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Sienna J, Kahalley LS, Mabbott D, Grosshans D, Santiago AT, Paulino ADC, Merchant TE, Manzar GS, Dama H, Hodgson DC, Chintagumpala M, Okcu MF, Whitehead WE, Laperriere N, Ramaswamy V, Bartels U, Tabori U, Bennett JM, Das A, Craig T, Tsang DS. Proton Therapy Mediates Dose Reductions to Brain Structures Associated With Cognition in Children With Medulloblastoma. Int J Radiat Oncol Biol Phys 2024; 119:200-207. [PMID: 38040059 PMCID: PMC11023754 DOI: 10.1016/j.ijrobp.2023.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 10/27/2023] [Accepted: 11/19/2023] [Indexed: 12/03/2023]
Abstract
PURPOSE Emerging evidence suggests proton radiation therapy may offer cognitive sparing advantages over photon radiation therapy, yet dosimetry has not been compared previously. The purpose of this study was to examine dosimetric correlates of cognitive outcomes in children with medulloblastoma treated with proton versus photon radiation therapy. METHODS AND MATERIALS In this retrospective, bi-institutional study, dosimetric and cognitive data from 75 patients (39 photon and 36 proton) were analyzed. Doses to brain structures were compared between treatment modalities. Linear mixed-effects models were used to create models of global IQ and cognitive domain scores. RESULTS The mean dose and dose to 40% of the brain (D40) were 2.7 and 4.1 Gy less among proton-treated patients compared with photon-treated patients (P = .03 and .007, respectively). Mean doses to the left and right hippocampi were 11.2 Gy lower among proton-treated patients (P < .001 for both). Mean doses to the left and right temporal lobes were 6.9 and 7.1 Gy lower with proton treatment, respectively (P < .001 for both). Models of cognition found statistically significant associations between higher mean brain dose and reduced verbal comprehension, increased right temporal lobe D40 with reduced perceptual reasoning, and greater left temporal mean dose with reduced working memory. Higher brain D40 was associated with reduced processing speed and global IQ scores. CONCLUSIONS Proton therapy reduces doses to normal brain structures compared with photon treatment. This leads to reduced cognitive decline after radiation therapy across multiple intellectual endpoints. Proton therapy should be offered to children receiving radiation for medulloblastoma.
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Affiliation(s)
- Julianna Sienna
- Juravinski Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada.
| | - Lisa S Kahalley
- Division of Psychology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Donald Mabbott
- Department of Psychology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - David Grosshans
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Anna Theresa Santiago
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | | | - Thomas E Merchant
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Gohar S Manzar
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hitesh Dama
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - David C Hodgson
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Murali Chintagumpala
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Mehmet Fatih Okcu
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - William E Whitehead
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Normand Laperriere
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Vijay Ramaswamy
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ute Bartels
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Uri Tabori
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Julie M Bennett
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Anirban Das
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Tim Craig
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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Grosshans D, Thomas R, Zhang D, Cronkite C, Thomas R, Singh S, Bronk L, Morales R, Duman J. Subcellular functions of tau mediates repair response and synaptic homeostasis in injury. Res Sq 2024:rs.3.rs-3897741. [PMID: 38464175 PMCID: PMC10925419 DOI: 10.21203/rs.3.rs-3897741/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Injury responses in terminally differentiated cells such as neurons is tightly regulated by pathways aiding homeostatic maintenance. Cancer patients subjected to neuronal injury in brain radiation experience cognitive declines similar to those seen in primary neurodegenerative diseases. Numerous studies have investigated the effect of radiation in proliferating cells of the brain, yet the impact in differentiated, post-mitotic neurons, especially the structural and functional alterations remain largely elusive. We identified that microtubule-associated tau is a critical player in neuronal injury response via compartmentalized functions in both repair-centric and synaptic regulatory pathways. Ionizing radiation-induced injury acutely induces increase in phosphorylated tau in the nucleus and directly interacts with histone 2AX (H2AX), a DNA damage repair (DDR) marker. Loss of tau significantly reduced H2AX after irradiation, indicating that tau may play an important role in neuronal DDR response. We also observed that loss of tau increases eukaryotic elongation factor levels after irradiation, the latter being a positive regulator of protein translation. This cascades into a significant increase in synaptic proteins, resulting in disrupted homeostasis. Consequently, novel object recognition test showed decrease in learning and memory in tau-knockout mice after irradiation, and electroencephalographic activity showed increase in delta and theta band oscillations, often seen in dementia patients. Our findings demonstrate tau's previously undefined, multifunctional role in acute responses to injury, ranging from DDR response in the nucleus to synaptic function within a neuron. Such knowledge is vital to develop therapeutic strategies targeting neuronal injury in cognitive decline for at risk and vulnerable populations.
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Goudarzi HM, Lim G, Grosshans D, Mohan R, Cao W. Incorporating variable RBE in IMPT optimization for ependymoma. J Appl Clin Med Phys 2024; 25:e14207. [PMID: 37985962 PMCID: PMC10795446 DOI: 10.1002/acm2.14207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 10/19/2023] [Accepted: 10/28/2023] [Indexed: 11/22/2023] Open
Abstract
PURPOSE To study the dosimetric impact of incorporating variable relative biological effectiveness (RBE) of protons in optimizing intensity-modulated proton therapy (IMPT) treatment plans and to compare it with conventional constant RBE optimization and linear energy transfer (LET)-based optimization. METHODS This study included 10 pediatric ependymoma patients with challenging anatomical features for treatment planning. Four plans were generated for each patient according to different optimization strategies: (1) constant RBE optimization (ConstRBEopt) considering standard-of-care dose requirements; (2) LET optimization (LETopt) using a composite cost function simultaneously optimizing dose-averaged LET (LETd ) and dose; (3) variable RBE optimization (VarRBEopt) using a recent phenomenological RBE model developed by McNamara et al.; and (4) hybrid RBE optimization (hRBEopt) assuming constant RBE for the target and variable RBE for organs at risk. By normalizing each plan to obtain the same target coverage in either constant or variable RBE, we compared dose, LETd , LET-weighted dose, and equivalent uniform dose between the different optimization approaches. RESULTS We found that the LETopt plans consistently achieved increased LET in tumor targets and similar or decreased LET in critical organs compared to other plans. On average, the VarRBEopt plans achieved lower mean and maximum doses with both constant and variable RBE in the brainstem and spinal cord for all 10 patients. To compensate for the underdosing of targets with 1.1 RBE for the VarRBEopt plans, the hRBEopt plans achieved higher physical dose in targets and reduced mean and especially maximum variable RBE doses compared to the ConstRBEopt and LETopt plans. CONCLUSION We demonstrated the feasibility of directly incorporating variable RBE models in IMPT optimization. A hybrid RBE optimization strategy showed potential for clinical implementation by maintaining all current dose limits and reducing the incidence of high RBE in critical normal tissues in ependymoma patients.
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Affiliation(s)
| | - Gino Lim
- Department of Industrial EngineeringUniversity of HoustonHoustonTexasUSA
| | - David Grosshans
- Department of Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Radhe Mohan
- Department of Radiation PhysicsThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Wenhua Cao
- Department of Radiation PhysicsThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
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Durante M, Bender T, Schickel E, Mayer M, Debus J, Grosshans D, Schroeder I. Aberrant choroid plexus formation in human cerebral organoids exposed to radiation. Res Sq 2023:rs.3.rs-3445801. [PMID: 37886443 PMCID: PMC10602134 DOI: 10.21203/rs.3.rs-3445801/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
Brain tumor patients are commonly treated with radiotherapy, but the efficacy of the treatment is limited by its toxicity, particularly the risk of radionecrosis. We used human cerebral organoids to investigate the mechanisms and nature of postirradiation brain image changes commonly linked to necrosis. Irradiation of cerebral organoids lead to increased formation of ZO1+/AQP1+/CLN3+-choroid plexus (CP) structures. Increased CP formation was triggered by radiation via the NOTCH/WNT signaling pathways and associated with delayed growth and neural stem cell differentiation, but not necrosis. The effect was more pronounced in immature than in mature organoids, reflecting the clinically-observed increased radiosensitivity of the pediatric brain. Protons were more effective than X-rays at the same dose, as also observed in clinical treatments. We conclude that radiation-induced brain image-changes can be attributed to aberrant CP formation, providing a new cellular mechanism and strategy for possible countermeasures.
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Cao W, Li Y, Zhang X, Poenisch F, Yepes P, Sahoo N, Grosshans D, McGovern S, Gunn GB, Frank SJ, Zhu XR. Intensity modulated proton arc therapy via geometry-based energy selection for ependymoma. J Appl Clin Med Phys 2023:e13954. [PMID: 36913484 DOI: 10.1002/acm2.13954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 02/06/2023] [Accepted: 02/14/2023] [Indexed: 03/14/2023] Open
Abstract
PURPOSE We developed and tested a novel method of creating intensity modulated proton arc therapy (IMPAT) plans that uses computing resources similar to those for regular intensity-modulated proton therapy (IMPT) plans and may offer a dosimetric benefit for patients with ependymoma or similar tumor geometries. METHODS Our IMPAT planning method consists of a geometry-based energy selection step with major scanning spot contributions as inputs computed using ray-tracing and single-Gaussian approximation of lateral spot profiles. Based on the geometric relation of scanning spots and dose voxels, our energy selection module selects a minimum set of energy layers at each gantry angle such that each target voxel is covered by sufficient scanning spots as specified by the planner, with dose contributions above the specified threshold. Finally, IMPAT plans are generated by robustly optimizing scanning spots of the selected energy layers using a commercial proton treatment planning system (TPS). The IMPAT plan quality was assessed for four ependymoma patients. Reference three-field IMPT plans were created with similar planning objective functions and compared with the IMPAT plans. RESULTS In all plans, the prescribed dose covered 95% of the clinical target volume (CTV) while maintaining similar maximum doses for the brainstem. While IMPAT and IMPT achieved comparable plan robustness, the IMPAT plans achieved better homogeneity and conformity than the IMPT plans. The IMPAT plans also exhibited higher relative biological effectiveness (RBE) enhancement than did the corresponding reference IMPT plans for the CTV in all four patients and brainstem in three of them. CONCLUSIONS The proposed method demonstrated potential as an efficient technique for IMPAT planning and may offer a dosimetric benefit for patients with ependymoma or tumors in close proximity to critical organs. IMPAT plans created using this method had elevated RBE enhancement associated with increased linear energy transfer (LET) in both targets and abutting critical organs.
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Affiliation(s)
- Wenhua Cao
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Yupeng Li
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Xiaodong Zhang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Falk Poenisch
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Pablo Yepes
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Physics and Astronomy, Rice University, Houston, Texas, USA
| | - Narayan Sahoo
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Grosshans
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Susan McGovern
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - G Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Xiaorong R Zhu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Bronk J, Zhang M, Mcaleer M, Mcgovern S, Lassen-Ramshad Y, Safwat A, Daw N, Rainusso N, Mahajan A, Grosshans D, Paulino A. Comprehensive Radiotherapy For Pediatric Ewing Sarcoma: Outcomes of a Prospective Proton Study. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Kirkman MA, Day J, Gehring K, Zienius K, Grosshans D, Taphoorn M, Li J, Brown PD. Interventions for preventing and ameliorating cognitive deficits in adults treated with cranial irradiation. Cochrane Database Syst Rev 2022; 11:CD011335. [PMID: 36427235 PMCID: PMC9697842 DOI: 10.1002/14651858.cd011335.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cognitive deficits are common in people who have received cranial irradiation and have a serious impact on daily functioning and quality of life. The benefit of pharmacological and non-pharmacological treatment of cognitive deficits in this population is unclear. This is an updated version of the original Cochrane Review published in Issue 12, 2014. OBJECTIVES To assess the effectiveness of interventions for preventing or ameliorating cognitive deficits in adults treated with cranial irradiation. SEARCH METHODS For this review update we searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE via Ovid, Embase via Ovid, and PsycInfo via Ovid to 12 September 2022. SELECTION CRITERIA We included randomised controlled (RCTs) trials that evaluated pharmacological or non-pharmacological interventions in cranial irradiated adults, with objective cognitive functioning as a primary or secondary outcome measure. DATA COLLECTION AND ANALYSIS Two review authors (MK, JD) independently extracted data from selected studies and carried out a risk of bias assessment. Cognitive function, fatigue and mood outcomes were reported. No data were pooled. MAIN RESULTS Eight studies met the inclusion criteria and were included in this updated review. Six were from the original version of the review, and two more were added when the search was updated. Nineteen further studies were assessed as part of this update but did not fulfil the inclusion criteria. Of the eight included studies, four studies investigated "prevention" of cognitive problems (during radiotherapy and follow-up) and four studies investigated "amelioration" (interventions to treat cognitive impairment as a late complication of radiotherapy). There were five pharmacological studies (two studies on prevention and three in amelioration) and three non-pharmacological studies (two on prevention and one in amelioration). Due to differences between studies in the interventions being evaluated, a meta-analysis was not possible. Studies in early radiotherapy treatment phase (five studies) Pharmacological studies in the "early radiotherapy treatment phase" were designed to prevent or ameliorate cognitive deficits and included drugs used in dementia (memantine) and fatigue (d-threo-methylphenidate hydrochloride). Non-pharmacological studies in the "early radiotherapy treatment phase" included a ketogenic diet and a two-week cognitive rehabilitation and problem-solving programme. In the memantine study, the primary cognitive outcome of memory at six months did not reach significance, but there was significant improvement in overall cognitive function compared to placebo, with similar adverse events across groups. The d-threo-methylphenidate hydrochloride study found no statistically significant difference between arms, with few adverse events. The study of a calorie-restricted ketogenic diet found no effect, although a lower than expected calorie intake in the control group complicates interpretation of the results. The study investigating the utility of a rehabilitation program did not carry out a statistical comparison of cognitive performance between groups. Studies in delayed radiation or late effect phase (four studies) The "amelioration" pharmacological studies to treat cognitive complications of radiotherapy included drugs used in dementia (donepezil) or psychostimulants (methylphenidate and modafinil). Non-pharmacological measures included cognitive rehabilitation and problem solving (Goal Management Training). These studies included patients with cognitive problems at entry who had "stable" brain cancer. The donepezil study did not find an improvement in the primary cognitive outcome of overall cognitive performance, but did find improvement in an individual test of memory, compared to placebo; adverse events were not reported. A study comparing methylphenidate with modafinil found improvements in cognitive function in both the methylphenidate and modafinil arms; few adverse events were reported. Another study comparing two different doses of modafinil combined treatment arms and found improvements across all cognitive tests, however, a number of adverse events were reported. Both studies were limited by a small sample size. The Goal Management Training study suggested a benefit of the intervention, a behavioural intervention that combined mindfulness and strategy training, on executive function and processing speed. There were a number of limitations across studies and few were without high risks of bias. AUTHORS' CONCLUSIONS In this update, limited additional evidence was found for the treatment or amelioration of cognitive deficits in adults treated with cranial irradiation. As concluded in the original review, there is supportive evidence that memantine may help prevent cognitive deficits for adults with brain metastases receiving cranial irradiation. There is supportive evidence that donepezil, methylphenidate and modafinil may have a role in treating cognitive deficits in adults with brain tumours who have been treated with cranial irradiation; patient withdrawal affected the statistical power of these studies. Further research that tries to minimise the withdrawal of consent, and subsequently reduce the requirement for imputation procedures, may offer a higher certainty of evidence. There is evidence from only a single small study to support non-pharmacological interventions in the amelioration of cognitive deficits. Further research is required.
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Affiliation(s)
- Matthew A Kirkman
- Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Julia Day
- Community Rehabilitation and Brain Injury Service (CRABIS), Strathbrock Partnership Centre, West Lothian, UK
| | - Karin Gehring
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, Netherlands
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, Netherlands
| | - Karolis Zienius
- Edinburgh Centre for Neuro-Oncology (ECNO), Western General Hospital, Edinburgh, UK
| | - David Grosshans
- Radiation Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Martin Taphoorn
- Department of Neurology, Haaglanden Medical Center, PO Box 432, Netherlands
| | - Jing Li
- Radiation Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Paul D Brown
- Radiation Oncology, Mayo Clinic, Rochester, MN, USA
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McNerlin C, Guan F, Bronk L, Lei K, Grosshans D, Young DW, Gaber MW, Maletic-Savatic M. Targeting hippocampal neurogenesis to protect astronauts' cognition and mood from decline due to space radiation effects. Life Sci Space Res (Amst) 2022; 35:170-179. [PMID: 36336363 DOI: 10.1016/j.lssr.2022.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/30/2022] [Accepted: 07/26/2022] [Indexed: 06/16/2023]
Abstract
Neurogenesis is an essential, lifelong process during which neural stem cells generate new neurons within the hippocampus, a center for learning, memory, and mood control. Neural stem cells are vulnerable to environmental insults spanning from chronic stress to radiation. These insults reduce their numbers and diminish neurogenesis, leading to memory decline, anxiety, and depression. Preserving neural stem cells could thus help prevent these neurogenesis-associated pathologies, an outcome particularly important for long-term space missions where environmental exposure to radiation is significantly higher than on Earth. Multiple developments, from mechanistic discoveries of radiation injury on hippocampal neurogenesis to new platforms for the development of selective, specific, effective, and safe small molecules as neurogenesis-protective agents hold great promise to minimize radiation damage on neurogenesis. In this review, we summarize the effects of space-like radiation on hippocampal neurogenesis. We then focus on current advances in drug discovery and development and discuss the nuclear receptor TLX/NR2E1 (oleic acid receptor) as an example of a neurogenic target that might rescue neurogenesis following radiation.
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Affiliation(s)
- Clare McNerlin
- Georgetown University School of Medicine, 3900 Reservoir Rd NW, Washington D.C. 20007, United States of America
| | - Fada Guan
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, 06510, United States of America
| | - Lawrence Bronk
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, United States of America
| | - Kevin Lei
- Graduate School for Biomedical Sciences, Baylor College of Medicine, Houston, Texas, 77030, United States of America; Jan and Dan Duncan Neurological Research Institute, 1250 Moursund St. Houston, TX 77030, United States of America
| | - David Grosshans
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, United States of America
| | - Damian W Young
- Jan and Dan Duncan Neurological Research Institute, 1250 Moursund St. Houston, TX 77030, United States of America; Center for Drug Discovery, Department of Pathology and Immunology Baylor College of Medicine, Houston, Texas, 77030, United States of America; Department of Pharmacology and Chemical Biology, Baylor College of Medicine, Houston, Texas 77030, United States of America
| | - M Waleed Gaber
- Department of Pediatrics, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, United States of America.
| | - Mirjana Maletic-Savatic
- Jan and Dan Duncan Neurological Research Institute, 1250 Moursund St. Houston, TX 77030, United States of America; Department of Pediatrics, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, United States of America; Department of Neuroscience, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, United States of America.
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Bokhari RS, Beheshti A, Blutt SE, Bowles DE, Brenner D, Britton R, Bronk L, Cao X, Chatterjee A, Clay DE, Courtney C, Fox DT, Gaber MW, Gerecht S, Grabham P, Grosshans D, Guan F, Jezuit EA, Kirsch DG, Liu Z, Maletic-Savatic M, Miller KM, Montague RA, Nagpal P, Osenberg S, Parkitny L, Pierce NA, Porada C, Rosenberg SM, Sargunas P, Sharma S, Spangler J, Tavakol DN, Thomas D, Vunjak-Novakovic G, Wang C, Whitcomb L, Young DW, Donoviel D. Looking on the horizon; potential and unique approaches to developing radiation countermeasures for deep space travel. Life Sci Space Res (Amst) 2022; 35:105-112. [PMID: 36336356 DOI: 10.1016/j.lssr.2022.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 07/29/2022] [Accepted: 08/04/2022] [Indexed: 06/16/2023]
Abstract
Future lunar missions and beyond will require new and innovative approaches to radiation countermeasures. The Translational Research Institute for Space Health (TRISH) is focused on identifying and supporting unique approaches to reduce risks to human health and performance on future missions beyond low Earth orbit. This paper will describe three funded and complementary avenues for reducing the risk to humans from radiation exposure experienced in deep space. The first focus is on identifying new therapeutic targets to reduce the damaging effects of radiation by focusing on high throughput genetic screens in accessible, sometimes called lower, organism models. The second focus is to design innovative approaches for countermeasure development with special attention to nucleotide-based methodologies that may constitute a more agile way to design therapeutics. The final focus is to develop new and innovative ways to test radiation countermeasures in a human model system. While animal studies continue to be beneficial in the study of space radiation, they can have imperfect translation to humans. The use of three-dimensional (3D) complex in vitro models is a promising approach to aid the development of new countermeasures and personalized assessments of radiation risks. These three distinct and unique approaches complement traditional space radiation efforts and should provide future space explorers with more options to safeguard their short and long-term health.
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Affiliation(s)
- Rihana S Bokhari
- Agile Decision Sciences, NRESS, Arlington, VA 22202, United States of America.
| | - Afshin Beheshti
- KBR, Space Biosciences Division, NASA Ames Research Center, Moffett Field, CA, 94035, United States of America; Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA, 02142, United States of America
| | - Sarah E Blutt
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX 77030, United States of America; Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, TX 77030, United States of America
| | - Dawn E Bowles
- Division of Surgical Sciences, Department of Surgery, Duke University, Durham NC, United States of America
| | - David Brenner
- Columbia University, New York, NY, 10027, United States of America
| | - Robert Britton
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX 77030, United States of America
| | - Lawrence Bronk
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, United States of America
| | - Xu Cao
- Stanford University School of Medicine, Stanford, CA 94305, United States of America
| | - Anushree Chatterjee
- Sachi Bioworks, Louisville, CO 80027, United States of America; University of Colorado Boulder, Boulder, CO 80303, United States of America
| | - Delisa E Clay
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, NC 27710, United States of America
| | | | - Donald T Fox
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, NC 27710, United States of America
| | - M Waleed Gaber
- Department of Pediatrics, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, United States of America
| | - Sharon Gerecht
- Chemical and Biomolecular Engineering and Biomedical Engineering, Johns Hopkins University, Baltimore, MD 21218 United States of America; Biomedical Engineering, Duke University, Durham, NC 27708, United States of America
| | - Peter Grabham
- Center for Radiological Research, College of Physicians and Surgeons, Columbia University, New York, NY 10027 United States of America
| | - David Grosshans
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, United States of America
| | - Fada Guan
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, United States of America
| | - Erin A Jezuit
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, NC 27710, United States of America
| | - David G Kirsch
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, NC 27710, United States of America
| | - Zhandong Liu
- Department of Pediatrics, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, United States of America; Jan and Dan Duncan Neurological Research Institute, 1250 Moursund St. Houston, TX 77030, United States of America
| | - Mirjana Maletic-Savatic
- Department of Pediatrics, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, United States of America; Jan and Dan Duncan Neurological Research Institute, 1250 Moursund St. Houston, TX 77030, United States of America
| | - Kyle M Miller
- Department of Molecular Biosciences, The University of Texas, Austin, TX 78712, United States of America
| | - Ruth A Montague
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, NC 27710, United States of America
| | - Prashant Nagpal
- Sachi Bioworks, Louisville, CO 80027, United States of America
| | - Sivan Osenberg
- Department of Pediatrics, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, United States of America; Jan and Dan Duncan Neurological Research Institute, 1250 Moursund St. Houston, TX 77030, United States of America
| | - Luke Parkitny
- Department of Pediatrics, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, United States of America; Jan and Dan Duncan Neurological Research Institute, 1250 Moursund St. Houston, TX 77030, United States of America
| | - Niles A Pierce
- Division of Biology & Biological Engineering, California Institute of Technology, Pasadena, CA 91125, United States of America; Division of Engineering & Applied Science, California Institute of Technology, Pasadena, CA 91125, United States of America; Weatherall Institute of Molecular Medicine, University of Oxford, Oxford OX3 9DS, United Kingdom
| | - Christopher Porada
- Wake Forest Institute for Regenerative Medicine, Fetal Research and Therapy Program Wake Forest School of Medicine, Winston-Salem, NC 27157, United States of America
| | - Susan M Rosenberg
- Department of Molecular and Human Genetics, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77303, United States of America; Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77303, United States of America; Department of Biochemistry and Molecular Biology, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77303, United States of America; Department of Molecular Virology and Microbiology, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77303, United States of America
| | - Paul Sargunas
- Chemical and Biomolecular Engineering and Biomedical Engineering, Johns Hopkins University, Baltimore, MD 21218 United States of America
| | - Sadhana Sharma
- Sachi Bioworks, Louisville, CO 80027, United States of America
| | - Jamie Spangler
- Chemical and Biomolecular Engineering and Biomedical Engineering, Johns Hopkins University, Baltimore, MD 21218 United States of America
| | | | - Dilip Thomas
- Stanford University School of Medicine, Stanford, CA 94305, United States of America
| | | | - Chunbo Wang
- Division of Surgical Sciences, Department of Surgery, Duke University, Durham NC, United States of America
| | - Luke Whitcomb
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO 80523, United States of America
| | - Damian W Young
- Department of Pharmacology, Baylor College of Medicine, Houston, TX 77030, United States of America
| | - Dorit Donoviel
- Translational Research Institute for Space Health, Houston, TX 77030, United States of America; Center for Space Medicine, Baylor College of Medicine, Houston, TX 77030, United States of America.
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10
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McCurdy MD, Raghubar KP, Christopher K, Okcu MF, Wilde E, Desai N, Chu ZD, Gragert M, Stancel H, Warren EH, Whitehead WE, Grosshans D, Paulino AC, Chintagumpala M, Kahalley LS. Predicting neurocognitive function in pediatric brain tumor early survivorship: The neurological predictor scale and the incremental validity of tumor size. Pediatr Blood Cancer 2022; 69:e29803. [PMID: 35709014 PMCID: PMC10265925 DOI: 10.1002/pbc.29803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 05/03/2022] [Accepted: 05/04/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND The Neurological Predictor Scale (NPS) quantifies cumulative exposure to conventional treatment-related neurological risks but does not capture potential risks posed by tumors themselves. This study evaluated the predictive validity of the NPS, and the incremental value of tumor location and size, for neurocognitive outcomes in early survivorship following contemporary therapies for pediatric brain tumors. PROCEDURE Survivors (N = 69) diagnosed from 2010 to 2016 were administered age-appropriate versions of the Wechsler Intelligence Scales. Hierarchical multiple regressions examined the predictive and incremental validity of NPS score, tumor location, and tumor size. RESULTS Participants (51% female) aged 6-20 years (M = 13.22, SD = 4.09) completed neurocognitive evaluations 5.16 years (SD = 1.29) postdiagnosis. The NPS significantly predicted Full-Scale Intelligence Quotient (FSIQ; ΔR2 = .079), Verbal Comprehension Index (VCI; ΔR2 = 0.051), Perceptual Reasoning Index (PRI; ΔR2 = 0.065), and Processing Speed Index (PSI; ΔR2 = 0.049) performance after controlling for sex, age at diagnosis, and maternal education. Tumor size alone accounted for a significant amount of unique variance in FSIQ (ΔR2 = 0.065), PRI (ΔR2 = 0.076), and PSI (ΔR2 = 0.080), beyond that captured by the NPS and relevant covariates. Within the full model, the NPS remained a significant independent predictor of FSIQ (β = -0.249, P = 0.016), VCI (β = -0.223, P = 0.048), and PRI (β = -0.229, P = 0.037). CONCLUSIONS Tumor size emerged as an independent predictor of neurocognitive functioning and added incrementally to the predictive utility of the NPS. Pretreatment disease burden may provide one of the earliest markers of neurocognitive risk following contemporary treatments. With perpetual treatment advances, measures quantifying treatment-related risk may need to be updated and revalidated to maintain their clinical utility.
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Affiliation(s)
- Mark D. McCurdy
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | - Kimberly P. Raghubar
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | | | - M. Fatih Okcu
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | - Elisabeth Wilde
- Baylor College of Medicine, Houston, TX, US
- University of Utah, Salt Lake City, UT, US
| | - Nilesh Desai
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | - Zili D. Chu
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | - Marsha Gragert
- The University of Texas MD Anderson Cancer Center, Houston, TX US
| | | | - Emily H. Warren
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | - William E. Whitehead
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | - David Grosshans
- The University of Texas MD Anderson Cancer Center, Houston, TX US
| | | | - Murali Chintagumpala
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
| | - Lisa S. Kahalley
- Baylor College of Medicine, Houston, TX, US
- Texas Children’s Hospital, Houston, TX, US
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11
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MD JKB, Amer A, Khose S, Flint D, Adair A, Yepes P, Grosshans D, Johnson J, Chung C. Brain Radionecrosis Outside the Target Volume after Proton Radiotherapy: Analyses of Multiparametric Imaging and Proton Biological Effectiveness. Adv Radiat Oncol 2022; 7:101044. [DOI: 10.1016/j.adro.2022.101044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 07/27/2022] [Indexed: 11/17/2022] Open
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12
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McGovern S, Mackin D, Li J, Paulino A, Grosshans D, Weinberg J, Sandberg D, Chintagumpala M, Gill J, Zaky W, Briere T, McAleer MF. RONC-06. Stereotactic radiosurgery and stereotactic radiotherapy for pediatric brain metastases or recurrences. Neuro Oncol 2022. [PMCID: PMC9164904 DOI: 10.1093/neuonc/noac079.660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND/PURPOSE: Stereotactic radiosurgery (SRS) and stereotactic radiotherapy (SRT) deliver highly conformal, ablative doses of radiation over 1–5 treatments, while minimizing dose to surrounding normal tissues. To document toxicities and outcomes of these treatments in children, our updated institutional experience with SRS or SRT for intracranial targets in pediatric patients was reviewed. METHODS: On an IRB approved study, institutional databases were reviewed to identify pediatric patients with intracranial lesions treated with SRS or SRT from October 2009 to July 2021. Medical records were retrospectively reviewed for patient and treatment characteristics. Outcomes were analyzed for symptomatic radionecrosis and CNS progression. RESULTS: Thirty SRS or SRT treatment courses in 26 patients age 3.2 to 17.8y (median, 15.6y) at the time of SRS or SRT were identified. Twenty-two patients had one treatment and four had two treatments. Sixteen patients had brain metastases from extracranial primary disease; 10 had recurrence of a primary CNS tumor. Fifteen patients had prior fractionated radiation to the brain. Nineteen treatments used Gamma Knife (GK) with Leksell frame, three used GK ICON with mask, and eight used linear accelerator with volumetric modulated arc therapy with thermoplastic mask. All patients (10 treatments in nine patients) treated since July 2016 received mask-based radiation. Twelve of 26 (46%) patients were treated with anesthesia. With 9.6-month median follow up (range, 0.1-96.2m), five patients had progression of treated lesions, eight had distant CNS failure, and one had both local and distant failure, for a crude local failure rate of 6/26 (23%) and a crude distant failure rate of 9/26 (35%). There were no skull fractures or other complications from Leksell frame placement. One patient developed symptomatic radionecrosis requiring surgery. CONCLUSION: SRS and SRT can be safely performed in pediatric patients with intracranial lesions. Mask-based immobilization provides an alternative to frame-based treatments.
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Affiliation(s)
| | | | - Jing Li
- MD Anderson Cancer Center , Houston, TX , USA
| | | | | | | | - David Sandberg
- Children’s Memorial Hermann Hospital , Houston, TX , USA
| | | | | | - Wafik Zaky
- MD Anderson Cancer Center , Houston, TX , USA
| | - Tina Briere
- MD Anderson Cancer Center , Houston, TX , USA
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13
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Skaarup M, Lundemann M, Darkner S, Jørgensen M, Marner L, Mirkovic D, Grosshans D, Peeler C, Mohan R, Vogelius I, Appelt A. PO-1757 A framework for in-vivo, voxel-based assessment of radiation response through multimodal imaging. Radiother Oncol 2022. [DOI: 10.1016/s0167-8140(22)03721-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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14
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Brown PD, Chung C, Liu DD, McAvoy S, Grosshans D, Al Feghali K, Mahajan A, Li J, McGovern SL, McAleer MF, Ghia AJ, Sulman EP, Penas-Prado M, de Groot JF, Heimberger AB, Wang J, Armstrong TS, Gilbert MR, Guha-Thakurta N, Wefel JS. A prospective phase II randomized trial of proton radiotherapy vs intensity-modulated radiotherapy for patients with newly diagnosed glioblastoma. Neuro Oncol 2021; 23:1337-1347. [PMID: 33647972 DOI: 10.1093/neuonc/noab040] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND To determine if proton radiotherapy (PT), compared to intensity-modulated radiotherapy (IMRT), delayed time to cognitive failure in patients with newly diagnosed glioblastoma (GBM). METHODS Eligible patients were randomized unblinded to PT vs IMRT. The primary endpoint was time to cognitive failure. Secondary endpoints included overall survival (OS), intracranial progression-free survival (PFS), toxicity, and patient-reported outcomes (PROs). RESULTS A total of 90 patients were enrolled and 67 were evaluable with median follow-up of 48.7 months (range 7.1-66.7). There was no significant difference in time to cognitive failure between treatment arms (HR, 0.88; 95% CI, 0.45-1.75; P = .74). PT was associated with a lower rate of fatigue (24% vs 58%, P = .05), but otherwise, there were no significant differences in PROs at 6 months. There was no difference in PFS (HR, 0.74; 95% CI, 0.44-1.23; P = .24) or OS (HR, 0.86; 95% CI, 0.49-1.50; P = .60). However, PT significantly reduced the radiation dose for nearly all structures analyzed. The average number of grade 2 or higher toxicities was significantly higher in patients who received IMRT (mean 1.15, range 0-6) compared to PT (mean 0.35, range 0-3; P = .02). CONCLUSIONS In this signal-seeking phase II trial, PT was not associated with a delay in time to cognitive failure but did reduce toxicity and patient-reported fatigue. Larger randomized trials are needed to determine the potential of PT such as dose escalation for GBM and cognitive preservation in patients with lower-grade gliomas with a longer survival time.
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Affiliation(s)
- Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Caroline Chung
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Diane D Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sarah McAvoy
- Department of Radiation Oncology, University of Maryland, Baltimore, Maryland, USA
| | - David Grosshans
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Karine Al Feghali
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jing Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Susan L McGovern
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mary-Fran McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Amol J Ghia
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Erik P Sulman
- Department of Radiation Oncology, NYU Grossman School of Medicine, New York, New York, USA
| | - Marta Penas-Prado
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - John F de Groot
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Amy B Heimberger
- Department of Neurosurgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jihong Wang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Terri S Armstrong
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Mark R Gilbert
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Nandita Guha-Thakurta
- Department of Neuroradiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeffrey S Wefel
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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15
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Skaarup M, Lundemann MJ, Darkner S, Jørgensen M, Marner L, Mirkovic D, Grosshans D, Peeler C, Mohan R, Vogelius IR, Appelt A. A framework for voxel-based assessment of biological effect after proton radiotherapy in pediatric brain cancer patients using multi-modal imaging. Med Phys 2021; 48:4110-4121. [PMID: 34021597 DOI: 10.1002/mp.14989] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 04/19/2021] [Accepted: 05/13/2021] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION The exact dependence of biological effect on dose and linear energy transfer (LET) in human tissue when delivering proton therapy is unknown. In this study, we propose a framework for measuring this dependency using multi-modal image-based assays with deformable registrations within imaging sessions and across time. MATERIALS AND METHODS 3T MRI scans were prospectively collected from 6 pediatric brain cancer patients before they underwent proton therapy treatment, and every 3 months for a year after treatment. Scans included T1-weighted with contrast enhancement (T1), T2-FLAIR (T2) and fractional anisotropy (FA) images. In addition, the planning CT, dose distributions and Monte Carlo-calculated LET distributions were collected. A multi-modal deformable image registration framework was used to create a dataset of dose, LET and imaging intensities at baseline and follow-up on a voxel-by-voxel basis. We modelled the biological effect of dose and LET from proton therapy using imaging changes over time as a surrogate for biological effect. We investigated various models to show the feasibility of the framework to model imaging changes. To account for interpatient and intrapatient variations, we used a nested generalized linear mixed regression model. The models were applied to predict imaging changes over time as a function of dose and LET for each modality. RESULTS Using the nested models to predict imaging changes, we saw a decrease in the FA signal as a function of dose; however, the signal increased with increasing LET. Similarly, we saw an increase in T2 signal as a function of dose, but a decrease in signal with LET. We saw no changes in T1 voxel values as a function of either dose or LET. CONCLUSIONS The imaging changes could successfully model biological effect as a function of dose and LET using our proposed framework. Due to the low number of patients, the imaging changes observed for FA and T2 scans were not marked enough to draw any firm conclusions.
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Affiliation(s)
- Mikkel Skaarup
- Department of Oncology, Rigshospitalet, Copenhagen, Denmark
- Faculty of Science, Niels Bohr Institute, University of Copenhagen, Copenhagen, Denmark
| | | | - Sune Darkner
- Department of Computer Science, University of Copenhagen, Copenhagen, Denmark
| | | | - Lisbeth Marner
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Dragan Mirkovic
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Grosshans
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Christopher Peeler
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Radhe Mohan
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ivan Richter Vogelius
- Department of Oncology, Rigshospitalet, Copenhagen, Denmark
- Faculty of Health and Medical Science, Copenhagen University, Copenhagen, Denmark
| | - Ane Appelt
- Leeds Institute of Medical Research at St James's, University of Leeds and Leeds Cancer Centre, St. James's University Hospital, Leeds, UK
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16
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Spiotto MT, McGovern SL, Gunn GB, Grosshans D, McAleer MF, Frank SJ, Paulino AC. Proton Radiotherapy to Reduce Late Complications in Childhood Head and Neck Cancers. Int J Part Ther 2021; 8:155-167. [PMID: 34285943 PMCID: PMC8270100 DOI: 10.14338/ijpt-20-00069.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 12/07/2020] [Indexed: 11/21/2022] Open
Abstract
In most childhood head and neck cancers, radiotherapy is an essential component of treatment; however, it can be associated with problematic long-term complications. Proton beam therapy is accepted as a preferred radiation modality in pediatric cancers to minimize the late radiation side effects. Given that childhood cancers are a rare and heterogeneous disease, the support for proton therapy comes from risk modeling and a limited number of cohort series. Here, we discuss the role of proton radiotherapy in pediatric head and neck cancers with a focus on reducing radiation toxicities. First, we compare the efficacy and expected toxicities in proton and photon radiotherapy for childhood cancers. Second, we review the benefit of proton radiotherapy in reducing acute and late radiation toxicities, including risks for secondary cancers, craniofacial development, vision, and cognition. Finally, we review the cost effectiveness for proton radiotherapy in pediatric head and neck cancers. This review highlights the benefits of particle radiotherapy for pediatric head and neck cancers to improve the quality of life in cancer survivors, to reduce radiation morbidities, and to maximize efficient health care use.
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Affiliation(s)
- Michael T Spiotto
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan L McGovern
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Brandon Gunn
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David Grosshans
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mary Frances McAleer
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven J Frank
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Arnold C Paulino
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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17
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Hanania A, Paulino A, Ludmir E, Shah V, McGovern S, Grosshans D, Okcu F, Baxter P, Su J, Chintagumpala M. RONC-05. PRESERVING VISION IN OPTIC PATHWAY GLIOMA AMONG PATIENTS WITHOUT NEUROFIBROMATOSIS TYPE 1. Neuro Oncol 2020. [PMCID: PMC7715108 DOI: 10.1093/neuonc/noaa222.778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
PURPOSE Sporadic optic pathway/hypothalamic gliomas (OP/HGs) represent a unique entity within pediatric low-grade glioma. Despite favorable survival, the location makes treatment difficult and local progression debilitating. We conducted longitudinal assessment of visual acuity (VA) among patients treated in the modern era with chemotherapy (CT) or early radiotherapy (RT). METHODS Clinical characteristics were abstracted for patients treated over a 15-year period (2000–2015) at a single institution. Comprehensive ophthalmologic data taken at three to six-month intervals was examined with age-appropriate VA metrics converted to LogMAR scale. Kaplan-Meir “blindness-free survival” (BFS) curves were calculated as time to bilateral functional blindness (i.e. LogMAR ≥ 0.8 in both eyes), stratified by treatment and compared using log-rank test. RESULTS Thirty-six patients with median follow-up of 7.6 years (range: 2–17) were identified. Median age at diagnosis was 2.5 years (IQR: <1–5). Early RT was administered as initial therapy (n=6) or first-line salvage (n=5) in a total of eleven patients (31%) at a mean age of 12 years (range: 6–17). Twenty-five patients (69%) were maintained primarily on CT with a mean age at initiation of 2.4 years (range <1–8). Of these, five patients received RT after ≥2 systemic therapy regimens. In terms of visual preservation, five/eight-year BFS rates were 84%/59% and 100%/100%, for CT and early RT, respectively (p=0.046). CONCLUSIONS In a contemporary cohort, early RT, defined as initial or 1st line salvage therapy for OP/HGs manifested in superior VA. Children undergoing CT are at highest risk of functional blindness following five years of treatment.
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Affiliation(s)
- Alexander Hanania
- Department of Radiation Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Arnold Paulino
- Department of Radiation Oncology, University of Texas M D Anderson Cancer Center, Houston, Texas, USA
| | - Ethan Ludmir
- Department of Radiation Oncology, University of Texas M D Anderson Cancer Center, Houston, Texas, USA
| | - Veeral Shah
- Department of Ophthalmology, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Susan McGovern
- Department of Radiation Oncology, University of Texas M D Anderson Cancer Center, Houston, Texas, USA
| | - David Grosshans
- Department of Radiation Oncology, University of Texas M D Anderson Cancer Center, Houston, Texas, USA
| | - Fatih Okcu
- Texas Children’s Cancer Center, Baylor College of Medicine, Houston, Texas, USA
| | - Patricia Baxter
- Texas Children’s Cancer Center, Baylor College of Medicine, Houston, Texas, USA
| | - Jack Su
- Texas Children’s Cancer Center, Baylor College of Medicine, Houston, Texas, USA
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18
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Baig M, Osthoorn I, McGovern S, Grosshans D, McAleer M, Woodhouse K, Paulino A, Yang G, Stavinoha P, Zaky W. QOL-28. NEUROCOGNITIVE PROFILE OF PEDIATRIC MEDULLOBLASTOMA PATIENTS PRIOR TO RADIATION THERAPY. Neuro Oncol 2020. [PMCID: PMC7715197 DOI: 10.1093/neuonc/noaa222.690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Neurocognitive late effects are unfortunately common following treatment for pediatric medulloblastoma. While radiation therapy is an essential component of treatment for most pediatric medulloblastoma patients, it is associated with neurocognitive compromise. Effects include deficits in cognitive speed and performance efficiency, aspects of attention, as well as working memory. Yet long after treatment it is difficult to tease apart relative contributions of other risk factors to neurocognitive functioning beyond radiation. We examined neurocognitive functioning in a sample of pediatric medulloblastoma patients prior to radiation therapy, including investigation of neurocognitive risk factors such as hydrocephalus, presence of posterior fossa syndrome, and duration of neurological symptoms prior to diagnosis. Results indicated that the sample functioned in the average range in terms of overall IQ (n=34, X̅=103). Patients also functioned in the normal range in terms of language-based ability (X̅=106), nonverbal ability (X̅=104), and working memory (X̅=103). However, the sample performed statistically significantly lower than the general population in terms of cognitive speed and efficiency (z=-2.026, p=.043). The sample was also rated by parents as exhibiting more attention problems relative to the general population (z=1.988, p=.047). There was no specific association with hydrocephalus, duration of symptoms, or history of posterior fossa syndrome. Results suggest weaknesses in attention and processing speed may exist in some pediatric medulloblastoma patients prior to radiation therapy secondary to tumor and related complications. Implications for future research are presented, along with difficulties inherent to “baseline” assessment with pediatric brain tumor survivors.
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Affiliation(s)
| | | | | | | | | | | | | | - Grace Yang
- MD Anderson Cancer Center, Houston, TX, USA
| | | | - Wafik Zaky
- MD Anderson Cancer Center, Houston, TX, USA
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19
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Woodhouse K, Alvarez VA, Boyce D, Li J, Yeboa D, Grosshans D, Briere T, Tatsui C, Rhines L, Behrang A, McGovern S, Paulino A, McAleer MF, Ghia A. RONC-17. STEREOTACTIC RADIOSURGERY FOR SPINE METASTASES IN PEDIATRIC MALIGNANCIES. Neuro Oncol 2020. [PMCID: PMC7715826 DOI: 10.1093/neuonc/noaa222.786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Spine stereotactic radiosurgery (SSRS) is a non-invasive technique that delivers ablative radiotherapy for optimal control of bony disease. While SSRS is known to provide excellent local control (LC) and minimal toxicity in adults, the role of SSRS in pediatrics is less clear.
PURPOSE
To evaluate SSRS in pediatric patients with spinal metastases.
METHODS
A retrospective review of patients (<18 yrs) treated with SSRS at MDACC was performed after IRB approval. Descriptive statistics were utilized for analysis.
RESULTS
From 2011–2019, 12 metastatic osseous sites (3 cervical, 4 thoracic, 5 lumbar-sacral) in 9 patients were treated. Median follow-up was 9 months (range 2–41). Six males (67%) and 3 females (33%) all KPS ≥70, received radiation to ≤3 contiguous vertebral bodies. Median age was 16 yrs (range 8–18). No patients required sedation. Histologies included 7 osteosarcomas, one rhabdomyosarcoma and one Ewing’s sarcoma. Metastatic epidural spinal cord compression scores ranged from 0 (6), 1b (3) and 3 (3). No sites had surgery prior to SSRS and one site received prior conventional radiation. SSRS doses included 24 Gy in 1 fraction (7), 24–27 Gy in 3 fractions (4) and 50 Gy in 5 fractions (1). Six-month LC was 83% with one local failure following 27 Gy. OS at 6 and 12 mo were 55% and 23%. There was no grade ≥3 acute toxicity, no radiation myelopathy or vertebral compression fractures.
CONCLUSION
In this initial report, SSRS represents a promising modality that is well tolerated and provides excellent LC. However, further follow-up is warranted in the pediatric setting.
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Affiliation(s)
| | - Victor Albornoz Alvarez
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
| | - David Boyce
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Jing Li
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Debra Yeboa
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - David Grosshans
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Tina Briere
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Claudio Tatsui
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Laurence Rhines
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Amini Behrang
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Susan McGovern
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Arnold Paulino
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | | | - Amol Ghia
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA
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20
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Kahalley L, Peterson R, Ris MD, Janzen L, Okcu MF, Grosshans D, Ramaswamy V, Paulino A, Hodgson D, Mahajan A, Tsang D, Laperriere N, Whitehead W, Dauser R, Taylor M, Conklin H, Bouffet E, Chintagumpala M, Mabbott D. QOL-01. LONGITUDINAL COMPARISON OF NEUROCOGNITIVE TRAJECTORIES IN PEDIATRIC MEDULLOBLASTOMA PATIENTS TREATED WITH PROTON VERSUS PHOTON RADIOTHERAPY. Neuro Oncol 2020. [PMCID: PMC7715279 DOI: 10.1093/neuonc/noaa222.667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
PURPOSE By reducing dose to normal brain tissue, proton radiotherapy (PRT) may lessen neurocognitive risk traditionally associated with photon radiotherapy (XRT). We examined change in neurocognitive scores over time in pediatric medulloblastoma patients treated with PRT versus XRT. METHODS Neurocognitive scores from 79 patients (37 PRT, 42 XRT) were examined. Patients were treated between 2007–2018 on the same treatment protocols that differed only by craniospinal modality (PRT versus XRT). Change in scores over time since diagnosis were compared between groups. RESULTS Groups were similar on most demographic/clinical variables: sex (67.1% male), age at diagnosis (mean 8.6 years), CSI dose (median 23.4 Gy), length of follow-up (mean 4.3 years), and parental education (mean 14.3 years). Boost dose (p<0.001) and margin (p=0.001) differed between groups. Adjusting for covariates, the PRT group exhibited superior outcomes in global IQ, perceptual reasoning, and working memory versus the XRT group (all p<0.05). The XRT group exhibited significant decline in global IQ, working memory, and processing speed (all p<0.05). The PRT group exhibited stable scores in all domains except processing speed (p=0.003). Posterior fossa syndrome imparted risk independent of modality. CONCLUSION This is the first study comparing neurocognitive trajectories between pediatric patients treated for medulloblastoma with PRT versus XRT on comparable, contemporary protocols. PRT was associated with more favorable neurocognitive outcomes in most domains compared to XRT, although processing speed emerged as vulnerable in both groups. This is the strongest evidence to date of an intellectual sparing advantage with PRT in the treatment of pediatric medulloblastoma.
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Affiliation(s)
- Lisa Kahalley
- Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | | | - M Douglas Ris
- Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | - Laura Janzen
- The Hospital for Sick Children, Toronto, ON, Canada
| | - M Fatih Okcu
- Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | | | - Vijay Ramaswamy
- The Hospital for Sick Children, Toronto, ON, Canada
- The University of Toronto, Toronto, ON, Canada
| | | | - David Hodgson
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | - Derek Tsang
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | - William Whitehead
- Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | | | - Michael Taylor
- The Hospital for Sick Children, Toronto, ON, Canada
- The University of Toronto, Toronto, ON, Canada
| | | | - Eric Bouffet
- The Hospital for Sick Children, Toronto, ON, Canada
- The University of Toronto, Toronto, ON, Canada
| | - Murali Chintagumpala
- Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | - Donald Mabbott
- The Hospital for Sick Children, Toronto, ON, Canada
- The University of Toronto, Toronto, ON, Canada
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21
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Baig M, McAleer M, Grosshans D, Paulino A, Baxter P, Chintagumpala M, Zaky W, McGovern S. MBCL-35. SALVAGE RADIATION THERAPY FOR PROGRESSIVE AND/OR RELAPSED PEDIATRIC MEDULLOBLASTOMA. Neuro Oncol 2020. [PMCID: PMC7715850 DOI: 10.1093/neuonc/noaa222.511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Medulloblastoma (MB) has a dismal prognosis after progression or relapse, and there is no standard of care for salvage therapy. Medical records of pediatric patients with progressive/relapsed MB were reviewed for clinical characteristics. We identified 23 patients with recurrent MB with median age at diagnosis of 3.8 years, 14 males (60%). At diagnosis, 16 patients had gross total resection, 1 near total, 5 subtotal, and 1 had biopsy alone. Fifteen patients (66%) had metastatic disease. Tumor histology was classic/nodular in 10, 4 desmoplastic, 8 anaplastic and 1 myogenic. Ten patients (43%) ages < 3 years, were treated with induction chemotherapy followed by high dose chemo and stem cell rescue. Other 13 patients were treated with chemoradiation (11 craniospinal and 2 posterior fossa radiation). Progression free survival after initial treatment was 11 months (range, 3–58 months); 8 patients (34%) had local recurrence, 10 patients (43%) had distant metastasis, 4 patients (17%) had local and distant, and one patient had CSF only recurrence. Salvage therapy was surgery followed by radiation in 12 patients (52%), radiation alone in 3 patients (13%), chemoradiation in 7 patients (30%), and chemotherapy alone in 1 patient. Thirteen patients (56%) received CSI, 6 (26%) received focal and 2 received spinal radiation only. Five year progression free survival and overall survival from the time of relapse were 25% and 45%, respectively. Multidisciplinary care is essential for patients with relapsed MB. Salvage radiation that accounts for the patient’s initial treatment volumes should be considered for these patients.
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Affiliation(s)
| | | | | | | | | | | | - Wafik Zaky
- MD Anderson Cancer Center, Houston, TX, USA
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22
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Gibson A, Baig M, Raza S, Grosshans D, Zaky W. RARE-44. CLINICAL CHARACTERIZATION AND OUTCOME; OUR EXPERIENCE OF CHORDOMAS IN PEDIATRIC AND YOUNG ADULTS. Neuro Oncol 2020. [PMCID: PMC7715682 DOI: 10.1093/neuonc/noaa222.754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Pediatric chordomas are exceedingly rare and there are limited data to guide treatment decisions. We report a retrospective analysis of 19 patients with chordomas who received treatment at our institution from 2001–2020. Of the 19 patients, 15 had clival (79%), 3 cervical and 1 sacral chordoma. There were 9 males (47%). Median age at diagnosis of 10.6 years. Eight patients had gross total (42%) and 11 (58%) had sub-total resection. As front line therapy 15 patients (79%) underwent surgery followed by radiation (1 photon and 14 proton), 3 patients (16%) received surgery and chemotherapy (anaplastic histology) and 1 patient received only surgery. For patients treated with radiation therapy the average prescribed dose was 70 Gy (range: 52–74). Post-surgery and radiation, 14 of 15 patients remained in remission. Five (26%) patients had progressive disease (PD) with median time to progression of 13 months of whom 3 died of disease at median of 18 months. Treatment of PD consisted of chemotherapy and radiation for 3, re-resection with radiation for 1 and chemotherapy alone for 1 patient. The patients with metastatic and anaplastic disease mean survival is 21 month versus 45 for the rest of the cohort. In summary, post-operative adjuvant radiation provided an overall good outcome in majority of patients. Patients with anaplastic pathology and metastasis at diagnosis had worse outcome. Those who relapsed, subsequent treatment was palliative at best with short survival. Molecular analysis is warranted in future for better disease stratification.
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Affiliation(s)
| | | | - Shaan Raza
- MD Anderson Cancer Center, Houston, TX, USA
| | | | - Wafik Zaky
- MD Anderson Cancer Center, Houston, TX, USA
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23
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McGovern S, Johnson J, Kralik S, Grosshans D, McAleer MF, Zaky W, Baxter P, Lin F, Chintagumpala M, Paulino A. RONC-09. PSEUDOPROGRESSION AFTER PROTON THERAPY OF PEDIATRIC SPINAL PILOCYTIC ASTROCYTOMA AND MYXOPAPILLARY EPENDYMOMA. Neuro Oncol 2020. [PMCID: PMC7715742 DOI: 10.1093/neuonc/noaa222.781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Pseudoprogression after proton therapy of CNS tumors is a challenging clinical situation. The rate of pseudoprogression after proton therapy of pediatric spinal tumors is unknown. METHODS Records of pediatric patients with spinal pilocytic astrocytoma (sPA; n = 9) or myxopapillary ependymoma (MPE; n = 6) with gross disease treated with proton therapy with at least 6 months of follow up from completion of proton therapy were retrospectively reviewed for demographics, treatment characteristics, and occurrence of pseudoprogression. Pseudoprogression was defined as a post-radiation increase in tumor size with subsequent decrease in size without additional tumor-directed therapy. RESULTS The median age at radiation for sPA patients was 10.1y (range, 7.0 – 16.2y) and 12.7y (range, 7.9 – 14.4y) for MPE patients. The median prescribed dose was 45 GyRBE (range, 39.6 – 50.4 GyRBE) for sPA patients and 50.4 GyRBE (range, 45 – 54 GyRBE) for MPE patients. One sPA patient received concurrent vincristine. Median follow up after proton therapy was 44 months (range, 9 – 99 months). Six of nine sPA patients (67%) had pseudoprogression occurring at a median of 81 days (range, 34 – 136 days) after proton therapy; no MPE patients developed pseudoprogression (0%; p < 0.03). Two sPA patients with pseudoprogression were symptomatic and improved with medical therapy. CONCLUSION Preliminary analysis suggests that pseudoprogression occurs frequently within 6 months after proton therapy for sPA and infrequently after proton therapy for MPE.
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Affiliation(s)
| | | | | | | | | | - Wafik Zaky
- MD Anderson Cancer Center, Houston, TX, USA
| | | | - Frank Lin
- Texas Children’s Hospital, Houston, TX, USA
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24
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Heitzer A, Kahalley L, Grosshans D, Okcu MF, Raghubar K, Gragert M, McCurdy M, Warren E, Ris MD, Paulino A, Chintagumpala M. RONC-12. TREATMENT AGE AND NEUROCOGNITIVE OUTCOMES FOLLOWING PROTON BEAM RADIOTHERAPY FOR PEDIATRIC LOW GRADE GLIOMA. Neuro Oncol 2020. [PMCID: PMC7715617 DOI: 10.1093/neuonc/noaa222.782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Younger age at radiotherapy increases cognitive risk for patients with pediatric low grade glioma (LGG). We examined the impact of age at treatment on cognitive trajectories in LGG patients treated with proton radiotherapy (PRT) compared to patients treated without radiotherapy (surgery only; SO). METHODS We examined cognitive scores of 48 LGG patients on a prospective, longitudinal study. General linear mixed models evaluated change in cognitive scores over time. RESULTS The sample included 16 patients treated with PRT and 32 with SO (median follow-up=3.1 years, range 0.9–6.1). Median age of PRT patients was 8.2 years at diagnosis (range 1.0–14.4) and 9.4 years at PRT (range 4.2–16.7). 13 PRT patients also received surgery: 53.8% biopsy, 30.8% subtotal resection, 15.4% gross total resection. Tumor sites included: 31.2% hypothalamic/suprasellar, 25.0% optic pathway, 18.8% temporal, 25.0% other. Median age of SO patients was 8.2 years at diagnosis (range 2.9–18.6). Surgical outcomes were: 75.0% gross total resection, 21.9% biopsy/other. There were no group differences in diagnosis age, tumor volume, or shunt history (all p>0.05). Both PRT and SO groups displayed stable cognitive functioning over time (all p>0.1). Slopes (i.e., change in scores over time) did not differ between groups (all p>0.1). Age at treatment was not associated with slope or performance at last follow-up in either group (all p>0.05). CONCLUSIONS We observed stable cognitive functioning, independent of age at treatment, following PRT for LGG. Outcomes were similar to patients receiving surgery only. Further examination in a larger sample is warranted.
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Affiliation(s)
- Andrew Heitzer
- Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | - Lisa Kahalley
- Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | | | - M Fatih Okcu
- Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | - Kimberly Raghubar
- Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | - Marsha Gragert
- Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | - Mark McCurdy
- Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | - Emily Warren
- Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | | | | | - Murali Chintagumpala
- Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
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25
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Bronk L, Singh S, Thomas R, Parkitny L, Maletic-Savatic M, Mohan R, Lang F, Grosshans D. RBIO-06. IMPLEMENTATION OF HUMAN INDUCED PLURIPOTENT STEM CELL DERIVED CEREBRAL ORGANOIDS TO MODEL NORMAL TISSUE RADIORESPONSE. Neuro Oncol 2020. [DOI: 10.1093/neuonc/noaa215.806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Treatment-related sequelae following cranial irradiation have life changing impacts for patients and their caregivers. Characterization of the basic response of human brain tissue to irradiation has been difficult due to a lack of preclinical models. The direct study of human brain tissue in vitro is becoming possible due to advances in stem cell biology, neuroscience, and tissue engineering with the development of organoids as novel model systems which enable experimentation with human tissue models. We sought to establish a cerebral organoid (CO) model to study the radioresponse of normal human brain tissue. COs were grown using human induced pluripotent stem cells and a modified Lancaster protocol. Compositional analysis during development of the COs showed expected populations of neurons and glia. We confirmed a population of microglia-like cells within the model positive for the makers Iba1 and CD68. After 2-months of maturation, COs were irradiated to 0, 10, and 20 Gy using a Shepard Mark-II Cs-137 irradiator and returned to culture. Subsets of COs were prepared for immunostaining at 30- and 70-days post-irradiation. To examine the effect of irradiation on the neural stem cell (NSC) population, sections were stained for SOX2 and Ki-67 expression denoting NSCs and proliferation respectively. Slides were imaged and scored using the CellProfiler software package. The percentage of proliferating NSCs 30-days post-irradiation was found to be significantly reduced for irradiated COs (5.7% (P=0.007) and 3.4% (P=0.001) for 10 and 20 Gy respectively) compared to control (12.7%). The reduction in the proliferating NSC population subsequently translated to a reduced population of NeuN-labeled mature neurons 70 days post-irradiation. The loss of proliferating NSCs and subsequent reduction in mature neurons demonstrates the long-term effects of radiation. Our initial results indicate COs will be a valuable model to study the effects of radiation therapy on normal and diseased human tissue.
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26
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Abolfath R, Grosshans D, Mohan R. Oxygen depletion in FLASH ultra-high-dose-rate radiotherapy: A molecular dynamics simulation. Med Phys 2020; 47:6551-6561. [PMID: 33089504 DOI: 10.1002/mp.14548] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 10/03/2020] [Accepted: 10/08/2020] [Indexed: 11/07/2022] Open
Abstract
PURPOSE We present a first-principles molecular dynamics (MD) simulation and expound upon a mechanism of oxygen depletion hypothesis to explain the mitigation of normal tissue injury observed in ultra-high-dose-rate (UHDR) FLASH radiotherapy. METHODS We simulated damage to a segment of DNA (also representing other biomolecules such as RNA and proteins) in a simulation box filled with H 2 O and O 2 molecules. Attoseconds physical interactions (ionizations, electronic, and vibrational excitations) were simulated by using the Monte Carlo track structure code Geant4-DNA. Immediately after ionization, ab initio Car-Parrinello molecular dynamics (CPMD) simulation was used to identify which H 2 O and O 2 molecules surrounding the DNA molecule were converted into reactive oxygen species (ROS). Subsequently, the femto- to nanosecond reactions of ROS were simulated by using MD with reactive force field (ReaxFF), to illustrate ROS merging into new types of non-reactive oxygen species (NROS) due to strong coupling among ROS. A coarse-grained model was constructed to describe the relevant collective phenomenon at the macroscopic level on ROS aggregation and formation of NROS agglomerates consistent with the underlying microscopic pathways obtained from MD simulations. RESULTS Time-dependent molecular simulations revealed the formation of metastable and transient spaghetti-like complexes among ROS generated at UHDR. At the higher ROS densities produced under UHDR, stranded chains (i.e., NROS) are produced, mediated through attractive electric polarity forces, hydrogen bonds, and magnetic dipole-dipole interactions among hydroxyl ( . OH ) radicals. NROS tend to be less mobile than cellular biomolecules as opposed to the isolated and sparsely dense ROS generated at conventional dose rates (CDR). We attribute this effect to the suppression of biomolecular damage induced per particle track. At a given oxygen level, as the dose rate increases, the size and number of NROS chains increase, and correspondingly the population of toxic ROS components decreases. Similarly, at a given high dose rate, as the oxygen level increases, so do the size and number of NROS chains until an optimum level of oxygen is reached. Beyond that level, the amount of oxygen present may be sufficient to saturate the production of NROS chains, thereby reversing the sparing effects of UHDRs. CONCLUSIONS We showed that oxygen depletion, hypothesized to lead to lower normal-tissue toxicity at FLASH dose rates, takes place within femto- to nanoseconds after irradiation. The mechanism is governed by the slow dynamics of chains of ROS complexes (NROS). Under physoxic (≈ 4-5% oxygen) conditions (i.e., in normal tissues), NROS are more abundant than in hypoxic conditions (e.g., <0.3% in parts of tumors), suggesting that biomolecular damage would be reduced in an environment with physoxic oxygen levels. Hence irradiation at UHDRs would be more effective for sparing physoxic normal tissues but not tumors containing regions of hypoxia. At much higher levels of oxygen (e.g., >10-15%), oxygen depletion by UHDRs may not be sufficient for tissue sparing.
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Affiliation(s)
- Ramin Abolfath
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, TX, 75031, USA.,Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, 19104, USA.,Department of Radiation Oncology, New Jersey Urology, West Orange, NJ, 07052, USA
| | - David Grosshans
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, 75031, USA
| | - Radhe Mohan
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, TX, 75031, USA
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27
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Lin TA, Ludmir EB, Liao KP, McAleer MF, Bishop AJ, Grosshans D, McGovern S, Woodhouse KD, Paulino AC, Yeboa DN. Relationship between treatment center case volume and survival for localized Ewing sarcoma: The role of radiotherapy timing. Pediatr Blood Cancer 2020; 67:e28685. [PMID: 32881378 DOI: 10.1002/pbc.28685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 08/18/2020] [Accepted: 08/20/2020] [Indexed: 11/06/2022]
Abstract
In the treatment of localized Ewing sarcoma (EWS), delays in local therapy are known to adversely impact overall survival (OS). However, the role of treatment center volume in EWS outcomes, and the interaction between center volume and local therapy timing with definitive radiotherapy, remains unknown. Using the National Cancer Database, we demonstrate that treatment at the lowest EWS volume centers is associated with reduced OS, explained partly by higher rates of delayed local therapy. Treatment at the highest volume centers results in improved OS, but appears independent of radiotherapy timing. Future efforts to improve care for EWS patients across treatment centers are imperative.
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Affiliation(s)
- Timothy A Lin
- The University of Texas MD Anderson Cancer Center, Houston, Texas.,The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ethan B Ludmir
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kai-Ping Liao
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Andrew J Bishop
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David Grosshans
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Susan McGovern
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Arnold C Paulino
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Debra Nana Yeboa
- The University of Texas MD Anderson Cancer Center, Houston, Texas
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28
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Toussaint L, Eskildsen S, Casares-Magaz O, Stokkevåg C, Lassen-Ramshad Y, Hasle H, Tofting-Olesen K, Grosshans D, Mohan R, Høyer M, Muren L. PO-1721: A voxel-based method to quantify longitudinal MRI changes after pediatric brain irradiation. Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(21)01739-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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29
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Bai X, Lim G, Grosshans D, Mohan R, Cao W. A biological effect-guided optimization approach using beam distal-edge avoidance for intensity-modulated proton therapy. Med Phys 2020; 47:3816-3825. [PMID: 32557747 DOI: 10.1002/mp.14335] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 05/03/2020] [Accepted: 06/02/2020] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Linear energy transfer (LET)-guided methods have been applied to intensity-modulated proton therapy (IMPT) to improve its biological effect. However, using LET as a surrogate for biological effect ignores the topological relationship of the scanning spot to different structures of interest. In this study, we developed an optimization method that takes advantage of the continuing increase in LET beyond the physical dose Bragg peak. This method avoids placing high biological effect values in critical structures and increases biological effect in the tumor area without compromising target coverage. METHODS We selected the cases of two patients with brain tumors and two patients with head and neck tumors who had been treated with proton therapy at our institution. Three plans were created for each case: a plan based on conventional dose-based optimization (DoseOpt), one based on LET-incorporating optimization (LETOpt), and one based on the proposed distal-edge avoidance-guided optimization method (DEAOpt). In DEAOpt, an L1 -norm sparsity term, in which the penalty of each scanning spot was set according to the topological relationship between the organ positions and the location of the peak scaled LET-weighted dose (c LETxD) was added to a conventional dose-based optimization objective function. All plans were normalized to give the same target dose coverage. Dose (assuming a constant relative biological effectiveness value of 1.1, as in clinical practice), biological effect (c LETxD), and computing time consumption were evaluated and compared among the three optimization approaches for each patient case. RESULTS For all four cases, all three optimization methods generated comparable dose coverage in both target and critical structures. The LETOpt plans and DEAOpt plans reduced biological effect hot spots in critical structures and increased biological effect in the target volumes to a similar extent. For the target, the c LETxD98% and c LETxD2% in the DEAOpt plans were on average 7.2% and 11.74% higher than in the DoseOpt plans, respectively. For the brainstem, the c LETxDmean in the DEAOpt plans was on average 33.38% lower than in the DoseOpt plans. In addition, the DEAOpt method saved 30.37% of the computation cost over the LETOpt method. CONCLUSIONS DEAOpt is an alternative IMPT optimization approach that correlates the location of scanning spots with biological effect distribution. IMPT could benefit from the use of DEAOpt because this method not only delivers comparable biological effects to LETOpt plans, but also is faster.
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Affiliation(s)
- Xuemin Bai
- Department of Industrial Engineering, University of Houston, Houston, TX, 77004, USA.,Linking Medical Technology, Beijing, 100085, China
| | - Gino Lim
- Department of Industrial Engineering, University of Houston, Houston, TX, 77004, USA
| | - David Grosshans
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Radhe Mohan
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Wenhua Cao
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
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30
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Abolfath R, Helo Y, Carlson DJ, Stewart R, Grosshans D, Mohan R. A new approach to modeling the microdosimetry of proton therapy beams. Med Phys 2020; 47:3184-3190. [PMID: 32249429 PMCID: PMC10019905 DOI: 10.1002/mp.14165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 03/12/2020] [Accepted: 03/26/2020] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION To revisit the formulation of the mean chord length in microdosimetry and replace it by the particle mean free path appropriate for modelings in radiobiology. METHODS We perform a collision-by-collision followed by event-by-event Geant4 Monte Carlo simulation and calculate double-averaged stepping length, 〈〈l〉〉, for a range of target sizes from mm down to μm and depth in water. We consider 〈〈l〉〉 to represent the particle mean free path. RESULTS We show that 〈〈l〉〉 continuously drops as a function of depth and asymptotically saturates to a minimum value in low energies, where it exhibits a universal scaling behavior, independent of particle nominal beam energy. We correlate 〈〈l〉〉 to linear density of DNA damage, complexities of initial lethal lesions and illustrate a relative difference between predictive RBEs in model calculations using mean chord length vs the proposed mean free path. We demonstrate consistency between rapid increase in RBE within and beyond the Bragg peak and 〈〈l〉〉, a decreasing function of depth. DISCUSSION AND CONCLUSION An interplay between localities in imparted energy at nanometer scale and subsequent physio-chemical processes, causalities and pathways in DNA damage requires substitution of geometrical chord length of cell nuclei by mean-free path of proton and charged particles to account for a mean distance among sequential collisions in DNA materials. To this end, the event averaging over cell volume in the current microdosimetry formalism must be superseded by the collision averaging scored within the volume. The former, is fundamentally a global attribute of the cell nuclei surfaces and boundaries and is characterized by their membrane diameters, hence such global indices are not appropriate to quantitatively represent the radiobiological strength of the particles and their RBE variabilities that is associated with the sensitivities to local structure of the collisions and their spatio-temporal collective patterns in DNA materials.
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Affiliation(s)
- Ramin Abolfath
- Department of Radiation Physics and Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, 75031, USA.,Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Yusuf Helo
- Department of Medical Physics and Bioengineering, University College London, London, UK
| | - David J Carlson
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Robert Stewart
- School of Medicine, Department of Radiation Oncology, University of Washington, Seattle, WA, 98195, USA
| | - David Grosshans
- Department of Radiation Physics and Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, 75031, USA
| | - Radhe Mohan
- Department of Radiation Physics and Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, 75031, USA
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31
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Noticewala SS, Ludmir EB, Bishop AJ, Chung C, Ghia AJ, Grosshans D, McGovern S, Paulino ADLC, Wang C, Woodhouse KD, Yeboa DN, Prabhu SS, Weathers SP, Das P, Koong AC, McAleer MF, Li J. Radiation for Glioblastoma in the Era of Coronavirus Disease 2019 (COVID-19): Patient Selection and Hypofractionation to Maximize Benefit and Minimize Risk. Adv Radiat Oncol 2020; 5:743-745. [PMID: 32775785 PMCID: PMC7251361 DOI: 10.1016/j.adro.2020.04.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 04/16/2020] [Accepted: 04/16/2020] [Indexed: 11/16/2022] Open
Abstract
We describe the institutional guidelines of a major tertiary cancer center with regard to using hypofractionated radiation regimens to treat glioblastoma as a measure to minimize exposure to coronavirus disease 2019 (COVID-19) while not sacrificing clinical outcomes. Our guidelines review level one evidence of various hypofractionated regimens, and recommend a multidisciplinary approach while balancing the risk of morbidity and mortality among individuals at high risk for severe illness from COVID-19 infection. We also briefly outline strategies our department is taking in mitigating risk among our cancer patients undergoing radiation.
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Affiliation(s)
- Sonal S Noticewala
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ethan B Ludmir
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Andrew J Bishop
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Caroline Chung
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amol J Ghia
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David Grosshans
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Susan McGovern
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Chenyang Wang
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kristina D Woodhouse
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Debra N Yeboa
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sujit S Prabhu
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shiao-Pei Weathers
- Department of Neurooncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Prajnan Das
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Albert C Koong
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mary Frances McAleer
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jing Li
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Abolfath R, Peeler C, Mirkovic D, Mohan R, Grosshans D. A DNA damage multiscale model for NTCP in proton and hadron therapy. Med Phys 2020; 47:2005-2012. [PMID: 31955444 PMCID: PMC10015418 DOI: 10.1002/mp.14034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 12/18/2019] [Accepted: 01/03/2020] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To develop a first principle and multiscale model for normal tissue complication probability (NTCP) as a function of dose and LET for proton and in general for particle therapy with a goal of incorporating nanoscale radio-chemical to macroscale cell biological pathways, spanning from initial DNA damage to tissue late effects. METHODS The method is a combination of analytical and multiscale computational steps including (a) derivation of functional dependencies of NTCP on DNA-driven cell lethality in nanometer and mapping to dose and LET in millimeter, and (b) three-dimensional-surface fitting to Monte Carlo data set generated based on postradiation image change and gathered for a cohort of 14 pediatric patients treated by scanning beam of protons for ependymoma. We categorize voxel-based dose and LET associated with development of necrosis in NTCP. RESULT Our model fits well the clinical data, generated for postradiation tissue toxicity and necrosis. The fitting procedure results in extraction of in vivo radio-biological α-β indices and their numerical values. DISCUSSION AND CONCLUSION The NTCP model, explored in this work, allows to correlate the tissue toxicities to DNA initial damage, cell lethality and the properties and qualities of radiation, dose, and LET.
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Brown PD, Gondi V, Pugh S, Tome WA, Wefel JS, Armstrong TS, Bovi JA, Robinson C, Konski A, Khuntia D, Grosshans D, Benzinger TLS, Bruner D, Gilbert MR, Roberge D, Kundapur V, Devisetty K, Shah S, Usuki K, Anderson BM, Stea B, Yoon H, Li J, Laack NN, Kruser TJ, Chmura SJ, Shi W, Deshmukh S, Mehta MP, Kachnic LA. Hippocampal Avoidance During Whole-Brain Radiotherapy Plus Memantine for Patients With Brain Metastases: Phase III Trial NRG Oncology CC001. J Clin Oncol 2020; 38:1019-1029. [PMID: 32058845 PMCID: PMC7106984 DOI: 10.1200/jco.19.02767] [Citation(s) in RCA: 413] [Impact Index Per Article: 103.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2020] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Radiation dose to the neuroregenerative zone of the hippocampus has been found to be associated with cognitive toxicity. Hippocampal avoidance (HA) using intensity-modulated radiotherapy during whole-brain radiotherapy (WBRT) is hypothesized to preserve cognition. METHODS This phase III trial enrolled adult patients with brain metastases to HA-WBRT plus memantine or WBRT plus memantine. The primary end point was time to cognitive function failure, defined as decline using the reliable change index on at least one of the cognitive tests. Secondary end points included overall survival (OS), intracranial progression-free survival (PFS), toxicity, and patient-reported symptom burden. RESULTS Between July 2015 and March 2018, 518 patients were randomly assigned. Median follow-up for alive patients was 7.9 months. Risk of cognitive failure was significantly lower after HA-WBRT plus memantine versus WBRT plus memantine (adjusted hazard ratio, 0.74; 95% CI, 0.58 to 0.95; P = .02). This difference was attributable to less deterioration in executive function at 4 months (23.3% v 40.4%; P = .01) and learning and memory at 6 months (11.5% v 24.7% [P = .049] and 16.4% v 33.3% [P = .02], respectively). Treatment arms did not differ significantly in OS, intracranial PFS, or toxicity. At 6 months, using all data, patients who received HA-WBRT plus memantine reported less fatigue (P = .04), less difficulty with remembering things (P = .01), and less difficulty with speaking (P = .049) and using imputed data, less interference of neurologic symptoms in daily activities (P = .008) and fewer cognitive symptoms (P = .01). CONCLUSION HA-WBRT plus memantine better preserves cognitive function and patient-reported symptoms, with no difference in intracranial PFS and OS, and should be considered a standard of care for patients with good performance status who plan to receive WBRT for brain metastases with no metastases in the HA region.
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Affiliation(s)
| | - Vinai Gondi
- Northwestern Medicine Cancer Center Warrenville and Northwestern Medicine Proton Center, Warrenville, IL
| | - Stephanie Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
| | - Wolfgang A. Tome
- Montefiore Medical Center, Albert Einstein College of Medicine, The Bronx, NY
| | | | | | - Joseph A. Bovi
- Froedtert & the Medical College of Wisconsin, Milwaukee, WI
| | | | | | - Deepak Khuntia
- East Bay Radiation Oncology Center, Eden Medical Center, Castro Valley, CA
| | - David Grosshans
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Deborah Bruner
- Winship Cancer Institute of Emory University, Atlanta, GA
| | - Mark R. Gilbert
- National Cancer Institute Center for Cancer Research, Bethesda, MD
| | - David Roberge
- CHUM-Hôtel-Dieu de Montréal, Montreal, Quebec, Canada
| | | | - Kiran Devisetty
- Wayne State University, Karmanos Cancer Institute, Detroit, MI
| | - Sunjay Shah
- ChristianaCare National Cancer Institute Community Oncology Research Program, Newark, DE
| | | | | | - Baldassarre Stea
- University of Arizona Medical Center-University Campus, Tucson, AZ
| | - Harold Yoon
- Heartland Cancer Research National Cancer Institute Community Oncology Research Program, Decatur, IL
| | - Jing Li
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - Steven J. Chmura
- The University of Chicago Comprehensive Cancer Center, Chicago, IL
| | - Wenyin Shi
- Thomas Jefferson University Hospital, Philadelphia, PA
| | - Snehal Deshmukh
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
| | | | - Lisa A. Kachnic
- Vanderbilt University Medical Center, Ingram Cancer Center, Nashville, TN
| | - for NRG Oncology
- Mayo Clinic, Rochester, MN
- Northwestern Medicine Cancer Center Warrenville and Northwestern Medicine Proton Center, Warrenville, IL
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
- Montefiore Medical Center, Albert Einstein College of Medicine, The Bronx, NY
- The University of Texas MD Anderson Cancer Center, Houston, TX
- National Cancer Institute Center for Cancer Research, Bethesda, MD
- Froedtert & the Medical College of Wisconsin, Milwaukee, WI
- Washington University in St Louis, St Louis, MO
- Chester County Hospital, West Chester, PA
- East Bay Radiation Oncology Center, Eden Medical Center, Castro Valley, CA
- Winship Cancer Institute of Emory University, Atlanta, GA
- CHUM-Hôtel-Dieu de Montréal, Montreal, Quebec, Canada
- Saskatoon Cancer Center, Saskatoon, Saskatchewan, Canada
- Wayne State University, Karmanos Cancer Institute, Detroit, MI
- ChristianaCare National Cancer Institute Community Oncology Research Program, Newark, DE
- University of Rochester, Rochester, NY
- University of Wisconsin Hospitals and Clinics, Madison, WI
- University of Arizona Medical Center-University Campus, Tucson, AZ
- Heartland Cancer Research National Cancer Institute Community Oncology Research Program, Decatur, IL
- Northwestern Memorial Hospital, Chicago, IL
- The University of Chicago Comprehensive Cancer Center, Chicago, IL
- Thomas Jefferson University Hospital, Philadelphia, PA
- Miami Cancer Institute, Miami, FL
- Vanderbilt University Medical Center, Ingram Cancer Center, Nashville, TN
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Roth AK, Ris MD, Orobio J, Xue J, Mahajan A, Paulino AC, Grosshans D, Okcu MF, Chintagumpala M, Kahalley L. Cognitive mediators of adaptive functioning outcomes in survivors of pediatric brain tumors treated with proton radiotherapy. Pediatr Blood Cancer 2020; 67:e28064. [PMID: 31736188 PMCID: PMC7433211 DOI: 10.1002/pbc.28064] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 09/10/2019] [Accepted: 10/12/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Cranial radiotherapy (RT) is associated with risk for cognitive and adaptive dysfunction. Proton RT (PRT) is a technique hypothesized to spare cognition by reducing exposure to nontarget brain tissue. However, little is known regarding functional outcomes in survivors of pediatric brain tumor (BT) treated with PRT. The present study examined the relationship between cognitive and adaptive outcomes in pediatric BT survivors post-PRT. METHODS Survivors treated with either focal (n = 33) or craniospinal irradiation (CSI; n = 37) PRT completed neurocognitive evaluations approximately 5 years post-treatment. Results of intelligence testing and ratings of adaptive functioning are reported. Mediation models examined the relationship among radiation field, cognition, and adaptive functioning. RESULTS The PRT CSI group demonstrated worse cognitive outcomes than the PRT Focal group across each cognitive index (Cohen's d = 0.56-0.70). Parent ratings of adaptive functioning were also worse in the PRT CSI group than the PRT Focal group (Global Adaptive Composite, d = 0.53; conceptual skills, d = 0.67). Cognitive performance fully mediated the relationship between radiation field and adaptive outcomes, while controlling for group differences in tumor histology and RT dose. CONCLUSIONS Focal PRT survivors demonstrated generally positive outcomes with weaknesses in processing speed and aspects of adaptive functioning. CSI exposure was associated with more consistently poor cognitive and adaptive outcomes. The increased risk for adaptive dysfunction in the PRT CSI group appeared due to the effects of CSI on cognition. Efforts to reduce the volume of tissue exposure to RT remain important.
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Affiliation(s)
- Alexandra K. Roth
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | - M. Douglas Ris
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | - Jessica Orobio
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | - Judy Xue
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
| | | | - Arnold C. Paulino
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - David Grosshans
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - M. Fatih Okcu
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, United States
| | - Murali Chintagumpala
- Department of Pediatrics, Section of Hematology Oncology, Baylor College of Medicine, Houston, United States
| | - Lisa Kahalley
- Department of Pediatrics, Section of Psychology, Baylor College of Medicine, Houston, United States
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McGovern S, Luo D, Johnson M, Nguyen K, Li J, McAleer M, Yeboa D, Grosshans D, Ghia A, Chung C, Thall P, Sulman E, Brown P, Mahajan A. RTHP-23. PROSPECTIVE TRIAL OF CONVENTIONALLY FRACTIONATED DOSE CONSTRAINTS FOR RE-IRRADIATION OF PRIMARY BRAIN TUMORS. Neuro Oncol 2019. [DOI: 10.1093/neuonc/noz175.894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
PURPOSE/OBJECTIVE
Dose constraints for re-irradiation of recurrent primary brain tumors are not well-established, especially for treatment volumes too large for stereotactic radiotherapy. This prospective trial was performed to test dose constraints for conventionally-fractionated re-irradiation of recurrent primary brain tumors
MATERIALS/METHODS
A single-institution, prospective trial of 21 adults with recurrent brain tumors was performed. Electronic dosimetry records from the first course of radiation (RT1) were obtained and deformed onto the simulation CT for the second course of radiation (RT2). Treatment plans for RT2 were developed that met protocol-assigned dose constraints for RT2 alone and the composite dose of RT1+RT2. Dose constraints were also based on histology and interval since RT1. The primary endpoint was the rate of symptomatic brain necrosis after RT2.
RESULTS
Twenty one adults enrolled from March 2017 to May 2018. Twelve had glioblastoma, four had oligodendroglioma, two had anaplastic astrocytoma, and one each had choroid plexus papilloma, hemangiopericytoma, and pleomorphic xanthroastrocytoma (PXA). Twenty patients were treated with VMAT and one was treated with proton CSI. Median RT1-RT2 interval was 45 months (range, 9–141 months). Median RT2 dose was 42.8 Gy (range, 17.5–60 Gy). Median PTV volume was 208 cc (range, 7–1537 cc). Median imaging followup was 9 months (range, 1–20 months). Two months after RT2, the patient with PXA developed a trapped temporal horn adjacent to the RT2 treatment volume; pathology from emergent resection revealed necrotic brain tissue. The patient recovered fully and lived another 18 months until dying of disease progression. No other patient developed symptomatic radionecrosis. Median overall survival from RT2 for all patients was 11 months (range, 3–20 months).
CONCLUSION
Re-irradiation can be performed with conventionally fractionated schemes. Given the low rate of symptomatic radionecrosis, the dose constraints described here are a starting point for future studies of conventionally fractionated re-irradiation.
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Affiliation(s)
- Susan McGovern
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Dershan Luo
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael Johnson
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kham Nguyen
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jing Li
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mary McAleer
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Debra Yeboa
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David Grosshans
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amol Ghia
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Caroline Chung
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Peter Thall
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Erik Sulman
- NYU Langone School of Medicine, New York, NY, USA
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Al Feghali K, Randall J, Wefel J, Guha-Thakurta N, Grosshans D, Dibaj S, McAvoy S, Li J, McGovern S, McAleer M, Ghia A, Paulino A, Sulman E, Penas-Prado M, Wang J, DeGroot J, Heimberger A, Armstrong T, Gilbert M, Mahajan A, Brown P, Chung C. NIMG-03. PROSPECTIVE PHASE II RANDOMIZED TRIAL COMPARING PROTON THERAPY VS. PHOTON IMRT FOR GBM: SECONDARY ANALYSIS COMPARISON OF PROGRESSION FREE SURVIVAL BETWEEN RANO VS. CLINICAL AND RADIOLOGICAL ASSESSMENT. Neuro Oncol 2019. [DOI: 10.1093/neuonc/noz175.675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
PURPOSE
To compare tumor progression based on clinical radiological assessment and on Response Assessment in Neuro-Oncology (RANO) criteria between GBM patients treated with proton radiotherapy (PT) vs. photon intensity modulated radiotherapy (IMRT).
METHODS
Eligible patients were enrolled on the described prospective phase II trial and had MR imaging at baseline and follow-up beyond 12 weeks from treatment completion. ‘Clinical’ progression was based on a radiology report of progression in combination with changes in treatment due to suspected disease progression. A single blinded observer applied RANO criteria to determine the RANO-based tumor progression.
RESULTS
Of 90 enrolled patients, 66 were evaluable, with median follow-up of 19.8 (Range: 3.2–65.1) months; median of 22.6 months for PT (n=25) vs. 18.9 months for IMRT (n=41). Median time to progression (TTP) was 7.9 months based on clinical progression criteria (8.1 months IMRT, 6.3 months PT) and 7.2 months (7.3 months IMRT, 5.7 months PT) by RANO criteria (p=ns for all). Median ‘clinical’ progression-free survival (PFS) was 8.7 (Range: 6.4–11.1) months; 8.9 months IMRT vs. 8.7 months PT (p=0.065). Median RANO PFS was 8.3 (range, 5.8–11.6) months: 8.3 months IMRT vs. 6.9 months PT (p=0.226). There were 14 discrepant cases: 3 had progression based on ‘clinical’ but not RANO criteria, and 11 had progression based on RANO but not ‘clinical’ criteria.
CONCLUSION
Based on this secondary analysis of a randomized trial of PT vs. IMRT for GBM, there was no difference in tumor progression relative to treatment technique used. There was no statistical difference in PFS noted between clinical and RANO-based assessments, but RANO criteria identified progression more often than clinical assessment, and TTP was shortened with the use of RANO criteria alone. Further development of tumor assessment tools that improve consistency and accuracy of determining tumor progression are needed to guide therapeutic trials in GBM.
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Affiliation(s)
| | - James Randall
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey Wefel
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - David Grosshans
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Seyedeh Dibaj
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sarah McAvoy
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jing Li
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan McGovern
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mary McAleer
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amol Ghia
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Arnold Paulino
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Erik Sulman
- NYU Langone School of Medicine, New York, NY, USA
| | - Marta Penas-Prado
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jihong Wang
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John DeGroot
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amy Heimberger
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Terri Armstrong
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Mark Gilbert
- NCI Center for Cancer Research, Bethesda, MD, USA
| | | | | | - Caroline Chung
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Randall J, Al Feghali K, Wefel J, Grosshans D, Dibaj S, Milton D, McAvoy S, Li J, McGovern S, McAleer M, Ghia A, Paulino A, Sulman E, Penas-Prado M, Wang J, DeGroot J, Heimberger A, Armstrong T, Gilbert M, Mahajan A, Brown P, Chung C. RTHP-18. PROSPECTIVE PHASE II RANDOMIZED TRIAL COMPARING PROTON THERAPY VS. PHOTON IMRT FOR NEWLY DIAGNOSED GBM: SECONDARY ANALYSIS COMPARISON OF GENDER AND NEUTROPHIL-LYMPHOCYTE RATIO (NLR) IN GBM OUTCOMES. Neuro Oncol 2019. [DOI: 10.1093/neuonc/noz175.889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
While glioblastoma (GBM) is more prevalent in males, studies show that females with GBM tend to have longer overall survival (OS) than males. Pretreatment neutrophil to lymphocyte ratio (NLR) has also proven to be prognostic in GBM, with lower NLR having favorable outcomes. This secondary analysis of a prospective randomized trial of proton vs. photon intensity modulated radiotherapy aims to explore the interaction of gender and NLR on GBM outcomes.
METHODS
Analysis was performed on the full patient population. Kaplan-Meier methods estimated OS with censoring at last follow-up for those who were alive. Univariate (UVA) and multivariate (MVA)Cox proportional hazards models assessed predictors of OS.
RESULTS
Of 90 patients, 77 were included (43 males; 34 females) with median age of 52 years (range: 26–82 years). Median OS was longer for females than males (30.7 vs 18.2 months, p=0.004). On UVA, patients with NLR below median value (NLR= 3.1) tended to have longer OS than those above median, though not meeting statistical significance (23.1 vs. 17.9 months, p=0.051). Difference in OS was statistically significant in females (OS 36.4 months NLR >median vs. 16.7 months NLR< median, p=0.002), but not in males (OS 17.8 months NLR >median vs. 19.1 NLR< median, p=0.95). MVA analysis was consistent, with female gender predicting reduced hazard ratio (HR) (0.28, p=0.034) and females with below median NLR showing a reduced HR over those with above median (0.28, p=0.005). Again, males did not benefit (HR 0.90, p=0.77).
CONCLUSION
Consistent with prior publications, females and all patients with lower pre-treatment NLR with newly diagnosed GBM had longer OS. However, combining these two factors revealed that the benefits from lower pre-treatment NLR were conferred only in females with no impact on males. This different impact of NLR between genders may suggest innate immune differences in gender during response to malignancy.
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Affiliation(s)
- James Randall
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Jeffrey Wefel
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David Grosshans
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Seyedeh Dibaj
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Denai Milton
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sarah McAvoy
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jing Li
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan McGovern
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mary McAleer
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amol Ghia
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Arnold Paulino
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Erik Sulman
- NYU Langone School of Medicine, New York, NY, USA
| | - Marta Penas-Prado
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jihong Wang
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John DeGroot
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amy Heimberger
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Terri Armstrong
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Mark Gilbert
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | | | | | - Caroline Chung
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Lin T, Ludmir E, Liao K, Mcaleer M, Grosshans D, Mcgovern S, Bishop A, Woodhouse K, Paulino A, Yeboa D. Timing of Local Therapy Affects Survival in Ewing Sarcoma. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.07.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ludmir E, Buszek S, Grosshans D, Mcaleer M, Mcgovern S, Harrison D, Okcu M, Chintagumpala M, Mahajan A, Paulino A. Disease Control and Patterns of Failure following Proton Beam Therapy for Rhabdomyosarcoma. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.07.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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40
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Wefel JS, Pugh S, Gondi V, Brown PD, Tome W, Armstrong TS, Bruner D, Bovi J, Robinson C, Khuntia D, Grosshans D, Konski A, Roberge D, Kundapur V, Devisetty K, Shah S, Usuki K, Anderson B, Mehta MP, Kachnic L. NRG Oncology CC001 Neurocognitive Final Analysis: A Phase III Trial of Hippocampal Avoidance (HA) in Addition to Whole-Brain Radiotherapy (WBRT) Plus Memantine to Preserve Neurocognitive Function (NCF) in Patients With Brain Metastases (BM). Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Tomé W, Deshmukh S, Gondi V, Brown P, Wefel J, Armstrong T, Bruner D, Bovi J, Robinson C, Khuntia D, Grosshans D, Konski A, Roberge D, Kundapur V, Devisetty K, Shah S, Usuki K, Anderson BM, Mehta M, Kachnic L. RADI-11. NRG ONCOLOGY CC001: A PHASE III TRIAL OF HIPPOCAMPAL AVOIDANCE IN ADDITION TO WHOLE-BRAIN RADIOTHERAPY (WBRT) PLUS MEMANTINE TO PRESERVE NEUROCOGNITIVE FUNCTION IN PATIENTS WITH BRAIN METASTASES (BM). Neurooncol Adv 2019. [PMCID: PMC7213360 DOI: 10.1093/noajnl/vdz014.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND: NRG CC001, a phase III trial of WBRT+memantine (WBRT+M) with or without Hippocampal Avoidance (HA), sought to assess the neuro-protective effects of lowering the radiation dose received by the hippocampus. METHODS: Patients (pts) with brain metastases were stratified by RPA class and prior radiosurgery/surgery and randomized to either WBRT+M or HA-WBRT+M (30Gy/10 fractions). Standardized neurocognitive function (NCF) tests were performed at baseline, 2, 4, 6, and 12 months (mos.). The primary endpoint was NCF failure, defined as decline using the reliable change index on Hopkins Verbal Learning Test-Revised, Trail Making Test, or Controlled Oral Word Association. Cumulative incidence estimated NCF failure (death without NCF failure was competing risk); between-arms differences tested using Gray’s test. Deterioration at each collection time point was tested using a chi-square test. Patient-reported symptoms were assessed using the MD Anderson Symptom Inventory with Brain Tumor module and analyzed using mixed effects models and t-tests. RESULTS: From 7/2016 to 3/2018, 518 patients were randomized. Median follow-up was 7.9 mos. HA-WBRT+M was associated with lower NCF failure risk (adjusted HR=0.74, p=0.02) due to lower risk of deterioration in executive function at 4 mos. (p=0.01); and encoding (p=0.049) and consolidation (p=0.02) at 6 mos. Age≤61 predicted for lower NCF failure risk (HR=0.60, p=0.0002); non-significant test for interaction indicated independent effects of HA and age. Patient-reported fatigue (p=0.036); difficulty speaking (p=0.049); and problems remembering things (p=0.013) at 6 mos. favored the HA-WBRT+M arm. Imputation models accounting for missing data also favored the HA-WBRT+M arm for patient-reported cognition (p=0.011) and symptom interference (p=0.008) at 6 mos. Treatment arms did not significantly differ in toxicity; intracranial progression or overall survival. CONCLUSIONS: While achieving similar intracranial control and survival; Hippocampal Avoidance during WBRT+M for brain metastases better preserves NCF and patient-reported symptoms. Supported by UG1CA189867 (NCORP) and DCP from the NCI.
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Affiliation(s)
| | | | - Vinai Gondi
- Northwestern Medicine Cancer Institute, Warrenville, IL, USA
| | | | | | | | | | - Joseph Bovi
- Medical College of Wisconsin, Milwaukee, WI, USA
| | | | | | | | - Andre Konski
- Univerrsity of Pennsylvania, Philadelphia, PA, USA
| | | | | | | | - Sunjay Shah
- Christiana Care Health System, Newark, DE, USA
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Darne CD, Alsanea F, Robertson DG, Guan F, Pan T, Grosshans D, Beddar S. A proton imaging system using a volumetric liquid scintillator: a preliminary study. Biomed Phys Eng Express 2019; 5:045032. [PMID: 32194988 PMCID: PMC7082085 DOI: 10.1088/2057-1976/ab2e4a] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
With the expansion of proton radiotherapy for cancer treatments, it has become important to explore proton-based imaging technologies to increase the accuracy of proton treatment planning, alignment, and verification. The purpose of this study is to demonstrate the feasibility of using a volumetric liquid scintillator to generate proton radiographs at a clinically relevant energy (180 MeV) using an integrating detector approach. The volumetric scintillator detector is capable of capturing a wide distribution of residual proton beam energies from a single beam irradiation. It has the potential to reduce acquisition time and imaging dose compared to other proton radiography methods. The imaging system design is comprised of a volumetric (20 × 20 × 20 cm3) organic liquid scintillator working as a residual-range detector and a charge-coupled device (CCD) placed along the beams'-eye-view for capturing radiographic projections. The scintillation light produced within the scintillator volume in response to a 3-dimensional distribution of residual proton beam energies is captured by the CCD as a 2-dimensional grayscale image. A light intensity-to-water equivalent thickness (WET) curve provided WET values based on measured light intensities. The imaging properties of the system, including its contrast, signal-to-noise ratio, and spatial resolution (0.19 line-pairs/mm) were determined. WET values for selected Gammex phantom inserts including solid water, acrylic, and cortical bone were calculated from the radiographs with a relative accuracy of -0.82%, 0.91%, and -2.43%, respectively. Image blurring introduced by system optics was accounted for, resulting in sharper image features. Finally, the system's ability to reconstruct proton CT images from radiographic projections was demonstrated using a filtered back-projection algorithm. The WET retrieved from the reconstructed CT slice was within 0.3% of the WET obtained from MC. In this work, the viability of a cumulative approach to proton imaging using a volumetric liquid scintillator detector and at a clinically-relevant energy was demonstrated.
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Affiliation(s)
- Chinmay D Darne
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Fahed Alsanea
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- The University of Texas MD Anderson UTHealth Graduate School of Biomedical Sciences, Houston, TX 77030, USA
| | | | - Fada Guan
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Tinsu Pan
- The University of Texas MD Anderson UTHealth Graduate School of Biomedical Sciences, Houston, TX 77030, USA
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - David Grosshans
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Sam Beddar
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- The University of Texas MD Anderson UTHealth Graduate School of Biomedical Sciences, Houston, TX 77030, USA
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Amsbaugh MJ, Mahajan A, Thall PF, McAleer MF, Paulino AC, Grosshans D, Khatua S, Ketonen L, Fontanilla H, McGovern SL. In Reply to Krishnatry and Manjali. Int J Radiat Oncol Biol Phys 2019; 104:468-469. [DOI: 10.1016/j.ijrobp.2019.02.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 02/12/2019] [Accepted: 02/14/2019] [Indexed: 11/27/2022]
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Skaarup M, Appelt A, Lundemann M, Darkner S, Jørgensen M, Thomsen C, Law I, Mirkovic D, Mohan R, Grosshans D, Peeler C, Vogelius I. EP-1919 Voxel-based assessment of proton RBE in paediatric brain cancer radiotherapy from multimodal imaging. Radiother Oncol 2019. [DOI: 10.1016/s0167-8140(19)32339-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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45
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Yeboa D, Yu J, Liao K, Huse J, Penas-Prado M, Kann B, Sulman E, Grosshans D, Contessa J. OC-0165 Patterns of treatment and outcomes for 1p19q co-deleted gliomas. Radiother Oncol 2019. [DOI: 10.1016/s0167-8140(19)30585-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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46
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Haas-Kogan D, Indelicato D, Paganetti H, Esiashvili N, Mahajan A, Yock T, Flampouri S, MacDonald S, Fouladi M, Stephen K, Kalapurakal J, Terezakis S, Kooy H, Grosshans D, Makrigiorgos M, Mishra K, Poussaint TY, Cohen K, Fitzgerald T, Gondi V, Liu A, Michalski J, Mirkovic D, Mohan R, Perkins S, Wong K, Vikram B, Buchsbaum J, Kun L. National Cancer Institute Workshop on Proton Therapy for Children: Considerations Regarding Brainstem Injury. Int J Radiat Oncol Biol Phys 2019; 101:152-168. [PMID: 29619963 DOI: 10.1016/j.ijrobp.2018.01.013] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 12/21/2017] [Accepted: 01/01/2018] [Indexed: 01/08/2023]
Abstract
PURPOSE Proton therapy can allow for superior avoidance of normal tissues. A widespread consensus has been reached that proton therapy should be used for patients with curable pediatric brain tumor to avoid critical central nervous system structures. Brainstem necrosis is a potentially devastating, but rare, complication of radiation. Recent reports of brainstem necrosis after proton therapy have raised concerns over the potential biological differences among radiation modalities. We have summarized findings from the National Cancer Institute Workshop on Proton Therapy for Children convened in May 2016 to examine brainstem injury. METHODS AND MATERIALS Twenty-seven physicians, physicists, and researchers from 17 institutions with expertise met to discuss this issue. The definition of brainstem injury, imaging of this entity, clinical experience with photons and photons, and potential biological differences among these radiation modalities were thoroughly discussed and reviewed. The 3 largest US pediatric proton therapy centers collectively summarized the incidence of symptomatic brainstem injury and physics details (planning, dosimetry, delivery) for 671 children with focal posterior fossa tumors treated with protons from 2006 to 2016. RESULTS The average rate of symptomatic brainstem toxicity from the 3 largest US pediatric proton centers was 2.38%. The actuarial rate of grade ≥2 brainstem toxicity was successfully reduced from 12.7% to 0% at 1 center after adopting modified radiation guidelines. Guidelines for treatment planning and current consensus brainstem constraints for proton therapy are presented. The current knowledge regarding linear energy transfer (LET) and its relationship to relative biological effectiveness (RBE) are defined. We review the current state of LET-based planning. CONCLUSIONS Brainstem injury is a rare complication of radiation therapy for both photons and protons. Substantial dosimetric data have been collected for brainstem injury after proton therapy, and established guidelines to allow for safe delivery of proton radiation have been defined. Increased capability exists to incorporate LET optimization; however, further research is needed to fully explore the capabilities of LET- and RBE-based planning.
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Affiliation(s)
- Daphne Haas-Kogan
- Department of Radiation Oncology, Harvard Medical School and Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, Massachusetts
| | - Daniel Indelicato
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida
| | - Harald Paganetti
- Department of Radiation Oncology, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - Natia Esiashvili
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Anita Mahajan
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas; Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Torunn Yock
- Department of Radiation Oncology, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - Stella Flampouri
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida
| | - Shannon MacDonald
- Department of Radiation Oncology, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - Maryam Fouladi
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kry Stephen
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - John Kalapurakal
- Department of Radiation Oncology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Stephanie Terezakis
- Department of Radiation Oncology, Johns Hopkins Medical Institute, Baltimore, Maryland
| | - Hanne Kooy
- Department of Radiation Oncology, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - David Grosshans
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mike Makrigiorgos
- Department of Radiation Oncology, Harvard Medical School and Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kavita Mishra
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | - Tina Young Poussaint
- Department of Radiology, Harvard Medical School and Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, Massachusetts
| | - Kenneth Cohen
- Department of Pediatrics, Johns Hopkins Medical Institute, Baltimore, Maryland
| | - Thomas Fitzgerald
- Department of Radiation Oncology, UMass Memorial Medical Center, Worcester, Massachusetts
| | - Vinai Gondi
- Northwestern Medicine Chicago Proton Center, Chicago, Illinois
| | - Arthur Liu
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Jeff Michalski
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Dragan Mirkovic
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Radhe Mohan
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stephanie Perkins
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Kenneth Wong
- Children's Hospital of Angeles and University of Southern California Keck School of Medicine, Los Angles, California
| | - Bhadrasain Vikram
- Radiation Research Program, National Cancer Institute, National Institutes of Health, Rockville, Maryland
| | - Jeff Buchsbaum
- Radiation Research Program, National Cancer Institute, National Institutes of Health, Rockville, Maryland
| | - Larry Kun
- Department of Radiation Oncology, University of Texas Southwestern Medical School, Dallas, Texas.
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Cao W, Khabazian A, Yepes P, Lim G, Poenisch F, Grosshans D, Mohan R. Reply to Comment on ‘Linear energy transfer incorporated intensity modulated proton therapy optimization’. Phys Med Biol 2019; 64:058002. [DOI: 10.1088/1361-6560/aaff72] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Paganetti H, Blakely E, Carabe-Fernandez A, Carlson DJ, Das IJ, Dong L, Grosshans D, Held KD, Mohan R, Moiseenko V, Niemierko A, Stewart RD, Willers H. Report of the AAPM TG-256 on the relative biological effectiveness of proton beams in radiation therapy. Med Phys 2019; 46:e53-e78. [PMID: 30661238 DOI: 10.1002/mp.13390] [Citation(s) in RCA: 177] [Impact Index Per Article: 35.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 11/21/2018] [Accepted: 01/13/2019] [Indexed: 12/14/2022] Open
Abstract
The biological effectiveness of proton beams relative to photon beams in radiation therapy has been taken to be 1.1 throughout the history of proton therapy. While potentially appropriate as an average value, actual relative biological effectiveness (RBE) values may differ. This Task Group report outlines the basic concepts of RBE as well as the biophysical interpretation and mathematical concepts. The current knowledge on RBE variations is reviewed and discussed in the context of the current clinical use of RBE and the clinical relevance of RBE variations (with respect to physical as well as biological parameters). The following task group aims were designed to guide the current clinical practice: Assess whether the current clinical practice of using a constant RBE for protons should be revised or maintained. Identifying sites and treatment strategies where variable RBE might be utilized for a clinical benefit. Assess the potential clinical consequences of delivering biologically weighted proton doses based on variable RBE and/or LET models implemented in treatment planning systems. Recommend experiments needed to improve our current understanding of the relationships among in vitro, in vivo, and clinical RBE, and the research required to develop models. Develop recommendations to minimize the effects of uncertainties associated with proton RBE for well-defined tumor types and critical structures.
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Affiliation(s)
- Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Eleanor Blakely
- Biological Systems and Engineering Division, Lawrence Berkeley National Laboratory, Berkeley, CA, USA
| | | | - David J Carlson
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Indra J Das
- New York University Langone Medical Center & Laura and Isaac Perlmutter Cancer Center, New York, NY, USA
| | - Lei Dong
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - David Grosshans
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kathryn D Held
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Radhe Mohan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vitali Moiseenko
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
| | - Andrzej Niemierko
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Robert D Stewart
- Department of Radiation Oncology, School of Medicine, University of Washington, Seattle, WA, USA
| | - Henning Willers
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Wilke C, Grosshans D, Duman J, Brown P, Li J. Radiation-induced cognitive toxicity: pathophysiology and interventions to reduce toxicity in adults. Neuro Oncol 2019; 20:597-607. [PMID: 29045710 DOI: 10.1093/neuonc/nox195] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Radiotherapy is ubiquitous in the treatment of patients with both primary brain tumors as well as disease which is metastatic to the brain. This therapy is not without cost, however, as cognitive decline is frequently associated with cranial radiation, particularly with whole brain radiotherapy (WBRT). The precise mechanisms responsible for radiation-induced morbidity remain incompletely understood and continue to be an active area of ongoing research. In this article, we review the hypothetical means by which cranial radiation induces cognitive decline as well as potential therapeutic approaches to prevent, minimize, or reverse treatment-induced cognitive deterioration. We additionally review advances in imaging modalities that can potentially be used to identify site-specific radiation-induced anatomic or functional changes in the brain and their correlation with clinical outcomes.
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Affiliation(s)
- Christopher Wilke
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas (C.W., D.G., J.L.); Department of Neuroscience, Baylor College of Medicine, Houston, Texas (J.D.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (P.B.)
| | - David Grosshans
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas (C.W., D.G., J.L.); Department of Neuroscience, Baylor College of Medicine, Houston, Texas (J.D.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (P.B.)
| | - Joseph Duman
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas (C.W., D.G., J.L.); Department of Neuroscience, Baylor College of Medicine, Houston, Texas (J.D.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (P.B.)
| | - Paul Brown
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas (C.W., D.G., J.L.); Department of Neuroscience, Baylor College of Medicine, Houston, Texas (J.D.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (P.B.)
| | - Jing Li
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas (C.W., D.G., J.L.); Department of Neuroscience, Baylor College of Medicine, Houston, Texas (J.D.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota (P.B.)
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50
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Bai X, Lim G, Grosshans D, Mohan R, Cao W. Robust optimization to reduce the impact of biological effect variation from physical uncertainties in intensity-modulated proton therapy. Phys Med Biol 2019; 64:025004. [PMID: 30523932 DOI: 10.1088/1361-6560/aaf5e9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Robust optimization (RO) methods are applied to intensity-modulated proton therapy (IMPT) treatment plans to ensure their robustness in the face of treatment delivery uncertainties, such as proton range and patient setup errors. However, the impact of those uncertainties on the biological effect of protons has not been specifically considered. In this study, we added biological effect-based objectives into a conventional RO cost function for IMPT optimization to minimize the variation in biological effect. One brain tumor case, one prostate tumor case and one head & neck tumor case were selected for this study. Three plans were generated for each case using three different optimization approaches: planning target volume (PTV)-based optimization, conventional RO, and RO incorporating biological effect (BioRO). In BioRO, the variation in biological effect caused by IMPT delivery uncertainties was minimized for voxels in both target volumes and critical structures, in addition to a conventional voxel-based worst-case RO objective function. The biological effect was approximated by the product of dose-averaged linear energy transfer (LET) and physical dose. All plans were normalized to give the same target dose coverage, assuming a constant relative biological effectiveness (RBE) of 1.1. Dose, biological effect, and their uncertainties were evaluated and compared among the three optimization approaches for each patient case. Compared with PTV-based plans, RO plans achieved more robust target dose coverage and reduced biological effect hot spots in critical structures near the target. Moreover, with their sustained robust dose distributions, BioRO plans not only reduced variations in biological effect in target and normal tissues but also further reduced biological effect hot spots in critical structures compared with RO plans. Our findings indicate that IMPT could benefit from the use of conventional RO, which would reduce the biological effect in normal tissues and produce more robust dose distributions than those of PTV-based optimization. More importantly, this study provides a proof of concept that incorporating biological effect uncertainty gap into conventional RO would not only control the IMPT plan robustness in terms of physical dose and biological effect but also achieve further reduction of biological effect in normal tissues.
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Affiliation(s)
- Xuemin Bai
- Department of Industrial Engineering, University of Houston, Houston, TX, United States of America
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