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Tang X, Wan Chan Tseung H, Moseley D, Zverovitch A, Hughes CO, George J, Johnson JE, Breen WG, Qian J. Deep learning based linear energy transfer calculation for proton therapy. Phys Med Biol 2024; 69:115058. [PMID: 38714191 DOI: 10.1088/1361-6560/ad4844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 05/07/2024] [Indexed: 05/09/2024]
Abstract
Objective.This study aims to address the limitations of traditional methods for calculating linear energy transfer (LET), a critical component in assessing relative biological effectiveness (RBE). Currently, Monte Carlo (MC) simulation, the gold-standard for accuracy, is resource-intensive and slow for dose optimization, while the speedier analytical approximation has compromised accuracy. Our objective was to prototype a deep-learning-based model for calculating dose-averaged LET (LETd) using patient anatomy and dose-to-water (DW) data, facilitating real-time biological dose evaluation and LET optimization within proton treatment planning systems.Approach. 275 4-field prostate proton Stereotactic Body Radiotherapy plans were analyzed, rendering a total of 1100 fields. Those were randomly split into 880, 110, and 110 fields for training, validation, and testing. A 3D Cascaded UNet model, along with data processing and inference pipelines, was developed to generate patient-specific LETddistributions from CT images and DW. The accuracy of the LETdof the test dataset was evaluated against MC-generated ground truth through voxel-based mean absolute error (MAE) and gamma analysis.Main results.The proposed model accurately inferred LETddistributions for each proton field in the test dataset. A single-field LETdcalculation took around 100 ms with trained models running on a NVidia A100 GPU. The selected model yielded an average MAE of 0.94 ± 0.14 MeV cm-1and a gamma passing rate of 97.4% ± 1.3% when applied to the test dataset, with the largest discrepancy at the edge of fields where the dose gradient was the largest and counting statistics was the lowest.Significance.This study demonstrates that deep-learning-based models can efficiently calculate LETdwith high accuracy as a fast-forward approach. The model shows great potential to be utilized for optimizing the RBE of proton treatment plans. Future efforts will focus on enhancing the model's performance and evaluating its adaptability to different clinical scenarios.
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Affiliation(s)
- Xueyan Tang
- Department of Radiation Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Hok Wan Chan Tseung
- Department of Radiation Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Douglas Moseley
- Department of Radiation Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | | | - Cian O Hughes
- Google Inc, Mountain View, CA, United States of America
| | - Jon George
- Google Inc, Mountain View, CA, United States of America
| | - Jedediah E Johnson
- Department of Radiation Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - William G Breen
- Department of Radiation Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Jing Qian
- Department of Radiation Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
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Yu H, He S, He Y, Dai G, Fu Y, Zeng X, Liu M, Ai P. Dosimetric comparison of advanced radiation techniques for scalp-sparing in low-grade gliomas. Strahlenther Onkol 2024:10.1007/s00066-024-02229-3. [PMID: 38649484 DOI: 10.1007/s00066-024-02229-3] [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: 10/23/2023] [Accepted: 03/03/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Alopecia causes significant distress for patients and negatively impacts quality of life for low-grade glioma (LGG) patients. We aimed to compare and evaluate variations in dose distribution for scalp-sparing in LGG patients with proton therapy and photon therapy, namely intensity-modulated proton therapy (IMPT), intensity-modulated radiotherapy (IMRT), volumetric modulated arc therapy (VMAT), and helical tomotherapy (HT). METHODS This retrospective study utilized a dataset comprising imaging data from 22 patients with LGG who underwent postoperative radiotherapy. Treatment plans were generated for each patient with scalp-optimized (SO) approaches and scalp-non-optimized (SNO) approaches using proton techniques and photons techniques; all plans adhered to the same dose constraint of delivering a total radiation dose of 54.04 Gy to the target volume. All treatment plans were subsequently analyzed. RESULTS All the plans generated in this study met the dose constraints for the target volume and OARs. The SO plans resulted in reduced maximum scalp dose (Dmax), mean scalp dose (Dmean), and volume of the scalp receiving 30 Gy (V30) and 40 Gy (V40) compared with SNO plans in all radiation techniques. Among all radiation techniques, the IMPT plans exhibited superior performance compared to other plans for dose homogeneity as for SO plans. Also, IMPT showed lower values for Dmean and Dmax than all photon radiation techniques. CONCLUSION Our study provides evidence that the SO approach is a feasible technique for reducing scalp radiation dose. However, it is imperative to conduct prospective trials to assess the benefits associated with this approach.
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Affiliation(s)
- Hang Yu
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, 610041, Chengdu, Sichuan Province, China
| | - Shuangshuang He
- Department of Radiation Oncology and Department of Head and Neck Oncology, Cancer Center, West China Hospital, Sichuan University, Sichuan, China
| | - Yisong He
- Medical Physics Laboratory, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, 610072, Chengdu, China
| | - Guyu Dai
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, 610041, Chengdu, Sichuan Province, China
| | - Yuchuan Fu
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, 610041, Chengdu, Sichuan Province, China
| | - Xianhu Zeng
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, 610041, Chengdu, Sichuan Province, China
| | - Mengyuan Liu
- Department of Radiation Oncology and Department of Head and Neck Oncology, Cancer Center, West China Hospital, Sichuan University, Sichuan, China
| | - Ping Ai
- Department of Radiation Oncology and Department of Head and Neck Oncology, Cancer Center, West China Hospital, Sichuan University, Sichuan, China.
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Voshart DC, Klaver M, Jiang Y, van Weering HRJ, van Buuren-Broek F, van der Linden GP, Cinat D, Kiewiet HH, Malimban J, Vazquez-Matias DA, Reali Nazario L, Scholma AC, Sewdihal J, van Goethem MJ, van Luijk P, Coppes RP, Barazzuol L. Proton therapy induces a local microglial neuroimmune response. Radiother Oncol 2024; 193:110117. [PMID: 38453539 DOI: 10.1016/j.radonc.2024.110117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 01/25/2024] [Accepted: 01/28/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND AND PURPOSE Although proton therapy is increasingly being used in the treatment of paediatric and adult brain tumours, there are still uncertainties surrounding the biological effect of protons on the normal brain. Microglia, the brain-resident macrophages, have been shown to play a role in the development of radiation-induced neurotoxicity. However, their molecular and hence functional response to proton irradiation remains unknown. This study investigates the effect of protons on microglia by comparing the effect of photons and protons as well as the influence of age and different irradiated volumes. MATERIALS AND METHODS Rats were irradiated with 14 Gy to the whole brain with photons (X-rays), plateau protons, spread-out Bragg peak (SOBP) protons or to 50 % anterior, or 50 % posterior brain sub-volumes with plateau protons. RNA sequencing, validation of microglial priming gene expression using qPCR and high-content imaging analysis of microglial morphology were performed in the cortex at 12 weeks post irradiation. RESULTS Photons and plateau protons induced a shared transcriptomic response associated with neuroinflammation. This response was associated with a similar microglial priming gene expression signature and distribution of microglial morphologies. Expression of the priming gene signature was less pronounced in juvenile rats compared to adults and slightly increased in rats irradiated with SOBP protons. High-precision partial brain irradiation with protons induced a local microglial priming response and morphological changes. CONCLUSION Overall, our data indicate that the brain responds in a similar manner to photons and plateau protons with a shared local upregulation of microglial priming-associated genes, potentially enhancing the immune response to subsequent inflammatory challenges.
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Affiliation(s)
- Daniëlle C Voshart
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen 9700 RB, The Netherlands; Department of Biomedical Sciences, Section of Molecular Cell Biology, University Medical Center Groningen, University of Groningen, Groningen 9700 AD, The Netherlands
| | - Myrthe Klaver
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen 9700 RB, The Netherlands; Department of Biomedical Sciences, Section of Molecular Cell Biology, University Medical Center Groningen, University of Groningen, Groningen 9700 AD, The Netherlands
| | - Yuting Jiang
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen 9700 RB, The Netherlands; Department of Biomedical Sciences, Section of Molecular Cell Biology, University Medical Center Groningen, University of Groningen, Groningen 9700 AD, The Netherlands
| | - Hilmar R J van Weering
- Department of Biomedical Sciences, Section of Molecular Neurobiology, University Medical Center Groningen, University of Groningen, Groningen 9700 AD, The Netherlands
| | - Fleur van Buuren-Broek
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen 9700 RB, The Netherlands; Department of Biomedical Sciences, Section of Molecular Cell Biology, University Medical Center Groningen, University of Groningen, Groningen 9700 AD, The Netherlands
| | - Gideon P van der Linden
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen 9700 RB, The Netherlands; Department of Biomedical Sciences, Section of Molecular Cell Biology, University Medical Center Groningen, University of Groningen, Groningen 9700 AD, The Netherlands
| | - Davide Cinat
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen 9700 RB, The Netherlands; Department of Biomedical Sciences, Section of Molecular Cell Biology, University Medical Center Groningen, University of Groningen, Groningen 9700 AD, The Netherlands
| | - Harry H Kiewiet
- Department of Biomedical Sciences, PARTREC, University Medical Center Groningen, University of Groningen, Groningen 9747 AA, The Netherlands
| | - Justin Malimban
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen 9700 RB, The Netherlands
| | - Daniel A Vazquez-Matias
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen 9700 RB, The Netherlands; Department of Biomedical Sciences, Section of Molecular Cell Biology, University Medical Center Groningen, University of Groningen, Groningen 9700 AD, The Netherlands
| | - Luiza Reali Nazario
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen 9700 RB, The Netherlands; Department of Biomedical Sciences, Section of Molecular Cell Biology, University Medical Center Groningen, University of Groningen, Groningen 9700 AD, The Netherlands
| | - Ayla C Scholma
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen 9700 RB, The Netherlands; Department of Biomedical Sciences, Section of Molecular Cell Biology, University Medical Center Groningen, University of Groningen, Groningen 9700 AD, The Netherlands
| | - Jeffrey Sewdihal
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen 9700 RB, The Netherlands; Department of Biomedical Sciences, Section of Molecular Cell Biology, University Medical Center Groningen, University of Groningen, Groningen 9700 AD, The Netherlands
| | - Marc-Jan van Goethem
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen 9700 RB, The Netherlands; Department of Biomedical Sciences, PARTREC, University Medical Center Groningen, University of Groningen, Groningen 9747 AA, The Netherlands
| | - Peter van Luijk
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen 9700 RB, The Netherlands; Department of Biomedical Sciences, Section of Molecular Cell Biology, University Medical Center Groningen, University of Groningen, Groningen 9700 AD, The Netherlands
| | - Rob P Coppes
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen 9700 RB, The Netherlands; Department of Biomedical Sciences, Section of Molecular Cell Biology, University Medical Center Groningen, University of Groningen, Groningen 9700 AD, The Netherlands
| | - Lara Barazzuol
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen 9700 RB, The Netherlands; Department of Biomedical Sciences, Section of Molecular Cell Biology, University Medical Center Groningen, University of Groningen, Groningen 9700 AD, The Netherlands.
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Heuchel L, Hahn C, Ödén J, Traneus E, Wulff J, Timmermann B, Bäumer C, Lühr A. The dirty and clean dose concept: Towards creating proton therapy treatment plans with a photon-like dose response. Med Phys 2024; 51:622-636. [PMID: 37877574 DOI: 10.1002/mp.16809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 10/11/2023] [Accepted: 10/11/2023] [Indexed: 10/26/2023] Open
Abstract
BACKGROUND Applying tolerance doses for organs at risk (OAR) from photon therapy introduces uncertainties in proton therapy when assuming a constant relative biological effectiveness (RBE) of 1.1. PURPOSE This work introduces the novel dirty and clean dose concept, which allows for creating treatment plans with a more photon-like dose response for OAR and, thus, less uncertainties when applying photon-based tolerance doses. METHODS The concept divides the 1.1-weighted dose distribution into two parts: the clean and the dirty dose. The clean and dirty dose are deposited by protons with a linear energy transfer (LET) below and above a set LET threshold, respectively. For the former, a photon-like dose response is assumed, while for the latter, the RBE might exceed 1.1. To reduce the dirty dose in OAR, a MaxDirtyDose objective was added in treatment plan optimization. It requires setting two parameters: LET threshold and max dirty dose level. A simple geometry consisting of one target volume and one OAR in water was used to study the reduction in dirty dose in the OAR depending on the choice of the two MaxDirtyDose objective parameters during plan optimization. The best performing parameter combinations were used to create multiple dirty dose optimized (DDopt) treatment plans for two cranial patient cases. For each DDopt plan, 1.1-weighted dose, variable RBE-weighted dose using the Wedenberg RBE model and dose-average LETd distributions as well as resulting normal tissue complication probability (NTCP) values were calculated and compared to the reference plan (RefPlan) without MaxDirtyDose objectives. RESULTS In the water phantom studies, LET thresholds between 1.5 and 2.5 keV/µm yielded the best plans and were subsequently used. For the patient cases, nearly all DDopt plans led to a reduced Wedenberg dose in critical OAR. This reduction resulted from an LET reduction and translated into an NTCP reduction of up to 19 percentage points compared to the RefPlan. The 1.1-weighted dose in the OARs was slightly increased (patient 1: 0.45 Gy(RBE), patient 2: 0.08 Gy(RBE)), but never exceeded clinical tolerance doses. Additionally, slightly increased 1.1-weighted dose in healthy brain tissue was observed (patient 1: 0.81 Gy(RBE), patient 2: 0.53 Gy(RBE)). The variation of NTCP values due to variation of α/β from 2 to 3 Gy was much smaller for DDopt (2 percentage points (pp)) than for RefPlans (5 pp). CONCLUSIONS The novel dirty and clean dose concept allows for creating biologically more robust proton treatment plans with a more photon-like dose response. The reduced uncertainties in RBE can, therefore, mitigate uncertainties introduced by using photon-based tolerance doses for OAR.
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Affiliation(s)
- Lena Heuchel
- Department of Physics, TU Dortmund University, Dortmund, Germany
| | - Christian Hahn
- Department of Physics, TU Dortmund University, Dortmund, Germany
- OncoRay-National Center of Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jakob Ödén
- RaySearch Laboratories AB, Stockholm, Sweden
| | | | - Jörg Wulff
- West German Proton Therapy Center Essen, Essen, Germany
- West German Cancer Center (WTZ), University Hospital Essen, Essen, Germany
| | - Beate Timmermann
- West German Proton Therapy Center Essen, Essen, Germany
- West German Cancer Center (WTZ), University Hospital Essen, Essen, Germany
- Department of Particle Therapy, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Essen, Germany
| | - Christian Bäumer
- Department of Physics, TU Dortmund University, Dortmund, Germany
- West German Proton Therapy Center Essen, Essen, Germany
- West German Cancer Center (WTZ), University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Essen, Germany
| | - Armin Lühr
- Department of Physics, TU Dortmund University, Dortmund, Germany
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Henjum H, Tjelta J, Fjæra LF, Pilskog S, Stokkevåg CH, Lyngholm E, Handeland AH, Ytre-Hauge KS. Influence of beam pruning techniques on LET and RBE in proton arc therapy. Front Oncol 2023; 13:1155310. [PMID: 37731633 PMCID: PMC10508957 DOI: 10.3389/fonc.2023.1155310] [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: 01/31/2023] [Accepted: 08/15/2023] [Indexed: 09/22/2023] Open
Abstract
Introduction Proton arc therapy (PAT) is an emerging treatment modality that holds promise to improve target volume coverage and reduce linear energy transfer (LET) in organs at risk. We aimed to investigate if pruning the highest energy layers in each beam direction could increase the LET in the target and reduce LET in tissue and organs at risk (OAR) surrounding the target volume, thus reducing the relative biological effectiveness (RBE)-weighted dose and sparing healthy tissue. Methods PAT plans for a germinoma, an ependymoma and a rhabdomyosarcoma patient were created in the Eclipse treatment planning system with a prescribed dose of 54 Gy(RBE) using a constant RBE of 1.1 (RBE1.1). The PAT plans was pruned for high energy spots, creating several PAT plans with different amounts of pruning while maintaining tumor coverage, denoted PX-PAT plans, where X represents the amount of pruning. All plans were recalculated in the FLUKA Monte Carlo software, and the LET, physical dose, and variable RBE-weighted dose from the phenomenological Rørvik (ROR) model and an LET weighted dose (LWD) model were evaluated. Results and discussion For the germinoma case, all plans but the P6-PAT reduced the mean RBE-weighted dose to the surrounding healthy tissue compared to the PAT plan. The LET was increasingly higher within the PTV for each pruning iteration, where the mean LET from the P6-PAT plan was 1.5 keV / μm higher than for the PAT plan, while the P4- and P5-PAT plans provided an increase of 0.4 and 0.7 keV / μm , respectively. The other plans increased the LET by a smaller margin compared to the PAT plan. Likewise, the LET values to the healthy tissue were reduced for each degree of pruning. Similar results were found for the ependymoma and the rhabdomyosarcoma case. We demonstrated a PAT pruning technique that can increase both LET and RBE in the target volume and at the same time decreased values in healthy tissue, without affecting the target volume dose coverage.
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Affiliation(s)
- Helge Henjum
- Department of Physics and Technology, University of Bergen, Bergen, Norway
| | - Johannes Tjelta
- Department of Physics and Technology, University of Bergen, Bergen, Norway
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Lars Fredrik Fjæra
- Department of Physics and Technology, University of Bergen, Bergen, Norway
| | - Sara Pilskog
- Department of Physics and Technology, University of Bergen, Bergen, Norway
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Camilla H. Stokkevåg
- Department of Physics and Technology, University of Bergen, Bergen, Norway
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Erlend Lyngholm
- Department of Physics and Technology, University of Bergen, Bergen, Norway
| | - Andreas H. Handeland
- Department of Physics and Technology, University of Bergen, Bergen, Norway
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
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Handeland AH, Indelicato DJ, Fredrik Fjæra L, Ytre-Hauge KS, Pettersen HES, Muren LP, Lassen-Ramshad Y, Stokkevåg CH. Linear energy transfer-inclusive models of brainstem necrosis following proton therapy of paediatric ependymoma. Phys Imaging Radiat Oncol 2023; 27:100466. [PMID: 37457667 PMCID: PMC10345333 DOI: 10.1016/j.phro.2023.100466] [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: 02/17/2023] [Revised: 06/22/2023] [Accepted: 06/24/2023] [Indexed: 07/18/2023] Open
Abstract
Background and Purpose Radiation-induced brainstem necrosis after proton therapy is a severe toxicity with potential association to uncertainties in the proton relative biological effectiveness (RBE). A constant RBE of 1.1 is assumed clinically, but the RBE is known to vary with linear energy transfer (LET). LET-inclusive predictive models of toxicity may therefore be beneficial during proton treatment planning. Hence, we aimed to construct models describing the association between brainstem necrosis and LET in the brainstem. Materials and methods A matched case-control cohort (n = 28, 1:3 case-control ratio) of symptomatic brainstem necrosis was selected from 954 paediatric ependymoma brain tumour patients treated with passively scattered proton therapy. Dose-averaged LET (LETd) parameters in restricted volumes (L50%, L10% and L0.1cm3, the cumulative LETd) within high-dose thresholds were included in linear- and logistic regression normal tissue complication probability (NTCP) models. Results A 1 keV/µm increase in L10% to the brainstem volume receiving dose over 54 Gy(RBE) led to an increased brainstem necrosis risk [95% confidence interval] of 2.5 [0.0, 7.8] percentage points. The corresponding logistic regression model had area under the receiver operating characteristic curve (AUC) of 0.76, increasing to 0.84 with the anterior pons substructure as a second parameter. 19 [7, 350] patients with toxicity were required to associate the L10% (D > 54 Gy(RBE)) and brainstem necrosis with 80% statistical power. Conclusion The established models of brainstem necrosis illustrate a potential impact of high LET regions in patients receiving high doses to the brainstem, and thereby support LET mitigation during clinical treatment planning.
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Affiliation(s)
- Andreas H. Handeland
- Department of Physics and Technology, University of Bergen, Bergen, Norway
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | | | - Lars Fredrik Fjæra
- Department of Physics and Technology, University of Bergen, Bergen, Norway
- Department of Medical Physics, Oslo University Hospital, Norway
| | | | | | - Ludvig P. Muren
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Camilla H. Stokkevåg
- Department of Physics and Technology, University of Bergen, Bergen, Norway
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
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Soltwedel J, Suckert T, Beyreuther E, Schneider M, Boucsein M, Bodenstein E, Nexhipi S, Stolz-Kieslich L, Krause M, von Neubeck C, Haase R, Lühr A, Dietrich A. Slice2Volume: Fusion of multimodal medical imaging and light microscopy data of irradiation-injured brain tissue in 3D. Radiother Oncol 2023; 182:109591. [PMID: 36858201 DOI: 10.1016/j.radonc.2023.109591] [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: 08/26/2022] [Revised: 01/20/2023] [Accepted: 02/22/2023] [Indexed: 03/03/2023]
Abstract
Comprehending cellular changes of radiation-induced brain injury is crucial to prevent and treat the pathology. We provide a unique open dataset of proton-irradiated mouse brains consisting of medical imaging, radiation dose simulations, and large-scale microscopy images, all registered into a common coordinate system. This allows dose-dependent analyses on single-cell level.
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Affiliation(s)
- Johannes Soltwedel
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technical University Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden 01309, Germany; Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden 01309, Germany; DFG Cluster of Excellence Physics of Life, TU Dresden, Dresden 01307, Germany
| | - Theresa Suckert
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technical University Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden 01309, Germany; German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg 69120, Germany; Institute for Research in Biomedicine (IRB Barcelona), Barcelona Institute of Science and Technology (BIST), Barcelona 08028, Spain
| | - Elke Beyreuther
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technical University Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden 01309, Germany; Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiation Physics, Dresden 01328, Germany
| | - Moritz Schneider
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technical University Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden 01309, Germany; Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiation Physics, Dresden 01328, Germany
| | - Marc Boucsein
- Im Neuenheimer Feld 223, E050 Clinical Cooperation Unit Radiation Oncology, 69120 Heidelberg, Germany; Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg 69120, Germany
| | - Elisabeth Bodenstein
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technical University Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden 01309, Germany; Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden 01309, Germany
| | - Sindi Nexhipi
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technical University Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden 01309, Germany; Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden 01309, Germany
| | - Liane Stolz-Kieslich
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technical University Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden 01309, Germany; German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg 69120, Germany
| | - Mechthild Krause
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technical University Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden 01309, Germany; Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden 01309, Germany; German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg 69120, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden 01307, Germany; National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden 01307, Germany
| | - Cläre von Neubeck
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technical University Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden 01309, Germany; German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg 69120, Germany; Department of Particle Therapy, University Hospital Essen, University of Duisburg-Essen, Essen 45147, Germany
| | - Robert Haase
- DFG Cluster of Excellence Physics of Life, TU Dresden, Dresden 01307, Germany
| | - Armin Lühr
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technical University Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden 01309, Germany; Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden 01309, Germany; Medical Physics and Radiotherapy, Department of Physics, TU Dortmund University, Dortmund 44227, Germany
| | - Antje Dietrich
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technical University Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden 01309, Germany; German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg 69120, Germany.
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8
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Eulitz J, G C Troost E, Klünder L, Raschke F, Hahn C, Schulz E, Seidlitz A, Thiem J, Karpowitz C, Hahlbohm P, Grey A, Engellandt K, Löck S, Krause M, Lühr A. Increased relative biological effectiveness and periventricular radiosensitivity in proton therapy of glioma patients. Radiother Oncol 2023; 178:109422. [PMID: 36435337 DOI: 10.1016/j.radonc.2022.11.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 10/25/2022] [Accepted: 11/17/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Currently, there is an intense debate on variations in intra-cerebral radiosensitivity and relative biological effectiveness (RBE) in proton therapy of primary brain tumours. Here, both effects were retrospectively investigated using late radiation-induced brain injuries (RIBI) observed in follow-up after proton therapy of patients with diagnosed glioma. METHODS In total, 42 WHO grade 2-3 glioma patients out of a consecutive patient cohort having received (adjuvant) proton radio(chemo)therapy between 2014 and 2017 were eligible for analysis. RIBI lesions (symptomatic or clinically asymptomatic) were diagnosed and delineated on contrast-enhanced T1-weighted magnetic resonance imaging scans obtained in the first two years of follow-up. Correlation of RIBI location and occurrence with dose (D), proton dose-averaged linear energy transfer (LET) and variable RBE dose parameters were tested in voxel- and in patient-wise logistic regression analyses. Additionally, anatomical and clinical parameters were considered. Model performance was estimated through cross-validated area-under-the-curve (AUC) values. RESULTS In total, 64 RIBI lesions were diagnosed in 21 patients. The median time between start of proton radio(chemo)therapy and RIBI appearance was 10.2 months. Median distances of the RIBI volume centres to the cerebral ventricles and to the clinical target volume border were 2.1 mm and 1.3 mm, respectively. In voxel-wise regression, the multivariable model with D, D × LET and periventricular region (PVR) revealed the highest AUC of 0.90 (95 % confidence interval: 0.89-0.91) while the corresponding model without D × LET revealed a value of 0.84 (0.83-0.86). In patient-level analysis, the equivalent uniform dose (EUD11, a = 11) in the PVR using a variable RBE was the most prominent predictor for RIBI with an AUC of 0.63 (0.32-0.90). CONCLUSIONS In this glioma cohort, an increased radiosensitivity within the PVR was observed as well as a spatial correlation of RIBI with an increased RBE. Both need to be considered when delivering radio(chemo)therapy using proton beams.
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Affiliation(s)
- Jan Eulitz
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Esther G C Troost
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumour Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany; German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Lauritz Klünder
- Department of Physics, TU Dortmund University, Dortmund, Germany
| | - Felix Raschke
- Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Christian Hahn
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Department of Physics, TU Dortmund University, Dortmund, Germany
| | - Erik Schulz
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Annekatrin Seidlitz
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumour Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany; German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Justus Thiem
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumour Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany; German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Caroline Karpowitz
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumour Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany; German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Patricia Hahlbohm
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Institute and Polyclinic for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Arne Grey
- National Center for Tumour Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany; German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; Institute and Polyclinic for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Kay Engellandt
- National Center for Tumour Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany; German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; Institute and Polyclinic for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Steffen Löck
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumour Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany; German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Mechthild Krause
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumour Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany; German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Armin Lühr
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; Department of Physics, TU Dortmund University, Dortmund, Germany.
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9
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Yang Y, Rwigema JCM, Vargas C, Yu NY, Keole SR, Wong WW, Schild SE, Bues M, Liu W, Shen J. Technical note: Investigation of dose and LET d effect to rectum and bladder by using non-straight laterals in prostate cancer receiving proton therapy. Med Phys 2022; 49:7428-7437. [PMID: 36208196 DOI: 10.1002/mp.16008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 09/02/2022] [Accepted: 09/22/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Parallel-opposed lateral beams are the conventional beam arrangements in proton therapy for prostate cancer. However, when considering linear energy transfer (LET) and RBE effects, alternative beam arrangements should be investigated. PURPOSE To investigate the dose and dose averaged LET (LETd ) impact of using new beam arrangements rotating beams 5°-15° posteriorly to the laterals in prostate cancer treated with pencil-beam-scanning (PBS) proton therapy. METHODS Twenty patients with localized prostate cancer were included in this study. Four proton treatment plans for each patient were generated utilizing 0°, 5°, 10°, and 15° posterior oblique beam pairs relative to parallel-opposed lateral beams. Dose-volume histograms (DVHs) from posterior oblique beams were analyzed. Dose-LETd -volume histogram (DLVH) was employed to study the difference in dose and LETd with each beam arrangement. DLVH indices, V ( d , l ) $V( {d,l} )$ , defined as the cumulative absolute volume that has a dose of at least d (Gy[RBE]) and a LETd of at least l (keV/µm), were calculated for both the rectum and bladder to the whole group of patients and two-sub groups with and without hydrogel spacer. These metrics were tested using Wilcoxon signed-rank test. RESULTS Rotating beam angles from laterals to slightly posterior by 5°-15° reduced high LETd volumes while it increased the dose volume in the rectum and increased LETd in bladders. Beam angles rotated five degrees posteriorly from laterals (i.e., gantry in 95° and 265°) are proposed since they achieved the optimal balance of better LETd sparing and minimal dose increase in the rectum. A reduction of V(50 Gy[RBE], 2.6 keV/µm) from 7.41 to 3.96 cc (p < 0.01), and a slight increase of V(50 Gy[RBE], 0 keV/µm) from 20.1 to 21.6 cc (p < 0.01) were observed for the group without hydrogel spacer. The LETd sparing was less effective for the group with hydrogel spacer, which achieved the reduction of V(50 Gy[RBE], 2.6 keV/µm) from 4.28 to 2.10 cc (p < 0.01). CONCLUSIONS Posterior oblique angle plans improved LETd sparing of the rectum while sacrificing LETd sparing in the bladder in the treatment of prostate cancer with PBS. Beam angle modification from laterals to slightly posterior may be a strategy to redistribute LETd and perhaps reduce rectal toxicity risks in prostate cancer patients treated with PBS. However, the effect is reduced for patients with hydrogel spacer.
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Affiliation(s)
- Yunze Yang
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | | | - Carlos Vargas
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Nathan Y Yu
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Sameer R Keole
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - William W Wong
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Martin Bues
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Jiajian Shen
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
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10
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Vaniqui A, Vaassen F, Di Perri D, Eekers D, Compter I, Rinaldi I, van Elmpt W, Unipan M. Linear Energy Transfer and Relative Biological Effectiveness Investigation of Various Structures for a Cohort of Proton Patients With Brain Tumors. Adv Radiat Oncol 2022; 8:101128. [PMID: 36632089 PMCID: PMC9827037 DOI: 10.1016/j.adro.2022.101128] [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: 09/21/2022] [Accepted: 10/31/2022] [Indexed: 11/27/2022] Open
Abstract
Purpose The current knowledge on biological effects associated with proton therapy is limited. Therefore, we investigated the distributions of dose, dose-averaged linear energy transfer (LETd), and the product between dose and LETd (DLETd) for a patient cohort treated with proton therapy. Different treatment planning system features and visualization tools were explored. Methods and Materials For a cohort of 24 patients with brain tumors, the LETd, DLETd, and dose was calculated for a fixed relative biological effectiveness value and 2 variable models: plan-based and phenomenological. Dose threshold levels of 0, 5, and 20 Gy were imposed for LETd visualization. The relationship between physical dose and LETd and the frequency of LETd hotspots were investigated. Results The phenomenological relative biological effectiveness model presented consistently higher dose values. For lower dose thresholds, the LETd distribution was steered toward higher values related to low treatment doses. Differences up to 26.0% were found according to the threshold. Maximum LETd values were identified in the brain, periventricular space, and ventricles. An inverse relationship between LETd and dose was observed. Frequency information to the domain of dose and LETd allowed for the identification of clusters, which steer the mean LETd values, and the identification of higher, but sparse, LETd values. Conclusions Identifying, quantifying, and recording LET distributions in a standardized fashion is necessary, because concern exists over a link between toxicity and LET hotspots. Visualizing DLETd or dose × LETd during treatment planning could allow for clinicians to make informed decisions.
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11
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Hahn C, Heuchel L, Ödén J, Traneus E, Wulff J, Plaude S, Timmermann B, Bäumer C, Lühr A. Comparing biological effectiveness guided plan optimization strategies for cranial proton therapy: potential and challenges. Radiat Oncol 2022; 17:169. [PMID: 36273132 DOI: 10.1186/s13014-022-02143-x] [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: 05/19/2022] [Accepted: 10/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To introduce and compare multiple biological effectiveness guided (BG) proton plan optimization strategies minimizing variable relative biological effectiveness (RBE) induced dose burden in organs at risk (OAR) while maintaining plan quality with a constant RBE. METHODS Dose-optimized (DOSEopt) proton pencil beam scanning reference treatment plans were generated for ten cranial patients with prescription doses ≥ 54 Gy(RBE) and ≥ 1 OAR close to the clinical target volume (CTV). For each patient, four additional BG plans were created. BG objectives minimized either proton track-ends, dose-averaged linear energy transfer (LETd), energy depositions from high-LET protons or variable RBE-weighted dose (DRBE) in adjacent serially structured OARs. Plan quality (RBE = 1.1) was assessed by CTV dose coverage and robustness (2 mm setup, 3.5% density), dose homogeneity and conformity in the planning target volumes and adherence to OAR tolerance doses. LETd, DRBE (Wedenberg model, α/βCTV = 10 Gy, α/βOAR = 2 Gy) and resulting normal tissue complication probabilities (NTCPs) for blindness and brainstem necrosis were derived. Differences between DOSEopt and BG optimized plans were assessed and statistically tested (Wilcoxon signed rank, α = 0.05). RESULTS All plans were clinically acceptable. DOSEopt and BG optimized plans were comparable in target volume coverage, homogeneity and conformity. For recalculated DRBE in all patients, all BG plans significantly reduced near-maximum DRBE to critical OARs with differences up to 8.2 Gy(RBE) (p < 0.05). Direct DRBE optimization primarily reduced absorbed dose in OARs (average ΔDmean = 2.0 Gy; average ΔLETd,mean = 0.1 keV/µm), while the other strategies reduced LETd (average ΔDmean < 0.3 Gy; average ΔLETd,mean = 0.5 keV/µm). LET-optimizing strategies were more robust against range and setup uncertaintes for high-dose CTVs than DRBE optimization. All BG strategies reduced NTCP for brainstem necrosis and blindness on average by 47% with average and maximum reductions of 5.4 and 18.4 percentage points, respectively. CONCLUSIONS All BG strategies reduced variable RBE-induced NTCPs to OARs. Reducing LETd in high-dose voxels may be favourable due to its adherence to current dose reporting and maintenance of clinical plan quality and the availability of reported LETd and dose levels from clinical toxicity reports after cranial proton therapy. These optimization strategies beyond dose may be a first step towards safely translating variable RBE optimization in the clinics.
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Affiliation(s)
- Christian Hahn
- Department of Physics, TU Dortmund University, Dortmund, Germany. .,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany. .,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
| | - Lena Heuchel
- Department of Physics, TU Dortmund University, Dortmund, Germany
| | - Jakob Ödén
- RaySearch Laboratories AB, Stockholm, Sweden
| | | | - Jörg Wulff
- West German Proton Therapy Centre Essen, Essen, Germany.,West German Cancer Center (WTZ), University Hospital Essen, Essen, Germany
| | - Sandija Plaude
- West German Proton Therapy Centre Essen, Essen, Germany.,West German Cancer Center (WTZ), University Hospital Essen, Essen, Germany
| | - Beate Timmermann
- West German Proton Therapy Centre Essen, Essen, Germany.,West German Cancer Center (WTZ), University Hospital Essen, Essen, Germany.,Department of Particle Therapy, University Hospital Essen, Essen, Germany.,German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Christian Bäumer
- Department of Physics, TU Dortmund University, Dortmund, Germany.,West German Proton Therapy Centre Essen, Essen, Germany.,West German Cancer Center (WTZ), University Hospital Essen, Essen, Germany.,German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Armin Lühr
- Department of Physics, TU Dortmund University, Dortmund, Germany
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12
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Faught AM, Wilson LJ, Gargone M, Pirlepesov F, Moskvin VP, Hua C. Treatment-planning approaches to intensity modulated proton therapy and the impact on dose-weighted linear energy transfer. J Appl Clin Med Phys 2022; 24:e13782. [PMID: 36161765 PMCID: PMC9859995 DOI: 10.1002/acm2.13782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 07/13/2022] [Accepted: 08/16/2022] [Indexed: 01/26/2023] Open
Abstract
PURPOSE We quantified the effect of various forward-based treatment-planning strategies in proton therapy on dose-weighted linear energy transfer (LETd). By maintaining the dosimetric quality at a clinically acceptable level, we aimed to evaluate the differences in LETd among various treatment-planning approaches and their practicality in minimizing biologic uncertainties associated with LETd. METHOD Eight treatment-planning strategies that are achievable in commercial treatment-planning systems were applied on a cylindrical water phantom and four pediatric brain tumor cases. Each planning strategy was compared to either an opposed lateral plan (phantom study) or original clinical plan (patient study). Deviations in mean and maximum LETd from clinically acceptable dose distributions were compared. RESULTS In the phantom study, using a range shifter and altering the robust scenarios during optimization had the largest effect on the mean clinical target volume LETd, which was reduced from 4.5 to 3.9 keV/μm in both cases. Variations in the intersection angle between beams had the largest effect on LETd in a ring defined 3 to 5 mm outside the target. When beam intersection angles were reduced from opposed laterals (180°) to 120°, 90°, and 60°, corresponding maximum LETd increased from 7.9 to 8.9, 10.9, and 12.2 keV/μm, respectively. A clear trend in mean and maximum LETd variations in the clinical cases could not be established, though spatial distribution of LETd suggested a strong dependence on patient anatomy and treatment geometry. CONCLUSION Changes in LETd from treatment-plan setup follow intuitive trends in a controlled phantom experiment. Anatomical and other patient-specific considerations, however, can preclude generalizable strategies in clinical cases. For pediatric cranial radiation therapy, we recommend using opposed lateral treatment fields to treat midline targets.
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Affiliation(s)
- Austin M. Faught
- Department of Radiation OncologySt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Lydia J. Wilson
- Department of Radiation OncologySt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Melissa Gargone
- Department of Radiation OncologySt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Fakhriddin Pirlepesov
- Department of Radiation OncologySt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Vadim P. Moskvin
- Department of Radiation OncologySt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Chia‐Ho Hua
- Department of Radiation OncologySt. Jude Children's Research HospitalMemphisTennesseeUSA
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13
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Eichkorn T, Lischalk JW, Sandrini E, Meixner E, Regnery S, Held T, Bauer J, Bahn E, Harrabi S, Hörner-Rieber J, Herfarth K, Debus J, König L. Iatrogenic Influence on Prognosis of Radiation-Induced Contrast Enhancements in Patients with Glioma WHO 1-3 following Photon and Proton Radiotherapy. Radiother Oncol 2022; 175:133-143. [PMID: 36041565 DOI: 10.1016/j.radonc.2022.08.025] [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: 03/17/2022] [Revised: 07/20/2022] [Accepted: 08/23/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Radiation-induced contrast enhancement (RICE) is a common side effect following radiotherapy for glioma, but both diagnosis and handling are challenging. Due to the potential risks associated with RICE and its challenges in differentiating RICE from tumor progression, it is critical to better understand how RICE prognosis depends on iatrogenic influence. MATERIALS AND METHODS We identified 99 patients diagnosed with RICE who were previously treated with either photon or proton therapy for World Health Organization (WHO) grade 1-3 primary gliomas. Post-treatment brain MRI-based volumetric analysis and clinical data collection was performed at multiple time points. RESULTS The most common histologic subtypes were astrocytoma (50%) and oligodendroglioma (46%). In 67%, it was graded WHO grade 2 and in 86% an IDH mutation was present. RICE first occurred after 16 months (range: 1 - 160) in median. At initial RICE occurrence, 39% were misinterpreted as tumor progression. A tumor-specific therapy including chemotherapy or re-irradiation led to a RICE size progression in 86% and 92% of cases, respectively and RICE symptom progression in 57% and 65% of cases, respectively. A RICE-specific therapy such as corticosteroids or Bevacizumab for larger or symptomatic RICE led to a RICE size regression in 81% of cases with symptom stability or regression in 62% of cases. CONCLUSIONS While with chemotherapy and re-irradiation a RICE progression was frequently observed, anti-edematous or anti-VEGF treatment frequently went along with a RICE regression. For RICE, correct diagnosis and treatment decisions are challenging and critical and should be made interdisciplinarily.
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Affiliation(s)
- Tanja Eichkorn
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; National Center for Tumor diseases (NCT), Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.
| | - Jonathan W Lischalk
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University Langone Health at Long Island, New York, NY, USA.
| | - Elisabetta Sandrini
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; National Center for Tumor diseases (NCT), Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.
| | - Eva Meixner
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; National Center for Tumor diseases (NCT), Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.
| | - Sebastian Regnery
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; National Center for Tumor diseases (NCT), Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.
| | - Thomas Held
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; National Center for Tumor diseases (NCT), Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.
| | - Julia Bauer
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.
| | - Emanuel Bahn
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Semi Harrabi
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; National Center for Tumor diseases (NCT), Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; National Center for Tumor diseases (NCT), Heidelberg, Germany; Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; German Cancer Consortium (DKTK), partner site Heidelberg, Germany.
| | - Klaus Herfarth
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; National Center for Tumor diseases (NCT), Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; National Center for Tumor diseases (NCT), Heidelberg, Germany; Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; German Cancer Consortium (DKTK), partner site Heidelberg, Germany.
| | - Laila König
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany; National Center for Tumor diseases (NCT), Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.
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14
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A systematic review of clinical studies on variable proton Relative Biological Effectiveness (RBE). Radiother Oncol 2022; 175:79-92. [PMID: 35988776 DOI: 10.1016/j.radonc.2022.08.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 08/05/2022] [Accepted: 08/12/2022] [Indexed: 11/21/2022]
Abstract
Recently, a number of clinical studies have explored links between possible Relative Biological Effectiveness (RBE) elevations and patient toxicities and/or image changes following proton therapy. Our objective was to perform a systematic review of such studies. We applied a "Problem [RBE], Intervention [Protons], Population [Patients], Outcome [Side effect]" search strategy to the PubMed database. From our search, we retrieved studies which: (a) performed novel voxel-wise analyses of patient effects versus physical dose and LET (n = 13), and (b) compared image changes between proton and photon cohorts with regard to proton RBE (n = 9). For each retrieved study, we extracted data regarding: primary tumour type; size of patient cohort; type of image change studied; image-registration method (deformable or rigid); LET calculation method, and statistical methodology. We compared and contrasted their methods in order to discuss the weight of clinical evidence for variable proton RBE. We concluded that clinical evidence for variable proton RBE remains statistically weak at present. Our principal recommendation is that proton centres and clinical trial teams collaborate to standardize follow-up protocols and statistical analysis methods, so that larger patient cohorts can ultimately be considered for RBE analyses.
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15
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Mairani A, Mein S, Blakely E, Debus J, Durante M, Ferrari A, Fuchs H, Georg D, Grosshans DR, Guan F, Haberer T, Harrabi S, Horst F, Inaniwa T, Karger CP, Mohan R, Paganetti H, Parodi K, Sala P, Schuy C, Tessonnier T, Titt U, Weber U. Roadmap: helium ion therapy. Phys Med Biol 2022; 67. [PMID: 35395649 DOI: 10.1088/1361-6560/ac65d3] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 04/08/2022] [Indexed: 12/16/2022]
Abstract
Helium ion beam therapy for the treatment of cancer was one of several developed and studied particle treatments in the 1950s, leading to clinical trials beginning in 1975 at the Lawrence Berkeley National Laboratory. The trial shutdown was followed by decades of research and clinical silence on the topic while proton and carbon ion therapy made debuts at research facilities and academic hospitals worldwide. The lack of progression in understanding the principle facets of helium ion beam therapy in terms of physics, biological and clinical findings persists today, mainly attributable to its highly limited availability. Despite this major setback, there is an increasing focus on evaluating and establishing clinical and research programs using helium ion beams, with both therapy and imaging initiatives to supplement the clinical palette of radiotherapy in the treatment of aggressive disease and sensitive clinical cases. Moreover, due its intermediate physical and radio-biological properties between proton and carbon ion beams, helium ions may provide a streamlined economic steppingstone towards an era of widespread use of different particle species in light and heavy ion therapy. With respect to the clinical proton beams, helium ions exhibit superior physical properties such as reduced lateral scattering and range straggling with higher relative biological effectiveness (RBE) and dose-weighted linear energy transfer (LETd) ranging from ∼4 keVμm-1to ∼40 keVμm-1. In the frame of heavy ion therapy using carbon, oxygen or neon ions, where LETdincreases beyond 100 keVμm-1, helium ions exhibit similar physical attributes such as a sharp lateral penumbra, however, with reduced radio-biological uncertainties and without potentially spoiling dose distributions due to excess fragmentation of heavier ion beams, particularly for higher penetration depths. This roadmap presents an overview of the current state-of-the-art and future directions of helium ion therapy: understanding physics and improving modeling, understanding biology and improving modeling, imaging techniques using helium ions and refining and establishing clinical approaches and aims from learned experience with protons. These topics are organized and presented into three main sections, outlining current and future tasks in establishing clinical and research programs using helium ion beams-A. Physics B. Biological and C. Clinical Perspectives.
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Affiliation(s)
- Andrea Mairani
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Centre of Oncological Hadrontherapy (CNAO), Medical Physics, Pavia, Italy.,Division of Molecular and Translational Radiation Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Stewart Mein
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Division of Molecular and Translational Radiation Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,German Cancer Consortium (DKTK) Core-Center Heidelberg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Eleanor Blakely
- Biological Systems and Engineering Division, Lawrence Berkeley National Laboratory, Berkeley, CA, United States of America
| | - Jürgen Debus
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Division of Molecular and Translational Radiation Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,German Cancer Consortium (DKTK) Core-Center Heidelberg, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg University and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Marco Durante
- GSI Helmholtzzentrum für Schwerionenforschung, D-64291 Darmstadt, Germany.,Technische Universität Darmstadt, Institut für Physik Kondensierter Materie, Darmstadt, Germany
| | - Alfredo Ferrari
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Hermann Fuchs
- Division of Medical Physics, Department of Radiation Oncology, Medical University of Vienna, Austria.,MedAustron Ion Therapy Center, Wiener Neustadt, Austria
| | - Dietmar Georg
- Division of Medical Physics, Department of Radiation Oncology, Medical University of Vienna, Austria.,MedAustron Ion Therapy Center, Wiener Neustadt, Austria
| | - David R Grosshans
- The University of Texas MD Anderson cancer Center, Houston, Texas, United States of America
| | - Fada Guan
- The University of Texas MD Anderson cancer Center, Houston, Texas, United States of America.,Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, 06510, United States of America
| | - Thomas Haberer
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Semi Harrabi
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,German Cancer Consortium (DKTK) Core-Center Heidelberg, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg University and German Cancer Research Center (DKFZ), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Felix Horst
- GSI Helmholtzzentrum für Schwerionenforschung, D-64291 Darmstadt, Germany
| | - Taku Inaniwa
- Department of Accelerator and Medical Physics, Institute for Quantum Medical Science, QST, 4-9-1 Anagawa, Inage-ku, Chiba 263-8555, Japan.,Medical Physics Laboratory, Division of Health Science, Graduate School of Medicine, Osaka University, 1-7 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Christian P Karger
- National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,Department of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Radhe Mohan
- The University of Texas MD Anderson cancer Center, Houston, Texas, United States of America
| | - Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, United States of America.,Harvard Medical School, Boston, United States of America
| | - Katia Parodi
- Ludwig-Maximilians-Universität München, Department of Experimental Physics-Medical Physics, Munich, Germany
| | - Paola Sala
- Ludwig-Maximilians-Universität München, Department of Experimental Physics-Medical Physics, Munich, Germany
| | - Christoph Schuy
- GSI Helmholtzzentrum für Schwerionenforschung, D-64291 Darmstadt, Germany
| | - Thomas Tessonnier
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Uwe Titt
- The University of Texas MD Anderson cancer Center, Houston, Texas, United States of America
| | - Ulrich Weber
- GSI Helmholtzzentrum für Schwerionenforschung, D-64291 Darmstadt, Germany
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16
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A case-control study of linear energy transfer and relative biological effectiveness related to symptomatic brainstem toxicity following pediatric proton therapy. Radiother Oncol 2022; 175:47-55. [PMID: 35917900 DOI: 10.1016/j.radonc.2022.07.022] [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: 04/07/2022] [Revised: 06/28/2022] [Accepted: 07/25/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND PURPOSE A fixed relative biological effectiveness (RBE) of 1.1 (RBE1.1) is used clinically in proton therapy even though the RBE varies with properties such as dose level and linear energy transfer (LET). We therefore investigated if symptomatic brainstem toxicity in pediatric brain tumor patients treated with proton therapy could be associated with a variable LET and RBE. MATERIALS AND METHODS 36 patients treated with passive scattering proton therapy were selected for a case-control study from a cohort of 954 pediatric brain tumor patients. Nine children with symptomatic brainstem toxicity were each matched to three controls based on age, diagnosis, adjuvant therapy, and brainstem RBE1.1 dose characteristics. Differences across cases and controls related to the dose-averaged LET (LETd) and variable RBE-weighted dose from two RBE models were analyzed in the high-dose region. RESULTS LETd metrics were marginally higher for cases vs. controls for the majority of dose levels and brainstem substructures. Considering areas with doses above 54 Gy(RBE1.1), we found a moderate trend of 13% higher median LETd in the brainstem for cases compared to controls (P = .08), while the difference in the median variable RBE-weighted dose for the same structure was only 2% (P = .6). CONCLUSION Trends towards higher LETd for cases compared to controls were noticeable across structures and LETd metrics for this patient cohort. While case-control differences were minor, an association with the observed symptomatic brainstem toxicity cannot be ruled out.
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17
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Yang Y, Patel SH, Bridhikitti J, Wong WW, Halyard MY, McGee LA, Rwigema JCM, Schild SE, Vora SA, Liu T, Bues M, Fatyga M, Foote RL, Liu W. Exploratory study of seed spots analysis to characterize dose and linear energy transfer effect in adverse event initialization of pencil beam scanning proton therapy. Med Phys 2022; 49:6237-6252. [PMID: 35820062 DOI: 10.1002/mp.15859] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 06/20/2022] [Accepted: 07/06/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Both dose and linear-energy-transfer (LET) could play a substantial role in adverse event (AE) initialization of cancer patients treated with pencil-beam-scanning proton therapy (PBS). However, not all the voxels within the AE regions are directly induced from the dose and LET effect. It is important to study the synergistic effect of dose and LET in AE initialization by only including a subset of voxels that are dosimetrically important. PURPOSE To perform exploratory investigation of the dose and LET effects upon AE initialization in PBS using seed spots analysis. METHODS 113 head and neck (H&N) cancer patients receiving curative PBS were included. Among them, 20 patients experienced unanticipated CTCAEv4.0 grade≥3 AEs (AE group) and 93 patients did not (control group). Within the AE group, 13 AE patients were included in the seed spot analysis to derive the descriptive features of AE initialization and the remaining 7 mandible osteoradionecrosis patients and 93 control patients were used to derive the feature-based volume constraint of mandible osteoradionecrosis. The AE regions were contoured and the corresponding dose-LET volume histograms (DLVHs) of AE regions were generated for all patients in the AE group. We selected high LET voxels (the highest 5% of each dose bin) with a range of moderate to high dose (≥∼40 Gy[RBE]) as critical voxels. Critical voxels which were contiguous with each other were grouped into clusters. Each cluster was considered as a potential independent seed spot for AE initialization. Seed spots were displayed in a 2D dose-LET plane based on their mean dose and LET to derive the descriptive features of AE initialization. A volume constraint of mandible osteoradionecrosis was then established based on the extracted features using a receiver operating characteristic curve. RESULTS The product of dose and LET (xBD) was found to be a descriptive feature of seed spots leading to AE initialization in this preliminary study. The derived xBD volume constraint for mandible osteoradionecrosis showed good performance with an area-under-curve of 0.87 (sensitivity of 0.714 and specificity of 0.807 in the leave-one-out cross validation) for the very limited patient data included in this study. CONCLUSION Our exploratory study showed that both dose and LET were observed to be important in AE initializations. The derived xBD volume constraint could predict mandible osteoradionecrosis reasonably well in the very limited H&N cancer patient data treated with PBS included in this study. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Yunze Yang
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Samir H Patel
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Jidapa Bridhikitti
- Department of Radiation Oncology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - William W Wong
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Michele Y Halyard
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | | | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Sujay A Vora
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Tianming Liu
- Department of Computer Science, the University of Georgia, Athens, Georgia, USA
| | - Martin Bues
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Mirek Fatyga
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
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18
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Tian L, Hahn C, Lühr A. An ion-independent phenomenological relative biological effectiveness (RBE) model for proton therapy. Radiother Oncol 2022; 174:69-76. [PMID: 35803365 DOI: 10.1016/j.radonc.2022.06.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 06/14/2022] [Accepted: 06/28/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND A relative biological effectiveness (RBE) of 1.1 is used for proton therapy though clinical evidence of varying RBE was raised. Clinical studies on RBE variability have been conducted for decades for carbon radiation, which could advance the understanding of the clinical proton RBE given an ion-independent RBE model. In this work, such a model, linear and simple, using the beam quantity Q = Z2/E (Z = ion charge, E = kinetic energy per nucleon) was tested and compared to the commonly used, proton-specific and linear energy transfer (LET) based Wedenberg RBE model. MATERIAL AND METHODS The Wedenberg and Q models, both predicting RBEmax and RBEmin (i.e., RBE at vanishing and very high dose, respectively), are compared in terms of ion-dependence and prediction power. An experimental in-vitro data ensemble covering 115 publications for various ions was used as dataset. RESULTS The model parameter of the Q model was observed to be similar for different ions (in contrast to LET). The Q model was trained without any prior knowledge of proton data. For proton RBE, the differences between experimental data and corresponding predictions of the Wedenberg or the Q model were highly comparable. CONCLUSIONS A simple linear RBE model using Q instead of LET was proposed and tested to be able to predict proton RBE using model parameter trained based on only RBE data of other particles in a clinical proton energy range for a large in-vitro dataset. Adding (pre)clinical knowledge from carbon ion therapy may, therefore, reduce the dominating biological uncertainty in proton RBE modelling. This would translate in reduced RBE related uncertainty in proton therapy treatment planning.
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Affiliation(s)
- Liheng Tian
- TU Dortmund University, Department of Physics, Dortmund, Germany.
| | - Christian Hahn
- TU Dortmund University, Department of Physics, Dortmund, Germany; OncoRay, National Center for Radiation Research in Oncology, Faculty of Medicine, and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Armin Lühr
- TU Dortmund University, Department of Physics, Dortmund, Germany.
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19
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Heuchel L, Hahn C, Pawelke J, Sørensen BS, Dosanjh M, Lühr A. Clinical use and future requirements of relative biological effectiveness: survey among all european proton therapy centres. Radiother Oncol 2022; 172:134-139. [PMID: 35605747 DOI: 10.1016/j.radonc.2022.05.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/29/2022] [Accepted: 05/15/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND PURPOSE The relative biological effectiveness (RBE) varies along the treatment field. However, in clinical practice, a constant RBE of 1.1 is assumed, which can result in undesirable side effects. This study provides an accurate overview of current clinical practice for considering proton RBE in Europe. MATERIALS AND METHODS A survey was devised and sent to all proton therapy centres in Europe that treat patients. The online questionnaire consisted of 39 questions addressing various aspects of RBE consideration in clinical practice, including treatment planning, patient follow-up and future demands. RESULTS All 25 proton therapy centres responded. All centres prescribed a constant RBE of 1.1, but also applied measures (except for one eye treatment centre) to counteract variable RBE effects such as avoiding beams stopping inside or in front of an organ at risk and putting restrictions on the minimum number and opening angle of incident beams for certain treatment sites. For the future, most centres (16) asked for more retrospective or prospective outcome studies investigating the potential effect of the effect of a variable RBE. To perform such studies, 18 centres asked for LET and RBE calculation and visualisation tools developed by treatment planning system vendors. CONCLUSION All European proton centres are aware of RBE variability but comply with current guidelines of prescribing a constant RBE. However, they actively mitigate uncertainty and risk of side effects resulting from increased RBE by applying measures and restrictions during treatment planning. To change RBE-related clinical guidelines in the future more clinical data on RBE are explicitly demanded.
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Affiliation(s)
- Lena Heuchel
- Department of Physics, TU Dortmund University, Germany
| | - Christian Hahn
- Department of Physics, TU Dortmund University, Germany; OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Jörg Pawelke
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Germany; Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Germany
| | - Brita Singers Sørensen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark; Danish Center for Particle Therapy, DCPT, Aarhus University Hospital, Denmark
| | - Manjit Dosanjh
- Department of Physics, University of Oxford, UK; CERN, Geneva, Switzerland
| | - Armin Lühr
- Department of Physics, TU Dortmund University, Germany.
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20
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Qi Y, Mao L, Lu H, Jin S, Huang J, Wang Z, Zhang J, Wang K. Multi-centric analysis of linear energy transfer distribution from clinical proton beam based on TOPAS. Radiat Phys Chem Oxf Engl 1993 2022. [DOI: 10.1016/j.radphyschem.2022.110035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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21
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Mohan R. A review of proton therapy – Current status and future directions. PRECISION RADIATION ONCOLOGY 2022; 6:164-176. [DOI: 10.1002/pro6.1149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Radhe Mohan
- Department of Radiation Physics, MD Anderson Cancer Center Houston Texas USA
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22
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Hahn C, Ödén J, Dasu A, Vestergaard A, Fuglsang Jensen M, Sokol O, Pardi C, Bourhaleb F, Leite A, de Marzi L, Smith E, Aitkenhead A, Rose C, Merchant M, Kirkby K, Grzanka L, Pawelke J, Lühr A. Towards harmonizing clinical linear energy transfer (LET) reporting in proton radiotherapy: a European multi-centric study. Acta Oncol 2022; 61:206-214. [PMID: 34686122 DOI: 10.1080/0284186x.2021.1992007] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 10/06/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Clinical data suggest that the relative biological effectiveness (RBE) in proton therapy (PT) varies with linear energy transfer (LET). However, LET calculations are neither standardized nor available in clinical routine. Here, the status of LET calculations among European PT institutions and their comparability are assessed. MATERIALS AND METHODS Eight European PT institutions used suitable treatment planning systems with their center-specific beam model to create treatment plans in a water phantom covering different field arrangements and fulfilling commonly agreed dose objectives. They employed their locally established LET simulation environments and procedures to determine the corresponding LET distributions. Dose distributions D1.1 and DRBE assuming constant and variable RBE, respectively, and LET were compared among the institutions. Inter-center variability was assessed based on dose- and LET-volume-histogram parameters. RESULTS Treatment plans from six institutions fulfilled all clinical goals and were eligible for common analysis. D1.1 distributions in the target volume were comparable among PT institutions. However, corresponding LET values varied substantially between institutions for all field arrangements, primarily due to differences in LET averaging technique and considered secondary particle spectra. Consequently, DRBE using non-harmonized LET calculations increased inter-center dose variations substantially compared to D1.1 and significantly in mean dose to the target volume of perpendicular and opposing field arrangements (p < 0.05). Harmonizing LET reporting (dose-averaging, all protons, LET to water or to unit density tissue) reduced the inter-center variability in LET to the order of 10-15% within and outside the target volume for all beam arrangements. Consequentially, inter-institutional variability in DRBE decreased to that observed for D1.1. CONCLUSION Harmonizing the reported LET among PT centers is feasible and allows for consistent multi-centric analysis and reporting of tumor control and toxicity in view of a variable RBE. It may serve as basis for harmonized variable RBE dose prescription in PT.
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Affiliation(s)
- Christian Hahn
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Medical Physics and Radiotherapy, Department of Physics, TU Dortmund University, Dortmund, Germany
| | - Jakob Ödén
- RaySearch Laboratories AB, Stockholm, Sweden
| | - Alexandru Dasu
- The Skandion Clinic, Uppsala, Sweden
- Medical Radiation Sciences, Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Anne Vestergaard
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | | | - Olga Sokol
- GSI Helmholtz Centre for Heavy Ion Research, Darmstadt, Germany
| | - Claudia Pardi
- I-SEE (Internet-Simulation Evaluation Envision), Torino, Italy
| | - Faiza Bourhaleb
- I-SEE (Internet-Simulation Evaluation Envision), Torino, Italy
| | - Amélia Leite
- Institut Curie, PSL Research University, Radiation Oncology Department, Proton Therapy Centre, Centre Universitaire, Orsay, France
| | - Ludovic de Marzi
- Institut Curie, PSL Research University, Radiation Oncology Department, Proton Therapy Centre, Centre Universitaire, Orsay, France
- Institut Curie, PSL Research University, University Paris Saclay, Inserm LITO, Orsay, France
| | - Edward Smith
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, UK
| | - Adam Aitkenhead
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, UK
| | - Christopher Rose
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, UK
| | - Michael Merchant
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, UK
| | - Karen Kirkby
- Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, UK
| | - Leszek Grzanka
- Institute of Nuclear Physics Polish Academy of Sciences, Krakow, Poland
| | - Jörg Pawelke
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Armin Lühr
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Medical Physics and Radiotherapy, Department of Physics, TU Dortmund University, Dortmund, Germany
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
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23
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Paganetti H. Mechanisms and Review of Clinical Evidence of Variations in Relative Biological Effectiveness in Proton Therapy. Int J Radiat Oncol Biol Phys 2022; 112:222-236. [PMID: 34407443 PMCID: PMC8688199 DOI: 10.1016/j.ijrobp.2021.08.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/14/2021] [Accepted: 08/10/2021] [Indexed: 01/03/2023]
Abstract
Proton therapy is increasingly being used as a radiation therapy modality. There is uncertainty about the biological effectiveness of protons relative to photon therapies as it depends on several physical and biological parameters. Radiation oncology currently applies a constant and generic value for the relative biological effectiveness (RBE) of 1.1, which was chosen conservatively to ensure tumor coverage. The use of a constant value has been challenged particularly when considering normal tissue constraints. Potential variations in RBE have been assessed in several published reviews but have mostly focused on data from clonogenic cell survival experiments with unclear relevance for clinical proton therapy. The goal of this review is to put in vitro findings in relation to clinical observations. Relevant in vivo pathways determining RBE for tumors and normal tissues are outlined, including not only damage to tumor cells and parenchyma but also vascular damage and immune response. Furthermore, the current clinical evidence of varying RBE is reviewed. The assessment can serve as guidance for treatment planning, personalized dose prescriptions, and outcome analysis.
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Affiliation(s)
- Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
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24
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Smith EAK, Winterhalter C, Underwood TSA, Aitkenhead AH, Richardson JC, Merchant MJ, Kirkby NF, Kirby KJ, Mackay RI. A Monte Carlo study of different LET definitions and calculation parameters for proton beam therapy. Biomed Phys Eng Express 2021; 8. [PMID: 34874308 DOI: 10.1088/2057-1976/ac3f50] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 12/02/2021] [Indexed: 12/19/2022]
Abstract
The strongin vitroevidence that proton Relative Biological Effectiveness (RBE) varies with Linear Energy Transfer (LET) has led to an interest in applying LET within treatment planning. However, there is a lack of consensus on LET definition, Monte Carlo (MC) parameters or clinical methodology. This work aims to investigate how common variations of LET definition may affect potential clinical applications. MC simulations (GATE/GEANT4) were used to calculate absorbed dose and different types of LET for a simple Spread Out Bragg Peak (SOBP) and for four clinical PBT plans covering a range of tumour sites. Variations in the following LET calculation methods were considered: (i) averaging (dose-averaged LET (LETd) & track-averaged LET); (ii) scoring (LETdto water, to medium and to mass density); (iii) particle inclusion (LETdto all protons, to primary protons and to particles); (iv) MC settings (hit type and Maximum Step Size (MSS)). LET distributions were compared using: qualitative comparison, LET Volume Histograms (LVHs), single value criteria (maximum and mean values) and optimised LET-weighted dose models. Substantial differences were found between LET values in averaging, scoring and particle type. These differences depended on the methodology, but for one patient a difference of ∼100% was observed between the maximum LETdfor all particles and maximum LETdfor all protons within the brainstem in the high isodose region (4 keVμm-1and 8 keVμm-1respectively). An RBE model using LETdincluding heavier ions was found to predict substantially different LET-weighted dose compared to those using other LET definitions. In conclusion, the selection of LET definition may affect the results of clinical metrics considered in treatment planning and the results of an RBE model. The authors' advocate for the scoring of dose-averaged LET to water for primary and secondary protons using a random hit type and automated MSS.
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Affiliation(s)
- Edward A K Smith
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom.,Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Carla Winterhalter
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom.,The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Tracy S A Underwood
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom.,The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Adam H Aitkenhead
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom.,Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Jenny C Richardson
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom.,Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Michael J Merchant
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom.,The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Norman F Kirkby
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom.,The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Karen J Kirby
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom.,The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Ranald I Mackay
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom.,Christie Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, United Kingdom
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25
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Rucinski A, Biernacka A, Schulte R. Applications of nanodosimetry in particle therapy planning and beyond. Phys Med Biol 2021; 66. [PMID: 34731854 DOI: 10.1088/1361-6560/ac35f1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 11/03/2021] [Indexed: 12/28/2022]
Abstract
This topical review summarizes underlying concepts of nanodosimetry. It describes the development and current status of nanodosimetric detector technology. It also gives an overview of Monte Carlo track structure simulations that can provide nanodosimetric parameters for treatment planning of proton and ion therapy. Classical and modern radiobiological assays that can be used to demonstrate the relationship between the frequency and complexity of DNA lesion clusters and nanodosimetric parameters are reviewed. At the end of the review, existing approaches of treatment planning based on relative biological effectiveness (RBE) models or dose-averaged linear energy transfer are contrasted with an RBE-independent approach based on nandosimetric parameters. Beyond treatment planning, nanodosimetry is also expected to have applications and give new insights into radiation protection dosimetry.
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Affiliation(s)
| | - Anna Biernacka
- University of Gdansk, Intercollegiate Faculty of Biotechnology of University of Gdańsk and Medical University of Gdansk, 80-307 Gdansk, Poland
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26
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Henjum H, Dahle TJ, Fjæra LF, Rørvik E, Pilskog S, Stokkevåg CH, Mairani A, Ytre-Hauge KS. The Organ Sparing Potential of Different Biological Optimization Strategies in Proton Therapy. Adv Radiat Oncol 2021; 6:100776. [PMID: 34765804 PMCID: PMC8573123 DOI: 10.1016/j.adro.2021.100776] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/20/2021] [Accepted: 08/09/2021] [Indexed: 02/03/2023] Open
Abstract
Purpose Variable relative biological effectiveness (RBE) models allow for differences in linear energy transfer (LET), physical dose, and tissue type to be accounted for when quantifying and optimizing the biological damage of protons. These models are complex and fraught with uncertainties, and therefore, simpler RBE optimization strategies have also been suggested. Our aim was to compare several biological optimization strategies for proton therapy by evaluating their performance in different clinical cases. Methods and Materials Two different optimization strategies were compared: full variable RBE optimization and differential RBE optimization, which involve applying fixed RBE for the planning target volume (PTV) and variable RBE in organs at risk (OARs). The optimization strategies were coupled to 2 variable RBE models and 1 LET-weighted dose model, with performance demonstrated on 3 different clinical cases: brain, head and neck, and prostate tumors. Results In cases with low (α/β)x in the tumor, the full RBE optimization strategies had a large effect, with up to 10% reduction in RBE-weighted dose to the PTV and OARs compared with the reference plan, whereas smaller variations (<5%) were obtained with differential optimization. For tumors with high (α/β)x, the differential RBE optimization strategy showed a greater reduction in RBE-weighted dose to the OARs compared with the reference plan and the full RBE optimization strategy. Conclusions Differences between the optimization strategies varied across the studied cases, influenced by both biological and physical parameters. Whereas full RBE optimization showed greater OAR sparing, awareness of underdosage to the target must be carefully considered.
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Affiliation(s)
- Helge Henjum
- Department of Physics and Technology, University of Bergen, Bergen, Norway
- Corresponding author: Helge Henjum, MSc
| | - Tordis J. Dahle
- Department of Physics and Technology, University of Bergen, Bergen, Norway
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Lars Fredrik Fjæra
- Department of Physics and Technology, University of Bergen, Bergen, Norway
| | - Eivind Rørvik
- Department of Physics and Technology, University of Bergen, Bergen, Norway
| | - Sara Pilskog
- Department of Physics and Technology, University of Bergen, Bergen, Norway
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Camilla H. Stokkevåg
- Department of Physics and Technology, University of Bergen, Bergen, Norway
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Andrea Mairani
- Centro Nazionale di Adroterapia Oncologica (CNAO Foundation), Pavia, Italy
- Heidelberg Ion Beam Therapy Center, Heidelberg, Germany
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27
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Wagenaar D, Schuit E, van der Schaaf A, Langendijk JA, Both S. Can the mean linear energy transfer of organs be directly related to patient toxicities for current head and neck cancer intensity-modulated proton therapy practice? Radiother Oncol 2021; 165:159-165. [PMID: 34534614 DOI: 10.1016/j.radonc.2021.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 08/05/2021] [Accepted: 09/04/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND PURPOSE The relative biological effectiveness (RBE) of proton therapy is predicted to vary with the dose-weighted average linear energy transfer (LETd). However, RBE values may substantially vary for different clinical endpoints. Therefore, the aim of this study was to assess the feasibility of relating mean D⋅LETd parameters to patient toxicity for HNC patients treated with proton therapy. MATERIALS AND METHODS The delivered physical dose (D) and the voxel-wise product of D and LETd (D⋅LETd) distributions were calculated for 100 head and neck cancer (HNC) proton therapy patients using our TPS (Raystation v6R). The means and covariance matrix of the accumulated D and D⋅LETd of all relevant organs-at-risk (OARs) were used to simulate 2.500 data sets of different sizes. For each dataset, an attempt was made to add mean D⋅LETd parameters to a multivariable NTCP model based on mean D parameters of the same OAR for xerostomia, tube feeding and dysphagia. The likelihood of creating an NTCP model with statistically significant parameters (i.e. power) was calculated as a function of the simulated sample size for various RBE models. RESULTS The sample size required to have a power of at least 80% to show an independent effect of mean D⋅LETd parameters on toxicity is over 15,000 patients for all toxicities. CONCLUSION For current clinical practice, it is not feasible to directly model NTCP with both mean D and mean D⋅LETd of OARs. These findings should not be interpreted as a contradiction of previous evidence for the relationship between RBE and LETd.
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Affiliation(s)
- Dirk Wagenaar
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, the Netherlands.
| | - Ewoud Schuit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Arjen van der Schaaf
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, the Netherlands
| | - Johannes A Langendijk
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, the Netherlands
| | - Stefan Both
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, the Netherlands
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Garbacz M, Cordoni FG, Durante M, Gajewski J, Kisielewicz K, Krah N, Kopeć R, Olko P, Patera V, Rinaldi I, Rydygier M, Schiavi A, Scifoni E, Skóra T, Tommasino F, Rucinski A. Study of relationship between dose, LET and the risk of brain necrosis after proton therapy for skull base tumors. Radiother Oncol 2021; 163:143-149. [PMID: 34461183 DOI: 10.1016/j.radonc.2021.08.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 07/27/2021] [Accepted: 08/21/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE We investigated the relationship between RBE-weighted dose (DRBE) calculated with constant (cRBE) and variable RBE (vRBE), dose-averaged linear energy transfer (LETd) and the risk of radiographic changes in skull base patients treated with protons. METHODS Clinical treatment plans of 45 patients were recalculated with Monte Carlo tool FRED. Radiographic changes (i.e. edema and/or necrosis) were identified by MRI. Dosimetric parameters for cRBE and vRBE were computed. Biological margin extension and voxel-based analysis were employed looking for association of DRBE(vRBE) and LETd with brain edema and/or necrosis. RESULTS When using vRBE, Dmax in the brain was above the highest dose limits for 38% of patients, while such limit was never exceeded assuming cRBE. Similar values of Dmax were observed in necrotic regions, brain and temporal lobes. Most of the brain necrosis was in proximity to the PTV. The voxel-based analysis did not show evidence of an association with high LETd values. CONCLUSIONS When looking at standard dosimetric parameters, the higher dose associated with vRBE seems to be responsible for an enhanced risk of radiographic changes. However, as revealed by a voxel-based analysis, the large inter-patient variability hinders the identification of a clear effect for high LETd.
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Affiliation(s)
- Magdalena Garbacz
- Institute of Nuclear Physics Polish Academy of Sciences, 31342 Krakow, Poland.
| | - Francesco Giuseppe Cordoni
- University of Verona, Department of Computer Science, Verona, Italy; Trento Institute for Fundamental Physics and Applications, TIFPA-INFN, Trento, Italy
| | - Marco Durante
- GSI Helmholtzzentrum fur Schwerionenforschung, Darmstadt, Germany; The Technical University of Darmstadt, Germany
| | - Jan Gajewski
- Institute of Nuclear Physics Polish Academy of Sciences, 31342 Krakow, Poland
| | - Kamil Kisielewicz
- National Oncology Institute, National Research Institute, Krakow Branch, Krakow, Poland
| | - Nils Krah
- University of Lyon, CREATIS, CNRS UMR5220, Inserm U1044, INSA-Lyon, Université Lyon 1, Centre Léon Bérard, France; University of Lyon, Université Claude Bernard Lyon 1, CNRS/IN2P3, IP2I Lyon, UMR 5822, Villeurbanne, France
| | - Renata Kopeć
- Institute of Nuclear Physics Polish Academy of Sciences, 31342 Krakow, Poland
| | - Paweł Olko
- Institute of Nuclear Physics Polish Academy of Sciences, 31342 Krakow, Poland
| | - Vincenzo Patera
- INFN - Section of Rome, Italy; Department of Basic and Applied Sciences for Engineering, Sapienza University of Rome, Italy
| | - Ilaria Rinaldi
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Marzena Rydygier
- Institute of Nuclear Physics Polish Academy of Sciences, 31342 Krakow, Poland
| | - Angelo Schiavi
- Department of Basic and Applied Sciences for Engineering, Sapienza University of Rome, Italy
| | - Emanuele Scifoni
- Trento Institute for Fundamental Physics and Applications, TIFPA-INFN, Trento, Italy
| | - Tomasz Skóra
- National Oncology Institute, National Research Institute, Krakow Branch, Krakow, Poland
| | - Francesco Tommasino
- Trento Institute for Fundamental Physics and Applications, TIFPA-INFN, Trento, Italy; Department of Physics, University of Trento, Trento, Italy
| | - Antoni Rucinski
- Institute of Nuclear Physics Polish Academy of Sciences, 31342 Krakow, Poland
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29
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Suckert T, Nexhipi S, Dietrich A, Koch R, Kunz-Schughart LA, Bahn E, Beyreuther E. Models for Translational Proton Radiobiology-From Bench to Bedside and Back. Cancers (Basel) 2021; 13:4216. [PMID: 34439370 PMCID: PMC8395028 DOI: 10.3390/cancers13164216] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/09/2021] [Accepted: 08/17/2021] [Indexed: 12/25/2022] Open
Abstract
The number of proton therapy centers worldwide are increasing steadily, with more than two million cancer patients treated so far. Despite this development, pending questions on proton radiobiology still call for basic and translational preclinical research. Open issues are the on-going discussion on an energy-dependent varying proton RBE (relative biological effectiveness), a better characterization of normal tissue side effects and combination treatments with drugs originally developed for photon therapy. At the same time, novel possibilities arise, such as radioimmunotherapy, and new proton therapy schemata, such as FLASH irradiation and proton mini-beams. The study of those aspects demands for radiobiological models at different stages along the translational chain, allowing the investigation of mechanisms from the molecular level to whole organisms. Focusing on the challenges and specifics of proton research, this review summarizes the different available models, ranging from in vitro systems to animal studies of increasing complexity as well as complementing in silico approaches.
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Affiliation(s)
- Theresa Suckert
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, 01309 Dresden, Germany; (T.S.); (S.N.); (A.D.); (L.A.K.-S.)
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Sindi Nexhipi
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, 01309 Dresden, Germany; (T.S.); (S.N.); (A.D.); (L.A.K.-S.)
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology-OncoRay, 01309 Dresden, Germany
| | - Antje Dietrich
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, 01309 Dresden, Germany; (T.S.); (S.N.); (A.D.); (L.A.K.-S.)
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Robin Koch
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany; (R.K.); (E.B.)
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Leoni A. Kunz-Schughart
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, 01309 Dresden, Germany; (T.S.); (S.N.); (A.D.); (L.A.K.-S.)
- National Center for Tumor Diseases (NCT), Partner Site Dresden, 01307 Dresden, Germany
| | - Emanuel Bahn
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany; (R.K.); (E.B.)
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- German Cancer Research Center (DKFZ), Clinical Cooperation Unit Radiation Oncology, 69120 Heidelberg, Germany
| | - Elke Beyreuther
- OncoRay—National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, 01309 Dresden, Germany; (T.S.); (S.N.); (A.D.); (L.A.K.-S.)
- Helmholtz-Zentrum Dresden—Rossendorf, Institute of Radiation Physics, 01328 Dresden, Germany
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30
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Bertolet A, Abolfath R, Carlson DJ, Lustig RA, Hill-Kayser C, Alonso-Basanta M, Carabe A. Correlation of LET With MRI Changes in Brain and Potential Implications for Normal Tissue Complication Probability for Patients With Meningioma Treated With Pencil Beam Scanning Proton Therapy. Int J Radiat Oncol Biol Phys 2021; 112:237-246. [PMID: 34425196 DOI: 10.1016/j.ijrobp.2021.08.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 08/11/2021] [Accepted: 08/15/2021] [Indexed: 01/05/2023]
Abstract
PURPOSE This study aimed to investigate the correlation between imaging changes in brain normal tissue and the spatial distribution of linear energy transfer (LET) for a cohort of patients with meningioma treated with scanned proton beams. Then, assuming imaging changes are induced by cell lethality, we studied the correlation between normal tissue complication probability and LET. METHODS AND MATERIALS Magnetic resonance imaging T2/fluid attenuated inversion recovery acquired at different intervals after proton radiation were coregistered with the planning computed tomography (CT) images from 26 patients with meningioma with abnormalities after proton radiation therapy. For this purpose, the T2/fluid attenuated inversion recovery areas not on the original magnetic resonance images were contoured, and the LET values for each voxel in the patient geometry were calculated to investigate the correlation between the position of imaging changes and the LET at those positions. To separate the effect of the dose as the inductor of these changes, we compared the LET in these areas with a sample of voxels matching the dose distributions across the image change areas. Patients with a higher LET in image change areas were grouped to verify whether they shared common characteristics. RESULTS Eleven of the patients showed higher dose-averaged LET (LETd) in imaging change regions than in the group of voxels with the same dose. This group of patients had significantly shallower targets for their treatment than the other 15 and used fewer beams and angles. CONCLUSIONS This study points toward the possibility that areas with imaging change are more likely to occur in regions with high dose or in areas with lower dose but increased LETd. The effect of LETd on imaging changes seems to be more relevant when treating superficial lesions with few nonopposed beams. However, most patients did not show a spatial correlation between their image changes and the LETd values, limiting the cases for the possible role of high LET as a toxicity inductor.
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Affiliation(s)
- Alejandro Bertolet
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ramin Abolfath
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Radiation Oncology, New Jersey Urology, West Orange, New Jersey
| | - David J Carlson
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert A Lustig
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christine Hill-Kayser
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Alejandro Carabe
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania; Hampton University Proton Institute, Hampton, Virginia.
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Li D, Gao J, Yang C, Li B, Sun J, Yu M, Wang Y, Wang H, Lu Y. cRGDyK-modified procaine liposome inhibits the proliferation and motility of glioma cells via the ERK/p38MAPK pathway. Exp Ther Med 2021; 22:859. [PMID: 34178132 PMCID: PMC8220655 DOI: 10.3892/etm.2021.10291] [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: 05/07/2020] [Accepted: 05/27/2021] [Indexed: 12/15/2022] Open
Abstract
Glioma is a common type of primary tumor in the central nervous system. Glioma has been increasing in incidence yearly and is a serious threat to human life and health. The aim of the present study was to prepare liposomes for enhanced penetration of the blood-brain barrier and targeting of glioma. A procaine-loaded liposome modified with the cyclic pentapeptide cRGDyK (Pro/cRGDyK-L) was designed and developed. The particle size, ζ potential, encapsulation efficiency, release profile, stability and hemolysis of Pro/cRGDyK-L were characterized in vitro. The targeting and antitumor effects of Pro/cRGDyK-L were also investigated in vitro and in vivo. The results suggested that the cRGDyK peptide significantly facilitated the ability of liposomes to transfer procaine across the BBB and improved the cellular uptake of procaine by C6 glioma cells. The results further demonstrated that Pro/cRGDyK-L strongly suppressed cell motility, stimulated apoptosis and induced cell cycle arrest. The findings further confirmed that Pro/cRGDyK-L exhibited superior antitumor effects by targeting the ERK/p38MAPK pathway and thereby suppressed tumor growth in mice. In conclusion, the present study indicated the potential of Pro/cRGDyK-L as a means to provide improved therapeutic effects on glioma through the ERK/p38MAPK pathway.
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Affiliation(s)
- Dedong Li
- Department of Anesthesiology, Second Hospital of Tianjin Medical University, Tianjin 300211, P.R. China
| | - Jie Gao
- Department of Anesthesiology, Tianjin Haihe Hospital, Tianjin 300350, P.R. China
| | - Chenyi Yang
- Department of Anesthesiology, Tianjin Third Central Hospital, Tianjin 300052, P.R. China
| | - Bo Li
- Department of Anesthesiology, Second Hospital of Tianjin Medical University, Tianjin 300211, P.R. China
| | - Jian Sun
- Department of Anesthesiology, Second Hospital of Tianjin Medical University, Tianjin 300211, P.R. China
| | - Mingdong Yu
- Department of Anesthesiology, Second Hospital of Tianjin Medical University, Tianjin 300211, P.R. China
| | - Ying Wang
- Department of Anesthesiology, Second Hospital of Tianjin Medical University, Tianjin 300211, P.R. China
| | - Haiyun Wang
- Department of Anesthesiology, Tianjin Third Central Hospital, Tianjin 300052, P.R. China
| | - Yuechun Lu
- Department of Anesthesiology, Second Hospital of Tianjin Medical University, Tianjin 300211, P.R. China
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Zhang YY, Huo WL, Goldberg SI, Slater JM, Adams JA, Deng XW, Sun Y, Ma J, Fullerton BC, Paganetti H, Loeffler JS, Lu HM, Chan AW. Brain-Specific Relative Biological Effectiveness of Protons Based on Long-term Outcome of Patients With Nasopharyngeal Carcinoma. Int J Radiat Oncol Biol Phys 2021; 110:984-992. [PMID: 33600889 DOI: 10.1016/j.ijrobp.2021.02.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 02/07/2021] [Accepted: 02/08/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE Uncertainties in relative biological effectiveness (RBE) constitute a major pitfall of the use of protons in clinics. An RBE value of 1.1, which is based on cell culture and animal models, is currently used in clinical proton planning. The purpose of this study was to determine RBE for temporal lobe radiographic changes using long-term follow-up data from patients with nasopharyngeal carcinoma. METHODS AND MATERIALS Five hundred sixty-six patients with newly diagnosed nasopharyngeal carcinoma received double-scattering proton therapy or intensity modulated radiation therapy at our institutions. The 2 treatment cohorts were well matched. Proton dose distributions were simulated using Monte Carlo and compared with those obtained from the proton clinical treatment planning system. Late treatment effect was defined as development of enhancement of temporal lobe on T1-weighted magnetic resonance imaging, with or without accompanying clinical symptoms. The tolerance dose was calculated with receiving operator characteristic analysis and the Youden index. Tolerance curves, expressed as a cumulative dose-volume histogram, were generated using the cutoff points. RESULTS With a median follow-up period >5 years for both cohorts, 10% of proton patients and 4% of patients undergoing intensity modulated radiation therapy developed temporal lobe enhancement in unilateral temporal lobe. There was no significant difference in dose distributions between the Monte Carlo method and treatment planning system. The tolerance dose-volume levels were V10 (26.1%), V20 (21.9%), V30 (14.0%), V40 (7.7%), V50 (4.8%), and V60 (3.3%) for proton therapy (P < .03). Comparison of the two tolerance curves revealed that tolerance doses of proton treatments were lower than that of photon treatments at all dose levels. The dose tolerance at D1% was 58.56 Gy for protons and 69.07 Gy for photons. The RBE for temporal lobe enhancement from proton treatments were calculated to be 1.18. CONCLUSIONS Using long-term clinical outcome of patients with nasopharyngeal carcinoma, our data suggest that the RBE for temporal lobe enhancement is 1.18 at D1%. A prospective study in a large cohort would be necessary to confirm these findings.
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Affiliation(s)
- Ying Y Zhang
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Oncology, Xiangya Hospital of Central South University, Changsha, People's Republic of China
| | - Wan L Huo
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Saveli I Goldberg
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jason M Slater
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Judith A Adams
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Xiao-Wu Deng
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
| | - Ying Sun
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
| | - Jun Ma
- Department of Radiation Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
| | - Barbara C Fullerton
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jay S Loeffler
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hsiao M Lu
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Annie W Chan
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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Skaarup M, Lundemann MJ, Darkner S, Jørgensen M, Marner L, Mirkovic D, Grosshans D, Peeler C, Mohan R, Vogelius IR, Appelt A. A framework for voxel-based assessment of biological effect after proton radiotherapy in pediatric brain cancer patients using multi-modal imaging. Med Phys 2021; 48:4110-4121. [PMID: 34021597 DOI: 10.1002/mp.14989] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 04/19/2021] [Accepted: 05/13/2021] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION The exact dependence of biological effect on dose and linear energy transfer (LET) in human tissue when delivering proton therapy is unknown. In this study, we propose a framework for measuring this dependency using multi-modal image-based assays with deformable registrations within imaging sessions and across time. MATERIALS AND METHODS 3T MRI scans were prospectively collected from 6 pediatric brain cancer patients before they underwent proton therapy treatment, and every 3 months for a year after treatment. Scans included T1-weighted with contrast enhancement (T1), T2-FLAIR (T2) and fractional anisotropy (FA) images. In addition, the planning CT, dose distributions and Monte Carlo-calculated LET distributions were collected. A multi-modal deformable image registration framework was used to create a dataset of dose, LET and imaging intensities at baseline and follow-up on a voxel-by-voxel basis. We modelled the biological effect of dose and LET from proton therapy using imaging changes over time as a surrogate for biological effect. We investigated various models to show the feasibility of the framework to model imaging changes. To account for interpatient and intrapatient variations, we used a nested generalized linear mixed regression model. The models were applied to predict imaging changes over time as a function of dose and LET for each modality. RESULTS Using the nested models to predict imaging changes, we saw a decrease in the FA signal as a function of dose; however, the signal increased with increasing LET. Similarly, we saw an increase in T2 signal as a function of dose, but a decrease in signal with LET. We saw no changes in T1 voxel values as a function of either dose or LET. CONCLUSIONS The imaging changes could successfully model biological effect as a function of dose and LET using our proposed framework. Due to the low number of patients, the imaging changes observed for FA and T2 scans were not marked enough to draw any firm conclusions.
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Affiliation(s)
- Mikkel Skaarup
- Department of Oncology, Rigshospitalet, Copenhagen, Denmark
- Faculty of Science, Niels Bohr Institute, University of Copenhagen, Copenhagen, Denmark
| | | | - Sune Darkner
- Department of Computer Science, University of Copenhagen, Copenhagen, Denmark
| | | | - Lisbeth Marner
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Dragan Mirkovic
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Grosshans
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Christopher Peeler
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Radhe Mohan
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ivan Richter Vogelius
- Department of Oncology, Rigshospitalet, Copenhagen, Denmark
- Faculty of Health and Medical Science, Copenhagen University, Copenhagen, Denmark
| | - Ane Appelt
- Leeds Institute of Medical Research at St James's, University of Leeds and Leeds Cancer Centre, St. James's University Hospital, Leeds, UK
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Deng W, Yang Y, Liu C, Bues M, Mohan R, Wong WW, Foote RH, Patel SH, Liu W. A Critical Review of LET-Based Intensity-Modulated Proton Therapy Plan Evaluation and Optimization for Head and Neck Cancer Management. Int J Part Ther 2021; 8:36-49. [PMID: 34285934 PMCID: PMC8270082 DOI: 10.14338/ijpt-20-00049.1] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 10/14/2020] [Indexed: 12/15/2022] Open
Abstract
In this review article, we review the 3 important aspects of linear-energy-transfer (LET) in intensity-modulated proton therapy (IMPT) for head and neck (H&N) cancer management. Accurate LET calculation methods are essential for LET-guided plan evaluation and optimization, which can be calculated either by analytical methods or by Monte Carlo (MC) simulations. Recently, some new 3D analytical approaches to calculate LET accurately and efficiently have been proposed. On the other hand, several fast MC codes have also been developed to speed up the MC simulation by simplifying nonessential physics models and/or using the graphics processor unit (GPU)–acceleration approach. Some concepts related to LET are also briefly summarized including (1) dose-weighted versus fluence-weighted LET; (2) restricted versus unrestricted LET; and (3) microdosimetry versus macrodosimetry. LET-guided plan evaluation has been clinically done in some proton centers. Recently, more and more studies using patient outcomes as the biological endpoint have shown a positive correlation between high LET and adverse events sites, indicating the importance of LET-guided plan evaluation in proton clinics. Various LET-guided plan optimization methods have been proposed to generate proton plans to achieve biologically optimized IMPT plans. Different optimization frameworks were used, including 2-step optimization, 1-step optimization, and worst-case robust optimization. They either indirectly or directly optimize the LET distribution in patients while trying to maintain the same dose distribution and plan robustness. It is important to consider the impact of uncertainties in LET-guided optimization (ie, LET-guided robust optimization) in IMPT, since IMPT is sensitive to uncertainties including both the dose and LET distributions. We believe that the advancement of the LET-guided plan evaluation and optimization will help us exploit the unique biological characteristics of proton beams to improve the therapeutic ratio of IMPT to treat H&N and other cancers.
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Affiliation(s)
- Wei Deng
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Yunze Yang
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Chenbin Liu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, Guangdong, China
| | - Martin Bues
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Radhe Mohan
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William W Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Robert H Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Samir H Patel
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
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Update of the EPTN atlas for CT- and MR-based contouring in Neuro-Oncology. Radiother Oncol 2021; 160:259-265. [PMID: 34015385 DOI: 10.1016/j.radonc.2021.05.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/04/2021] [Accepted: 05/12/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE To update the digital online atlas for organs at risk (OARs) delineation in neuro-oncology based on high-quality computed tomography (CT) and magnetic resonance (MR) imaging with new OARs. MATERIALS AND METHODS In this planned update of the neurological contouring atlas published in 2018, ten new clinically relevant OARs were included, after thorough discussion between experienced neuro-radiation oncologists (RTOs) representing 30 European radiotherapy-oncology institutes. Inclusion was based on daily practice and research requirements. Consensus was reached for the delineation after critical review. Contouring was performed on registered CT with intravenous (IV) contrast (soft tissue & bone window setting) and 3 Tesla (T) MRI (T1 with gadolinium & T2 FLAIR) images of one patient (1 mm slices). For illustration purposes, delineation on a 7 T MRI without IV contrast from a healthy volunteer was added. OARs were delineated by three experienced RTOs and a neuroradiologist based on the relevant literature. RESULTS The presented update of the neurological contouring atlas was reviewed and approved by 28 experts in the field. The atlas is available online and includes in total 25 OARs relevant to neuro-oncology, contoured on CT and MRI T1 and FLAIR (3 T & 7 T). Three-dimensional (3D) rendered films are also available online. CONCLUSION In order to further decrease inter- and intra-observer OAR delineation variability in the field of neuro-oncology, we propose the use of this contouring atlas in photon and particle therapy, in clinical practice and in the research setting. The updated atlas is freely available on www.cancerdata.org.
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Bäumer C, Plaude S, Khalil DA, Geismar D, Kramer PH, Kröninger K, Nitsch C, Wulff J, Timmermann B. Clinical Implementation of Proton Therapy Using Pencil-Beam Scanning Delivery Combined With Static Apertures. Front Oncol 2021; 11:599018. [PMID: 34055596 PMCID: PMC8149965 DOI: 10.3389/fonc.2021.599018] [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: 08/26/2020] [Accepted: 04/06/2021] [Indexed: 11/13/2022] Open
Abstract
Proton therapy makes use of the favorable depth-dose distribution with its characteristic Bragg peak to spare normal tissue distal of the target volume. A steep dose gradient would be desired in lateral dimensions, too. The widespread spot scanning delivery technique is based, however, on pencil-beams with in-air spot full-widths-at-half-maximum of typically 1 cm or more. This hampers the sparing of organs-at-risk if small-scale structures adjacent to the target volume are concerned. The trimming of spot scanning fields with collimating apertures constitutes a simple measure to increase the transversal dose gradient. The current study describes the clinical implementation of brass apertures in conjunction with the pencil-beam scanning delivery mode at a horizontal, clinical treatment head based on commercial hardware and software components. Furthermore, clinical cases, which comprised craniopharyngiomas, re-irradiations and ocular tumors, were evaluated. The dosimetric benefits of 31 treatment plans using apertures were compared to the corresponding plans without aperture. Furthermore, an overview of the radiation protection aspects is given. Regarding the results, robust optimization considering range and setup uncertainties was combined with apertures. The treatment plan optimizations followed a single-field uniform dose or a restricted multi-field optimization approach. Robustness evaluation was expanded to account for possible deviations of the center of the pencil-beam delivery and the mechanical center of the aperture holder. Supplementary apertures improved the conformity index on average by 15.3%. The volume of the dose gradient surrounding the PTV (evaluated between 80 and 20% dose levels) was decreased on average by 17.6%. The mean dose of the hippocampi could be reduced on average by 2.9 GyRBE. In particular cases the apertures facilitated a sparing of an organ-at-risk, e.g. the eye lens or the brainstem. For six craniopharyngioma cases the inclusion of apertures led to a reduction of the mean dose of 1.5 GyRBE (13%) for the brain and 3.1 GyRBE (16%) for the hippocampi.
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Affiliation(s)
- Christian Bäumer
- West German Proton Therapy Centre Essen, Essen, Germany
- West German Cancer Center (WTZ), University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
- Faculty of Physics, TU Dortmund University, Dortmund, Germany
| | - Sandija Plaude
- West German Proton Therapy Centre Essen, Essen, Germany
- West German Cancer Center (WTZ), University Hospital Essen, Essen, Germany
| | - Dalia Ahmad Khalil
- West German Proton Therapy Centre Essen, Essen, Germany
- West German Cancer Center (WTZ), University Hospital Essen, Essen, Germany
- Department of Particle Therapy, University Hospital Essen, Essen, Germany
| | - Dirk Geismar
- West German Proton Therapy Centre Essen, Essen, Germany
- West German Cancer Center (WTZ), University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
- Department of Particle Therapy, University Hospital Essen, Essen, Germany
| | - Paul-Heinz Kramer
- West German Proton Therapy Centre Essen, Essen, Germany
- West German Cancer Center (WTZ), University Hospital Essen, Essen, Germany
| | - Kevin Kröninger
- Faculty of Physics, TU Dortmund University, Dortmund, Germany
| | | | - Jörg Wulff
- West German Proton Therapy Centre Essen, Essen, Germany
- West German Cancer Center (WTZ), University Hospital Essen, Essen, Germany
| | - Beate Timmermann
- West German Proton Therapy Centre Essen, Essen, Germany
- West German Cancer Center (WTZ), University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
- Department of Particle Therapy, University Hospital Essen, Essen, Germany
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Radiation-induced brain injury in patients with meningioma treated with proton or photon therapy. J Neurooncol 2021; 153:169-180. [PMID: 33886111 DOI: 10.1007/s11060-021-03758-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Radiation therapy is often used to treat meningioma with adverse features or when unresectable. Proton therapy has advantages over photon therapy in reducing integral dose to the brain. This study compared the incidence of radiological and clinical adverse events after photon versus proton therapy in the treatment of meningioma. METHODS A retrospective review was conducted on patients with meningioma treated with proton or photon therapy at two high-volume tertiary cancer centers. Patients with a history of prior radiation therapy (RT) or less than 3 months of follow-up were excluded. Post-RT imaging changes were categorized into abnormal T2 signal intensities (T2 changes) or abnormal T1 post-contrast and T2 signal intensities (T1c+T2 changes) on magnetic resonance imaging (MRI). Clinical outcomes of adverse events and survival were compared between the proton and photon therapies. RESULTS Among the total of 77 patients, 38 patients received proton therapy and 39 patients received photon therapy. The median age at diagnosis was 55 years and median follow-up was 2.2 years. No significant differences in symptomatic adverse events were observed between the two groups: grade ≥ 2 adverse events were seen in 4 (10.5%) patients in the proton group and 3 (7.7%) patients in the photon group (p = 0.67). The 2-year cumulative incidences of T2 changes were 38.3% after proton therapy and 47.7% after photon therapy (p = 0.53) and the 2-year cumulative incidences of T1c+T2 changes were 26.8% after proton therapy and 5.3% after photon therapy (p = 0.02). One patient experienced grade ≥ 4 adverse event in each group (p = 0.99). Estimated 2-year progression-free survival was 79.5% (proton therapy 76.0% vs. photon therapy 81.3%, p = 0.66) and 2-year overall survival was 89.7% (proton therapy 86.6% vs. photon therapy 89.3%, p = 0.65). CONCLUSIONS Following RT, high rates of T2 changes were seen in meningioma patients regardless of treatment modality. Proton therapy was associated with significantly higher rates of T1c+T2 changes compared with photon therapy, but severe adverse events were uncommon in both groups and survival outcomes were comparable between the two groups. Future studies will aim at correlating the MRI changes with models that can be incorporated into RT planning to avoid toxicity.
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Dutz A, Lühr A, Troost EGC, Agolli L, Bütof R, Valentini C, Baumann M, Vermeren X, Geismar D, Timmermann B, Krause M, Löck S. Identification of patient benefit from proton beam therapy in brain tumour patients based on dosimetric and NTCP analyses. Radiother Oncol 2021; 160:69-77. [PMID: 33872640 DOI: 10.1016/j.radonc.2021.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 03/17/2021] [Accepted: 04/08/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND The limited availability of proton beam therapy (PBT) requires individual treatment selection strategies, such as the model-based approach. In this study, we assessed the dosimetric benefit of PBT compared to photon therapy (XRT), analysed the corresponding changes in normal tissue complication probability (NTCP) on a variety of available models, and illustrated model-based patient selection in an in-silico study for patients with brain tumours. METHODS For 92 patients treated at two PBT centres, volumetric modulated arc therapy treatment plans were retrospectively created for comparison with the clinically applied PBT plans. Several dosimetric parameters for the brain excluding tumour and margins, cerebellum, brain stem, frontal and temporal lobes, hippocampi, cochleae, chiasm, optic nerves, lacrimal glands, lenses, pituitary gland, and skin were compared between both modalities using Wilcoxon signed-rank tests. NTCP differences (ΔNTCP) were calculated for 11 models predicting brain necrosis, delayed recall, temporal lobe injury, hearing loss, tinnitus, blindness, ocular toxicity, cataract, endocrine dysfunction, alopecia, and erythema. A patient was assumed to be selected for PBT if ΔNTCP exceeded a threshold of 10 percentage points for at least one of the side-effects. RESULTS PBT substantially reduced the dose in almost all investigated OARs, especially in the low and intermediate dose ranges and for contralateral organs. In general, NTCP predictions were significantly lower for PBT compared to XRT, in particular in ipsilateral organs. Considering ΔNTCP of all models, 80 patients (87.0%) would have been selected for PBT in this in-silico study, mainly due to predictions of a model on delayed recall (51 patients). CONCLUSION In this study, substantial dose reductions for PBT were observed, mainly in contralateral organs. However, due to the sigmoidal dose response, NTCP was particularly reduced in ipsilateral organs. This underlines that physical dose-volume parameters alone may not be sufficient to describe the clinical relevance between different treatment techniques and highlights potential benefits of NTCP models. Further NTCP models for different modern treatment techniques are mandatory and existing models have to be externally validated in order to implement the model-based approach in clinical practice for cranial radiotherapy.
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Affiliation(s)
- Almut Dutz
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Armin Lühr
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; Medical Physics and Radiotherapy, Faculty of Physics, TU Dortmund University, Germany
| | - Esther G C Troost
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Linda Agolli
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Rebecca Bütof
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Chiara Valentini
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Michael Baumann
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany; Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany
| | - Xavier Vermeren
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, Germany
| | - Dirk Geismar
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, Germany; Department of Particle Therapy, University Hospital Essen, Germany; West German Cancer Center (WTZ), University Hospital Essen, Germany
| | - Beate Timmermann
- West German Proton Therapy Center Essen (WPE), University Hospital Essen, Germany; Department of Particle Therapy, University Hospital Essen, Germany; West German Cancer Center (WTZ), University Hospital Essen, Germany; German Cancer Consortium (DKTK), partner site Essen, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Mechthild Krause
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Steffen Löck
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany; German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
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Dutz A, Lühr A, Agolli L, Bütof R, Valentini C, Troost EG, Baumann M, Vermeren X, Geismar D, Lamba N, Lebow ES, Bussière M, Daly JE, Bussière MR, Krause M, Timmermann B, Shih HA, Löck S. Modelling of late side-effects following cranial proton beam therapy. Radiother Oncol 2021; 157:15-23. [DOI: 10.1016/j.radonc.2021.01.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 01/04/2021] [Accepted: 01/05/2021] [Indexed: 02/06/2023]
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40
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Distinct imaging patterns of pseudoprogression in glioma patients following proton versus photon radiation therapy. J Neurooncol 2021; 152:583-590. [PMID: 33751335 DOI: 10.1007/s11060-021-03734-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/05/2021] [Indexed: 01/07/2023]
Abstract
PURPOSE Criteria by the Radiologic Assessment in Neuro-Oncology (RANO) group outline the diagnosis of pseudoprogression (Ps) after photon therapy for gliomas based on timing and location. We noted that patients receiving proton therapy manifested radiographic changes that appear different than Ps after photon therapy, which could be interpreted as tumor progression. In this study, we retrospectively reviewed MR imaging after proton or photon radiation for gliomas. We propose criteria to characterize proton pseudoprogression (ProPs) as distinct from Ps seen after photons. METHODS Post-treatment MR imaging, clinical and pathological data of low grade glioma patients were reviewed. Overall, 57 patients receiving protons were reviewed for the presence of ProPs, and 43 patients receiving photons were reviewed for any equivalent imaging changes. Data collected included the location and timing of the new enhancement, tumor grade, molecular subtype, chemotherapy received, and clinical symptoms. RESULTS Fourteen patients (24.6%) had new enhancement following radiation therapy that was unique to treatment with protons. The mean time to development of the ProPs was 15.4 months (7-27 months). We established the following criteria to characterize ProPs: located at the distal end of the proton beam; resolves without tumor-directed therapy; and subjectively multifocal, patchy, and small (< 1 cm). In the group receiving photons, none had changes that met our criteria for ProPs. CONCLUSION Patients who receive protons have unique imaging changes after radiation therapy. ProPs could be mistaken for tumor progression, but typically resolves on follow up. Further studies are needed to understand the radiobiology and pathophysiology underlying these imaging changes.
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Paganetti H, Beltran C, Both S, Dong L, Flanz J, Furutani K, Grassberger C, Grosshans DR, Knopf AC, Langendijk JA, Nystrom H, Parodi K, Raaymakers BW, Richter C, Sawakuchi GO, Schippers M, Shaitelman SF, Teo BKK, Unkelbach J, Wohlfahrt P, Lomax T. Roadmap: proton therapy physics and biology. Phys Med Biol 2021; 66. [DOI: 10.1088/1361-6560/abcd16] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 11/23/2020] [Indexed: 12/12/2022]
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Fjæra LF, Indelicato DJ, Ytre-Hauge KS, Muren LP, Lassen-Ramshad Y, Toussaint L, Dahl O, Stokkevåg CH. Spatial Agreement of Brainstem Dose Distributions Depending on Biological Model in Proton Therapy for Pediatric Brain Tumors. Adv Radiat Oncol 2021; 6:100551. [PMID: 33490724 PMCID: PMC7811129 DOI: 10.1016/j.adro.2020.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/13/2020] [Accepted: 08/20/2020] [Indexed: 11/02/2022] Open
Abstract
Purpose During radiation therapy for pediatric brain tumors, the brainstem is a critical organ at risk, possibly with different radio-sensitivity across its substructures. In proton therapy, treatment planning is currently performed using a constant relative biological effectiveness (RBE) of 1.1 (RBE1.1), whereas preclinical studies point toward spatial variability of this factor. To shed light on this biological uncertainty, we investigated the spatial agreement between isodose maps produced by different RBE models, with emphasis on (smaller) substructures of the brainstem. Methods and Materials Proton plans were recalculated using Monte Carlo simulations in 3 anonymized pediatric patients with brain tumors (a craniopharyngioma, a low-grade glioma, and a posterior fossa ependymoma) to obtain dose and linear energy transfer distributions. Doses and volume metrics for the brainstem and its substructures were calculated using a constant RBE1.1, 4 phenomenological RBE models with varying (α/β)x parameters, and with a simpler linear energy transfer-dependent model. The spatial agreement between the dose distributions of constant RBE1.1 versus the variable RBE models was compared using the Dice similarity coefficient. Results The spatial agreement between the variable RBE dose distributions and RBE1.1 decreased with increasing isodose levels in all patient cases. The patient with ependymoma showed the greatest variation in dose and dose volumes, where V50Gy(RBE) in the brainstem increased from 32% (RBE1.1) to 35% to 49% depending on the applied model, corresponding to a spatial agreement (Dice similarity coefficient) between 0.79 and 0.95. The remaining patients showed similar trends, however, with lower absolute values due to lower brainstem doses. Conclusions All phenomenological RBE models fully enclosed the isodose volumes of the constant RBE1.1, and the volumes based on variable RBE spatially agreed. The spatial agreement was dependent on the isodose level, where higher isodose levels showed larger expansions and less agreement between the variable RBE models and RBE1.1.
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Affiliation(s)
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida
| | | | - Ludvig P Muren
- Department of Medical Physics, Aarhus University/Aarhus University Hospital, Denmark
| | | | - Laura Toussaint
- Department of Medical Physics, Aarhus University/Aarhus University Hospital, Denmark
| | - Olav Dahl
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Camilla H Stokkevåg
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
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Suckert T, Beyreuther E, Müller J, Azadegan B, Meinhardt M, Raschke F, Bodenstein E, von Neubeck C, Lühr A, Krause M, Dietrich A. Late Side Effects in Normal Mouse Brain Tissue After Proton Irradiation. Front Oncol 2021; 10:598360. [PMID: 33520710 PMCID: PMC7842140 DOI: 10.3389/fonc.2020.598360] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 11/16/2020] [Indexed: 12/16/2022] Open
Abstract
Radiation-induced late side effects such as cognitive decline and normal tissue complications can severely affect quality of life and outcome in long-term survivors of brain tumors. Proton therapy offers a favorable depth-dose deposition with the potential to spare tumor-surrounding normal tissue, thus potentially reducing such side effects. In this study, we describe a preclinical model to reveal underlying biological mechanisms caused by precise high-dose proton irradiation of a brain subvolume. We studied the dose- and time-dependent radiation response of mouse brain tissue, using a high-precision image-guided proton irradiation setup for small animals established at the University Proton Therapy Dresden (UPTD). The right hippocampal area of ten C57BL/6 and ten C3H/He mice was irradiated. Both strains contained four groups (nirradiated = 3, ncontrol = 1) treated with increasing doses (0 Gy, 45 Gy, 65 Gy or 85 Gy and 0 Gy, 40 Gy, 60 Gy or 80 Gy, respectively). Follow-up examinations were performed for up to six months, including longitudinal monitoring of general health status and regular contrast-enhanced magnetic resonance imaging (MRI) of mouse brains. These findings were related to comprehensive histological analysis. In all mice of the highest dose group, first symptoms of blood-brain barrier (BBB) damage appeared one week after irradiation, while a dose-dependent delay in onset was observed for lower doses. MRI contrast agent leakage occurred in the irradiated brain areas and was progressive in the higher dose groups. Mouse health status and survival corresponded to the extent of contrast agent leakage. Histological analysis revealed tissue changes such as vessel abnormalities, gliosis, and granule cell dispersion, which also partly affected the non-irradiated contralateral hippocampus in the higher dose groups. All observed effects depended strongly on the prescribed radiation dose and the outcome, i.e. survival, image changes, and tissue alterations, were very consistent within an experimental dose cohort. The derived dose–response model will determine endpoint-specific dose levels for future experiments and may support generating clinical hypotheses on brain toxicity after proton therapy.
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Affiliation(s)
- Theresa Suckert
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
| | - Elke Beyreuther
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiation Physics, Dresden, Germany
| | - Johannes Müller
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Behnam Azadegan
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,Department of Physics, Hakim Sabzevari University, Sabzevar, Iran
| | - Matthias Meinhardt
- Neuropathology, Institute of Pathology, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Felix Raschke
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Elisabeth Bodenstein
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
| | - Cläre von Neubeck
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,Department of Particle Therapy, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Armin Lühr
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany.,Department of Medical Physics and Radiotherapy, Faculty of Physics, TU Dortmund University, Dortmund, Germany
| | - Mechthild Krause
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Antje Dietrich
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
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Niemierko A, Schuemann J, Niyazi M, Giantsoudi D, Maquilan G, Shih HA, Paganetti H. Brain Necrosis in Adult Patients After Proton Therapy: Is There Evidence for Dependency on Linear Energy Transfer? Int J Radiat Oncol Biol Phys 2021; 109:109-119. [PMID: 32911019 PMCID: PMC7736370 DOI: 10.1016/j.ijrobp.2020.08.058] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 08/26/2020] [Accepted: 08/27/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE To investigate if radiographic imaging changes defined as necrosis correlate with regions in the brain with elevated linear energy transfer (LET) for proton radiation therapy treatments with partial brain involvement in central nervous system and patients with head and neck cancer. METHODS AND MATERIALS Fifty patients with head and neck, skull base, or intracranial tumors who underwent proton therapy between 2004 to 2016 with a minimum prescription dose of 59.4 Gy (relative biological effectiveness) and with magnetic resonance imaging changes indicative of brain necrosis after radiation therapy were retrospectively reviewed. Each treatment plan was recalculated using Monte Carlo simulations to provide accurate dose distributions as well as 3-dimensional distributions of LET. To assess the effect of LET on radiographic imaging changes several voxel-based analyses were performed. RESULTS In this patient cohort, LET adjusted for dose was not found to be associated with risk of brain necrosis. CONCLUSIONS A voxel-based analysis of brain necrosis as an endpoint is difficult owing to uncertainties in the origin of necrosis, timing of imaging, variability in patient specific radiosensitivity, and the simultaneous effect of dose and LET. Even though it is expected that the LET and thus relative biological effectiveness increases at the end of range, effects in patients might be small compared with interpatient variability of radiosensitivity and might be obscured by other confounding factors.
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Affiliation(s)
- Andrzej Niemierko
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Jan Schuemann
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Maximilian Niyazi
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany; German Cancer Consortium, partner site Munich, Heidelberg, Germany; German Cancer Research Center, Heidelberg, Germany
| | - Drosoula Giantsoudi
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Genevieve Maquilan
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Helen A Shih
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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45
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Fjæra LF, Indelicato DJ, Stokkevåg CH, Muren LP, Hsi WC, Ytre-Hauge KS. Implementation of a double scattering nozzle for Monte Carlo recalculation of proton plans with variable relative biological effectiveness. Phys Med Biol 2020; 65. [PMID: 33053524 DOI: 10.1088/1361-6560/abc12d] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/14/2020] [Indexed: 11/12/2022]
Abstract
A constant relative biological effectiveness (RBE) of 1.1 is currently used in clinical proton therapy. However, theRBEvaries with factors such as dose level, linear energy transfer (LET) and tissue type. MultipleRBEmodels have been developed to account for this biological variation. To enable recalculation of patients treated with double scattering (DS) proton therapy, includingLETand variableRBE, we implemented and commissioned a Monte Carlo (MC) model of a DS treatment nozzle. The main components from the IBA nozzle were implemented in the FLUKA MC code. We calibrated and verified the following entities to experimental measurements: range of pristine Bragg peaks (PBPs) and spread-out Bragg peaks (SOBPs), energy spread, lateral profiles, compensator range degradation, and absolute dose. We recalculated two patients with different field setups, comparing FLUKA vs. treatment planning system (TPS) dose, also obtainingLETand variableRBEdoses. We achieved good agreement between FLUKA and measurements. The range differences between FLUKA and measurements were for the PBPs within ±0.9 mm (83% ⩽ 0.5 mm), and for SOBPs ±1.6 mm (82% ⩽ 0.5 mm). The differences in modulation widths were below 5 mm (79% ⩽ 2 mm). The differences in the distal dose fall off (D80%-D20%) were below 0.5 mm for all PBPs and the lateral penumbras diverged from measurements by less than 1 mm. The mean dose difference (RBE= 1.1) in the target between the TPS and FLUKA were below 0.4% in a three-field plan and below 1.4% in a four-field plan. A dose increase of 9.9% and 7.2% occurred when using variableRBEfor the two patients, respectively. We presented a method to recalculate DS proton plans in the FLUKA MC code. The implementation was used to obtainLETand variableRBEdose and can be used for investigating variableRBEfor previously treated patients.
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Affiliation(s)
- Lars Fredrik Fjæra
- Department of Physics and Technology, University of Bergen, Bergen, Norway
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida, Jacksonville, FL, United States of America
| | - Camilla H Stokkevåg
- Department of Physics and Technology, University of Bergen, Bergen, Norway.,Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Ludvig P Muren
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Wen C Hsi
- Department of Radiation Oncology, University of Florida, Jacksonville, FL, United States of America
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van der Weide HL, Kramer MCA, Scandurra D, Eekers DBP, Klaver YLB, Wiggenraad RGJ, Méndez Romero A, Coremans IEM, Boersma L, van Vulpen M, Langendijk JA. Proton therapy for selected low grade glioma patients in the Netherlands. Radiother Oncol 2020; 154:283-290. [PMID: 33197495 DOI: 10.1016/j.radonc.2020.11.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 11/06/2020] [Accepted: 11/08/2020] [Indexed: 12/12/2022]
Abstract
Proton therapy offers an attractive alternative to conventional photon-based radiotherapy in low grade glioma patients, delivering radiotherapy with equivalent efficacy to the tumour with less radiation exposure to the brain. In the Netherlands, patients with favourable prognosis based on tumour and patient characteristics can be offered proton therapy. Radiation-induced neurocognitive function decline is a major concern in these long surviving patients. Although level 1 evidence of superior clinical outcome with proton therapy is lacking, the Dutch National Health Care Institute concluded that there is scientific evidence to assume that proton therapy can have clinical benefit by reducing radiation-induced brain damage. Based on this decision, proton therapy is standard insured care for selected low grade glioma patients. Patients with other intracranial tumours can also qualify for proton therapy, based on the same criteria. In this paper, the evidence and considerations that led to this decision are summarised. Additionally, the eligibility criteria for proton therapy and the steps taken to obtain high-quality data on treatment outcome are discussed.
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Affiliation(s)
- Hiska L van der Weide
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, the Netherlands.
| | - Miranda C A Kramer
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, the Netherlands
| | - Daniel Scandurra
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, the Netherlands
| | - Daniëlle B P Eekers
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, the Netherlands
| | | | | | - Alejandra Méndez Romero
- Holland Proton Therapy Center, Delft, the Netherlands; Department of Radiation Oncology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ida E M Coremans
- Department of Radiation Oncology, Leiden University Medical Center, the Netherlands
| | - Liesbeth Boersma
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, the Netherlands
| | - Marco van Vulpen
- Holland Proton Therapy Center, Delft, the Netherlands; Department of Radiation Oncology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Radiation Oncology, Leiden University Medical Center, the Netherlands
| | - Johannes A Langendijk
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, the Netherlands
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Hahn C, Eulitz J, Peters N, Wohlfahrt P, Enghardt W, Richter C, Lühr A. Impact of range uncertainty on clinical distributions of linear energy transfer and biological effectiveness in proton therapy. Med Phys 2020; 47:6151-6162. [PMID: 33118161 DOI: 10.1002/mp.14560] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/01/2020] [Accepted: 10/20/2020] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Increased radiation response after proton irradiation, such as late radiation-induced toxicity, is determined by high dose and elevated linear energy transfer (LET). Steep dose-averaged LET (LETd ) gradients and elevated LETd occur at the end of proton range and might be particularly sensitive to uncertainties in range prediction. Therefore, this study quantified LETd distributions and the impact of range uncertainty in robust dose-optimized proton treatment plans and assessed the biological effect in normal tissues and tumors of patients. METHODS For each of six cancer patients (two brain, head-and-neck, and prostate), two nominal treatment plans were robustly dose optimized using single- and multi-field optimization, respectively. For each plan, two additional scenarios with ±3.5% range deviation relative to the nominal plan were derived by global rescaling of stopping-power ratios. Dose and LETd distributions were calculated for each scenario using the beam parameters of the corresponding nominal plan. The variability in relative biological effectiveness (RBE) and probability of late radiation-induced brain toxicity (PIC ) was assessed. RESULTS The optimization technique (single- vs multi-field) had a negligible impact on the LETd distributions in the clinical target volume (CTV) and in most organs at risk (OARs). LETd distributions in the CTV were rather homogeneous with arithmetic mean of LETd below 3.2 keV/µm and robust against range deviations. The RBE variability within the CTV induced by range uncertainty was small (≤0.05, 95% confidence interval). In OARs, LETd hotspots (>7 keV/µm) occurred and LETd distributions were inhomogeneous and sensitive to range deviations. LETd hotspots and the impact of range deviations were most prominent in OARs of brain tumor patients which translated in RBE values exceeding 1.1 in all brain OARs. The near-maximum predicted PIC in healthy brain tissue of brain tumor patients was smaller than 5% and occurred adjacent to the CTV. Range deviations induced absolute differences in PIC up to 1.2%. CONCLUSIONS Robust dose optimization generates LETd distributions in the target volume robust against range deviations. The current findings support using a constant RBE within the CTV. The impact of range deviations on the considered probability of late radiation-induced toxicity in brain tissue was limited for robust dose-optimized treatment plans. Incorporation of LETd in robust optimization frameworks may further reduce uncertainty related to the RBE-weighted dose estimation in normal tissues.
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Affiliation(s)
- Christian Hahn
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Department of Medical Physics and Radiotherapy, Faculty of Physics, TU Dortmund University, Dortmund, Germany
| | - Jan Eulitz
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Nils Peters
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Patrick Wohlfahrt
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Wolfgang Enghardt
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany.,German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Christian Richter
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany.,German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Armin Lühr
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany.,Department of Medical Physics and Radiotherapy, Faculty of Physics, TU Dortmund University, Dortmund, Germany.,Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany.,German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
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Permatasari FF, Eulitz J, Richter C, Wohlfahrt P, Lühr A. Material assignment for proton range prediction in Monte Carlo patient simulations using stopping-power datasets. Phys Med Biol 2020; 65:185004. [DOI: 10.1088/1361-6560/ab9702] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Dose-averaged linear energy transfer per se does not correlate with late rectal complications in carbon-ion radiotherapy. Radiother Oncol 2020; 153:272-278. [PMID: 32898559 DOI: 10.1016/j.radonc.2020.08.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 08/28/2020] [Accepted: 08/31/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE Several studies have focused on increasing the linear energy transfer (LET) within tumours to achieve higher biological effects in carbon-ion radiotherapy (C-ion RT). However, it remains unclear whether LET affects late complications. We assessed whether physical dose and LET distribution can be specific factors for late rectal complications in C-ion RT. MATERIALS AND METHODS Overall, 134 patients with uterine carcinomas were registered and retrospectively analysed. Of 134 patients, 132 who were followed up for >6 months were enrolled. The correlations between the relative biological effectiveness (RBE)-weighted dose based on the Kanai model (the ostensible "clinical dose"), dose-averaged LET (LETd), or physical dose and rectal complications were evaluated. Rectal complications were graded according to the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer criteria. RESULTS Nine patients developed grade 3 or 4 late rectal complications. Linear regression analysis found that D2cc in clinical dose was the sole risk factor for ≥grade 3 late rectal complications (p = 0.012). The receiver operating characteristic analysis found that D2cc of 60.2 Gy (RBE) was a suitable cut-off value for predicting ≥grade 3 late rectal complications. Among 35 patients whose rectal D2cc was ≥60.2 Gy (RBE), no correlations were found between severe rectal toxicities and LETd alone or physical dose per se. CONCLUSION We demonstrated that severe rectal toxicities were related to the rectal D2cc of the clinical dose in C-ion RT. However, no correlations were found between severe rectal toxicities and LETd alone or physical dose per se.
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50
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De Marzi L, Patriarca A, Scher N, Thariat J, Vidal M. Exploiting the full potential of proton therapy: An update on the specifics and innovations towards spatial or temporal optimisation of dose delivery. Cancer Radiother 2020; 24:691-698. [PMID: 32753235 DOI: 10.1016/j.canrad.2020.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/07/2020] [Accepted: 06/09/2020] [Indexed: 02/07/2023]
Abstract
Prescription and delivery of protons are somewhat different compared to photons and may influence outcomes (tumour control and toxicity). These differences should be taken into account to fully exploit the clinical potential of proton therapy. Innovations in proton therapy treatment are also required to widen the therapeutic window and determine appropriate populations of patients that would benefit from new treatments. Therefore, strategies are now being developed to reduce side effects to critical normal tissues using alternative treatment configurations and new spatial or temporal-driven optimisation approaches. Indeed, spatiotemporal optimisation (based on flash, proton minibeam radiation therapy or hypofractionated delivery methods) has been gaining some attention in proton therapy as a mean of improving (biological and physical) dose distribution. In this short review, the main differences in planning and delivery between protons and photons, as well as some of the latest developments and methodological issues (in silico modelling) related to providing scientific evidence for these new techniques will be discussed.
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Affiliation(s)
- L De Marzi
- Institut Curie, centre de protonthérapie d'Orsay, campus universitaire, bâtiment 101, 91898 Orsay, France; Université PSL (Paris Sciences & Lettres), 60, rue Mazarine, 75006 Paris, France; Université Paris-Saclay, route de l'Orme-aux-Merisiers, RD 128, 91190 Saint-Aubin, France; Inserm U1021, centre universitaire, bâtiment 110, rue Henri-Becquerel, 91405 Orsay cedex, France; CNRS, UMR 3347, centre universitaire, bâtiment 110, rue Henri-Becquerel, 91405 Orsay cedex, France.
| | - A Patriarca
- Institut Curie, centre de protonthérapie d'Orsay, campus universitaire, bâtiment 101, 91898 Orsay, France; Université PSL (Paris Sciences & Lettres), 60, rue Mazarine, 75006 Paris, France
| | - N Scher
- Institut Curie, centre de protonthérapie d'Orsay, campus universitaire, bâtiment 101, 91898 Orsay, France; Université PSL (Paris Sciences & Lettres), 60, rue Mazarine, 75006 Paris, France
| | - J Thariat
- Service de radiothérapie oncologique, centre François-Baclesse, 3, avenue General-Harris, 14000 Caen, France; Laboratoire de physique corpusculaire de Caen, 6, boulevard du Maréchal-Juin, 14050 Caen cedex, France; Institut national de physique nucléaire et physique des particules (IN2P3), 6, boulevard du Maréchal-Juin, 14050 Caen cedex, France; EnsiCaen, 6, boulevard du Maréchal-Juin, 14050 Caen cedex, France; CNRS, UMR6534, 6, boulevard du Maréchal-Juin, 14050 Caen cedex, France; Unicaen, 6, boulevard du Maréchal-Juin, 14050 Caen cedex, France; Normandie Université, 6, boulevard du Maréchal-Juin, 14050 Caen cedex, France
| | - M Vidal
- Centre Antoine-Lacassagne, 33, avenue Valombrose, 06000 Nice, France
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