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Holtzman AL, Mohammadi H, Furutani KM, Koffler DM, McGee LA, Lester SC, Gamez ME, Routman DM, Beltran CJ, Liang X. Impact of Relative Biologic Effectiveness for Proton Therapy for Head and Neck and Skull-Base Tumors: A Technical and Clinical Review. Cancers (Basel) 2024; 16:1947. [PMID: 38893068 PMCID: PMC11171304 DOI: 10.3390/cancers16111947] [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: 05/02/2024] [Revised: 05/17/2024] [Accepted: 05/18/2024] [Indexed: 06/21/2024] Open
Abstract
Proton therapy has emerged as a crucial tool in the treatment of head and neck and skull-base cancers, offering advantages over photon therapy in terms of decreasing integral dose and reducing acute and late toxicities, such as dysgeusia, feeding tube dependence, xerostomia, secondary malignancies, and neurocognitive dysfunction. Despite its benefits in dose distribution and biological effectiveness, the application of proton therapy is challenged by uncertainties in its relative biological effectiveness (RBE). Overcoming the challenges related to RBE is key to fully realizing proton therapy's potential, which extends beyond its physical dosimetric properties when compared with photon-based therapies. In this paper, we discuss the clinical significance of RBE within treatment volumes and adjacent serial organs at risk in the management of head and neck and skull-base tumors. We review proton RBE uncertainties and its modeling and explore clinical outcomes. Additionally, we highlight technological advancements and innovations in plan optimization and treatment delivery, including linear energy transfer/RBE optimizations and the development of spot-scanning proton arc therapy. These advancements show promise in harnessing the full capabilities of proton therapy from an academic standpoint, further technological innovations and clinical outcome studies, however, are needed for their integration into routine clinical practice.
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Affiliation(s)
- Adam L. Holtzman
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Homan Mohammadi
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Keith M. Furutani
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Daniel M. Koffler
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Lisa A. McGee
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Scott C. Lester
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Mauricio E. Gamez
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - David M. Routman
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Chris J. Beltran
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Xiaoying Liang
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
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Tominaga Y, Suga M, Takeda M, Yamamoto Y, Akagi T, Kato T, Tokumaru S, Yamamoto M, Oita M. Dose-volume comparisons of proton therapy for pencil beam scanning with and without multi-leaf collimator and passive scattering in patients with lung cancer. Med Dosim 2023; 49:13-18. [PMID: 37940436 DOI: 10.1016/j.meddos.2023.10.006] [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: 05/26/2023] [Revised: 10/05/2023] [Accepted: 10/06/2023] [Indexed: 11/10/2023]
Abstract
This study evaluated the dose distributions of proton pencil beam scanning (PBS) with/without a multileaf collimator (MLC) compared to passive scattering (PS) for stage I/II lung cancers. Collimated/uncollimated (PBS+/PBS-) and PS plans were created for 20 patients. Internal-clinical-target-volumes (ICTVs) and planning-target-volumes (PTVs) with a 5 mm margin were defined on the gated CTs. Organs-at-risk (OARs) are defined as the normal lungs, spinal cord, esophagus, and heart. The prescribed dose was 66 Gy relative-biological-effectiveness (RBE) in 10 fractions at the isocenter and 50% volume of the ICTVs for the PS and PBS, respectively. We compared the target and OAR dose statistics from the dose volume histograms. The PBS+ group had a significantly better mean PTV conformity index than the PBS- and PS groups. The mean dose sparing for PBS+ was better than those for PBS- and PS. Only the normal lung doses of PBS- were worse than those of PS. The overall performance of the OAR sparing was in the order of PBS+, PBS-, and PS. The PBS+ plan showed significantly better target homogeneity and OAR sparing than the PBS- and PS plans. PBS requires collimating systems to treat lung cancers with the most OAR sparing while maintaining the target coverage.
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Affiliation(s)
- Yuki Tominaga
- Medical Co. Hakuhokai, Osaka Proton Therapy Clinic, Konohana-ku, Osaka 554-0022, Japan.
| | - Masaki Suga
- Hyogo Ion Beam Medical Center, Tatsuno, Hyogo 679-5165, Japan
| | - Mikuni Takeda
- Hyogo Ion Beam Medical Center, Tatsuno, Hyogo 679-5165, Japan
| | - Yuki Yamamoto
- Hyogo Ion Beam Medical Center, Tatsuno, Hyogo 679-5165, Japan
| | - Takashi Akagi
- Hyogo Ion Beam Medical Center, Tatsuno, Hyogo 679-5165, Japan
| | - Takahiro Kato
- Depertment of Radiological Sciences, School of Health Sciences, Fukushima, Medical University, Fukushima 960-1295, Japan; Depertment of Radiation Physics and Technology, Southern Tohoku Proton Therapy Center, Koriyama, Fukushima 963-8052, Japan
| | - Sunao Tokumaru
- Hyogo Ion Beam Medical Center, Tatsuno, Hyogo 679-5165, Japan
| | - Michinori Yamamoto
- Medical Co. Hakuhokai, Osaka Proton Therapy Clinic, Konohana-ku, Osaka 554-0022, Japan
| | - Masataka Oita
- Faculty of Interdisciplinary Science and Engineering in Health Systems, Okayama University, Okayama 700-8558, Japan
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3
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Jiang K, MacFarlane M, Mossahebi S, Zakhary MJ. Evaluation of treatment planning system accuracy in estimating the stopping-power ratio of immobilization devices for proton therapy. J Appl Clin Med Phys 2023; 24:e13831. [PMID: 36593751 PMCID: PMC9924110 DOI: 10.1002/acm2.13831] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 09/30/2022] [Accepted: 10/04/2022] [Indexed: 01/04/2023] Open
Abstract
PURPOSE To assess treatment planning system (TPS) accuracy in estimating the stopping-power ratio (SPR) of immobilization devices commonly used in proton therapy and to evaluate the dosimetric effect of SPR estimation error for a set of clinical treatment plans. METHODS Computed tomography scans of selected clinical immobilization devices were acquired. Then, the water-equivalent thickness (WET) and SPR values of these devices based on the scans were estimated in a commercial TPS. The reference SPR of each device was measured using a multilayer ion chamber (MLIC), and the differences between measured and TPS-estimated SPRs were calculated. These findings were utilized to calculate corrected dose distributions of 15 clinical proton plans for three treatment sites: extremity, abdomen, and head-and-neck. The original and corrected dose distributions were compared using a set of target and organs-at-risk (OARs) dose-volume histogram (DVH) parameters. RESULTS On average, the TPS-estimated SPR was 19.5% lower (range, -35.1% to 0.2%) than the MLIC-measured SPR. Due to the relatively low density of most immobilization devices used, the WET error was typically <1 mm, but up to 2.2 mm in certain devices. Overriding the SPR of the immobilization devices to the measured values did not result in significant changes in the DVH metrics of targets and most OARs. However, some critical OARs showed noticeable changes of up to 6.7% in maximum dose. CONCLUSIONS The TPS tends to underestimate the SPR of selected proton immobilization devices by an average of about 20%, but this does not induce major WET errors because of the low density of the devices. The dosimetric effect of this SPR error was negligible for most treatment sites, although the maximum dose of a few OARs exhibited noticeable variations.
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Affiliation(s)
- Kai Jiang
- Department of Radiation OncologyUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Michael MacFarlane
- Department of Radiation OncologyUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Sina Mossahebi
- Department of Radiation OncologyUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Mark J. Zakhary
- Department of Radiation OncologyUniversity of Maryland School of MedicineBaltimoreMarylandUSA
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4
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Chang C, Charyyev S, Harms J, Slopsema R, Wolf J, Refai D, Yoon T, McDonald MW, Bradley JD, Leng S, Zhou J, Yang X, Lin L. A component method to delineate surgical spine implants for proton Monte Carlo dose calculation. J Appl Clin Med Phys 2023; 24:e13800. [PMID: 36210177 PMCID: PMC9859997 DOI: 10.1002/acm2.13800] [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: 06/14/2022] [Revised: 09/09/2022] [Accepted: 09/22/2022] [Indexed: 01/26/2023] Open
Abstract
PURPOSE Metallic implants have been correlated to local control failure for spinal sarcoma and chordoma patients due to the uncertainty of implant delineation from computed tomography (CT). Such uncertainty can compromise the proton Monte Carlo dose calculation (MCDC) accuracy. A component method is proposed to determine the dimension and volume of the implants from CT images. METHODS The proposed component method leverages the knowledge of surgical implants from medical supply vendors to predefine accurate contours for each implant component, including tulips, screw bodies, lockers, and rods. A retrospective patient study was conducted to demonstrate the feasibility of the method. The reference implant materials and samples were collected from patient medical records and vendors, Medtronic and NuVasive. Additional CT images with extensive features, such as extended Hounsfield units and various reconstruction diameters, were used to quantify the uncertainty of implant contours. RESULTS For in vivo patient implant estimation, the reference and the component method differences were 0.35, 0.17, and 0.04 cm3 for tulips, screw bodies, and rods, respectively. The discrepancies by a conventional threshold method were 5.46, 0.76, and 0.05 cm3 , respectively. The mischaracterization of implant materials and dimensions can underdose the clinical target volume coverage by 20 cm3 for a patient with eight lumbar implants. The tulip dominates the dosimetry uncertainty as it can be made from titanium or cobalt-chromium alloys by different vendors. CONCLUSIONS A component method was developed and demonstrated using phantom and patient studies with implants. The proposed method provides more accurate implant characterization for proton MCDC and can potentially enhance the treatment quality for proton therapy. The current proof-of-concept study is limited to the implant characterization for lumbar spine. Future investigations could be extended to cervical spine and dental implants for head-and-neck patients where tight margins are required to spare organs at risk.
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Affiliation(s)
- Chih‐Wei Chang
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Serdar Charyyev
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Joseph Harms
- Department of Radiation OncologyUniversity of AlabamaBirminghamAlabamaUSA
| | - Roelf Slopsema
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Jonathan Wolf
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Daniel Refai
- Department of NeurosurgeryEmory UniversityAtlantaGeorgiaUSA
| | - Tim Yoon
- Department of OrthopaedicsEmory UniversityAtlantaGeorgiaUSA
| | - Mark W. McDonald
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Jeffrey D. Bradley
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Shuai Leng
- Department of RadiologyMayo ClinicRochesterMinnesotaUSA
| | - Jun Zhou
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Xiaofeng Yang
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
- Department of Biomedical InformaticsEmory UniversityAtlantaGeorgiaUSA
| | - Liyong Lin
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
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5
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Butkus MP, Brovold N, Diwanji T, Xu Y, De Ornelas M, Dal Pra A, Abramowitz M, Pollack A, Dogan N. Assessment of IMPT versus VMAT plans using different uncertainty scenarios for prostate cancer. Radiat Oncol 2022; 17:162. [PMID: 36175971 PMCID: PMC9523999 DOI: 10.1186/s13014-022-02126-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 08/07/2022] [Indexed: 11/10/2022] Open
Abstract
Background To assess the impact of systematic setup and range uncertainties for robustly optimized (RO) intensity modulated proton therapy (IMPT) and volumetric modulated arc therapy (VMAT) plans in patients with localized prostate cancer. Methods Twenty-six localized prostate patients previously treated with VMAT (CTV to PTV expansion of 3-5 mm) were re-planned with RO-IMPT with 3 mm and 5 mm geometrical uncertainties coupled with 3% range uncertainties. Robust evaluations (RE) accounting for the geometrical uncertainties of 3 and 5 mm were evaluated for the IMPT and VMAT plans. Clinical target volume (CTV), anorectum, and bladder dose metrics were analyzed between the nominal plans and their uncertainty perturbations. Results With geometric uncertainties of 5 mm and accounting for potential inter-fractional perturbations, RO-IMPT provided statistically significant (p < 0.05) sparing at intermediate doses (V4000cGy) to the anorectum and bladder and high dose sparring (V8000cGy) to the bladder compared to VMAT. Decreasing the RO and RE parameters to 3 mm improved IMPT sparing over VMAT at all OAR dose levels investigated while maintaining equivalent coverage to the CTV. Conclusions For localized prostate treatments, if geometric uncertainties can be maintained at or below 3 mm, RO-IMPT provides clear dosimetric advantages in anorectum and bladder sparing compared to VMAT. This advantage remains even under uncertainty scenarios. As geometric uncertainties increase to 5 mm, RO-IMPT still provides dosimetric advantages, but to a smaller magnitude.
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Affiliation(s)
- Michael P Butkus
- Department of Radiation Oncology, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, Florida, 33136, USA.
| | - Nellie Brovold
- Department of Radiation Oncology, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, Florida, 33136, USA.,Department of Radiation Oncology, Mayo Clinic, 200 First St. SW, Minnesota, Rochester, 55905, USA
| | - Tejan Diwanji
- Department of Radiation Oncology, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, Florida, 33136, USA.,Department of Radiation Oncology, Mid-Atlantic Permanente Medical Group, 1701 Twin Springs Rd, Maryland, Halethrope, 21227, USA
| | - Yihang Xu
- Department of Radiation Oncology, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, Florida, 33136, USA
| | - Mariluz De Ornelas
- Department of Radiation Oncology, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, Florida, 33136, USA
| | - Alan Dal Pra
- Department of Radiation Oncology, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, Florida, 33136, USA
| | - Matt Abramowitz
- Department of Radiation Oncology, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, Florida, 33136, USA
| | - Alan Pollack
- Department of Radiation Oncology, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, Florida, 33136, USA
| | - Nesrin Dogan
- Department of Radiation Oncology, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, Florida, 33136, USA
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6
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Koh WYC, Tan HQ, Ng YY, Lin YH, Ang KW, Lew WS, Lee JCL, Park SY. Quantifying Systematic RBE-Weighted Dose Uncertainty Arising from Multiple Variable RBE Models in Organ at Risk. Adv Radiat Oncol 2022; 7:100844. [PMID: 35036633 PMCID: PMC8749202 DOI: 10.1016/j.adro.2021.100844] [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: 06/12/2021] [Revised: 09/27/2021] [Accepted: 10/29/2021] [Indexed: 11/22/2022] Open
Abstract
PURPOSE Relative biological effectiveness (RBE) uncertainties have been a concern for treatment planning in proton therapy, particularly for treatment sites that are near organs at risk (OARs). In such a clinical situation, the utilization of variable RBE models is preferred over constant RBE model of 1.1. The problem, however, lies in the exact choice of RBE model, especially when current RBE models are plagued with a host of uncertainties. This paper aims to determine the influence of RBE models on treatment planning, specifically to improve the understanding of the influence of the RBE models with regard to the passing and failing of treatment plans. This can be achieved by studying the RBE-weighted dose uncertainties across RBE models for OARs in cases where the target volume overlaps the OARs. Multi-field optimization (MFO) and single-field optimization (SFO) plans were compared in order to recommend which technique was more effective in eliminating the variations between RBE models. METHODS Fifteen brain tumor patients were selected based on their profile where their target volume overlaps with both the brain stem and the optic chiasm. In this study, 6 RBE models were analyzed to determine the RBE-weighted dose uncertainties. Both MFO and SFO planning techniques were adopted for the treatment planning of each patient. RBE-weighted dose uncertainties in the OARs are calculated assuming( α β ) x of 3 Gy and 8 Gy. Statistical analysis was used to ascertain the differences in RBE-weighted dose uncertainties between MFO and SFO planning. Additionally, further investigation of the linear energy transfer (LET) distribution was conducted to determine the relationship between LET distribution and RBE-weighted dose uncertainties. RESULTS The results showed no strong indication on which planning technique would be the best for achieving treatment planning constraints. MFO and SFO showed significant differences (P <.05) in the RBE-weighted dose uncertainties in the OAR. In both clinical target volume (CTV)-brain stem and CTV-chiasm overlap region, 10 of 15 patients showed a lower median RBE-weighted dose uncertainty in MFO planning compared with SFO planning. In the LET analysis, 8 patients (optic chiasm) and 13 patients (brain stem) showed a lower mean LET in MFO planning compared with SFO planning. It was also observed that lesser RBE-weighted dose uncertainties were present with MFO planning compared with SFO planning technique. CONCLUSIONS Calculations of the RBE-weighted dose uncertainties based on 6 RBE models and 2 different( α β ) x revealed that MFO planning is a better option as opposed to SFO planning for cases of overlapping brain tumor with OARs in eliminating RBE-weighted dose uncertainties. Incorporation of RBE models failed to dictate the passing or failing of a treatment plan. To eliminate RBE-weighted dose uncertainties in OARs, the MFO planning technique is recommended for brain tumor when CTV and OARs overlap.
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Affiliation(s)
- Wei Yang Calvin Koh
- Division of Physics and Applied Physics, Nanyang Technological University, Singapore
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - Hong Qi Tan
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - Yan Yee Ng
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - Yen Hwa Lin
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - Khong Wei Ang
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - Wen Siang Lew
- Division of Physics and Applied Physics, Nanyang Technological University, Singapore
| | - James Cheow Lei Lee
- Division of Physics and Applied Physics, Nanyang Technological University, Singapore
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - Sung Yong Park
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
- Oncology Academic Clinical Programme, Duke-NUS Medical School, National University of Singapore, Singapore
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Hanania AN, Zhang X, Gunn GB, Rosenthal DI, Garden AS, Fuller CD, Phan J, Reddy JP, Moreno A, Chronowski G, Shah S, Ausat N, Hanna E, Ferrarotto R, Frank SJ. Proton Therapy for Major Salivary Gland Cancer: Clinical Outcomes. Int J Part Ther 2021; 8:261-272. [PMID: 34285952 PMCID: PMC8270094 DOI: 10.14338/ijpt-20-00044.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 11/23/2020] [Indexed: 11/21/2022] Open
Abstract
Purpose To report clinical outcomes in terms of disease control and toxicity in patients with major salivary gland cancers (SGCs) treated with proton beam therapy. Materials and Methods Clinical and dosimetric characteristics of patients with SGCs treated from August 2011 to February 2020 on an observational, prospective, single-institution protocol were abstracted. Local control and overall survival were calculated by the Kaplan-Meier method. During radiation, weekly assessments of toxicity were obtained, and for patients with ≥ 90 days of follow-up, late toxicity was assessed. Results Seventy-two patients were identified. Median age was 54 years (range, 23-87 years). Sixty-three patients (88%) received postoperative therapy, and nine patients (12%) were treated definitively. Twenty-six patients (36%) received concurrent chemotherapy. Nine patients (12%) had received prior radiation. All (99%) but one patient received unilateral treatment with a median dose of 64 GyRBE (relative biological effectiveness) (interquartile range [IQR], 60-66), and 53 patients (74%) received intensity-modulated proton therapy with either single-field or multifield optimization. The median follow-up time was 30 months. Two-year local control and overall survival rates were 96% (95% confidence interval [CI] 85%-99%) and 89% (95% CI 76%-95%], respectively. Radiation dermatitis was the predominant grade-3 toxicity (seen in 21% [n = 15] of the patients), and grade ≥ 2 mucositis was rare (14%; n = 10 patients). No late-grade ≥ 3 toxicities were reported. Conclusion Proton beam therapy for treatment of major SGCs manifests in low rates of acute mucosal toxicity. In addition, the current data suggest a high rate of local control and minimal late toxicity.
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Affiliation(s)
- Alexander N Hanania
- Department of Radiation Oncology, Baylor College of Medicine, Houston, TX, USA.,Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xiaodong Zhang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Adam S Garden
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - C David Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jack Phan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jay P Reddy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amy Moreno
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gregory Chronowski
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shalin Shah
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Noveen Ausat
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ehab Hanna
- Department of Head and Neck Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Renata Ferrarotto
- Department of Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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8
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Lalonde A, Bobić M, Winey B, Verburg J, Sharp GC, Paganetti H. Anatomic changes in head and neck intensity-modulated proton therapy: Comparison between robust optimization and online adaptation. Radiother Oncol 2021; 159:39-47. [PMID: 33741469 PMCID: PMC8205952 DOI: 10.1016/j.radonc.2021.03.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 03/08/2021] [Accepted: 03/08/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND/PURPOSE Setup variations and anatomical changes can severely affect the quality of head and neck intensity-modulated proton therapy (IMPT) treatments. The impact of these changes can be alleviated by increasing the plan's robustness a priori, or by adapting the plan online. This work compares these approaches in the context of head and neck IMPT. MATERIALS/METHODS A representative cohort of 10 head and neck squamous cell carcinoma (HNSCC) patients with daily cone-beam computed tomography (CBCT) was evaluated. For each patient, three IMPT plans were created: 1- a classical robust optimization (cRO) plan optimized on the planning CT, 2- an anatomical robust optimization (aRO) plan additionally including the two first daily CBCTs and 3- a plan optimized without robustness constraints, but online-adapted (OA) daily, using a constrained spot intensity re-optimization technique only. RESULTS The cumulative dose following OA fulfilled the clinical objective of both the high-risk and low-risk clinical target volumes (CTV) coverage in all 10 patients, compared to 8 for aRO and 4 for cRO. aRO did not significantly increase the dose to most organs at risk compared to cRO, although the integral dose was higher. OA significantly reduced the integral dose to healthy tissues compared to both robust methods, while providing equivalent or superior target coverage. CONCLUSION Using a simple spot intensity re-optimization, daily OA can achieve superior target coverage and lower dose to organs at risk than robust optimization methods.
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Affiliation(s)
- Arthur Lalonde
- Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, USA.
| | - Mislav Bobić
- Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, USA; ETH Zürich, Zürich, Switzerland
| | - Brian Winey
- Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, USA
| | - Joost Verburg
- Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, USA
| | - Gregory C Sharp
- Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, USA
| | - Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, USA
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9
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Yasuda K, Minatogawa H, Dekura Y, Takao S, Tamura M, Tsushima N, Suzuki T, Kano S, Mizumachi T, Mori T, Nishioka K, Shido M, Katoh N, Taguchi H, Fujima N, Onimaru R, Yokota I, Kobashi K, Shimizu S, Homma A, Shirato H, Aoyama H. Analysis of acute-phase toxicities of intensity-modulated proton therapy using a model-based approach in pharyngeal cancer patients. JOURNAL OF RADIATION RESEARCH 2021; 62:329-337. [PMID: 33372202 PMCID: PMC7948838 DOI: 10.1093/jrr/rraa130] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 11/09/2020] [Indexed: 05/21/2023]
Abstract
Pharyngeal cancer patients treated with intensity-modulated proton therapy (IMPT) using a model-based approach were retrospectively reviewed, and acute toxicities were analyzed. From June 2016 to March 2019, 15 pharyngeal (7 naso-, 5 oro- and 3 hypo-pharyngeal) cancer patients received IMPT with robust optimization. Simulation plans for IMPT and intensity-modulated X-ray therapy (IMXT) were generated before treatment. We also reviewed 127 pharyngeal cancer patients with IMXT in the same treatment period. In the simulation planning comparison, all of the normal-tissue complication probability values for dysphagia, dysgeusia, tube-feeding dependence and xerostomia were lower for IMPT than for IMXT in the 15 patients. After completing IMPT, 13 patients completed the evaluation, and 12 of these patients had a complete response. The proportions of patients who experienced grade 2 or worse acute toxicities in the IMPT and IMXT cohorts were 21.4 and 56.5% for dysphagia (P < 0.05), 46.7 and 76.3% for dysgeusia (P < 0.05), 73.3 and 62.8% for xerostomia (P = 0.43), 73.3 and 90.6% for mucositis (P = 0.08) and 66.7 and 76.4% for dermatitis (P = 0.42), respectively. Multivariate analysis revealed that IMPT was independently associated with a lower rate of grade 2 or worse dysphagia and dysgeusia. After propensity score matching, 12 pairs of IMPT and IMXT patients were selected. Dysphagia was also statistically lower in IMPT than in IMXT (P < 0.05). IMPT using a model-based approach may have clinical benefits for acute dysphagia.
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Affiliation(s)
- Koichi Yasuda
- Corresponding author. Department of Radiation Oncology, Hokkaido University Hospital. North-15 West-7, Sapporo, 060-8638, Japan. Tel: (+81)11-706-5977; Fax: (+81)11-706-7876;
| | - Hideki Minatogawa
- Department of Radiation Oncology, Hokkaido University Hospital, North-15 West-7, Sapporo, Japan
- Department of Radiation Oncology, Faculty and Graduate School of Medicine, Hokkaido University, North-15 West-7, Sapporo, Japan
| | - Yasuhiro Dekura
- Department of Radiation Oncology, Hokkaido University Hospital, North-15 West-7, Sapporo, Japan
- Department of Radiation Medical Science and Engineering, Faculty and Graduate School of Medicine,Hokkaido University, North-15 West-7, Sapporo, Japan
| | - Seishin Takao
- Department of Medical Physics, Hokkaido University Hospital, North-15 West-7, Sapporo, Japan
| | - Masaya Tamura
- Department of Medical Physics, Hokkaido University Hospital, North-15 West-7, Sapporo, Japan
| | - Nayuta Tsushima
- Department of Otolaryngology-Head and Neck Surgery, Faculty and Graduate School of Medicine,Hokkaido University, North-15 West-7, Sapporo, Japan
| | - Takayoshi Suzuki
- Department of Otolaryngology-Head and Neck Surgery, Faculty and Graduate School of Medicine,Hokkaido University, North-15 West-7, Sapporo, Japan
| | - Satoshi Kano
- Department of Otolaryngology-Head and Neck Surgery, Faculty and Graduate School of Medicine,Hokkaido University, North-15 West-7, Sapporo, Japan
| | - Takatsugu Mizumachi
- Department of Otolaryngology-Head and Neck Surgery, Faculty and Graduate School of Medicine,Hokkaido University, North-15 West-7, Sapporo, Japan
| | - Takashi Mori
- Department of Oral Radiology, Graduate School of Dental Medicine, Hokkaido University, Hokkaido University, North-13 West-7, Sapporo, Japan
| | - Kentaro Nishioka
- Department of Radiation Medical Science and Engineering, Faculty and Graduate School of Medicine,Hokkaido University, North-15 West-7, Sapporo, Japan
| | - Motoyasu Shido
- Department of Radiation Oncology, Hokkaido University Hospital, North-15 West-7, Sapporo, Japan
| | - Norio Katoh
- Department of Radiation Oncology, Faculty and Graduate School of Medicine, Hokkaido University, North-15 West-7, Sapporo, Japan
| | - Hiroshi Taguchi
- Department of Radiation Oncology, Hokkaido University Hospital, North-15 West-7, Sapporo, Japan
| | - Noriyuki Fujima
- Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Rikiya Onimaru
- Department of Radiation Oncology, Faculty and Graduate School of Medicine, Hokkaido University, North-15 West-7, Sapporo, Japan
| | - Isao Yokota
- Department of Biostatistics, Faculty and Graduate School of Medicine, Hokkaido University, North-15 West-7, Sapporo, Japan
| | - Keiji Kobashi
- Department of Medical Physics, Hokkaido University Hospital, North-15 West-7, Sapporo, Japan
- Department of Radiation Medical Science and Engineering, Faculty and Graduate School of Medicine,Hokkaido University, North-15 West-7, Sapporo, Japan
| | - Shinichi Shimizu
- Department of Radiation Medical Science and Engineering, Faculty and Graduate School of Medicine,Hokkaido University, North-15 West-7, Sapporo, Japan
| | - Akihiro Homma
- Department of Otolaryngology-Head and Neck Surgery, Faculty and Graduate School of Medicine,Hokkaido University, North-15 West-7, Sapporo, Japan
| | - Hiroki Shirato
- Department of Radiation Oncology, Faculty and Graduate School of Medicine, Hokkaido University, North-15 West-7, Sapporo, Japan
| | - Hidefumi Aoyama
- Department of Radiation Oncology, Faculty and Graduate School of Medicine, Hokkaido University, North-15 West-7, Sapporo, Japan
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10
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Dickmann J, Kamp F, Hillbrand M, Corradini S, Belka C, Schulte RW, Parodi K, Dedes G, Landry G. Fluence-modulated proton CT optimized with patient-specific dose and variance objectives for proton dose calculation. Phys Med Biol 2021; 66:064001. [PMID: 33545701 DOI: 10.1088/1361-6560/abe3d2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Particle therapy treatment planning requires accurate volumetric maps of the relative stopping power, which can directly be acquired using proton computed tomography (pCT). With fluence-modulated pCT (FMpCT) imaging fluence is concentrated in a region-of-interest (ROI), which can be the vicinity of the treatment beam path, and imaging dose is reduced elsewhere. In this work we present a novel optimization algorithm for FMpCT which, for the first time, calculates modulated imaging fluences for joint imaging dose and image variance objectives. Thereby, image quality is maintained in the ROI to ensure accurate calculations of the treatment dose, and imaging dose is minimized outside the ROI with stronger minimization penalties given to imaging organs-at-risk. The optimization requires an initial scan at uniform fluence or a previous x-ray CT scan. We simulated and optimized FMpCT images for three pediatric patients with tumors in the head region. We verified that the target image variance inside the ROI was achieved and demonstrated imaging dose reductions outside of the ROI of 74% on average, reducing the imaging dose from 1.2 to 0.3 mGy. Such dose savings are expected to be relevant compared to the therapeutic dose outside of the treatment field. Treatment doses were re-calculated on the FMpCT images and compared to treatment doses re-recalculated on uniform fluence pCT scans using a 1% criterion. Passing rates were above 98.3% for all patients. Passing rates comparing FMpCT treatment doses to the ground truth treatment dose were above 88.5% for all patients. Evaluation of the proton range with a 1 mm criterion resulted in passing rates above 97.5% (FMpCT/pCT) and 95.3% (FMpCT/ground truth). Jointly optimized fluence-modulated pCT images can be used for proton dose calculation maintaining the full dosimetric accuracy of pCT but reducing the required imaging dose considerably by three quarters. This may allow for daily imaging during particle therapy ensuring a safe and accurate delivery of the therapeutic dose and avoiding excess dose from imaging.
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Affiliation(s)
- J Dickmann
- Department of Medical Physics, Fakultät für Physik, Ludwig-Maximilians-Universität München (LMU Munich), D-85748 Garching bei München, Germany
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11
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Wolf M, Anderle K, Durante M, Graeff C. Robust treatment planning with 4D intensity modulated carbon ion therapy for multiple targets in stage IV non-small cell lung cancer. Phys Med Biol 2020; 65:215012. [PMID: 32610300 DOI: 10.1088/1361-6560/aba1a3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Intensity modulated particle therapy (IMPT) with carbon ions can generate highly conformal treatment plans; however, IMPT is limited in robustness against range and positioning uncertainty. This is particularly true for moving targets, even though all motion states of a 4DCT are considered in 4D-IMPT. Here, we expand 4D-IMPT to include robust non-linear RBE-weighted optimization to explore its potential in improving plan robustness and sparing critical organs. In this study, robust 4D-optimization-based on worst-case optimization on 9 scenarios-was compared to conventional 4D-optimization with PTV margins using 4D dose calculation and robustness analysis for 21 uncertainty scenarios. Slice-by-slice rescanning was used for motion mitigation. Both 4D-optimization strategies were tested on a cohort of 8 multi-lesion lung cancer patients with the goal of prioritizing OAR sparing in a hypofractionated treatment plan. Planning objectives were to keep the OAR volume doses below corresponding limits while simultaneously achieve CTV coverage with D95% ≥ 95 %. For the conventional plans, average D95% was at 98.7% which fulfilled the target objective in 83.2% of scenarios. For the robust plans, average D95% was reduced to 97.6% which still fulfilled the target objective in 80.7% of cases, but led to significantly improved overall OAR sparing: Volume doses were below the limits in 96.2% of cases for the conventional and 99.5% for the robust plans. When considering the particularly critical smaller airways only, fulfillment rates could be increased from 76.2% to 96% for the robust plans. This study has shown that plan robustness of 4D-IMPT could be improved by using robust 4D-optimization, offering greater control over uncertainties in the actual delivered dose. In some cases, this required sacrificing target coverage for the benefit of better OAR sparing.
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Affiliation(s)
- M Wolf
- GSI Helmholtz Center, Darmstadt, Germany
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12
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Zhang Y, Ho MW, Li Z. A Beam-Angle-Selection Method to Improve Inter-Fraction Motion Robustness for Lung Tumor Irradiation With Passive Proton Scattering. Technol Cancer Res Treat 2020; 19:1533033820948052. [PMID: 32844716 PMCID: PMC7453456 DOI: 10.1177/1533033820948052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
In terms of dose distribution, protons are more sensitive to range variations than photons due to their unique properties. The aim of this study was to develop a method to identify patient-specific robust proton beam angles for lung tumor irradiation by investigating the association between water equivalent thickness (WET) variation and inter-fraction motion-induced target dose degradation. Using 3-dimensional computed tomography (3D-CT) images, the impact of WET variations on the target dose coverage of a series of coplanar proton beams was evaluated for 4 patients with lung cancer. Using ray tracing, WET maps, or WET baseline, were estimated for the internal target volume (ITV) at every 5° gantry interval in the axial plane. After calculating the WET baseline, the planning CT was shifted 5 mm in each anterior-posterior (AP), superior-inferior (SI), and left-right (LR) direction, yielding a total of 6 shifted CTs, and differential WET maps between the planning CT and each shifted CT were calculated. Target dose differences were associated with the average WET change between the original planning CT and the shifted CTs for all 360° gantry rotation beams. Target and OAR dose metrics in the ΔWET-guided plans were compared with those of the clinical plans. The WET variation maps showed areas of both high and low WET variations, with overall similar patterns yet individual differences reflecting tumor position differences. For all 4 patients investigated in this study, the coplanar plans demonstrated a strong correlation between WET changes and ITV dose reductions. Target dose coverage was more stable with the ΔWET-guided plan while OAR doses were comparable to the clinical plan. The WET variation maps have been used in this pilot study to identify proton beam angles that are either sensitive or robust to WET changes in proton passive scattering. This work demonstrates the feasibility of using WET variation maps to assist the planner in inter-fraction motion-robust proton beam angle selection.
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Affiliation(s)
- Yawei Zhang
- 90618University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA.,Department of Radiation Oncology, University of Florida, Gainesville, FL, USA
| | - Meng Wei Ho
- 90618University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA.,Department of Radiation Oncology, University of Florida, Gainesville, FL, USA
| | - Zuofeng Li
- 90618University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA.,Department of Radiation Oncology, University of Florida, Gainesville, FL, USA
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13
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Miyashita H, Fukumoto M, Kuwahara Y, Takahashi T, Fukumoto M. ISG20 is overexpressed in clinically relevant radioresistant oral cancer cells. INTERNATIONAL JOURNAL OF CLINICAL AND EXPERIMENTAL PATHOLOGY 2020; 13:1633-1639. [PMID: 32782682 PMCID: PMC7414473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 04/28/2020] [Indexed: 06/11/2023]
Abstract
Global standard fractionated radiotherapy (RT) for the treatment of malignancies consists of X-ray irradiation with 2-Gy/day, 5 days a week for 5-7 weeks. Recently, clinically relevant radioresistant (CRR) cells were first defined as cells that can continue to grow even after exposure to daily 2-Gy of X-rays for more than 30 days in vitro. To analyze the characteristics of radioresistant cancer cells, CRR oral cancer cells (CRR-OCCs) were established, and the expression level of interferon-stimulated exonuclease gene 20 (ISG20) was evaluated with qRT-PCR and immunohistochemical analysis. Our result revealed that the expression level of both ISG20 mRNA and its protein in CRR-OCCs were higher than those of corresponding parental cells. We concluded that ISG20 was statistically overexpressed in CRR-OCCs. ISG20 overexpression may be necessary for the radioresistant phenotype in CRR-OCCs, and targeting ISG20 of human cancer cells may lead to more efficient RT or chemoradiotherapy for eliminating cancer.
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Affiliation(s)
- Hitoshi Miyashita
- Division of Oral and Maxillofacial Surgery, Department of Oral Medicine and Surgery, Graduate School of Dentistry, Tohoku UniversitySendai, Japan
| | | | - Yoshikazu Kuwahara
- Division of Radiation Biology and Medicine, Faculty of Medicine, Tohoku Medical and Pharmaceutical UniversitySendai, Japan
| | - Tetsu Takahashi
- Division of Oral and Maxillofacial Surgery, Department of Oral Medicine and Surgery, Graduate School of Dentistry, Tohoku UniversitySendai, Japan
| | - Manabu Fukumoto
- Pathology Informatics Team, RIKEN Center for Advanced Intelligence ProjectTokyo, Japan
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14
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Yue C, Li X, Zhao W, Cui X, Wang Y. RETRACTED: The role of antibiotics in the preparation of antitumor drugs under fuzzy system. JOURNAL OF INTELLIGENT & FUZZY SYSTEMS 2020. [DOI: 10.3233/jifs-179584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This article has been retracted. A retraction notice can be found at https://doi.org/10.3233/JIFS-219320.
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Affiliation(s)
- Changwu Yue
- Yan’an Key Laboratory of Microbial Drug Innovation and Transformation, College of Medicine, Yan’an University, Yan’an, Shaanxi, China
| | - Xiaoqian Li
- Central Laboratory, Zunyi First People’s Hospital/Third Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou Province
| | - Wen Zhao
- Yan’an Key Laboratory of Microbial Drug Innovation and Transformation, College of Medicine, Yan’an University, Yan’an, Shaanxi, China
| | - Xiangyi Cui
- Yan’an Key Laboratory of Microbial Drug Innovation and Transformation, College of Medicine, Yan’an University, Yan’an, Shaanxi, China
| | - Yinyin Wang
- School of Biological Science and Technology, University of Jinan, Jinan, China
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15
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Albertini F, Matter M, Nenoff L, Zhang Y, Lomax A. Online daily adaptive proton therapy. Br J Radiol 2020; 93:20190594. [PMID: 31647313 PMCID: PMC7066958 DOI: 10.1259/bjr.20190594] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 10/15/2019] [Accepted: 10/22/2019] [Indexed: 12/11/2022] Open
Abstract
It is recognized that the use of a single plan calculated on an image acquired some time before the treatment is generally insufficient to accurately represent the daily dose to the target and to the organs at risk. This is particularly true for protons, due to the physical finite range. Although this characteristic enables the generation of steep dose gradients, which is essential for highly conformal radiotherapy, it also tightens the dependency of the delivered dose to the range accuracy. In particular, the use of an outdated patient anatomy is one of the most significant sources of range inaccuracy, thus affecting the quality of the planned dose distribution. A plan should be ideally adapted as soon as anatomical variations occur, ideally online. In this review, we describe in detail the different steps of the adaptive workflow and discuss the challenges and corresponding state-of-the art developments in particular for an online adaptive strategy.
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Affiliation(s)
| | | | | | - Ye Zhang
- Paul Scherrer Institute, Center for Proton Therapy, Switzerland
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16
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Cubillos-Mesías M, Troost EGC, Lohaus F, Agolli L, Rehm M, Richter C, Stützer K. Quantification of plan robustness against different uncertainty sources for classical and anatomical robust optimized treatment plans in head and neck cancer proton therapy. Br J Radiol 2020; 93:20190573. [PMID: 31778315 PMCID: PMC7066968 DOI: 10.1259/bjr.20190573] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 11/05/2019] [Accepted: 11/11/2019] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Classical robust optimization (cRO) in intensity-modulated proton therapy (IMPT) considers isocenter position and particle range uncertainties; anatomical robust optimization (aRO) aims to consider additional non-rigid positioning variations. This work compares the influence of different uncertainty sources on the robustness of cRO and aRO IMPT plans for head and neck squamous cell carcinoma (HNSCC). METHODS Two IMPT plans were optimized for 20 HNSCC patients who received weekly control CTs (cCT): cRO, using solely the planning CT, and aRO, including 2 additional cCTs. The robustness of the plans in terms of clinical target volume (CTV) coverage and organ at risk (OAR) sparing was analyzed considering stepwise the influence of (1) non-rigid anatomical variations given by the weekly cCT, (2) with fraction-wise added rigid random setup errors and (3) additional systematic proton range uncertainties. RESULTS cRO plans presented significantly higher nominal CTV coverage but are outperformed by aRO plans when considering non-rigid anatomical variations only, as cRO and aRO plans presented a median target coverage (D98%) decrease for the low-risk/high-risk CTV of 1.8/1.1 percentage points (pp) and -0.2 pp/-0.3 pp, respectively. Setup and range uncertainties had larger influence on cRO CTV coverage, but led to similar OAR dose changes in both plans. Considering all error sources, 10/2 cRO/aRO patients missed the CTV coverage and a limited number exceeded some OAR constraints in both plans. CONCLUSION Non-rigid anatomical variations are mainly responsible for critical target coverage loss of cRO plans, whereas the aRO approach was robust against such variations. Both plans provide similar robustness of OAR parameters. ADVANCES IN KNOWLEDGE The influence of different uncertainty sources was quantified for robust IMPT HNSCC plans.
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Affiliation(s)
- Macarena Cubillos-Mesías
- 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
| | | | | | - Linda Agolli
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Maximilian Rehm
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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17
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Lomax AJ. Myths and realities of range uncertainty. Br J Radiol 2020; 93:20190582. [PMID: 31778317 PMCID: PMC7066970 DOI: 10.1259/bjr.20190582] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 11/01/2019] [Accepted: 11/24/2019] [Indexed: 12/25/2022] Open
Abstract
Range uncertainty is a much discussed topic in proton therapy. Although a very real aspect of proton therapy, its magnitude and consequences are sometimes misunderstood or overestimated. In this article, the sources and consequences of range uncertainty are reviewed, a number of myths associated with the effect discussed with the aim of putting range uncertainty into clinical context and attempting to de-bunk some of the more exaggerated claims made as to its consequences.
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Affiliation(s)
- Antony John Lomax
- Centre for Proton Therapy, Paul Scherrer Institute, Switzerland and Department of Physics, ETH Zurich, Switzerland
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18
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Tommasino F, Widesott L, Fracchiolla F, Lorentini S, Righetto R, Algranati C, Scifoni E, Dionisi F, Scartoni D, Amelio D, Cianchetti M, Schwarz M, Amichetti M, Farace P. Clinical implementation in proton therapy of multi-field optimization by a hybrid method combining conventional PTV with robust optimization. Phys Med Biol 2020; 65:045002. [PMID: 31851957 DOI: 10.1088/1361-6560/ab63b9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
To implement a robust multi-field optimization (MFO) technique compatible with the application of a Monte Carlo (MC) algorithm and to evaluate its robustness. Nine patients (three brain, five head-and-neck, one spine) underwent proton treatment generated by a novel robust MFO technique. A hybrid (hMFO) approach was implemented, planning dose coverage on isotropic PTV compensating for setup errors, whereas range calibration uncertainties are incorporated into PTV robust optimization process. hMFO was compared with single-field optimization (SFO) and full robust multi-field optimization (fMFO), both on the nominal plan and the worst-case scenarios assessed by robustness analysis. The SFO and the fMFO plans were normalized to hMFO on CTV to obtain iso-D95 coverage, and then the organs at risk (OARs) doses were compared. On the same OARs, in the normalized nominal plans the potential impact of variable relative biological effectiveness (RBE) was investigated. hMFO reduces the number of scenarios computed for robust optimization (from twenty-one in fMFO to three), making it practicable with the application of a MC algorithm. After normalizing on D95 CTV coverage, nominal hMFO plans were superior compared to SFO in terms of OARs sparing (p < 0.01), without significant differences compared to fMFO. The improvement in OAR sparing with hMFO with respect to SFO was preserved in worst-case scenarios (p < 0.01), confirming that hMFO is as robust as SFO to physical uncertainties, with no significant differences when compared to the worst case scenarios obtained by fMFO. The dose increase on OARs due to variable RBE was comparable to the increase due to physical uncertainties (i.e. 4-5 Gy(RBE)), but without significant differences between these techniques. hMFO allows improving plan quality with respect to SFO, with no significant differences with fMFO and without affecting robustness to setup, range and RBE uncertainties, making clinically feasible the application of MC-based robust optimization.
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Affiliation(s)
- Francesco Tommasino
- Department of Physics, University of Trento, Via Sommarive, 14-38123 Povo (TN), Italy. Trento Institute for Fundamental Physics and Applications (TIFPA), National Institute for Nuclear Physics, (INFN), Povo, Italy. Author to whom any correspondence should be addressed
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19
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Liu G, Li X, Qin A, Zheng W, Yan D, Zhang S, Stevens C, Kabolizadeh P, Ding X. Improve the dosimetric outcome in bilateral head and neck cancer (HNC) treatment using spot-scanning proton arc (SPArc) therapy: a feasibility study. Radiat Oncol 2020; 15:21. [PMID: 32000817 PMCID: PMC6990547 DOI: 10.1186/s13014-020-1476-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 01/20/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND To explore the dosimetric improvement, delivery efficiency, and plan robustness for bilateral head and neck cancer (HNC) treatment utilizing a novel proton therapy technique - the spot-scanning proton arc (SPArc) therapy. METHODS We evaluated fourteen bilateral HNC patients retrospectively. Both SPArc and 3-field Intensity Modulated Proton Therapy (IMPT) plans were generated for each patient using the same robust optimization parameters. The prescription doses were 70Gy (relative biological effectiveness (RBE) for CTV_high and 60Gy[RBE] for CTV_low. Clinically significant dosimetric parameters were extracted and compared. Root-mean-square deviation dose (RMSDs) Volume Histogram(RVH) was used to evaluate the plan robustness. Total treatment delivery time was estimated based on the machine parameters. RESULTS The SPArc plan was able to provide equivalent or better robust target coverage while showed significant dosimetric improvements over IMPT in most of the organs at risk (OARs). More specifically, it reduced the mean dose of the ipsilateral parotid, contralateral parotid, and oral cavity by 25.8%(p = 0.001), 20.8%(p = 0.001) and 20.3%(p = 0.001) respectively compared to IMPT. This technique reduced D1 (the maximum dose covering 1% volume of a structure) of cord and brain stem by 20.8% (p = 0.009) and 10.7% (p = 0.048), respectively. SPArc also reduced the average integral dose by 17.2%(p = 0.001) and external V3Gy (the volume received 3Gy[RBE]) by 8.3%(p = 0.008) as well. RVH analysis showed that the SPArc plans reduced the dose uncertainties in most OARs compared to IMPT, such as cord: 1.1 ± 0.4Gy[RBE] vs 0.7 ± 0.3Gy[RBE](p = 0.001), brain stem: 0.9 ± 0.7Gy[RBE] vs 0.7 ± 0.7Gy[RBE](p = 0.019), contralateral parotid: 2.5 ± 0.5Gy[RBE] vs 2.2 ± 0.6Gy[RBE](p = 0.022) and ipsilateral parotid: 3.1 ± 0.7Gy[RBE] vs 2.8 ± 0.6Gy[RBE](p = 0.004) respectively. The average total estimated treatment delivery time were 283.4 ± 56.2 s, 469.2 ± 62.0 s and 1294.9 ± 106.7 s based on energy-layer-switching-time (ELST) of 0.1 s, 1 s, and 5 s respectively for SPArc plans, compared to the respective values of 328.0 ± 47.6 s(p = 0.002), 434.1 ± 52.0 s(p = 0.002), and 901.7 ± 74.8 s(p = 0.001) for 3-field IMPT plans. The potential clinical benefit of utilizing SPArc will lead to a decrease in the mean probability of salivary flow dysfunction by 31.3%(p = 0.001) compared with IMPT. CONCLUSIONS SPArc could significantly spare OARs while providing a similar or better robust target coverage compared with IMPT in the treatment of bilateral HNC. In the modern proton system with ELST less than 0.5 s, SPArc could potentially be implemented in the routine clinic with a practical, achievable treatment delivery efficiency.
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Affiliation(s)
- Gang Liu
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430023 China
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI 48074 USA
- School of Physics and Technology, Wuhan University, Hubei, Wuhan, 430072 China
| | - Xiaoqiang Li
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI 48074 USA
| | - An Qin
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI 48074 USA
| | - Weili Zheng
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI 48074 USA
| | - Di Yan
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI 48074 USA
| | - Sheng Zhang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430023 China
| | - Craig Stevens
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI 48074 USA
| | - Peyman Kabolizadeh
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI 48074 USA
| | - Xuanfeng Ding
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI 48074 USA
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20
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Buti G, Souris K, Montero AMB, Lee JA, Sterpin E. Towards fast and robust 4D optimization for moving tumors with scanned proton therapy. Med Phys 2019; 46:5434-5443. [DOI: 10.1002/mp.13850] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 09/11/2019] [Accepted: 09/26/2019] [Indexed: 01/02/2023] Open
Affiliation(s)
- Gregory Buti
- Institut de Recherche Expérimentale et Clinique (IREC), Center of Molecular Imaging, Radiotherapy and Oncology (MIRO) Université Catholique de Louvain Brussels 1200Belgium
| | - Kevin Souris
- Institut de Recherche Expérimentale et Clinique (IREC), Center of Molecular Imaging, Radiotherapy and Oncology (MIRO) Université Catholique de Louvain Brussels 1200Belgium
| | - Ana Maria Barragán Montero
- Institut de Recherche Expérimentale et Clinique (IREC), Center of Molecular Imaging, Radiotherapy and Oncology (MIRO) Université Catholique de Louvain Brussels 1200Belgium
| | - John Aldo Lee
- Institut de Recherche Expérimentale et Clinique (IREC), Center of Molecular Imaging, Radiotherapy and Oncology (MIRO) Université Catholique de Louvain Brussels 1200Belgium
| | - Edmond Sterpin
- Institut de Recherche Expérimentale et Clinique (IREC), Center of Molecular Imaging, Radiotherapy and Oncology (MIRO) Université Catholique de Louvain Brussels 1200Belgium
- Department of Oncology, Laboratory of Experimental Radiotherapy Katholieke Universiteit Leuven Leuven 3000Belgium
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21
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Korevaar EW, Habraken SJM, Scandurra D, Kierkels RGJ, Unipan M, Eenink MGC, Steenbakkers RJHM, Peeters SG, Zindler JD, Hoogeman M, Langendijk JA. Practical robustness evaluation in radiotherapy - A photon and proton-proof alternative to PTV-based plan evaluation. Radiother Oncol 2019; 141:267-274. [PMID: 31492443 DOI: 10.1016/j.radonc.2019.08.005] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 07/23/2019] [Accepted: 08/10/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE A planning target volume (PTV) in photon treatments aims to ensure that the clinical target volume (CTV) receives adequate dose despite treatment uncertainties. The underlying static dose cloud approximation (the assumption that the dose distribution is invariant to errors) is problematic in intensity modulated proton treatments where range errors should be taken into account as well. The purpose of this work is to introduce a robustness evaluation method that is applicable to photon and proton treatments and is consistent with (historic) PTV-based treatment plan evaluations. MATERIALS AND METHODS The limitation of the static dose cloud approximation was solved in a multi-scenario simulation by explicitly calculating doses for various treatment scenarios that describe possible errors in the treatment course. Setup errors were the same as the CTV-PTV margin and the underlying theory of 3D probability density distributions was extended to 4D to include range errors, maintaining a 90% confidence level. Scenario dose distributions were reduced to voxel-wise minimum and maximum dose distributions; the first to evaluate CTV coverage and the second for hot spots. Acceptance criteria for CTV D98 and D2 were calibrated against PTV-based criteria from historic photon treatment plans. RESULTS CTV D98 in worst case scenario dose and voxel-wise minimum dose showed a very strong correlation with scenario average D98 (R2 > 0.99). The voxel-wise minimum dose visualised CTV dose conformity and coverage in 3D in agreement with PTV-based evaluation in photon therapy. Criteria for CTV D98 and D2 of the voxel-wise minimum and maximum dose showed very strong correlations to PTV D98 and D2 (R2 > 0.99) and on average needed corrections of -0.9% and +2.3%, respectively. CONCLUSIONS A practical approach to robustness evaluation was provided and clinically implemented for PTV-less photon and proton treatment planning, consistent with PTV evaluations but without its static dose cloud approximation.
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Affiliation(s)
- Erik W Korevaar
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, The Netherlands.
| | - Steven J M Habraken
- Holland Proton Therapy Center, Delft, The Netherlands; Department of Radiation Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Daniel Scandurra
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Roel G J Kierkels
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Mirko Unipan
- Proton Therapy Centre South-East Netherlands (ZON-PTC), Maastricht, The Netherlands
| | | | - Roel J H M Steenbakkers
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Stephanie G Peeters
- Proton Therapy Centre South-East Netherlands (ZON-PTC), Maastricht, The Netherlands
| | - Jaap D Zindler
- Holland Proton Therapy Center, Delft, The Netherlands; Department of Radiation Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Mischa Hoogeman
- Holland Proton Therapy Center, Delft, The Netherlands; Department of Radiation Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Johannes A Langendijk
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, The Netherlands
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22
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Cubillos-Mesías M, Troost EG, Lohaus F, Agolli L, Rehm M, Richter C, Stützer K. Including anatomical variations in robust optimization for head and neck proton therapy can reduce the need of adaptation. Radiother Oncol 2019; 131:127-134. [DOI: 10.1016/j.radonc.2018.12.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 10/29/2018] [Accepted: 12/05/2018] [Indexed: 10/27/2022]
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23
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Intensity modulated proton therapy (IMPT) - The future of IMRT for head and neck cancer. Oral Oncol 2018; 88:66-74. [PMID: 30616799 DOI: 10.1016/j.oraloncology.2018.11.015] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 11/11/2018] [Accepted: 11/12/2018] [Indexed: 12/13/2022]
Abstract
Radiation therapy plays an integral role in the management of head and neck cancers (HNCs). While most HNC patients have historically been treated with photon-based radiation techniques such as intensity modulated radiation therapy (IMRT), there is a growing awareness of the potential clinical benefits of proton therapy over IMRT in the definitive, postoperative and reirradiation settings given the unique physical properties of protons. Intensity modulated proton therapy (IMPT), also known as "pencil beam proton therapy," is a sophisticated mode of proton therapy that is analogous to IMRT and an active area of investigation in cancer care. Multifield optimization IMPT allows for high quality plans that can target superficially located HNCs as well as large neck volumes while significantly reducing integral doses. Several dosimetric studies have demonstrated the superiority of IMPT over IMRT to improve dose sparing of nearby organs such as the larynx, salivary glands, and esophagus. Evidence of the clinical translation of these dosimetric advantages has been demonstrated with documented toxicity reductions (such as decreased feeding tube dependency) after IMPT for patients with HNCs. While there are relative challenges to IMPT planning that exist today such as particle range uncertainties and high sensitivity to anatomical changes, ongoing investigations in image-guidance techniques and robust optimization methods are promising. A systematic approach towards utilizing IMPT and additional prospective studies are necessary in order to more accurately estimate the clinical benefit of IMPT over IMRT and passive proton therapy on a case-by-case basis for patients with sub-site specific HNCs.
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Unkelbach J, Alber M, Bangert M, Bokrantz R, Chan TCY, Deasy JO, Fredriksson A, Gorissen BL, van Herk M, Liu W, Mahmoudzadeh H, Nohadani O, Siebers JV, Witte M, Xu H. Robust radiotherapy planning. ACTA ACUST UNITED AC 2018; 63:22TR02. [DOI: 10.1088/1361-6560/aae659] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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