Is Mini Beam Ready for Human Trials? Results of Randomized Study of Treating De-Novo Brain Tumors in Canines Using Linear Accelerator Generated Mini Beams

Design and validation of a minibeam treatment delivery system for use with a radiation therapy research platform

Minibeam radiation therapy (MBRT) is a promising treatment technique in the early stages of clinical use. In this work, two hexagonal minibeam collimators were designed, fabricated, and validated using film measurements and Monte Carlo simulations. Film and Monte Carlo results demonstrated strong agreement, with the greatest agreement near the beam central axis. One of the previously validated MBRT collimators was then modified to allow for dose calculations on a mouse cone beam computed tomography (CBCT) dataset, and a MBRT dose distribution was preserved in the animal dataset. This validated system can be used in future cell and small animal studies to further explore MBRT in a preclinical setting.

Carbon minibeam radiation therapy results in tumor growth delay in an osteosarcoma murine model

Despite remarkable advances, radiation therapy (RT) remains inefficient for some bulky tumors, radioresistant tumors, and certain pediatric tumors. Minibeam radiation therapy (MBRT) has emerged as a promising approach, reducing normal tissue toxicity while enhancing immune responses. Preclinical studies using X-rays and proton MBRT have demonstrated enhanced therapeutic index for aggressive tumor models. Combining MBRT's advantages of spatial dose fractionation with the physical and biological benefits of carbon ions could be a step further toward unleashing the full potential of MBRT. This study aims to perform the first in vivo study of local and systemic responses of a subcutaneous mouse osteosarcoma (metastatic) model to carbon MBRT (C-MBRT) versus conventional carbon ion therapy (CT). Irradiations were conducted at the GSI Helmholtz Centre in Germany using 180 MeV/u 12C ions beam. All irradiated animals received an average dose (20 Gy) and displayed a significant and similar tumor growth delay in addition to a decreased metastasis score compared to the non-irradiated group. In the C-MBRT group, 70% of the tumor volume received the valley dose, which is a very low dose of 1.5 Gy. The remaining 30% of the tumor received the peak dose of 105 Gy, resulting in an average dose of 20 Gy. These results suggest that C-MBRT triggered distinct mechanisms from CT and encourage further investigations to confirm the potential of C-MBRT for efficient treatment of radioresistant tumors.

Proton minibeam (pMBRT) radiation therapy: experimental validation of Monte Carlo dose calculation in the RayStation TPS

Background.Proton minibeam radiation therapy (pMBRT) is a spatially fractionated radiation therapy modality that uses a multi-slit collimator (MSC) to create submillimeter slit openings for spatial dose modulation. The pMBRT dose profile is characterized by highly heterogeneous dose in the plane perpendicular to the beam and rapidly changing depth dose profiles. Dose measurements are typically benchmarked against in-house Monte Carlo (MC) simulation tools. For preclinical and clinical translation, a treatment planning system (TPS) capable of accurately predicting pMBRT doses in tissue and accessible on a commercial platform is essential. This study focuses on the beam modeling and verification of pMBRT using the RayStation TPS, a critical step in advancing its clinical implementation.Methods.The pMBRT system was implemented in RayStation for the IBA Proteus®ONE single-room compact proton machine. The RayStation pMBRT model is an extension of the clinical beam model, allowing pMBRT dose calculations through the MSC using the existing clinical beam model. Adjustable MSC parameters include air gap, slit thickness, slit pitch, number of slits, slits direction and slit thickness. The pMBRT TPS was validated experimentally against measurements using six different collimators with various slit widths (0.4-1.4 mm) and center-to-center slit distances (2.8-4.0 mm). Each collimator comprised five non-divergent slits. Validation involved MatriXX measurements for average dose, Gafchromic film placed at varying depths to measure lateral dose profiles, and film placed along the beam axis to measure depth-dose curves in solid water phantoms. A single 150 MeV energy layer with a 0.5 cm spot spacing was used to create a uniform radiation map across the MSC field.Results.The comparison of average depth dose measurements with RayStation MC calculations showed a gamma passing rate better than 95% using 3 mm/3% criteria, except for the 0.4 mm slit width. After adjusting the slit width by 40-60μm to account for machining uncertainties, the gamma passing rate exceeded 95% under the same criteria. For the peaks and valleys of the percentage depth doses, agreement between RayStation and film measurements was above 90% using 2 mm/5% criteria, except in the high linear energy transfer region. Lateral profile comparisons at depths of 2, 6, and 10 cm demonstrated over 90% agreement for all curves using 0.2 mm/5% criteria.Conclusions.The pMBRT beam model for the Proteus®ONE-based system has been successfully implemented in RayStation TPS, with its initial accuracy validated experimentally. Further measurements, including additional energies and Spread Out Bragg Peaks, are required to complete the clinical commissioning process.

Synchrotron-based infrared microspectroscopy unveils the biomolecular response of healthy and tumour cell lines to neon minibeam radiation therapy

Radioresistant tumours remain complex to manage with current radiotherapy (RT) techniques. Heavy ion beams were proposed for their treatment given their advantageous radiobiological properties. However, previous studies with patients resulted in serious adverse effects in the surrounding healthy tissues. Heavy ion RT could therefore benefit from the tissue-sparing effects of minibeam radiation therapy (MBRT). To investigate the potential of this combination, here we assessed the biochemical response to neon MBRT (NeMBRT) through synchrotron-based Fourier transform infrared microspectroscopy (SR-FTIRM). Healthy (BJ) and tumour (B16-F10) cell lines were subjected to seamless (broad beam) neon RT (NeBB) and NeMBRT at HIMAC. SR-FTIRM measurements were conducted at the MIRAS beamline of ALBA Synchrotron. Principal component analysis (PCA) permitted to assess the biochemical effects after the irradiations and 24 hours post-irradiation for the different RT modalities and doses. For the healthy cells, NeMBRT resulted in the most dissimilar spectral signatures from non-irradiated cells early after irradiations, mainly due to protein conformational modifications. Nevertheless, most of the damage appeared to recover one day post-RT; conversely, protein- and nucleic acid-related IR bands were strongly affected by NeBB 24 hours after treatment, suggesting superior oxidative damage and nucleic acid degradation. Tumour cells appeared to be less sensitive to NeBB than to NeMBRT shortly after RT. Still, after one day, both NeBB and the high-dose NeMBRT regions yielded important spectral modifications, suggestive of cell death processes, protein oxidation or oxidative stress. Lipid-associated spectral changes, especially due to the NeBB and NeMBRT peak groups for the tumour cell line, were consistent with reactive oxygen species attacks.

The significance of dose heterogeneity on the anti-tumor response of minibeam radiation therapy

BACKGROUND AND PURPOSE

Proton Minibeam Radiation Therapy (pMBRT) is an unconventional radiation technique based on a strong modulation of the dose deposition. Due to its specific pattern, pMBRT involves several dosimetry (peak and valley doses, peak-to-valley dose ratio (PVDR)) and geometrical parameters (beam width, spacing) that can influence the biological response. This study aims at contributing to the efforts to deepen the comprehension of how the various parameters relate to central biological mechanisms, particularly anti-tumor immunity, and how these correlations affect treatment outcomes with the goal to fully unleash the potential of pMBRT. We also evaluated the effects of X-ray MBRT to further elucidate the influence of peak dose and dose heterogeneity.

METHODS AND MATERIALS

An orthotopic rat model of glioblastoma underwent several pMBRT configurations. The impact of different dosimetric parameters on survival and on the modulation of crucial mechanisms for pMBRT, such as immune response, was investigated. The latter was assessed by immunohistochemistry and flow cytometry at 7 days post-irradiation.

RESULTS

Survival was improved across the various pMBRT regimens via maintaining a minimum valley dose as well as a higher dose heterogeneity, which is driven by peak dose. While the mean dose did not impact immune infiltration, a higher PVDR promoted a less immunosuppressive microenvironment.

CONCLUSIONS

Our results suggest that both tumor eradication, and immune infiltration are associated with higher dose heterogeneity. Higher dose heterogeneity was achieved by optimizing the peak dose, as well as maintaining a minimum valley dose. These parameters contributed to direct tumor eradication as well as reduction of immunosuppression, which is a departure from the more immunosuppressive tumor environment found in conventional proton therapy that delivers uniform dose distributions.

Particle Beam Radiobiology Status and Challenges: A PTCOG Radiobiology Subcommittee Report

Particle therapy (PT) represents a significant advancement in cancer treatment, precisely targeting tumor cells while sparing surrounding healthy tissues thanks to the unique depth-dose profiles of the charged particles. Furthermore, their linear energy transfer and relative biological effectiveness enhance their capability to treat radioresistant tumors, including hypoxic ones. Over the years, extensive research has paved the way for PT's clinical application, and current efforts aim to refine its efficacy and precision, minimizing the toxicities. In this regard, radiobiology research is evolving toward integrating biotechnology to advance drug discovery and radiation therapy optimization. This shift from basic radiobiology to understanding the molecular mechanisms of PT aims to expand the therapeutic window through innovative dose delivery regimens and combined therapy approaches. This review, written by over 30 contributors from various countries, provides a comprehensive look at key research areas and new developments in PT radiobiology, emphasizing the innovations and techniques transforming the field, ranging from the radiobiology of new irradiation modalities to multimodal radiation therapy and modeling efforts. We highlight both advancements and knowledge gaps, with the aim of improving the understanding and application of PT in oncology.

Dosimetric study for breathing-induced motion effects in an abdominal pancreas phantom for carbon ion mini-beam radiotherapy

BACKGROUND

Particle mini-beam therapy exhibits promise in sparing healthy tissue through spatial fractionation, particularly notable for heavy ions, further enhancing the already favorable differential biological effectiveness at both target and entrance regions. However, breathing-induced organ motion affects particle mini-beam irradiation schemes since the organ displacements exceed the mini-beam structure dimensions, decreasing the advantages of spatial fractionation.

PURPOSE

In this study, the impact of breathing-induced organ motion on the dose distribution was examined at the target and organs at risk(OARs) during carbon ion mini-beam irradiation for pancreatic cancer.

METHODS

As a first step, the carbon ion mini-beam pattern was characterized with Monte Carlo simulations. To analyze the impact of breathing-induced organ motion on the dose distribution of a virtual pancreas tumor as target and related OARs, the anthropomorphic Pancreas Phantom for Ion beam Therapy (PPIeT) was irradiated with carbon ions. A mini-beam collimator was used to deliver a spatially fractionated dose distribution. During irradiation, varying breathing motion amplitudes were induced, ranging from 5 to 15 mm. Post-irradiation, the 2D dose pattern was analyzed, focusing on the full width at half maximum (FWHM), center-to-center distance (ctc), and the peak-to-valley dose ratio (PVDR).

RESULTS

The mini-beam pattern was visible within OARs, while in the virtual pancreas tumor a more homogeneous dose distribution was achieved. Applied motion affected the mini-beam pattern within the kidney, one of the OARs, reducing the PVDR from 3.78  ± $\pm$  0.12 to 1.478  ± $\pm$  0.070 for the 15 mm motion amplitude. In the immobile OARs including the spine and the skin at the back, the PVDR did not change within 3.4% comparing reference and motion conditions.

CONCLUSIONS

This study provides an initial understanding of how breathing-induced organ motion affects spatial fractionation during carbon ion irradiation, using an anthropomorphic phantom. A decrease in the PVDR was observed in the right kidney when breathing-induced motion was applied, potentially increasing the risk of damage to OARs. Therefore, further studies are needed to explore the clinical viability of mini-beam radiotherapy with carbon ions when irradiating abdominal regions.

Neuro-Oncologic Veterinary Trial for the Clinical Transfer of Microbeam Radiation Therapy: Acute to Subacute Radiotolerance after Brain Tumor Irradiation in Pet Dogs

Synchrotron Microbeam Radiation Therapy (MRT) has repeatedly proven its superiority compared with conventional radiotherapy for glioma control in preclinical research. The clinical transfer phase of MRT has recently gained momentum; seven dogs with suspected glioma were treated under clinical conditions to determine the feasibility and safety of MRT. We administered a single fraction of 3D-conformal, image-guided MRT. Ultra-high-dose rate synchrotron X-ray microbeams (50 µm-wide, 400 µm-spaced) were delivered through five conformal irradiation ports. The PTV received ~25 Gy peak dose (within microbeams) per port, corresponding to a minimal cumulated valley dose (diffusing between microbeams) of 2.8 Gy. The dogs underwent clinical and MRI follow-up, and owner evaluations. One dog was lost to follow-up. Clinical exams of the remaining six dogs during the first 3 months did not indicate radiotoxicity induced by MRT. Quality of life improved from 7.3/10 [±0.7] to 8.9/10 [±0.3]. Tumor-induced seizure activity decreased significantly. A significant tumor volume reduction of 69% [±6%] was reached 3 months after MRT. Our study is the first neuro-oncologic veterinary trial of 3D-conformal Synchrotron MRT and reveals that MRT does not induce acute to subacute radiotoxicity in normal brain tissues. MRT improves quality of life and leads to remarkable tumor volume reduction despite low valley dose delivery. This trial is an essential step towards the forthcoming clinical application of MRT against deep-seated human brain tumors.

Spatially Fractionated Radiotherapy in the Era of Immunotherapy

Spatially fractionated radiotherapy (SFRT) includes historical grid therapy approaches but more recently encompasses the controlled introduction of one or more cold dose regions using intensity modulation delivery techniques. The driving hypothesis behind SFRT is that it may allow for an increased immune response that is otherwise suppressed by radiation effects. With both two- and three-dimensional SFRT approaches, SFRT dose distributions typically include multiple dose cold spots or valleys. Despite its unconventional methods, reported clinical experience shows that SFRT can sometimes induce marked tumor regressions, even in patients with large hypoxic tumors. Preclinical models using extreme dose distributions (i.e., half-sparing) have been shown to nevertheless result in full tumor eradications, a more robust immune response, and systemic anti-tumor immunity. SFRT takes advantage of the complementary immunomodulatory features of low- and high-dose radiotherapy to integrate the delivery of both into a single target. Clinical trials using three-dimensional SFRT (i.e., lattice-like dose distributions) have reported both promising tumor and toxicity results, and ongoing clinical trials are investigating synergy between SFRT and immunotherapies.

The Story Behind the First Mini-BEAM Photon Radiation Treatment: What is the Mini-Beam and Why is it Such an Advance?

Radiation treatment has been the cornerstone in cancer management. However, long term treatment-related morbidity always accompanies tumor control which has significant impact on quality of life of the patient who has survived the cancer. Spatially fractionated radiation has the potential to achieve both cure and to avoid dreaded long term sequelae. The first ever randomized study of mini-beam radiation treatment (MBRT) of canine brain tumor has clearly shown the ability to achieve this goal. Dogs have gyrencephalic brains functionally akin to human brain. We here report long term follow-up and final outcome of the dogs, revealing both tumor control and side effects on normal brain. The results augur potential for conducting human studies with MBRT.

Design and characterisation of a minibeam collimator utilising Monte Carlo simulation and a clinical linear accelerator

Objective.Spatially fractionated radiotherapy is showing promise as a treatment modality. Initial focus was on beams of photons at low energy produced from a synchrotron but more recently research has expanded to include applications in proton therapy. Interest in photon beams remains and this is the focus of this paperApproach.This study presents a 3D printed tungsten minibeam collimator intended to produce peak-to-valley dose ratios (PVDR) of between seven and ten with a 1 MV, bremsstrahlung generated, photon beam. The design of the collimator is motivated by a Monte Carlo study estimating the PVDR for different collimator designs at different energies. This collimator was characterised on a clinical linear accelerator (Elekta VersaHD) as well as an orthovoltage unit.Main results.The performance of the fabricated collimator was measured on Elekta VersaHD running in unflattened mode with a 6 MV beam. On the Elekta VersaHD units the PVDR was measured to be between approximately 1.5 and 2.0 at 3 cm deep. For measurements with the orthovoltage unit PVDRs of greater than 10 were observed at a depth of 4 cm.Significance.The results confirmed that the predictions from simulation could be reproduced on linear accelerators currently in clinical usage, producing PVDRs between 2-2.5. Using the model to predict PVDRs using 1 MV photon beams, the threshold considered to produce enhanced normal tissue dose tolerance (>7) was surpassed. This suggests the possibility of using such techniques with versions of existing Linac technology which have been modified to operate at low energy and high beam currents.

Investigating the biochemical response of proton minibeam radiation therapy by means of synchrotron-based infrared microspectroscopy

The biology underlying proton minibeam radiation therapy (pMBRT) is not fully understood. Here we aim to elucidate the biological effects of pMBRT using Fourier Transform Infrared Microspectroscopy (FTIRM). In vitro (CTX-TNA2 astrocytes and F98 glioma rat cell lines) and in vivo (healthy and F98-bearing Fischer rats) irradiations were conducted, with conventional proton radiotherapy and pMBRT. FTIRM measurements were performed at ALBA Synchrotron, and multivariate data analysis methods were employed to assess spectral differences between irradiation configurations and doses. For astrocytes, the spectral regions related to proteins and nucleic acids were highly affected by conventional irradiations and the high-dose regions of pMBRT, suggesting important modifications on these biomolecules. For glioma, pMBRT had a great effect on the nucleic acids and carbohydrates. In animals, conventional radiotherapy had a remarkable impact on the proteins and nucleic acids of healthy rats; analysis of tumour regions in glioma-bearing rats suggested major nucleic acid modifications due to pMBRT.

Spatially fractionated radiation therapy: a critical review on current status of clinical and preclinical studies and knowledge gaps

Spatially fractionated radiation therapy (SFRT) is a therapeutic approach with the potential to disrupt the classical paradigms of conventional radiation therapy. The high spatial dose modulation in SFRT activates distinct radiobiological mechanisms which lead to a remarkable increase in normal tissue tolerances. Several decades of clinical use and numerous preclinical experiments suggest that SFRT has the potential to increase the therapeutic index, especially in bulky and radioresistant tumors. To unleash the full potential of SFRT a deeper understanding of the underlying biology and its relationship with the complex dosimetry of SFRT is needed. This review provides a critical analysis of the field, discussing not only the main clinical and preclinical findings but also analyzing the main knowledge gaps in a holistic way.

Development and characterization of a versatile mini-beam collimator for pre-clinical photon beam irradiation

BACKGROUND

Interest in spatial fractionation radiotherapy has exponentially increased over the last decade as a significant reduction of healthy tissue toxicity was observed by mini-beam irradiation. Published studies, however, mostly use rigid mini-beam collimators dedicated to their exact experimental arrangement such that changing the setup or testing new mini-beam collimator configurations becomes challenging and expensive.

PURPOSE

In this work, a versatile, low-cost mini-beam collimator was designed and manufactured for pre-clinical applications with X-ray beams. The mini-beam collimator enables variability of the full width at half maximum (FWHM), the center-to-center distance (ctc), the peak-to-valley dose ratio (PVDR), and the source-to-collimator distance (SCD).

METHODS

The mini-beam collimator is an in-house development, which was constructed of 10 ×  40 mm2 tungsten or brass plates. These metal plates were combined with 3D-printed plastic plates that can be stacked together in the desired order. A standard X-ray source was used for the dosimetric characterization of four different configurations of the collimator, including a combination of plastic plates of 0.5, 1, or 2 mm width, assembled with 1 or 2 mm thick metal plates. Irradiations were done at three different SCDs for characterizing the performance of the collimator. For the SCDs closer to the radiation source, the plastic plates were 3D-printed with a dedicated angle to compensate for the X-ray beam divergence, making it possible to study ultra-high dose rates of around 40 Gy/s. All dosimetric quantifications were performed using EBT-XD films. Additionally, in vitro studies with H460 cells were carried out.

RESULTS

Characteristic mini-beam dose distributions were obtained with the developed collimator using a conventional X-ray source. With the exchangeable 3D-printed plates, FWHM and ctc from 0.52 to 2.11 mm, and from 1.77 to 4.61 mm were achieved, with uncertainties ranging from 0.01% to 8.98%, respectively. The FWHM and ctc obtained with the EBT-XD films are in agreement with the design of each mini-beam collimator configuration. For dose rates in the order of several Gy/min, the highest PVDR of 10.09 ± 1.08 was achieved with a collimator configuration of 0.5 mm thick plastic plates and 2 mm thick metal plates. Exchanging the tungsten plates with the lower-density metal brass reduced the PVDR by approximately 50%. Also, increasing the dose rate to ultra-high dose rates was feasible with the mini-beam collimator, where a PVDR of 24.26 ± 2.10 was achieved. Finally, it was possible to deliver and quantify mini-beam dose distribution patterns in vitro.

CONCLUSIONS

With the developed collimator, we achieved various mini-beam dose distributions that can be adjusted according to the needs of the user in regards to FWHM, ctc, PVDR and SCD, while accounting for beam divergence. Therefore, the designed mini-beam collimator may enable low-cost and versatile pre-clinical research on mini-beam irradiation.

Novel unconventional radiotherapy techniques: Current status and future perspectives - Report from the 2nd international radiation oncology online seminar

•Improvement of therapeutic ratio by novel unconventional radiotherapy approaches.•Immunomodulation using high-dose spatially fractionated radiotherapy.•Boosting radiation anti-tumor effects by adding an immune-mediated cell killing.

Challenges in radiobiology - technology duality as a key for a risk-free α/β ratio

Since radiotherapy discovery, prediction of biological response to ionizing radiation remains a major challenge. Indeed, several radiobiological models appeared through radiotherapy history. Nominal single dose so popular in the 1970s, was tragically linked to the dark years in radiobiology by underestimating the late toxicity of the high-dose fractions. The actual prominent linear-quadratic model continues to prove to be an effective tool in radiobiology. Mainly with its pivotal α/β ratio, which gives a reliable estimate of tissues sensitivity to fractions. Despite these arguments, this model experiences limitations with substantial doubts of α/β ratio values. Interestingly, the story of radiobiology since X-ray discovery is truly instructive and teaches modern clinicians to refine fractionation schemes. Many fractionation schemes have been tested with successes or dramas. This review retraces radiobiological models' history, and confronts these models to new fractionation schemes, drawing a preventive message.