801
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Shelley CE, Barraclough LH, Nelder CL, Otter SJ, Stewart AJ. Adaptive Radiotherapy in the Management of Cervical Cancer: Review of Strategies and Clinical Implementation. Clin Oncol (R Coll Radiol) 2021; 33:579-590. [PMID: 34247890 DOI: 10.1016/j.clon.2021.06.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/19/2021] [Accepted: 06/11/2021] [Indexed: 02/08/2023]
Abstract
The complex and varied motion of the cervix-uterus target during external beam radiotherapy (EBRT) underscores the clinical benefits afforded by adaptive radiotherapy (ART) techniques. These gains have already been realised in the implementation of image-guided adaptive brachytherapy, where adapting to anatomy at each fraction has seen improvements in clinical outcomes and a reduction in treatment toxicity. With regards to EBRT, multiple adaptive strategies have been implemented, including a personalised internal target volume, offline replanning and a plan of the day approach. With technological advances, there is now the ability for real-time online ART using both magnetic resonance imaging and computed tomography-guided imaging. However, multiple challenges remain in the widespread dissemination of ART. This review investigates the ART strategies and their clinical implementation in EBRT delivery for cervical cancer.
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Affiliation(s)
- C E Shelley
- Department of Clinical Oncology, St. Luke's Cancer Centre, Royal Surrey County Hospital, Guildford, UK.
| | - L H Barraclough
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - C L Nelder
- Department of Radiotherapy, The Christie NHS Foundation Trust, Manchester, UK
| | - S J Otter
- Department of Clinical Oncology, St. Luke's Cancer Centre, Royal Surrey County Hospital, Guildford, UK
| | - A J Stewart
- Department of Clinical Oncology, St. Luke's Cancer Centre, Royal Surrey County Hospital, Guildford, UK; University of Surrey, Guildford, UK
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802
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Kilian-Meneghin J, Ma T, Kumaraswamy L. Impact of prostate focused alignment on planned pelvic lymph node dose. J Appl Clin Med Phys 2021; 22:27-35. [PMID: 34231945 PMCID: PMC8292696 DOI: 10.1002/acm2.13092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 09/13/2019] [Accepted: 10/06/2019] [Indexed: 11/11/2022] Open
Abstract
Purpose Prostate patients with positive lymph node margins receive an initial course of 45 Gy to the planning target volume (PTV) comprised of prostate, seminal vesicles, and lymph nodes with a 1‐cm margin. The prostate is localized via implanted fiducial markers before each fraction is delivered using portal‐imaging. However, the pelvic lymph nodes are affixed to the bony anatomy and are not mobile in concert with the prostate. The aim of this study was to determine whether a significant difference in pelvic lymph node coverage exists between planned and delivered external beam therapy treatments for these patients. Methods The recorded prostate motions were gathered for 19 patients; conjointly the pelvic lymph node motions were determined by manual registration of the bony anatomy in the kV‐images. The difference between the prostate and the bony anatomy coordinates was input into Eclipse as field shifts to represent the deviation in planned vs delivered pelvic lymph node coverage. Results Structure volume at V(100) was recorded for each patient for two structures: summed pelvic lymph nodes (LN CTV) and pelvic lymph nodes +1 cm margin (LN PTV) to express their contribution to the PTV. For the LN PTV, the average difference between the planned coverage and calculated delivered coverage was 3.5%, with a paired t‐test value of P = 0.005. Based upon bony anatomy registration, 26% of patients received less than 95% dose coverage using V(100) criteria for LN PTV. Dose value differences between the two plans at minimum were 6.96 ± 6.23 Gy, at mean were 0.54 ± 0.40 Gy, and at maximum were 0.10 ± 0.29 Gy. For the LN CTV, the average difference between the planned coverage and calculated delivered coverage was 1%, with a paired t‐test value of P = 0.53. Conclusions The results indicate a significant difference exists between the planned coverage and calculated delivered coverage for the LN PTV. There was no significant difference found for the LN CTV. We conclude that lymph node motion must be considered with the prostate motion when aligning patients before each fraction.
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Affiliation(s)
| | - Tianjun Ma
- Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
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803
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Nasser NJ, Klein J, Fenig E, Agbarya A. Automatic localization of the prostatic urethra for image guided radiation therapy. Tech Innov Patient Support Radiat Oncol 2021; 19:1-6. [PMID: 34189284 PMCID: PMC8215297 DOI: 10.1016/j.tipsro.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/27/2021] [Accepted: 05/27/2021] [Indexed: 11/28/2022] Open
Abstract
Prostatic urethra can be used for image guided radiation for prostate cancer. Computer “finds” the urethra by digital subtraction of scans with / without contrast. Urethra segmentation used to setup the patient and position prostate as in simulation. A catheter with continuous aerated gel flow is used to detect the urethra under US.
Treatment of prostate cancer with radiation therapy (RT) requires image guided RT (IGRT) to focus the radiation on the target volumes while minimizing doses to organs at risk. Here we describe a urinary catheter that allows imaging of the prostatic urethra and uses it for automatic localization of the prostate for IGRT. The catheter has a contrast lumen that can be empty or full with contrast. Computerized tomography is performed twice, with contrast lumen empty and full, allowing urethral autosegmentation using digital subtraction. Under ultrasound, continuous urethral visualization is possible by pumping aerated gel in- and out of the contrast lumen.
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Affiliation(s)
- Nicola J Nasser
- Department of Radiation Oncology, University of Maryland School of Medicine, Maryland Proton Treatment Center, Baltimore, MD, USA
| | - Jonathan Klein
- Department of Radiation Oncology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Eyal Fenig
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Abed Agbarya
- Institute of Oncology, Bnai Zion Medical Center, Haifa, Israel
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804
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Webster A, Hafeez S, Lewis R, Griffins C, Warren-Oseni K, Patel E, Hansen VN, Hall E, Huddart R, Miles E, McNair HA. The Development of Therapeutic Radiographers in Imaging and Adaptive Radiotherapy Through Clinical Trial Quality Assurance. Clin Oncol (R Coll Radiol) 2021; 33:461-467. [PMID: 33766503 DOI: 10.1016/j.clon.2021.02.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 01/29/2021] [Accepted: 02/17/2021] [Indexed: 02/06/2023]
Abstract
AIMS Adaptive radiotherapy (ART) is an emerging advanced treatment option for bladder cancer patients. Therapeutic radiographers (RTTs) are central to the successful delivery of this treatment. The purpose of this work was to evaluate the image-guided radiotherapy (IGRT) and ART experience of RTTs before participating in the RAIDER trial. A plan of the day (PoD) quality assurance programme was then implemented. Finally, the post-trial experience of RTTs was evaluated, together with the impact of trial quality assurance participation on their routine practice. MATERIALS AND METHODS A pre-trial questionnaire to assess the experience of the RTT staff group in IGRT and ART in bladder cancer was sent to each centre. Responses were grouped according to experience. The PoD quality assurance programme was implemented, and the RAIDER trial commenced. During stage 1 of the trial, RTTs reported difficulties in delivering PoD and the quality assurance programme was updated accordingly. A follow-up questionnaire was sent assessing experience in IGRT and ART post-trial. Any changes in routine practice were also recorded. RESULTS The experience of RTTs in IGRT and ART pre-trial varied. For centres deemed to have RTTs with more experience, the initial PoD quality assurance programme was streamlined. For RTTs without ART experience, the full quality assurance programme was implemented, of which 508 RTTs completed. The quality assurance programme was updated (as the trial recruited) and it was mandated that at least one representative RTT (regardless of pre-trial experience) participated in the update in real-time. The purpose of the updated quality assurance programme was to provide further support to RTTs in delivering a complex treatment. Engagement with the updated quality assurance programme was high, with RTTs in 24/33 centres participating in the real-time online workshop. All 33 UK centres reported all RTTs reviewed the updated training offline. Post-trial, the RTTs' experience in IGRT and ART was increased. CONCLUSION Overall, 508 RTTs undertook the PoD quality assurance programme. There was a high engagement of RTTs in the PoD quality assurance programme and trial. RTTs increased their experience in IGRT and ART and subsequently updated their practice for bladder cancer and other treatment sites.
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Affiliation(s)
- A Webster
- National Radiotherapy Trials Quality Assurance Group, Mount Vernon Cancer Centre, London, UK.
| | - S Hafeez
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK
| | - R Lewis
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - C Griffins
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | | | - E Patel
- University College Hospital, London, UK
| | - V N Hansen
- Odense University Hospital, Odense, Denmark
| | - E Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - R Huddart
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK
| | - E Miles
- National Radiotherapy Trials Quality Assurance Group, Mount Vernon Cancer Centre, London, UK
| | - H A McNair
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK
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805
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Tyagi N, Liang J, Burleson S, Subashi E, Godoy Scripes P, Tringale KR, Romesser PB, Reyngold M, Crane CH. Feasibility of ablative stereotactic body radiation therapy of pancreas cancer patients on a 1.5 Tesla magnetic resonance-linac system using abdominal compression. Phys Imaging Radiat Oncol 2021; 19:53-59. [PMID: 34307919 PMCID: PMC8295846 DOI: 10.1016/j.phro.2021.07.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 07/03/2021] [Accepted: 07/05/2021] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND AND PURPOSE Stereotactic body radiation therapy delivered using MR-guided radiotherapy (MRgRT) and automatic breathold gating has shown to improve overall survival for locally advanced pancreatic cancer (LAPC) patients. The goal of our study was to evaluate feasibility of treating LAPC patients using abdominal compression (AC) and impact of potential intrafraction motion on planned dose on a 1.5T MR-linac. METHODS & MATERIALS Ten LAPC patients were treated with MRgRT to 50 Gy in 5 fractions with daily online plan adaptation and AC. Three orthogonal plane cine MRI were acquired to assess stability of AC pressure in minimizing tumor motion. Three sets of T2w MR scans, pre-treatment (MRIpre), verification (MRIver) and post-treatment (MRIpost) MRI, were acquired for every fraction. A total of 150 MRIs and doses were evaluated. Impact of intrafraction organ motion was evaluated by propagating pre-treatment plan and structures to MRIver and MRIpost, editing contours and recalculating doses. Gross tumor volume (GTV) coverage and organs-at-risk (OARs) doses were evaluated on MRIver and MRIpost. RESULTS Median total treatment time was 75.5 (49-132) minutes. Median tumor motion in AC for all fractions was 1.7 (0.7-7), 2.1 (0.6-6.3) and 4.1 (1.4-10.0) mm in anterior-posterior, left-right and superior-inferior direction. Median GTV V50Gy was 78.7%. Median D5cm3 stomach_duodenum was 24.2 (18.4-29.3) Gy on MRIver and 24.2 (18.3-30.5) Gy on MRIpost. Median D5cm3 small bowel was 24.3 (18.2-32.8) Gy on MRIver and 24.4 (16.0-33.6) Gy on MRIpost. CONCLUSION Dose-volume constraints for OARs were exceeded for some fractions on MRIver and MRIpost. Longer follow up is needed to see the dosimetric impact of intrafraction motion on gastrointestinal toxicity.
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Affiliation(s)
- Neelam Tyagi
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
| | - Jiayi Liang
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
| | - Sarah Burleson
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
| | - Ergys Subashi
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
| | - Paola Godoy Scripes
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
| | - Kathryn R. Tringale
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
| | - Paul B. Romesser
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
| | - Marsha Reyngold
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
| | - Christopher H. Crane
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
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806
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Field M, Hardcastle N, Jameson M, Aherne N, Holloway L. Machine learning applications in radiation oncology. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2021; 19:13-24. [PMID: 34307915 PMCID: PMC8295850 DOI: 10.1016/j.phro.2021.05.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 05/19/2021] [Accepted: 05/22/2021] [Indexed: 12/23/2022]
Abstract
Machine learning technology has a growing impact on radiation oncology with an increasing presence in research and industry. The prevalence of diverse data including 3D imaging and the 3D radiation dose delivery presents potential for future automation and scope for treatment improvements for cancer patients. Harnessing this potential requires standardization of tools and data, and focused collaboration between fields of expertise. The rapid advancement of radiation oncology treatment technologies presents opportunities for machine learning integration with investments targeted towards data quality, data extraction, software, and engagement with clinical expertise. In this review, we provide an overview of machine learning concepts before reviewing advances in applying machine learning to radiation oncology and integrating these techniques into the radiation oncology workflows. Several key areas are outlined in the radiation oncology workflow where machine learning has been applied and where it can have a significant impact in terms of efficiency, consistency in treatment and overall treatment outcomes. This review highlights that machine learning has key early applications in radiation oncology due to the repetitive nature of many tasks that also currently have human review. Standardized data management of routinely collected imaging and radiation dose data are also highlighted as enabling engagement in research utilizing machine learning and the ability integrate these technologies into clinical workflow to benefit patients. Physicists need to be part of the conversation to facilitate this technical integration.
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Affiliation(s)
- Matthew Field
- South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,Ingham Institute for Applied Medical Research, Sydney, NSW, Australia
| | - Nicholas Hardcastle
- Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Centre for Medical Radiation Physics, University of Wollongong, Wollongong, NSW, Australia
| | - Michael Jameson
- GenesisCare, Alexandria, NSW, Australia.,St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Australia
| | - Noel Aherne
- Mid North Coast Cancer Institute, NSW, Australia.,Rural Clinical School, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Lois Holloway
- South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.,Cancer Therapy Centre, Liverpool Hospital, Sydney, NSW, Australia.,Centre for Medical Radiation Physics, University of Wollongong, Wollongong, NSW, Australia
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807
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Bertholet J, Aznar MC, Garibaldi C, Thwaites D, Gershkevitsh E, Thorwarth D, Verellen D, Heijmen B, Hurkmans C, Muren L, Redalen KR, Siebert FA, Schwarz M, Van Elmpt W, Georg D, Jornet N, Clark CH. Professional practice changes in radiotherapy physics during the COVID-19 pandemic. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2021; 19:25-32. [PMID: 34179522 PMCID: PMC8216850 DOI: 10.1016/j.phro.2021.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/29/2021] [Accepted: 06/12/2021] [Indexed: 11/11/2022]
Abstract
The experience of 433 medical physicists during COVID-19 was analysed. Changes in clinical practice had an impact on treatment planning and quality assurance tasks. The effects of the changes were perceived differently by management vs clinical medical physicists. There is a clear willingness to learn from this experience.
Background and purpose The COVID-19 pandemic has imposed changes in radiotherapy (RT) departments worldwide. Medical physicists (MPs) are key healthcare professionals in maintaining safe and effective RT. This study reports on MPs experience during the first pandemic peak and explores the consequences on their work. Methods A 39-question survey on changes in departmental and clinical practice and on the impact for the future was sent to the global MP community. A total of 433 responses were analysed by professional role and by country clustered on the daily infection numbers. Results The impact of COVID-19 was bigger in countries with high daily infection rate. The majority of MPs worked in alternation at home/on-site. Among practice changes, implementation and/or increased use of hypofractionation was the most common (47% of the respondents). Sixteen percent of respondents modified patient-specific quality assurance (QA), 21% reduced machine QA, and 25% moved machine QA to weekends/evenings. The perception of trust in leadership and team unity was reversed between management MPs (towards increased trust and unity) and clinical MPs (towards a decrease). Changes such as home-working and increased use of hypofractionation were welcomed. However, some MPs were concerned about pressure to keep negative changes (e.g. weekend work). Conclusion COVID-19 affected MPs through changes in practice and QA procedures but also in terms of trust in leadership and team unity. Some changes were welcomed but others caused worries for the future. This report forms the basis, from a medical physics perspective, to evaluate long-lasting changes within a multi-disciplinary setting.
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Affiliation(s)
- Jenny Bertholet
- European Society for Radiotherapy and Oncology (ESTRO), Physics Committee, Brussels, Belgium
- Division of Medical Radiation Physics, Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Switzerland
- Corresponding author.
| | - Marianne C. Aznar
- European Society for Radiotherapy and Oncology (ESTRO), Physics Committee, Brussels, Belgium
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, The Christie NHS Foundation Trust, Manchester, UK
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Cristina Garibaldi
- European Society for Radiotherapy and Oncology (ESTRO), Physics Committee, Brussels, Belgium
- Unit of Radiation Research, IEO European Institute of Oncology, IRCCS, Milano, Italy
| | - David Thwaites
- European Society for Radiotherapy and Oncology (ESTRO), Physics Committee, Brussels, Belgium
- Institute of Medical Physics, School of Physics, University of Sydney, Sydney, Australia
- Medical Physics, Leeds Institute of Cancer and Pathology, School of Medicine, Leeds University, Leeds, UK
| | - Eduard Gershkevitsh
- European Society for Radiotherapy and Oncology (ESTRO), Physics Committee, Brussels, Belgium
- North Estonia Medical Centre, Tallinn, Estonia
| | - Daniela Thorwarth
- European Society for Radiotherapy and Oncology (ESTRO), Physics Committee, Brussels, Belgium
- Section for Biomedical Physics, Department of Radiation Oncology, University Hospital Tübingen, Germany
| | - Dirk Verellen
- European Society for Radiotherapy and Oncology (ESTRO), Physics Committee, Brussels, Belgium
- Iridium Network, Antwerp University (Faculty of Medicine and Health Sciences), Antwerp, Belgium
| | - Ben Heijmen
- European Society for Radiotherapy and Oncology (ESTRO), Physics Committee, Brussels, Belgium
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, The Netherlands
| | - Coen Hurkmans
- European Society for Radiotherapy and Oncology (ESTRO), Physics Committee, Brussels, Belgium
- Catharina Hospital, Department of Radiation Oncology, Eindhoven, The Netherlands
| | - Ludvig Muren
- European Society for Radiotherapy and Oncology (ESTRO), Physics Committee, Brussels, Belgium
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Kathrine Røe Redalen
- European Society for Radiotherapy and Oncology (ESTRO), Physics Committee, Brussels, Belgium
- Department of Physics, Norwegian University of Science and Technology, Trondheim, Norway
| | - Frank-André Siebert
- European Society for Radiotherapy and Oncology (ESTRO), Physics Committee, Brussels, Belgium
- Clinic of Radiotherapy, University Hospital of Schleswig-Holstein, Campus Kiel, Germany
| | - Marco Schwarz
- European Society for Radiotherapy and Oncology (ESTRO), Physics Committee, Brussels, Belgium
- Proton Therapy Department, Trento Hospital, TIFPA-INFN, Trento, Italy
| | - Wouter Van Elmpt
- European Society for Radiotherapy and Oncology (ESTRO), Physics Committee, Brussels, Belgium
- Department of Radiation Oncology (MAASTRO), GROW – School for Oncology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Dietmar Georg
- European Society for Radiotherapy and Oncology (ESTRO), Physics Committee, Brussels, Belgium
- Division Medical Radiation Physics, Department of Radiation Oncology, Medical University of Vienna, AKH Wien, Austria
| | - Nuria Jornet
- European Society for Radiotherapy and Oncology (ESTRO), Physics Committee, Brussels, Belgium
- Servei de Radiofísica i Radioprotecció, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Catharine H. Clark
- European Society for Radiotherapy and Oncology (ESTRO), Physics Committee, Brussels, Belgium
- Department of Radiotherapy Physics, University College London Hospital, UK
- Department of Medical Physics and Bioengineering, University College London, UK
- National Physical Laboratory, London, UK
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808
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Kang SK, An HJ, Jin H, Kim JI, Chie EK, Park JM, Lee JS. Synthetic CT generation from weakly paired MR images using cycle-consistent GAN for MR-guided radiotherapy. Biomed Eng Lett 2021; 11:263-271. [PMID: 34350052 DOI: 10.1007/s13534-021-00195-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/01/2021] [Accepted: 06/11/2021] [Indexed: 12/22/2022] Open
Abstract
Although MR-guided radiotherapy (MRgRT) is advancing rapidly, generating accurate synthetic CT (sCT) from MRI is still challenging. Previous approaches using deep neural networks require large dataset of precisely co-registered CT and MRI pairs that are difficult to obtain due to respiration and peristalsis. Here, we propose a method to generate sCT based on deep learning training with weakly paired CT and MR images acquired from an MRgRT system using a cycle-consistent GAN (CycleGAN) framework that allows the unpaired image-to-image translation in abdomen and thorax. Data from 90 cancer patients who underwent MRgRT were retrospectively used. CT images of the patients were aligned to the corresponding MR images using deformable registration, and the deformed CT (dCT) and MRI pairs were used for network training and testing. The 2.5D CycleGAN was constructed to generate sCT from the MRI input. To improve the sCT generation performance, a perceptual loss that explores the discrepancy between high-dimensional representations of images extracted from a well-trained classifier was incorporated into the CycleGAN. The CycleGAN with perceptual loss outperformed the U-net in terms of errors and similarities between sCT and dCT, and dose estimation for treatment planning of thorax, and abdomen. The sCT generated using CycleGAN produced virtually identical dose distribution maps and dose-volume histograms compared to dCT. CycleGAN with perceptual loss outperformed U-net in sCT generation when trained with weakly paired dCT-MRI for MRgRT. The proposed method will be useful to increase the treatment accuracy of MR-only or MR-guided adaptive radiotherapy. Supplementary Information The online version contains supplementary material available at 10.1007/s13534-021-00195-8.
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Affiliation(s)
- Seung Kwan Kang
- Department of Biomedical Sciences and Nuclear Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080 South Korea.,Institute of Radiation Medicine, Medical Research Center, Seoul National University College of Medicine, Seoul, 03080 South Korea
| | - Hyun Joon An
- Department of Radiation Oncology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080 South Korea
| | - Hyeongmin Jin
- Department of Radiation Oncology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080 South Korea
| | - Jung-In Kim
- Department of Radiation Oncology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080 South Korea.,Institute of Radiation Medicine, Medical Research Center, Seoul National University College of Medicine, Seoul, 03080 South Korea
| | - Eui Kyu Chie
- Department of Radiation Oncology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080 South Korea.,Institute of Radiation Medicine, Medical Research Center, Seoul National University College of Medicine, Seoul, 03080 South Korea
| | - Jong Min Park
- Department of Radiation Oncology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080 South Korea.,Institute of Radiation Medicine, Medical Research Center, Seoul National University College of Medicine, Seoul, 03080 South Korea
| | - Jae Sung Lee
- Department of Biomedical Sciences and Nuclear Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080 South Korea.,Department of Nuclear Medicine, Seoul National University Hospital, Seoul, 03080 South Korea.,Institute of Radiation Medicine, Medical Research Center, Seoul National University College of Medicine, Seoul, 03080 South Korea
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809
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Cleland S, Chan P, Chua B, Crowe SB, Dawes J, Kenny L, Lin C, Obereigner E, Peet SC, Trapp JV, Poroa T, Kairn T. Dosimetric evaluation of a patient-specific 3D-printed oral positioning stent for head-and-neck radiotherapy. Phys Eng Sci Med 2021; 44:887-899. [PMID: 34110611 DOI: 10.1007/s13246-021-01025-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/03/2021] [Indexed: 12/21/2022]
Abstract
As head-and-neck radiotherapy treatments become more complex and sophisticated, and the need to control and stabilise the positioning of intra-oral anatomy becomes more important, leading the increasing use of oral positioning stents during head-and-neck radiotherapy simulation and delivery. As an alternative to the established practice of creating oral positioning stents using wax, this study investigated the use of a 3D printing technique. An Ender 5 3D printer (Creality 3D, Shenzhen, China) was used, with PLA+ "food-safe" polylactic acid filament (3D Fillies, Dandenong South, Australia), to produce a low-density 3D printed duplicate of a conventional wax stent. The physical and dosimetric effects of the two stents were evaluated using radiochromic film in a solid head phantom that was modified to include flexible parts. The Varian Eclipse treatment planning system (Varian Medical Systems, Palo Alto, USA) was used to calculate the dose from two different head-and-neck treatment plans for the phantom with each of the two stents. Examination of the resulting four dose distributions showed that both stents effectively pushed sensitive oral tissues away from the treatment targets, even though most of the phantom was solid. Film measurements confirmed the accuracy of the dose calculations from the treatment planning system, despite the steep density gradients in the treated volume, and demonstrated that the 3D print could be a suitable replacement for the wax stent. This study demonstrated a useful method for dosimetrically testing novel oral positioning stents. We recommend the development of flexible phantoms for future studies.
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Affiliation(s)
- Susannah Cleland
- Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia.,Queensland University of Technology, Brisbane, QLD, 4001, Australia.,Herston Bifabrication Institute, Metro North Hospital and Health Service, Herston, QLD, 4029, Australia.,Radiation Oncology Princess Alexandra Hospital Raymond Terrace, South Brisbane, QLD, 4101, Australia
| | - Philip Chan
- Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia.,University of Queensland, Brisbane, QLD, 4072, Australia
| | - Benjamin Chua
- Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia.,University of Queensland, Brisbane, QLD, 4072, Australia
| | - Scott B Crowe
- Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia.,Queensland University of Technology, Brisbane, QLD, 4001, Australia.,Herston Bifabrication Institute, Metro North Hospital and Health Service, Herston, QLD, 4029, Australia.,University of Queensland, Brisbane, QLD, 4072, Australia
| | - Jodi Dawes
- Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia
| | - Lizbeth Kenny
- Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia.,University of Queensland, Brisbane, QLD, 4072, Australia
| | - Charles Lin
- Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia.,University of Queensland, Brisbane, QLD, 4072, Australia
| | - Elise Obereigner
- Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia.,Herston Bifabrication Institute, Metro North Hospital and Health Service, Herston, QLD, 4029, Australia
| | - Samuel C Peet
- Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia.,Queensland University of Technology, Brisbane, QLD, 4001, Australia
| | - Jamie V Trapp
- Queensland University of Technology, Brisbane, QLD, 4001, Australia
| | - Tania Poroa
- Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia.,Herston Bifabrication Institute, Metro North Hospital and Health Service, Herston, QLD, 4029, Australia
| | - Tanya Kairn
- Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia. .,Queensland University of Technology, Brisbane, QLD, 4001, Australia. .,Herston Bifabrication Institute, Metro North Hospital and Health Service, Herston, QLD, 4029, Australia. .,University of Queensland, Brisbane, QLD, 4072, Australia.
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810
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Votta C, Cusumano D, Boldrini L, Dinapoli N, Placidi L, Turco G, Antonelli MV, Pollutri V, Romano A, Indovina L, Valentini V. Delivery of online adaptive magnetic resonance guided radiotherapy based on isodose boundaries. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2021; 18:78-81. [PMID: 34258412 PMCID: PMC8254198 DOI: 10.1016/j.phro.2021.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 05/14/2021] [Accepted: 05/19/2021] [Indexed: 11/29/2022]
Abstract
Magnetic Resonance-guided Radiotherapy (MRgRT) allows direct monitoring of treated volumes. The aim of this study was to investigate the feasibility of a new gating strategy consisting in using an isodose as boundary. Forty-four patients treated for thoracic and abdominal lesions using MRgRT were enrolled. The accuracy of the new strategy was compared to the conventional one in terms of area improvement available for gating without compromising target coverage. A mean increase of 24% for lung, 15% for liver and 11% for pancreas was observed, demonstrating how the new method can be useful in challenging situations with low dose conformality.
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811
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Wong J, Huang V, Giambattista JA, Teke T, Kolbeck C, Giambattista J, Atrchian S. Training and Validation of Deep Learning-Based Auto-Segmentation Models for Lung Stereotactic Ablative Radiotherapy Using Retrospective Radiotherapy Planning Contours. Front Oncol 2021; 11:626499. [PMID: 34164335 PMCID: PMC8215371 DOI: 10.3389/fonc.2021.626499] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 05/14/2021] [Indexed: 12/22/2022] Open
Abstract
PURPOSE Deep learning-based auto-segmented contour (DC) models require high quality data for their development, and previous studies have typically used prospectively produced contours, which can be resource intensive and time consuming to obtain. The aim of this study was to investigate the feasibility of using retrospective peer-reviewed radiotherapy planning contours in the training and evaluation of DC models for lung stereotactic ablative radiotherapy (SABR). METHODS Using commercial deep learning-based auto-segmentation software, DC models for lung SABR organs at risk (OAR) and gross tumor volume (GTV) were trained using a deep convolutional neural network and a median of 105 contours per structure model obtained from 160 publicly available CT scans and 50 peer-reviewed SABR planning 4D-CT scans from center A. DCs were generated for 50 additional planning CT scans from center A and 50 from center B, and compared with the clinical contours (CC) using the Dice Similarity Coefficient (DSC) and 95% Hausdorff distance (HD). RESULTS Comparing DCs to CCs, the mean DSC and 95% HD were 0.93 and 2.85mm for aorta, 0.81 and 3.32mm for esophagus, 0.95 and 5.09mm for heart, 0.98 and 2.99mm for bilateral lung, 0.52 and 7.08mm for bilateral brachial plexus, 0.82 and 4.23mm for proximal bronchial tree, 0.90 and 1.62mm for spinal cord, 0.91 and 2.27mm for trachea, and 0.71 and 5.23mm for GTV. DC to CC comparisons of center A and center B were similar for all OAR structures. CONCLUSIONS The DCs developed with retrospective peer-reviewed treatment contours approximated CCs for the majority of OARs, including on an external dataset. DCs for structures with more variability tended to be less accurate and likely require using a larger number of training cases or novel training approaches to improve performance. Developing DC models from existing radiotherapy planning contours appears feasible and warrants further clinical workflow testing.
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Affiliation(s)
- Jordan Wong
- Radiation Oncology, British Columbia Cancer – Vancouver, Vancouver, BC, Canada
| | - Vicky Huang
- Medical Physics, British Columbia Cancer – Fraser Valley, Surrey, BC, Canada
| | - Joshua A. Giambattista
- Radiation Oncology, Saskatchewan Cancer Agency, Regina, SK, Canada
- Limbus AI Inc, Regina, SK, Canada
| | - Tony Teke
- Medical Physics/Radiation Oncology, British Columbia Cancer – Kelowna, Kelowna, BC, Canada
| | | | | | - Siavash Atrchian
- Medical Physics/Radiation Oncology, British Columbia Cancer – Kelowna, Kelowna, BC, Canada
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812
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Mihai AM, Armstrong PJ, Hickey D, Milano MT, Dunne M, Healy K, Thirion P, Heron DE, ElBeltagi N, Armstrong JG. Late Toxicity and Long-Term Local Control in Patients With Ultra-Central Lung Tumours Treated by Intensity-Modulated Radiotherapy-Based Stereotactic Ablative Body Radiotherapy With Homogenous Dose Prescription. Clin Oncol (R Coll Radiol) 2021; 33:627-637. [PMID: 34092462 DOI: 10.1016/j.clon.2021.05.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/21/2021] [Accepted: 05/13/2021] [Indexed: 12/14/2022]
Abstract
AIMS To report late toxicity and long-term outcomes of intensity-modulated radiotherapy (IMRT)-based stereotactic ablative body radiotherapy (SABR) in patients with ultra-central lung tumours. MATERIALS AND METHODS This is a single-institution retrospective analysis of patients treated with SABR for ultra-central tumours between May 2008 and April 2016. Ultra-central location was defined as tumour (GTV) abutting or involving trachea, main or lobar bronchi. Respiratory motion management and static-field dynamic-IMRT were used, with dose prescribed homogeneously (maximum <120%). Descriptive analysis, Kaplan-Meier method, log-rank test and Cox regression were used to assess outcomes. RESULTS Sixty-five per cent of patients had inoperable primary non-small cell lung cancer and 35% had lung oligometastases. The median age was 72 (range 34-85) years. The median gross tumour volume and planning target volume (PTV) were 19.6 (range 1.7-203.3) cm3 and 57.4 (range 7.7-426.6) cm3, respectively. The most commonly used dose fractionation was 60 Gy in eight fractions (n = 51, 87.8%). Median BED10 for D98%PTV and D2%PTV were 102.6 Gy and 115.06 Gy, respectively. With a median follow-up of 26.5 (range 3.2-100.5) months, fatal haemoptysis occurred in five patients (8.7%), of which two were directly attributable to SABR. A statistically significant difference was identified between median BED3 for 4 cm3 of airway, for patients who developed haemoptysis versus those who did not (147.4 versus 47.2 Gy, P = 0.005). At the last known follow-up, 50 patients (87.7%) were without local recurrence. Freedom from local progression at 2 and 4 years was 92 and 79.8%, respectively. The median overall survival was 34.3 (95% confidence interval 6.1-61.6) months. Overall survival at 2 and 4 years was 55.1 and 41.2%, respectively. CONCLUSION In patients with high-risk ultra-central lung tumours, IMRT-based SABR with homogenous dose prescription achieves high local control, similar to that reported for peripheral tumours. Although fatal haemoptysis occurred in 8.7% of patients, a direct causality with SABR was evident in only 3%. Larger studies are warranted to ascertain factors associated with outcomes, especially toxicity, and identify patients who would probably benefit from this treatment.
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Affiliation(s)
- A M Mihai
- Department of Radiotherapy, Beacon Hospital, Dublin, Ireland.
| | - P J Armstrong
- University College Dublin School of Medicine, Dublin, Ireland
| | - D Hickey
- Department of Radiotherapy, Beacon Hospital, Dublin, Ireland
| | - M T Milano
- University of Rochester, Rochester, NY, USA
| | - M Dunne
- St Luke's Radiation Oncology Network, Dublin, Ireland
| | - K Healy
- University College Dublin School of Medicine, Dublin, Ireland
| | - P Thirion
- St Luke's Radiation Oncology Network, Dublin, Ireland
| | - D E Heron
- Bon Secours Mercy Health, Cincinnati, OH, USA
| | - N ElBeltagi
- St Luke's Radiation Oncology Network, Dublin, Ireland
| | - J G Armstrong
- Department of Radiotherapy, Beacon Hospital, Dublin, Ireland
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813
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Kong V, Hansen VN, Hafeez S. Image-guided Adaptive Radiotherapy for Bladder Cancer. Clin Oncol (R Coll Radiol) 2021; 33:350-368. [PMID: 33972024 DOI: 10.1016/j.clon.2021.03.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 03/30/2021] [Indexed: 12/12/2022]
Abstract
Technological advancement has facilitated patient-specific radiotherapy in bladder cancer. This has been made possible by developments in image-guided radiotherapy (IGRT). Particularly transformative has been the integration of volumetric imaging into the workflow. The ability to visualise the bladder target using cone beam computed tomography and magnetic resonance imaging initially assisted with determining the magnitude of inter- and intra-fraction target change. It has led to greater confidence in ascertaining true anatomy at each fraction. The increased certainty of dose delivered to the bladder has permitted the safe reduction of planning target volume margins. IGRT has therefore improved target coverage with a reduction in integral dose to the surrounding tissue. Use of IGRT to feed back into plan and dose delivery optimisation according to the anatomy of the day has enabled adaptive radiotherapy bladder solutions. Here we undertake a review of the stepwise developments underpinning IGRT and adaptive radiotherapy strategies for external beam bladder cancer radiotherapy. We present the evidence in accordance with the framework for systematic clinical evaluation of technical innovations in radiation oncology (R-IDEAL).
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Affiliation(s)
- V Kong
- Radiation Medicine, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - V N Hansen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
| | - S Hafeez
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK; Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, UK.
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814
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Corradini S, Alongi F, Andratschke N, Azria D, Bohoudi O, Boldrini L, Bruynzeel A, Hörner-Rieber J, Jürgenliemk-Schulz I, Lagerwaard F, McNair H, Raaymakers B, Schytte T, Tree A, Valentini V, Wilke L, Zips D, Belka C. ESTRO-ACROP recommendations on the clinical implementation of hybrid MR-linac systems in radiation oncology. Radiother Oncol 2021; 159:146-154. [PMID: 33775715 DOI: 10.1016/j.radonc.2021.03.025] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 03/17/2021] [Indexed: 01/11/2023]
Abstract
Online magnetic resonance-guided radiotherapy (oMRgRT) represents one of the most innovative applications of current image-guided radiation therapy (IGRT). The revolutionary concept of oMRgRT systems is the ability to acquire MR images for adaptive treatment planning and also online imaging during treatment delivery. The daily adaptive planning strategies allow to improve targeting accuracy while avoiding critical structures. This ESTRO-ACROP recommendation aims to provide an overview of available systems and guidance for best practice in the implementation phase of hybrid MR-linac systems. Unlike the implementation of other radiotherapy techniques, oMRgRT adds the MR environment to the daily practice of radiotherapy, which might be a new experience for many centers. New issues and challenges that need to be thoroughly explored before starting clinical treatments will be highlighted.
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Affiliation(s)
- Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany.
| | - Filippo Alongi
- Department of Advanced Radiation Oncology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar-Verona, Italy, University of Brescia, Italy
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital of Zurich, University of Zurich, Switzerland
| | - David Azria
- Department of Radiation Oncology, University Federation of Radiation Oncology Montpellier-Nîmes, ICM, Montpellier Cancer Institute, University of Montpellier, INSERM U1194, France
| | - Omar Bohoudi
- Department of Radiation Oncology, Amsterdam University Medical Center, location de Boelelaan, The Netherlands
| | - Luca Boldrini
- Department of Bioimaging, Radiation Oncology and Hematology, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Roma, Italy
| | - Anna Bruynzeel
- Department of Radiation Oncology, Amsterdam University Medical Center, location de Boelelaan, The Netherlands
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany, Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | | | - Frank Lagerwaard
- Department of Radiation Oncology, Amsterdam University Medical Center, location de Boelelaan, The Netherlands
| | - Helen McNair
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, United Kingdom
| | - Bas Raaymakers
- Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Tine Schytte
- Department of Oncology, Odense University Hospital, Odense, Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Alison Tree
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, United Kingdom
| | - Vincenzo Valentini
- Department of Bioimaging, Radiation Oncology and Hematology, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Roma, Italy
| | - Lotte Wilke
- Department of Radiation Oncology, University Hospital of Zurich, University of Zurich, Switzerland
| | - Daniel Zips
- Department of Radiation Oncology, University of Tübingen, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany
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815
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Victor Mugabe K. Barriers and facilitators to the adoption of artificial intelligence in radiation oncology: A New Zealand study. Tech Innov Patient Support Radiat Oncol 2021; 18:16-21. [PMID: 33981867 PMCID: PMC8085695 DOI: 10.1016/j.tipsro.2021.03.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/08/2021] [Accepted: 03/30/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Advances in computing capabilities and automated data collection have led to an increase in the use of Artificial Intelligence (AI) in radiation therapy. This has implications to workflow and workforce planning in radiation oncology departments. A survey was conducted in New Zealand to determine the likelihood of departments adopting AI into their practice. Survey responses were used to determine barriers and facilitators to the adoption of AI. MATERIALS AND METHODS An online electronic survey was sent to all ten radiation therapy centres in New Zealand. The survey was sent to radiation oncologists, medical physicists and senior radiation therapists involved in treatment planning. Descriptive analysis, factor analysis, analysis of variance and hierarchical multiple regression were used to analyse the data. RESULTS AI usage was low across the country and there was middling expertise. Most respondents found AI had a lot of perceived benefits. On the whole, respondents reported a high likelihood to adopt AI. There were significant differences on the Expertise factor between the staff groupsp = 0.016 with radiation therapists reporting more expertise than oncologists. Innovation factors (Perceived Benefit) on their own accounted for over 51 % of total variance and was the biggest predictor of likelihood to adopt AI ( p < 0.001 ) . Organisational factors (Expertise) was a moderate predictor ( p < 0.059 ) . CONCLUSION The survey results have been used to investigate the barriers and facilitators to the adoption of AI. These results demonstrate that respondents are likely to adopt AI in their practice. Perceived benefits were a facilitator as high scores were correlated with high likelihood of adoption of AI. Low expertise on the other hand was a barrier to adoption as the low scores were linked to lower likelihood of adoption.
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Affiliation(s)
- Koki Victor Mugabe
- Waikato Hospital, Regional Cancer Centre Selwyn Street Level 1 Lomas Street Hamilton, Waikato 3240 New Zealand
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816
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Pang EPP, Knight K, Leung RW, Wang MLC, Chan JWS, Low GK, Seah IKL, Atan MAB, Chai JYH, Ng GC, Yang TC, Tuan JKL. Technical considerations for positioning and placement of a transperineal ultrasound probe during prostate radiotherapy. J Med Radiat Sci 2021; 68:196-202. [PMID: 33017863 PMCID: PMC8168066 DOI: 10.1002/jmrs.439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/07/2020] [Accepted: 09/14/2020] [Indexed: 01/01/2023] Open
Abstract
This technical evaluation aims to provide practice 'how to' guidelines for radiation therapists (RTs) when positioning a transperineal ultrasound (TPUS) probe during prostate radiotherapy. Recommendations and practical tips will be provided for the best practice in TPUS-guided workflow to obtain optimal ultrasound images for accurate interpretation and registration of the prostate gland. This will assist the RTs in making consistent and accurate clinical decision in an ultrasound-guided radiotherapy workflow for prostate treatment. The implementation process and the associated successes and challenges will also be described to assist institutions who may be investigating the potential of implementing this system.
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Affiliation(s)
- Eric Pei Ping Pang
- Division of Radiation OncologyNational Cancer Centre SingaporeSingaporeSingapore
- Faculty of Medicine, Nursing and Health SciencesDepartment of Medical Imaging & Radiation SciencesMonash UniversityClaytonVICAustralia
| | - Kellie Knight
- Faculty of Medicine, Nursing and Health SciencesDepartment of Medical Imaging & Radiation SciencesMonash UniversityClaytonVICAustralia
| | | | - Michael Lian Chek Wang
- Division of Radiation OncologyNational Cancer Centre SingaporeSingaporeSingapore
- Duke‐NUS Graduate Medical SchoolSingaporeSingapore
| | - Jason Wei Siang Chan
- Division of Radiation OncologyNational Cancer Centre SingaporeSingaporeSingapore
| | - Gee Keng Low
- Division of Radiation OncologyNational Cancer Centre SingaporeSingaporeSingapore
| | - Irene Kai Ling Seah
- Division of Radiation OncologyNational Cancer Centre SingaporeSingaporeSingapore
| | | | - Jairia Yih Huei Chai
- Division of Radiation OncologyNational Cancer Centre SingaporeSingaporeSingapore
| | - Grace Chuk‐Kwan Ng
- Department of Clinical OncologyTuen Mun HospitalTuen Mun, New TerritoriesHong Kong
| | | | - Jeffrey Kit Loong Tuan
- Division of Radiation OncologyNational Cancer Centre SingaporeSingaporeSingapore
- Duke‐NUS Graduate Medical SchoolSingaporeSingapore
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817
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Ong A, Knight K, Panettieri V, Dimmock M, Tuan JKL, Tan HQ, Master Z, Wright C. Development of an automated radiotherapy dose accumulation workflow for locally advanced high-risk prostate cancer - A technical report. J Med Radiat Sci 2021; 68:203-210. [PMID: 33058720 PMCID: PMC8168070 DOI: 10.1002/jmrs.442] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 09/15/2020] [Accepted: 09/16/2020] [Indexed: 11/23/2022] Open
Abstract
An automated dose accumulation and contour propagation workflow using daily cone beam computed tomography (CBCTs) images for prostate cases that require pelvic lymph nodes irradiation (PLNs) was developed. This workflow was constructed using MIM® software with the intention to provide accurate dose transformations for plans with two different isocentres, whereby two sequential treatment phases were prescribed. The pre-processing steps for data extractions from treatment plans, CBCTs, determination of couch shift information and management of missing CBCTs are described. To ensure that the imported translational couch shifts were in the correct orientation and readable in MIM, phantom commissioning was performed. For dose transformation, rigid registration with corrected setup shifts and scaled fractional dose was performed for pCT to daily CBCTs, which were then deformed onto CBCT1 . Fractional dose summation resulted in the final accumulated dose for the patient allowing differences in dosimetry between the planned and accumulated dose to be analysed. Contour propagations of the prostate, bladder and rectum were performed within the same workflow. Transformed contours were then deformed onto daily CBCTs to generate trending reports for analysis, including Dice Similarity Coefficient (DSC) and Mean Distance to Agreement (MDA). Results obtained from phantom commissioning (DSC = 0.96, MDA = 0.89 mm) and geometrical analysis of the propagated contours for twenty patients; prostate (DSC: 0.9 ± 0.0, MDA: 1.0 ± 0.3 mm), rectum (DSC: 0.8 ± 0.1, mm, MDA: 1.7 ± 0.6 mm) and bladder (DSC: 0.8 ± 0.1, MDA: 2.8 ± 1.0 mm) were within clinically accepted tolerances for both DSC (>0.8) and MDA (< 0.3 mm). The developed workflow is being performed on a larger patient cohort for predictive model building, with the goal of correlating observed toxicity with the actual accumulated dose received by the patient.
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Affiliation(s)
- Ashley Ong
- Department of Radiation TherapyNational Cancer CentreSingapore
- Department of Medical Imaging and Radiation SciencesMonash UniversityClaytonAustralia
| | - Kellie Knight
- Department of Medical Imaging and Radiation SciencesMonash UniversityClaytonAustralia
| | - Vanessa Panettieri
- Department of Medical Imaging and Radiation SciencesMonash UniversityClaytonAustralia
- Alfred Health Radiation OncologyAlfred HospitalMelbourneAustralia
| | - Matthew Dimmock
- Department of Medical Imaging and Radiation SciencesMonash UniversityClaytonAustralia
| | | | - Hong Qi Tan
- Department of Radiation TherapyNational Cancer CentreSingapore
| | - Zubin Master
- Department of Radiation TherapyNational Cancer CentreSingapore
| | - Caroline Wright
- Department of Medical Imaging and Radiation SciencesMonash UniversityClaytonAustralia
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818
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Kim TH, Heo SY, Oh GW, Heo SJ, Jung WK. Applications of Marine Organism-Derived Polydeoxyribonucleotide: Its Potential in Biomedical Engineering. Mar Drugs 2021; 19:296. [PMID: 34067499 PMCID: PMC8224764 DOI: 10.3390/md19060296] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 12/18/2022] Open
Abstract
Polydeoxyribonucleotides (PDRNs) are a family of DNA-derived drugs with a molecular weight ranging from 50 to 1500 kDa, which are mainly extracted from the sperm cells of salmon trout or chum salmon. Many pre-clinical and clinical studies have demonstrated the wound healing and anti-inflammatory properties of PDRN, which are mediated by the activation of adenosine A2A receptor and salvage pathways, in addition to promoting osteoblast activity, collagen synthesis, and angiogenesis. In fact, PDRN is already marketed due to its therapeutic properties against various wound healing- and inflammation-related diseases. Therefore, this review assessed the most recent trends in marine organism-derived PDRN using the Google Scholar search engine. Further, we summarized the current applications and pharmacological properties of PDRN to serve as a reference for the development of novel PDRN-based technologies.
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Affiliation(s)
- Tae-Hee Kim
- Department of Biomedical Engineering and New-Senior Healthcare Innovation Center (BK21 Plus), Pukyong National University, Busan 48513, Korea;
| | - Seong-Yeong Heo
- Research Center for Marine Integrated Bionics Technology, Pukyong National University, Busan 48513, Korea; (S.-Y.H.); (G.-W.O.)
| | - Gun-Woo Oh
- Research Center for Marine Integrated Bionics Technology, Pukyong National University, Busan 48513, Korea; (S.-Y.H.); (G.-W.O.)
| | - Soo-Jin Heo
- Jeju Marine Research Center, Korea Institute of Ocean Science & Technology (KIOST), Jeju 63349, Korea
- Department of Marine Biology, Korea University of Science and Technology, Deajeon 34113, Korea
| | - Won-Kyo Jung
- Department of Biomedical Engineering and New-Senior Healthcare Innovation Center (BK21 Plus), Pukyong National University, Busan 48513, Korea;
- Research Center for Marine Integrated Bionics Technology, Pukyong National University, Busan 48513, Korea; (S.-Y.H.); (G.-W.O.)
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819
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Oelofse I, van Staden J, Coetzee N, Steyn J. Quality management in radiotherapy: A 9-year review of incident reporting within a multifacility organisation. SOUTH AFRICAN JOURNAL OF ONCOLOGY 2021. [DOI: 10.4102/sajo.v5i0.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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820
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Abreu AMD, Fraga DRDS, Giergowicz BB, Figueiró RB, Waterkemper R. Effectiveness of nursing interventions in preventing and treating radiotherapy side effects in cancer patients: a systematic review. Rev Esc Enferm USP 2021; 55:e03697. [PMID: 33978137 DOI: 10.1590/s1980-220x2019026303697] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 03/10/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To synthesize the best available evidence on the effectiveness of nursing interventions in radiotherapy patient care and to summarize the evidence on the experience and acceptability of interventions reported by health professionals involved in the prevention and treatment of side effects. METHOD A mixed-method systematic review. Quantitative and qualitative studies are presented. RESULTS Twelve studies published between 2013 and 2017 were included. Most interventions found focused on skin care, oral care, nausea and vomiting and nursing consultation. In accordance with high level of evidence and recommendation grade of the studies, the use of Calendula officinalis and thyme honey were considered effective for preventing and treating radiodermatitis and mucositis, respectively. CONCLUSION The quality of evidence of nursing interventions is weak. Although there are studies with a strong design and a high level of evidence, publication of nursing interventions is not enough and does not present a high quality to support practice to plan an effective patient-centered care.
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Affiliation(s)
- Aline Moraes de Abreu
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Porto Alegre, RS, Brazil
| | | | - Bruna Bastos Giergowicz
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Porto Alegre, RS, Brazil
| | | | - Roberta Waterkemper
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Porto Alegre, RS, Brazil
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821
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Placidi L, Nardini M, Cusumano D, Boldrini L, Chiloiro G, Romano A, Votta C, Antonelli MV, Valentini V, Indovina L. VMAT-like plans for magnetic resonance guided radiotherapy: Addressing unmet needs. Phys Med 2021; 85:72-78. [PMID: 33979726 DOI: 10.1016/j.ejmp.2021.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/29/2021] [Accepted: 05/03/2021] [Indexed: 12/12/2022] Open
Abstract
PURPOSE VMAT delivery technique is currently not applicable to Magnetic Resonance-guided radiotherapy (MRgRT) hybrid systems. Aim of this study is to evaluate an innovative VMAT-like (VML) delivery technique. MATERIAL AND METHODS First, planning and dosimetric evaluation of the MRgRT VML treatment have been performed on 10 different disease sites and the results have been compared with the corresponding IMRT plans. Then, in the second phase, 10 of the most dosimetrically challenging locally advanced pancreas treatment plans have been retrospectively re-planned using the VML approach to explore the potentiality of this new delivery technique. Finally, VML robustness was evaluated and compared with the IMRT plans, considering a lateral positioning error of ± 5 mm. RESULTS In phase one, all VML plans were within constraint for all OARs. When PTV coverage is considered, in the 50% of the cases VML PTV coverage is equal or higher than in IMRT plan. In the remaining 50%, the highest target under coverage difference in comparison with IMRT plan is -1.71%. The mean and maximum treatment time differences (VML-IMRT) is 0.2 min and 3.1 min respectively. In phase two, the treatment time variation (VML-IMRT), shows a mean, maximum and minimum variations of 1.3, 4.6 and -0.6 min respectively. All VML plans have a better target coverage if compared with IMRT plans, keeping in any case the OARs constraints within tolerance. VML doesn't increase plan robustness. CONCLUSION VMAT-like treatment approach appeared to be an efficient planning solution and it was decided to clinically implement it in daily practice, especially in the frame of hypo fractionated treatments.
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Affiliation(s)
- L Placidi
- Fondazione Policlinico Universitario ''A. Gemelli'' IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - M Nardini
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - D Cusumano
- Fondazione Policlinico Universitario ''A. Gemelli'' IRCCS, Roma, Italy.
| | - L Boldrini
- Fondazione Policlinico Universitario ''A. Gemelli'' IRCCS, Roma, Italy
| | - G Chiloiro
- Fondazione Policlinico Universitario ''A. Gemelli'' IRCCS, Roma, Italy
| | - A Romano
- Fondazione Policlinico Universitario ''A. Gemelli'' IRCCS, Roma, Italy
| | - C Votta
- Fondazione Policlinico Universitario ''A. Gemelli'' IRCCS, Roma, Italy
| | - M V Antonelli
- Fondazione Policlinico Universitario ''A. Gemelli'' IRCCS, Roma, Italy
| | - V Valentini
- Fondazione Policlinico Universitario ''A. Gemelli'' IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - L Indovina
- Fondazione Policlinico Universitario ''A. Gemelli'' IRCCS, Roma, Italy
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822
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Dudzisz-Śledź M, Bylina E, Teterycz P, Rutkowski P. Treatment of Metastatic Gastrointestinal Stromal Tumors (GIST): A Focus on Older Patients. Drugs Aging 2021; 38:375-396. [PMID: 33651369 PMCID: PMC8096750 DOI: 10.1007/s40266-021-00841-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2021] [Indexed: 11/24/2022]
Abstract
Gastrointestinal stromal tumors (GIST) originating in the Cajal cells are the most common mesenchymal neoplasms of the gastrointestinal tract. The median age of patients with this diagnosis is 65 years, and over 20% of cases affect people over the age of 70 years. The effectiveness and tolerability of systemic treatment with tyrosine kinase inhibitors in older patients with GIST seem to be similar to that in younger patients, but some studies have shown that treatment of older patients is suboptimal. Disability, frailty, comorbidities, and concomitant medications may influence treatment decisions, and toxicities also more often lead to treatment discontinuation. The known safety profile and oral administration route of the tyrosine kinase inhibitors used in GIST may allow maximization of treatment and the best efficacy, especially in older patients. This review summarizes the efficacy data for the systemic treatment of GIST, including data for older patients and from real-world experiences, if available and significant. The reported safety data and general rules for toxicity management, including appropriate patient selection and the need for careful monitoring during treatment, are also discussed.
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Affiliation(s)
- Monika Dudzisz-Śledź
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland.
| | - Elżbieta Bylina
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland
| | - Paweł Teterycz
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland
| | - Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland
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823
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Durie E, Nicholson E, Anthias C, Dunne EM, Potter M, Ethell M, Messiou C, Brennan J, Eagle S, Talbot J, Smyth G, Ingram W, Saran F, Mandeville HC. Determining the incidence of interstitial pneumonitis and chronic kidney disease following full intensity haemopoetic stem cell transplant conditioned using a forward-planned intensity modulated total body irradiation technique. Radiother Oncol 2021; 158:97-103. [PMID: 33636231 DOI: 10.1016/j.radonc.2021.02.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 02/01/2021] [Accepted: 02/15/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE/OBJECTIVE Total body irradiation (TBI) remains a key component of conditioning for allogeneic haemopoietic stem cell transplant (HSCT), with interstitial pneumonitis (IP) and chronic kidney disease (CKD) important late sequelae. We undertook a retrospective service evaluation of TBI patients treated with a forward-planned intensity modulated radiotherapy technique (FP IMRT). MATERIAL/METHODS 74 adult patients were identified; all received step and shoot FP IMRT TBI, 14.4 Gy in 8 fractions over 4 days. Mean doses to the lungs and kidneys were 12-12.5 Gy. Toxicities were defined as per CTCAE v4.0: IP as multilobar infiltrates on CT with symptoms of dyspnoea, and renal dysfunction as an Estimated Glomerular Filtration rate (eGFR) < 60 ml/min/1.73 m2 for > 3 months. Secondary endpoints were overall survival (OS), progression free survival (PFS), cumulative incidence of non-relapse mortality (NRM), relapse risk and of acute and chronic GvHD. RESULTS Patients received treatment for the following diagnosis: ALL/LBL (n = 37); AML (n = 33), CML-BC (n = 2) and High grade NHL (n = 2). The rate of IP due to any cause was 30%; positive microbiological evidence in 73% (16 /22). Idiopathic IP was seen in 8%, with only 4% (n = 3) having IP Grade ≥ 3. Two (4%) of 52 long term survivors developed CKD, one with thrombotic microangiopathy. 4 year NRM was 16% (CI 11-32%); no treatment related deaths in matched sibling or umbilical cord blood HSCT. CONCLUSION FP IMRT TBI, reducing dose to the lungs and kidneys, has lower rates of idiopathic IP and CKD compared to the literature. This technique is safe and effective conditioning for full intensity HSCT.
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Affiliation(s)
- Emily Durie
- Department of Radiotherapy, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Emma Nicholson
- Haemato-Oncology Unit, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Chloe Anthias
- Haemato-Oncology Unit, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Emma M Dunne
- Department of Radiotherapy, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Mike Potter
- Haemato-Oncology Unit, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Mark Ethell
- Haemato-Oncology Unit, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Christina Messiou
- Radiology Department, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Joy Brennan
- Haemato-Oncology Unit, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Sally Eagle
- Department of Radiotherapy, The Royal Marsden Hospital, Sutton, United Kingdom
| | - James Talbot
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Gregory Smyth
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Westley Ingram
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Frank Saran
- Department of Radiotherapy, Auckland City Hospital, New Zealand
| | - Henry C Mandeville
- Department of Radiotherapy, The Royal Marsden Hospital, Sutton, United Kingdom; The Institute of Cancer Research, Sutton, United Kingdom.
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824
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Yamaguchi S, Sato E, Ieko Y, Ariga H, Yoshioka K. Development of a dose-rate dosimeter for x-ray CT scanner using silicon x-ray diode. THE REVIEW OF SCIENTIFIC INSTRUMENTS 2021; 92:053103. [PMID: 34243345 DOI: 10.1063/5.0047546] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 05/02/2021] [Indexed: 06/13/2023]
Abstract
In an x-ray diagnosis, it is important to evaluate the entrance dose rate, as the dose rate of exposure becomes highest in that position. To investigate the effect of the entrance dose rate of x-ray CT scanners, a dose-rate dosimeter comprising a silicon x-ray diode (Si-XD), a CMOS dual operational amplifier, resistors, capacitors, and a mini-substrate measuring 20 × 17 mm2 were developed. The Si-XD is desirable for measuring the changing entrance dose rate, as it enables the reduction of the response time, dimensions, and cost of the dosimeter. The dosimeter was connected to a microcomputer (mbed), and the output voltages from the dosimeter were measured using an analog-digital converter in the mbed. The output voltages were proportional to the tube currents at a constant tube voltage of 100 kV using an industrial x-ray tube, and the calibrated dose rates corresponded well to those obtained using a commercially available semiconductor dosimeter. However, owing to the energy dependence of the dosimeter, the calibrated dose rate was ∼10% higher than that of a commercially available semiconductor dosimeter at the lower tube voltage. In the angular dependence of the dosimeter, the flatness measured from 60° to 120° was ∼103% in this study. A fundamental study for measuring the dose-rate variations with rotation was performed. The results showed a different profile than the angular dependence due to the distance from the source and the complex factors of the scattered radiation.
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Affiliation(s)
- Satoshi Yamaguchi
- Department of Radiology, School of Medicine, Iwate Medical University, 2-1-1 Idaidori, Yahaba, Iwate 028-3695, Japan
| | - Eiichi Sato
- Department of Physics, Iwate Medical University, 1-1-1 Idaidori, Yahaba, Iwate 028-3694, Japan
| | - Yoshiro Ieko
- Department of Radiation Oncology, Iwate Medical University Hospital, Iwate Medical University, 2-1-1 Idaidori, Yahaba, Iwate 028-3695, Japan
| | - Hisanori Ariga
- Department of Radiation Oncology, Iwate Medical University Hospital, Iwate Medical University, 2-1-1 Idaidori, Yahaba, Iwate 028-3695, Japan
| | - Kunihiro Yoshioka
- Department of Radiation Oncology, Iwate Medical University Hospital, Iwate Medical University, 2-1-1 Idaidori, Yahaba, Iwate 028-3695, Japan
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825
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Khullar K, Dhawan ST, Nosher J, Jabbour SK. Fiducial marker migration following computed tomography-guided placement in the liver: a case report. AME Case Rep 2021; 5:15. [PMID: 33912804 DOI: 10.21037/acr-20-153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 02/06/2021] [Indexed: 12/12/2022]
Abstract
Radiation therapy for liver tumors has been shown to provide a local control and overall survival benefit in patients with primary or oligometastatic liver tumors. However, accurate delineation of the target volume in intraabdominal tumors can be limited by diaphragmatic motion. In addition to image guidance during radiation therapy, computed tomography (CT)-guided fiducial marker placement can improve the accuracy of radiation treatment and optimize tumor control. Fiducial marker placement is often indicated in stereotactic body radiation therapy (SBRT) due to the ablative doses used as well as in proton therapy given that these markers are clearly visible on orthogonal kV image guidance and studies have suggested that their placement in liver tumors offers improved local control. However, fiducial marker migration is a rare risk associated with fiducial placement for which literature remains scarce. We report two separate cases of fiducial marker migrations from the liver into the inferior vena cava and right atrium which occurred following CT-guided placement without any resultant toxicity. Imaging using contrast-enhanced or volume navigation ultrasound techniques during fiducial marker deployment may mitigate the risk of fiducial marker migration and potential end-organ injury. Alternative techniques for motion management such as inspiratory or expiratory breath hold or use of residual lipiodol on imaging in patients who have undergone transarterial chemoembolization (TACE) should be considered as well to avoid potential complications from fiducial marker placement.
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Affiliation(s)
- Karishma Khullar
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, USA
| | | | - John Nosher
- Department of Radiology, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, USA
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826
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Keijnemans K, Borman PTS, van Lier ALHMW, Verhoeff JJC, Raaymakers BW, Fast MF. Simultaneous multi-slice accelerated 4D-MRI for radiotherapy guidance. Phys Med Biol 2021; 66. [PMID: 33827065 DOI: 10.1088/1361-6560/abf591] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 04/07/2021] [Indexed: 12/25/2022]
Abstract
4D-MRI is becoming increasingly important for daily guidance of thoracic and abdominal radiotherapy. This study exploits the simultaneous multi-slice (SMS) technique to accelerate the acquisition of a balanced turbo field echo (bTFE) and a turbo spin echo (TSE) coronal 4D-MRI sequence performed on 1.5 T MRI scanners. SMS single-shot bTFE and TSE sequences were developed to acquire a stack of 52 coronal 2D images over 30 dynamics. Simultaneously excited slices were separated by half the field of view. Slices intersecting with the liver-lung interface were used as navigator slices. For each navigator slice location, an end-exhale dynamic was automatically identified, and used to derive the self-sorting signal by rigidly registering the remaining dynamics. Navigator slices were sorted into 10 amplitude bins, and the temporal relationship of simultaneously excited slices was used to generate sorted 4D-MRIs for 12 healthy volunteers. The self-sorting signal was validated using anin vivopeak-to-peak motion analysis. The smoothness of the liver-lung interface was quantified by comparing to sagittal cine images acquired directly after the SMS-4D-MRI sequence. To ensure compatibility with the MR-linac radiotherapy workflow, the 4D-MRIs were transformed into 3D mid-position (MidP) images using deformable image registration. Consistency of the deformable vector fields was quantified in terms of the distance discordance metric (DDM) in the body. The SMS-4D-TSE sequence was additionally acquired for 3 lung cancer patients to investigate tumor visibility. SMS-4D-MRI acquisition and processing took approximately 7 min. 4D-MRI reconstruction was possible for 26 out of 27 acquired datasets. Missing data in the sorted 4D-MRIs varied from 4%-26% for the volunteers and varied from 8%-24% for the patients. Peak-to-peak (SD) amplitudes analysis agreed within 1.8 (1.1) mm and 0.9 (0.4) mm between the sorted 4D-MRIs and the self-sorting signals of the volunteers and patients, respectively. Liver-lung interface smoothness was found to be in the range of 0.6-3.1 mm for volunteers. The percentage of DDM values smaller than 2 mm was in the range of 85%-89% and 86%-92% for the volunteers and patients, respectively. Lung tumors were clearly visibility in the SMS-4D-TSE images and MidP images. Two fast SMS-accelerated 4D-MRI sequences were developed resulting in T2/T1or T2weighted contrast. The SMS-4D-MRIs and derived 3D MidP-MRIs yielded anatomically plausible images and good tumor visibility. SMS-4D-MRI is therefore a strong candidate to be used for treatment simulation and daily guidance of thoracic and abdominal MR-guided radiotherapy.
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Affiliation(s)
- K Keijnemans
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - P T S Borman
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - A L H M W van Lier
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - J J C Verhoeff
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - B W Raaymakers
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - M F Fast
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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827
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Grilo AM, Santos B, Baptista I, Monsanto F. Exploring the cancer patients' experiences during external radiotherapy: A systematic review and thematic synthesis of qualitative and quantitative evidence. Eur J Oncol Nurs 2021; 52:101965. [PMID: 34023669 DOI: 10.1016/j.ejon.2021.101965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 03/28/2021] [Accepted: 04/14/2021] [Indexed: 11/20/2022]
Abstract
PURPOSE To investigate the subjective experience of adult cancer patients undergoing external radiotherapy and provide evidence for better practices in radiotherapy services. METHODS A systematic review was performed according to the PRISMA Statement Guidelines. Qualitative and mixed studies were identified through five electronic databases (CINAHL, PsychINFO, Medline, Scopus and Web of Science), between March and April 2020, using defined criteria. Methodological quality assessment was conducted, and the data integrated into a thematic synthesis. RESULTS Of the 886 studies identified, 13 met our inclusion criteria. Patients experiences were described into four main themes: (1) Time, (2) Physical Environment, (3) Treatment Concerns and (4) Radiotherapy Team. Time refers to waiting time and treatment time; Physical Environment states temperature in the treatment room and equipment; Treatment Concerns included side effects, daily activities, positioning and immobilization and treatment preparation (e.g., bladder filling); radiotherapy team comprised patients support; response to patients needs and recognized team. The generating analytical phase of thematic analysis allowed us to recognize that the effectiveness of the radiotherapy team operates as a facilitator of the patients' experience. In contrast, time in the waiting room, the treatment preparation when is required, and the positioning and immobilization, specifically for the neck and head patients, act as barriers. CONCLUSION Four distinct themes were identified to be positively and negatively associated with patients' experience during external radiotherapy. The evidence provides valuable recommendations to improved radiotherapy services organization, as well as to the delivery of more patient-centred care adjusted to the concerns and needs of patients.
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Affiliation(s)
- Ana Monteiro Grilo
- H&TRC-Health & Technology Research Center, ESTeSL- Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, Portugal; CICPsi - Research Center for Psychological Science, Faculty of Psychology, University of Lisbon, Portugal.
| | - Bárbara Santos
- Medical Imaging and RT Degree, Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, Portugal.
| | - Inês Baptista
- Medical Imaging and RT Degree, Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, Portugal.
| | - Fátima Monsanto
- H&TRC-Health & Technology Research Center, ESTeSL- Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, Portugal.
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828
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Delta radiomics for rectal cancer response prediction using low field magnetic resonance guided radiotherapy: an external validation. Phys Med 2021; 84:186-191. [PMID: 33901863 DOI: 10.1016/j.ejmp.2021.03.038] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/20/2021] [Accepted: 03/29/2021] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION A recent study performed on 16 locally advanced rectal cancer (LARC) patients treated using magnetic resonance guided radiotherapy (MRgRT) has identified two delta radiomics features as predictors of clinical complete response (cCR) after neoadjuvant radio-chemotherapy (nCRT). This study aims to validate these features (ΔLleast and Δglnu) on an external larger dataset, expanding the analysis also for pathological complete response (pCR) prediction. METHODS A total of 43 LARC patients were enrolled: Gross Tumour Volume (GTV) was delineated on T2/T1* MR images acquired during MRgRT and the two delta features were calculated. Receiver Operating Characteristic (ROC) curve analysis was performed on the 16 cases of the original study and the best cut-off value was identified. The performance of ΔLleast and Δglnu was evaluated at the best cut-off value. RESULTS On the original dataset of 16 patients, ΔLleast reported an AUC of 0.81 for cCR and 0.93 for pCR, while Δglnu 0.72 and 0.54 respectively. The best cut-off values of ΔLleast was 0.73 for both outcomes, while Δglnu reported 0.54 for cCR and 0.93 for pCR. At the external validation, ΔLleast showed an accuracy of 81% for cCR and 79% for pCR, while Δglnu reported 63% for cCR and 40% for pCR. CONCLUSION The accuracy of ΔLleast in predicting cCR and pCR is significantly higher than those obtained considering Δglnu, but inferior if compared with other image-based biomarker, such as the early-regression index. Studies with larger cohorts of patients are recommended to further investigate the role of delta radiomic features in MRgRT.
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829
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Banegas-Luna AJ, Peña-García J, Iftene A, Guadagni F, Ferroni P, Scarpato N, Zanzotto FM, Bueno-Crespo A, Pérez-Sánchez H. Towards the Interpretability of Machine Learning Predictions for Medical Applications Targeting Personalised Therapies: A Cancer Case Survey. Int J Mol Sci 2021; 22:4394. [PMID: 33922356 PMCID: PMC8122817 DOI: 10.3390/ijms22094394] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 12/18/2022] Open
Abstract
Artificial Intelligence is providing astonishing results, with medicine being one of its favourite playgrounds. Machine Learning and, in particular, Deep Neural Networks are behind this revolution. Among the most challenging targets of interest in medicine are cancer diagnosis and therapies but, to start this revolution, software tools need to be adapted to cover the new requirements. In this sense, learning tools are becoming a commodity but, to be able to assist doctors on a daily basis, it is essential to fully understand how models can be interpreted. In this survey, we analyse current machine learning models and other in-silico tools as applied to medicine-specifically, to cancer research-and we discuss their interpretability, performance and the input data they are fed with. Artificial neural networks (ANN), logistic regression (LR) and support vector machines (SVM) have been observed to be the preferred models. In addition, convolutional neural networks (CNNs), supported by the rapid development of graphic processing units (GPUs) and high-performance computing (HPC) infrastructures, are gaining importance when image processing is feasible. However, the interpretability of machine learning predictions so that doctors can understand them, trust them and gain useful insights for the clinical practice is still rarely considered, which is a factor that needs to be improved to enhance doctors' predictive capacity and achieve individualised therapies in the near future.
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Affiliation(s)
- Antonio Jesús Banegas-Luna
- Structural Bioinformatics and High-Performance Computing Research Group (BIO-HPC), Universidad Católica de Murcia (UCAM), 30107 Murcia, Spain; (J.P.-G.); (A.B.-C.)
| | - Jorge Peña-García
- Structural Bioinformatics and High-Performance Computing Research Group (BIO-HPC), Universidad Católica de Murcia (UCAM), 30107 Murcia, Spain; (J.P.-G.); (A.B.-C.)
| | - Adrian Iftene
- Faculty of Computer Science, Universitatea Alexandru Ioan Cuza (UAIC), 700505 Jashi, Romania;
| | - Fiorella Guadagni
- Interinstitutional Multidisciplinary Biobank (BioBIM), IRCCS San Raffaele Roma, 00166 Rome, Italy; (F.G.); (P.F.)
- Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Roma Open University, 00166 Rome, Italy;
| | - Patrizia Ferroni
- Interinstitutional Multidisciplinary Biobank (BioBIM), IRCCS San Raffaele Roma, 00166 Rome, Italy; (F.G.); (P.F.)
- Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Roma Open University, 00166 Rome, Italy;
| | - Noemi Scarpato
- Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Roma Open University, 00166 Rome, Italy;
| | - Fabio Massimo Zanzotto
- Dipartimento di Ingegneria dell’Impresa “Mario Lucertini”, University of Rome Tor Vergata, 00133 Rome, Italy;
| | - Andrés Bueno-Crespo
- Structural Bioinformatics and High-Performance Computing Research Group (BIO-HPC), Universidad Católica de Murcia (UCAM), 30107 Murcia, Spain; (J.P.-G.); (A.B.-C.)
| | - Horacio Pérez-Sánchez
- Structural Bioinformatics and High-Performance Computing Research Group (BIO-HPC), Universidad Católica de Murcia (UCAM), 30107 Murcia, Spain; (J.P.-G.); (A.B.-C.)
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830
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Groot Koerkamp ML, de Hond YJM, Maspero M, Kontaxis C, Mandija S, Vasmel JE, Charaghvandi RK, Philippens MEP, van Asselen B, van den Bongard HJGD, Hackett SS, Houweling AC. Synthetic CT for single-fraction neoadjuvant partial breast irradiation on an MRI-linac. Phys Med Biol 2021; 66. [PMID: 33761491 DOI: 10.1088/1361-6560/abf1ba] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/24/2021] [Indexed: 01/08/2023]
Abstract
A synthetic computed tomography (sCT) is required for daily plan optimization on an MRI-linac. Yet, only limited information is available on the accuracy of dose calculations on sCT for breast radiotherapy. This work aimed to (1) evaluate dosimetric accuracy of treatment plans for single-fraction neoadjuvant partial breast irradiation (PBI) on a 1.5 T MRI-linac calculated on a) bulk-density sCT mimicking the current MRI-linac workflow and b) deep learning-generated sCT, and (2) investigate the number of bulk-density levels required. For ten breast cancer patients we created three bulk-density sCTs of increasing complexity from the planning-CT, using bulk-density for: (1) body, lungs, and GTV (sCTBD1); (2) volumes for sCTBD1plus chest wall and ipsilateral breast (sCTBD2); (3) volumes for sCTBD2plus ribs (sCTBD3); and a deep learning-generated sCT (sCTDL) from a 1.5 T MRI in supine position. Single-fraction neoadjuvant PBI treatment plans for a 1.5 T MRI-linac were optimized on each sCT and recalculated on the planning-CT. Image evaluation was performed by assessing mean absolute error (MAE) and mean error (ME) in Hounsfield Units (HU) between the sCTs and the planning-CT. Dosimetric evaluation was performed by assessing dose differences, gamma pass rates, and dose-volume histogram (DVH) differences. The following results were obtained (median across patients for sCTBD1/sCTBD2/sCTBD3/sCTDLrespectively): MAE inside the body contour was 106/104/104/75 HU and ME was 8/9/6/28 HU, mean dose difference in the PTVGTVwas 0.15/0.00/0.00/-0.07 Gy, median gamma pass rate (2%/2 mm, 10% dose threshold) was 98.9/98.9/98.7/99.4%, and differences in DVH parameters were well below 2% for all structures except for the skin in the sCTDL. Accurate dose calculations for single-fraction neoadjuvant PBI on an MRI-linac could be performed on both bulk-density and deep learning sCT, facilitating further implementation of MRI-guided radiotherapy for breast cancer. Balancing simplicity and accuracy, sCTBD2showed the optimal number of bulk-density levels for a bulk-density approach.
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Affiliation(s)
- M L Groot Koerkamp
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Y J M de Hond
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - M Maspero
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands.,Computational Imaging Group for MR diagnostics & therapy, Center for Image Sciences, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C Kontaxis
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - S Mandija
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands.,Computational Imaging Group for MR diagnostics & therapy, Center for Image Sciences, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J E Vasmel
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - R K Charaghvandi
- Department of Radiation Oncology, Radboudumc, Nijmegen, The Netherlands
| | - M E P Philippens
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - B van Asselen
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - S S Hackett
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - A C Houweling
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
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831
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Babar M, Katz A, Ciatto M. Dosimetric and clinical outcomes of SpaceOAR in men undergoing external beam radiation therapy for localized prostate cancer: A systematic review. J Med Imaging Radiat Oncol 2021; 65:384-397. [PMID: 33855816 DOI: 10.1111/1754-9485.13179] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 03/08/2021] [Accepted: 03/11/2021] [Indexed: 12/30/2022]
Abstract
SpaceOAR, an absorbable polyethylene glycol hydrogel, increases the space between the prostate and rectum to reduce the radiation received by the rectum during prostate cancer radiation therapy. The objective of this systematic review was to evaluate controlled studies on the dosimetric and clinical outcomes of SpaceOAR in men undergoing external beam radiation therapy for localized prostate cancer. Eight studies were included in the review. All of the studies showed SpaceOAR to reduce the radiation dose volume to the rectum over numerous dosimetry levels. Of the four studies that assessed toxicity, one reported SpaceOAR to significantly decrease acute Grade 1 diarrhoea and two reported SpaceOAR to significantly decrease late Grade 1 and Grade ≥2 rectal toxicities. Two studies assessed cumulative incidence of toxicity at 3 years in which one reported SpaceOAR to significantly decrease urinary incontinence and Grade ≥1 and Grade ≥2 rectal toxicities, and the other reported SpaceOAR to significantly decrease Grade 1 diarrhoea and Grade 2 proctitis. Moreover, one study reported that fewer SpaceOAR patients experienced 10-point declines in bowel quality of life at 3 years, but another study reported no significant difference in 10-point declines in bowel quality of life between the SpaceOAR and control groups at 5 years. With the current research available, SpaceOAR may be beneficial to those who did not meet the standard rectal dose-volume criteria, have higher risk factors of developing rectal toxicities post-radiation, or wish to decrease the length and costs of radiotherapy by increasing the dose of radiation per fraction.
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Affiliation(s)
| | - Alan Katz
- St. Francis Hospital, Roslyn, NY, USA
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832
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Bryant CM, Henderson RH, Nichols RC, Mendenhall WM, Hoppe BS, Vargas CE, Daniels TB, Choo CR, Parikh RR, Giap H, Slater JD, Vapiwala N, Barrett W, Nanda A, Mishra MV, Choi S, Liao JJ, Mendenhall NP. Consensus Statement on Proton Therapy for Prostate Cancer. Int J Part Ther 2021; 8:1-16. [PMID: 34722807 PMCID: PMC8489490 DOI: 10.14338/ijpt-20-00031.1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 02/02/2021] [Indexed: 11/21/2022] Open
Abstract
Proton therapy is a promising but controversial treatment in the management of prostate cancer. Despite its dosimetric advantages when compared with photon radiation therapy, its increased cost to patients and insurers has raised questions regarding its value. Multiple prospective and retrospective studies have been published documenting the efficacy and safety of proton therapy for patients with localized prostate cancer and for patients requiring adjuvant or salvage pelvic radiation after surgery. The Particle Therapy Co-Operative Group (PTCOG) Genitourinary Subcommittee intends to address current proton therapy indications, advantages, disadvantages, and cost effectiveness. We will also discuss the current landscape of clinical trials. This consensus report can be used to guide clinical practice and research directions.
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Affiliation(s)
- Curtis M. Bryant
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Randal H. Henderson
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - R. Charles Nichols
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - William M. Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Bradford S. Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | | | | | - C. Richard Choo
- Department of Radiation Oncology, Mayo Clinic Rochester, Rochester, MN, USA
| | - Rahul R. Parikh
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Huan Giap
- Department of Radiation Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Jerry D. Slater
- Department of Radiation Oncology, Loma Linda University, Loma Linda, CA, USA
| | - Neha Vapiwala
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - William Barrett
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - Akash Nanda
- Department of Radiation Oncology, Orlando Health, Orlando, FL, USA
| | - Mark V. Mishra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Seungtaek Choi
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Jay J. Liao
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, WA, USA
| | - Nancy P. Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
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833
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Ingrosso G, Saldi S, Marani S, Wong AYW, Bertelli M, Aristei C, Zelante T. Breakdown of Symbiosis in Radiation-Induced Oral Mucositis. J Fungi (Basel) 2021; 7:jof7040290. [PMID: 33921294 PMCID: PMC8068946 DOI: 10.3390/jof7040290] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/07/2021] [Accepted: 04/08/2021] [Indexed: 01/06/2023] Open
Abstract
Oral mucositis is an acute side effect of radiation therapy that is especially common with head and neck cancer treatment. In recent years, several studies have revealed the predisposing factors for mucositis, leading to the pre-treatment of patients to deter the development of opportunistic oral fungal infections. Although many clinical protocols already advise the use of probiotics to counteract inflammation and fungal colonization, preclinical studies are needed to better delineate the mechanisms by which a host may acquire benefits via co-evolution with oral microbiota, probiotics, and fungal commensals, such as Candida albicans, especially during acute inflammation. Here, we review the current understanding of radiation therapy-dependent oral mucositis in terms of pathology, prevention, treatment, and related opportunistic infections, with a final focus on the oral microbiome and how it may be important for future therapy.
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Affiliation(s)
- Gianluca Ingrosso
- Radiation Oncology Section, Department of Medicine and Surgery, University of Perugia, 06129 Perugia, Italy; (G.I.); (S.M.); (C.A.)
- Radiation Oncology Section, Perugia General Hospital, 06129 Perugia, Italy;
| | - Simonetta Saldi
- Radiation Oncology Section, Perugia General Hospital, 06129 Perugia, Italy;
| | - Simona Marani
- Radiation Oncology Section, Department of Medicine and Surgery, University of Perugia, 06129 Perugia, Italy; (G.I.); (S.M.); (C.A.)
- Radiation Oncology Section, Perugia General Hospital, 06129 Perugia, Italy;
| | - Alicia Y. W. Wong
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institute, 141 86 Stockholm, Sweden;
| | | | - Cynthia Aristei
- Radiation Oncology Section, Department of Medicine and Surgery, University of Perugia, 06129 Perugia, Italy; (G.I.); (S.M.); (C.A.)
- Radiation Oncology Section, Perugia General Hospital, 06129 Perugia, Italy;
| | - Teresa Zelante
- Pathology Section, Department of Medicine and Surgery, University of Perugia, 06129 Perugia, Italy
- Correspondence: ; Tel.: +39-075-585-8236
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834
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Sakai Y, Tanooka M, Okada W, Sano K, Nakamura K, Shibata M, Ueda Y, Mizuno H, Tanaka M. Characteristics of a bolus created using thermoplastic sheets for postmastectomy radiation therapy. Radiol Phys Technol 2021; 14:179-185. [PMID: 33837911 DOI: 10.1007/s12194-021-00618-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/19/2021] [Accepted: 04/06/2021] [Indexed: 10/21/2022]
Abstract
This study applied a "shell bolus," an immobilizing thermoplastic shell locally thickened with extra layers over the radiation target, during postmastectomy radiation therapy (PMRT). We performed ion chamber and film measurements for a solid water phantom for thermoplastic sheets and a gel bolus for dosimetric characterization using a 6-MV X-ray flattening-filter-free (FFF) beam. The air gaps between the body surface for the gel and shell bolus were measured using computed tomography (CT) images in patients who underwent PMRT. This included seven and 13 patients treated with the gel and shell boluses, respectively. A comparison of the dose differences between a 10-mm gel bolus and a 9.6-mm-thick thermoplastic sheet at the surface and 5 cm below the surface showed a 4.2% higher surface dose and 0.5% lower dose at 5-cm depth for the thermoplastic sheet compared to those for the gel bolus. The mean (p = 0.029) and maximum (p < 0.001) air gaps of the shell bolus were significantly thinner than those of the gel bolus. Thus, the shell bolus provided a close fit and robust bolus effect. In addition, the shell bolus reduced respiratory motion and eliminated the need for skin marking. Therefore, this system can be effectively used as a bolus for PMRT.
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Affiliation(s)
- Yusuke Sakai
- Radiation Therapy Center, Takarazuka City Hospital, 4-5-1 Kohama, Takarazuka, Hyogo, 665-0827, Japan.
| | - Masao Tanooka
- Radiation Therapy Center, Takarazuka City Hospital, 4-5-1 Kohama, Takarazuka, Hyogo, 665-0827, Japan
| | - Wataru Okada
- Radiation Therapy Center, Takarazuka City Hospital, 4-5-1 Kohama, Takarazuka, Hyogo, 665-0827, Japan
| | - Keisuke Sano
- Radiation Therapy Center, Takarazuka City Hospital, 4-5-1 Kohama, Takarazuka, Hyogo, 665-0827, Japan
| | - Kenji Nakamura
- Radiation Therapy Center, Takarazuka City Hospital, 4-5-1 Kohama, Takarazuka, Hyogo, 665-0827, Japan
| | - Mayuri Shibata
- Radiation Therapy Center, Takarazuka City Hospital, 4-5-1 Kohama, Takarazuka, Hyogo, 665-0827, Japan
| | - Yoshihiro Ueda
- Department of Radiation Oncology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 537-8567, Japan
| | - Hirokazu Mizuno
- Division of Central Radiology, Osaka Rosai Hospital, 1179-3 Nagasone-cho, Kita-ku, Sakai, Osaka, 591-8025, Japan
| | - Masahiro Tanaka
- Radiation Therapy Center, Takarazuka City Hospital, 4-5-1 Kohama, Takarazuka, Hyogo, 665-0827, Japan
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835
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Intensity-modulated proton therapy for oropharyngeal cancer reduces rates of late xerostomia. Radiother Oncol 2021; 160:32-39. [PMID: 33839202 DOI: 10.1016/j.radonc.2021.03.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 03/23/2021] [Accepted: 03/28/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND PURPOSE To determine rates of xerostomia after intensity-modulated radiotherapy (IMRT) or intensity-modulated proton therapy (IMPT) for oropharyngeal cancer (OPC) and identify dosimetric factors associated with xerostomia risk. MATERIALS AND METHODS Patients with OPC who received IMRT (n = 429) or IMPT (n = 103) from January 2011 through June 2015 at a single institution were studied retrospectively. Every 3 months after treatment, each patient completed an eight-item self-reported xerostomia-specific questionnaire (XQ; summary XQ score, 0-100). An XQ score of 50 was selected as the demarcation value for moderate-severe (XQs ≥ 50) and no-mild (XQs < 50) xerostomia. The mean doses and percent volumes of organs at risk receiving various doses (V5-V70) were extracted from the initial treatment plans. The dosimetric variables and xerostomia risk were compared using an independent-sample t-test or chi-square test. RESULTS The median follow-up time was 36.2 months. The proportions of patients with moderate-severe xerostomia were similar in the two treatment groups up to 18 months after treatment. However, moderate-severe xerostomia was less common in the IMPT group than in the IMRT group at 18-24 months (6% vs. 20%; p = 0.025) and 24-36 months (6% vs. 20%; p = 0.01). During the late xerostomia period (24-36 months), high dose/volume exposures (V25-V70) in the oral cavity were associated with high proportions of patients with moderate-severe xerostomia (all p < 0.05), but dosimetric variables regarding the salivary glands were not associated with late xerostomia. CONCLUSION IMPT was associated with less late xerostomia than was IMRT in OPC patients. Oral cavity dosimetric variables were related to the occurrence of late xerostomia.
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836
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Katano A, Ishida A, Yamashita H, Nakagawa K. Radiotherapy for symptom palliation of splenomegaly in patients with haematological malignancies. Mol Clin Oncol 2021; 14:114. [PMID: 33903820 DOI: 10.3892/mco.2021.2276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 03/09/2021] [Indexed: 11/06/2022] Open
Abstract
Splenomegaly severely compromises the quality of life of those affected. The aim of the present study was to describe the clinical characteristics of patients with haematological disorders who receive radiotherapy for splenomegaly, particularly focusing on the changes in spleen volume. The present study conducted a retrospective analysis of consecutive patients with haematological disorders who underwent splenic radiotherapy with palliative intent at the Department of Radiology of the University of Tokyo Hospital between June 2008 and June 2019. Pre- and post-radiotherapy spleen volumes were measured from computed tomography images. A total of 8 patients (5 men and 3 women) with a median age of 59 years (range, 46-76 years) were included. The median total prescription and fractional doses were 4.5 Gy (range, 1.5-10 Gy) and 0.78 Gy (range, 0.5-2.0 Gy), respectively. A total of 5 patients (62.5%) experienced a reduction in spleen volume. The mean ± SD spleen sizes pre- and post-radiotherapy were 1,887±1,011 and 1,368±577 ml, respectively. The mean variation rate in spleen volume was -19.1±24.7%, and the case with the most notable improvement in the present study exhibited a -52.4% change. Of the 5 patients who experienced pain prior to radiotherapy, 3 achieved pain relief, 1 did not experience any change and 1 patient was not assessed post-radiotherapy. Therefore, the findings of the present study revealed that palliative radiotherapy for splenomegaly may achieve symptom palliation and radiological volumetric effects in patients with haematological disorders.
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Affiliation(s)
- Atsuto Katano
- Department of Radiology, The University of Tokyo Hospital, Bunkyo, Tokyo 113-8655, Japan
| | - Aki Ishida
- Department of Radiology, The University of Tokyo Hospital, Bunkyo, Tokyo 113-8655, Japan
| | - Hideomi Yamashita
- Department of Radiology, The University of Tokyo Hospital, Bunkyo, Tokyo 113-8655, Japan
| | - Keiichi Nakagawa
- Department of Radiology, The University of Tokyo Hospital, Bunkyo, Tokyo 113-8655, Japan
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837
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Mercieca S, Belderbos JSA, van Herk M. Challenges in the target volume definition of lung cancer radiotherapy. Transl Lung Cancer Res 2021; 10:1983-1998. [PMID: 34012808 PMCID: PMC8107734 DOI: 10.21037/tlcr-20-627] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Radiotherapy, with or without systemic treatment has an important role in the management of lung cancer. In order to deliver the treatment accurately, the clinician must precisely outline the gross tumour volume (GTV), mostly on computed tomography (CT) images. However, due to the limited contrast between tumour and non-malignant changes in the lung tissue, it can be difficult to distinguish the tumour boundaries on CT images leading to large interobserver variation and differences in interpretation. Therefore the definition of the GTV has often been described as the weakest link in radiotherapy with its inaccuracy potentially leading to missing the tumour or unnecessarily irradiating normal tissue. In this article, we review the various techniques that can be used to reduce delineation uncertainties in lung cancer.
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Affiliation(s)
- Susan Mercieca
- Faculty of Health Science, University of Malta, Msida, Malta.,The University of Amsterdam, Amsterdam, The Netherlands
| | - José S A Belderbos
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Marcel van Herk
- University of Manchester, Manchester Academic Health Centre, The Christie NHS Foundation Trust, Manchester, UK
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838
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Southworth A, Ketterer SJ, Kirby M. Patient and radiographer acceptability of prophylactic skin care for breast patients receiving radiotherapy. Radiography (Lond) 2021; 27:755-760. [PMID: 33745827 DOI: 10.1016/j.radi.2021.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/28/2021] [Accepted: 02/14/2021] [Indexed: 12/01/2022]
Abstract
INTRODUCTION This study aimed to: • Address the lack of information surrounding patient preference within radiotherapy skin care. • Identify if prophylactic skin care is the preferred approach of patients and staff. • Establish if patients and staff are accepting of the use of a type of barrier film, such as 3M™ Cavilon™ No Sting Barrier Film. METHODS Twelve patients undergoing standard whole breast radiotherapy and four staff members who were based mainly on a breast-specific treatment unit were interviewed using semi-structured techniques. The interview transcripts were coded for areas of interest and a thematic map generated using the qualitative data analysis software (NVivo V12, QSR International). RESULTS One Hundred percent of patients (n = 12) would have preferred a proactive approach to skin care management over the reactive one currently implemented. Staff were also in favour of a proactive approach to skin care with 100% (n = 4) supportive of a trial into the film's effectiveness. Three key themes were identified: • Theme 1: Patient Ownership of Own care - all patients identified they preferred a prophylactic approach and that more specific skin care guidance from healthcare professionals would be beneficial. • Theme 2: Product Practicality - 93% of patients and 100% of staff accepted the product and would be open to the use of it clinically. • Theme 3: Staff Acknowledgement of Skin Care - all staff identified a patient group in need of prophylaxis and that Cavilon No Sting may be a product of interest. CONCLUSION Patients and staff were in support of prophylactic skin care, both approved of the proposed product. However, there is a significant lack of clinical evidence to support the use of any topical products within radiotherapy skincare due to the lack of high-quality studies. IMPLICATIONS FOR PRACTICE Changes to skin care practice could be considered due to patient preference in favour of proactive management.
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Affiliation(s)
- A Southworth
- Radiotherapy Department Leeds Cancer Centre St James's Hospital, Becket Street, Leeds, LS9 7TF, UK.
| | - S-J Ketterer
- Directorate of Radiotherapy, School of Health Sciences, University of Liverpool, Brownlow Hill, Liverpool, L69 3GB, UK
| | - M Kirby
- Directorate of Radiotherapy, School of Health Sciences, University of Liverpool, Brownlow Hill, Liverpool, L69 3GB, UK
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839
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Safai Zadeh E, Dietrich CF, Görg C, Bleyl T, Alhyari A, Ignee A, Jenssen C, Trenker C. [Spleen biopsy: "pros and cons" or better "when and when not?"]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2021; 59:879-885. [PMID: 33752245 DOI: 10.1055/a-1404-3926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Due to the relatively high complication rate, the necessity of a spleen biopsy is controversially discussed. In establishing its indication, the clinical background and performed diagnostics must be considered. Based on the medical history, imaging procedures and sonographic course, different clinical scenarios are conceivable. The aim of this review is to describe the indications of splenic biopsy considering various clinical scenarios.
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Affiliation(s)
- Ehsan Safai Zadeh
- Interdisziplinäres Ultraschallzentrum, UKGM Marburg und Philipps-Universität Marburg
| | - Christoph F Dietrich
- Department Allgemeine Innere Medizin (DAIM), Kliniken Hirslanden Bern, Beau Site, Salem und Permanence, Bern, Schweiz
| | - Christian Görg
- Interdisziplinäres Ultraschallzentrum, UKGM Marburg und Philipps-Universität Marburg
| | - Tobias Bleyl
- Klinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, UKGM Marburg und Philipps-Universität Marburg
| | - Amjad Alhyari
- Klinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, UKGM Marburg und Philipps-Universität Marburg
| | - Andre Ignee
- Department für Innere Medizin, Caritas Hospital, Bad Mergentheim, Germany
| | - Christian Jenssen
- Department für Innere Medizin, Krankenhaus Märkisch Oderland, Strausberg/Wriezen, Brandenburg Institute for Clinical Ultrasound at Medical Universitäy Brandenburg, Neuruppin, Germany
| | - Corinna Trenker
- Klinik für Hämatologie, Onkologie und Immunologie, UKGM Marburg und Philipps-Universität Marburg
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840
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Bellyei S, Boronkai Á, Pozsgai E, Fodor D, Mangel L. Effective chemotherapy and targeted therapy supplemented with stereotactic radiotherapy of a patient with metastatic colon cancer following renal transplantation: a case report. J Med Case Rep 2021; 15:125. [PMID: 33741057 PMCID: PMC7980581 DOI: 10.1186/s13256-021-02702-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 01/27/2021] [Indexed: 12/18/2022] Open
Abstract
Background Previous studies have shown that patients who underwent renal transplantation were at a greater risk of developing malignancies. Due to advances in effective surgical techniques and immunosuppressive therapies, organ recipients live longer. Yet, there is insufficient information about the recommended type of therapy for colorectal cancer patients following transplantation. We describe the oncological treatment of a patient with renal transplantation, who presented with metastatic colon cancer 5 years after transplantation. Case presentation A 66-year-old Caucasian male patient, with hypertension, type 2 diabetes mellitus, paroxysmal atrial fibrillation, and renal failure underwent successful kidney transplantation in 2013. In April 2018, the adenocarcinoma of the sigmoid colon was found, and surgical resection was performed. The histological diagnosis was low-grade adenocarcinoma. Fluorodeoxyglucose positron emission tomography/computerized tomography scan showed a 2.5-cm metastasis in the VIIth segment of the liver and a metastatic paraaortical lymph node on the left. The clinical diagnosis was, therefore, metastatic (stage IV) sigmoid colon cancer (AJCC TNM system). The ongoing medications of the patient included immunosuppressive drugs and medication for his cardiovascular comorbidities. In July 2018, palliative cetuximab plus folinic acid–fluorouracil–irinotecan chemotherapeutic treatment was initiated, then cetuximab was substituted for panitumumab because of adverse events. In August 2018, the follow-up positron emission tomography/computerized tomography scan revealed stable disease. Because of side effects, the patient was unwilling to continue with the panitumumab plus folinic acid–fluorouracil–irinotecan treatment regimen. Therefore, the patient received 10× 5 Gy stereotactic body irradiation for his liver metastasis and mono-panitumumab therapy. By January 2019, the positron emission tomography/computerized tomography scan showed regression of the liver metastasis but a progression in the paraaortic lymph node. Therefore, 5× 8 Gy stereotactic irradiation was given to the paraaortic lesion. Meanwhile, the patient received altogether 16 cycles of panitumumab until June 2019, when complete remission was attained. In July 2019, the patient suffered a hemorrhagic stroke, probably due to his cardiovascular comorbidities, and died subsequently. Conclusions Since information is scarce regarding oncological treatment of patients following organ transplantation, data about their oncological treatment is essential. To our knowledge, this is the first case report to describe the successful chemotherapy and targeted therapy supplemented with stereotactic radiotherapy of a posttransplant patient with metastatic colorectal cancer.
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Affiliation(s)
- Szabolcs Bellyei
- Department of Oncotherapy, Clinical Center, University of Pécs, Édesanyák Street 10, 7624, Pécs, Hungary
| | - Árpád Boronkai
- Department of Oncotherapy, Clinical Center, University of Pécs, Édesanyák Street 10, 7624, Pécs, Hungary
| | - Eva Pozsgai
- Department of Public Health, Medical School, University of Pécs, Szigeti Street 12, 7624, Pécs, Hungary. .,Institute of Primary Health Care, Medical School, University of Pécs, Rákóczi Street 2, 7623, Pécs, Hungary.
| | - Dávid Fodor
- Department of Oncotherapy, Clinical Center, University of Pécs, Édesanyák Street 10, 7624, Pécs, Hungary
| | - László Mangel
- Department of Oncotherapy, Clinical Center, University of Pécs, Édesanyák Street 10, 7624, Pécs, Hungary
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841
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Lis M, Newhauser W, Donetti M, Wolf M, Steinsberger T, Paz A, Durante M, Graeff C. A Modular System for Treating Moving Anatomical Targets With Scanned Ion Beams at Multiple Facilities: Pre-Clinical Testing for Quality and Safety of Beam Delivery. Front Oncol 2021; 11:620388. [PMID: 33816251 PMCID: PMC8018284 DOI: 10.3389/fonc.2021.620388] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/25/2021] [Indexed: 12/26/2022] Open
Abstract
Background Quality management and safety are integral to modern radiotherapy. New radiotherapy technologies require new consensus guidelines on quality and safety. Established analysis strategies, such as the failure modes and effects analysis (FMEA) and incident learning systems have been developed as tools to assess the safety of several types of radiation therapies. An extensive literature documents the widespread application of risk analysis methods to photon radiation therapy. Relatively little attention has been paid to performing risk analyses of nascent radiation therapy systems to treat moving tumors with scanned heavy ion beams. The purpose of this study was to apply a comprehensive safety analysis strategy to a motion-synchronized dose delivery system (M-DDS) for ion therapy. Methods We applied a risk analysis method to new treatment planning and treatment delivery processes with scanned heavy ion beams. The processes utilize a prototype, modular dose delivery system, currently undergoing preclinical testing, that provides new capabilities for treating moving anatomy. Each step in the treatment process was listed in a process map, potential errors for each step were identified and scored using the risk probability number in an FMEA, and the possible causes of each error were described in a fault tree analysis. Solutions were identified to mitigate the risk of these errors, including permanent corrective actions, periodic quality assurance (QA) tests, and patient specific QA (PSQA) tests. Each solution was tested experimentally. Results The analysis revealed 58 potential errors that could compromise beam delivery quality or safety. Each of the 14 binary (pass-or-fail) tests passed. Each of the nine QA and four PSQA tests were within anticipated clinical specifications. The modular M-DDS was modified accordingly, and was found to function at two centers. Conclusion We have applied a comprehensive risk analysis strategy to the M-DDS and shown that it is a clinically viable motion mitigation strategy. The described strategy can be utilized at any ion therapy center that operates with the modular M-DDS. The approach can also be adapted for use at other facilities and can be combined with existing safety analysis systems.
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Affiliation(s)
- Michelle Lis
- Biophysics, GSI Helmholtzzentrum für Schwerionenforschung GmbH, Darmstadt, Germany.,Department of Physics and Astronomy, Louisiana State University, Baton Rouge, LA, United States
| | - Wayne Newhauser
- Department of Physics and Astronomy, Louisiana State University, Baton Rouge, LA, United States.,Department of Radiation Physics, Mary Bird Perkins Cancer Center, Baton Rouge, LA, United States
| | - Marco Donetti
- Research and Development Department, Centro Nazionale di Androterapia Oncologia, Pavia, Italy
| | - Moritz Wolf
- Biophysics, GSI Helmholtzzentrum für Schwerionenforschung GmbH, Darmstadt, Germany
| | - Timo Steinsberger
- Biophysics, GSI Helmholtzzentrum für Schwerionenforschung GmbH, Darmstadt, Germany.,Institute of Condensed Matter Physics, Technical University of Darmstadt, Darmstadt, Germany
| | - Athena Paz
- Biophysics, GSI Helmholtzzentrum für Schwerionenforschung GmbH, Darmstadt, Germany
| | - Marco Durante
- Biophysics, GSI Helmholtzzentrum für Schwerionenforschung GmbH, Darmstadt, Germany.,Institute of Condensed Matter Physics, Technical University of Darmstadt, Darmstadt, Germany
| | - Christian Graeff
- Biophysics, GSI Helmholtzzentrum für Schwerionenforschung GmbH, Darmstadt, Germany
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842
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Skubish S, Starrs C, McDonagh D. Exploring opportunities & pathways for advanced practice radiation therapy roles in the United States. Tech Innov Patient Support Radiat Oncol 2021; 17:59-62. [PMID: 34007908 PMCID: PMC8110941 DOI: 10.1016/j.tipsro.2021.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 11/24/2022] Open
Abstract
Educational and regulatory frameworks do not exist for RTT scope expansion in the U.S. Institutions have tools through other AP roles and established international models. The APRT role could offer solutions to new pressures on the US health system. Institutional support, therapy initiated research and regulatory changes are required. Formal collaboration among institutions can revive efforts within the profession.
The evolution of practice of Radiation Therapy in the United States (U.S.) is inevitable. The scope of a radiation therapists role has progressed with advancing technology, implementation of special procedures and patient care requirements. Internationally, Canada, Australia and the United Kingdom have formalized this evolution through the Advanced Practice Radiation Therapist (APRT) role to provide new models of care, to meet growing demands in the practice of Radiation Oncology, to increase efficiency, decrease cost and retain skilled staff (Harnett et al., 2018; Society of Radiographers; Linden et al., 2019; Coleman et al., 2014) [1], [2], [3], [4]. Through evidence based practice, the APRT role has proven to provide benefits for multiple stakeholders including service-reconfiguration to reduce wait times, developing and retaining highly skilled radiation therapists, treatment review and most importantly improving patient care within much needed patient cohorts such as the palliative population (Duffton et al., 2019) [5]. The U.S. is no exception to requiring innovative care models and solutions to similar complex, care delivery challenges experienced internationally. The U.S. is experiencing an increase in demand for cancer services and a rapid rate of technological and treatment advancements. Under the current infrastructure, this has impacted the daily tasks of physicians; increasing workload, increasing the complexity of clinical decision making, increasing movement toward site specific subspecialty practice and pushing the scope of radiation therapists informally toward maximization, increased autonomy and a higher level of education and specialized skills (American Society of Clinical Oncology, 2016; ARRT, 2020; Vu et al., 2018) [6], [7], [8]. Objective The following reviews the current radiation therapy practice and professional landscape in the United States as it relates to advanced practice, exploring opportunities and challenges under the U.S. health care infrastructure. This broad analysis provides comparison to other countries and disciplines such as the Radiologist Assistant and Nurse Practitioner for potential pathways to establishing the role and describes current needs and value of the expanding scope of RT’s practicing in the U.S.
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Affiliation(s)
- Samantha Skubish
- Department of Radiation Oncology, Mount Sinai Health System, 1184 5 Avenue, New York, NY 10029, United States
- Corresponding author.
| | - Clodagh Starrs
- Department of Radiation Oncology, Mount Sinai Hospital, 1184 5 Avenue, New York, NY 10029, United States
| | - Danielle McDonagh
- Department of Radiation Oncology, Mount Sinai Beth Israel, 10 Union Square East, New York, NY 10003, United States
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843
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Take Action Protocol: A radiation therapist led approach to act on anatomical changes seen on CBCT. Tech Innov Patient Support Radiat Oncol 2021; 17:71-77. [PMID: 34007910 PMCID: PMC8110944 DOI: 10.1016/j.tipsro.2020.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/29/2020] [Accepted: 12/01/2020] [Indexed: 11/24/2022] Open
Abstract
Take Action Protocol is an accurate RTT led method to act on anatomical changes. The Take Action Protocol gives RTTs more responsibility in IGRT treatment evaluation. RTTs experience the responsibility of decision making on anatomical changes as satisfactory. The TAP improves the balance of the workload vs. clinical relevance of anatomical changes.
Until recently Traffic Light Protocols (TLP) have been developed to recognize and react to Anatomical Changes (ACs) seen on Cone Beam Computer Tomography (CBCT) scans for the most common treatment sites. This involves alerting the Radiation Oncologist (RO), handing over findings, and RO providing the final decision, making it quite labour-intensive for the ROs as well as the Radiation Therapists (RTTs). A new approach was developed to act on ACs: the Take Action Protocol (TAP). In this protocol the RTTs do not only have a role in detecting ACs, but also decide on the appropriate action and follow up, resulting in a significant shift in responsibility. In this study we present the TAP and evaluated the benefit and outcomes of the implementation of TAP compared to the TLP. During a pilot period of six months the TAP was applied for 34 bladder and prostate patients. In 2 bladder and 6 prostate patients further decision making by an RO was required (compared to all 34 in the TLP), showing a large reduction in workload. ACs were accurately assessed by RTTs in >99% of the cases. In 5/34 patients RTTs specialized in Image Guided Radiotherapy provided additional instructions to improve accurate use of the TAP. Two surveys conducted by both ROs and RTTs on the TLP and TAP showed that the perceived involvement of the ROs and burden of responsibility for RTTs was comparable between the two protocols. The identification of patients with truly clinical relevant ACs and the adaptation of treatment for the remaining fractions improved according to ROs and RTTs responses. The TAP provides a better balance between workload and efficiency in relation to the clinical relevance of acting on ACs.
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844
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Matthews K, Duchesne G, Baird M. Navigating uncertainty: The implementation of Australian radiation therapy advanced practitioners. Tech Innov Patient Support Radiat Oncol 2021; 17:82-88. [PMID: 34007912 PMCID: PMC8110939 DOI: 10.1016/j.tipsro.2020.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/01/2020] [Accepted: 12/08/2020] [Indexed: 11/29/2022] Open
Abstract
The implementation of advanced practice for radiation therapists in Australia is limited. A constructivist grounded theory study identified the key processes influencing implementation. ‘Navigating uncertainty’ includes conceptual, practical, social and contextual features. A national strategy is required to overcome uncertainty and inform systematic implementation.
Radiation therapy advanced practice has been implemented in several international jurisdictions; however, it is yet to be systematically integrated into Australian radiation oncology centres. This paper presents the outcomes of a doctoral research study to explore the factors that may be influencing the implementation of radiation therapy advanced practice in Australia. Using a constructivist grounded theory methodological approach to guide procedures, data collection occurred via 6 nationally facilitated online (video mediated) focus groups, and during interviews and observations at 5 purposively selected clinical case study locations. Data analysis led to the development of a grounded theory ‘navigating uncertainty’ to describe the process influencing the implementation of radiation therapy advanced practice in Australia. Navigating uncertainty is explained by three inter-related contextual processes of conceptualising radiation therapy advanced practice, integrating radiation therapy advanced practice, and becoming the radiation therapy advanced practitioner. The research suggests that the process of actively finding a way to accommodate uncertainty is necessary for advanced practice implementation objectives to be realised.
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Affiliation(s)
- Kristie Matthews
- Department of Medical Imaging and Radiation Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia.,Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Gillian Duchesne
- Department of Medical Imaging and Radiation Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
| | - Marilyn Baird
- Department of Medical Imaging and Radiation Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
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845
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Speleers B, Schoepen M, Belosi F, Vakaet V, De Neve W, Deseyne P, Paelinck L, Vercauteren T, Parkes MJ, Lomax T, Van Greveling A, Bolsi A, Weber DC, Veldeman L, De Gersem W. Effects of deep inspiration breath hold on prone photon or proton irradiation of breast and regional lymph nodes. Sci Rep 2021; 11:6085. [PMID: 33727599 PMCID: PMC7966795 DOI: 10.1038/s41598-021-85401-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 02/23/2021] [Indexed: 12/14/2022] Open
Abstract
We report on a comparative dosimetrical study between deep inspiration breath hold (DIBH) and shallow breathing (SB) in prone crawl position for photon and proton radiotherapy of whole breast (WB) and locoregional lymph node regions, including the internal mammary chain (LN_MI). We investigate the dosimetrical effects of DIBH in prone crawl position on organs-at-risk for both photon and proton plans. For each modality, we further estimate the effects of lung and heart doses on the mortality risks of different risk profiles of patients. Thirty-one patients with invasive carcinoma of the left breast and pathologically confirmed positive lymph node status were included in this study. DIBH significantly decreased dose to heart for photon and proton radiotherapy. DIBH also decreased lung doses for photons, while increased lung doses were observed using protons because the retracting heart is displaced by low-density lung tissue. For other organs-at-risk, DIBH resulted in significant dose reductions using photons while minor differences in dose deposition between DIBH and SB were observed using protons. In patients with high risks for cardiac and lung cancer mortality, average thirty-year mortality rates from radiotherapy-related cardiac injury and lung cancer were estimated at 3.12% (photon DIBH), 4.03% (photon SB), 1.80% (proton DIBH) and 1.66% (proton SB). The radiation-related mortality risk could not outweigh the ~ 8% disease-specific survival benefit of WB + LN_MI radiotherapy in any of the assessed treatments.
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Affiliation(s)
- Bruno Speleers
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University, Radiotherapiepark, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
| | - Max Schoepen
- Department of Industrial Systems Engineering and Product Design, Faculty of Engineering and Architecture, Ghent University, Ghent, Belgium
| | | | - Vincent Vakaet
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University, Radiotherapiepark, Corneel Heymanslaan 10, 9000, Ghent, Belgium
- Department of Radiation Oncology, University Hospital Ghent, Ghent, Belgium
| | - Wilfried De Neve
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University, Radiotherapiepark, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Pieter Deseyne
- Department of Radiation Oncology, University Hospital Ghent, Ghent, Belgium
| | - Leen Paelinck
- Department of Radiation Oncology, University Hospital Ghent, Ghent, Belgium
| | - Tom Vercauteren
- Department of Radiation Oncology, University Hospital Ghent, Ghent, Belgium
| | - Michael J Parkes
- Academic Medical Centre (AMC), University of Amsterdam, Amsterdam, the Netherlands
| | - Tony Lomax
- Paul Scherrer Institut, Villigen, Switzerland
| | | | | | - Damien C Weber
- Paul Scherrer Institut, Villigen, Switzerland
- Radiation Oncology Department, University Hospital of Bern, Bern, Switzerland
- Radiation Oncology Department, University Hospital of Zurich, Zurich, Switzerland
| | - Liv Veldeman
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University, Radiotherapiepark, Corneel Heymanslaan 10, 9000, Ghent, Belgium
- Department of Radiation Oncology, University Hospital Ghent, Ghent, Belgium
| | - Werner De Gersem
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University, Radiotherapiepark, Corneel Heymanslaan 10, 9000, Ghent, Belgium
- Department of Radiation Oncology, University Hospital Ghent, Ghent, Belgium
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846
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Evaluation of the surface dose for total body irradiation (TBI) technique with parallel-opposed anterior posterior geometry. JOURNAL OF RADIOTHERAPY IN PRACTICE 2021. [DOI: 10.1017/s1460396921000121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Aim:
Total body irradiation (TBI) is an external radiotherapy technique in which the whole body including the superficial regions is required to receive the therapeutic dose. The purpose of this study is to evaluate the received surface dose during TBI technique.
Methods and materials:
The anterior/posterior (AP/PA) TBI was implemented with 18-MV photon beam at 312-cm treatment distance for human-like phantom. The GAFCHROMIC-EBT3 films were used for superficial dose measurements.
Results and discussion:
The percentage of surface-absorbed dose relative to the prescription point for 8 points of measurements was between 102·78–121·48% and 104·51–127·43% at 5 and 10 mm depth, respectively. In the chest wall region due to the presence of lung blocks, the absorbed dose was below the acceptable level, so an electron boost was required to increase the chest wall absorbed dose.
Conclusions:
According to the results, the implemented technique was able to deliver sufficient dose to the shallow surface of phantom’s body.
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847
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Alam SR, Li T, Zhang P, Zhang SY, Nadeem S. Generalizable cone beam CT esophagus segmentation using physics-based data augmentation. Phys Med Biol 2021; 66:065008. [PMID: 33535199 DOI: 10.1088/1361-6560/abe2eb] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Automated segmentation of the esophagus is critical in image-guided/adaptive radiotherapy of lung cancer to minimize radiation-induced toxicities such as acute esophagitis. We have developed a semantic physics-based data augmentation method for segmenting the esophagus in both planning CT (pCT) and cone beam CT (CBCT) using 3D convolutional neural networks. One hundred and ninety-one cases with their pCTs and CBCTs from four independent datasets were used to train a modified 3D U-Net architecture and a multi-objective loss function specifically designed for soft-tissue organs such as the esophagus. Scatter artifacts and noises were extracted from week-1 CBCTs using a power-law adaptive histogram equalization method and induced to the corresponding pCT were reconstructed using CBCT reconstruction parameters. Moreover, we leveraged physics-based artifact induction in pCTs to drive the esophagus segmentation in real weekly CBCTs. Segmentations were evaluated using the geometric Dice coefficient and Hausdorff distance as well as dosimetrically using mean esophagus dose and D 5cc. Due to the physics-based data augmentation, our model trained just on the synthetic CBCTs was robust and generalizable enough to also produce state-of-the-art results on the pCTs and CBCTs, achieving Dice overlaps of 0.81 and 0.74, respectively. It is concluded that our physics-based data augmentation spans the realistic noise/artifact spectrum across patient CBCT/pCT data and can generalize well across modalities, eventually improving the accuracy of treatment setup and response analysis.
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Affiliation(s)
- Sadegh R Alam
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
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848
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Tsang Y. Advanced practice in radiotherapy: How to move to the next level? Tech Innov Patient Support Radiat Oncol 2021; 17:57-58. [PMID: 34007907 PMCID: PMC8111034 DOI: 10.1016/j.tipsro.2021.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Yat Tsang
- Radiotherapy Department, Mount Vernon Cancer Centre, Northwood, Middlesex, United Kingdom
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849
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Vanneste BG, Van Limbergen EJ, Marcelissen T, Reynders K, Melenhorst J, van Roermund JG, Lutgens L. Is prostate cancer radiotherapy using implantable rectum spacers safe and effective in inflammatory bowel disease patients? Clin Transl Radiat Oncol 2021; 27:121-125. [PMID: 33604459 PMCID: PMC7875819 DOI: 10.1016/j.ctro.2021.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 01/11/2021] [Accepted: 01/13/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Prostate cancer radiotherapy (RT) in patients with (active) inflammatory bowel disease (IBD) remains controversial. We hypothesized that RT in combination with a biodegradable prostate-rectum spacer balloon implantation, might be a safe treatment approach with acceptable toxicities for these high risk for rectal toxicity patients. MATERIALS AND METHODS We report on a small prospective mono-centric series of 8 patients with all-risk prostate cancer with the comorbidity of an IBD. Four patients had Crohn's disease and 4 patients had ulcerative colitis. One out of four had an active status of IBD. All patients were intended to be treated with curative high-dose RT: 5 patients were treated with external beam RT (70 Gray (Gy) in 28 fractions), and 3 patients were treated with 125I-implant (145 Gy). Toxicities were scored according to the CTCAE v4.03: acute side effects occur up to 3 months after RT, and late side effects start after 3 months. RESULTS Median follow-up was 13 months (range: 3-42 months). Only one acute grade 2 gastro-intestinal (GI) toxicity was observed: an increased diarrhea (4-6 above baseline) during RT, which resolved completely 6 weeks after treatment. No late grade 3 or more GI toxicity was reported, and no acute and late grade ≥2 genitourinary toxicity events were observed. CONCLUSION Prostate cancer patients with IBD are a challenge to treat with RT. Our results suggest that RT in combination with a balloon implant in selective patients with (active) IBD may be promising, however additional validation is needed.
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Affiliation(s)
- Ben G.L. Vanneste
- Department of Radiation Oncology (MAASTRO), GROW – School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Evert J. Van Limbergen
- Department of Radiation Oncology (MAASTRO), GROW – School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Tom Marcelissen
- Department of Urology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Kobe Reynders
- Department of Radiation Oncology (MAASTRO), GROW – School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Jarno Melenhorst
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Joep G.H. van Roermund
- Department of Urology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Ludy Lutgens
- Department of Radiation Oncology (MAASTRO), GROW – School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, the Netherlands
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850
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Wong SM, Sin S, Lim L, Nurul Tassha B, Lin J, Melissa K, Koh W, Ho F, Quah DS, Sommat K, Tuan JK, Wong F, Ng W, Yeo RM, Soong Y, Wang ML. The implementation of an advanced practice radiation therapy (APRT) program in Singapore. Tech Innov Patient Support Radiat Oncol 2021; 17:63-70. [PMID: 34007909 PMCID: PMC8111035 DOI: 10.1016/j.tipsro.2021.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 02/01/2021] [Accepted: 02/01/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The exploration of Advanced Practiced Radiation Therapists (APRTs) development in Singapore started in 2011. This study aims to provide an overview of the development of the APRT roles, and to discuss the approaches used to develop and implement these roles in Singapore. MATERIALS AND METHODS A mixed methods approach was used in the development of the APRT program. A literature review was carried out to define the APRT scope of practice and core responsibilities. A competency and assessment framework were setup to assess the core competency areas. With this framework, a structured 1-year residency training program was developed. RESULTS The scope of practice and core responsibilities of APRTs were defined with five proposed advanced practice profiles being successfully validated. A competency framework was set up to assess the core competency domains: clinical, technical and professional competencies, research, education and leadership. A 4-point scoring system was developed for the competency assessment based on two criteria; the frequency with which RTTs would demonstrate competency, and the ability of performing the task competently. A 1-year structured APRT residency program was developed and implemented. The programme consisted of structured lectures, and clinical practice-based modules where APRT residents receive structured mentoring under a mentorship program. CONCLUSION The APRT program in Singapore employed an evidence-based implementation process that tested the feasibility of a new practice model. Multidisciplinary involvements, mentorship and clinical training were important factors for the success of the APRT program.
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Affiliation(s)
- Sharon M.M. Wong
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
- College of Allied Health-SingHealth Academy, Singapore
- Singapore Institute of Technology, Singapore
| | - S.Y. Sin
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - L.H. Lim
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | | | - Jeannie Lin
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - K. Melissa
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - W.Y. Koh
- Department of Radiation Oncology, National University Cancer Institute, Singapore
| | - Francis Ho
- Department of Radiation Oncology, National University Cancer Institute, Singapore
| | - Daniel S.C. Quah
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
- Duke-National University of Singapore, Graduate Medical School, Singapore
| | - Kiatissa Sommat
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
- Duke-National University of Singapore, Graduate Medical School, Singapore
| | - Jeffrey K.L. Tuan
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
- Duke-National University of Singapore, Graduate Medical School, Singapore
| | - F.Y. Wong
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
- Duke-National University of Singapore, Graduate Medical School, Singapore
| | - W.L. Ng
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
- Duke-National University of Singapore, Graduate Medical School, Singapore
| | - Richard M.C. Yeo
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
- Duke-National University of Singapore, Graduate Medical School, Singapore
| | - Y.L. Soong
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
- Duke-National University of Singapore, Graduate Medical School, Singapore
| | - Michael L.C. Wang
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
- Duke-National University of Singapore, Graduate Medical School, Singapore
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