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Purpose: Adjuvant radio(chemo)therapy (RT) is part of the standard treatment of gliomas. Safety margins ensuring the coverage of microscopic tumour expansion of diffusely infiltrating gliomas and compensating for systematic positioning errors inevitably result in the normal-appearing (NA) brain tissue surrounding the tumour to be affected by radiation. The aim of the study was to investigate dose- and time-dependent diffusion alterations of NA white matter (WM) structures following RT using tract-based spatial statistics (TBSS). Methods: As part of a prospective, longitudinal study, magnetic resonance imaging (MRI) data of 24 grade II-IV glioma patients treated with photons, protons or mixed-modality therapy were acquired. MRIs before RT and 3-monthly during follow-up obtained up to three years after RT included diffusion tensor images (DTI) (TR/TE=6500/66ms, 2×2×2mm³, 32 directions, b=1000mm/s²). Fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD) were calculated from the DTI data. Corresponding radiation dose maps and clinical target volume (CTV) contours were aligned to MRI using ANTs. NA tissue was defined as brain tissue, excluding the CTV and areas of T2-hyperintensities. All FA images were nonlinearly registered to the “FMRI58B-FA atlas” from FSL with ANTs before applying parts of the TBSS algorithm to create a FA skeleton (Figure 1). The FA skeleton was combined with the “JHU-ICBM-labels-1mm atlas” to measure the diffusion in 19 WM structures. Relative signal changes of each WM structure were calculated as the difference between follow-up and the corresponding baseline signal and evaluated using a paired t-test. A multivariate linear mixed effects model was applied to determine diffusion changes as function of time after RT and mean dose delivered to the corresponding structure. Data from paired structures of the right and left hemispheres were combined for the analysis. Structures containing less than 50 vo

Purpose: Radio(chemo)therapy is used as standard treatment for glioma patients. The surrounding normal tissue is inevitably affected by the irradiation. The aim of this longitudinal study was to investigate perfusion alterations in the normal-appearing tissue after proton irradiation and assess the dose sensitivity of the normal tissue perfusion. Methods: In 14 glioma patients, a sub-cohort of a prospective clinical trial (NCT02824731), perfusion changes in normal-appearing white matter (WM), grey matter (GM) and subcortical GM structures, i.e. caudate nucleus, hippocampus, amygdala, putamen, pallidum and thalamus, were evaluated before treatment and at three-monthly intervals after proton beam irradiation. The relative cerebral blood volume (rCBV) was assessed with dynamic susceptibility contrast MRI and analysed as the percentage ratio between follow-up and baseline image (∆rCBV). Radiation-induced alterations were evaluated using Wilcoxon signed rank test. Dose and time correlations were investigated with univariate and multivariate linear regression models. Results: No significant ∆rCBV changes were found in any normal-appearing WM and GM region after proton beam irradiation. A positive correlation with radiation dose was observed in the multivariate regression model applied to the combined ∆rCBV values of low (1-20Gy), intermediate (21-40Gy) and high (41-60Gy) dose regions of GM (p<0.001), while no time dependency was detected in any normal-appearing area. Conclusion: The perfusion in normal-appearing brain tissue remained unaltered after proton beam therapy. In further studies, a direct comparison with changes after photon therapy is recommended to confirm the different effect of proton therapy on the normal-appearing tissue.

Purpose Currently, there is an intense debate on variations in intra-cerebral radiosensitivity and relative biological effectiveness (RBE) in proton therapy of primary brain tumours. Here, both effects were retrospectively investigated using late radiation-induced brain injuries (RIBI) observed in follow-up after proton therapy of patients with diagnosed glioma. Methods In total, 42 WHO grade 2–3 glioma patients out of a consecutive patient cohort having received (adjuvant) proton radio(chemo)therapy between 2014 and 2017 were eligible for analysis. RIBI lesions (symptomatic or clinically asymptomatic) were diagnosed and delineated on contrast-enhanced T1-weighted magnetic resonance imaging scans obtained in the first two years of follow-up. Correlation of RIBI location and occurrence with dose (D), proton dose-averaged linear energy transfer (LET) and variable RBE dose parameters were tested in voxel- and in patient-wise logistic regression analyses. Additionally, anatomical and clinical parameters were considered. Model performance was estimated through cross-validated area-under-the-curve (AUC) values. Results In total, 64 RIBI lesions were diagnosed in 21 patients. The median time between start of proton radio(chemo)therapy and RIBI appearance was 10.2 months. Median distances of the RIBI volume centres to the cerebral ventricles and to the clinical target volume border were 2.1 mm and 1.3 mm, respectively. In voxel-wise regression, the multivariable model with D, D × LET and periventricular region (PVR) revealed the highest AUC of 0.90 (95 % confidence interval: 0.89–0.91) while the corresponding model without D × LET revealed a value of 0.84 (0.83–0.86). In patient-level analysis, the equivalent uniform dose (EUD11, a = 11) in the PVR using a variable RBE was the most prominent predictor for RIBI with an AUC of 0.63 (0.32–0.90). Conclusions In this glioma cohort, an increased radiosensitivity within the PVR was observed as well as a spatial correlation of RIBI

Introduction: Adjuvant radio(chemo)therapy (RT) is part of the treatment of patients with primary brain tumors. A major challenge following radiotherapy is to distinguish between tumor recurrence and radiation-induced effects. Hyperintensities in T2-weighted (T2w) MRI are commonly observed after radiotherapy but are not specific to the underlying tissue changes. The value of advanced methods, such as perfusion MRI, has already been shown for differentiating between tumor and treatment effect [1,2]. The aim of this study was to evaluate changes of relative cerebral blood volume (rCBV) in areas of T2w-hyperintensities in order to establish an imaging biomarker differentiating between tumor and treatment effect. Methods: In a longitudinal study, anatomical and functional MRI data of glioma patients undergoing gross tumor resection followed by RT were collected. We analyzed a subset of this cohort, which consisted of 14 glioma patients (3 grade II, 8 grade III, 3 grade IV, average age 48.1y ± 13.5y) with tissue hyperintensities on T2w FLAIR images after proton beam irradiation. All MRI data were collected on a 3T Philips Ingenuity PET/MR scanner (Philips, Eindhoven, The Netherlands) using an 8 channel head coil and included anatomical T1w images [3D-GRE, TR/TE=10/3.7ms, FA=20°, voxel size 1×1×1mm3], contrast enhanced T1w images (CET1w) [3D Turbo Field Echo (TFE), TR/TE=8.2/3.7ms, FA=8°, voxel size 1×1×1mm3], 3D FLAIR images [TR/TE = 4800/293ms, TI = 1650ms, 2 averages, voxel size 0.49×0.49×0.5mm3, 360 slices], and dynamic susceptibility contrast (DSC) images using a PRESTO sequence [TR/TE=15/21ms, FA=7°, 60 dynamics, dynamic scan time=1.7s, voxel size 1.8×1.8×3.5mm3] with intravenous gadolinium contrast agent (0.1mol/kg, 4ml/s, 7s delay) followed by a saline flush (20ml, 4ml/s). The same dose of contrast agent was given as a pre-bolus for leakage correction of the DSC perfusion images. MRI scans were acquired prior to RT and post RT in three monthly intervals. In this a

Background: Radiotherapy in patients with primary brain tumors may affect hippocampal structure and cause dyscognitive side-effects. Patients and methods: Using structural MRI and comprehensive neurocognitive evaluation, we investi- gated associations between hippocampal structure and memory deficits in 15 patients with WHO grade 3 and grade 4 gliomas receiving standard radio(chemo)therapy. Results: We did not find changes in hippocampal thickness or cognitive abilities three months after com- pleting radiotherapy. However, subjective memory impairment was associated with symptoms of depression, but not with objective memory performance, cortical thickness of the hippocampus or radi- ation dose. Conclusions: Irrespective of whether there is a bidirectional relationship between affective changes and subjective cognitive dysfunction in these patients, depressive symptoms remain a target for intervention to improve their quality of life. The results of our pilot study highlight that future assessment of side effects of radiotherapy concerning memory should include assessments of depressive symptoms.

Background and purpose: Radiotherapy (RT) is an adjuvant treatment option for glioma patients. Side effects include tissue atrophy, which might be a contributing factor to neurocognitive decline after treatment. The goal of this study was to determine potential atrophy of the hippocampus, amygdala, thalamus, putamen, pallidum and caudate nucleus in glioma patients having undergone magnetic resonance imaging (MRI) before and after RT. Materials and methods: Subcortical volumes were measured using T1-weighted MRI from patients before RT (N = 91) and from longitudinal follow-ups acquired in three-monthly intervals (N = 349). The volumes were normalized to the baseline values, while excluding structures touching the clinical target volume (CTV) or abnormal tissue seen on FLAIR imaging. A multivariate linear effects model was used to determine if time after RT and mean RT dose delivered to the corresponding structures were significant predictors of tissue atrophy. Results: The hippocampus, amygdala, thalamus, putamen, and pallidum showed significant atrophy after RT as function of both time after RT and mean RT dose delivered to the corresponding structure. Only the caudate showed no dose or time dependant atrophy. Conversely, the hippocampus was the structure with the highest atrophy rate of 5.2 % after one year and assuming a mean dose of 30 Gy. Conclusion: The hippocampus showed the highest atrophy rates followed by the thalamus and the amygdala. The subcortical structures here found to decrease in volume indicative of radiosensitivity should be the focus of future studies investigating the relationship between neurocognitive decline and RT. © 2022 The Authors

Introduction: Adjuvant radio(chemo)therapy (RT) is part of the treatment of primary brain tumor patients. In order to capture microscopic tumor extension and to compensate for random and systematic positioning uncertainties, it is inevitable that tumor-surrounding normal brain tissue is irradiated. The aim of this study was to determine relative cerebral blood volume (rCBV) changes in glioma patients before and after RT in normal appearing white matter (WM) and grey matter (GM). Methods: As part of an ongoing study, anatomical and functional MRI data of glioma patients undergoing gross tumor resection followed by RT is being collected. The analysis of a subset of this cohort, 17 glioma patients (3 grade II, 11 grade III, 3 grade IV, average age 46.9y ± 13.2y) is presented here. Two patients were treated with photon therapy, 14 patients with proton therapy and one patient received treatment modalities. MRI scans acquired prior to RT and at least one follow-up MRI obtained 3, 6 and 9 months after RT was evaluated. All MRI data were collected on a 3T Philips Ingenuity PET/MR scanner (Philips, Eindhoven, The Netherlands) using an 8 channel head coil and included anatomical T1w-images (3D-GRE, TR/TE=10/3.7ms, FA=20°, voxel size 1×1×1mm3) and dynamic susceptibility contrast (DSC) imaging using a PRESTO sequence (TR/TE=15/21ms, 60 dynamics, dynamic scantime=1.7s, voxel size 3.6×3.6×3.5mm3) with intravenous gadolinium contrast agent (0.1mol/kg, 4ml/s, 7s delay) followed by a saline flush (20ml, 4ml/s). The CBV-map (fig. 1D) was calculated as the area under curve (AUC) of the voxelwise time course of the 4D PRESTO image. Computed tomographies (CTs) used for planning, radiation dose (fig.1C) and clinical target volume (CTV) contours were registered to the T1w images using ANTs1 . T1w-images were segmented into GM and WM using SPM122 and the corresponding 95% tissue probability maps were rigidly registered with ANTs1 to the CBV-map. B1 inhomogeneities as well as voxels with st

Background and purpose: Radiotherapy is a standard treatment option for high-grade gliomas. Cognitive impairment is a side effect associated with radiotherapy particularly in long-term survivors. Recent findings suggest involvement of the cerebellum in cognitive function. The goal of this study was therefore to investigate dose dependent cerebellar atrophy using prospective, longitudinal MR data from adult glioma patients who received radiotherapy. Materials and methods: Cerebellar volumes were measured using T1-weighted MR images from 91 glioma patients before radiotherapy and every three months thereafter. We calculated the average cerebellar volume change per year per Gy, based on the mean cerebellar dose, using linear regression analysis. Subsequently, patient age was investigated as a confounding factor using multiple linear regression analysis. The impact of chemotherapy was assessed separately in a subgroup of patients receiving a cerebellar dose ≤ 1 Gy. Cerebellar mean dose and cerebellar volume changes were compared between patients treated with proton (N = 38) and photon therapy (N = 52). Results: Cerebellar volume decreased 2.4 % per 10 Gy per year (p < 0.001). The cerebellar volume loss was progressive over time without signs of recovery within the observational period of two years. Neither patient age (p = 0.27) nor chemotherapy (p = 0.43) had a significant impact on cerebellar atrophy. Compared to patients treated with photons, the cerebellar dose was significantly lower in patients treated with proton therapy (p < 0.001, r = 0.62) which also translated to a significantly lower cerebellar volume reduction per year (p = 0.016, r = 0.25). Conclusion: Cerebellar volume decreased significantly and irreversibly after radiotherapy as function of time and dose. Further work is now needed to correlate these results with cognitive function and motor performance.

Background and purpose Radio(chemo)therapy is standard in the adjuvant treatment of glioblastoma. Inevitably, brain tissue surrounding the target volume is also irradiated, potentially causing acute and late side-effects. Diffusion imaging has been shown to be a sensitive method to detect early changes in the cerebral white matter (WM) after radiation. The aim of this work was to assess possible changes in the mean diffusivity (MD) of WM after radio(chemo)therapy using Diffusion-weighted imaging (DWI) and to compare these effects between patients treated with proton and photon irradiation. Materials and methods 70 patients with glioblastoma underwent adjuvant radio(chemo)therapy with protons (n = 20) or photons (n = 50) at the University Hospital Dresden. MRI follow-ups were performed at three-monthly intervals and in this study were evaluated until 33 months after the end of therapy. Relative white matter MD changes between baseline and all follow-up visits were calculated in different dose regions. Results We observed a significant decrease of MD (p < 0.05) in WM regions receiving more than 20 Gy. MD reduction was progressive with dose and time after radio(chemo)therapy (maximum: −7.9 ± 1.2% after 24 months, ≥50 Gy). In patients treated with photons, significant reductions of MD in the entire WM (p < 0.05) were seen at all time points. Conversely, in proton patients, whole brain MD did not change significantly. Conclusions Irradiation leads to measurable MD reduction in white matter, progressing with both increasing dose and time. Treatment with protons reduces this effect most likely due to a lower total dose in the surrounding white matter. Further investigations are needed to assess whether those MD changes correlate with known radiation induced side-effects.

Radiotherapy is part of the standard treatment of most primary brain tumors. Large clinical target volumes and physical characteristics of photon beams inevitably lead to irradiation of surrounding normal brain tissue. This can cause radiation-induced brain injury. In particular, late brain injury, such as cognitive dysfunction, is often irreversible and progressive over time, resulting in a significant reduction in quality of life. Since 50% of patients have survival times greater than six months, radiation-induced side effects become more relevant and need to be balanced against radiation treatment given with curative intent. To develop adequate treatment and prevention strategies, the underlying cause of radiation-induced side-effects needs to be understood. This paper provides an overview of radiation-induced changes observed in normal-appearing brains measured with conventional and advanced MRI techniques and summarizes the current findings and conclusions. Brain atrophy was observed with anatomical MRI. Changes in tissue microstructure were seen on diffusion imaging. Vascular changes were examined with perfusion-weighted imaging and susceptibility-weighted imaging. MR spectroscopy revealed decreasing N-acetyl aspartate, indicating decreased neuronal health or neuronal loss. Based on these findings, multicenter prospective studies incorporating advanced MR techniques as well as neurocognitive function tests should be designed in order to gain more evidence on radiation-induced sequelae.

Radiation induced late side effects such as cognitive decline and normal tissue complications can severely affect quality of life and outcome in long-term survivors of brain tumors. Proton therapy offers a favorable depth-dose deposition with the potential to spare tumor-surrounding normal tissue, thus potentially reducing such side effects. In this study, we describe a preclinical model to reveal underlying biological mechanisms caused by precise high-dose proton irradiation of a brain subvolume. We studied the dose- and time-dependent radiation response of mouse brain tissue, using a high-precision image-guided proton irradiation setup for small animals established at the University Proton Therapy Dresden. The right hippocampal area of ten C57BL/6 and ten C3H/He mice was irradiated. Both strains consisted of four groups treated with increasing doses (0 – 85 Gy and 0 – 80 Gy, respectively). Follow-ups were performed up to six months, including longitudinal monitoring of general health status and regular contrast-enhanced magnetic resonance imaging (MRI) of mouse brains. These findings were related to comprehensive final histological analysis. In mice of the highest dose group, first symptoms of blood-brain barrier (BBB) damage appeared one week after irradiation, while a dose-dependent delay in onset was observed for lower doses. MRI contrast agent leakage occurred in the irradiated brain areas and was progressive in the higher dose groups. Mouse health status and survival corresponded to the extent of contrast agent leakage. Histological analysis revealed tissue changes such as vessel abnormalities, gliosis, and granule cell dispersion, which also partly affected the non-irradiated contralateral hippocampus. All observed effects depended strongly on the prescribed radiation doses and the outcome, i.e. survival, image changes and tissue alterations, within an experimental dose cohort was very consistent. A derived dose-response model will determine doses in future

Purpose: Currently, there is an intense debate on the need to consider variable clinical relative biological effectiveness (RBE) in proton therapy. Here, the variability of the clinical RBE is studied for late radiation-induced brain injuries (RIBI) observed after proton therapy in WHO grade 2-3 glioma patients. Methods: In total, 42 patients out of a consecutive WHO grade 2-3 glioma patient cohort that received (adjuvant) proton radio(chemo)therapy between 2014 and 2017, were eligible for analysis. RIBI lesions (symptomatic or clinically silent) were diagnosed and delineated on T1-weighted magnetic resonance imaging with contrast agent scans obtained in the first two years of follow-up. Correlation of RIBI location and occurrence with simulated dose (D), proton linear energy transfer (LET, dose-averaged) and variable RBE dose parameters were tested in voxel- and in patient-wise logistic regression analyses, respectively. Additionally, anatomical and clinical parameters were considered and model performance was estimated through cross-validated area-under-the-curve (AUC) values. Results: In 23 patients, 69 RIBI lesions were diagnosed. RIBI location and occurrence were significantly correlated with D×LET and variable RBE dose in voxel- and patient-wise regression analysis with cross-validated AUC values of 0.90 (95% confidence interval: 0.90-0.90) and 0.83 (0.60-1.00), respectively, when incorporating the periventricular region and tumor histology in the analysis. Models without D×LET and constant RBE revealed AUC values of 0.88 (0.88-0.88) and 0.78 (0.51-1.00), respectively. Conclusions: Models with variable RBE performed substantially better in predicting occurrence and location of RIBI when compared to fixed RBE models. The obtained clinical evidence for a variable proton RBE suggests its consideration in proton treatment planning of brain tumors.

The periventricular region (PVR) has been shown to have an increased susceptibility to dose-dependent brain injury after proton therapy of gliomas (Eulitz 2019, Harrabi 2019). However, the PVR has not been considered in proton treatment planning so far. Here, we present an approach for incorporating the PVR as a novel organ at risk in proton treatment planning. The PVR was defined as a 4 mm uniformly expanded margin around the ventricular system. The PVR tolerance dose was estimated as the observed near-min dose derived within late post-treatment radiation-associated contrast-enhancements (CE) on T1wCE-follow up images. All grade II/III glioma patients treated between 2014 and 2018 with (adjuvant) proton radio(chemo)therapy to 54/60 Gy(RBE), respectively, were analyzed. Retrospective PVR-sparing treatment planning was performed for 11 (4/7) consecutive glioma patients (Fig.1). Patient-wise comparison to the clinically delivered plans considered the near-max dose D2% and the volume Vx that received more than x% of prescribed dose in PVR tissue outside the target boost volume. The median distance of the observed CE lesion centers to the cerebral ventricles was 2.5 mm. The median and near-min CE lesion dose was 57.6 Gy(RBE) and 53.0 Gy(RBE), respectively. PVR-sparing treatment planning reduced D2% and V90% by 4.3 (±1.4)% and 53.2 (±22.4)%, respectively, while maintaining clinical goals (Fig.1). PVR-sparing in treatment planning is a promising approach to reduce late brain injury. In many cases this should be possible without compromising target coverage and field homogeneity. Further experience will improve the arrangement of PVR-sparing in the priority order of planning goals.

Purpose or Objective: Radio(chemo)therapy is part of the standard treatment of high-grade glioma patients and has been associated with cerebral atrophy [1,2]. Preclinical work also suggests radiation induced atrophy of the cerebellum [3,4]. Investigating cerebellar atrophy in patients treated with radiation is a further step in understanding radiation-induced deficits in both motor function and cognition. The aim of this study was to investigate cerebellar volume changes in a cohort of glioblastoma patients treated with photon or proton radio(chemo)therapy. Material and Methods: Data was acquired on a 3T Philips Ingenuity TF PET/MRI scanner (Philips Healthcare, Best, The Netherlands) as part of a prospective, longitudinal study investigating the effect of 11C-methionine PET/MR for tailoring the treatment of patients with glioblastoma (NCT01873469). In total, 71 patients with cerebral GBM (21 treated with proton therapy) had a baseline MR and at least one follow-up MRI, obtained in 3 monthly intervals after irradiation, available, including 3D T1-weighted (T1w) imaging (1×1×1 mm3) before and after intravenous injection of contrast agent (CE). Patients were treated with a total dose of 60 Gy(RBE=1.1) delivered in 2Gy fractions. On average 3.6 follow-ups were available covering a time period of 413 days ± 432 days (mean ± SD). The cerebellum was cut out from each MRI by warping [5] the MNI152 brain atlas and a corresponding cerebellar mask to each brain extracted T1w MRI. Sigmoid and transverse sinuses mimicking cerebellar tissue were removed using the CE T1w MRI. The cerebellum was segmented into grey matter (GM), white matter (WM) and cerebrospinal fluid (CSF) [6]. Its volume was calculated as the sum of all GM and WM probabilities and normalized to the baseline value for each patient. The mean relative cerebellar volume change per year was estimated for each patient with a linear regression. The resulting rate of volume change per year was plotted against the mean d

Background and purpose: Radiotherapy is a standard treatment option for high-grade gliomas. Cognitive impairment is a side effect associated with radiotherapy particularly in long-term survivors. Recent findings suggest involvement of the cerebellum in cognitive function. The goal of this study was therefore to investigate dose dependent cerebellar atrophy using prospective, longitudinal MR data from adult glioma patients who received radiotherapy. Materials and methods: Cerebellar volumes were measured using T1-weighted MR images from 91 glioma patients before radiotherapy and every three months thereafter. We calculated the average cerebellar volume change per year per Gy, based on the mean cerebellar dose, using linear regression analysis. Subsequently, patient age was investigated as a confounding factor using multiple linear regression analysis. The impact of chemotherapy was assessed separately in a subgroup of patients receiving a cerebellar dose ≤ 1 Gy. Cerebellar mean dose and cerebellar volume changes were compared between patients treated with proton (N = 38) and photon therapy (N = 52). Results: Cerebellar volume decreased 2.4 % per 10 Gy per year (p < 0.001). The cerebellar volume loss was progressive over time without signs of recovery within the observational period of two years. Neither patient age (p = 0.27) nor chemotherapy (p = 0.43) had a significant impact on cerebellar atrophy. Compared to patients treated with photons, the cerebellar dose was significantly lower in patients treated with proton therapy (p < 0.001, r = 0.62) which also translated to a significantly lower cerebellar volume reduction per year (p = 0.016, r = 0.25). Conclusion: Cerebellar volume decreased significantly and irreversibly after radiotherapy as function of time and dose. Further work is now needed to correlate these results with cognitive function and motor performance.