Advertisement

Initial Report of Pencil Beam Scanning Proton Therapy for Posthysterectomy Patients With Gynecologic Cancer

      Purpose

      To report the acute toxicities associated with pencil beam scanning proton beam radiation therapy (PBS) for whole pelvis radiation therapy in women with gynecologic cancers and the results of a dosimetric comparison of PBS versus intensity modulated radiation therapy (IMRT) plans.

      Methods and Materials

      Eleven patients with posthysterectomy gynecologic cancer received PBS to the whole pelvis. The patients received a dose of 45 to 50.4 Gy relative biological effectiveness (RBE) in 1.8 Gy (RBE) daily fractions. Acute toxicity was scored according to the Common Terminology Criteria for Adverse Events, version 4. A dosimetric comparison between a 2-field posterior oblique beam PBS and an IMRT plan was conducted. The Wilcoxon signed rank test was used to assess the potential dosimetric differences between the 2 plans and PBS target coverage robustness relative to setup uncertainties.

      Results

      The median patient age was 55 years (range 23-76). The primary site was cervical in 7, vaginal in 1, and endometrial in 3. Of the 11 patients, 7 received concurrent cisplatin, 1 each received sandwich carboplatin and paclitaxel chemotherapy, both sandwich and concurrent chemotherapy, and concurrent and adjuvant chemotherapy, and 1 received no chemotherapy. All patients completed treatment. Of the 9 patients who received concurrent chemotherapy, the rate of grade 2 and 3 hematologic toxicities was 33% and 11%, respectively. One patient (9%) developed grade 3 acute gastrointestinal toxicity; no patient developed grade ≥3 genitourinary toxicity. The volume of pelvic bone marrow, bladder, and small bowel receiving 10 to 30 Gy was significantly lower with PBS than with intensity modulated radiation therapy (P<.001). The target coverage for all PBS plans was robust relative to the setup uncertainties (P>.05) with the clinical target volume mean dose percentage received by 95% and 98% of the target volume coverage changes within 2% for the individual plans.

      Conclusions

      Our results have demonstrated the clinical feasibility of PBS and the dosimetric advantages, especially for the low-dose sparing of normal tissues in the pelvis with the target robustness maintained relative to the setup uncertainties. Future studies with larger patient numbers are planned to further validate our preliminary findings.
      To read this article in full you will need to make a payment
      ASTRO Member Login
      ASTRO Members, full access to the journal is a member benefit. Use your society credentials to access all journal content and features.

      Purchase one-time access:

      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Mauch P.
        • Constine L.
        • Greenberger J.
        • et al.
        Hematopoietic stem cell compartment: Acute and late effects of radiation therapy and chemotherapy.
        Int J Radiat Oncol Biol Phys. 1995; 31: 1319-1339
        • Rose P.G.
        • Bundy B.N.
        • Watkins E.B.
        • et al.
        Concurrent cisplatin-based radiotherapy and chemotherapy for locally advanced cervical cancer.
        N Engl J Med. 1999; 340: 1144-1153
        • Keys H.M.
        • Bundy B.N.
        • Stehman F.B.
        • et al.
        Cisplatin, radiation, and adjuvant hysterectomy compared with radiation and adjuvant hysterectomy for bulky stage IB cervical carcinoma.
        N Engl J Med. 1999; 340: 1154-1161
        • Peters III, W.A.
        • Liu P.Y.
        • Barrett II, R.J.
        • et al.
        Concurrent chemotherapy and pelvic radiation therapy compared with pelvic radiation therapy alone as adjuvant therapy after radical surgery in high-risk early-stage cancer of the cervix.
        J Clin Oncol. 2000; 18: 1606-1613
        • Parker K.
        • Gallop-Evans E.
        • Hanna L.
        • et al.
        Five years’ experience treating locally advanced cervical cancer with concurrent chemoradiotherapy and high-dose-rate brachytherapy: Results from a single institution.
        Int J Radiat Oncol Biol Phys. 2009; 74: 140-146
        • Rose B.S.
        • Liang Y.
        • Lau S.K.
        • et al.
        Correlation between radiation dose to (1)(8)F-FDG-PET defined active bone marrow subregions and acute hematologic toxicity in cervical cancer patients treated with chemoradiotherapy.
        Int J Radiat Oncol Biol Phys. 2012; 83: 1185-1191
        • Mell L.K.
        • Kochanski J.D.
        • Roeske J.C.
        • et al.
        Dosimetric predictors of acute hematologic toxicity in cervical cancer patients treated with concurrent cisplatin and intensity-modulated pelvic radiotherapy.
        Int J Radiat Oncol Biol Phys. 2006; 66: 1356-1365
        • Albuquerque K.
        • Giangreco D.
        • Morrison C.
        • et al.
        Radiation-related predictors of hematologic toxicity after concurrent chemoradiation for cervical cancer and implications for bone marrow-sparing pelvic IMRT.
        Int J Radiat Oncol Biol Phys. 2011; 79: 1043-1047
        • Lin A.
        • Ben-Josef E.
        Intensity-modulated radiation therapy for the treatment of anal cancer.
        Clin Colorectal Cancer. 2007; 6: 716-719
        • Song W.Y.
        • Huh S.N.
        • Liang Y.
        • et al.
        Dosimetric comparison study between intensity modulated radiation therapy and three-dimensional conformal proton therapy for pelvic bone marrow sparing in the treatment of cervical cancer.
        J Appl Clin Med. 2010; 11: 3255
        • Milby A.B.
        • Both S.
        • Ingram M.
        • et al.
        Dosimetric comparison of combined intensity-modulated radiotherapy (IMRT) and proton therapy versus IMRT alone for pelvic and para-aortic radiotherapy in gynecologic malignancies.
        Int J Radiat Oncol Biol Phys. 2012; 82: e477-e484
        • Lomax A.J.
        • Pedroni E.
        • Rutz H.
        • et al.
        The clinical potential of intensity modulated proton therapy.
        Z Med Phys. 2004; 14: 147-152
        • Small Jr., W.
        • Mell L.K.
        • Anderson P.
        • et al.
        Consensus guidelines for delineation of clinical target volume for intensity-modulated pelvic radiotherapy in postoperative treatment of endometrial and cervical cancer.
        Int J Radiat Oncol Biol Phys. 2008; 71: 428-434
        • Mell L.K.
        • Tiryaki H.
        • Ahn K.H.
        • et al.
        Dosimetric comparison of bone marrow-sparing intensity-modulated radiotherapy versus conventional techniques for treatment of cervical cancer.
        Int J Radiat Oncol Biol Phys. 2008; 71: 1504-1510
        • Kirk M.L.
        • Tang S.
        • Zhai H.
        • et al.
        Comparison of prostate proton treatment planning technique, interfraction robustness, and analysis of single-field treatment feasibility.
        Pract Radiat Oncol. 2015; 5: 99-105
        • Rose B.S.
        • Aydogan B.
        • Liang Y.
        • et al.
        Normal tissue complication probability modeling of acute hematologic toxicity in cervical cancer patients treated with chemoradiotherapy.
        Int J Radiat Oncol Biol Phys. 2011; 79: 800-807
        • International Commission on Radiation Units and Measurements
        Prescribing, recording, and reporting proton-beam therapy. ICRU Report 78.
        2007
        • Lin H.
        • Ding X.
        • Kirk M.
        Supine craniospinal irradiation using a proton pencil beam scanning technique without mach line changes for field junctions.
        Int J Radiat Oncol Biol Phys. 2014; 90: 71-78
        • Klopp A.H.
        • Moughan J.
        • Portelance L.
        • et al.
        Hematologic toxicity in RTOG 0418: A phase 2 study of postoperative IMRT for gynecologic cancer.
        Int J Radiat Oncol Biol Phys. 2013; 86: 83-90
        • Tang S.
        • Both S.
        • Bentefour H.
        • et al.
        Improvement of prostate treatment by anterior proton fields.
        Int J Radiat Oncol Biol Phys. 2012; 83: 408-418
        • Roeske J.C.
        • Bonta D.
        • Mell L.K.
        • et al.
        A dosimetric analysis of acute gastrointestinal toxicity in women receiving intensity-modulated whole-pelvic radiation therapy.
        Radiother Oncol. 2003; 69: 201-207
        • Simpson D.R.
        • Song W.Y.
        • Moiseenko V.
        • et al.
        Normal tissue complication probability analysis of acute gastrointestinal toxicity in cervical cancer patients undergoing intensity modulated radiation therapy and concurrent cisplatin.
        Int J Radiat Oncol Biol Phys. 2012; 83: e81-e86
        • Chopra S.
        • Dora T.
        • Chinnachamy A.N.
        • et al.
        Predictors of grade 3 or higher late bowel toxicity in patients undergoing pelvic radiation for cervical cancer: Results from a prospective study.
        Int J Radiat Oncol Biol Phys. 2014; 88: 630-635
        • Kagei K.
        • Tokuuye K.
        • Okumura T.
        • et al.
        Long-term results of proton beam therapy for carcinoma of the uterine cervix.
        Int J Radiat Oncol Biol Phys. 2003; 55: 1265-1271
        • Dvorak T.
        • Fitzek M.M.
        • Wazer D.E.
        Utilization of proton therapy: Evidence-based, market-driven, or something in-between?.
        Am J Clin Oncol. 2013; 36: 192-196
        • Levin C.V.
        Potential for gain in the use of proton beam boost to the para-aortic lymph nodes in carcinoma of the cervix.
        Int J Radiat Oncol Biol Phys. 1992; 22: 355-359
        • Duenas-Gonzalez A.
        • Zarba J.J.
        • Patel F.
        • et al.
        Phase III, open-label, randomized study comparing concurrent gemcitabine plus cisplatin and radiation followed by adjuvant gemcitabine and cisplatin versus concurrent cisplatin and radiation in patients with stage IIB to IVA carcinoma of the cervix.
        J Clin Oncol. 2011; 29: 1678-1685
        • Shah P.H.
        • Kudrimoti M.
        • Feddock J.
        • et al.
        Adjuvant treatment for stage IIIC endometrial cancer: Options and controversies.
        Gynecol Oncol. 2011; 122: 675-683

      Comments

      Commenting Guidelines

      To submit a comment for a journal article, please use the space above and note the following:

      • We will review submitted comments as soon as possible, striving for within two business days.
      • This forum is intended for constructive dialogue. Comments that are commercial or promotional in nature, pertain to specific medical cases, are not relevant to the article for which they have been submitted, or are otherwise inappropriate will not be posted.
      • We require that commenters identify themselves with names and affiliations.
      • Comments must be in compliance with our Terms & Conditions.
      • Comments are not peer-reviewed.