Proton Radiation for Tumors in the Brain: a Family Connection In the records of Jennifer improved quickly. She says works for American Medical Response as the department of that she had no side effects from proton an emergency medical technician (EMT) radiation medicine at treatment and, in fact, pursued vigorous and, at this writing, is seeking certification Loma Linda University athletic activities during proton treatment, as a flight medic. She continues to be a Health, it is not uncommon including cross-country running, swimming highly active, athletic young woman. to find patients who are and surfing. Follow-up examinations In 2002, Cheryl Bellerose began members of the same showed complete regression of her tumor to experience unexplained dizziness. immediate or extended and at this writing, 16 years later, she no She went to her doctor, who referred her family. It is unusual, however, longer needs to be followed regularly. to a neurologist. A work-up revealed that to encounter two patients Jennifer says that one of her main she had an acoustic neuroma, a benign from the same family who recollections of proton therapy at tumor of the auditory nerve. Cheryl was were treated for two different Loma Linda was the superb team spirit referred to a surgeon, who recommended types of brain lesions. That is she encountered among the radiation an operation. Cheryl did check out several the case, however, with Jennifer oncologists, nurses and radiation therapy options, including centers in Los Angeles. Gardner and Cheryl Bellerose, technologists she met in the department Cheryl, however, remembered her both of Redlands, California. of radiation medicine. As an athlete younger cousin, Jennifer. At that time In 1997, when she was a teenager, herself, she appreciated this spirit, which Jennifer was already five years past proton Jennifer received proton therapy for included her as the patient. The feeling of treatment for a malignant brain tumor an astrocytoma of the cerebellum and all working together toward a successful and was doing very well. This encouraged brain stem. She had symptoms that treatment outcome was strong, so much Cheryl to wonder whether protons could included headache, vomiting and some so that, Jennifer says, it eventually altered be used for her case as well; she inquired, unsteadiness in walking. She and her her own life plans: she wanted to be and was seen by Dr. Lilia Loredo in the family consulted surgeons, including a part of the medical environment too. department of radiation medicine. pediatric neurosurgeon at Loma Linda Today Jennifer works at Loma Linda Dr. Loredo examined Cheryl and her University Children’s Hospital, and University Health. She is a medical assistant records, including CT scans. She told Cheryl learned that the tumor was inoperable. in the emergency department at Loma she was confident that proton therapy could She did require several surgical Linda University Medical Center. She also be used successfully in her case; Cheryl procedures to relieve hydrocephalus (fluid in the brain), including by means of a ventriculoperitoneal (VP) shunt. Her case was referred to the department of radiation medicine. Jennifer was seen by two radiation oncologists then at Loma Linda, one a specialist in pediatric oncology and the other a specialist in brain tumors. They decided that she was a candidate for proton therapy because her tumor, although causing distressing symptoms, was localized. She was treated in the spring of 1997. Between proton therapy and her surgical procedures (nine altogether), Cousins Jennifer Gardner (left) and Cheryl Bellerose (right) felt confidence in Dr. Loredo’s seeing various places and hiking in the to simple physics. Protons have mass; judgment. Cheryl then began nearby mountains. Today, 11 years after photons, the fundamental particles of a six-week treatment course of her last proton treatment, she needs x-ray beams, do not. Accelerated protons, 30 fractions of proton radiation follow-up visits only every three years. therefore, are much less likely to scatter therapy. She says she experienced The family connection in Cheryl and in tissue than photons are, so they can no side effects from treatment Jennifer’s cases goes on. Two of their reach the target volume using fewer and, more importantly, no loss of uncles have received proton radiation beams than are needed for photons. hearing, either from the tumor or as therapy for cancer of the prostate. Further, protons do not release the bulk a side-effect of radiation treatment. of their energy until they stop in the Proton Therapy for Tumors of the targeted tissue; at that point, they release Central Nervous System (CNS) all of their energy and no tissue beyond In many respects, Jennifer’s and the target is irradiated. Photons release Cheryl’s situations were different: energy all the way to the target and past Jennifer had a malignant tumor that it. Taken together, these are the physical required several surgical interventions reasons that protons can spare normal before and during proton therapy; Cheryl tissue to a much greater extent than is had a benign tumor that was discovered possible with photons. The differences early. In both cases, however, their in dose distribution between proton treatments called for radiation to the brain, and photon beams often are dramatic. and in both cases protons offered a way to deliver that radiation without irradiating other parts of the brain. Sparing tissue that does not need to be irradiated is what proton therapy is all about. Isodose distribution of cavernous sinus meningioma Because the beam can be treated with four proton beams. Colored lines show dose conformed so closely to the from the beams; red indicates the highest dose, blue, the volume that needs to be irradiated, lowest. Note that most of the brain receives no radiation. Dr. Loredo and other radiation The ragged green line represents the brain stem, most oncologists in the department of of which is also avoided by the proton beams. From radiation medicine can deliver the Slater JD, Loredo LN, Chung A, Bush DA, Patyal B, high doses needed to control the Johnson WD, Hsu FP, Slater JM. Fractionated proton tumor without causing radiation radiotherapy for benign cavernous sinus meningiomas. damage to nearby brain tissue. Int J Radiat Oncol Biol Phys. 2012;83:e633-637. This is always important, but especially so when treating in At the time she was treated, Cheryl the brain and even more so worked at the School of Dentistry on when treating children, whose the Loma Linda University Medical tissues are still developing. Center campus. “My treatments Both Cheryl and Jennifer Comparing treatment plans using intensity-modulated were easy,” she says. “I worked reported no side effects from X-ray therapy (left) and proton radiation therapy for a right next door, so every day I proton therapy. Both continued to 35-year-old patient with a history of seizure from a grade II would walk over to the hospital, lead active lives during treatment. oligodendroglioma. Tumor location prevented complete surgical get my proton therapy, and This was made possible by the removal.The proton plan spares the greatest volume of normal walk back to work.” Cheryl says tissue-sparing capabilities of tissue. From Gridley DS, Grove RS, Loredo LN, Wroe AJ, she felt very comfortable with proton therapy. Although needed Slater JD. Proton-beam therapy for tumors of the CNS. the treatment setting and conformal doses of radiation can Expert Rev Neurother 2010 Feb;10(2):319-330. personnel in the department be delivered to brain volumes of radiation medicine. with modern forms of x-ray “I loved the Christian therapy such as IMRT, surrounding tissue Dr. Loredo, who treated Cheryl and atmosphere,” she says; “it cannot be spared from lower doses of treats many of the CNS patients at was a good place to be.” radiation, as is the case with protons. It Loma Linda University Health, perhaps Cheryl has since is this ability to spare tissue that helped describes the proton advantage best. retired from her job at prevent hearing loss in Cheryl’s case, and “We want to destroy the tumor and the School of Dentistry. development problems in Jennifer’s. allow normal tissues to keep functioning She and her husband The reason that proton therapy is normally. The best way to do both love to travel and so advantageous in treating tumors in is to conform the dose to the tumor live an active life, the brain and in children comes down cells and leave the rest alone.” LLUMCMKTG#PTC-006-13/1113/1000