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Trofimov AV, Aronow ME, Gragoudas ES, Keane FK, Kim IK, Shih HA, Bhagwat MS. A Systematic Comparison of Dose Distributions Delivered in 125I Plaque Brachytherapy and Proton Radiation Therapy for Ocular Melanoma. Int J Radiat Oncol Biol Phys 2023; 115:501-510. [PMID: 35878716 DOI: 10.1016/j.ijrobp.2022.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 07/06/2022] [Accepted: 07/13/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE To characterize dose distributions with 125I plaque brachytherapy compared with proton radiation therapy for ocular melanoma for relevant clinical scenarios, based on tumor base diameter (d), apical height (h), and location. METHODS AND MATERIALS Plaque and proton treatment plans were created for 4 groups of cases: (1) REF: 39 instances of reference midsize circular-base tumor (d = 12 mm, h = 5 mm), in locations varying by retinal clock hours and distance to fovea, optic disc, and corneal limbus; (2) SUP: 25 superiorly located; (3) TEMP: 25 temporal; and (4) NAS: 25 nasally located tumors that were a fixed distance from the fovea but varying in d (6-18 mm) and h (3-11 mm). For both modalities, 111 unique scenarios were characterized in terms of the distance to points of interest, doses delivered to fovea, optic disc, optic nerve at 3 mm posterior to the disc (ON@3mm), lens, and retina. Comparative statistical evaluation was performed with the Mann-Whitney U test. RESULTS Superior dose distributions favored plaque for sparing of (1) fovea in large (d + h ≥ 21 mm) NAS tumors; (2) ON@3mm in REF cases located ≤4 disc diameters from disc, and in NAS overall. Protons achieved superior dose sparing of (1) fovea and optic disc in REF, SUP, and TEMP; (2) ON@3mm in REF >4 disc diameters from disc, and in SUP and TEMP; and (3) the lens center overall and lens periphery in REF ≤6 mm from the corneal limbus, and in TEMP with h = 3 mm. Although protons could completely spare sections of the retina, plaque dose was more target conformal in the high-dose range (50% and 90% of prescription dose). CONCLUSIONS Although comparison between plaque and proton therapy is not straightforward because of the disparity in dose rate, prescriptions, applicators, and delivery techniques, it is possible to identify distinctions between dose distributions, which could help inform decisions by providers and patients.
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Affiliation(s)
- Alexei V Trofimov
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Mary E Aronow
- Ocular Melanoma Center, Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Evangelos S Gragoudas
- Ocular Melanoma Center, Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Florence K Keane
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ivana K Kim
- Ocular Melanoma Center, Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Helen A Shih
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Mandar S Bhagwat
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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2
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Hérault J, Gérard A, Carnicer A, Aloi D, Peyrichon ML, Barnel C, Vidal M, Angellier G, Fayaud D, Grini JC, Giusto A, Armando C, Donadey G, Cabannes M, Dumas S, Payan Y, Di Carlo JF, Salicis C, Bergerot JM, Rolion M, Trimaud R, Hofverberg P, Mandrillon P, Sauerwein W, Thariat J. 30 years of ocular proton therapy, the Nice view. Cancer Radiother 2022; 26:1016-1026. [PMID: 35803860 DOI: 10.1016/j.canrad.2022.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/15/2022] [Indexed: 11/08/2022]
Abstract
PURPOSE Radiotherapy with protons (PT) is a standard treatment of ocular tumors. It achieves excellent tumor control, limited toxicities, and the preservation of important functional outcomes, such as vision. Although PT may appear as one homogenous technique, it can be performed using dedicated ocular passive scattering PT or, increasingly, Pencil Beam Scanning (PBS), both with various degrees of patient-oriented customization. MATERAIAL AND METHODS MEDICYC PT facility of Nice are detailed with respect to their technical, dosimetric, microdosimetric and radiobiological, patient and tumor-customization process of PT planning and delivery that are key. 6684 patients have been treated for ocular tumors (1991-2020). Machine characteristics (accelerator, beam line, beam monitoring) allow efficient proton extraction, high dose rate, sharp lateral and distal penumbrae, and limited stray radiation in comparison to beam energy reduction and subsequent straggling with high-energy PBS PT. Patient preparation before PT includes customized setup and image-guidance, CT-based planning, and ocular PT software modelling of the patient eye with integration of beam modifiers. Clinical reports have shown excellent tumor control rates (∼95%), vision preservation and limited toxicity rates (papillopathy, retinopathy, neovascular glaucoma, dry eye, madarosis, cataract). RESULTS Although demanding, dedicated ocular PT has proven its efficiency in achieving excellent tumor control, OAR sparing and patient radioprotection. It is therefore worth adaptations of the equipments and practice. CONCLUSIONS Some of these adaptations can be transferred to other PT centers and should be acknowledeged when using non-PT options.
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Affiliation(s)
- J Hérault
- Institut Méditerranéen de ProtonThérapie, Centre Antoine Lacassagne, 227, avenue de la Lanterne, 06200 Nice, France.
| | - A Gérard
- Institut Méditerranéen de ProtonThérapie, Centre Antoine Lacassagne, 227, avenue de la Lanterne, 06200 Nice, France
| | - A Carnicer
- IDOM Consulting, Engineering, Architecture, Avinguda de la Fama, 11-15, Arboretum Business Park, Arce Building, 08940 Cornellà de Llobregat, Barcelona, Spain
| | - D Aloi
- Institut Méditerranéen de ProtonThérapie, Centre Antoine Lacassagne, 227, avenue de la Lanterne, 06200 Nice, France
| | - M-L Peyrichon
- Institut Méditerranéen de ProtonThérapie, Centre Antoine Lacassagne, 227, avenue de la Lanterne, 06200 Nice, France
| | - C Barnel
- Institut Méditerranéen de ProtonThérapie, Centre Antoine Lacassagne, 227, avenue de la Lanterne, 06200 Nice, France
| | - M Vidal
- Institut Méditerranéen de ProtonThérapie, Centre Antoine Lacassagne, 227, avenue de la Lanterne, 06200 Nice, France
| | - G Angellier
- Institut Méditerranéen de ProtonThérapie, Centre Antoine Lacassagne, 227, avenue de la Lanterne, 06200 Nice, France
| | - D Fayaud
- Institut Méditerranéen de ProtonThérapie, Centre Antoine Lacassagne, 227, avenue de la Lanterne, 06200 Nice, France
| | - J-C Grini
- Institut Méditerranéen de ProtonThérapie, Centre Antoine Lacassagne, 227, avenue de la Lanterne, 06200 Nice, France
| | - A Giusto
- Institut Méditerranéen de ProtonThérapie, Centre Antoine Lacassagne, 227, avenue de la Lanterne, 06200 Nice, France
| | - C Armando
- Institut Méditerranéen de ProtonThérapie, Centre Antoine Lacassagne, 227, avenue de la Lanterne, 06200 Nice, France
| | - G Donadey
- Institut Méditerranéen de ProtonThérapie, Centre Antoine Lacassagne, 227, avenue de la Lanterne, 06200 Nice, France
| | - M Cabannes
- Institut Méditerranéen de ProtonThérapie, Centre Antoine Lacassagne, 227, avenue de la Lanterne, 06200 Nice, France
| | - S Dumas
- Institut Méditerranéen de ProtonThérapie, Centre Antoine Lacassagne, 227, avenue de la Lanterne, 06200 Nice, France
| | - Y Payan
- Institut Méditerranéen de ProtonThérapie, Centre Antoine Lacassagne, 227, avenue de la Lanterne, 06200 Nice, France
| | - J-F Di Carlo
- Institut Méditerranéen de ProtonThérapie, Centre Antoine Lacassagne, 227, avenue de la Lanterne, 06200 Nice, France
| | - C Salicis
- Institut Méditerranéen de ProtonThérapie, Centre Antoine Lacassagne, 227, avenue de la Lanterne, 06200 Nice, France
| | - J-M Bergerot
- Institut Méditerranéen de ProtonThérapie, Centre Antoine Lacassagne, 227, avenue de la Lanterne, 06200 Nice, France
| | - M Rolion
- Institut Méditerranéen de ProtonThérapie, Centre Antoine Lacassagne, 227, avenue de la Lanterne, 06200 Nice, France
| | - R Trimaud
- Institut Méditerranéen de ProtonThérapie, Centre Antoine Lacassagne, 227, avenue de la Lanterne, 06200 Nice, France
| | - P Hofverberg
- Institut Méditerranéen de ProtonThérapie, Centre Antoine Lacassagne, 227, avenue de la Lanterne, 06200 Nice, France
| | - P Mandrillon
- AIMA Development, 227, avenue de la Lanterne, 06200 Nice, France
| | - W Sauerwein
- NCTeam, Strahlenklinik, Universitätsklinikum Essen, Hufelandstraße 55, 45122 Essen, Germany
| | - J Thariat
- Department of Radiation Oncology, Centre François Baclesse, 14000 Caen, France; Laboratoire de Physique Corpusculaire IN2P3/ENSICAEN-UMR6534-Unicaen-Normandie Université, 14000 Caen, France
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3
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Gerard A, Peyrichon M, Vidal M, Barnel C, Sauerwein W, Carnicer A, Angellier G, Mathis T, Mishra K, Thariat J, Herault J. Ocular proton therapy, pencil beam scanning high energy proton therapy or stereotactic radiotherapy for uveal melanoma; an in silico study. Cancer Radiother 2022; 26:1027-1033. [PMID: 35803862 DOI: 10.1016/j.canrad.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 03/23/2022] [Accepted: 03/30/2022] [Indexed: 11/15/2022]
Abstract
PURPOSE In radiotherapy, the dose and volumes of the irradiated normal tissues is correlated to the complication rate. We assessed the performances of low-energy proton therapy (ocular PT) with eye-dedicated equipment, high energy PT with pencil-beam scanning (PBS) or CyberKnifeR -based stereotactic irradiation (SBRT). MATERIAL AND METHODS CT-based comparative dose distribution between external beam radiotherapy techniques was assessed using an anthropomorphic head phantom. The prescribed dose was 60Gy_RBE in 4 fractions to a typical posterior pole uveal melanoma. Clinically relevant structures were delineated, and doses were calculated using radiotherapy treatment planning softwares and measured using Gafchromic dosimetry films inserted at the ocular level. RESULTS Precision was significantly better with ocular PT than both PBS or SBRT in terms of beam penumbra (80%-20%: laterally 1.4 vs. ≥10mm, distally 0.8 vs. ≥2.5mm). Ocular PT duration was shorter, allowing eye gating and lid sparing more easily. Tumor was excellent with all modalities, but ocular PT resulted in more homogenous and conformal dose compared to PBS or SBRT. The maximal dose to ocular/orbital structures at risk was smaller and often null with ocular PT compared to other modalities. Mean dose to ocular/orbital structures was also lower with ocular PT. Structures like the lids and lacrimal punctum could be preserved with ocular PT using gaze orientation and lid retractors, which is easier to implement clinically than with the other modalities. The dose to distant organs was null with ocular PT and PBS, in contrast to SBRT. CONCLUSIONS ocular PT showed significantly improved beam penumbra, shorter treatment delivery time, better dose homogeneity, and reduced maximal/mean doses to critical ocular structures compared with other current external beam radiation modalities. Similar comparisons may be warranted for other tumor presentations.
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Fleury E, Trnková P, van Rij C, Rodrigues M, Klaver Y, Spruijt K, Naus N, Zolnay A, Pignol JP, Kiliç E, Hoogeman MS. Improving Organs-at-Risk Sparing for Choroidal Melanoma Patients: A CT-based Two-Beam Strategy in Ocular Proton Therapy with a Dedicated Eyeline. Radiother Oncol 2022; 171:173-181. [PMID: 35487435 DOI: 10.1016/j.radonc.2022.04.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 04/20/2022] [Accepted: 04/21/2022] [Indexed: 01/15/2023]
Abstract
PURPOSE To investigate the potential clinical benefit of a two-beam arrangement technique using three-dimensional (3D) imaging of uveal melanoma (UM) patients treated with proton therapy and a dedicated eyeline. MATERIAL/METHODS Retrospective CT-based treatment plans of 39 UM patients performed using a single beam (SB) were compared to plans with two beams (TB) optimized for better trade-offs in organs-at-risk sparing. The RBE-weighted prescribed dose was 60 Gy (DRBE, GTV = 60 Gy) in four fractions, assuming an RBE of 1.1. Dosimetric findings were analyzed for three patient groups based on tumor-optic nerve distance and UM staging (group GrA: ≤ 3 mm, T1 T2 UM; GrB: ≤ 3 mm, T3 UM; GrC: > 3 mm, T1 T2 T3 UM). Finally, two schedules were compared on biologically effective dose (BED): both beams being delivered either the same day (TB) or on alternate days (TBalter). RESULTS All strategies resulted in dosimetrically acceptable plans. A dose reduction to the anterior structures was achieved in 23/39 cases with the two-beam plans. D25% was significantly lowered compared to SB plans by 12.4 and 15.4 Gy RBE-weighted median dose in GrA and GrB, respectively. D2% was reduced by 18.6 and 6.0 Gy RBE-weighted median dose in GrA and GrB, respectively. A cost to the optic nerve was observed with a median difference up to 3.8 Gy RBE-weighted dose in GrB. BED differences were statistically significant for all considered parameters in favor of two beams delivered the same day. CONCLUSION A two-beam strategy appears beneficial for posterior tumors abutting the optic nerve. This strategy might have a positive impact on the risk of ocular complications.
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Affiliation(s)
- Emmanuelle Fleury
- Erasmus Medical Center, Cancer Institute, Department of Radiotherapy, Rotterdam, The Netherlands; Holland Proton Therapy Center, Delft, The Netherlands.
| | - Petra Trnková
- Erasmus Medical Center, Cancer Institute, Department of Radiotherapy, Rotterdam, The Netherlands; Medical University of Vienna, Department of Radiation Oncology, Vienna, Austria
| | - Caroline van Rij
- Erasmus Medical Center, Cancer Institute, Department of Radiotherapy, Rotterdam, The Netherlands; Erasmus Medical Center, Department of Ophthalmology, Rotterdam, The Netherlands
| | | | - Yvonne Klaver
- Holland Proton Therapy Center, Delft, The Netherlands
| | - Kees Spruijt
- Holland Proton Therapy Center, Delft, The Netherlands
| | - Nicole Naus
- Erasmus Medical Center, Department of Ophthalmology, Rotterdam, The Netherlands
| | - Andras Zolnay
- Erasmus Medical Center, Cancer Institute, Department of Radiotherapy, Rotterdam, The Netherlands
| | | | - Emine Kiliç
- Erasmus Medical Center, Department of Ophthalmology, Rotterdam, The Netherlands; Erasmus Medical Center, Department of Clinical Genetics, Rotterdam, The Netherlands
| | - Mischa S Hoogeman
- Erasmus Medical Center, Cancer Institute, Department of Radiotherapy, Rotterdam, The Netherlands; Holland Proton Therapy Center, Delft, The Netherlands
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5
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Fleury E, Trnková P, Spruijt K, Herault J, Lebbink F, Heufelder J, Hrbacek J, Horwacik T, Kajdrowicz T, Denker A, Gerard A, Hofverberg P, Mamalui M, Slopsema R, Pignol J, Hoogeman M. Characterization of the HollandPTC proton therapy beamline dedicated to uveal melanoma treatment and an interinstitutional comparison. Med Phys 2021; 48:4506-4522. [PMID: 34091930 PMCID: PMC8457201 DOI: 10.1002/mp.15024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/08/2021] [Accepted: 05/25/2021] [Indexed: 12/30/2022] Open
Abstract
PURPOSE Eye-dedicated proton therapy (PT) facilities are used to treat malignant intraocular lesions, especially uveal melanoma (UM). The first commercial ocular PT beamline from Varian was installed in the Netherlands. In this work, the conceptual design of the new eyeline is presented. In addition, a comprehensive comparison against five PT centers with dedicated ocular beamlines is performed, and the clinical impact of the identified differences is analyzed. MATERIAL/METHODS The HollandPTC eyeline was characterized. Four centers in Europe and one in the United States joined the study. All centers use a cyclotron for proton beam generation and an eye-dedicated nozzle. Differences among the chosen ocular beamlines were in the design of the nozzle, nominal energy, and energy spectrum. The following parameters were collected for all centers: technical characteristics and a set of distal, proximal, and lateral region measurements. The measurements were performed with detectors available in-house at each institution. The institutions followed the International Atomic Energy Agency (IAEA) Technical Report Series (TRS)-398 Code of Practice for absolute dose measurement, and the IAEA TRS-398 Code of Practice, its modified version or International Commission on Radiation Units and Measurements Report No. 78 for spread-out Bragg peak normalization. Energy spreads of the pristine Bragg peaks were obtained with Monte Carlo simulations using Geant4. Seven tumor-specific case scenarios were simulated to evaluate the clinical impact among centers: small, medium, and large UM, located either anteriorly, at the equator, or posteriorly within the eye. Differences in the depth dose distributions were calculated. RESULTS A pristine Bragg peak of HollandPTC eyeline corresponded to the constant energy of 75 MeV (maximal range 3.97 g/cm2 in water) with an energy spread of 1.10 MeV. The pristine Bragg peaks for the five participating centers varied from 62.50 to 104.50 MeV with an energy spread variation between 0.10 and 0.70 MeV. Differences in the average distal fall-offs and lateral penumbrae (LPs) (over the complete set of clinically available beam modulations) among all centers were up to 0.25 g/cm2 , and 0.80 mm, respectively. Average distal fall-offs of the HollandPTC eyeline were 0.20 g/cm2 , and LPs were between 1.50 and 2.15 mm from proximal to distal regions, respectively. Treatment time, around 60 s, was comparable among all centers. The virtual source-to-axis distance of 120 cm at HollandPTC was shorter than for the five participating centers (range: 165-350 cm). Simulated depth dose distributions demonstrated the impact of the different beamline characteristics among institutions. The largest difference was observed for a small UM located at the posterior pole, where a proximal dose between two extreme centers was up to 20%. CONCLUSIONS HollandPTC eyeline specifications are in accordance with five other ocular PT beamlines. Similar clinical concepts can be applied to expect the same high local tumor control. Dosimetrical properties among the six institutions induce most likely differences in ocular radiation-related toxicities. This interinstitutional comparison could support further research on ocular post-PT complications. Finally, the findings reported in this study could be used to define dosimetrical guidelines for ocular PT to unify the concepts among institutions.
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Affiliation(s)
- Emmanuelle Fleury
- Department of RadiotherapyErasmus MC Cancer Institute, University Medical Center RotterdamThe Netherlands
- Holland Proton Therapy CenterDelftThe Netherlands
| | - Petra Trnková
- Department of RadiotherapyErasmus MC Cancer Institute, University Medical Center RotterdamThe Netherlands
- Departement of Radiation OncologyMedical University of ViennaViennaAustria
| | - Kees Spruijt
- Holland Proton Therapy CenterDelftThe Netherlands
| | - Joël Herault
- Departement of Radiation OncologyCentre Antoine LacassagneNiceFrance
| | | | - Jens Heufelder
- Helmholtz‐Zentrum Berlin für Materialien und EnergieBerlinGermany
- Department of OphthalmologyCharité ‐ Universitätsmedizin BerlinBerlinGermany
| | - Jan Hrbacek
- Paul Scherrer Institute Center for Proton TherapyVilligenSwitzerland
| | - Tomasz Horwacik
- Institute of Nuclear PhysicsPolish Academy of SciencesKrakówPoland
| | | | - Andrea Denker
- Helmholtz‐Zentrum Berlin für Materialien und EnergieBerlinGermany
| | - Anaïs Gerard
- Departement of Radiation OncologyCentre Antoine LacassagneNiceFrance
| | - Petter Hofverberg
- Departement of Radiation OncologyCentre Antoine LacassagneNiceFrance
| | - Maria Mamalui
- Department of Radiation OncologyUniversity of FloridaGainesvilleFloridaUSA
| | - Roelf Slopsema
- Department of Radiation OncologyEmory Proton Therapy CenterAtlantaGeorgiaUSA
| | | | - Mischa Hoogeman
- Department of RadiotherapyErasmus MC Cancer Institute, University Medical Center RotterdamThe Netherlands
- Holland Proton Therapy CenterDelftThe Netherlands
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6
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Lee HJ, Stacey A, Klesert TR, Wells C, Skalet AH, Bloch C, Fung A, Bowen SR, Wong TP, Shibata D, Halasz LM, Rengan R. Corneal Substructure Dosimetry Predicts Corneal Toxicity in Patients With Uveal Melanoma Treated With Proton Beam Therapy. Int J Radiat Oncol Biol Phys 2019; 104:374-382. [PMID: 30763658 DOI: 10.1016/j.ijrobp.2019.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 01/25/2019] [Accepted: 02/04/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE This study examines the relationship between dose to corneal substructures and incidence of corneal toxicity within 6 months of proton beam therapy (PBT) for uveal melanoma. We aim to develop clinically meaningful dose constraints that can be used to mitigate corneal toxicity. METHODS AND MATERIALS Ninety-two patients were treated with PBT between 2015 and 2017 and evaluated for grade 2+ (GR2+) intervention-requiring corneal toxicity in our prospectively maintained database. Most patients were treated with 50 Gy (relative biological effectiveness [RBE]) in 5 fractions, and all had complete six-month follow-up. Analyses included Mann-Whitney, χ2, Fisher exact, and receiver operating curve tests to identify risk factors for GR2+ toxicity. Bivariate logistic regression was used to identify independent dose-volume histogram (DVH) predictors of toxicity after adjustment for the most important clinical risk factor. RESULTS The 6-month PBT GR2+ corneal toxicity rate was 10.9%, with half of patients experiencing grade 2 toxicity and half experiencing grade 3 toxicity, with no grade 4 events. Patients with anterior chamber tumors had a higher risk (58.3%) for toxicity than those with posterior tumors (0%) or posterior tumors extending past the equator (25%, P < .0001). On univariate analysis, larger size according to Collaborative Ocular Melanoma Studies was associated with increased toxicity rate (P < .004). DVH analysis revealed that cutoffs of 58% for V25, 32% for V45, 51.8 Gy (RBE) for maximum dose, and 32 Gy (RBE) for mean dose to the cornea separated patients into groups experiencing and not experiencing toxicity with 90% sensitivity and ≥96% specificity. Bivariate logistic regression indicated that corneal V25, V45, and mean dose independently predicted for toxicity after adjusting for tumor location. CONCLUSIONS Patients receiving PBT for anterior uveal melanomas experience a high rate of GR2+ corneal toxicity because of increased corneal dose. Anterior location and corneal DVH parameters independently predict toxicity risk. We propose dosimetric constraints to facilitate treatment planning and toxicity mitigation.
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Affiliation(s)
- Howard J Lee
- Duke University School of Medicine, Durham, North Carolina.
| | - Andrew Stacey
- Department of Ophthalmology, University of Washington School of Medicine, Seattle, Washington
| | - Todd R Klesert
- Vitreoretinal Associates of Washington, Seattle, Washington
| | - Craig Wells
- Vitreoretinal Associates of Washington, Seattle, Washington
| | - Alison H Skalet
- Casey Eye Institute, Oregon Health and Science University, Portland, Oregon; Department of Radiation Medicine, Oregon Health and Science University, Portland, Oregon
| | - Charles Bloch
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
| | - Angela Fung
- Seattle Cancer Care Alliance Proton Therapy Center, Seattle, Washington
| | - Stephen R Bowen
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington; Department of Radiology, University of Washington School of Medicine, Seattle, Washington
| | - Tony P Wong
- Seattle Cancer Care Alliance Proton Therapy Center, Seattle, Washington
| | - Dean Shibata
- Department of Radiology, University of Washington School of Medicine, Seattle, Washington
| | - Lia M Halasz
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
| | - Ramesh Rengan
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
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Via R, Pella A, Romanò F, Fassi A, Ricotti R, Tagaste B, Vai A, Mastella E, Rosaria Fiore M, Valvo F, Ciocca M, Baroni G. A platform for patient positioning and motion monitoring in ocular proton therapy with a non-dedicated beamline. Phys Med 2019; 59:55-63. [PMID: 30928066 DOI: 10.1016/j.ejmp.2019.02.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 02/25/2019] [Accepted: 02/25/2019] [Indexed: 11/08/2022] Open
Abstract
PURPOSE At Centro Nazionale di Adroterapia Oncologica (CNAO, Pavia, Italy) ocular proton therapy (OPT) is delivered using a non-dedicated beamline. This paper describes the novel clinical workflow as well as technologies and methods adopted to achieve accurate target positioning and verification during ocular proton therapy at CNAO. METHOD The OPT clinical protocol at CNAO prescribes a treatment simulation and a delivery phase, performed in the CT and treatment rooms, respectively. The patient gaze direction is controlled and monitored during the entire workflow by means of an eye tracking system (ETS) featuring two optical cameras and an embedded fixation diode light. Thus, the accurate alignment of the fixation light provided to the patient to the prescribed gazed direction is required for an effective treatment. As such, a technological platform based on active robotic manipulators and IR optical tracking-based guidance was developed and tested. The effectiveness of patient positioning strategies was evaluated on a clinical dataset comprising twenty patients treated at CNAO. RESULTS According to experimental testing, the developed technologies guarantee uncertainties lower than one degree in gaze direction definition by means of ETS-guided positioning. Patient positioning and monitoring strategies during treatment effectively mitigated set-up uncertainties and exhibited sub-millimetric accuracy in radiopaque markers alignment. CONCLUSION Ocular proton therapy is currently delivered at CNAO with a non-dedicated beamline. The technologies developed for patient positioning and motion monitoring have proven to be compliant with the high geometrical accuracy required for the treatment of intraocular tumors.
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Affiliation(s)
- Riccardo Via
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milano 20133, Italy.
| | - Andrea Pella
- Centro Nazionale di Adroterapia Oncologica Foundation, Pavia 27100, Italy
| | | | - Aurora Fassi
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milano 20133, Italy
| | - Rosalinda Ricotti
- Centro Nazionale di Adroterapia Oncologica Foundation, Pavia 27100, Italy
| | - Barbara Tagaste
- Centro Nazionale di Adroterapia Oncologica Foundation, Pavia 27100, Italy
| | - Alessandro Vai
- Centro Nazionale di Adroterapia Oncologica Foundation, Pavia 27100, Italy
| | - Edoardo Mastella
- Centro Nazionale di Adroterapia Oncologica Foundation, Pavia 27100, Italy
| | | | - Francesca Valvo
- Centro Nazionale di Adroterapia Oncologica Foundation, Pavia 27100, Italy
| | - Mario Ciocca
- Centro Nazionale di Adroterapia Oncologica Foundation, Pavia 27100, Italy
| | - Guido Baroni
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milano 20133, Italy
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8
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Ciocca M, Magro G, Mastella E, Mairani A, Mirandola A, Molinelli S, Russo S, Vai A, Fiore MR, Mosci C, Valvo F, Via R, Baroni G, Orecchia R. Design and commissioning of the non-dedicated scanning proton beamline for ocular treatment at the synchrotron-based CNAO facility. Med Phys 2019; 46:1852-1862. [PMID: 30659616 DOI: 10.1002/mp.13389] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 12/11/2018] [Accepted: 01/09/2019] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Only few centers worldwide treat intraocular tumors with proton therapy, all of them with a dedicated beamline, except in one case in the USA. The Italian National Center for Oncological Hadrontherapy (CNAO) is a synchrotron-based hadrontherapy facility equipped with fixed beamlines and pencil beam scanning modality. Recently, a general-purpose horizontal proton beamline was adapted to treat also ocular diseases. In this work, the conceptual design and main dosimetric properties of this new proton eyeline are presented. METHODS A 28 mm thick water-equivalent range shifter (RS) was placed along the proton beamline to shift the minimum beam penetration at shallower depths. FLUKA Monte Carlo (MC) simulations were performed to optimize the position of the RS and patient-specific collimator, in order to achieve sharp lateral dose gradients. Lateral dose profiles were then measured with radiochromic EBT3 films to evaluate the dose uniformity and lateral penumbra width at several depths. Different beam scanning patterns were tested. Discrete energy levels with 1 mm water-equivalent step within the whole ocular energy range (62.7-89.8 MeV) were used, while fine adjustment of beam range was achieved using thin polymethylmethacrylate additional sheets. Depth-dose distributions (DDDs) were measured with the Peakfinder system. Monoenergetic beam weights to achieve flat spread-out Bragg Peaks (SOBPs) were numerically determined. Absorbed dose to water under reference conditions was measured with an Advanced Markus chamber, following International Atomic Energy Agency (IAEA) Technical Report Series (TRS)-398 Code of Practice. Neutron dose at the contralateral eye was evaluated with passive bubble dosimeters. RESULTS Monte Carlo simulations and experimental results confirmed that maximizing the air gap between RS and aperture reduces the lateral dose penumbra width of the collimated beam and increases the field transversal dose homogeneity. Therefore, RS and brass collimator were placed at about 98 cm (upstream of the beam monitors) and 7 cm from the isocenter, respectively. The lateral 80%-20% penumbra at middle-SOBP ranged between 1.4 and 1.7 mm depending on field size, while 90%-10% distal fall-off of the DDDs ranged between 1.0 and 1.5 mm, as a function of range. Such values are comparable to those reported for most existing eye-dedicated facilities. Measured SOBP doses were in very good agreement with MC simulations. Mean neutron dose at the contralateral eye was 68 μSv/Gy. Beam delivery time, for 60 Gy relative biological effectiveness (RBE) prescription dose in four fractions, was around 3 min per session. CONCLUSIONS Our adapted scanning proton beamline satisfied the requirements for intraocular tumor treatment. The first ocular treatment was delivered in August 2016 and more than 100 patients successfully completed their treatment in these 2 yr.
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Affiliation(s)
- Mario Ciocca
- Fondazione CNAO, strada Campeggi 53, 27100, Pavia, Italy
| | - Giuseppe Magro
- Fondazione CNAO, strada Campeggi 53, 27100, Pavia, Italy
| | | | - Andrea Mairani
- Fondazione CNAO, strada Campeggi 53, 27100, Pavia, Italy
| | | | | | - Stefania Russo
- Fondazione CNAO, strada Campeggi 53, 27100, Pavia, Italy
| | - Alessandro Vai
- Fondazione CNAO, strada Campeggi 53, 27100, Pavia, Italy
| | | | - Carlo Mosci
- Ente Ospedaliero Ospedali Galliera, via Mura delle Cappuccine 14, 16128, Genova, Italy
| | | | - Riccardo Via
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, piazza Leonardo da Vinci 32, 20133, Milano, Italy
| | - Guido Baroni
- Fondazione CNAO, strada Campeggi 53, 27100, Pavia, Italy.,Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, piazza Leonardo da Vinci 32, 20133, Milano, Italy
| | - Roberto Orecchia
- Fondazione CNAO, strada Campeggi 53, 27100, Pavia, Italy.,Istituto Europeo di Oncologia, via Ripamonti 435, 20100, Milano, Italy
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De Caluwé A, Termote K, Van Gestel D, Van Limbergen E. Dose-response in choroidal melanoma. Radiother Oncol 2018; 127:374-378. [PMID: 29680322 DOI: 10.1016/j.radonc.2018.03.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 03/13/2018] [Accepted: 03/15/2018] [Indexed: 01/21/2023]
Abstract
PURPOSE In choroidal melanoma the radiation threshold dose for local control remains largely unknown. The present study examined a group of patients that received a wide range of minimum tumor dose in order to investigate a dose-response relationship. A literature review is performed to compare our results with available evidence in brachytherapy and charged particle external beam radiotherapy. MATERIALS AND METHODS A retrospective study was conducted on all choroidal melanomas treated with Strontium-90 (Sr-90) at the University Hospital of Leuven between 1983 and 2012. Local failure was defined as primary endpoint and was estimated according to the competing risk method. RESULTS In 135 patients, the minimum tumor dose (Dmin) ranged from 0 Gy to 287 Gy (median: 27.6 Gy). Multivariable analysis revealed Dmin ≥ 65 Gy (p = 0.04; HR = 0.09) and tumor distant from the optic disc (p < 0.001, HR = 0.09) to be independent variables favoring local control. The scleral dose, the tumor diameter and tumor height did not significantly affect local failure in multivariate analysis. CONCLUSION This is the first study to examine a group of patients treated with a Dmin ranging from 0 Gy to >250 Gy. Treatment with a Dmin of 65 Gy is necessary to achieve durable tumor response. The dose-response data provided by our study could be used for the design of future trials examining the ideal dose for the treatment of choroidal melanoma with brachytherapy or charged particle external beam radiotherapy.
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Affiliation(s)
- Alex De Caluwé
- Department of Radiation Oncology, Institut Jules Bordet - Université Libre de Bruxelles (ULB), Brussels, Belgium.
| | - Karolien Termote
- Department of Ophthalmology, University Hospital of Brussels (UZ Brussel), Brussels, Belgium
| | - Dirk Van Gestel
- Department of Radiation Oncology, Institut Jules Bordet - Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Erik Van Limbergen
- Department of Radiation Oncology, University Hospital of Leuven (UZ Leuven), Leuven, Belgium
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