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Li Y, Mizumoto M, Nitta H, Fukushima H, Suzuki R, Hosaka S, Yamaki Y, Murakami M, Baba K, Nakamura M, Ishida T, Makishima H, Iizumi T, Saito T, Numajiri H, Nakai K, Kamizawa S, Kawano C, Oshiro Y, Sakurai H. Late Changes in Renal Volume and Function after Proton Beam Therapy in Pediatric and Adult Patients: Children Show Significant Renal Atrophy but Deterioration of Renal Function Is Minimal in the Long-Term in Both Groups. Cancers (Basel) 2024; 16:1634. [PMID: 38730586 PMCID: PMC11083097 DOI: 10.3390/cancers16091634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/13/2024] [Accepted: 04/22/2024] [Indexed: 05/13/2024] Open
Abstract
To compare late renal effects in pediatric and adult patients with malignancies after PBT involving part of the kidney. A retrospective study was conducted to assess changes in renal volume and function in 24 patients, including 12 children (1-14 years old) and 12 adults (51-80 years old). Kidney volumes were measured from CT or MRI images during follow-up. Dose-volume histograms were calculated using a treatment planning system. In children, the median volume changes for the irradiated and control kidneys were -5.58 (-94.95 to +4.79) and +14.92 (-19.45 to +53.89) mL, respectively, with a relative volume change of -28.38 (-119.45 to -3.87) mL for the irradiated kidneys. For adults, these volume changes were -22.43 (-68.7 to -3.48) and -21.56 (-57.26 to -0.16) mL, respectively, with a relative volume change of -5.83 (-28.85 to +30.92) mL. Control kidneys in children exhibited a marked increase in size, while those in adults showed slight volumetric loss. The percentage of irradiated volume receiving 10 Gy (RBE) (V10) and 20 Gy (RBE) (V20) were significantly negatively associated with the relative volume change per year, especially in children. The CKD stage based on eGFR for all patients ranged from 1 to 3 and no cases with severe renal dysfunction were found before or after PBT. Late effects on the kidneys after PBT vary among age groups. Children are more susceptible than adults to significant renal atrophy after PBT. V10 and V20 might serve as predictors of the degree of renal atrophy after PBT, especially in children. PBT has a minimal impact on deterioration of renal function in both children and adults.
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Affiliation(s)
- Yinuo Li
- Department of Radiation Oncology, University of Tsukuba, Tsukuba 305-8577, Ibaraki, Japan; (Y.L.); (H.N.); (M.M.); (M.N.); (T.I.); (H.M.); (T.I.); (T.S.); (H.N.); (K.N.); (S.K.); (C.K.); (H.S.)
| | - Masashi Mizumoto
- Department of Radiation Oncology, University of Tsukuba, Tsukuba 305-8577, Ibaraki, Japan; (Y.L.); (H.N.); (M.M.); (M.N.); (T.I.); (H.M.); (T.I.); (T.S.); (H.N.); (K.N.); (S.K.); (C.K.); (H.S.)
| | - Hazuki Nitta
- Department of Radiation Oncology, University of Tsukuba, Tsukuba 305-8577, Ibaraki, Japan; (Y.L.); (H.N.); (M.M.); (M.N.); (T.I.); (H.M.); (T.I.); (T.S.); (H.N.); (K.N.); (S.K.); (C.K.); (H.S.)
| | - Hiroko Fukushima
- Department of Child Health, Institute of Medicine, University of Tsukuba, Tsukuba 305-8577, Ibaraki, Japan; (H.F.); (R.S.)
| | - Ryoko Suzuki
- Department of Child Health, Institute of Medicine, University of Tsukuba, Tsukuba 305-8577, Ibaraki, Japan; (H.F.); (R.S.)
| | - Sho Hosaka
- Department of Pediatrics, University of Tsukuba Hospital, Tsukuba 305-8576, Ibaraki, Japan; (S.H.); (Y.Y.)
| | - Yuni Yamaki
- Department of Pediatrics, University of Tsukuba Hospital, Tsukuba 305-8576, Ibaraki, Japan; (S.H.); (Y.Y.)
| | - Motohiro Murakami
- Department of Radiation Oncology, University of Tsukuba, Tsukuba 305-8577, Ibaraki, Japan; (Y.L.); (H.N.); (M.M.); (M.N.); (T.I.); (H.M.); (T.I.); (T.S.); (H.N.); (K.N.); (S.K.); (C.K.); (H.S.)
| | - Keiichiro Baba
- Department of Radiation Oncology, University of Tsukuba, Tsukuba 305-8577, Ibaraki, Japan; (Y.L.); (H.N.); (M.M.); (M.N.); (T.I.); (H.M.); (T.I.); (T.S.); (H.N.); (K.N.); (S.K.); (C.K.); (H.S.)
| | - Masatoshi Nakamura
- Department of Radiation Oncology, University of Tsukuba, Tsukuba 305-8577, Ibaraki, Japan; (Y.L.); (H.N.); (M.M.); (M.N.); (T.I.); (H.M.); (T.I.); (T.S.); (H.N.); (K.N.); (S.K.); (C.K.); (H.S.)
| | - Toshiki Ishida
- Department of Radiation Oncology, University of Tsukuba, Tsukuba 305-8577, Ibaraki, Japan; (Y.L.); (H.N.); (M.M.); (M.N.); (T.I.); (H.M.); (T.I.); (T.S.); (H.N.); (K.N.); (S.K.); (C.K.); (H.S.)
| | - Hirokazu Makishima
- Department of Radiation Oncology, University of Tsukuba, Tsukuba 305-8577, Ibaraki, Japan; (Y.L.); (H.N.); (M.M.); (M.N.); (T.I.); (H.M.); (T.I.); (T.S.); (H.N.); (K.N.); (S.K.); (C.K.); (H.S.)
| | - Takashi Iizumi
- Department of Radiation Oncology, University of Tsukuba, Tsukuba 305-8577, Ibaraki, Japan; (Y.L.); (H.N.); (M.M.); (M.N.); (T.I.); (H.M.); (T.I.); (T.S.); (H.N.); (K.N.); (S.K.); (C.K.); (H.S.)
| | - Takashi Saito
- Department of Radiation Oncology, University of Tsukuba, Tsukuba 305-8577, Ibaraki, Japan; (Y.L.); (H.N.); (M.M.); (M.N.); (T.I.); (H.M.); (T.I.); (T.S.); (H.N.); (K.N.); (S.K.); (C.K.); (H.S.)
| | - Haruko Numajiri
- Department of Radiation Oncology, University of Tsukuba, Tsukuba 305-8577, Ibaraki, Japan; (Y.L.); (H.N.); (M.M.); (M.N.); (T.I.); (H.M.); (T.I.); (T.S.); (H.N.); (K.N.); (S.K.); (C.K.); (H.S.)
| | - Kei Nakai
- Department of Radiation Oncology, University of Tsukuba, Tsukuba 305-8577, Ibaraki, Japan; (Y.L.); (H.N.); (M.M.); (M.N.); (T.I.); (H.M.); (T.I.); (T.S.); (H.N.); (K.N.); (S.K.); (C.K.); (H.S.)
| | - Satoshi Kamizawa
- Department of Radiation Oncology, University of Tsukuba, Tsukuba 305-8577, Ibaraki, Japan; (Y.L.); (H.N.); (M.M.); (M.N.); (T.I.); (H.M.); (T.I.); (T.S.); (H.N.); (K.N.); (S.K.); (C.K.); (H.S.)
| | - Chie Kawano
- Department of Radiation Oncology, University of Tsukuba, Tsukuba 305-8577, Ibaraki, Japan; (Y.L.); (H.N.); (M.M.); (M.N.); (T.I.); (H.M.); (T.I.); (T.S.); (H.N.); (K.N.); (S.K.); (C.K.); (H.S.)
| | - Yoshiko Oshiro
- Department of Radiation Oncology, Tsukuba Medical Center Hospital, Tsukuba 305-8558, Ibaraki, Japan;
| | - Hideyuki Sakurai
- Department of Radiation Oncology, University of Tsukuba, Tsukuba 305-8577, Ibaraki, Japan; (Y.L.); (H.N.); (M.M.); (M.N.); (T.I.); (H.M.); (T.I.); (T.S.); (H.N.); (K.N.); (S.K.); (C.K.); (H.S.)
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Zhou P, Du Y, Zhang Y, Zhu M, Li T, Tian W, Wu T, Xiao Z. Efficacy and Safety in Proton Therapy and Photon Therapy for Patients With Esophageal Cancer: A Meta-Analysis. JAMA Netw Open 2023; 6:e2328136. [PMID: 37581887 PMCID: PMC10427943 DOI: 10.1001/jamanetworkopen.2023.28136] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/29/2023] [Indexed: 08/16/2023] Open
Abstract
Importance Radiotherapy plays an important role in the treatment of esophageal cancer. Proton therapy has unique physical properties and higher relative biological effectiveness. However, whether proton therapy has greater benefit than photon therapy is still unclear. Objective To evaluate whether proton was associated with better efficacy and safety outcomes, including dosimetric, prognosis, and toxic effects outcomes, compared with photon therapy and to evaluate the efficacy and safety of proton therapy singly. Data Sources A systematic search of PubMed, Embase, the Cochrane Library, Web of Science, SinoMed, and China National Knowledge Infrastructure databases was conducted for articles published through November 25, 2021, and updated to March 25, 2023. Study Selection For the comparison of proton and photon therapy, studies including dosimetric, prognosis, and associated toxic effects outcomes were included. The separate evaluation of proton therapy evaluated the same metrics. Data Extraction and Synthesis Data on study design, individual characteristics, and outcomes were extracted. If I2 was greater than 50%, the random-effects model was selected. This meta-analysis is reported following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Main Outcomes and Measures The main outcomes were organs at risk (OARs) dosimetric outcomes, prognosis (overall survival [OS], progression-free survival [PFS], and objective response rate [ORR]), and radiation-related toxic effects. Results A total of 45 studies were included in the meta-analysis. For dosimetric analysis, proton therapy was associated with significantly reduced OARs dose. Meta-analysis showed that photon therapy was associated with poor OS (hazard ratio [HR], 1.31; 95% CI, 1.07-1.61; I2 = 11%), but no difference in PFS was observed. Subgroup analysis showed worse OS (HR, 1.42; 95% CI, 1.14-1.78; I2 = 34%) and PFS (HR, 1.48; 95% CI, 1.06-2.08; I2 = 7%) in the radical therapy group with photon therapy. The pathological complete response rate was similar between groups. Proton therapy was associated with significantly decreased grade 2 or higher radiation pneumonitis and pericardial effusion, and grade 4 or higher lymphocytopenia. Single-rate analysis of proton therapy found 89% OS and 65% PFS at 1 year, 71% OS and 56% PFS at 2 years, 63% OS and 48% PFS at 3 years, and 56% OS and 42% PFS at 5 years. The incidence of grade 2 or higher radiation esophagitis was 50%, grade 2 or higher radiation pneumonitis was 2%, grade 2 or higher pleural effusion was 4%, grade 2 or higher pericardial effusion was 3%, grade 3 or higher radiation esophagitis was 8%, and grade 4 or higher lymphocytopenia was 17%. Conclusions and Relevance In this meta-analysis, proton therapy was associated with reduced OARs doses and toxic effects and improved prognosis compared with photon therapy for esophageal cancer, but caution is warranted. In the future, these findings should be further validated in randomized clinical trials.
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Affiliation(s)
- Pixiao Zhou
- Department of Oncology, Changde Hospital, Xiangya School of Medicine, Central South University, Changde, China
| | - Yangfeng Du
- Department of Oncology, Changde Hospital, Xiangya School of Medicine, Central South University, Changde, China
| | - Ying Zhang
- The Second People’s Hospital of Yibin, Yibin, China
| | - Mei Zhu
- Department of Oncology, Changde Hospital, Xiangya School of Medicine, Central South University, Changde, China
| | - Ting Li
- Department of Oncology, Changde Hospital, Xiangya School of Medicine, Central South University, Changde, China
| | - Wei Tian
- Department of Oncology, Changde Hospital, Xiangya School of Medicine, Central South University, Changde, China
| | - Tao Wu
- Department of Oncology, Changde Hospital, Xiangya School of Medicine, Central South University, Changde, China
| | - Zemin Xiao
- Department of Oncology, Changde Hospital, Xiangya School of Medicine, Central South University, Changde, China
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Cinicola J, Mamidanna S, Yegya-Raman N, Spencer K, Deek MP, Jabbour SK. A Review of Advances in Radiotherapy in the Setting of Esophageal Cancers. Surg Oncol Clin N Am 2023; 32:433-459. [PMID: 37182986 DOI: 10.1016/j.soc.2023.03.004] [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: 05/16/2023]
Abstract
Esophageal cancer is the eighth most common cancer worldwide and is the sixth most common cause of cancer-related mortality. The paradigm has shifted to include a multimodality approach with surgery, chemotherapy, targeted therapy (including immunotherapy), and radiation therapy. Advances in radiotherapy through techniques such as intensity modulated radiotherapy and proton beam therapy have allowed for the more dose homogeneity and improved organ sparing. In addition, recent studies of targeted therapies and predictive approaches in patients with locally advanced disease provide clinicians with new approaches to modify multimodality treatment to improve clinical outcomes.
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Affiliation(s)
- Joshua Cinicola
- Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA
| | - Swati Mamidanna
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson School of Medicine, Rutgers University, New Brunswick, NJ, USA
| | - Nikhil Yegya-Raman
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Kristen Spencer
- New York Langone Perlmutter Cancer Center, New York, NY, USA
| | - Matthew P Deek
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson School of Medicine, Rutgers University, New Brunswick, NJ, USA
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson School of Medicine, Rutgers University, New Brunswick, NJ, USA.
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Kowalchuk RO, Spears GM, Morris LK, Owen D, Yoon HH, Jethwa K, Chuong MD, Ferris MJ, Haddock MG, Hallemeier CL, Wigle D, Lin SH, Merrell KW. Risk stratification of postoperative cardiopulmonary toxicity after trimodality therapy for esophageal cancer. Front Oncol 2023; 13:1081024. [PMID: 36845682 PMCID: PMC9948243 DOI: 10.3389/fonc.2023.1081024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 01/27/2023] [Indexed: 02/11/2023] Open
Abstract
Purpose/objective Postoperative toxicity for esophageal cancer impacts patient quality of life and potentially overall survival (OS). We studied whether patient and toxicity parameters post-chemoradiation therapy predict for post-surgical cardiopulmonary total toxicity burden (CPTTB) and whether CPTTB was associated with short and long-term outcomes. Materials/methods Patients had biopsy-proven esophageal cancer treated with neoadjuvant chemoradiation and esophagectomy. CPTTB was derived from total perioperative toxicity burden (Lin et al. JCO 2020). To develop a CPTTB risk score predictive for major CPTTB, recursive partitioning analysis was used. Results From 3 institutions, 571 patients were included. Patients were treated with 3D (37%), IMRT (44%), and proton therapy (19%). 61 patients had major CPTTB (score ≥ 70). Increasing CPTTB was predictive of decreased OS (p<0.001), lengthier post-esophagectomy length of stay (LOS, p<0.001), and death or readmission within 60 days of surgery (DR60, p<0.001). Major CPTTB was also predictive of decreased OS (hazard ratio = 1.70, 95% confidence interval: 1.17-2.47, p=0.005). The RPA-based risk score included: age ≥ 65, grade ≥ 2 nausea or esophagitis attributed to chemoradiation, and grade ≥ 3 hematologic toxicity attributed to chemoradiation. Patients treated with 3D radiotherapy had inferior OS (p=0.010) and increased major CPTTB (18.5% vs. 6.1%, p<0.001). Conclusion CPTTB predicts for OS, LOS, and DR60. Patients with 3D radiotherapy or age ≥ 65 years and chemoradiation toxicity are at highest risk for major CPTTB, predicting for higher short and long-term morbidity and mortality. Strategies to optimize medical management and reduce toxicity from chemoradiation should be strongly considered.
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Affiliation(s)
- Roman O. Kowalchuk
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Grant M. Spears
- Department of Statistics, Mayo Clinic, Rochester, MN, United States
| | - Lindsay K. Morris
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Dawn Owen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Harry H. Yoon
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, United States
| | - Krishan Jethwa
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Michael D. Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL, United States
| | - Matthew J. Ferris
- Department of Radiation Oncology, University of Maryland Medical System, Baltimore, MD, United States
| | - Michael G. Haddock
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | | | - Dennis Wigle
- Department of Thoracic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Steven H. Lin
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, United States
| | - Kenneth W. Merrell
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States,*Correspondence: Kenneth W. Merrell,
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Cui Y, Pan Y, Li Z, Wu Q, Zou J, Han D, Yin Y, Ma C. Dosimetric analysis and biological evaluation between proton radiotherapy and photon radiotherapy for the long target of total esophageal squamous cell carcinoma. Front Oncol 2022; 12:954187. [PMID: 36263217 PMCID: PMC9574336 DOI: 10.3389/fonc.2022.954187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 09/05/2022] [Indexed: 11/13/2022] Open
Abstract
Objective The purpose of this study is to compare the dosimetric and biological evaluation differences between photon and proton radiation therapy. Methods Thirty esophageal squamous cell carcinoma (ESCC) patients were generated for volumetric modulated arc therapy (VMAT) planning and intensity-modulated proton therapy (IMPT) planning to compare with intensity-modulated radiation therapy (IMRT) planning. According to dose–volume histogram (DVH), dose–volume parameters of the plan target volume (PTV) and homogeneity index (HI), conformity index (CI), and gradient index (GI) were used to analyze the differences between the various plans. For the organs at risk (OARS), dosimetric parameters were compared. Tumor control probability (TCP) and normal tissue complication probability (NTCP) was also used to evaluate the biological effectiveness of different plannings. Results CI, HI, and GI of IMPT planning were significantly superior in the three types of planning (p < 0.001, p < 0.001, and p < 0.001, respectively). Compared to IMRT and VMAT planning, IMPT planning improved the TCP (p<0.001, p<0.001, respectively). As for OARs, IMPT reduced the bilateral lung and heart accepted irradiation dose and volume. The dosimetric parameters, such as mean lung dose (MLD), mean heart dose (MHD), V5, V10, and V20, were significantly lower than IMRT or VMAT. IMPT afforded a lower maximum dose (Dmax) of the spinal cord than the other two-photon plans. What’s more, the radiation pneumonia of the left lung, which was caused by IMPT, was lower than IMRT and VMAT. IMPT achieved the pericarditis probability of heart is only 1.73% ± 0.24%. For spinal cord myelitis necrosis, there was no significant difference between the three different technologies. Conclusion Proton radiotherapy is an effective technology to relieve esophageal cancer, which could improve the TCP and spare the heart, lungs, and spinal cord. Our study provides a prediction of radiotherapy outcomes and further guides the individual treatment.
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Affiliation(s)
- Yongbin Cui
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Yuteng Pan
- Medical Science and Technology Innovation Center, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Zhenjiang Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Qiang Wu
- Affiliated Hospital of Weifang Medical University, School of Clinical Medicine, Weifang Medical University, Weifang, China
| | - Jingmin Zou
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Dali Han
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Yong Yin
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
- *Correspondence: Yong Yin, ; Changsheng Ma,
| | - Changsheng Ma
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
- *Correspondence: Yong Yin, ; Changsheng Ma,
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Kobeissi JM, Simone CB, Hilal L, Wu AJ, Lin H, Crane CH, Hajj C. Proton Therapy in the Management of Luminal Gastrointestinal Cancers: Esophagus, Stomach, and Anorectum. Cancers (Basel) 2022; 14:cancers14122877. [PMID: 35740544 PMCID: PMC9221464 DOI: 10.3390/cancers14122877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 05/28/2022] [Accepted: 06/07/2022] [Indexed: 11/29/2022] Open
Abstract
Simple Summary Radiation treatment plays a major role in the management of luminal gastrointestinal cancers, mainly esophageal and anorectal cancers. There is a growing interest in the application of protons for gastrointestinal cancers, mainly owing to its dosimetric characteristics in decreasing dose to nearby organs at risk. We present here an up-to-date comprehensive review of the dosimetric and clinical literature on the use of proton therapy in the management of luminal gastrointestinal cancers. Abstract While the role of proton therapy in gastric cancer is marginal, its role in esophageal and anorectal cancers is expanding. In esophageal cancer, protons are superior in sparing the organs at risk, as shown by multiple dosimetric studies. Literature is conflicting regarding clinical significance, but the preponderance of evidence suggests that protons yield similar or improved oncologic outcomes to photons at a decreased toxicity cost. Similarly, protons have improved sparing of the organs at risk in anorectal cancers, but clinical data is much more limited to date, and toxicity benefits have not yet been shown clinically. Large, randomized trials are currently underway for both disease sites.
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Affiliation(s)
- Jana M. Kobeissi
- Department of Radiation Oncology, School of Medicine, American University of Beirut Medical Center, Beirut 1007, Lebanon; (J.M.K.); (L.H.)
| | - Charles B. Simone
- Department of Radiation Oncology, New York Proton Center, New York, NY 10035, USA; (C.B.S.II); (H.L.)
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10027, USA; (A.J.W.); (C.H.C.)
| | - Lara Hilal
- Department of Radiation Oncology, School of Medicine, American University of Beirut Medical Center, Beirut 1007, Lebanon; (J.M.K.); (L.H.)
| | - Abraham J. Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10027, USA; (A.J.W.); (C.H.C.)
| | - Haibo Lin
- Department of Radiation Oncology, New York Proton Center, New York, NY 10035, USA; (C.B.S.II); (H.L.)
| | - Christopher H. Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10027, USA; (A.J.W.); (C.H.C.)
| | - Carla Hajj
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10027, USA; (A.J.W.); (C.H.C.)
- Correspondence:
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