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Adjuvant intensity-modulated proton therapy in malignant pleural mesothelioma

A comparison with intensity-modulated radiotherapy and a spot size variation assessment

Adjuvante intensitätsmodulierte Protonentherapie bei malignem Pleuramesotheliom

Ein Vergleich mit intensitätsmodulierter Strahlentherapie und eine Bewertung der Variation der Fokusgrößen

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Abstract

Purpose

Intensity-modulated radiation therapy (IMRT) is the state-of-the-art treatment for patients with malignant pleural mesothelioma (MPM). The goal of this work was to assess whether intensity-modulated proton therapy (IMPT) could further improve the dosimetric results allowed by IMRT.

Patients and methods

We re-planned 7 MPM cases using both photons and protons, by carrying out IMRT and IMPT plans. For both techniques, conventional dose comparisons and normal tissue complication probability (NTCP) analysis were performed. In 3 cases, additional IMPT plans were generated with different beam dimensions.

Results

IMPT allowed a slight improvement in target coverage and clear advantages in dose conformity (p < 0.001) and dose homogeneity (p = 0.01). Better organ at risk (OAR) sparing was obtained with IMPT, in particular for the liver (Dmean reduction of 9.5 Gy, p = 0.001) and ipsilateral kidney (V20 reduction of 58%, p = 0.001), together with a very large reduction of mean dose for the contralateral lung (0.2 Gy vs 6.1 Gy, p = 0.0001). NTCP values for the liver showed a systematic superiority of IMPT with respect to IMRT for both the esophagus (average NTCP 14% vs. 30.5%) and the ipsilateral kidney (p = 0.001). Concerning plans obtained with different spot dimensions, a slight loss of target coverage was observed along with sigma increase, while maintaining OAR irradiation always under planning constraints.

Conclusion

Results suggest that IMPT allows better OAR sparing with respect to IMRT, mainly for the liver, ipsilateral kidney, and contralateral lung. The use of a spot dimension larger than 3 × 3 mm (up to 9 × 9 mm) does not compromise dosimetric results and allows a shorter delivery time.

Zusammenfassung

Ziel

Die intensitätsmodulierte Strahlentherapie (IMRT) erhöht die therapeutische Dosis auf die Pleurahöhle und reduziert die Dosis auf die Risikoorgane (OAR) bei Patienten mit malignem Pleuramesotheliom (MPM). Ziel dieser Arbeit ist zu prüfen, ob Protonen, als intensitätsmodulierte Protonentherapie (IMPT) angewendet, die dosimetrischen Ergebnisse im Vergleich zu einer IMRT weiter verbessern können.

Patienten und Methoden

Wir haben für 7 MPM-Fälle jeweils mit Photonen und Protonen, unter Verwendung von IMRT und IMPT, Bestrahlungspläne wiedererstellt. Für beide Verfahren haben wir eine Analyse der Normalgewebskomplikationen (NTCP) durchgeführt. In 3 Fällen wurden zusätzliche IMPT-Pläne mit geänderter Fokusgröße erstellt.

Ergebnisse

Die IMPT erlaubt eine leichte Verbesserung der Zielvolumenabdeckung und klare Vorteile in der Konformität (p < 0,001) sowie in der Homogenität (p = 0,01). Durch IMPT wurde eine bessere Schonung der OAR erreicht, im Einzelnen für die Leber mit einer Reduktion der Dmean auf 9,5 Gy, (p = 0,001), für die ipsilaterale Niere (58%-Reduktion von V20; p = 0,001) sowie eine starke Reduktion der mittleren Dosis der kontralateralen Lunge (0,2 Gy vs. 6,1 Gy; p = 0,0001). NTCP-Werte für die Leber zeigten eine systematische Überlegenheit der IMPT gegenüber der IMRT, Ähnliches für die Speiseröhre (Durchschnitts-NTCP 14% vs. 30,5%) und die ipsilaterale Niere (p = 0,001). Bezüglich der Pläne mit anderer Fokusgröße zeigt sich ein leichter Verlust der Zielvolumenabdeckung zusammen mit einer Sigma-Erhöhung. Die vorgegebenen Dosisbegrenzungen für die Risikoorgane wurden immer eingehalten.

Schlussfolgerungen

Die Ergebnisse zeigen, dass IMPT eine bessere Schonung der OAR ermöglicht, vor allem für Leber, ipsilaterale Niere und kontralaterale Lunge. Die Verwendung von Fokusgrößen größer als 3 × 3 mm (bis 9 × 9 mm) gefährdet nicht die dosimetrischen Ergebnisse und ermöglicht eine kürzere Bestrahlungszeit.

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Acknowledgments

We thank Valentina Piffer (ATreP – Trento) for her language editing of the manuscript.

Conflict of interest

The corresponding author states that there are no conflicts of interest.

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Authors and Affiliations

  1. ATreP – Agenzia Provinciale per la Protonterapia, Via F.lli Perini, 181, 38122, Trento, Italy

    S. Lorentini, M. Amichetti, F. Fellin & M. Schwarz PhD

  2. Medical Physics School, University of Padova, Padova, Italy

    S. Lorentini

  3. Medical Physics Department, Brescia Hospital, Brescia, Italy

    L. Spiazzi

  4. Radiation Oncology Department, Brescia Hospital, Brescia, Italy

    S. Tonoli & S.M. Magrini

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  1. S. Lorentini
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  2. M. Amichetti
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  3. L. Spiazzi
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  4. S. Tonoli
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  5. S.M. Magrini
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  6. F. Fellin
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  7. M. Schwarz PhD
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Correspondence to M. Schwarz PhD.

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Lorentini, S., Amichetti, M., Spiazzi, L. et al. Adjuvant intensity-modulated proton therapy in malignant pleural mesothelioma. Strahlenther Onkol 188, 216–225 (2012). https://doi.org/10.1007/s00066-011-0038-3

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  • DOI: https://doi.org/10.1007/s00066-011-0038-3

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