Managing treatment-related uncertainties in proton beam radiotherapy for gastrointestinal cancers

Tryggestad, E.; Liu, Wei; Pepin, M.; Hallemeier, Christopher L.; Sio, Terence T.

doi:10.21037/jgo.2019.11.07

Cited by 38 publications

(42 citation statements)

References 87 publications

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“…Robust optimization 24–47 has been introduced to mitigate the impact of uncertainties, and is now widely accepted in the routine proton clinical practice. However, techniques to mitigate interplay effect would still require further improvement 48 . Abdominal compression and breath holding can help limit the motion, but often result in less patient comfort during treatments.…”

Section: Introductionmentioning

confidence: 99%

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Beam angle comparison for distal esophageal carcinoma patients treated with intensity‐modulated proton therapy

Feng

Sio

Rule

et al. 2020

J Applied Clin Med Phys

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Purpose: To compare the dosimetric performances of intensity-modulated proton therapy (IMPT) plans generated with two different beam angle configurations (the Right-Left oblique posterior beams and the Superior-Inferior oblique posterior beams) for the treatment of distal esophageal carcinoma in the presence of uncertainties and interplay effect. Methods and Materials: Twenty patients' IMPT plans were retrospectively selected, with 10 patients treated with the R-L oblique posterior beams (Group R-L) and the other 10 patients treated with the S-I oblique posterior beams (Group S-I). Patients in both groups were matched by their clinical target volumes (CTVs-high and low dose levels) and respiratory motion amplitudes. Dose-volume-histogram (DVH) indices were used to assess plan quality. DVH bandwidth was calculated to evaluate plan robustness. Interplay effect was quantified using four-dimensional (4D) dynamic dose calculation with random respiratory starting phase of each fraction. Normal tissue complication probability (NTCP) for heart, liver, and lung was calculated, respectively, to estimate the clinical outcomes. Wilcoxon signed-rank test was used for statistical comparison between the two groups. Results: Compared with plans in Group R-L, plans in Group S-I resulted in significantly lower liver D mean and lung V 30Gy[RBE] with slightly higher but clinically acceptable spinal cord D max. Similar plan robustness was observed between the two groups. When interplay effect was considered, plans in Group S-I performed statistically better for heart D mean and V 30Gy[RBE] , lung Dmean and V 5Gy[RBE] , and liver D mean , with slightly increased but clinically acceptable spinal cord D max. NTCP for liver was significantly better in Group S-I. Conclusions: IMPT plans in Group S-I have better sparing of liver, heart, and lungs at the slight cost of spinal cord maximum dose protection, and are more interplayeffect resilient compared to IMPT plans in Group R-L. Our study supports the routine use of the S-I oblique posterior beams for the treatments of distal esophageal carcinoma.

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Section: Introductionmentioning

confidence: 99%

“…However, techniques to mitigate interplay effect would still require further improvement. 48 Abdominal compression and breath holding can help limit the motion, but often result in less patient comfort during treatments. Gating 49 and repainting 13,16,50 can provide better dose distribution during motion, but will inherently prolong the treatment time.…”

mentioning

confidence: 99%

Beam angle comparison for distal esophageal carcinoma patients treated with intensity‐modulated proton therapy

Feng

Sio

Rule

et al. 2020

J Applied Clin Med Phys

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“…Esophageal stents have been associated with early life-threatening morbidity and higher mortality rates during concurrent neoadjuvant chemoradiation compared to no stent placement (11). In addition, radiation planning is affected by placement of self-expanding metallic stents (12), which cause radiation dose perturbations ranging from 0 to 30%. Patients who have pain associated with stent placement and concurrent chemoradiation are difficult to manage as outpatients because their severe odynophagia precludes them from obtaining adequate oral nutrition even when the esophageal lumen remains patent.…”

Section: Discussionmentioning

confidence: 99%

Outcomes following interventions to sustain body weight in esophageal cancer patients starting preoperative therapy: a retrospective cohort study

Velotta¹,

Dusendang²,

Kwak³

et al. 2021

J Thorac Dis

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Background: To improve nutritional status and dysphagia, esophageal cancer patients starting neoadjuvant therapy in advance of curative-intent surgery may receive a jejunostomy tube (J-tube) or esophageal stent, or they may be managed without a feeding modality. We examined percent total weight loss (%TWL), reinterventions, and progression to surgery in relation to these options. Methods: The retrospective cohort study included stage II-III esophageal cancer patients diagnosed during 2010-2017 who received J-tube, stent, or nutritional counseling only, without a procedure, when starting chemotherapy or combined modality chemoradiation. Data were obtained from the electronic medical record and chart review. We compared median %TWL between intervention groups and reinterventions using Chi-square and Kruskal-Wallis tests. Results: Among the 366 patients, median %TWL reached a nadir at 120 days, when it was 7% for patients with no procedure (N=307), 4% for J-tube (N=39), and 16% for stent (N=20) (P=0.01). Individual case analysis revealed 72-80% of the patients in the three groups started chemotherapy or chemoradiation as neoadjuvant curative-intent therapy (P difference=0.79). In J-tube patients, the reasons for intervention was anticipation of weight loss in 49% and mitigation of actual weight loss in 15%, whereas 95% of stent patients received the stent for dysphagia (P<0.001). A complication of the procedure was recorded in 85% of stent patients and 74% of J-tube patients (P<0.001). Among those who received no procedure initially, 25% received one later, compared with 15% of J-tube patients and 70% of stent patients who received a second procedure (P<0.001). Progression to surgery was observed in 65% of patients with no procedure, 51% of patients with J-tube, and 40% of stent patients, P=0.28). Conclusions: For stage II-III esophageal cancer patients starting chemotherapy, this study gives evidence that stents were associated with significant %TWL and risk of reintervention. Although J-tube patients returned to baseline weight sooner than those with no procedure, they experienced complications from their J-tubes. For esophageal cancer patients undergoing curative-intent treatment and with acceptable levels of weight loss, no procedure at all may be superior to placing a J-tube in terms of complications, weight loss, and progression to curative-intent surgery.

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“…There are several important challenges in treating tumors within the thorax or upper abdomen (e.g., esophagus tumors), which are discussed in more detail by Tryggestad et al in this issue of the journal (39). A few pertinent challenges specific for esophageal cancer are the intra-fraction anatomical changes which occur due to periodic tumor motion and the associated "interplay effect" (which is specific to PBS-PBT) (40), diaphragmatic motion, and inter-fraction variation in patient anatomy which can occur in the context of setup variability, weight loss, pleural effusions, stomach distension, or tumor changes.…”

Section: Planning Considerationsmentioning

confidence: 99%

The emerging role of proton therapy for esophagus cancer

Jethwa

Haddock

Tryggestad

et al. 2020

J Gastrointest Oncol

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Chemoradiotherapy (CRT) plays an essential role in the treatment of esophageal cancer as either curative or neoadjuvant therapy. When delivered with conventional photon-based techniques, multiple adjacent organs at risk including the heart, lungs, kidneys, liver, stomach, and bowel, receive considerable radiation dose which may contribute to acute and late adverse events (AEs). Proton beam therapy (PBT) offers a reduction in radiation exposure to these organs and potentially an improvement in the therapeutic ratio. Herein we discuss the emerging role of PBT for esophageal cancer, including rationale, treatment planning, early dosimetric and clinical comparisons of PBT with photon-based techniques, ongoing prospective trials, and potential areas of opportunity for the incorporation of PBT with the goal of improving outcomes for patients with esophageal cancer.

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Managing treatment-related uncertainties in proton beam radiotherapy for gastrointestinal cancers

Cited by 38 publications

References 87 publications

Beam angle comparison for distal esophageal carcinoma patients treated with intensity‐modulated proton therapy

Beam angle comparison for distal esophageal carcinoma patients treated with intensity‐modulated proton therapy

Outcomes following interventions to sustain body weight in esophageal cancer patients starting preoperative therapy: a retrospective cohort study

The emerging role of proton therapy for esophagus cancer

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