Cancer Treatment Today » Radiation Therapy

Proton Beam Radiotherapy for Craniospinal Radiation – pro

M Levin, MD — Mon, 09 Sep 2013 17:14:12 +0000

Proton beam therapy is similar to 3-Dimensional and cofnromal readiatherapy but it uses proton beams that are directed to the tumor. Protons are positive parts of atoms. Unlike x-rays, which are what conventional radiation emplys, protons release energy both before and after they hit their target. If interst to physicians, protons cause little damage to tissues they pass through and release their energy after traveling a certain distance.

The proponents of this novel therapy argue that this feature of proton Beam radiotherapy justifies its use. However, there are other ways to spare normal tissue, including: Three-dimensional conformal radiation therapy (3D-CRT. Intensity modulated radiation therapy (IMRT), Conformal proton beam radiation therapy, Stereotactic radiosurgery/stereotactic radiotherapy and Brachytherapy (internal radiotherapy). In addition, the claim that safety alone is the reason to adopt proton beam for routine use should not be made in the absence of studies that confirm better outcomes. Because proton beam technology is available on only a number of US facilities and because craniospinal radiation is not performed very frequently, studies to support the assertion that proton beam radiotherapy is superior have not been done and the treatment should still be considered investigational.

Proton beam therapy systems are approved by the FDA 510(k) process as a “medical device designed to produce and deliver a proton beam for the treatment of patients with localized tumors and other conditions susceptible to treatment by radiation” (FDA, 2006). Examples of such systems are the Optivus Proton Beam Therapy System (Optivus Technology Inc., Loma Linda, CA) and the IBA Proton Therapy System-Proteus 235 (Ion Beam Applications S.A., Philadelphia, PA).

The Agency for Healthcare Research and Quality published a 2009 technology report on particle beam radiation therapies for the treatment of cancers including skull base and brain tumors. They noted that there is a proposed advantage of using particle beam therapy, including PBT, where precise radiation targeting is critical in tumors of the skull base and tumors adjacent to the brain and brain stem. The report concluded that studies on charged particle therapy “do not document the circumstances in contemporary treatment strategies in which radiotherapy with charged particles is superior to other modalities. Comparative studies in general, and randomized trials in particular (when feasible) are needed to document the theoretical advantages of charged particle radiotherapy to specific clinical situations”.

In a technology assessment on the use of PBT for the treatment of cancer, the Australia and New Zealand Horizon Scanning Network (2006) stated that PBT “may be of particular benefit” in the treatment of patients with intermediate depth tumors such as those in the head, cancers that are located in difficult or dangerous-to-treat areas, and tumors in locations where “conventional radiotherapy would damage surrounding tissue to an unacceptable level” (e.g., central nervous system and head). PBT “may be ideal for use in the treatment of pediatric patients where the need to avoid secondary tumors is important due to the potentially long life span after radiation treatment when they may develop radiation induced malignancies. It is not clear how this may relate to cranio-spinal radiation.

Y. Lievens, W. den BogaertProton beam therapy: Too expensive to become true?. Radiotherapy and Oncology, Volume 75, Issue 2, Pages 131-133 2005

Yock TI, Tarbell NJ.Technology insight: Proton beam radiotherapy for treatment in pediatric brain tumors. Nat Clin Pract Oncol. 2004 Dec;1(2):97-103;

Semenova J.Proton beam radiation therapy in the treatment of pediatric central nervous system malignancies: a review of the literature. J Pediatr Oncol Nurs. 2009 May-Jun;26(3):142-9. Epub 2009 May 21.

Radiofrequency Ablation of chest wall tumor – pro

M Levin, MD — Sun, 09 Dec 2012 17:03:48 +0000

Radiofrequency Ablation(RFA) is a tool used primarily for liver cancer and liver metastases. Percutaneous radiofrequency coagulation is performed by using an electrode placed in the lesion, coupled with a radiofrequency generator that produces local tissue destruction by converting radiofrequency into heat. After the liver, most reports are of lung, breast and kidney cancers. There are is very little literature to guide its use for recurrent chest wall tumors. A large case series by Dupuy included 19 cancers in the chest wall skeleton. It concluded that this technique can safely palliate pain but did not provide information on overall survival and recurrence rates. RFA has been reported to cause nerve damage and nonehaling wounds. There is also the expense of this procedure and the radiation exposure to operators and patients. It would be prudent to obtain more experimental information before routinely using this procedure for recurrent chest wall tumors.

J. H. Lefevre, Y. Parc, M. Lewinet al, Radioequency ablation for recurrent pelvic cancer Colorectal Disease, Volume 10, Issue 8, pages 781–784, October 2008

Arianna Bertocchini, Radiofrequency Thermoablation in Chest Wall Mesenchymal Hamartoma of an Infant Thorac Surg 2007;84:2091-2093

D. E. Dupuy, D. Liu, D. Hartfeil, L. Hanna, J. Blume, K. Ahrar, R. Lopez, H. Safran, T. DiPetrillo and W. Mayo-Smith, rcutaneous radiofrequency ablation of painful osseous metastases: A multicenter trial: American College of Radiology Imaging Network 6661 Journal of Clinical Oncology, 2007 ASCO Annual Meeting Proceedings (Post-Meeting Edition). Vol 25, No 18S (June 20 Supplement), 2007: 9101

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IMRT for prostate cancer – pro

M Levin, MD — Sun, 23 Sep 2012 16:52:15 +0000

IMRT is a rapidly evolving technique, which affords a more precise radiation dose delivery of escalated doses, in appropriate cases, to targeted tumors, while sparing nearby healthy tissue structures. The FDA clearance of numerous devices for the technical delivery of IMRT is based on the capability of this technology to incorporate accurate dose calculation algorithms, associated with a verifiable dose distribution, as managed by the treating physician, (i.e., radiation oncologist). Although, to date, no randomized trials have matured to document long-term outcomes data and efficacy for IMRT, the scientific evidence currently available indicates that IMRT permits better treatment planning and sparing of surrounding tissues, which is of particular usefulness with “Radiosensitive” tumors of the head/neck, prostate and CNS lesions where the target volume is in close proximity to critical healthy structures that must be protected. These results may be extrapolated to the treatment of other cancers at other anatomic sites; however, a number of technical issues need to be resolved before IMRT can be recommended routinely for lung cancer use, particularly the issue of tumor mobility must be addressed, (e.g., a lung tumor moving with respiration)” . CCited from: htttp://atc.wustl.edu/home/NCI/NCI_IMRT_Guidelines_2006.pdf

Currently, there are no randomized controlled trials of IMRT compared with other radiation techniques for treatment of prostate cancer. Non-randomized studies consistently demonstrate reduced rates of toxicity in IMRT-treated patients. The 2010 Agency for Healthcare Research and Quality (AHRQ) comparative evaluation of radiation treatments for clinically localized prostate cancer concluded that data on comparative effectiveness between different forms of radiation treatments are inconclusive with respect to overall or disease-specific survival. In addition, the AHRQ technology assessment states that more studies of better quality are needed to confirm or refute the suggested findings in the studies that compared outcomes in patients treated with different forms of radiation therapy.

Sheets NC, Goldin GH, Meyer AM, et al. Intensity-modulated radiation therapy, proton therapy, or conformal radiation therapy and morbidity and disease control in localized prostate cancer. JAMA 2012; 307:1611.

Alongi F, Fiorino C, Cozzarini C, et al. IMRT significantly reduces acute toxicity of whole-pelvis irradiation in patients treated with post-operative adjuvant or salvage radiotherapy after radical prostatectomy. Radiother Oncol 2009; 93:207.

Zelefsky MJ, Levin EJ, Hunt M, et al. Incidence of late rectal and urinary toxicities after three-dimensional conformal radiotherapy and intensity-modulated radiotherapy for localized prostate cancer. Int J Radiat Oncol Biol Phys 2008; 70:1124

Blue Cross Blue Shield Association. Special Report: Intensity Modulation Radiation Therapy for Cancer of the Breast or Lung. TEC Assessment. Chicago, IL. December 2005; 20 (13)

Das, I., Cheng, C., Chopra, K., et al. Intensity modulated radiation therapy dose prescription, recording, and delivery: patterns of variability among institutions and treatment planning systems. Journal of the National Cancer Institute. 2008.National Cancer Institute (NCI). National Cancer Institute Guidelines for the use of Intensity Modulated Radiation Therapy in Clinical Trials. Bethesda, MD: NCI; January 14, 2005

Agency for Healthcare Research and Quality (AHRQ) Technology Assessments. Comparative evaluation of radiation treatments for clinically locazlized prostate cancer: an update. Available from: http://www.cms.gov/coveragegeninfo/downloads/id69ta.pdf

Wilt TJ, Shamliyan T, Taylor B et al. Comparative effectiveness of therapies for clinically localized prostate cancer. Comparative Effectiveness Review No. 13. Agency for Healthcare Research and Quality. February 2008.

Pearson SD, Ladapo, Prosser L. Intensity modulated radiation therapy (IMRT) for localized prostate cancer. Institute for Clinical and Economic Review. 2007.

Staffurth, J. A review of the clinical evidence for intensity-modulated radiotherapy. Clin Oncol (R Coll Radiol). 2010 Oct;22(8):643-57.

Zelefsky, MJ, Levin, EJ, Hunt, M, et al. Incidence of late rectal and urinary toxicities after three-dimensional conformal radiotherapy and intensity-modulated radiotherapy for localized prostate cancer. Int J Radiat Oncol Biol Phys. 2008 Mar 15;70(4):1124-9.

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Zevalin and Rituxan for relapsed large cell lymphoma or for consolidation – pro

M Levin, MD — Fri, 14 Sep 2012 15:11:19 +0000

Zevalin, 90Y-ibritumomab tiuxetan, is a novel radioimmunotherapeutic agent approved forthe treatment of relapsed or refractory, low-grade or follicular B-cell non-Hodgkin’s lymphoma (NHL). Zevalin is also indicated for the treatment of previously untreated follicular NHL in patients who achieve a partial or complete response to first-line chemotherapy.

90Y-ibritumomab tiuxetan consists of a murine monoclonal antibody covalently attached to a metal chelator, which stably chelates 111In for imaging and 90Y for therapy. It is often used for other than first line of treatment for lymphoma.

A recent guideline states experts’ consensus: “It is the opinion of the Hematology Disease Site Group that the benefit of 90Y-ibritumomab tiuxetan radioimmunotherapy may be generalizable to other relapsed or refractory indolent non-Hodgkin’s lymphomas previously treated with rituximab….but not CLL.

F. Morschhauser, T. Illidge, D. Huglo et al., “Efficacy and safety of yttrium-90 ibritumomab tiuxetan in patients with relapsed or refractory diffuse large B-cell lymphoma not appropriate for autologous stem-cell transplantation,” Blood, vol. 110, no. 1, pp. 54–58, 2007.

Leung M, Haynes AE, Stevens A, Meyer RM, Imrie K, Hematology Disease Site Group. Ibritumomab tiuxetan in lymphoma: a clinical practice guideline. Toronto (ON): Cancer Care Ontario (CCO); 2006 Jul 17. 42 p. (Evidence-based series; no. 6-17). [44 references]

Giulia Motta, Michele Cea, Eva Moran, Federico Carbone, Valeria Augusti, Franco Patrone, and Alessio Nencioni Monoclonal Antibodies for Non-Hodgkin’s Lymphoma: State of the Art and Perspectives Clinical and Developmental ImmunologyVolume 2010 (2010),

Yang DH, Kim WS, Kim SJ, Kim JS, Kwak JY, Chung JS, Oh SY, Suh C, Lee JJ. Pilot trial of yttrium-90 ibritumomab tiuxetan consolidation following rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone chemotherapy in patients with limited-stage, bulky diffuse large B-cell lymphoma. Leuk Lymphoma. 2012 May;53(5):807-11.

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Motefaxin gadollinium for brain metstases and gliblastoma – pro

M Levin, MD — Thu, 13 Sep 2012 15:44:11 +0000

Motexafin gadolinium is a member of a class of rationally designed porphyrin-like molecules called texaphyrins. The rationale for its use in cancer therapy is that, like naturally occurring porphyrins, it tends to concentrate selectively in cancer cells and it has a novel mechanism of action as it induces redox stress, triggering apoptosis in a broad range of cancers. RECENT FINDINGS: In vitro studies have shown that motexafin gadolinium is synergistic with radiation and varied chemotherapeutic agents. A phase III international study has shown that the onset of neurologic progression is significantly delayed in patients with brain metastases from lung cancer treated with whole-brain radiation and motexafin gadolinium (compared with radiation alone). Recent preclinical data have shown that motexafin gadolinium alone is cytotoxic to cancers such as multiple myeloma, non-Hodgkin lymphoma, and chronic lymphocytic leukemia through redox and apoptotic pathways. Multiple clinical trials examining motexafin gadolinium as a single agent and in combination with radiation and/or chemotherapy for the treatment of solid and hematopoietic tumors are underway. SUMMARY: Motexafin gadolinium is a novel tumor-targeted agent that disrupts redox balance in cancer cells by futile redox cycling. Motexafin gadolinium is currently in numerous hematology/oncology clinical trials for use as a single agent and in combination with chemotherapy and/or radiation therapy. Most of the reprots ahve been in the treatment of brain metastases. Trials for brain mets and gliomas are ongoing.

nccn.org, brain cancers

GM, Khuntia D, Mehta MPMotexafin gadolinium: a novel radiosensitizer for brain tumors.Forouzannia A, Richards.Expert Rev Anticancer Ther. 2007 Jun;7(6):785-94.

D. R. Miles, J. A. Smith, S.-C. Phan, S. J. Hutcheson, M. F. Renschler, J. M. Ford, and G. W. Boswell
Population Pharmacokinetics of Motexafin Gadolinium in Adults With Brain Metastases or Glioblastoma Multiforme
J. Clin. Pharmacol., March 1, 2005; 45(3): 299 – 312.

Hyperthermia – current status – pro

M Levin, MD — Thu, 13 Sep 2012 15:36:07 +0000

Hyperthermia was first described in a radiation text in 1935, in a paper that was titled, “Preliminary study of the effect of artificial fever upon hopeless tumor cases.” I think “hopeless tumor cases” is the key here. There were a number of well-designed trials in the 1970s and 1980s looking at the use of heat or hyperthermia and radiation, but by the late 1980s, most hyperthermia trials were abandoned because of technical issues. 1989 was the last year of a report from a phase III trial of any size through the Radiation Therapy Oncology Group (RTOG), and it was a negative trial. Heat added nothing to radiation in a palliative setting. But in the last decade, there have been six randomized trials, including the one from Duke, looking again at this issue. These six trials together included a total of less than 400 women with breast cancer and less than 160 women with re-irradiation of a chest wall lesion. None of the trials showed any survival advantage but palliation was achieved.

Hyperthermia has a place in standard therapeutic armamentarium for breast cancer. National Comprehensive Cancer Network (NCCN) has for the first time included it in its 2007 Breast Cancer Guidelines for recurrent cancer of the chest wall (breast cancer) and other localized cancer recurrences.

This was possible because surface cancers are accessible to heat. Internal mets are much harder to treat. The Germans at St. Geirge are exploring nanotechnology heating, and others are using microwaves but this is cearly a very experimental approach at thsi time, as is combination of hyperthermia and chemotherapy for breast cancer.

At this point, there are several supporting trials in other cancers than breast. I list them as presented in a recent review ACRO 2/2007). In a clinical study conducted in Italy involving 41 patients (44 nodes) with inoperable Stage IV head and neck cancer, patients receiving hyperthermia and radiation therapy had an 83% complete response rate compared to 41% for patients who received radiation therapy alone, and the 3-year local relapse-free survival rate was 24% for patients receiving only radiation and 68% for those who received both radiation and hyperthermia therapy. (International Journal of Radiation Oncology, Biology, Physics Vol. 28, pp. 163-169.)

– In an international clinical study conducted in Denmark, the Netherlands and Norway involving 128 patients with recurrent or metastatic malignant melanoma, patients who received hyperthermia therapy along with radiation had a complete response rate for recurrent malignant melanoma lesions of 62% compared to 35% for those who received radiation treatments alone, and the local relapse-free survival rate at 5 years was 46% for those who received both hyperthermia and radiation and 28% for those who received radiation alone. (See International Journal of Hyperthermia, Vol., 12, No. 1, 3-20.)

– In a clinical study conducted at UCSF involving 112 patients with glioblastoma maltiforme (brain cancer), patients who received both hyperthermia and interstitial radiation therapy (brachytherapy) had a more than double 2-year survival rate as compared to patients who received brachytherapy alone. (See International Journal of Radiation Oncology, Biology, Physics, Vol. 40, No. 2, pp. 287-295.)

– In a clinical study conducted in the Netherlands involving 358 patients with locally advanced pelvic tumors, bladder cancer patients who received radiation alone had a complete response rate of 51% compared to 73% for those who received hyperthermia and radiation. The complete response rate for patients with advanced cervical cancer was 83% for those who received radiation plus hyperthermia and 57% for those who received radiation alone. (See The Lancet, Vol. 355, pp. 1119-1125.) In addition, a clinical study of 61 patients at Duke University using the tri-modality treatments hyperthermia, radiation and chemotherapy together for the treatment of advanced cervical cancer resulted in a complete remission in 90%. (See CANCER, August 14, 2005, Vol. 104, No. 4.)

– In a clinical study conducted in the United Kingdom, the Netherlands and Canada involving 306 patients with superficial localized breast cancer, patients who received both hyperthermia and radiation therapy had a complete response rate of 59% compared to 41% for those who received radiation treatments alone. Local relapse-free survival was 50% for those who received both therapies and 30% for those who received radiation alone. (See International Journal of Radiation Oncology, Biology, Physics, Vol. 35, No. 4, pp. 731-744.) In addition, a clinical study conducted at Duke University involving patients with previously irradiated superficial tumors, 23.5% had a complete response when treated with radiation alone compared to a response rate of 68.2% for patients treated with hyperthermia plus radiation. (See Journal of Clinical Oncology, Vol. 23, No. 13, May 1, 2005.)

National Clinical Practice Guidelines in Oncology for Soft Tissue Sarcoma (V.2.2008) issued by the National Comprehensive Cancer Network (NCCN) include reference to the preliminary results from a 341 patient phase III randomized multi-center clinical trial (EORTC-62961 and NCT00003052) involving the use of regional hyperthermia and chemotherapy with EIA (etoposide, ifosfamide and adriamycin), as compared to EIA alone.

In conclusion, hypertehrmia with radiation clearly is effective to palliate as seen in various cancers in superficial locations. There is also supporting evdidence specifically in melanoma.

Sakurai H, Mitsuhashi N, Tamaki Y, et al. Interaction between low dose-rate irradiation, mild hyperthermia and low-dose caffeine in a human lung cancer cell line. Int J Radiat Biol. 1999 Jun;75(6):739-45.

nccn.org, breast cancer

L. Kronberger, P. Wagner, M. Puchinger, H. Stranzl, P. Kohek: Radiofrequency-Hyperthermia in Combination with Chemo and Radiotherapy in Palliative Treatment of Breast Cancer: A Case Report. The Internet Journal of Surgery. 2004. Volume 5 Number 2.

Vernon C C and Hand J W (2002) Hyperthermia in the treatment of cancer in Treatment Of Cancer (4th Edition) Eds. Price P and Sikora K. London, Arnold, 81 –102.Wust P et al (2002)

Hafstrom L, Rudenstam CM, Blomquist E, et al. Regional hyperthermic perfusion with melphalan after surgery for recurrent malignant melanoma. J Clin Oncol. 1991;9(12):2091-2094.

Radiation for Dupuytren – pro

M Levin, MD — Thu, 13 Sep 2012 15:33:05 +0000

Radiation therapy (radiotherapy) is a non-surgical treatment that can stop or slow down Dupuytren’s disease in its early stage. In radiation therapy, the nodules and cords associated with Dupuytren’s are irradiated from a distance of .5 – 1 cm either with X-Rays (e.g. 120 kV = soft X-Rays that do not penetrate deeply into the body) or with electrons (3 – 10 MeV). This is typically done over five days in a row applying an efficient dose (single dose 3 Gy, total dose 15 Gy). After a break of six weeks, this treatment is repeated. This treatment has not been compared to surgery or other nonopeartive interventions. Instead a trial of two different radiation concepts showed that both concepts were effective.

Habash A, Rinker B. Dupuytren’s disease involving the wrist. J Hand Surg [Am]. Mar 2007;32(3):352-4.

Seegenschmiedt MH, Olschewski T, Guntrum F.. Radiotherapy optimization in early-stage Dupuytren’s contracture: first results of a randomized clinical Int J Radiat Oncol Biol Phys. 2001 Mar 1;49(3):785-98

Townley WA, Baker R, Sheppard N, et al; Dupuytren’s contracture unfolded. BMJ. 2006 Feb 18;332(7538):397-400.

Trojian TH, Chu SM; Dupuytren’s disease: diagnosis and treatment. Am Fam Physician. 2007 Jul 1;76(1):86-9

IMRT for rectal cancer – pro

M Levin, MD — Thu, 13 Sep 2012 15:29:44 +0000

IMRT is a rapidly evolving technique, which affords a more precise radiation dose delivery of escalated doses, in appropriate cases, to targeted tumors, while sparing nearby healthy tissue structures. The FDA clearance of numerous devices for the technical delivery of IMRT is based on the capability of this technology to incorporate accurate dose calculation algorithms, associated with a verifiable dose distribution, as managed by the treating physician, (i.e., radiation oncologist). Although, to date, no randomized trials have matured to document long-term outcomes data and efficacy for IMRT, the scientific evidence currently available indicates that IMRT permits better treatment planning and sparing of surrounding tissues, which is of particular usefulness with “Radiosensitive” tumors of the head/neck, prostate and CNS lesions where the target volume is in close proximity to critical healthy structures that must be protected. These results may be extrapolated to the treatment of other cancers at other anatomic sites; however, a number of technical issues need to be resolved before IMRT can be recommended routinely. The NCI was sufficiently concerned aboyt these issues to issue a recently updated report for use in planning and design of clicnial trials. It can be found at http://atc.wustl.edu/home/NCI/NCI_IMRT_Guidelines_2006.pdf

A recent retrospective review of 53 uses of IMRT in anal cancer concluded: “Preliminary outcomes suggest that concurrent chemotherapy and IMRT for anal canal cancers is effective and tolerated favorably compared with historical standards.” More studies are needed.

For rectal cancer, the literature suggests that the dose is better distributed and may be better tolerated. What has not yet been proven, however, is the clinical significance of this factor. Thus far, there are no guidelines that recommend IMRT for rectal cancer.

http://atc.wustl.edu/home/NCI/NCI_IMRT_Guidelines_2006.pdf

J. K. Salama, L. K. Mell, D. A. Schomas, R. C. Miller, K. Devisetty, A. B. Jani, A. J. Mundt, J. C. Roeske, S. L. Liauw, and S. J. Chmura
Concurrent Chemotherapy and Intensity-Modulated Radiation Therapy for Anal Canal Cancer Patients: A Multicenter Experience
J. Clin. Oncol., October 10, 2007; 25(29): 4581 – 4586.

National Cancer Institute (NCI). National Cancer Institute Guidelines for the use of Intensity Modulated Radiation Therapy in Clinical Trials. Bethesda, MD: NCI; January 14, 2005

M. Callister, G. Ezzell, L. Gunderson 2143IMRT Reduces the Dose to Small Bowel and Other Pelvic Organs in the Preoperative Treatment of Rectal Cancer
International Journal of Radiation OncologyBiologyPhysics, Volume 66, Issue 3, Pages S290-S290

M.C.W.M. Bloemers, L. Portelance, R. Ruo, M. Duclos, B. Bahoric, L. Souhami A Dosimetric Analysis of IMRT versus 3D Conventional Radiation in Vulvar Cancer
International Journal of Radiation Oncology*Biology*Physics, Volume 72, Issue 1, Supplement 1, 1 September 2008, Pages S362-S363
M. Teresa Guerrero Urbano, Anthony J. Henrys, Elisabeth J. Adams, Andrew R. Norman, James L. Bedford, Kevin J. Harrington, Christopher M. Nutting, David P. Dearnaley, Diana M. Tait Intensity-modulated radiotherapy in patients with locally advanced rectal cancer reduces volume of bowel treated to high dose levels
International Journal of Radiation Oncology*Biology*Physics, Volume 65, Issue 3, 1 July 2006, Pages 907-916

Neutron Beam Radiotherapy – pro

M Levin, MD — Thu, 13 Sep 2012 15:26:51 +0000

Neutron beam therapy is a specialized form of external beam radiation therapy. It is often used to treat inoperable tumors or tumors that are radioresistant, meaning that they are very resistant to conventional X-ray radiation therapy. Neutrons have a greater biologic impact on cells than other types of radiation. Used carefully, this added impact can be an advantage in certain situations. Neutron therapy is available at only a few specialized centers. Certain tumors seem to be more susceptible to the cytotoxic effects of neutrons, including salivary gland tumors.
According to the American Society of Clinical Oncology (ASCO) supports the use of this modality for salivary gland tumors. There are studies that sugest that it is beneficial for prostate, lung and some sarcomas. An assessment of the evidence for neutron beam radiotherapy prepared by the Australia and New Zealand Horizon Scanning Network found that NBT is a promising technology. The assessment cautioned, however, that “[t]he studies identified in this prioritising summary were not of high quality and, as such, the conclusions must be taken as preliminary in nature.”

There is insufficient support to consider it appropriate for melanoma.

Lodge M, Pijls-Johannesma M, Stirk L, et al. A systematic literature review of the clinical and cost-effectiveness of hadron therapy in cancer. Radiother Oncol. 2007; 83(2):110-122.

Smith RP, Heron DE, Huq MS, Yue NJ. Modern radiation treatment planning and delivery–from Rontgen to real time. Hematol Oncol Clin North Am. 2006; 20(1):45-62.
Government Agency, Medical Society, and Other Authoritative Publications:

American Society for Therapeutic Radiology and Oncology (ASTRO). External Beam Radiation Treatments. Available at: http://www.rtanswers.org/treatment/external_beam.htm#neutron

Purins A, Mundy L, Hiller J. Boron neutron capture therapy for cancer treatment. Horizon Scanning Prioritising Summary. Adelaide, SA: Adelaide Health Technology Assessment (AHTA); October 2007.

Hyperbaric oxygen for late radiation tissue toxicity – pro

M Levin, MD — Thu, 13 Sep 2012 15:22:18 +0000

Radiation therapy can have proximal as well as delayed(late) radiation tissue injury(LRTI). LRTI affecting the head, neck and lower end of the bowel can be improved with HBOT. There is little evidence for or against benefit in other tissues affected by LRTI and this conclusion is based on eight randomised trials with a limited number of patients. Cochrane guideline recommends more study. There is an ongoing trial: Study to Determine if Hyperbaric Oxygen Therapy is Helpful for Treating Radiation Tissue Injuries, NCT00134628.

The Canadian Agency for Drugs and Technologies in Health’s review on the use of HBOT for difficult wound (Boudreau et al, 2010) identified 7 health technology assessments, 5 systematic reviews, and 1 RCT. Overall, the authors of the identified studies found that HBOT was clinically effective as well as cost-effective when it was used to treat patients with diabetes who have lower extremity chronic ulcers. There was some positive evidence to suggest that HBOT was clinically effective when it was used to treat radiation proctitis. The evidence base was considered insufficient to promote the routine use of HBOT for non-diabetic pressure ulcers, delayed radiation-induced injury, thermal burns, as well as skin grafts and flaps. No evidence was identified on the use of HBOT in post-organ transplantation re-vascularization. The authors concludd that overall, the best evidence on the use of adjunctive HBOT was associated with the treatment of chronic diabetic wounds. The evidence that supported its use, however, was not reliable. Although there were many recommendations on the use of HBOTas adjunctive treatment for specific indications, there is little evidence on its clinical and economic benefits.

According to the Department of Health and Human Services OFFICE OF INSPECTOR GENERAL (http://oig.hhs.gov/oei/reports/oei-06-99-00090.pdf), depending on the response of the individual patient and the severity of the original problem, treatment may range from less than 1 week to several months duration, the average being 2 to 4 weeks.

Another interesting application is for treatment of autism but thus far the evidence for its efficacy is not compelling.

Bennett MH, Feldmeier J, Hampson N, Smee R, Milross C. Hyperbaric oxygen therapy for late radiation tissue injury. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD005005

Gesell, Laurie B. (Chair and editor) (2008). Hyperbaric Oxygen Therapy Indications. The Hyperbaric Oxygen Therapy Committee Report (12 ed.). Durham, NC: Undersea and Hyperbaric Medical Society. ISBN 0930406230.

Boudreau R, Moulton K, McGill S. Hyperbaric oxygen therapy for difficult wound healing: Systematic review of clinical effectiveness and cost-effectiveness. Ottawa: Canadian Agency for Drugs and Technologies in Health; 2010. available at: http://64.26.163.205/media/pdf/M0016_HBOT_L3_e.pdf.