Common Challenges and Problems in Clinical Trials of Boron Neutron Capture Therapy of Brain Tumors

Clinical trials for binary therapies, like boron neutron capture therapy (BNCT), pose a number of unique problems and challenges in design, performance, and interpretation of results. In neutron beam development, different groups use different optimization parameters, resulting in beams being considerably different from each other. The design, development, testing, execution of patient pharmacokinetics and the evaluation of results from these studies differ widely. Finally, the clinical trials involving patient treatments vary in many aspects such as their dose escalation strategies, treatment planning methodologies, and the reporting of data. The implications of these differences in the data accrued from these trials are discussed. The BNCT community needs to standardize each aspect of the design, implementation, and reporting of clinical trials so that the data can be used meaningfully.     

Dosimetric effect of set-up error in accelerator-based boron neutron capture therapy for head and neck cancer

The dosimetric effect of set-up error in boron neutron capture therapy (BNCT) for head and neck cancer remains unclear. In this study, we analyzed the tendency of dose error by treatment location when simulating the set-up error of patients. We also determined the tolerance level of the set-up error in BNCT for head and neck cancer. As a method, the distal direction was shifted with an interval of 2.5 mm, from 0.0 mm to +20.0 mm and compared with the dose at the reference position. Similarly, the horizontal direction and vertical direction were shifted, with an interval of 5.0 mm, from −20.0 mm to +20.0 mm. In addition, cases with 3.0 mm and 5.0 mm simultaneous shifts in all directions were analyzed as the worst-case scenario. The dose metrics of the minimum dose of the tumor and the maximum dose of the mucosa were evaluated. From unidirectional set-up error analysis, in most cases, the set-up errors with dose errors within ±5% were Δdistal < +2.5 mm, Δhorizontal < ±5.0 mm and Δvertical < ±5.0 mm. In the simulation of 3.0 mm shifts in all directions, the errors in the minimum tumor dose and maximum mucosal dose were −3.6% ±1.4% (range, −5.4% to −0.6%) and 2% ±1.4% (range, 0.4% to 4.5%), respectively. From these results, if the set-up error was within ±3.0 mm in each direction, the dose errors of the tumor and mucosa could be suppressed within approximately ±5%, which is suggested as a tolerance level.     

Extended set of activation monitors for NCT beam characterization and spectral conditions of the beam after reactor fuel conversion

Since 2010 the LVR-15 reactor has been gradually converted from highly enriched fuel (36 wt% ²³⁵U) to low enriched fuel with the enrichment of 19.75 wt% ²³⁵U. Paper presents influence of the core pattern changes on the neutron characteristics of the epithermal beam. The determination of neutron spectrum free in the beam was done with a set of neutron activation monitors. After the reactor conversion the change in neutron spectrum is not provable as differences are in the range of measurement errors.     

Case numbers for a randomized clinical trial of boron neutron capture therapy for Glioblastoma multiforme

Boron neutron capture therapy (BNCT) with Na₂B₁₂H₁₁SH (BSH) or p-dihydroxyborylphenylalanine (BPA), and with a combination of both, was compared to radiotherapy with temozolomide, and the number of patients required to show statistically significant differences between the treatments was calculated. Whereas arms using BPA require excessive number of patients in each arm, a two-armed clinical trial with BSH and radiotherapy plus temozolomide is feasible.     

Drug delivery system design and development for boron neutron capture therapy on cancer treatment

We have already synthesized a boron-containing polymeric micellar drug delivery system for boron neutron capture therapy (BNCT). The synthesized diblock copolymer, boron-terminated copolymers (Bpin-PLA-PEOz), consisted of biodegradable poly(D,l-lactide) (PLA) block and water-soluble polyelectrolyte poly(2-ethyl-2-oxazoline) (PEOz) block, and a cap of pinacol boronate ester (Bpin). In this study, we have demonstrated that synthesized Bpin-PLA-PEOz micelle has great potential to be boron drug delivery system with preliminary evaluation of biocompatibility and boron content.     

Insight into the mechanisms underlying tumor response to boron neutron capture therapy in the hamster cheek pouch oral cancer model

Objective: The therapeutic success of different boron neutron capture therapy (BNCT) protocols employing the hamster cheek pouch oral cancer model has been previously reported by our laboratory. The aim of this study was to explore potential mechanisms of BNCT‐induced damage to tumor in terms of potential inhibition in DNA synthesis and induction of apoptosis in the tumors that underwent partial remission following application of the different BNCT protocols in this model. Materials and methods: We evaluated DNA synthesis employing incorporation of 5‐bromo‐2′‐deoxyuridine as an end‐point. Apoptosis was evaluated by immunohistochemistry employing the deoxynucleotidyl transferase‐mediated deoxyuridine triphosphate‐biotin nick end‐labeling technique and Bax and Bcl‐2 labeling. These studies were performed in tumors that underwent partial remission 1–30 days post‐BNCT mediated by boronophenylalanine (BPA), GB‐10 (Na₂¹⁰B₁₀H₁₀) or (BPA + GB‐10). Results: BNCT exerted a marked inhibitory effect on DNA synthesis in tumors for all the protocols under study. The inhibitory effect of BPA‐BNCT occurred as soon as 1 day post‐treatment (P < 0.001). Conversely, the effect of GB‐10‐BNCT became apparent 7–14 days after therapy (P < 0.001) and was sustained until killed at 30 days post‐treatment (P < 0.001). (GB‐10 + BPA)‐BNCT exerted a rapid and persistent effect, conceivably because of the combined effect of BNCT mediated by both boron compounds. The apoptosis studies did not show differences between the pre‐treatment group and any of the BNCT groups. Conclusions: One of the mechanisms involved in BNCT‐induced tumor control in our model would be an inhibitory effect on DNA synthesis. Apoptosis does not seem to have a significant role in BNCT‐induced tumor control in our model.     

Somatostatin receptors: From signaling to clinical practice

Somatostatin is a peptide with a potent and broad antisecretory action, which makes it an invaluable drug target for the pharmacological management of pituitary adenomas and neuroendocrine tumors. Somatostatin receptors (SSTR1, 2A and B, 3, 4 and 5) belong to the G protein coupled receptor family and have a wide expression pattern in both normal tissues and solid tumors. Investigating the function of each SSTR in several tumor types has provided a wealth of information about the common but also distinct signaling cascades that suppress tumor cell proliferation, survival and angiogenesis. This provided the rationale for developing multireceptor-targeted somatostatin analogs and combination therapies with signaling-targeted agents such as inhibitors of the mammalian (or mechanistic) target of rapamycin (mTOR). The ability of SSTR to internalize and the development of rabiolabeled somatostatin analogs have improved the diagnosis and treatment of neuroendocrine tumors.     

The refinement of dose assessment of the THOR BNCT beam

A refined dose assessment method has been used now in the THOR BNCT facility, which takes into account more delicate corrections, carefully handled calibration factors, and the spectrum- and kerma-weighted k_t value. The refined method solved the previous problem of negative derived neutron dose in phantom at deeper positions. With the improved dose assessment, the calculated and measured gamma-ray dose rates match perfectly in a 15×15×15 cm³ PMMA phantom.     

Development of high intensity ion sources for a Tandem-Electrostatic-Quadrupole facility for Accelerator-Based Boron Neutron Capture Therapy

Several ion sources have been developed and an ion source test stand has been mounted for the first stage of a Tandem-Electrostatic-Quadrupole facility For Accelerator-Based Boron Neutron Capture Therapy. A first source, designed, fabricated and tested is a dual chamber, filament driven and magnetically compressed volume plasma proton ion source. A 4 mA beam has been accelerated and transported into the suppressed Faraday cup. Extensive simulations of the sources have been performed using both 2D and 3D self-consistent codes.