Accelerated partial-breast irradiation using intensity-modulated proton radiotherapy: do uncertainties outweigh potential benefits?

Wang, X; Zhang, X; Li, X; Amos, R.; Shaitelman, Simona F.; Hoffman, Karen E.; Howell, Rebecca M.; Salehpour, Mohammad; Zhang, S X; Sun, Tzouh Liang; Smith, Benjamin D.; Tereffe, Welela; Perkins, George H.; Buchholz, Thomas A.; Strom, Eric A.; Woodward, Wendy A.

doi:10.1259/bjr.20130176

Cited by 25 publications

(19 citation statements)

References 26 publications

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“…This is very important for both radiotherapy and space exploration. Proton therapy can efficiently spare the heart during the treatment of left-side breast cancer, 139 whereas with X-rays, a large fraction of the heart is generally exposed. Breast cancer is therefore becoming a major application of protontherapy.…”

Section: Late Effectsmentioning

confidence: 99%

New challenges in high-energy particle radiobiology

Durante

2014

BJR

122

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Densely ionizing radiation has always been a main topic in radiobiology. In fact, a-particles and neutrons are sources of radiation exposure for the general population and workers in nuclear power plants. More recently, high-energy protons and heavy ions attracted a large interest for two applications: hadrontherapy in oncology and space radiation protection in manned space missions. For many years, studies concentrated on measurements of the relative biological effectiveness (RBE) of the energetic particles for different end points, especially cell killing (for radiotherapy) and carcinogenesis (for late effects). Although more recently, it has been shown that densely ionizing radiation elicits signalling pathways quite distinct from those involved in the cell and tissue response to photons. The response of the microenvironment to charged particles is therefore under scrutiny, and both the damage in the target and non-target tissues are relevant. The role of individual susceptibility in therapy and risk is obviously a major topic in radiation research in general, and for ion radiobiology as well. Particle radiobiology is therefore now entering into a new phase, where beyond RBE, the tissue response is considered. These results may open new applications for both cancer therapy and protection in deep space.Biological effects of densely ionizing radiation have been studied since the beginning of radiobiology. As a matter of fact, a-particles deliver the main contribution to the background radiation dose on Earth, owing to inhalation of the indoor radon.1 Neutrons have also been extensively studied because of protection of workers in nuclear power plants; use of fast neutrons in radiotherapy; and of the exposure of the survivors of the atomic bomb in Hiroshima and Nagasaki, where a neutron component was added to g-rays. Bacq and Alexander 2 already elegantly described the radiobiology of a-particles and neutrons in their 1955 seminal book.More recently, radiobiology research has focused on highenergy protons and heavy ions, mostly for two reasons: charged particle therapy (CPT) in oncology and radiation protection in manned space missions. In both cases, charged particles at energies .100 MeV n 21 are involved. The characteristic depth-dose distribution with the sharp Bragg peak at the end of the range can be exploited for killing tumours; on the other hand, densely ionizing radiation can effectively delay tissue morbidity. Notwithstanding the many differences in exposure conditions, CPT and space radiation protection share several research topics, including individual sensitivity, non-targeted effects, late stochastic effects and so forth.3 Research in these fields requires large high-energy accelerators and is often performed by the same research groups with a common interest in particle radiobiology. Research is rapidly moving forward owing to the diffusion of CPT centres in the USA, Europe, and Asia 4 and to the growing interest in manned space exploration, now a priority for all space agencies, 5 but wi...

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Section: Late Effectsmentioning

confidence: 99%

New challenges in high-energy particle radiobiology

Durante

2014

BJR

122

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“…In a study of postmastectomy radiation using SBPT [9], the averaged dosimetric effect with respiratory motion after multiple fractions was evaluated. In another study of partial-breast irradiation with intensity-modulated proton therapy [18], the motion effect was estimated by the differences between planned dose on the FB CT and the recalculated dose on the BH CT. Both studies indicated that overall dose deviations resulting from FB motion were small.…”

Section: Introductionmentioning

confidence: 99%

Free Breathing versus Breath-Hold Scanning Beam Proton Therapy and Cardiac Sparing in Breast Cancer

Park

Herman

et al. 2016

International Journal of Particle Therapy

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Purpose: To assess dose errors caused by the interplay effects of free-breathing (FB) motion and to assess the value of breath-hold (BH) in terms of cardiac dose reduction for scanning beam proton therapy (SBPT). Materials and Methods: Three patients with left-sided breast cancer previously treated with photon therapy were included in this dosimetric study: 2 following breast-conserving surgery with 2 hypothetical target volumes (whole breast alone and whole breast plus regional nodes, including supraclavicular, axillary, and internal mammary lymph nodes); and 1 postmastectomy, with the target volume including the chest wall plus regional nodes. SBPT plans were generated with various beam angles that ranged between 2 tangential directions. For treatment with FB, nominal dose and dose with interplay effects considered were calculated based on FB 4-dimensional computed tomography scans. SBPT plans on the BH computed tomography were also calculated for one of the patients, who was selected to be treated with photon therapy with BH. Results: Dosimetric differences between nominal and interplay dose were small (average target mean dose, −0.06 Gy; range, −0.23 to 0.06 Gy; average heart mean dose, 0.001 Gy; range, −0.12 to 0.05 Gy). The largest dose deviations occurred in plans calculated with tangential beam arrangements; the smallest was noted with the en face beam. The average value of the mean heart dose with FB was <1 Gy. For the selected patient, the mean heart doses were 0.5 and 0.2 Gy for FB and BH, respectively. Conclusion: Dose deviations caused by the interplay effects of respiratory motion during FB do not have a significant impact in SBPT with en face beam arrangement. BH does not significantly reduce cardiac dose. SBPT delivery is feasible with FB and can provide optimal target coverage and maximal sparing of the cardiopulmonary system, which can translate into improved clinical outcomes and a decrease in treatment-related morbidity in left-sided breast cancer patients or those who require internal mammary node coverage.

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“…IMPT significantly was show to significantly reduce the dose to normal tissue compared with 3 DCRT [119]. While studies have indicated that PBT, as well as IMPT using scanning beams produces superior dose distribution for multiple disease sites, IMPT is sensitive to delivery uncertainties [120] [121] [122].…”

Section: Proton Beammentioning

confidence: 99%