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Briens A, Castelli J, Barateau A, Jaksic N, Gnep K, Simon A, De Crevoisier R. Radiothérapie adaptative : stratégies et bénéfices selon les localisations tumorales. Cancer Radiother 2019; 23:592-608. [DOI: 10.1016/j.canrad.2019.07.135] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 07/16/2019] [Indexed: 12/14/2022]
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52
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Pillai M, Adapa K, Das SK, Mazur L, Dooley J, Marks LB, Thompson RF, Chera BS. Using Artificial Intelligence to Improve the Quality and Safety of Radiation Therapy. J Am Coll Radiol 2019; 16:1267-1272. [DOI: 10.1016/j.jacr.2019.06.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 06/03/2019] [Indexed: 02/06/2023]
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Sun XS, Li XY, Chen QY, Tang LQ, Mai HQ. Future of Radiotherapy in Nasopharyngeal Carcinoma. Br J Radiol 2019; 92:20190209. [PMID: 31265322 DOI: 10.1259/bjr.20190209] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Nasopharyngeal carcinoma (NPC) is a malignancy with unique clinical biological profiles such as associated Epstein-Barr virus infection and high radiosensitivity. Radiotherapy has long been recognized as the mainstay for the treatment of NPC. However, the further efficacy brought by radical radiotherapy has reached the bottleneck in advanced patients, who are prone to develop recurrence and distant metastasis after treatment. The application of photon therapy makes it possible for radiation dose escalation in refractory cases and may provide second chance for recurrent patients with less unrecoverable tissue damage. The concept of adaptive radiotherapy is put forward in consideration of target volume shrinkage during treatment. The replanning procedure offers better protection for the organ at risk. However, the best timing and candidates for adaptive radiotherapy is still under debate. The current tendency of artificial intelligence in NPC mainly focuses on image recognition, auto-segmentation and dose prediction. Although artificial intelligence is still in developmental stage, the future of it is promising.To further improve the efficacy of NPC, multimodality treatment is encouraged. In-depth studies on genetic and epigenetic variations help to explain the great heterogeneity among patients, and could further be applied to precise screening and prediction, personalized radiotherapy and the evolution of targeted drugs. Given the clinical benefit of immunotherapy in other cancers, the application of immunotherapy, especially immune checkpoint inhibitor, in NPC is also of great potential. Results from ongoing clinical trials combining immunotherapy with radiotherapy in NPC are expected.
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Affiliation(s)
- Xue-Song Sun
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, P R China.,Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road East, Guangzhou, P R China
| | - Xiao-Yun Li
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, P R China.,Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road East, Guangzhou, P R China
| | - Qiu-Yan Chen
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, P R China.,Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road East, Guangzhou, P R China
| | - Lin-Quan Tang
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, P R China.,Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road East, Guangzhou, P R China
| | - Hai-Qiang Mai
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, P R China.,Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Road East, Guangzhou, P R China
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Head and Neck Cancer Adaptive Radiation Therapy (ART): Conceptual Considerations for the Informed Clinician. Semin Radiat Oncol 2019; 29:258-273. [PMID: 31027643 DOI: 10.1016/j.semradonc.2019.02.008] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
For nearly 2 decades, adaptive radiation therapy (ART) has been proposed as a method to account for changes in head and neck tumor and normal tissue to enhance therapeutic ratios. While technical advances in imaging, planning and delivery have allowed greater capacity for ART delivery, and a series of dosimetric explorations have consistently shown capacity for improvement, there remains a paucity of clinical trials demonstrating the utility of ART. Furthermore, while ad hoc implementation of head and neck ART is reported, systematic full-scale head and neck ART remains an as yet unreached reality. To some degree, this lack of scalability may be related to not only the complexity of ART, but also variability in the nomenclature and descriptions of what is encompassed by ART. Consequently, we present an overview of the history, current status, and recommendations for the future of ART, with an eye toward improving the clarity and description of head and neck ART for interested clinicians, noting practical considerations for implementation of an ART program or clinical trial. Process level considerations for ART are noted, reminding the reader that, paraphrasing the writer Elbert Hubbard, "Art is not a thing, it is a way."
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Green OL, Henke LE, Hugo GD. Practical Clinical Workflows for Online and Offline Adaptive Radiation Therapy. Semin Radiat Oncol 2019; 29:219-227. [PMID: 31027639 DOI: 10.1016/j.semradonc.2019.02.004] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Adaptive radiotherapy emerged over 20 years ago and is now an established clinical practice in a number of organ sites. No one solution for adaptive therapy exists. Rather, adaptive radiotherapy is a process which combines multiple tools for imaging, assessment of need for adaptation, treatment planning, and quality assurance of this process. Workflow is therefore a critical aspect to ensure safe, effective, and efficient implementation of adaptive radiotherapy. In this work, we discuss the tools for online and offline adaptive radiotherapy and introduce workflow concepts for these types of adaptive radiotherapy. Common themes and differences between the workflows are introduced and controversies and areas of active research are discussed.
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Affiliation(s)
- Olga L Green
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Lauren E Henke
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Geoffrey D Hugo
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO.
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Massaccesi M, Cusumano D, Boldrini L, Dinapoli N, Fionda B, Teodoli S, Azario L, Mattiucci GC, Balducci M, Cellini F, Valentini V. A new frontier of image guidance: Organs at risk avoidance with MRI-guided respiratory-gated intensity modulated radiotherapy: Technical note and report of a case. J Appl Clin Med Phys 2019; 20:194-198. [PMID: 31055870 PMCID: PMC6560311 DOI: 10.1002/acm2.12575] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 02/20/2019] [Accepted: 03/11/2019] [Indexed: 01/28/2023] Open
Abstract
The case of a 50‐year‐old man affected by a rhabdomiosarcoma metastatic lesion in the left flank Is reported. The patient was addressed to 50.4 Gy radiotherapy with concomitant chemotherapy in order to locally control the lesion. A Tri‐60‐Co magnetic resonance hybrid radiotherapy unit was used for treatment delivery and a respiratory gating protocol was applied for the different breathing phases (Free Breathing, Deep Inspiration Breath Hold and Final Expiration Breath Hold). Three intensity modulated radiation therapy (IMRT) plans were calculated and Final Expiration Breath Hold plan was finally selected due to the absence of PTV coverage differences and better organs at risk sparing (i.e. kidneys). This case report suggests that organs at risk avoidance with MRI‐guided respiratory‐gated Radiotherapy is feasible and particularly advantageous whenever sparing the organs at risk is of utmost dosimetric or clinical importance.
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Affiliation(s)
- Mariangela Massaccesi
- Dipartimento di Diagnostica per Immagini, UOC di Radioterapia Oncologica, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Davide Cusumano
- Dipartimento di Diagnostica per Immagini, UOC di Fisica Sanitaria, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy.,Istituto di Radiologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luca Boldrini
- Dipartimento di Diagnostica per Immagini, UOC di Radioterapia Oncologica, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy.,Istituto di Radiologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Nicola Dinapoli
- Dipartimento di Diagnostica per Immagini, UOC di Radioterapia Oncologica, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Bruno Fionda
- Dipartimento di Diagnostica per Immagini, UOC di Radioterapia Oncologica, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Stefania Teodoli
- Dipartimento di Diagnostica per Immagini, UOC di Fisica Sanitaria, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Luigi Azario
- Dipartimento di Diagnostica per Immagini, UOC di Fisica Sanitaria, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy.,Istituto di Fisica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gian Carlo Mattiucci
- Dipartimento di Diagnostica per Immagini, UOC di Radioterapia Oncologica, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy.,Istituto di Radiologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mario Balducci
- Dipartimento di Diagnostica per Immagini, UOC di Radioterapia Oncologica, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy.,Istituto di Radiologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Cellini
- Dipartimento di Diagnostica per Immagini, UOC di Radioterapia Oncologica, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Vincenzo Valentini
- Dipartimento di Diagnostica per Immagini, UOC di Radioterapia Oncologica, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy.,Istituto di Radiologia, Università Cattolica del Sacro Cuore, Rome, Italy
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Lowther NJ, Hamilton DA, Kim H, Evans JM, Marsh SH, Louwe RJ. Monitoring anatomical changes of individual patients using statistical process control during head-and-neck radiotherapy. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2018; 9:21-27. [PMID: 33458422 PMCID: PMC7807752 DOI: 10.1016/j.phro.2018.12.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 11/27/2018] [Accepted: 12/07/2018] [Indexed: 11/27/2022]
Abstract
EWMA trends from DIR data enabled timely detection of anatomical changes. The majority of the systematic trends occurred before the 4th week of treatment. Using SPC control limits, only 24% of patient positioning trends could be confirmed. Using a 2 mm threshold, 82% of patient positioning trends could be confirmed. Using SPC control limits, 90% of the soft tissue changes could be confirmed.
Background and purpose Reduced toxicity while maintaining loco-regional control rates have been reported after reducing planning target volume (PTV) margins for head-and-neck radiotherapy (HNRT). In this context, quantifying anatomical changes to monitor patient treatment is preferred. This retrospective feasibility study investigated the application of deformable image registration (DIR) and Exponentially Weighted Moving Average (EWMA) Statistical Process Control (SPC) charts for this purpose. Materials and methods DIR between the computed tomography for treatment planning (pCT) images of twelve patients and their daily on-treatment cone beam computed tomography (CBCT) images quantified anatomical changes during treatment. EWMA charts investigated corresponding trends. Uncertainty analysis provided 90% confidence limits which were used to confirm whether a trend previously breached a threshold. Results Trends in patient positioning reproducibility occurred before the end of treatment week four in 54% of cases. Using SPC process limits, only 24% of these were confirmed at a 90% confidence level before the end of treatment. Using an a priori clinical limit of 2 mm, absolute changes in patient pose were detected in 39% of cases, of which 82% were confirmed. Soft tissue trends outside SPC process limits occurring before the end of treatment week four were confirmed in 90% of cases. Conclusion Structure specific action thresholds enabled detection of systematic anatomical changes during the first four weeks of treatment. Investigation of the dosimetric impact of the observed deviations is needed to show the efficacy of SPC to timely indicate required treatment adaptation and provide a safety net for PTV margin reduction.
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Affiliation(s)
- Nicholas J. Lowther
- Wellington Blood and Cancer Centre, Department of Radiation Oncology, Wellington, New Zealand
- University of Canterbury, School of Physical and Chemical Sciences, Christchurch, New Zealand
| | - David A. Hamilton
- Wellington Blood and Cancer Centre, Department of Radiation Oncology, Wellington, New Zealand
| | - Han Kim
- Wellington Blood and Cancer Centre, Department of Radiation Oncology, Wellington, New Zealand
| | - Jamie M. Evans
- Wellington Blood and Cancer Centre, Department of Radiation Oncology, Wellington, New Zealand
| | - Steven H. Marsh
- University of Canterbury, School of Physical and Chemical Sciences, Christchurch, New Zealand
| | - Robert J.W. Louwe
- Wellington Blood and Cancer Centre, Department of Radiation Oncology, Wellington, New Zealand
- Corresponding author.
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58
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Hu YC, Tsai KW, Lee CC, Peng NJ, Chien JC, Tseng HH, Chen PC, Lin JC, Liu WS. Which nasopharyngeal cancer patients need adaptive radiotherapy? BMC Cancer 2018; 18:1234. [PMID: 30526538 PMCID: PMC6288867 DOI: 10.1186/s12885-018-5159-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 11/29/2018] [Indexed: 11/16/2022] Open
Abstract
Background Adaptive radiotherapy (ART) has potential benefits in patients with nasopharyngeal cancer (NPC). This retrospective study aimed to identify the factors favoring ART. Materials and methods Forty NPC patients were retrospectively included in this study. All patients received two-phase, volumetric modulated arc radiotherapy (VMAT) and underwent a second computed tomography (CT) for the phase II ART. We generated phantom, non-ART plans by a hybrid method for comparison with ART plans. A paired t-test was used to evaluate the dose differences between these two plans. A subgroup analysis through a paired t-test was used to evaluate the factors favoring ART. Results The second CT images were captured at the median 22 fractions. The median total dose of the planning target volume-one (PTV-1) was 72 Gy, and the phase II dose was 16 Gy. The volumes of the ipsilateral parotid gland (23.2 vs. 19.2 ml, p < 0.000), contralateral parotid gland (23.0 vs. 18.4 ml, p < 0.000), clinical target volume-1 (CTV-1, 32.2 vs. 20.9 ml, p < 0.000), and PTV-1 (125.8 vs. 107.3 ml, p < 0.000) all shrunk significantly between these two CT simulation procedures. Among the nearby critical organs, only the ipsilateral parotid gland displayed significant dose reduction by the ART plan (5.3 vs. 6.0 Gy, p = 0.004). Compared to the phantom plan, the ART could significantly improve the PTV-1 target volume coverage of D98 (15.4 vs. 12.3 Gy, p < 0.000). Based on the D98 of PTV-1, the factors of a large initial weight (> 60 kg, p < 0.000), large body mass index (BMI) (> 21.5, p < 0.000), obvious weight loss (> 2.8 kg, p < 0.000), concurrent chemoradiotherapy (p < 0.000), and stages III–IV (p < 0.000) favored the use of ART. Conclusions ART could significantly reduce the mean dose to the ipsilateral parotid gland. ART has dosimetrical benefit for patients with a heavy initial weight, large BMI, obvious weight loss, concurrent chemoradiotherapy, and cancer in stages III–IV.
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Affiliation(s)
- Yu-Chang Hu
- Department of Radiation Oncology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Kuo-Wang Tsai
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Department of Chemical Biology, National Pingtung University of Education, Pingtung, Taiwan
| | - Ching-Chih Lee
- School of Medicine, National Defense Medical Center, Taipei, Taiwan.,Department of ENT, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Nan-Jing Peng
- School of Medicine, National Defense Medical Center, Taipei, Taiwan.,Department of Nuclear Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Ju-Chun Chien
- Department of Radiation Oncology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Hsin-Hui Tseng
- Department of Radiation Oncology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Po-Chun Chen
- Department of Radiation oncology, Pingtung Christian Hospital, Pingtung, Taiwan.,Graduate Institute of Bioresources, National Pingtung University of Science and Technology, Pingtung, Taiwan
| | - Jin-Ching Lin
- Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wen-Shan Liu
- Department of Radiation Oncology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan. .,School of Medicine, National Defense Medical Center, Taipei, Taiwan.
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Routine Adaptive Replanning of p16-Positive Stage N2b Oropharyngeal Cancer: Quality Improvement or Waste of Time? Am J Clin Oncol 2018; 41:1211-1215. [PMID: 29727312 DOI: 10.1097/coc.0000000000000453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE/OBJECTIVE(S) To determine if routinely replanning patients treated for oropharyngeal cancer that is p16-positive and clinical neck stage N2b (AJCC 7th edition) is likely to result in dose changes that will improve patient outcomes to a meaningful degree. METHODS In 10 consecutive patients treated with primary radiotherapy (RT) and concurrent weekly chemotherapy for p16-positive N2b oropharyngeal carcinoma, we prospectively evaluated dose changes from replanning for the final 4 or 2 weeks of RT of a 7-week RT program. RESULTS Replanning for the final 4 or 2 weeks improved planning target volume coverage by an average of 4 and 2 percentage points, respectively. For all normal structures, the dose change was small (<1 Gy) with replanning. CONCLUSIONS In patients with p16-positive N2b oropharynx cancer, the value of replanning RT is a small improvement in target coverage with minimal improvement in normal tissue sparing. In response to our study, some of the physicians in our group replan most node-positive oropharyngeal cancer cases while others think routine replanning is not valuable.
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Zou W, Dong L, Kevin Teo BK. Current State of Image Guidance in Radiation Oncology: Implications for PTV Margin Expansion and Adaptive Therapy. Semin Radiat Oncol 2018; 28:238-247. [PMID: 29933883 DOI: 10.1016/j.semradonc.2018.02.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Image guidance technology has evolved and seen widespread application in the past several decades. Advancements in the diagnostic imaging field have found new applications in radiation oncology and promoted the development of therapeutic devices with advanced imaging capabilities. A recent example is the development of linear accelerators that offer magnetic resonance imaging for real-time imaging and online adaptive planning. Volumetric imaging, in particular, offers more precise localization of soft tissue targets and critical organs which reduces setup uncertainty and permit the use of smaller setup margins. We present a review of the status of current imaging modalities available for radiation oncology and its impact on target margins and use for adaptive therapy.
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Affiliation(s)
- Wei Zou
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA.
| | - Lei Dong
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Boon-Keng Kevin Teo
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
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61
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A prospective study of weekly intensity modulated radiation therapy plan adaptation for head and neck cancer: improved target coverage and organ at risk sparing. AUSTRALASIAN PHYSICAL & ENGINEERING SCIENCES IN MEDICINE 2018; 42:43-51. [PMID: 30406923 DOI: 10.1007/s13246-018-0707-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 10/30/2018] [Indexed: 10/27/2022]
Abstract
This prospective study of weekly CT scanning and plan adaption during H&N IMRT reports on the frequency of plan adaptations based on dosimetric differences between original and re-optimised IMRT plans. The volumetric and geometric change occurring in target volumes and salivary glands is also described. Ten H&N cancer patients underwent weekly planning CT imaging and re-optimisation of the IMRT plan if PTV or OAR coverage was unacceptable. Comparisons of PTV and parotid gland dosimetry between the original and adaptive plans were made. Parotid and submandibular gland volume changes and shift were calculated. Eight of ten patients required one or more plan adaptations, with 41% of adaptations occurring by fraction ten. Salivary glands reduced in volume, with a medial shift of the lateral border of the parotid gland and a superior shift of the submandibular gland. Change in PTV coverage did not correlate with weight loss or nutritional score. Inadequate PTV coverage, requiring plan adaptation, occurs early in the course of IMRT. A weekly Adaptive RT (ART) protocol results in significant improvement of PTV coverage. Implementation of a clinical ART protocol should include imaging and dose calculation within the first ten fractions.
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Gensheimer MF, Le QT. Adaptive radiotherapy for head and neck cancer: Are we ready to put it into routine clinical practice? Oral Oncol 2018; 86:19-24. [DOI: 10.1016/j.oraloncology.2018.08.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 08/17/2018] [Indexed: 12/27/2022]
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63
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Castelli J, Simon A, Lafond C, Perichon N, Rigaud B, Chajon E, De Bari B, Ozsahin M, Bourhis J, de Crevoisier R. Adaptive radiotherapy for head and neck cancer. Acta Oncol 2018; 57:1284-1292. [PMID: 30289291 DOI: 10.1080/0284186x.2018.1505053] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Large anatomical variations can be observed during the treatment course intensity-modulated radiotherapy (IMRT) for head and neck cancer (HNC), leading to potential dose variations. Adaptive radiotherapy (ART) uses one or several replanning sessions to correct these variations and thus optimize the delivered dose distribution to the daily anatomy of the patient. This review, which is focused on ART in the HNC, aims to identify the various strategies of ART and to estimate the dosimetric and clinical benefits of these strategies. MATERIAL AND METHODS We performed an electronic search of articles published in PubMed/MEDLINE and Science Direct from January 2005 to December 2016. Among a total of 134 articles assessed for eligibility, 29 articles were ultimately retained for the review. Eighteen studies evaluated dosimetric variations without ART, and 11 studies reported the benefits of ART. RESULTS Eight in silico studies tested a number of replanning sessions, ranging from 1 to 6, aiming primarily to reduce the dose to the parotid glands. The optimal timing for replanning appears to be early during the first two weeks of treatment. Compared to standard IMRT, ART decreases the mean dose to the parotid gland from 0.6 to 6 Gy and the maximum dose to the spinal cord from 0.1 to 4 Gy while improving target coverage and homogeneity in most studies. Only five studies reported the clinical results of ART, and three of those studies included a non-randomized comparison with standard IMRT. These studies suggest a benefit of ART in regard to decreasing xerostomia, increasing quality of life, and increasing local control. Patients with the largest early anatomical and dose variations are the best candidates for ART. CONCLUSION ART may decrease toxicity and improve local control for locally advanced HNC. However, randomized trials are necessary to demonstrate the benefit of ART before using the technique in routine practice.
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Affiliation(s)
- J. Castelli
- Radiotherapy Department, Centre Eugene Marquis, Rennes, France
- INSERM U1099 LTSI, Rennes, France
- Université de Rennes 1, Rennes, France
| | - A. Simon
- INSERM U1099 LTSI, Rennes, France
- Université de Rennes 1, Rennes, France
| | - C. Lafond
- Radiotherapy Department, Centre Eugene Marquis, Rennes, France
- INSERM U1099 LTSI, Rennes, France
- Université de Rennes 1, Rennes, France
| | - N. Perichon
- Radiotherapy Department, Centre Eugene Marquis, Rennes, France
| | - B. Rigaud
- INSERM U1099 LTSI, Rennes, France
- Université de Rennes 1, Rennes, France
| | - E. Chajon
- Radiotherapy Department, Centre Eugene Marquis, Rennes, France
| | - B. De Bari
- Radiotherapy Department, CHU Jean-Minjoz, Besançon, France
| | - M. Ozsahin
- Radiotherapy Department, Lausanne University Hospital, Lausanne, Switzerland
| | - J. Bourhis
- Radiotherapy Department, Lausanne University Hospital, Lausanne, Switzerland
| | - R. de Crevoisier
- Radiotherapy Department, Centre Eugene Marquis, Rennes, France
- INSERM U1099 LTSI, Rennes, France
- Université de Rennes 1, Rennes, France
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Giambattista J, McVicar N, Hamilton S, Martin M, Maas B, Ho C, Wu J, Tran E, Hay J, Berthelet E. Magnetic Resonance Imaging Volumetry of Primary Nasopharyngeal Cancer in Patients Treated with Induction Gemcitabine and Cisplatin Followed by Concurrent Cisplatin and Volumetric Modulated Arc Therapy. Cureus 2018; 10:e3296. [PMID: 30443466 PMCID: PMC6235650 DOI: 10.7759/cureus.3296] [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] [Indexed: 11/24/2022] Open
Abstract
Introduction The addition of induction chemotherapy (IC) to the standard concurrent chemoradiotherapy (CCRT) is under consideration in locally advanced nasopharyngeal carcinoma (LANPC). To-date, no studies have reported primary gross tumour volume (GTVp) changes using gemcitabine and cisplatin as the IC phase in LANPC. We investigated the timing and magnitude of GTVp response throughout sequential gemcitabine and cisplatin IC and CCRT for LANPC. Toxicity and tumour control probability (TCP) analyses are also presented Methods Ten patients with LANPC underwent sequential IC and CCRT between 2011 and 2015. All patients had magnetic resonance imaging (MRI) at three time points: before IC (MRI0), after IC (MRI1), and three months after CCRT (MRI3). Five of the 10 patients had an additional MRI four to five weeks into CCRT (MRI2). GTVp contours were delineated retrospectively using contrast-enhanced MRIs, and each GTVp underwent secondary review by a neuroradiologist. Acute toxicities were graded retrospectively via chart review based on the National Cancer Institute Common Terminology for Adverse Events version 4.0 (NCI CTCAE v4.0). Results Mean GTVp reduction between MRI0 - MRI1 was from 68 cc to 47 cc and from 47 cc to 9 cc between MRI1 - MRI3. In patients with MRI2, the mean GTVp reduction between MRI1 - MRI2 was from 57 cc to 32 cc. Tumour control probability estimates increased by 0.11 after IC. Patients tolerated the treatment well with one Grade IV toxicity event. Conclusion The observed GTVp response and improved tumor control probability support further investigation into the use of IC in LANPC.
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Affiliation(s)
- Joshua Giambattista
- Radiation Oncology, British Columbia Cancer, Vancouver Cancer Centre, Vancouver, CAN
| | - Nevin McVicar
- Medical Physics, British Columbia Cancer, Vancouver Cancer Centre, Vancouver, CAN
| | - Sarah Hamilton
- Radiation Oncology, British Columbia Cancer, Vancouver Cancer Centre, Vancouver, CAN
| | - Montgomery Martin
- Radiology, British Columbia Cancer, Vancouver Cancer Centre, Vancouver, CAN
| | - Benjamin Maas
- Radiation Oncology, British Columbia Cancer, Vancouver Cancer Centre, Vancouver, CAN
| | - Cheryl Ho
- Medical Oncology, British Columbia Cancer, Vancouver Cancer Centre, Vancouver, CAN
| | - Jonn Wu
- Radiation Oncology, British Columbia Cancer, Vancouver Cancer Centre, Vancouver, CAN
| | - Eric Tran
- Radiation Oncology, British Columbia Cancer, Vancouver Cancer Centre, Vancouver, CAN
| | - John Hay
- Radiation Oncology, British Columbia Cancer, Vancouver Cancer Centre, Vancouver, CAN
| | - Eric Berthelet
- Radiation Oncology, British Columbia Cancer, Vancouver Cancer Centre, Vancouver, CAN
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65
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Weppler S, Quon H, Banerjee R, Schinkel C, Smith W. Framework for the quantitative assessment of adaptive radiation therapy protocols. J Appl Clin Med Phys 2018; 19:26-34. [PMID: 30160025 PMCID: PMC6236815 DOI: 10.1002/acm2.12437] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 06/29/2018] [Accepted: 07/03/2018] [Indexed: 11/30/2022] Open
Abstract
Background Adaptive radiation therapy (ART) “flags,” such as change in external body contour or relative weight loss, are widely used to identify which head and neck cancer (HNC) patients may benefit from replanned treatment. Despite the popularity of ART, few published quantitative approaches verify the accuracy of replan candidate identification, especially with regards to the simple flagging approaches that are considered current standard of practice. We propose a quantitative evaluation framework, demonstrated through the assessment of a single institution's clinical ART flag: change in body contour exceeding 1.5 cm. Methods Ground truth replan criteria were established by surveying HNC radiation oncologists. Patient‐specific dose deviations were approximated by using weekly acquired CBCT images to deform copies of the CT simulation, yielding during treatment “synthetic CTs.” The original plan reapplied to the synthetic CTs estimated interfractional dose deposition and truth table analysis compared ground truth flagging with the clinical ART metric. This process was demonstrated by assessing flagged fractions for 15 HNC patients whose body contour changed by >1.5 cm at some point in their treatment. Results Survey results indicated that geometric shifts of high‐dose volumes relative to image‐guided radiation therapy alignment of bony anatomy were of most interest to HNC physicians. This evaluation framework successfully identified a fundamental discrepancy between the “truth” criteria and the body contour flagging protocol selected to identify changes in central axis dose. The body contour flag had poor sensitivity to survey‐derived major violation criteria (0%–28%). The sensitivity of a random sample for comparable violation/flagging frequencies was 27%. Conclusions These results indicate that centers should establish ground truth replan criteria to assess current standard of practice ART protocols. In addition, more effective replan flags may be tested and identified according to the proposed framework. Such improvements in ART flagging may contribute to better clinical resource allocation and patient outcome.
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Affiliation(s)
- Sarah Weppler
- Department of Physics and Astronomy, University of Calgary, Calgary, AB, Canada.,Department of Medical Physics, Tom Baker Cancer Centre, Calgary, AB, Canada
| | - Harvey Quon
- Department of Radiation Oncology, Tom Baker Cancer Centre, Calgary, AB, Canada.,Department of Oncology, University of Calgary, Calgary, AB, Canada
| | - Robyn Banerjee
- Department of Radiation Oncology, Tom Baker Cancer Centre, Calgary, AB, Canada.,Department of Oncology, University of Calgary, Calgary, AB, Canada
| | - Colleen Schinkel
- Department of Physics and Astronomy, University of Calgary, Calgary, AB, Canada.,Department of Medical Physics, Tom Baker Cancer Centre, Calgary, AB, Canada.,Department of Oncology, University of Calgary, Calgary, AB, Canada
| | - Wendy Smith
- Department of Physics and Astronomy, University of Calgary, Calgary, AB, Canada.,Department of Medical Physics, Tom Baker Cancer Centre, Calgary, AB, Canada.,Department of Oncology, University of Calgary, Calgary, AB, Canada
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66
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Noble DJ, Yeap PL, Seah SYK, Harrison K, Shelley LEA, Romanchikova M, Bates AM, Zheng Y, Barnett GC, Benson RJ, Jefferies SJ, Thomas SJ, Jena R, Burnet NG. Anatomical change during radiotherapy for head and neck cancer, and its effect on delivered dose to the spinal cord. Radiother Oncol 2018; 130:32-38. [PMID: 30049455 PMCID: PMC6358720 DOI: 10.1016/j.radonc.2018.07.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 06/14/2018] [Accepted: 07/07/2018] [Indexed: 12/12/2022]
Abstract
A cohort of 133 head & neck cancer patients treated with TomoTherapy was examined. Differences between planned and delivered maximum spinal cord dose were small. Substantial weight loss and anatomical change during treatment was observed. No link between weight loss or anatomical change, and dose differences was seen.
Background and purpose The impact of weight loss and anatomical change during head and neck (H&N) radiotherapy on spinal cord dosimetry is poorly understood, limiting evidence-based adaptive management strategies. Materials and methods 133 H&N patients treated with daily mega-voltage CT image-guidance (MVCT-IG) on TomoTherapy, were selected. Elastix software was used to deform planning scan SC contours to MVCT-IG scans, and accumulate dose. Planned (DP) and delivered (DA) spinal cord D2% (SCD2%) were compared. Univariate relationships between neck irradiation strategy (unilateral vs bilateral), T-stage, N-stage, weight loss, and changes in lateral separation (LND) and CT slice surface area (SSA) at C1 and the superior thyroid notch (TN), and ΔSCD2% [(DA – DP) D2%] were examined. Results The mean value for (DA – DP) D2% was −0.07 Gy (95%CI −0.28 to 0.14, range −5.7 Gy to 3.8 Gy), and the mean absolute difference between DP and DA (independent of difference direction) was 0.9 Gy (95%CI 0.76–1.04 Gy). Neck treatment strategy (p = 0.39) and T-stage (p = 0.56) did not affect ΔSCD2%. Borderline significance (p = 0.09) was seen for higher N-stage (N2-3) and higher ΔSCD2%. Mean reductions in anatomical metrics were substantial: weight loss 6.8 kg; C1LND 12.9 mm; C1SSA 12.1 cm2; TNLND 5.3 mm; TNSSA 11.2 cm2, but no relationship between weight loss or anatomical change and ΔSCD2% was observed (all r2 < 0.1). Conclusions Differences between delivered and planned spinal cord D2% are small in patients treated with daily IG. Even patients experiencing substantial weight loss or anatomical change during treatment do not require adaptive replanning for spinal cord safety.
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Affiliation(s)
- David J Noble
- Cancer Research UK VoxTox Research Group, University of Cambridge Department of Oncology, Cambridge Biomedical Campus, Addenbrooke's Hospital, UK; Oncology Centre, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, UK.
| | - Ping-Lin Yeap
- Cancer Research UK VoxTox Research Group, University of Cambridge Department of Oncology, Cambridge Biomedical Campus, Addenbrooke's Hospital, UK; Cavendish Laboratory, University of Cambridge, UK
| | - Shannon Y K Seah
- Cancer Research UK VoxTox Research Group, University of Cambridge Department of Oncology, Cambridge Biomedical Campus, Addenbrooke's Hospital, UK; Cavendish Laboratory, University of Cambridge, UK
| | - Karl Harrison
- Cancer Research UK VoxTox Research Group, University of Cambridge Department of Oncology, Cambridge Biomedical Campus, Addenbrooke's Hospital, UK; Cavendish Laboratory, University of Cambridge, UK
| | - Leila E A Shelley
- Cancer Research UK VoxTox Research Group, University of Cambridge Department of Oncology, Cambridge Biomedical Campus, Addenbrooke's Hospital, UK; Department of Engineering, University of Cambridge, UK; Department of Medical Physics and Clinical Engineering, Addenbrooke's Hospital, Cambridge, UK
| | - Marina Romanchikova
- Cancer Research UK VoxTox Research Group, University of Cambridge Department of Oncology, Cambridge Biomedical Campus, Addenbrooke's Hospital, UK; Department of Medical Physics and Clinical Engineering, Addenbrooke's Hospital, Cambridge, UK
| | - Amy M Bates
- Cancer Research UK VoxTox Research Group, University of Cambridge Department of Oncology, Cambridge Biomedical Campus, Addenbrooke's Hospital, UK; Cambridge Clinical Trials Unit, Box 401, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, UK
| | - Yaolin Zheng
- University of Cambridge School of Clinical Medicine, UK; Department of Medicine, Cheltenham General Hospital, UK
| | - Gillian C Barnett
- Cancer Research UK VoxTox Research Group, University of Cambridge Department of Oncology, Cambridge Biomedical Campus, Addenbrooke's Hospital, UK; Oncology Centre, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, UK
| | - Richard J Benson
- Oncology Centre, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, UK
| | - Sarah J Jefferies
- Oncology Centre, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, UK
| | - Simon J Thomas
- Cancer Research UK VoxTox Research Group, University of Cambridge Department of Oncology, Cambridge Biomedical Campus, Addenbrooke's Hospital, UK; Department of Medical Physics and Clinical Engineering, Addenbrooke's Hospital, Cambridge, UK
| | - Raj Jena
- Cancer Research UK VoxTox Research Group, University of Cambridge Department of Oncology, Cambridge Biomedical Campus, Addenbrooke's Hospital, UK; Oncology Centre, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, UK
| | - Neil G Burnet
- University of Manchester, Manchester Academic Health Science Centre and The Christie NHS Foundation Trust, Manchester, UK
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Thompson RF, Valdes G, Fuller CD, Carpenter CM, Morin O, Aneja S, Lindsay WD, Aerts HJWL, Agrimson B, Deville C, Rosenthal SA, Yu JB, Thomas CR. Artificial intelligence in radiation oncology: A specialty-wide disruptive transformation? Radiother Oncol 2018; 129:421-426. [PMID: 29907338 DOI: 10.1016/j.radonc.2018.05.030] [Citation(s) in RCA: 131] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 05/29/2018] [Accepted: 05/30/2018] [Indexed: 12/16/2022]
Abstract
Artificial intelligence (AI) is emerging as a technology with the power to transform established industries, and with applications from automated manufacturing to advertising and facial recognition to fully autonomous transportation. Advances in each of these domains have led some to call AI the "fourth" industrial revolution [1]. In healthcare, AI is emerging as both a productive and disruptive force across many disciplines. This is perhaps most evident in Diagnostic Radiology and Pathology, specialties largely built around the processing and complex interpretation of medical images, where the role of AI is increasingly seen as both a boon and a threat. In Radiation Oncology as well, AI seems poised to reshape the specialty in significant ways, though the impact of AI has been relatively limited at present, and may rightly seem more distant to many, given the predominantly interpersonal and complex interventional nature of the specialty. In this overview, we will explore the current state and anticipated future impact of AI on Radiation Oncology, in detail, focusing on key topics from multiple stakeholder perspectives, as well as the role our specialty may play in helping to shape the future of AI within the larger spectrum of medicine.
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Affiliation(s)
- Reid F Thompson
- Oregon Health & Science University, Portland, USA; VA Portland Health Care System, Portland, USA.
| | - Gilmer Valdes
- University of California San Francisco, San Francisco, USA
| | | | | | - Olivier Morin
- University of California San Francisco, San Francisco, USA
| | | | | | - Hugo J W L Aerts
- Brigham and Women's Hospital, Boston, USA; Dana Farber Cancer Institute, Boston, USA
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68
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Zhang L, Wang Z, Shi C, Long T, Xu XG. The impact of robustness of deformable image registration on contour propagation and dose accumulation for head and neck adaptive radiotherapy. J Appl Clin Med Phys 2018; 19:185-194. [PMID: 29851267 PMCID: PMC6036371 DOI: 10.1002/acm2.12361] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 04/13/2018] [Accepted: 04/21/2018] [Indexed: 12/03/2022] Open
Abstract
Deformable image registration (DIR) is the key process for contour propagation and dose accumulation in adaptive radiation therapy (ART). However, currently, ART suffers from a lack of understanding of “robustness” of the process involving the image contour based on DIR and subsequent dose variations caused by algorithm itself and the presetting parameters. The purpose of this research is to evaluate the DIR caused variations for contour propagation and dose accumulation during ART using the RayStation treatment planning system. Ten head and neck cancer patients were selected for retrospective studies. Contours were performed by a single radiation oncologist and new treatment plans were generated on the weekly CT scans for all patients. For each DIR process, four deformation vector fields (DVFs) were generated to propagate contours and accumulate weekly dose by the following algorithms: (a) ANACONDA with simple presetting parameters, (b) ANACONDA with detailed presetting parameters, (c) MORFEUS with simple presetting parameters, and (d) MORFEUS with detailed presetting parameters. The geometric evaluation considered DICE coefficient and Hausdorff distance. The dosimetric evaluation included D95, Dmax, Dmean, Dmin, and Homogeneity Index. For geometric evaluation, the DICE coefficient variations of the GTV were found to be 0.78 ± 0.11, 0.96 ± 0.02, 0.64 ± 0.15, and 0.91 ± 0.03 for simple ANACONDA, detailed ANACONDA, simple MORFEUS, and detailed MORFEUS, respectively. For dosimetric evaluation, the corresponding Homogeneity Index variations were found to be 0.137 ± 0.115, 0.006 ± 0.032, 0.197 ± 0.096, and 0.006 ± 0.033, respectively. The coherent geometric and dosimetric variations also consisted in large organs and small organs. Overall, the results demonstrated that the contour propagation and dose accumulation in clinical ART were influenced by the DIR algorithm, and to a greater extent by the presetting parameters. A quality assurance procedure should be established for the proper use of a commercial DIR for adaptive radiation therapy.
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Affiliation(s)
- Lian Zhang
- Center of Radiological Medical Physics, University of Science and Technology of China, Hefei, Anhui Province, China
| | - Zhi Wang
- Center of Radiological Medical Physics, University of Science and Technology of China, Hefei, Anhui Province, China.,Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China
| | - Chengyu Shi
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Tengfei Long
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China
| | - X George Xu
- Center of Radiological Medical Physics, University of Science and Technology of China, Hefei, Anhui Province, China.,Nuclear Engineering Program, Rensselaer Polytechnic Institute, Troy, NY, USA
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69
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Zhang J, Chen Y, Chen Y, Wang C, Cai J, Chu K, Jin J, Ge Y, Huang X, Guan Y, Li W. A Noninvasive Body Setup Method for Radiotherapy by Using a Multimodal Image Fusion Technique. Technol Cancer Res Treat 2018; 16:1187-1193. [PMID: 29333959 PMCID: PMC5762088 DOI: 10.1177/1533034617740302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Purpose: To minimize the mismatch error between patient surface and immobilization system for tumor location by a noninvasive patient setup method. Materials and Methods: The method, based on a point set registration, proposes a shift for patient positioning by integrating information of the computed tomography scans and that of optical surface landmarks. An evaluation of the method included 3 areas: (1) a validation on a phantom by estimating 100 known mismatch errors between patient surface and immobilization system. (2) Five patients with pelvic tumors were considered. The tumor location errors of the method were measured using the difference between the proposal shift of cone-beam computed tomography and that of our method. (3) The collected setup data from the evaluation of patients were compared with the published performance data of other 2 similar systems. Results: The phantom verification results showed that the method was capable of estimating mismatch error between patient surface and immobilization system in a precision of <0.22 mm. For the pelvic tumor, the method had an average tumor location error of 1.303, 2.602, and 1.684 mm in left–right, anterior–posterior, and superior–inferior directions, respectively. The performance comparison with other 2 similar systems suggested that the method had a better positioning accuracy for pelvic tumor location. Conclusion: By effectively decreasing an interfraction uncertainty source (mismatch error between patient surface and immobilization system) in radiotherapy, the method can improve patient positioning precision for pelvic tumor.
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Affiliation(s)
- Jie Zhang
- 1 Department of Biomedical Engineering, School of Electronic Science and Engineering, Nanjing University, Nanjing, China
| | - Ying Chen
- 1 Department of Biomedical Engineering, School of Electronic Science and Engineering, Nanjing University, Nanjing, China
| | - Yunxia Chen
- 1 Department of Biomedical Engineering, School of Electronic Science and Engineering, Nanjing University, Nanjing, China
| | - Chenchen Wang
- 1 Department of Biomedical Engineering, School of Electronic Science and Engineering, Nanjing University, Nanjing, China
| | - Jing Cai
- 2 Department of Radiotherapy, Nantong Tumor Hospital, Nantong, China
| | - Kaiyue Chu
- 2 Department of Radiotherapy, Nantong Tumor Hospital, Nantong, China
| | - Jianhua Jin
- 2 Department of Radiotherapy, Nantong Tumor Hospital, Nantong, China
| | - Yun Ge
- 1 Department of Biomedical Engineering, School of Electronic Science and Engineering, Nanjing University, Nanjing, China
| | - Xiaolin Huang
- 1 Department of Biomedical Engineering, School of Electronic Science and Engineering, Nanjing University, Nanjing, China
| | - Yue Guan
- 1 Department of Biomedical Engineering, School of Electronic Science and Engineering, Nanjing University, Nanjing, China
| | - Weifeng Li
- 1 Department of Biomedical Engineering, School of Electronic Science and Engineering, Nanjing University, Nanjing, China
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Hawkins PG, Kadam AS, Jackson WC, Eisbruch A. Organ-Sparing in Radiotherapy for Head-and-Neck Cancer: Improving Quality of Life. Semin Radiat Oncol 2018; 28:46-52. [DOI: 10.1016/j.semradonc.2017.08.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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71
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Chen AM, Yoshizaki T, Hsu S, Mikaeilian A, Cao M. Image-guided adaptive radiotherapy improves acute toxicity during intensity-modulated radiation therapy for head and neck cancer. ACTA ACUST UNITED AC 2017. [DOI: 10.1007/s13566-017-0336-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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72
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Stützer K, Jakobi A, Bandurska-Luque A, Barczyk S, Arnsmeyer C, Löck S, Richter C. Potential proton and photon dose degradation in advanced head and neck cancer patients by intratherapy changes. J Appl Clin Med Phys 2017; 18:104-113. [PMID: 28921843 PMCID: PMC5689930 DOI: 10.1002/acm2.12189] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 07/28/2017] [Accepted: 08/21/2017] [Indexed: 12/25/2022] Open
Abstract
Purpose Evaluation of dose degradation by anatomic changes for head‐and‐neck cancer (HNC) intensity‐modulated proton therapy (IMPT) relative to intensity‐modulated photon therapy (IMRT) and identification of potential indicators for IMPT treatment plan adaptation. Methods For 31 advanced HNC datasets, IMPT and IMRT plans were recalculated on a computed tomography scan (CT) taken after about 4 weeks of therapy. Dose parameter changes were determined for the organs at risk (OARs) spinal cord, brain stem, parotid glands, brachial plexus, and mandible, for the clinical target volume (CTV) and the healthy tissue outside planning target volume (PTV). Correlation of dose degradation with target volume changes and quality of rigid CT matching was investigated. Results Recalculated IMPT dose distributions showed stronger degradation than the IMRT doses. OAR analysis revealed significant changes in parotid median dose (IMPT) and near maximum dose (D1ml) of spinal cord (IMPT, IMRT) and mandible (IMPT). OAR dose parameters remained lower in IMPT cases. CTV coverage (V95%) and overdose (V107%) deteriorated for IMPT plans to (93.4 ± 5.4)% and (10.6 ± 12.5)%, while those for IMRT plans remained acceptable. Recalculated plans showed similarly decreased PTV conformity, but considerable hotspots, also outside the PTV, emerged in IMPT cases. Lower CT matching quality was significantly correlated with loss of PTV conformity (IMPT, IMRT), CTV homogeneity and coverage (IMPT). Target shrinkage correlated with increased dose in brachial plexus (IMRT, IMPT), hotspot generation outside the PTV (IMPT) and lower PTV conformity (IMRT). Conclusions The study underlines the necessity of precise positioning and monitoring of anatomy changes, especially in IMPT which might require adaptation more often. Since OAR doses remained typically below constraints, IMPT plan adaptation will be indicated by target dose degradations.
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Affiliation(s)
- Kristin Stützer
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Fetscherstr. 74, PF 41, 01307, Dresden, Germany.,Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Bautzner Landstr. 400, 01328, Dresden, Germany
| | - Annika Jakobi
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Fetscherstr. 74, PF 41, 01307, Dresden, Germany.,Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Bautzner Landstr. 400, 01328, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Anna Bandurska-Luque
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Fetscherstr. 74, PF 41, 01307, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Steffen Barczyk
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Fetscherstr. 74, PF 41, 01307, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Carolin Arnsmeyer
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Fetscherstr. 74, PF 41, 01307, Dresden, Germany
| | - Steffen Löck
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Fetscherstr. 74, PF 41, 01307, Dresden, Germany.,Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Bautzner Landstr. 400, 01328, Dresden, Germany
| | - Christian Richter
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Fetscherstr. 74, PF 41, 01307, Dresden, Germany.,Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Bautzner Landstr. 400, 01328, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany.,German Cancer Consortium (DKTK), partner site Dresden, Germany and German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69192, Heidelberg, Germany
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Lo Nigro C, Denaro N, Merlotti A, Merlano M. Head and neck cancer: improving outcomes with a multidisciplinary approach. Cancer Manag Res 2017; 9:363-371. [PMID: 28860859 PMCID: PMC5571817 DOI: 10.2147/cmar.s115761] [Citation(s) in RCA: 138] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
For early-stage head and neck cancer (HNC), surgery (S) or radiotherapy (RT) is a standard treatment. The multidisciplinary approach, which includes multimodality treatment with S followed by RT, with or without chemotherapy (CT) or concurrent chemoradiotherapy (CRT), is required for locally advanced head and neck cancer (LAHNC). CRT improves prognosis, locoregional control (LRC), and organ function in LAHNC, compared to RT alone. Prognosis in recurrent/metastatic HNC (R/M HNC) is dismal. Platinum-based CT, combined with the anti-Epidermal Growth Factor Receptor (EGFR) antibody (Ab) cetuximab, is used in first-line setting, while no further validated options are available at progression. The complexity of disease is, in part, due to the heterogeneity of organs and functions involved and the need for a multimodality approach. In addition, the patient population (often elderly and/or patients with smoking and alcohol habits) argues for an individually tailored treatment plan. Furthermore, treatment goals - which include cure, organ, and function preservation, quality of life and palliation - must also be considered. Thus, optimal management of patients with HNC should involve a range of healthcare professionals with relevant expertise. The purpose of the present review is to 1) highlight the importance and necessity of the multidisciplinary approach in the treatment of HNC; 2) update the knowledge regarding modern surgical techniques, new medical and RT treatment approaches, and their combination; 3) identify the treatment scenario for LAHNC and R/M HNC; and 4) discuss the current role of immunotherapy in HNC.
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Affiliation(s)
| | | | - Anna Merlotti
- Department of Radiation Oncology, S. Croce and Carle Teaching Hospital, Cuneo, Italy
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74
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Chen AM, Hsu S, Lamb J, Yang Y, Agazaryan N, Steinberg ML, Low DA, Cao M. MRI-guided radiotherapy for head and neck cancer: initial clinical experience. Clin Transl Oncol 2017; 20:160-168. [DOI: 10.1007/s12094-017-1704-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 06/05/2017] [Indexed: 01/16/2023]
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75
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Li X, Zhang Y, Shi Y, Wu S, Xiao Y, Gu X, Zhen X, Zhou L. Comprehensive evaluation of ten deformable image registration algorithms for contour propagation between CT and cone-beam CT images in adaptive head & neck radiotherapy. PLoS One 2017; 12:e0175906. [PMID: 28414799 PMCID: PMC5393623 DOI: 10.1371/journal.pone.0175906] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 04/02/2017] [Indexed: 01/16/2023] Open
Abstract
Deformable image registration (DIR) is a critical technic in adaptive radiotherapy (ART) for propagating contours between planning computerized tomography (CT) images and treatment CT/cone-beam CT (CBCT) images to account for organ deformation for treatment re-planning. To validate the ability and accuracy of DIR algorithms in organ at risk (OAR) contour mapping, ten intensity-based DIR strategies, which were classified into four categories—optical flow-based, demons-based, level-set-based and spline-based—were tested on planning CT and fractional CBCT images acquired from twenty-one head & neck (H&N) cancer patients who underwent 6~7-week intensity-modulated radiation therapy (IMRT). Three similarity metrics, i.e., the Dice similarity coefficient (DSC), the percentage error (PE) and the Hausdorff distance (HD), were employed to measure the agreement between the propagated contours and the physician-delineated ground truths of four OARs, including the vertebra (VTB), the vertebral foramen (VF), the parotid gland (PG) and the submandibular gland (SMG). It was found that the evaluated DIRs in this work did not necessarily outperform rigid registration. DIR performed better for bony structures than soft-tissue organs, and the DIR performance tended to vary for different ROIs with different degrees of deformation as the treatment proceeded. Generally, the optical flow-based DIR performed best, while the demons-based DIR usually ranked last except for a modified demons-based DISC used for CT-CBCT DIR. These experimental results suggest that the choice of a specific DIR algorithm depends on the image modality, anatomic site, magnitude of deformation and application. Therefore, careful examinations and modifications are required before accepting the auto-propagated contours, especially for automatic re-planning ART systems.
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Affiliation(s)
- Xin Li
- Department of Biomedical Engineering, Southern Medical University, Guangzhou, Guangdong, China
| | - Yuyu Zhang
- Department of Radiotherapy Oncology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yinghua Shi
- Department of Radiotherapy Oncology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Shuyu Wu
- Department of Biomedical Engineering, Southern Medical University, Guangzhou, Guangdong, China
| | - Yang Xiao
- Department of Biomedical Engineering, Southern Medical University, Guangzhou, Guangdong, China
| | - Xuejun Gu
- Department of Radiotherapy Oncology, The University of Texas, Southwestern Medical Center, Dallas, Texas, United States of America
| | - Xin Zhen
- Department of Biomedical Engineering, Southern Medical University, Guangzhou, Guangdong, China
- * E-mail: (XZ); (LZ)
| | - Linghong Zhou
- Department of Biomedical Engineering, Southern Medical University, Guangzhou, Guangdong, China
- * E-mail: (XZ); (LZ)
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Teske H, Bartelheimer K, Meis J, Bendl R, Stoiber EM, Giske K. Construction of a biomechanical head and neck motion model as a guide to evaluation of deformable image registration. Phys Med Biol 2017; 62:N271-N284. [PMID: 28350540 DOI: 10.1088/1361-6560/aa69b6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The use of deformable image registration methods in the context of adaptive radiotherapy leads to uncertainties in the simulation of the administered dose distributions during the treatment course. Evaluation of these methods is a prerequisite to decide if a plan adaptation will improve the individual treatment. Current approaches using manual references limit the validity of evaluation, especially for low-contrast regions. In particular, for the head and neck region, the highly flexible anatomy and low soft tissue contrast in control images pose a challenge to image registration and its evaluation. Biomechanical models promise to overcome this issue by providing anthropomorphic motion modelling of the patient. We introduce a novel biomechanical motion model for the generation and sampling of different postures of the head and neck anatomy. Motion propagation behaviour of the individual bones is defined by an underlying kinematic model. This model interconnects the bones by joints and thus is capable of providing a wide range of motion. Triggered by the motion of the individual bones, soft tissue deformation is described by an extended heterogeneous tissue model based on the chainmail approach. This extension, for the first time, allows the propagation of decaying rotations within soft tissue without the necessity for explicit tissue segmentation. Overall motion simulation and sampling of deformed CT scans including a basic noise model is achieved within 30 s. The proposed biomechanical motion model for the head and neck site generates displacement vector fields on a voxel basis, approximating arbitrary anthropomorphic postures of the patient. It was developed with the intention of providing input data for the evaluation of deformable image registration.
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Affiliation(s)
- Hendrik Teske
- Division of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany. National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
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Kim M, Phillips MH. A feasibility study of dynamic adaptive radiotherapy for nonsmall cell lung cancer. Med Phys 2017; 43:2153. [PMID: 27147327 DOI: 10.1118/1.4945023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE The final state of the tumor at the end of a radiotherapy course is dependent on the doses given in each fraction during the treatment course. This study investigates the feasibility of using dynamic adaptive radiotherapy (DART) in treating lung cancers assuming CBCT is available to observe midtreatment tumor states. DART adapts treatment plans using a dynamic programming technique to consider the expected changes of the tumor in the optimization process. METHODS DART is constructed using a stochastic control formalism framework. It minimizes the total expected number of tumor cells at the end of a treatment course, which is equivalent to maximizing tumor control probability, subject to the uncertainty inherent in the tumor response. This formulation allows for nonstationary dose distributions as well as nonstationary fractional doses as needed to achieve a series of optimal plans that are conformal to the tumor over time, i.e., spatiotemporally optimal plans. Sixteen phantom cases with various sizes and locations of tumors and organs-at-risk (OAR) were generated using in-house software. Each case was planned with DART and conventional IMRT prescribing 60 Gy in 30 fractions. The observations of the change in the tumor volume over a treatment course were simulated using a two-level cell population model. Monte Carlo simulations of the treatment course for each case were run to account for uncertainty in the tumor response. The same OAR dose constraints were applied for both methods. The frequency of replanning was varied between 1, 2, 5 (weekly), and 29 times (daily). The final average tumor dose and OAR doses have been compared to quantify the potential dosimetric benefits of DART. RESULTS The average tumor max, min, mean, and D95 doses using DART relative to these using conventional IMRT were 124.0%-125.2%, 102.1%-114.7%, 113.7%-123.4%, and 102.0%-115.9% (range dependent on the frequency of replanning). The average relative maximum doses for the cord and esophagus, mean doses for the heart and lungs, and D05 for the unspecified tissue resulting 84%-102.4%, 99.8%-106.9%, 66.9%-85.6%, 58.2%-78.8%, and 85.2%-94.0%, respectively. CONCLUSIONS It is feasible to apply DART to the treatment of NSCLC using CBCT to observe the midtreatment tumor state. Potential increases in the tumor dose and reductions in the OAR dose, particularly for parallel OARs with mean or dose-volume constraints, could be achieved using DART compared to nonadaptive IMRT.
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Affiliation(s)
- Minsun Kim
- Department of Radiation Oncology, University of Washington, Seattle, Washington 98195-6043
| | - Mark H Phillips
- Departments of Radiation Oncology and Neurological Surgery, University of Washington, Seattle, Washington 98195-6043
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Dewan A, Sharma S, Dewan A, Srivastava H, Rawat S, Kakria A, Mishra M, T S, Mehrotra K. Impact of Adaptive Radiotherapy on Locally Advanced Head and Neck Cancer - A Dosimetric and Volumetric Study. Asian Pac J Cancer Prev 2017; 17:985-92. [PMID: 27039824 DOI: 10.7314/apjcp.2016.17.3.985] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
UNLABELLED Objective of the study is to evaluate volumetric and dosimetric alterations taking place during radiotherapy for locally advanced head and neck cancer (LAHNC) and to assess benefit of replanning in them. MATERIALS AND METHODS Thirty patients with LAHNC fulfilling the inclusion and exclusion criteria were enrolled in a prospective study. Planning scans were acquired both pre-treatment and after 20 fractions (mid-course) of radiotherapy. Single plan (OPLAN) based on initial CT scan was generated and executed for entire treatment course. Beam configuration of OPLAN was applied to anatomy of interim scan and a hybrid plan (HPLAN30) was generated. Adaptive replanning (RPLAN30) for remaining fractions was done and dose distribution with and without replanning compared for remaining fractions. RESULTS Substantial shrinkage of target volume (TV) and parotids after 4 weeks of radiotherapy was reported (p<0.05). No significant difference between planned and delivered doses was seen for remaining fractions. Hybrid plans showed increase in delivered dose to spinal cord and parotids for remaining fractions. Interim replanning improved homogeneity of treatment plan and significantly reduced doses to cord (Dmax, D2% and D1%) and ipsilateral parotid (D33%, D50% and D66%) (p<0.05). CONCLUSIONS Use of one or two mid-treatment CT scans and replanning provides greater normal tissue sparing alongwith improved TV coverage.
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Affiliation(s)
- Abhinav Dewan
- Department of Radiotherapy, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India E-mail :
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Tyagi N, Riaz N, Hunt M, Wengler K, Hatzoglou V, Young R, Mechalakos J, Lee N. Weekly response assessment of involved lymph nodes to radiotherapy using diffusion-weighted MRI in oropharynx squamous cell carcinoma. Med Phys 2016; 43:137. [PMID: 26745906 PMCID: PMC5360161 DOI: 10.1118/1.4937791] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Purpose: Patients with cancers of oropharynx have a favorable prognosis and are an
ideal candidate for adaptive therapy. A replan to improve coverage or
escalate/de-escalate dose based on morphological information alone may not be
adequate as the grossly involved lymph nodes (LNs) of a subset of these patients
tend to become cystic and often do not regress. Functional adaptation may be a
better approach when considering replanning for these patients. The purpose of
this study was to evaluate the weekly trends in treatment related
morphological and physiological changes for these LNs using diffusion-weighted
MRI
(DW-MRI) and evaluate its implications for adaptive replanning. Methods: Ten patients with histologically proven oropharynx HNSCC undergoing concurrent
chemoradiation were analyzed in this study. MR imaging protocol
included axial T1w, T2w, and DW-MRI using a 3 T Philips MR scanner. The patients
were scanned weekly in radiation treatment planning position using a 16 element
phased-array anterior coil and a 44 element posterior coil. A total of 65 DWI and
T2w scans were analyzed. DWI was performed using an optimized single-shot
echo planar imaging sequence (TR/TE = 5000/65 ms, slice thickness = 5 mm;
slices = 28; b values = 0 and 800 s/mm2).
Quantification of the DW-MRI images was performed by calculating the apparent
diffusion coefficient (ADC). T2w and DWI scans were imported
into the Eclipse treatment planning system and gross tumor volumes (GTVs)
corresponding to grossly involved LNs were contoured on each axial slice by
physician experts. An attempt was made to remove any cystic or necrotic components
so that the ADC analysis was of viable tumor only. A
pixel-by-pixel fit of signal intensities within the GTVs was performed assuming
monoexponential behavior. From each GTV histogram mean, median, standard
deviation, skewness, and kurtosis were calculated. Absolute and percent change in
weekly ADC histogram parameters and percent change in T2w GTV were also
calculated. Results: For all nodes, an immediate change in ADC was observed during first 2–3 weeks
after which ADC values either continued to increase or plateaued. A few nodal
volumes had a slightly decreased ADC value during later weeks. Percent increase in
median ADC from weeks 1 to 6 with respect to baseline was 14%, 25%, 41%, 42%, 45%,
and 58%. The corresponding change in median T2 volumes was 8%, 10%, 16%, 22%, 40%,
and 42%, respectively. The ADC distribution of the viable tumors was initially
highly kurtotic; however, the kurtosis decreased as treatment progressed.
The ADC distribution also showed a higher degree of skewness in the first 2 weeks,
progressively becoming less skewed as treatment progressed so as to slowly approach a
more symmetric distribution. Conclusions: Physiological changes in LNs represented by changes in ADC evaluated using DW-MRI
are evident sooner than the morphological changes calculated from T2w
MRI.
The decisions for adaptive replanning may need to be individualized and should be
based primarily on tumor functional information. The authors’ data also suggest
that for many patients, week 3 maybe the optimal time to intervene and replan.
Larger studies are needed to confirm their findings.
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Affiliation(s)
- Neelam Tyagi
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, New York 10065
| | - Nadeem Riaz
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, New York 10065
| | - Margie Hunt
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, New York 10065
| | - Kenneth Wengler
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, New York 10065
| | - Vaios Hatzoglou
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, New York 10065
| | - Robert Young
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, New York 10065
| | - James Mechalakos
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, New York 10065
| | - Nancy Lee
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, New York 10065
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Effect of adaptive replanning in patients with locally advanced nasopharyngeal carcinoma treated by intensity-modulated radiotherapy: a propensity score matched analysis. Clin Transl Oncol 2016; 19:470-476. [PMID: 27718153 DOI: 10.1007/s12094-016-1551-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 09/19/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Limited data have been published regarding the effect of adaptive radiotherapy (ART) on clinical outcome in patients with nasopharyngeal carcinoma (NPC). We compared the long-term outcomes in patients with locally advanced NPC treated by adaptive intensity-modulated radiotherapy (IMRT) replanning versus IMRT. METHODS 200 NPC patients with stage T3/T4 were included between October 2004 and November 2010. Patients in both treatment groups were matched using propensity score matching method at the ratio of 1:1. Clinical outcomes were analyzed with Kaplan-Meier method, log-rank test and Cox regression. RESULTS After matching, 132 patients (66 patients in each group) were included for analysis. The median follow-up for the IMRT replanning group was 70 months, while the IMRT group was 69 months. The 5-year local-regional recurrence-free survival (LRFS) rate was higher in IMRT replanning group (96.7 vs. 88.1 %, P = 0.022). No significant differences in distant metastasis-free survival (DMFS), progression-free survival (PFS) and overall survival (OS) were observed between the two groups. 21.2 % patients in IMRT replanning group and 28.8 % patients in IMRT group had distant metastasis. In multivariable analysis, IMRT replanning was identified as an independent prognostic factor for LRFS (hazard ratio 0.229; 95 % CI 0.062-0.854; P = 0.028), but not for DMFS, PFS and OS. CONCLUSIONS IMRT replanning provides an improved LRFS for stage T3/T4 NPC patients compared with IMRT. Distant metastasis remains the main pattern of treatment failure. No significant advantage was observed in DMFS, PFS and OS when adaptive replanning was used.
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Raghavan G, Kishan AU, Cao M, Chen AM. Anatomic and dosimetric changes in patients with head and neck cancer treated with an integrated MRI-tri- 60Co teletherapy device. Br J Radiol 2016; 89:20160624. [PMID: 27653787 DOI: 10.1259/bjr.20160624] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Prior studies have relied on CT to assess alterations in anatomy among patients undergoing radiation for head and neck cancer. We sought to determine the feasibility of using MRI-based image-guided radiotherapy to quantify these changes and to ascertain their potential dosimetric implications. METHODS 6 patients with head and neck cancer were treated with intensity-modulated radiotherapy (IMRT) on a novel tri-60Co teletherapy system equipped with a 0.35-T MRI (VR, ViewRay Incorporated, Oakwood Village, OH) to 66-70 Gy in 33 fractions (fx). Pre-treatment MRIs on Fx 1, 5, 10, 15, 20, 25, 30 and 33 were imported into a contouring interface, where the primary gross tumour volume (GTV) and parotid glands were delineated. The centre of mass (COM) shifts for these structures were assessed relative to Day 1. Dosimetric data were co-registered with the MRIs, and doses to the GTV and parotid glands were assessed. RESULTS Primary GTVs decreased significantly over the course of IMRT (median % volume loss, 38.7%; range, 29.5-72.0%; p < 0.05) at a median rate of 1.2%/fx (range, 0.92-2.2%/fx). Both the ipsilateral and contralateral parotid glands experienced significant volume loss (p < 0.05, for all) and shifted medially during IMRT. Weight loss correlated significantly with parotid gland volume loss and medial COM shift (p < 0.05). CONCLUSION Integrated on-board MRI can be used to accurately contour and analyze primary GTVs and parotid glands over the course of IMRT. COM shifts and significant volume reductions were observed, confirming the results of prior CT-based exercises. Advances in knowledge: The superior resolution of on-board MRI may facilitate online adaptive replanning in the future.
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Affiliation(s)
- Govind Raghavan
- Department of Radiation Oncology, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Minsong Cao
- Department of Radiation Oncology, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Allen M Chen
- Department of Radiation Oncology, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA, USA
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Hou WH, Wang CW, Tsai CL, Hsu FM, Cheng JCH. The ratio of weight loss to planning target volume significantly impacts setup errors in nasopharyngeal cancer patients undergoing helical tomotherapy with daily megavoltage computed tomography. Radiol Oncol 2016; 50:427-432. [PMID: 27904451 PMCID: PMC5120582 DOI: 10.1515/raon-2016-0047] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 07/19/2016] [Indexed: 11/30/2022] Open
Abstract
Background Changes in head and neck anatomy during radiation therapy (RT) produce setup uncertainties of nasopharyngeal cancer (NPC) irradiation. We retrospectively analyzed image guidance data to identify clinical predictors of setup errors. Patients and methods The data of 217 NPC patients undergoing definitive RT on a helical tomotherapy (HT) unit were analyzed. Factors including tumor stage, body mass index, weight loss, and planning target volume (PTV) were assessed as predictors of daily megavoltage computed tomography (MVCT) setup displacements, which were automatically registered using software. Results Mean daily setup displacements (in mm) were 1.2 ± 0.6, 1.8 ± 0.8, 3.4 ± 1.4 in the medial-lateral (ML), superior-inferior (SI), and anterior-posterior (AP) directions, respectively. Mean weight loss was 4.6 ± 3.3 kg (6.8 ± 4.9%). Patients with weight loss > 5% had significantly larger setup displacements in the AP (3.6 ± 1.5 vs. 2.9 ± 1.1 mm, p < 0.001) and SI (1.6 ± 0.7 vs. 1.9 ± 0.9 mm, p = 0.01) direction, but not in the ML direction (p = 0.279). The AP setup error increased 0.06 mm (y = 0.055x + 2.927, x: percentage of weight loss/PTV, y: AP displacement) per one percent increase in weight loss normalized to PTV. Conclusions Patients with weight loss > 5% and smaller PTVs, possibly because of small body frame or neck girth, were more likely to have increased setup errors in the AP direction.
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Affiliation(s)
- Wei-Hsien Hou
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, California, United States of America
| | - Chun-Wei Wang
- Division of Radiation Oncology, Departments of Oncology, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan, Province of China
| | - Chiao-Ling Tsai
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, California, United States of America
| | - Feng-Ming Hsu
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, California, United States of America
| | - Jason Chia-Hsien Cheng
- Division of Radiation Oncology, Departments of Oncology, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan, Province of China; Graduate Institutes of Oncology, National Taiwan University College of Medicine, Taipei, Taiwan, Province of China; Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan, Province of China
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Surucu M, Shah KK, Roeske JC, Choi M, Small W, Emami B. Adaptive Radiotherapy for Head and Neck Cancer. Technol Cancer Res Treat 2016; 16:218-223. [PMID: 27502958 DOI: 10.1177/1533034616662165] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To investigate the effects of adaptive radiotherapy on dosimetric, clinical, and toxicity outcomes for patients with head and neck cancer undergoing chemoradiotherapy with intensity-modulated radiotherapy. METHODS Fifty-one patients with advanced head and neck cancer underwent definitive chemoradiotherapy with the original plan optimized to deliver 70.2 Gy. All patients were resimulated at a median dose of 37.8 Gy (range, 27.0-48.6 Gy) due to changes in tumor volume and/or patient weight loss (>15% from baseline). Thirty-four patients underwent adaptive replanning for their boost planning (21.6 Gy). The dosimetric effects of the adaptive plan were compared to the original plan and the original plan copied on rescan computed tomography. Acute and late toxicities and tumor local control were assessed. Gross tumor volume reduction rate was calculated. RESULTS With adaptive replanning, the maximum dose to the spinal cord, brain stem, mean ipsilateral, and contralateral parotid had a median reduction of -4.5%, -3.0%, -6.2%, and -2.5%, respectively (median of 34 patients). Median gross tumor volume and boost planning target volume coverage improved by 0.8% and 0.5%, respectively. With a median follow-up time of 17.6 months, median disease-free survival and overall survival was 14.8 and 21.1 months, respectively. Median tumor volume reduction rate was 35.2%. For patients with tumor volume reduction rate ≤35.2%, median disease-free survival was 8.7 months, whereas it was 16.9 months for tumor volume reduction rate >35.2%. Four patients had residual disease after chemoradiotherapy, whereas 64.7% (20 of 34) of patients achieved locoregional control. CONCLUSION Implementation of adaptive radiotherapy in head and neck cancer offers benefits including improvement in tumor coverage and decrease in dose to organs at risk. The tumor volume reduction rate during treatment was significantly correlated with disease-free survival and overall survival.
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Affiliation(s)
- Murat Surucu
- 1 Department of Radiation Oncology, Loyola University Medical Center, Maywood, IL, USA
| | - Karan K Shah
- 1 Department of Radiation Oncology, Loyola University Medical Center, Maywood, IL, USA
| | - John C Roeske
- 1 Department of Radiation Oncology, Loyola University Medical Center, Maywood, IL, USA
| | - Mehee Choi
- 1 Department of Radiation Oncology, Loyola University Medical Center, Maywood, IL, USA
| | - William Small
- 1 Department of Radiation Oncology, Loyola University Medical Center, Maywood, IL, USA
| | - Bahman Emami
- 1 Department of Radiation Oncology, Loyola University Medical Center, Maywood, IL, USA
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van Kranen S, Hamming-Vrieze O, Wolf A, Damen E, van Herk M, Sonke JJ. Head and Neck Margin Reduction With Adaptive Radiation Therapy: Robustness of Treatment Plans Against Anatomy Changes. Int J Radiat Oncol Biol Phys 2016; 96:653-60. [PMID: 27681762 DOI: 10.1016/j.ijrobp.2016.07.011] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 07/05/2016] [Accepted: 07/13/2016] [Indexed: 11/16/2022]
Abstract
PURPOSE We set out to investigate loss of target coverage from anatomy changes in head and neck cancer patients as a function of applied safety margins and to verify a cone beam computed tomography (CBCT)-based adaptive strategy with an average patient anatomy to overcome possible target underdosage. METHODS AND MATERIALS For 19 oropharyngeal cancer patients, volumetric modulated arc therapy treatment plans (2 arcs; simultaneous integrated boost, 70 and 54.25 Gy; 35 fractions) were automatically optimized with uniform clinical target volume (CTV)-to-planning target volume margins of 5, 3, and 0 mm. We applied b-spline CBCT-to-computed tomography (CT) deformable registration to allow recalculation of the dose on modified CT scans (planning CT deformed to daily CBCT following online positioning) and dose accumulation in the planning CT scan. Patients with deviations in primary or elective CTV coverage >2 Gy were identified as candidates for adaptive replanning. For these patients, a single adaptive intervention was simulated with an average anatomy from the first 10 fractions. RESULTS Margin reduction from 5 mm to 3 mm to 0 mm generally led to an organ-at-risk (OAR) mean dose (Dmean) sparing of approximately 1 Gy/mm. CTV shrinkage was mainly seen in the elective volumes (up to 10%), likely related to weight loss. Despite online repositioning, substantial systematic errors were present (>3 mm) in lymph node CTV, the parotid glands, and the larynx. Nevertheless, the average increase in OAR dose was small: maximum of 1.2 Gy (parotid glands, Dmean) for all applied margins. Loss of CTV coverage >2 Gy was found in 1, 3, and 7 of 73 CTVs, respectively. Adaptive intervention in 0-mm plans substantially improved coverage: in 5 of 7 CTVs (in 6 patients) to <2 Gy of initially planned. CONCLUSIONS Volumetric modulated arc therapy head and neck cancer treatment plans with 5-mm margins are robust for anatomy changes and show a modest increase in OAR dose. Margin reduction improves OAR sparing with approximately 1 Gy/mm at the expense of target coverage in a subgroup of patients. Patients at risk of CTV underdosage >2 Gy in 0-mm plans may be identified early in treatment using dose accumulation. A single intervention with an average anatomy derived from CBCT effectively mitigates discrepancies.
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Affiliation(s)
- Simon van Kranen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Olga Hamming-Vrieze
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Annelisa Wolf
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Eugène Damen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Marcel van Herk
- Christie Hospital and University of Manchester, Manchester, United Kingdom
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands.
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Brown E, Owen R, Harden F, Mengersen K, Oestreich K, Houghton W, Poulsen M, Harris S, Lin C, Porceddu S. Head and neck adaptive radiotherapy: Predicting the time to replan. Asia Pac J Clin Oncol 2016; 12:460-467. [PMID: 27435432 DOI: 10.1111/ajco.12516] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 02/10/2016] [Accepted: 04/11/2016] [Indexed: 11/27/2022]
Abstract
AIM Head and neck (H&N) cancer patients can undergo anatomical change throughout radiotherapy treatment. Adaptive radiotherapy (ART) is effective in addressing the impact of this change on the planned dose distribution. The aim of this study was to identify pretreatment factors that influence the need for and timing of replanning for patients receiving chemoradiotherapy for node-positive nasopharyngeal (NPC) and oropharyngeal carcinoma (OPC). METHODS Of 110 patients enrolled in a prospective H&N ART study, 21 (19%) underwent a second planning scan (re-CT) and were included in this review. Univariate and multivariate analysis was used to compare those patients who were replanned with those that were not. Factors influencing the timing of replanning were assessed including patient and tumor characteristics and structure volume details. RESULTS Of the five replanned patients, three were diagnosed with NPC (P = 0.06) and had significantly larger initial nodal volumes (median volume 140.3 cc vs. 39.1 cc, P = 0.019). Overall the median time of re-CT was significantly different between replanned and non-replanned patients, with replanned patients having an earlier re-CT: median fraction 18 versus fraction 23 (P = 0.01). Specifically, NPC patients who were replanned had a re-CT performed earlier than OPC patients (median fraction 11 vs. 20). CONCLUSION For H&N patients with large nodes receiving definitive chemoradiotherapy, replanning may be considered at the commencement of week 3 for NPC patients and in week 4 of treatment for OPC patients. This information may facilitate a forward planning approach to H&N ART that enables allocation of departmental resources prior to treatment commencement.
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Affiliation(s)
- Elizabeth Brown
- Radiation Oncology Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Queensland University of Technology, Brisbane, Queensland, Australia
| | - Rebecca Owen
- Queensland University of Technology, Brisbane, Queensland, Australia
| | - Fiona Harden
- Queensland University of Technology, Brisbane, Queensland, Australia
| | - Kerrie Mengersen
- Queensland University of Technology, Brisbane, Queensland, Australia
| | - Kimberley Oestreich
- Radiation Oncology Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Whitney Houghton
- Radiation Oncology Department, Radiation Oncology Mater Centre, Brisbane, Queensland, Australia
| | - Michael Poulsen
- Radiation Oncology Department, Radiation Oncology Mater Centre, Brisbane, Queensland, Australia
| | - Selina Harris
- Radiation Oncology Department, Royal Brisbane and Women's, Brisbane, Queensland, Australia
| | - Charles Lin
- Radiation Oncology Department, Royal Brisbane and Women's, Brisbane, Queensland, Australia
| | - Sandro Porceddu
- Radiation Oncology Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
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86
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Castelli J, Simon A, Rigaud B, Lafond C, Chajon E, Ospina JD, Haigron P, Laguerre B, Loubière AR, Benezery K, de Crevoisier R. A Nomogram to predict parotid gland overdose in head and neck IMRT. Radiat Oncol 2016; 11:79. [PMID: 27278960 PMCID: PMC4898383 DOI: 10.1186/s13014-016-0650-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 05/17/2016] [Indexed: 11/25/2022] Open
Abstract
Purposes To generate a nomogram to predict parotid gland (PG) overdose and to quantify the dosimetric benefit of weekly replanning based on its findings, in the context of intensity-modulated radiotherapy (IMRT) for locally-advanced head and neck carcinoma (LAHNC). Material and methods Twenty LAHNC patients treated with radical IMRT underwent weekly computed tomography (CT) scans during IMRT. The cumulated PG dose was estimated by elastic registration. Early predictors of PG overdose (cumulated minus planned doses) were identified, enabling a nomogram to be generated from a linear regression model. Its performance was evaluated using a leave-one-out method. The benefit of weekly replanning was then estimated for the nomogram-identified PG overdose patients. Results Clinical target volume 70 (CTV70) and the mean PG dose calculated from the planning and first weekly CTs were early predictors of PG overdose, enabling a nomogram to be generated. A mean PG overdose of 2.5Gy was calculated for 16 patients, 14 identified by the nomogram. All patients with PG overdoses >1.5Gy were identified. Compared to the cumulated delivered dose, weekly replanning of these 14 targeted patients enabled a 3.3Gy decrease in the mean PG dose. Conclusion Based on the planning and first week CTs, our nomogram allowed the identification of all patients with PG overdoses >2.5Gy to be identified, who then benefitted from a final 4Gy decrease in mean PG overdose by means of weekly replanning.
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Affiliation(s)
- J Castelli
- Centre Eugene Marquis, Radiotherapy, de la Bataille Flandre Dunkerque, F-35000, Rennes, France. .,Rennes University 1, LTSI, Campus de Beaulieu, Rennes, F-35000, France. .,INSERM, U1099, Campus de Beaulieu, Rennes, F-35000, France.
| | - A Simon
- Rennes University 1, LTSI, Campus de Beaulieu, Rennes, F-35000, France.,INSERM, U1099, Campus de Beaulieu, Rennes, F-35000, France
| | - B Rigaud
- Rennes University 1, LTSI, Campus de Beaulieu, Rennes, F-35000, France.,INSERM, U1099, Campus de Beaulieu, Rennes, F-35000, France
| | - C Lafond
- Centre Eugene Marquis, Radiotherapy, de la Bataille Flandre Dunkerque, F-35000, Rennes, France
| | - E Chajon
- Centre Eugene Marquis, Radiotherapy, de la Bataille Flandre Dunkerque, F-35000, Rennes, France
| | - J D Ospina
- Rennes University 1, LTSI, Campus de Beaulieu, Rennes, F-35000, France.,INSERM, U1099, Campus de Beaulieu, Rennes, F-35000, France
| | - P Haigron
- Rennes University 1, LTSI, Campus de Beaulieu, Rennes, F-35000, France.,INSERM, U1099, Campus de Beaulieu, Rennes, F-35000, France
| | - B Laguerre
- Centre Eugene Marquis, Medical oncology, Rennes, F-35000, France
| | | | - K Benezery
- Centre Antoine Lacassagne, Radiotherapy, Nice, F-06100, France
| | - R de Crevoisier
- Centre Eugene Marquis, Radiotherapy, de la Bataille Flandre Dunkerque, F-35000, Rennes, France.,Rennes University 1, LTSI, Campus de Beaulieu, Rennes, F-35000, France.,INSERM, U1099, Campus de Beaulieu, Rennes, F-35000, France
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87
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Clinical Outcome and Prognostic Factors of Intensity-Modulated Radiotherapy for T4 Stage Nasopharyngeal Carcinoma. BIOMED RESEARCH INTERNATIONAL 2016; 2016:4398498. [PMID: 27195286 PMCID: PMC4853936 DOI: 10.1155/2016/4398498] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Revised: 03/27/2016] [Accepted: 03/31/2016] [Indexed: 11/30/2022]
Abstract
Objective. To analyze the clinical outcomes and prognostic factors of intensity-modulated radiotherapy (IMRT) for T4 stage nasopharyngeal carcinoma (NPC). Methods. Between March 2005 and March 2010, 110 patients with T4 stage NPC without distant metastases were treated. All patients received IMRT. Induction and/or concurrent chemotherapy were given. 47 (42.7%) patients received IMRT replanning. Results. The 5-year local recurrence-free survival (LRFS), regional recurrence-free survival (RRFS), distant metastasis-free survival (DMFS), progression-free survival (PFS), and overall survival (OS) rates were 90.1%, 97.0%, 67.5%, 63.9%, and 64.5%, respectively. Eleven patients experienced local-regional failure and total distant metastasis occurred in 34 patients. 45 patients died and 26 patients died of distant metastasis alone. The 5-year LRFS rates were 97.7% and 83.8% for the patients that received and did not receive IMRT replanning, respectively (P = 0.023). Metastasis to the retropharyngeal lymph nodes (RLN) was associated with inferior 5-year OS rate (61.0% versus 91.7%, P = 0.034). The gross tumor volume of the right/left lymph nodes (GTVln) was an independent prognostic factor for DMFS (P = 0.006) and PFS (P = 0.018). GTVln was with marginal significance as the prognostic factor for OS (P = 0.050). Conclusion. IMRT provides excellent local-regional control for T4 stage NPC. Benefit of IMRT replanning may be associated with improvement in local control. Incorporating GTVln into the N staging system may provide better prognostic information.
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88
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Baumann M, Krause M, Overgaard J, Debus J, Bentzen SM, Daartz J, Richter C, Zips D, Bortfeld T. Radiation oncology in the era of precision medicine. Nat Rev Cancer 2016; 16:234-49. [PMID: 27009394 DOI: 10.1038/nrc.2016.18] [Citation(s) in RCA: 514] [Impact Index Per Article: 64.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Technological advances and clinical research over the past few decades have given radiation oncologists the capability to personalize treatments for accurate delivery of radiation dose based on clinical parameters and anatomical information. Eradication of gross and microscopic tumours with preservation of health-related quality of life can be achieved in many patients. Two major strategies, acting synergistically, will enable further widening of the therapeutic window of radiation oncology in the era of precision medicine: technology-driven improvement of treatment conformity, including advanced image guidance and particle therapy, and novel biological concepts for personalized treatment, including biomarker-guided prescription, combined treatment modalities and adaptation of treatment during its course.
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Affiliation(s)
- Michael Baumann
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden
- OncoRay - National Center for Radiation Research in Oncology (NCRO), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, and Helmholtz-Zentrum Dresden-Rossendorf, Fetscherstrasse 74, 01307 Dresden
- National Center for Tumor Diseases (NCT), Fetscherstrasse 74, 01307 Dresden
- German Cancer Consortium (DKTK) Dresden, Germany
- German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiation Oncology, Bautzner Landstrasse 400, 01328 Dresden, Germany
| | - Mechthild Krause
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden
- OncoRay - National Center for Radiation Research in Oncology (NCRO), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, and Helmholtz-Zentrum Dresden-Rossendorf, Fetscherstrasse 74, 01307 Dresden
- National Center for Tumor Diseases (NCT), Fetscherstrasse 74, 01307 Dresden
- German Cancer Consortium (DKTK) Dresden, Germany
- German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiation Oncology, Bautzner Landstrasse 400, 01328 Dresden, Germany
| | - Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Nørrebrogade 44, 8000 Aarhus C, Denmark
| | - Jürgen Debus
- German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), University of Heidelberg Medical School and German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Im Neuenheimer Feld 460, 69120 Heidelberg
- Heidelberg Ion Therapy Center (HIT), Department of Radiation Oncology, University of Heidelberg Medical School, Im Neuenheimer Feld 400, 69120 Heidelberg
- German Cancer Consortium (DKTK) Heidelberg, Germany
| | - Søren M Bentzen
- Department of Epidemiology and Public Health and Greenebaum Cancer Center, University of Maryland School of Medicine, 22 S Greene Street S9a03, Baltimore, Maryland 21201, USA
| | - Juliane Daartz
- Department of Radiation Oncology, Physics Division, Massachusetts General Hospital and Harvard Medical School, 1000 Blossom Street Cox 362, Boston, Massachusetts 02114, USA
| | - Christian Richter
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden
- OncoRay - National Center for Radiation Research in Oncology (NCRO), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, and Helmholtz-Zentrum Dresden-Rossendorf, Fetscherstrasse 74, 01307 Dresden
- National Center for Tumor Diseases (NCT), Fetscherstrasse 74, 01307 Dresden
- German Cancer Consortium (DKTK) Dresden, Germany
- German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Daniel Zips
- German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
- German Cancer Consortium Tübingen, Postfach 2669, 72016 Tübingen
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Tübingen, Eberhard Karls Universität Tübingen, Hoppe-Seyler-Strasse 3, 72016 Tübingen, Germany
| | - Thomas Bortfeld
- Department of Radiation Oncology, Physics Division, Massachusetts General Hospital and Harvard Medical School, 1000 Blossom Street Cox 362, Boston, Massachusetts 02114, USA
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89
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Adaptive Radiotherapy for Head Neck Cancer. J Maxillofac Oral Surg 2016; 15:549-554. [PMID: 27833352 DOI: 10.1007/s12663-016-0881-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 02/05/2016] [Indexed: 10/22/2022] Open
Abstract
Changes in patient anatomy may occur either from a tumour volume, position or function of a specific organ at risk, or target volume, weight loss or a reduction in postoperative oedema, and may vary between patients. Adaptive radiotherapy aims to correct morphological variations by realizing one or more plans during the treatment course. Imaging is used to detect these variations, thereby deciding on a potential replanning. At present, adaptive radiotherapy for head neck cancer (HNC) mainly deals with treatment response, such as weight loss or tumor shrinkage. Therefore a properly timed repeat CT scan during treatment is a suitable basis for plan adaptation to account for treatment response.
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90
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Thomson DJ, Beasley WJ, Garcez K, Lee LW, Sykes AJ, Rowbottom CG, Slevin NJ. Relative plan robustness of step-and-shoot vs rotational intensity–modulated radiotherapy on repeat computed tomographic simulation for weight loss in head and neck cancer. Med Dosim 2016; 41:154-8. [DOI: 10.1016/j.meddos.2016.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 10/12/2015] [Accepted: 01/13/2016] [Indexed: 10/22/2022]
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91
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Gutiontov SI, Shin EJ, Lok B, Lee NY, Cabanillas R. Intensity-modulated radiotherapy for head and neck surgeons. Head Neck 2015; 38 Suppl 1:E2368-73. [PMID: 26705685 DOI: 10.1002/hed.24338] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2015] [Indexed: 12/31/2022] Open
Abstract
The development of intensity-modulated radiotherapy (IMRT) has played a major role in improving outcomes and decreasing morbidity in patients with head and neck cancer. This review addresses this vital modality with a focus on the important role of the head and neck surgeon. The technique as well as its benefits and points of caution are outlined, the definitions of tumor and treatment volumes are discussed, and the dose and fractionation are detailed. Following this are several sections dedicated to the role of the head and neck surgeon in the planning of both definitive and postoperative radiotherapy to the primary site and neck. There is a focus throughout on anatomic and surgical considerations; commonly encountered situations are illustrated. With a deeper understanding of this technique and their own pivotal contribution to target delineation, head and neck surgeons will be poised to expand their role and improve cancer care for their patients. © 2015 Wiley Periodicals, Inc. Head Neck 38: E2368-E2373, 2016.
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Affiliation(s)
| | - Edward J Shin
- Department of Otolaryngology/Head and Neck Surgery, New York Eye and Ear Infirmary of Mount Sinai, New York, New York
| | - Benjamin Lok
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nancy Y Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ruben Cabanillas
- Department of Clinical and Translational Oncology, Institute of Molecular and Oncological Medicine of Asturias Oviedo, Asturias, Spain
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92
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Replanning Criteria and Timing Definition for Parotid Protection-Based Adaptive Radiation Therapy in Nasopharyngeal Carcinoma. BIOMED RESEARCH INTERNATIONAL 2015; 2015:476383. [PMID: 26793717 PMCID: PMC4697077 DOI: 10.1155/2015/476383] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 11/30/2015] [Indexed: 11/30/2022]
Abstract
The goal of this study was to evaluate real-time volumetric and dosimetric changes of the parotid gland so as to determine replanning criteria and timing for parotid protection-based adaptive radiation therapy in nasopharyngeal carcinoma. Fifty NPC patients were treated with helical tomotherapy; volumetric and dosimetric (Dmean, V1, and D50) changes of the parotid gland at the 1st, 6th, 11th, 16th, 21st, 26th, 31st, and 33rd fractions were evaluated. The clinical parameters affecting these changes were studied by analyses of variance methods for repeated measures. Factors influencing the actual parotid dose were analyzed by a multivariate logistic regression model. The cut-off values predicting parotid overdose were developed from receiver operating characteristic curves and judged by combining them with a diagnostic test consistency check. The median absolute value and percentage of parotid volume reduction were 19.51 cm3 and 35%, respectively. The interweekly parotid volume varied significantly (p < 0.05). The parotid Dmean, V1, and D50 increased by 22.13%, 39.42%, and 48.45%, respectively. The actual parotid dose increased by an average of 11.38% at the end of radiation therapy. Initial parotid volume, initial parotid Dmean, and weight loss rate are valuable indicators for parotid protection-based replanning.
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93
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Mendez LC, Moraes FY, Poon I, Marta GN. The management of head and neck tumors with high technology radiation therapy. Expert Rev Anticancer Ther 2015; 16:99-110. [PMID: 26568146 DOI: 10.1586/14737140.2016.1121111] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Squamous cell carcinoma is responsible for 90% of the head and neck cancers affecting over 600,000 people worldwide. Radiation therapy, surgery and chemotherapy are the most important treatment modalities in head and neck squamous cell carcinoma. The aim of this review is to summarize the recent innovations in head and neck radiation therapy, which intends to appreciate the cutting-edge intensity-modulated radiation therapy strategies to mitigate long-term toxicities and evaluate promising technologies in the field as adaptive treatment, dose painting and proton therapy.
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Affiliation(s)
- Lucas Castro Mendez
- a Service of Radiation Oncology , Hospital Israelita Albert Einstein and Instituto de Radiologia (INRAD) - Faculdade de Medicina da Universidade de São Paulo (FMUSP) , São Paulo , Brazil
| | - Fabio Ynoe Moraes
- b Department of Radiation Oncology , Hospital Sírio-Libanes , São Paulo , Brazil.,c Service of Radiotherapy , Instituto de Radiologia (INRAD) - Faculdade de Medicina da Universidade de São Paulo (University of São Paulo - FMUSP) , São Paulo , Brazil
| | - Ian Poon
- d Department of Radiation Oncology , Sunnybrook Odette Cancer Centre - University of Toronto , Toronto , Canada
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94
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CBCT-guided radiotherapy for locally advanced head and cancer: dosimetric impact of weight loss on VMAT and IMRT plans for selected organs at risk structures (OARs). JOURNAL OF RADIOTHERAPY IN PRACTICE 2015. [DOI: 10.1017/s1460396915000291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractPurposeIt is common for head and neck patients to be affected by time trend errors as a result of weight loss during a course of radiation treatment. The objective of this planning study was to investigate the impact of weight loss on volumetric modulated arc therapy (VMAT) as well as intensity modulated radiation therapy (IMRT) for locally advanced head and neck cancer using automatic co-registration of the cone beam computed tomography.Materials and methodsA retrospective analysis of previously treated IMRT plans for ten patients with locally advanced head and neck cancer was done. A VMAT plan was also produced for all patients. We calculated the dose–volume histograms (DVH) indices for spinal cord planning at risk volumes (PRVs), the brainstem PRVs (SC+0·5 cm and BS+0·5 cm, respectively) as well as mean dose to the parotid glands.ResultsThe results show that the mean difference in dose to the SC+0·5 cm was 1·03% and 1·27% for the IMRT and VMAT plans, respectively. As for dose to the BS+0·5, the percentage difference was 0·63% for the IMRT plans and 0·61% for the VMAT plans. The analysis of the parotid gland doses shows that the percentage change in mean dose to left parotid was −8·0% whereas that of the right parotid was −6·4% for the IMRT treatment plans. In the VMAT plans, the percentages change for the left and the right parotid glands were −6·6 and −6·7% respectively.ConclusionsThis study shows a clinically significant impact of weight loss on DVH indices analysed in head and neck organs at risk. It highlights the importance of adaptive radiotherapy in head and neck patients if organ at risk sparing is to be maintained.
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95
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Brown E, Owen R, Harden F, Mengersen K, Oestreich K, Houghton W, Poulsen M, Harris S, Lin C, Porceddu S. Predicting the need for adaptive radiotherapy in head and neck cancer. Radiother Oncol 2015; 116:57-63. [PMID: 26142268 DOI: 10.1016/j.radonc.2015.06.025] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Revised: 06/12/2015] [Accepted: 06/22/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Adaptive radiotherapy (ART) can account for the dosimetric impact of anatomical change in head and neck cancer patients; however it can be resource intensive. Consequently, it is imperative that patients likely to require ART are identified. The purpose of this study was to find predictive factors that identify oropharyngeal squamous cell carcinoma (OPC) and nasopharyngeal carcinoma (NPC) patients more likely to need ART. MATERIALS AND METHODS One hundred and ten patients with OPC or NPC were analysed. Patient demographics and tumour characteristics were compared between patients who were replanned and those that were not. Factors found to be significant were included in logistic regression models. Risk profiles were developed from these models. A dosimetric analysis was performed. RESULTS Nodal disease stage, pre-treatment largest involved node size, diagnosis and initial weight (categorised in 2 groups) were identified as significant for inclusion in the model. Two models were found to be significant (p=0.001), correctly classifying 98.2% and 96.1% of patients respectively. Three ART risk profiles were developed. CONCLUSION Predictive factors identifying OPC or NPC patients more likely to require ART were reported. A risk profile approach could facilitate the effective implementation of ART into radiotherapy departments through forward planning and appropriate resource allocation.
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Affiliation(s)
- Elizabeth Brown
- Radiation Oncology Department, Princess Alexandra Hospital, Brisbane, Australia; Queensland University of Technology, Institute of Health and Biomedical Innovation, Brisbane, Australia.
| | - Rebecca Owen
- Radiation Oncology Department, Radiation Oncology Mater Centre, Brisbane, Australia
| | - Fiona Harden
- Queensland University of Technology, Institute of Health and Biomedical Innovation, Brisbane, Australia
| | - Kerrie Mengersen
- Queensland University of Technology, Institute of Health and Biomedical Innovation, Brisbane, Australia
| | - Kimberley Oestreich
- Radiation Oncology Department, Princess Alexandra Hospital, Brisbane, Australia
| | - Whitney Houghton
- Radiation Oncology Department, Radiation Oncology Mater Centre, Brisbane, Australia
| | - Michael Poulsen
- Radiation Oncology Department, Radiation Oncology Mater Centre, Brisbane, Australia
| | - Selina Harris
- Radiation Oncology Department, Royal Brisbane and Women's Hospital, Australia
| | - Charles Lin
- Radiation Oncology Department, Royal Brisbane and Women's Hospital, Australia
| | - Sandro Porceddu
- Radiation Oncology Department, Princess Alexandra Hospital, Brisbane, Australia; School of Medicine, University of Queensland, Brisbane, Australia
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96
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Brouwer CL, Steenbakkers RJ, Langendijk JA, Sijtsema NM. Identifying patients who may benefit from adaptive radiotherapy: Does the literature on anatomic and dosimetric changes in head and neck organs at risk during radiotherapy provide information to help? Radiother Oncol 2015; 115:285-94. [DOI: 10.1016/j.radonc.2015.05.018] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 05/17/2015] [Accepted: 05/24/2015] [Indexed: 10/23/2022]
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97
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Ramadaan IS, Peick K, Hamilton DA, Evans J, Iupati D, Nicholson A, Greig L, Louwe RJW. Validation of Varian's SmartAdapt® deformable image registration algorithm for clinical application. Radiat Oncol 2015; 10:73. [PMID: 25889772 PMCID: PMC4465143 DOI: 10.1186/s13014-015-0372-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 03/03/2015] [Indexed: 11/17/2022] Open
Abstract
Background Re-contouring of structures on consecutive planning computed tomography (CT) images for patients that exhibit anatomical changes is elaborate and may negatively impact the turn-around time if this is required for many patients. This study was therefore initiated to validate the accuracy and usefulness of automatic contour propagation for head and neck cancer patients using SmartAdapt® which is the deformable image registration (DIR) application in Varian’s Eclipse™ treatment planning system. Methods CT images of eight head and neck cancer patients with multiple planning CTs were registered using SmartAdapt®. The contoured structures of target volumes and OARs of the primary planning CT were deformed accordingly and subsequently compared with a reference structure set being either: 1) a structure set independently contoured by the treating Radiation Oncologist (RO), or 2) the DIR-generated structure set after being reviewed and modified by the RO. Results Application of DIR offered a considerable time saving for ROs in delineation of structures on CTs that were acquired mid-treatment. Quantitative analysis showed that 84% of the volume of the DIR-generated structures overlapped with the independently re-contoured structures, while 94% of the volume overlapped with the DIR-generated structures after review by the RO. This apparent intra-observer variation was further investigated resulting in the identification of several causes. Qualitative analysis showed that 92% of the DIR-generated structures either need no or only minor modification during RO reviews. Conclusions SmartAdapt is a powerful tool with sufficient accuracy that saves considerable time in re-contouring structures on re-CTs. However, careful review of the DIR-generated structures is mandatory, in particular in areas where tumour regression plays a role.
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Affiliation(s)
- Ihab S Ramadaan
- Department of Radiation Oncology, Wellington Blood and Cancer Centre, Wellington Hospital, Private Bag 7902, 6242, Wellington, New Zealand. .,Current address: Liz Plummer Cancer Care Centre, Cairns, Australia.
| | - Karsten Peick
- Department of Radiation Oncology, Wellington Blood and Cancer Centre, Wellington Hospital, Private Bag 7902, 6242, Wellington, New Zealand.
| | - David A Hamilton
- Department of Radiation Oncology, Wellington Blood and Cancer Centre, Wellington Hospital, Private Bag 7902, 6242, Wellington, New Zealand.
| | - Jamie Evans
- Department of Radiation Oncology, Wellington Blood and Cancer Centre, Wellington Hospital, Private Bag 7902, 6242, Wellington, New Zealand.
| | - Douglas Iupati
- Department of Radiation Oncology, Wellington Blood and Cancer Centre, Wellington Hospital, Private Bag 7902, 6242, Wellington, New Zealand.
| | - Anna Nicholson
- Department of Radiation Oncology, Wellington Blood and Cancer Centre, Wellington Hospital, Private Bag 7902, 6242, Wellington, New Zealand.
| | - Lynne Greig
- Department of Radiation Oncology, Wellington Blood and Cancer Centre, Wellington Hospital, Private Bag 7902, 6242, Wellington, New Zealand.
| | - Robert J W Louwe
- Department of Radiation Oncology, Wellington Blood and Cancer Centre, Wellington Hospital, Private Bag 7902, 6242, Wellington, New Zealand.
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Stoll M, Giske K, Debus J, Bendl R, Stoiber EM. The frequency of re-planning and its variability dependent on the modification of the re-planning criteria and IGRT correction strategy in head and neck IMRT. Radiat Oncol 2014; 9:175. [PMID: 25112458 PMCID: PMC4251689 DOI: 10.1186/1748-717x-9-175] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 07/31/2014] [Indexed: 12/03/2022] Open
Abstract
Background To analyse the frequency of re-planning and its variability dependent on the IGRT correction strategy and on the modification of the dosimetric criteria for re-planning for the spinal cord in head and neck IG-IMRT. Methods Daily kV-control-CTs of six head and neck patients (=175 CTs) were analysed. All volumes of interest were re-contoured using deformable image registration. Three IGRT correction strategies were simulated and the resulting dose distributions were computed for all fractions. Different sets of criteria with varying dose thresholds for re-planning were investigated. All sets of criteria ensure equivalent target coverage of both CTVs, but vary in the tolerance threshold of the spinal cord. Results The variations of the D95 and D2 in respect to the planned values ranged from -7% to +3% for both CTVs, and -2% to +6% for the spinal cord. Despite different correction vectors of the three IGRT strategies, the dosimetric differences were small. The number of fractions not requiring re-planning varied between 0% and 11% dependent on the applied IGRT correction strategy. In contrast, this number ranged between 32% and 70% dependent on the dosimetric thresholds, even though these thresholds were only gently modified. Conclusions The more precise the planned dose needs to be maintained over the treatment course, the more frequently re-planning is required. The influence of different IGRT correction strategies, even though geometrically notable, was found to be of only limited relevance for the re-planning frequency. In contrast, the definition and modification of thresholds for re-planning have a major impact on the re-planning frequency.
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Affiliation(s)
- Markus Stoll
- Department of Medical Physics in Radiation Oncology, DKFZ, INF 280, 69120 Heidelberg, Germany.
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