, Inserm U1021, Signalisation Radiobiologie et Cancer, 91400 Orsay, France
| | - Olga A Martin
- Institute of Anatomy, University of Bern, Baltzerstrasse 2, 3012 Bern, Switzerland; Division of Radiation Oncology, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC 3000, Australia; University of Melbourne, Parkville, VIC 3010, Australia
| | - Verdiana Trappetti
- Institute of Anatomy, University of Bern, Baltzerstrasse 2, 3012 Bern, Switzerland
| | - Valentin Djonov
- Institute of Anatomy, University of Bern, Baltzerstrasse 2, 3012 Bern, Switzerland
| | - Yolanda Prezado
- Institut Curie, Université PSL, CNRS UMR3347, Inserm U1021, Signalisation Radiobiologie et Cancer, 91400 Orsay, France; Université Paris-Saclay, CNRS UMR3347, Inserm U1021, Signalisation Radiobiologie et Cancer, 91400 Orsay, France.
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Microbeam Radiation Therapy controls local growth of radioresistant melanoma and treats out-of-field locoregional metastasis. Int J Radiat Oncol Biol Phys 2022; 114:478-493. [DOI: 10.1016/j.ijrobp.2022.06.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 06/17/2022] [Accepted: 06/24/2022] [Indexed: 11/21/2022]
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Fernandez-Palomo C, Chang S, Prezado Y. Should Peak Dose Be Used to Prescribe Spatially Fractionated Radiation Therapy?-A Review of Preclinical Studies. Cancers (Basel) 2022; 14:cancers14153625. [PMID: 35892895 PMCID: PMC9330631 DOI: 10.3390/cancers14153625] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/20/2022] [Accepted: 07/21/2022] [Indexed: 12/04/2022] Open
Abstract
Spatially fractionated radiotherapy (SFRT) is characterized by the coexistence of multiple hot and cold dose subregions throughout the treatment volume. In preclinical studies using single-fraction treatment, SFRT can achieve a significantly higher therapeutic index than conventional radiotherapy (RT). Published clinical studies of SFRT followed by RT have reported promising results for bulky tumors. Several clinical trials are currently underway to further explore the clinical benefits of SFRT. However, we lack the important understanding of the correlation between dosimetric parameters and treatment response that we have in RT. In this work, we reviewed and analyzed this important correlation from previous preclinical SFRT studies. We reviewed studies prior to 2022 that treated animal-bearing tumors with minibeam radiotherapy (MBRT) or microbeam radiotherapy (MRT). Eighteen studies met our selection criteria. Increased lifespan (ILS) relative to control was used as the treatment response. The preclinical SFRT dosimetric parameters analyzed were peak dose, valley dose, average dose, beam width, and beam spacing. We found that valley dose was the dosimetric parameter with the strongest correlation with ILS (p-value < 0.01). For studies using MRT, average dose and peak dose were also significantly correlated with ILS (p-value < 0.05). This first comprehensive review of preclinical SFRT studies shows that the valley dose (rather than the peak dose) correlates best with treatment outcome (ILS).
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Affiliation(s)
| | - Sha Chang
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC 27599-7512, USA
- Correspondence:
| | - Yolanda Prezado
- Institut Curie, Université PSL, CNRS UMR3347, Inserm U1021, Signalisation Radiobiologie et Cancer, 91400 Orsay, France;
- Université Paris-Saclay, CNRS UMR3347, Inserm U1021, Signalisation Radiobiologie et Cancer, 91400 Orsay, France
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29
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Norman Coleman C, Mayr N. Tribulations and Trials: The Implementation of Biologically Dependent Radiation Therapy Technologies. Int J Radiat Oncol Biol Phys 2022; 113:701-704. [PMID: 35595576 DOI: 10.1016/j.ijrobp.2022.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 04/09/2022] [Indexed: 11/19/2022]
Affiliation(s)
- C Norman Coleman
- Radiation Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
| | - Nina Mayr
- College of Human Medicine, Michigan State University, East Lansing, Michigan
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Towards the virtual tumor for optimizing radiotherapy treatments of hypoxic tumors: a novel model of heterogeneous tissue vasculature and oxygenation. J Theor Biol 2022; 547:111175. [DOI: 10.1016/j.jtbi.2022.111175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 05/14/2022] [Accepted: 05/24/2022] [Indexed: 11/23/2022]
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Grams MP, Tseung HSWC, Ito S, Zhang Y, Owen D, Park SS, Ahmed SK, Petersen IA, Haddock MG, Harmsen WS, Ma DJ. A Dosimetric Comparison of Lattice, Brass, and Proton Grid Therapy Treatment Plans. Pract Radiat Oncol 2022; 12:e442-e452. [DOI: 10.1016/j.prro.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 02/28/2022] [Accepted: 03/09/2022] [Indexed: 11/28/2022]
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Moghaddasi L, Reid P, Bezak E, Marcu LG. Radiobiological and Treatment-Related Aspects of Spatially Fractionated Radiotherapy. Int J Mol Sci 2022; 23:3366. [PMID: 35328787 PMCID: PMC8954016 DOI: 10.3390/ijms23063366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 03/13/2022] [Accepted: 03/17/2022] [Indexed: 11/17/2022] Open
Abstract
The continuously evolving field of radiotherapy aims to devise and implement techniques that allow for greater tumour control and better sparing of critical organs. Investigations into the complexity of tumour radiobiology confirmed the high heterogeneity of tumours as being responsible for the often poor treatment outcome. Hypoxic subvolumes, a subpopulation of cancer stem cells, as well as the inherent or acquired radioresistance define tumour aggressiveness and metastatic potential, which remain a therapeutic challenge. Non-conventional irradiation techniques, such as spatially fractionated radiotherapy, have been developed to tackle some of these challenges and to offer a high therapeutic index when treating radioresistant tumours. The goal of this article was to highlight the current knowledge on the molecular and radiobiological mechanisms behind spatially fractionated radiotherapy and to present the up-to-date preclinical and clinical evidence towards the therapeutic potential of this technique involving both photon and proton beams.
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Affiliation(s)
- Leyla Moghaddasi
- Department of Medical Physics, Austin Health, Ballarat, VIC 3350, Australia;
- School of Physical Sciences, University of Adelaide, Adelaide, SA 5001, Australia;
| | - Paul Reid
- Radiation Health, Environment Protection Authority, Adelaide, SA 5000, Australia;
| | - Eva Bezak
- School of Physical Sciences, University of Adelaide, Adelaide, SA 5001, Australia;
- Cancer Research Institute, University of South Australia, Adelaide, SA 5001, Australia
| | - Loredana G. Marcu
- Cancer Research Institute, University of South Australia, Adelaide, SA 5001, Australia
- Faculty of Informatics and Science, University of Oradea, 1 Universitatii Str., 410087 Oradea, Romania
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Buchsbaum JC, Espey MG, Obcemea C, Capala J, Ahmed M, Prasanna PG, Vikram B, Hong JA, Teicher B, Aryankalayil MJ, Bylicky MA, Coleman CN. Tumor Heterogeneity Research and Innovation in Biologically Based Radiation Therapy From the National Cancer Institute Radiation Research Program Portfolio. J Clin Oncol 2022; 40:1861-1869. [PMID: 35245101 DOI: 10.1200/jco.21.02579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Gonçalves Jorge P, Grilj V, Bourhis J, Vozenin M, Germond J, Bochud F, Bailat C, Moeckli R. Technical note: Validation of an ultrahigh dose rate pulsed electron beam monitoring system using a current transformer for FLASH preclinical studies. Med Phys 2022; 49:1831-1838. [PMID: 35066878 PMCID: PMC9303205 DOI: 10.1002/mp.15474] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 12/20/2021] [Accepted: 01/07/2021] [Indexed: 11/07/2022] Open
Abstract
PURPOSE The Oriatron eRT6 is a linear accelerator (linac) used in FLASH preclinical studies able to reach dose rates ranging from conventional (CONV) up to ultrahigh (UHDR). This work describes the implementation of commercially available beam current transformers (BCTs) as online monitoring tools compatible with CONV and UHDR irradiations for preclinical FLASH studies. METHODS Two BCTs were used to measure the output of the Oriatron eRT6 linac. First, the correspondence between the set nominal beam parameters and those measured by the BCTs was checked. Then, we established the relationship between the total exit charge (measured by BCTs) and the absorbed dose to water. The influence of the pulse width (PW) and the pulse repetition frequency (PRF) at UHDR was characterized, as well as the short- and long-term stabilities of the relationship between the exit charge and the dose at CONV and UHDR. RESULTS The BCTs were able to determine consistently the number of pulses, PW, and PRF. For fixed PW and pulse height, the exit charge measured from BCTs was correlated with the dose, and linear relationships were found with uncertainties of 0.5 % and 3 % in CONV and UHDR mode, respectively. Short- and long-term stabilities of the dose-to-charge ratio were below 1.6 %. CONCLUSIONS We implemented commercially available BCTs and demonstrated their ability to act as online beam monitoring systems to support FLASH preclinical studies with CONV and UHDR irradiations. The implemented BCTs support dosimetric measurements, highlight variations among multiple measurements in a row, enable monitoring of the physics parameters used for irradiation, and are an important step for the safety of the clinical translation of FLASH radiation therapy.
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Affiliation(s)
- Patrik Gonçalves Jorge
- Institute of Radiation PhysicsLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Veljko Grilj
- Institute of Radiation PhysicsLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Jean Bourhis
- Radiation‐Oncology DepartmentLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Marie‐Catherine Vozenin
- Radiation‐Oncology LaboratoryLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Jean‐François Germond
- Institute of Radiation PhysicsLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - François Bochud
- Institute of Radiation PhysicsLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Claude Bailat
- Institute of Radiation PhysicsLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Raphaël Moeckli
- Institute of Radiation PhysicsLausanne University Hospital and University of LausanneLausanneSwitzerland
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Mayr NA, Snider JW, Regine WF, Mohiuddin M, Hippe DS, Peñagarícano J, Mohiuddin M, Kudrimoti MR, Zhang H, Limoli CL, Le QT, Simone CB. An International Consensus on the Design of Prospective Clinical–Translational Trials in Spatially Fractionated Radiation Therapy. Adv Radiat Oncol 2022; 7:100866. [PMID: 35198833 PMCID: PMC8843999 DOI: 10.1016/j.adro.2021.100866] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 11/12/2021] [Indexed: 12/17/2022] Open
Abstract
Purpose Spatially fractionated radiation therapy (SFRT), which delivers highly nonuniform dose distributions instead of conventionally practiced homogeneous tumor dose, has shown high rates of clinical response with minimal toxicities in large-volume primary or metastatic malignancies. However, prospective multi-institutional clinical trials in SFRT are lacking, and SFRT techniques and dose parameters remain variable. Agreement on dose prescription, technical administration, and clinical and translational design parameters for SFRT trials is essential to enable broad participation and successful accrual to rigorously test the SFRT approach. We aimed to develop a consensus for the design of multi-institutional clinical trials in SFRT, tailored to specific primary tumor sites, to help facilitate development and enhance the feasibility of such trials. Methods and Materials Primary tumor sites with sufficient pilot experience in SFRT were identified, and fundamental trial design questions were determined. For each tumor site, a comprehensive consensus effort was established through disease-specific expert panels. Clinical trial design criteria included eligibility, SFRT technology and technique, dose and fractionation, target- and normal-tissue dose parameters, systemic therapies, clinical trial endpoints, and translational science considerations. Iterative appropriateness rank voting, expert panel consensus reviews and discussions, and public comment posting were used for consensus development. Results Clinical trial criteria were developed for head and neck cancer and soft-tissue sarcoma. Final consensus among the 22 trial design categories each (a total of 163 criteria) was high to moderate overall. Uniform patient cohorts of advanced bulky disease, standardization of SFRT technologies and dosimetry and physics parameters, and collection of translational correlates were considered essential to trial design. Final guideline recommendations and the degree of agreement are presented and discussed. Conclusions This consensus provides design guidelines for the development of prospective multi-institutional clinical trials testing SFRT in advanced head and neck cancer and soft-tissue sarcoma through in-advance harmonization of the fundamental clinical trial design among SFRT experts, potential investigators, and the SFRT community.
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Affiliation(s)
- Nina A. Mayr
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
- Tumor Heterogeneity Imaging and Radiomics Laboratory, University of Washington School of Medicine, Seattle, Washington
- Corresponding author: Nina A. Mayr, MD
| | - James W. Snider
- Department of Radiation Oncology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - William F. Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Majid Mohiuddin
- Radiation Oncology Consultants and Northwestern Proton Center, Warrenville, Illinois
| | - Daniel S. Hippe
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | | | - Mahesh R. Kudrimoti
- Department of Radiation Medicine, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Hualin Zhang
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Charles L. Limoli
- Department of Radiation Oncology, University of California School of Medicine, Irvine, Irvine, California
| | - Quynh-Thu Le
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Charles B. Simone
- Department of Radiation Oncology, New York Proton Center, New York, New York
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Abstract
FLASH radiotherapy is a novel technique that has been shown in numerous preclinical in vivo studies to have the potential to be the next important improvement in cancer treatment. However, the biological mechanisms responsible for the selective FLASH sparing effect of normal tissues are not yet known. An optimal translation of FLASH radiotherapy into the clinic would require a good understanding of the specific beam parameters that induces a FLASH effect, environmental conditions affecting the response, and the radiobiological mechanisms involved. Even though the FLASH effect has generally been considered as an in vivo effect, studies finding these answers would be difficult and ethically challenging to carry out solely in animals. Hence, suitable in vitro studies aimed towards finding these answers are needed. In this review, we describe and summarise several in vitro assays that have been used or could be used to finally elucidate the mechanisms behind the FLASH effect.
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Johnson TR, Bassil AM, Williams NT, Brundage S, Kent CL, Palmer G, Mowery YM, Oldham M. An investigation of kV mini-GRID spatially fractionated radiation therapy: dosimetry and preclinical trial. Phys Med Biol 2022; 67:10.1088/1361-6560/ac508c. [PMID: 35100573 PMCID: PMC9167045 DOI: 10.1088/1361-6560/ac508c] [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: 10/04/2021] [Accepted: 01/31/2022] [Indexed: 11/11/2022]
Abstract
Objective. To develop and characterize novel methods of extreme spatially fractionated kV radiation therapy (including mini-GRID therapy) and to evaluate efficacy in the context of a pre-clinical mouse study.Approach. Spatially fractionated GRIDs were precision-milled from 3 mm thick lead sheets compatible with mounting on a 225 kVp small animal irradiator (X-Rad). Three pencil-beam GRIDs created arrays of 1 mm diameter beams, and three 'bar' GRIDs created 1 × 20 mm rectangular fields. GRIDs projected 20 × 20 mm2fields at isocenter, and beamlets were spaced at 1, 1.25, and 1.5 mm, respectively. Peak-to-valley ratios and dose distributions were evaluated with Gafchromic film. Syngeneic transplant tumors were induced by intramuscular injection of a soft tissue sarcoma cell line into the gastrocnemius muscle of C57BL/6 mice. Tumor-bearing mice were randomized to four groups: unirradiated control, conventional irradiation of entire tumor, GRID therapy, and hemi-irradiation (half-beam block, 50% tumor volume treated). All irradiated mice received a single fraction of 15 Gy.Results. High peak-to-valley ratios were achieved (bar GRIDs: 11.9 ± 0.9, 13.6 ± 0.4, 13.8 ± 0.5; pencil-beam GRIDs: 18.7 ± 0.6, 26.3 ± 1.5, 31.0 ± 3.3). Pencil-beam GRIDs could theoretically spare more intra-tumor immune cells than bar GRIDs, but they treat less tumor tissue (3%-4% versus 19%-23% area receiving 90% prescription, respectively). Bar GRID and hemi-irradiation treatments significantly delayed tumor growth (P < 0.05), but not as much as a conventional treatment (P < 0.001). No significant difference was found in tumor growth delay between GRID and hemi-irradiation.Significance. High peak-to-valley ratios were achieved with kV grids: two-to-five times higher than values reported in literature for MV grids. GRID irradiation and hemi-irradiation delayed tumor growth, but neither was as effective as conventional whole tumor uniform dose treatment. Single fraction GRID therapy could not initiate an anti-cancer immune response strong enough to match conventional RT outcomes, but follow-up studies will evaluate the combination of mini-GRID with immune checkpoint blockade.
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Affiliation(s)
- Timothy R Johnson
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States of America,Authors to whomany correspondence should be addressed. , and
| | - Alex M Bassil
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States of America
| | - Nerissa T Williams
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States of America
| | - Simon Brundage
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States of America
| | - Collin L Kent
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States of America
| | - Greg Palmer
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States of America
| | - Yvonne M Mowery
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States of America,Department of Head and Neck Surgery & Communication Sciences, Duke University Medical Center, Durham, NC, United States of America,Authors to whomany correspondence should be addressed. , and
| | - Mark Oldham
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States of America,Authors to whomany correspondence should be addressed. , and
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A Dosimetric Parameter Reference Look-Up Table for GRID Collimator-Based Spatially Fractionated Radiation Therapy. Cancers (Basel) 2022; 14:cancers14041037. [PMID: 35205785 PMCID: PMC8869958 DOI: 10.3390/cancers14041037] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 02/08/2022] [Accepted: 02/15/2022] [Indexed: 12/10/2022] Open
Abstract
Simple Summary Dose prescription for the inhomogeneous dosing in spatially fractionated radiation therapy (SFRT) is challenging, and further hampered by the inability of several planning systems to incorporate complex SFRT dose patterns. We developed dosing reference tables for an inventory of tumour scenarios and tested their accuracy with water phantom measurements of GRID therapy, delivered by a standard commercial GRID collimator. We find that dose heterogeneity parameters and EUD modeling are consistent across tumour sizes, configurations, and treatment depths. These results suggest that the developed reference tables can be used as a practical clinical resource for clinical decision-making on GRID therapy and to facilitate heterogeneity dose estimates in clinical patients when this commercially available GRID device is used. Abstract Computations of heterogeneity dose parameters in GRID therapy remain challenging in many treatment planning systems (TPS). To address this difficulty, we developed reference dose tables for a standard GRID collimator and validate their accuracy. The .decimal Inc. GRID collimator was implemented within the Eclipse TPS. The accuracy of the dose calculation was confirmed in the commissioning process. Representative sets of simulated ellipsoidal tumours ranging from 6–20 cm in diameter at a 3-cm depth; 16-cm ellipsoidal tumours at 3, 6, and 10 cm in depth were studied. All were treated with 6MV photons to a 20 Gy prescription dose at the tumour center. From these, the GRID therapy dosimetric parameters (previously recommended by the Radiosurgery Society white paper) were derived. Differences in D5 through D95 and EUD between different tumour sizes at the same depth were within 5% of the prescription dose. PVDR from profile measurements at the tumour center differed from D10/D90, but D10/D90 variations for the same tumour depths were within 11%. Three approximation equations were developed for calculating EUDs of different prescription doses for three radiosensitivity levels for 3-cm deep tumours. Dosimetric parameters were consistent and predictable across tumour sizes and depths. Our study results support the use of the developed tables as a reference tool for GRID therapy.
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Non-Targeted Effects of Synchrotron Radiation: Lessons from Experiments at the Australian and European Synchrotrons. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12042079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Studies have been conducted at synchrotron facilities in Europe and Australia to explore a variety of applications of synchrotron X-rays in medicine and biology. We discuss the major technical aspects of the synchrotron irradiation setups, paying specific attention to the Australian Synchrotron (AS) and the European Synchrotron Radiation Facility (ESRF) as those best configured for a wide range of biomedical research involving animals and future cancer patients. Due to ultra-high dose rates, treatment doses can be delivered within milliseconds, abiding by FLASH radiotherapy principles. In addition, a homogeneous radiation field can be spatially fractionated into a geometric pattern called microbeam radiotherapy (MRT); a coplanar array of thin beams of microscopic dimensions. Both are clinically promising radiotherapy modalities because they trigger a cascade of biological effects that improve tumor control, while increasing normal tissue tolerance compared to conventional radiation. Synchrotrons can deliver high doses to a very small volume with low beam divergence, thus facilitating the study of non-targeted effects of these novel radiation modalities in both in-vitro and in-vivo models. Non-targeted radiation effects studied at the AS and ESRF include monitoring cell–cell communication after partial irradiation of a cell population (radiation-induced bystander effect, RIBE), the response of tissues outside the irradiated field (radiation-induced abscopal effect, RIAE), and the influence of irradiated animals on non-irradiated ones in close proximity (inter-animal RIBE). Here we provide a summary of these experiments and perspectives on their implications for non-targeted effects in biomedical fields.
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Guerrieri P, Jacob NK, Maxim PG, Sawant A, Van Nest SJ, Mohindra P, Dominello MM, Burmeister JW, Joiner MC. Three discipline collaborative radiation therapy (3DCRT) special debate: FLASH radiotherapy needs ongoing basic and animal research before implementing it to a large clinical scale. J Appl Clin Med Phys 2022; 23:e13547. [PMID: 35104025 PMCID: PMC8992943 DOI: 10.1002/acm2.13547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 01/20/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Patrizia Guerrieri
- Department of Radiation Oncology, Bon Secours Mercy Health, Youngstown, Ohio, USA
| | | | - Peter G Maxim
- Department of Radiation Oncology, University of California, Irvine, California, USA
| | - Amit Sawant
- Department of Radiation Oncology, University of Maryland, Baltimore, Maryland, USA.,Maryland Proton Treatment Center, Baltimore, Maryland, USA
| | - Samantha J Van Nest
- Department of Radiation Oncology, Weill Cornell Medicine, New York, New York, USA
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland, Baltimore, Maryland, USA.,Maryland Proton Treatment Center, Baltimore, Maryland, USA
| | | | - Jay W Burmeister
- Department of Oncology, Wayne State University, Detroit, Michigan, USA.,Gershenson Radiation Oncology Center, Barbara Ann Karmanos Cancer Institute, Detroit, Michigan, USA
| | - Michael C Joiner
- Department of Oncology, Wayne State University, Detroit, Michigan, USA
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Zhang X, Griffin RJ, Galhardo EP, Penagaricano J. Feasibility Study of 3D-VMAT-Based GRID Therapy. Technol Cancer Res Treat 2022; 21:15330338221086420. [PMID: 35289202 DOI: 10.1177/15330338221086420] [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: 11/16/2022] Open
Abstract
Background: Spatially fractionated radiotherapy (GRID) could effectively de-bulk tumor volumes for shallow and deep-seated locally advanced tumors. A new treatment planning method using the three-dimensional-volumetric modulated arc therapy (VMAT) technique combined with a novel, software-generated, virtual GRID block (VGB) was developed which allows better conformity plans (VMAT-GRID) and maintain the GRID dosimetric characteristics. The dosimetric metrics calculated via the valley/peak ratio (Dmin/Dmax), D90/D10, gross tumor volume (GTV) mean dose (Dmean), GTV equivalent uniform dose (EUD), and normal tissue maximum dose. Methods: Twenty-five patients with tumor volumes ranging between 71.6 cc and 4683 cc at various tumor sites were retrospectively studied. The prescription was 20 Gy to the maximum point of GTV in a single fraction, and the VMAT-GRID plan was generated using 6 MV/10 MV flattening-filter-free beams. Results: The optimized VGB was designed with the median center-to-center distance of 27 mm, and 9 mm for the median diameter of the opening area in this study. These 2 values can be used to design any optimized VGB, the final VGB may be modified to generate a patient-specific VGB. The median GTV mean dose was 918 (877- 938) cGy, and the median GTV EUD dose was 818 (597-916) cGy. In terms of dose inhomogeneity, the median valley-to-peak dose ratio was 0.07 (0.02-0.26); and the median ratio of D90/D10 was 0.70 (0.38-0.94). For the organ-at-risk doses, there was a rapid dose drop-off in the normal tissue area immediately adjacent to the target, and the maximum global doses were all located inside the GTV. Conclusion: Our results indicated that the VMAT-GRID planning approach could successfully deliver dose with acceptable GRID dose metric while sparing the normal tissue especially in the region near the target due to the rapid dose drop-off and restricting maximum dose inside the target.
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Affiliation(s)
- Xin Zhang
- Department of Radiation Oncology, Boston Medical Center, 1836Boston University School of Medicine, Boston, MA, USA.,Department of Radiation Oncology, 12215University of Arkansas for Medical Science, Little Rock, AR, USA
| | - Robert J Griffin
- Department of Radiation Oncology, 12215University of Arkansas for Medical Science, Little Rock, AR, USA
| | - Edvaldo P Galhardo
- Department of Radiation Oncology, 12215University of Arkansas for Medical Science, Little Rock, AR, USA.,Department of Radiation Oncology, Genesis Care, Bradenton, FL, USA
| | - Jose Penagaricano
- Department of Radiation Oncology, 12215University of Arkansas for Medical Science, Little Rock, AR, USA.,Department of Radiation Oncology, 25301Moffitt Cancer Center, Tampa, FL, USA
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Bertho A, Iturri L, Prezado Y. Radiation-induced immune response in novel radiotherapy approaches FLASH and spatially fractionated radiotherapies. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2022; 376:37-68. [PMID: 36997269 DOI: 10.1016/bs.ircmb.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The last several years have revealed increasing evidence of the immunomodulatory role of radiation therapy. Radiotherapy reshapes the tumoral microenvironment can shift the balance toward a more immunostimulatory or immunosuppressive microenvironment. The immune response to radiation therapy appears to depend on the irradiation configuration (dose, particle, fractionation) and delivery modes (dose rate, spatial distributions). Although an optimal irradiation configuration (dose, temporal fractionation, spatial dose distribution, etc.) has not yet been determined, temporal schemes employing high doses per fraction appear to favor radiation-induced immune response through immunogenic cell death. Through the release of damage-associated molecular patterns and the sensing of double-stranded DNA and RNA breaks, immunogenic cell death activates the innate and adaptive immune response, leading to tumor infiltration by effector T cells and the abscopal effect. Novel radiotherapy approaches such as FLASH and spatially fractionated radiotherapies (SFRT) strongly modulate the dose delivery method. FLASH-RT and SFRT have the potential to trigger the immune system effectively while preserving healthy surrounding tissues. This manuscript reviews the current state of knowledge on the immunomodulation effects of these two new radiotherapy techniques in the tumor, healthy immune cells and non-targeted regions, as well as their therapeutic potential in combination with immunotherapy.
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Alanizy N, Attalla E, Abdelaal A, Yassen M, Shafaa M. Biological Evaluation of Grid versus 3D Conformal Radiotherapy in Bulky Head and Neck Cancer. J Med Phys 2022; 47:136-140. [PMID: 36212202 PMCID: PMC9542996 DOI: 10.4103/jmp.jmp_141_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/21/2022] [Accepted: 02/22/2022] [Indexed: 11/04/2022] Open
Abstract
Grid radiotherapy is one of the treatment techniques applied to treat patients with advanced bulky tumors.
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Wei S, Lin H, Choi JI, Simone CB, Kang M. A Novel Proton Pencil Beam Scanning FLASH RT Delivery Method Enables Optimal OAR Sparing and Ultra-High Dose Rate Delivery: A Comprehensive Dosimetry Study for Lung Tumors. Cancers (Basel) 2021; 13:5790. [PMID: 34830946 PMCID: PMC8616118 DOI: 10.3390/cancers13225790] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 11/13/2021] [Accepted: 11/15/2021] [Indexed: 12/25/2022] Open
Abstract
PURPOSE While transmission proton beams have been demonstrated to achieve ultra-high dose rate FLASH therapy delivery, they are unable to spare normal tissues distal to the target. This study aims to compare FLASH treatment planning using single energy Bragg peak proton beams versus transmission proton beams in lung tumors and to evaluate Bragg peak plan optimization, characterize plan quality, and quantify organ-at-risk (OAR) sparing. MATERIALS AND METHODS Both Bragg peak and transmission plans were optimized using an in-house platform for 10 consecutive lung patients previously treated with proton stereotactic body radiation therapy (SBRT). To bring the dose rate up to the FLASH-RT threshold, Bragg peak plans with a minimum MU/spot of 1200 and transmission plans with a minimum MU/spot of 400 were developed. Two common prescriptions, 34 Gy in 1 fraction and 54 Gy in 3 fractions, were studied with the same beam arrangement for both Bragg peak and transmission plans (n = 40 plans). RTOG 0915 dosimetry metrics and dose rate metrics based on different dose rate calculations, including average dose rate (ADR), dose-averaged dose rate (DADR), and dose threshold dose rate (DTDR), were investigated. We then evaluated the effect of beam angular optimization on the Bragg peak plans to explore the potential for superior OAR sparing. RESULTS Bragg peak plans significantly reduced doses to several OAR dose parameters, including lung V7.4Gy and V7Gy by 32.0% (p < 0.01) and 30.4% (p < 0.01) for 34Gy/fx plans, respectively; and by 40.8% (p < 0.01) and 41.2% (p < 0.01) for 18Gy/fx plans, respectively, compared with transmission plans. Bragg peak plans have ~3% less in DADR and ~10% differences in mean OARs in DTDR and DADR relative to transmission plans due to the larger portion of lower dose regions of Bragg peak plans. With angular optimization, optimized Bragg peak plans can further reduce the lung V7Gy by 20.7% (p < 0.01) and V7.4Gy by 19.7% (p < 0.01) compared with Bragg peak plans without angular optimization while achieving a similar 3D dose rate distribution. CONCLUSION The single-energy Bragg peak plans achieve superior dosimetry performances in OARs to transmission plans with comparable dose rate performances for lung cancer FLASH therapy. Beam angle optimization can further improve the OAR dosimetry parameters with similar 3D FLASH dose rate coverage.
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Affiliation(s)
| | | | | | | | - Minglei Kang
- New York Proton Center, New York, NY 10035, USA; (S.W.); (H.L.); (J.I.C.); (C.B.S.II)
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Schiff JP, Spraker MB, Duriseti S, Shaikh S, Murad HF, Mutch DG, Robinson CG, Kavanaugh J, Lin AJ. Tumor Lysis Syndrome in a Patient With Metastatic Endometrial Cancer Treated With Lattice Stereotactic Body Radiation Therapy. Adv Radiat Oncol 2021; 7:100797. [PMID: 34761139 PMCID: PMC8567179 DOI: 10.1016/j.adro.2021.100797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/06/2021] [Accepted: 08/11/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
| | | | | | | | | | - David G Mutch
- Obstetrics and Gynecology, Division of Gynecologic Oncology, Washington University School of Medicine, St Louis, Missouri
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Price LSL, Rivera JN, Madden AJ, Herity LB, Piscitelli JA, Mageau S, Santos CM, Roques JR, Midkiff B, Feinberg NN, Darr D, Chang SX, Zamboni WC. Minibeam radiation therapy enhanced tumor delivery of PEGylated liposomal doxorubicin in a triple-negative breast cancer mouse model. Ther Adv Med Oncol 2021; 13:17588359211053700. [PMID: 34733359 PMCID: PMC8558804 DOI: 10.1177/17588359211053700] [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] [Received: 09/15/2019] [Accepted: 09/29/2021] [Indexed: 12/13/2022] Open
Abstract
Background: Minibeam radiation therapy is an experimental radiation therapy utilizing an array of parallel submillimeter planar X-ray beams. In preclinical studies, minibeam radiation therapy has been shown to eradicate tumors and cause significantly less damage to normal tissue compared to equivalent radiation doses delivered by conventional broadbeam radiation therapy, where radiation dose is uniformly distributed. Methods: Expanding on prior studies that suggested minibeam radiation therapy increased perfusion in tumors, we compared a single fraction of minibeam radiation therapy (peak dose:valley dose of 28 Gy:2.1 Gy and 100 Gy:7.5 Gy) and broadbeam radiation therapy (7 Gy) in their ability to enhance tumor delivery of PEGylated liposomal doxorubicin and alter the tumor microenvironment in a murine tumor model. Plasma and tumor pharmacokinetic studies of PEGylated liposomal doxorubicin and tumor microenvironment profiling were performed in a genetically engineered mouse model of claudin-low triple-negative breast cancer (T11). Results: Minibeam radiation therapy (28 Gy) and broadbeam radiation therapy (7 Gy) increased PEGylated liposomal doxorubicin tumor delivery by 7.1-fold and 2.7-fold, respectively, compared to PEGylated liposomal doxorubicin alone, without altering the plasma disposition. The enhanced tumor delivery of PEGylated liposomal doxorubicin by minibeam radiation therapy is consistent after repeated dosing, is associated with changes in tumor macrophages but not collagen or angiogenesis, and nontoxic to local tissues. Our study indicated that the minibeam radiation therapy’s ability to enhance the drug delivery decreases from 28 to 100 Gy peak dose. Discussion: Our studies suggest that low-dose minibeam radiation therapy is a safe and effective method to significantly enhance the tumor delivery of nanoparticle agents.
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Affiliation(s)
- Lauren S L Price
- Division of Pharmacotherapy & Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Judith N Rivera
- Joint Department of Biomedical Engineering, The University of North Carolina at Chapel Hill and North Carolina State University, Chapel Hill, NC, USA
| | - Andrew J Madden
- Division of Pharmacotherapy & Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Leah B Herity
- Division of Pharmacotherapy & Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Joseph A Piscitelli
- Division of Pharmacotherapy & Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Savannah Mageau
- Division of Pharmacotherapy & Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | | | - Jose R Roques
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Bentley Midkiff
- Translational Pathology Lab, UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Nana N Feinberg
- Translational Pathology Lab, UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - David Darr
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Sha X Chang
- Joint Department of Biomedical Engineering, The University of North Carolina at Chapel Hill and North Carolina State University, Chapel Hill, NC, USA
| | - William C Zamboni
- Division of Pharmacotherapy & Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, 1022B Genetic Medicine Building, 120 Mason Farm Road, Campus Box 7361, Chapel Hill, NC 27599-7361, USA
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Sultana A, Alanazi A, Meesungnoen J, Jay-Gerin JP. Generation of ultrafast, transient, highly acidic pH spikes in the radiolysis of water at very high dose rates: relevance for FLASH radiotherapy. CAN J CHEM 2021. [DOI: 10.1139/cjc-2021-0259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Monte Carlo multi-track chemistry simulations were carried out to study the effects of high dose rates on the transient yields of hydronium ions (H3O+) formed during low linear energy transfer (LET) radiolysis of both pure, deaerated and aerated liquid water at 25 °C, in the interval ∼1 ps – 10 μs. Our simulation model consisted of randomly irradiating water with N interactive tracks of 300-MeV incident protons (LET ∼ 0.3 keV/µm), which simultaneously impact perpendicularly on the water within a circular surface. The effect of the dose rate was studied by varying N. Our calculations showed that the radiolytic formation of H3O+ causes the entire irradiated volume to temporarily become very acidic. The magnitude and duration of this abrupt “acid-spike” response depend on the value of N. It is most intense at times less than ∼10–100 ns, equal to ∼3.4 and 2.8 for N = 500 and 2000 (i.e., for dose rates of ∼1.9 × 109 and 8.7 × 109 Gy/s, respectively). At longer times, the pH gradually increases for all N values and eventually returns to the neutral value of seven, which corresponds to the non-radiolytic, pre-irradiation concentration of H3O+. It is worth noting that these early acidic pH responses are very little dependent on the presence or absence of oxygen. Finally, given the importance of pH for many cellular functions, this study suggests that these acidic pH spikes may contribute to the normal tissue-sparing effect of FLASH radiotherapy.
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Affiliation(s)
- Abida Sultana
- Département de médecine nucléaire et de radiobiologie, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, 3001, 12ème Avenue Nord, Sherbrooke, QC J1H 5N4, Canada
- Département de médecine nucléaire et de radiobiologie, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, 3001, 12ème Avenue Nord, Sherbrooke, QC J1H 5N4, Canada
| | - Ahmed Alanazi
- Département de médecine nucléaire et de radiobiologie, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, 3001, 12ème Avenue Nord, Sherbrooke, QC J1H 5N4, Canada
- Département de médecine nucléaire et de radiobiologie, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, 3001, 12ème Avenue Nord, Sherbrooke, QC J1H 5N4, Canada
| | - Jintana Meesungnoen
- Département de médecine nucléaire et de radiobiologie, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, 3001, 12ème Avenue Nord, Sherbrooke, QC J1H 5N4, Canada
- Département de médecine nucléaire et de radiobiologie, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, 3001, 12ème Avenue Nord, Sherbrooke, QC J1H 5N4, Canada
| | - Jean-Paul Jay-Gerin
- Département de médecine nucléaire et de radiobiologie, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, 3001, 12ème Avenue Nord, Sherbrooke, QC J1H 5N4, Canada
- Département de médecine nucléaire et de radiobiologie, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, 3001, 12ème Avenue Nord, Sherbrooke, QC J1H 5N4, Canada
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Massaccesi M, Boldrini L, Romano A, Rossi E, Schinzari G, Lepre E, Gambacorta MA, Valentini V. Unconventional radiotherapy to enhance immunotherapy efficacy in bulky tumors: a case report. Immunotherapy 2021; 13:1457-1463. [PMID: 34664999 DOI: 10.2217/imt-2020-0289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Determining the most appropriate management strategy for patients with large tumor masses is a very challenging issue. Unconventional radiotherapy modalities, such as spatially fractionated radiation therapy (SFRT), are associated with dramatic responses. Recent studies have suggested that systemic immune activation may be triggered by SFRT delivery to primary tumor lesion. This report describes the case of a patient treated with a novel form of immune-sparing partially ablative irradiation (ISPART) for a bulky peritoneal metastasis from renal cell cancer, refractory to anti-PD-1 therapy (nivolumab) as third-line therapy after sequential therapy with sunitinib and cabozantinib. The observed response suggests that there may be a synergistic effect between ISPART and immunotherapy. This case report supports the inclusion of ISPART in patients presenting with bulky lesions treated with checkpoint inhibitors .
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Affiliation(s)
- Mariangela Massaccesi
- UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario 'Agostino Gemelli' IRCCS, Rome, 00168, Italy
| | - Luca Boldrini
- UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario 'Agostino Gemelli' IRCCS, Rome, 00168, Italy
| | - Angela Romano
- UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario 'Agostino Gemelli' IRCCS, Rome, 00168, Italy
| | - Ernesto Rossi
- UOC di Oncologia Medica, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario 'Agostino Gemelli' IRCCS, Rome, 00168, Italy
| | - Giovanni Schinzari
- UOC di Oncologia Medica, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario 'Agostino Gemelli' IRCCS, Rome, 00168, Italy
| | | | - Maria Antonietta Gambacorta
- UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario 'Agostino Gemelli' IRCCS, Rome, 00168, Italy.,Università Cattolica del Sacro Cuore, Rome, 00168, Italy
| | - Vincenzo Valentini
- UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario 'Agostino Gemelli' IRCCS, Rome, 00168, Italy.,Università Cattolica del Sacro Cuore, Rome, 00168, Italy
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Hellevik T, Berzaghi R, Lode K, Islam A, Martinez-Zubiaurre I. Immunobiology of cancer-associated fibroblasts in the context of radiotherapy. J Transl Med 2021; 19:437. [PMID: 34663337 PMCID: PMC8524905 DOI: 10.1186/s12967-021-03112-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 10/08/2021] [Indexed: 12/14/2022] Open
Abstract
Radiotherapy (RT) still represents a mainstay of treatment in clinical oncology. Traditionally, the effectiveness of radiotherapy has been attributed to the killing potential of ionizing radiation (IR) over malignant cells, however, it has become clear that therapeutic efficacy of RT also involves activation of innate and adaptive anti-tumor immune responses. Therapeutic irradiation of the tumor microenvironment (TME) provokes profound cellular and biological reconfigurations which ultimately may influence immune recognition. As one of the major constituents of the TME, cancer-associated fibroblasts (CAFs) play central roles in cancer development at all stages and are recognized contributors of tumor immune evasion. While some studies argue that RT affects CAFs negatively through growth arrest and impaired motility, others claim that exposure of fibroblasts to RT promotes their conversion into a more activated phenotype. Nevertheless, despite the well-described immunoregulatory functions assigned to CAFs, little is known about the interplay between CAFs and immune cells in the context of RT. In this review, we go over current literature on the effects of radiation on CAFs and the influence that CAFs have on radiotherapy outcomes, and we summarize present knowledge on the transformed cellular crosstalk between CAFs and immune cells after radiation.
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Affiliation(s)
- Turid Hellevik
- Department of Radiation Oncology, University Hospital of Northern Norway, Tromsø, Norway
| | - Rodrigo Berzaghi
- Department of Clinical Medicine, Faculty of Health Sciences, UiT-the Arctic University of Norway, Tromsø, Norway
| | - Kristin Lode
- Department of Clinical Medicine, Faculty of Health Sciences, UiT-the Arctic University of Norway, Tromsø, Norway
| | - Ashraful Islam
- Department of Clinical Medicine, Faculty of Health Sciences, UiT-the Arctic University of Norway, Tromsø, Norway
| | - Inigo Martinez-Zubiaurre
- Department of Clinical Medicine, Faculty of Health Sciences, UiT-the Arctic University of Norway, Tromsø, Norway.
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50
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Zakaria AM, Colangelo NW, Meesungnoen J, Jay-Gerin JP. Transient hypoxia in water irradiated by swift carbon ions at ultra-high dose rates: implication for FLASH carbon-ion therapy. CAN J CHEM 2021. [DOI: 10.1139/cjc-2021-0110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Large doses of ionizing radiation delivered to tumors at ultra-high dose rates (i.e., in a few milliseconds) paradoxically spare the surrounding healthy tissue while preserving anti-tumor activity (compared with conventional radiotherapy delivered at much lower dose rates). This new modality is known as “FLASH radiotherapy” (FLASH-RT). Although the molecular mechanisms underlying FLASH-RT are not yet fully understood, it has been suggested that radiation delivered at high dose rates spares normal tissue via oxygen depletion followed by subsequent radioresistance of the irradiated tissue. To date, FLASH-RT has been studied using electrons, photons, and protons in various basic biological experiments, pre-clinical studies, and recently in a human patient. However, the efficacy of heavy ions, such as energetic carbon ions, under FLASH-RT conditions remains unclear. Given that living cells and tissues consist mainly of water, we set out to study, from a pure radiation chemistry perspective, the effects of ultra-high dose rates on the transient yields and concentrations of radiolytic species formed in water irradiated by 300-MeV per nucleon carbon ions (LET ∼ 11.6 keV/µm). This mimics irradiation in the “plateau” region of the depth–dose distribution of ions, i.e., in the “normal” tissue region in which the LET is rather low. We used Monte Carlo simulations of multiple, simultaneously interacting radiation tracks together with an “instantaneous pulse” irradiation model. Our calculations show a pronounced oxygen depletion around 0.2 μs, strongly suggesting, as with electrons, photons, and protons, that irradiation with energetic carbon ions at ultra-high dose rates is suitable for FLASH-RT.
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Affiliation(s)
- Abdullah Muhammad Zakaria
- Département de médecine nucléaire et de radiobiologie, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, 3001, 12ème Avenue Nord, Sherbrooke, QC J1H 5N4, Canada
| | - Nicholas W. Colangelo
- Department of Radiation Oncology, NYU Grossman School of Medicine, New York, NY, USA
| | - Jintana Meesungnoen
- Département de médecine nucléaire et de radiobiologie, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, 3001, 12ème Avenue Nord, Sherbrooke, QC J1H 5N4, Canada
| | - Jean-Paul Jay-Gerin
- Département de médecine nucléaire et de radiobiologie, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, 3001, 12ème Avenue Nord, Sherbrooke, QC J1H 5N4, Canada
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