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Gambetta V, Fredriksson A, Menkel S, Richter C, Stützer K. The partial adaptation strategy for online-adaptive proton therapy: A proof of concept study in head and neck cancer patients. Med Phys 2024. [PMID: 38837396 DOI: 10.1002/mp.17178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 03/06/2024] [Accepted: 04/08/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND The accuracy of intensity-modulated proton therapy (IMPT) is greatly affected by anatomy variations that might occur during the treatment course. Online plan adaptations have been proposed as a solution to intervene promptly during a treatment session once the anatomy changes are detected. The implementation of online-adaptive proton therapy (OAPT) is still hindered by time-consuming tasks in the workflow. PURPOSE The study introduces the novel concept of partial adaptation and aims at investigating its feasibility as a potential solution to parallelize tasks during an OAPT workflow for saving valuable in-room time. METHODS The proof-of-principle simulation study includes datasets from six head and neck cancer (HNC) patients, each consisting of one planning CT (pCT) and three contoured control CTs (cCTs). Robust 3-field normo-fractionated initial IMPT plans were generated on the pCTs with a standardized field configuration, delivering 66 Gy and 54 Gy to the high-risk and low-risk clinical target volume (CTVHigh and CTVLow), respectively. For each cCT, a dose-mimicking-based partial adaptation was applied: two fields were adapted on the current anatomy taking into account the background dose of the first non-adapted field supposedly delivered in the meantime. Fraction doses on the cCTs resulting from partially adapted plans with different first (non-adapted) field assignments were compared against those from non-adapted and fully adapted plans regarding target coverage and organs at risk (OARs) sparing. The robustness of partially adapted plans was also evaluated. RESULTS Partially adapted plans showed comparable results to fully adapted plans and were superior to non-adapted plans for both target coverage and OAR sparing. Target coverage degradation in the non-adapted plans (median D98%: 95.9% and 97.5% for CTVLow and CTVHigh, respectively) was recovered by both partial (98.0% and 98.5%) and full adaptation (98.2% and 98.7%) in comparison to the initial plans (98.7% and 98.8%). The initial hotspot dose for the CTVHigh (median D2%: 101.8%) increased in the non-adapted plans (102.9%) and was recovered by the adaptive strategies (partial: 102.5%, full: 101.9%). The near-maximum dose (D0.01cc) to brainstem and spinal cord was within clinical constraints for all investigated dose distributions, but clearly increased for no adaptation and improved in the (both partially and fully) adapted plans with respect to the non-adapted ones. The parotids' median doses (D50) were mainly patient-specific depending on the proximity to the target region, but anyway lower for the partially and fully adapted plans compared to the non-adapted ones. OAR sparing was furthermore improved for the partially adapted plans in comparison to full adaptation. Robustness of the target dose metrics was preserved in all evaluated scenarios. CONCLUSIONS For OAPT of HNC patients, partial adaptation is able to generate plans of superior conformity to non-adapted plans and of comparable conformity as fully adapted plans, while having the potential to speed up the online-adaptive workflows. Thus, partial adaptation represents an intermediate approach until fast online adaptation workflows become available. Furthermore, it can be applied in workflows where online treatment verification stops the delivery and triggers an online adaptation for the remaining fraction.
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Affiliation(s)
- Virginia Gambetta
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany
- Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | | | - Stefan Menkel
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 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, Dresden, Germany
- Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - 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, Dresden, Germany
- Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
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Amstutz F, D'Almeida PG, Wu X, Albertini F, Bachtiary B, Weber DC, Unkelbach J, Lomax AJ, Zhang Y. Quantification of deformable image registration uncertainties for dose accumulation on head and neck cancer proton treatments. Phys Med 2024; 122:103386. [PMID: 38805762 DOI: 10.1016/j.ejmp.2024.103386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 03/11/2024] [Accepted: 05/21/2024] [Indexed: 05/30/2024] Open
Abstract
PURPOSE Head and neck cancer (HNC) patients in radiotherapy require adaptive treatment plans due to anatomical changes. Deformable image registration (DIR) is used in adaptive radiotherapy, e.g. for deformable dose accumulation (DDA). However, DIR's ill-posedness necessitates addressing uncertainties, often overlooked in clinical implementations. DIR's further clinical implementation is hindered by missing quantitative commissioning and quality assurance tools. This study evaluates one pathway for more quantitative DDA uncertainties. METHODS For five HNC patients, each with multiple repeated CTs acquired during treatment, a simultaneous-integrated boost (SIB) plan was optimized. Recalculated doses were warped individually using multiple DIRs from repeated to reference CTs, and voxel-by-voxel dose ranges determined an error-bar for DDA. Followed by evaluating, a previously proposed early-stage DDA uncertainty estimation method tested for lung cancer, which combines geometric DIR uncertainties, dose gradients and their directional dependence, in the context of HNC. RESULTS Applying multiple DIRs show dose differences, pronounced in high dose gradient regions. The patient with largest anatomical changes (-13.1 % in ROI body volume), exhibited 33 % maximum uncertainty in contralateral parotid, with 54 % of voxels presenting an uncertainty >5 %. Accumulation over multiple CTs partially mitigated uncertainties. The estimation approach predicted 92.6 % of voxels within ±5 % to the reference dose uncertainty across all patients. CONCLUSIONS DIR variations impact accumulated doses, emphasizing DDA uncertainty quantification's importance for HNC patients. Multiple DIR dose warping aids in quantifying DDA uncertainties. An estimation approach previously described for lung cancer was successfully validated for HNC, for SIB plans, presenting different dose gradients, and for accumulated treatments.
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Affiliation(s)
- Florian Amstutz
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland; Department of Physics, ETH Zurich, Switzerland
| | - Peter G D'Almeida
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland; Department of Information Technology & Electrical Engineering, ETH Zurich, Switzerland
| | - Xin Wu
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland; Department of Information Technology & Electrical Engineering, ETH Zurich, Switzerland
| | | | | | - Damien C Weber
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland; Department of Radiation Oncology, University Hospital Zurich, Switzerland; Department of Radiation Oncology, University Hospital Bern, Switzerland
| | - Jan Unkelbach
- Department of Radiation Oncology, University Hospital Zurich, Switzerland
| | - Antony J Lomax
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland; Department of Physics, ETH Zurich, Switzerland
| | - Ye Zhang
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland.
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3
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Amstutz F, Krcek R, Bachtiary B, Weber DC, Lomax AJ, Unkelbach J, Zhang Y. Treatment planning comparison for head and neck cancer between photon, proton, and combined proton-photon therapy - From a fixed beam line to an arc. Radiother Oncol 2024; 190:109973. [PMID: 37913953 DOI: 10.1016/j.radonc.2023.109973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 09/25/2023] [Accepted: 10/26/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND AND PURPOSE This study investigates whether combined proton-photon therapy (CPPT) improves treatment plan quality compared to single-modality intensity-modulated radiation therapy (IMRT) or intensity-modulated proton therapy (IMPT) for head and neck cancer (HNC) patients. Different proton beam arrangements for CPPT and IMPT are compared, which could be of specific interest concerning potential future upright-positioned treatments. Furthermore, it is evaluated if CPPT benefits remain under inter-fractional anatomical changes for HNC treatments. MATERIAL AND METHODS Five HNC patients with a planning CT and multiple (4-7) repeated CTs were studied. CPPT with simultaneously optimized photon and proton fluence, single-modality IMPT, and IMRT treatment plans were optimized on the planning CT and then recalculated and reoptimized on each repeated CT. For CPPT and IMPT, plans with different degrees of freedom for the proton beams were optimized. Fixed horizontal proton beam line (FHB), gantry-like, and arc-like plans were compared. RESULTS The target coverage for CPPT without adaptation is insufficient (average V95%=88.4 %), while adapted plans can recover the initial treatment plan quality for target (average V95%=95.5 %) and organs-at-risk. CPPT with increased proton beam flexibility increases plan quality and reduces normal tissue complication probability of Xerostomia and Dysphagia. On average, Xerostomia NTCP reductions compared to IMRT are -2.7 %/-3.4 %/-5.0 % for CPPT FHB/CPPT Gantry/CPPT Arc. The differences for IMPT FHB/IMPT Gantry/IMPT Arc are + 0.8 %/-0.9 %/-4.3 %. CONCLUSION CPPT for HNC needs adaptive treatments. Increasing proton beam flexibility in CPPT, either by using a gantry or an upright-positioned patient, improves treatment plan quality. However, the photon component is substantially reduced, therefore, the balance between improved plan quality and costs must be further determined.
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Affiliation(s)
- Florian Amstutz
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland; Department of Physics, ETH Zurich, Switzerland
| | - Reinhardt Krcek
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland; Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | | | - Damien C Weber
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland; Department of Radiation Oncology, University Hospital Zurich, Switzerland; Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Antony J Lomax
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland; Department of Physics, ETH Zurich, Switzerland
| | - Jan Unkelbach
- Department of Radiation Oncology, University Hospital Zurich, Switzerland
| | - Ye Zhang
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland.
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Reiners K, Dagan R, Holtzman A, Bryant C, Andersson S, Nilsson R, Hong L, Johnson P, Zhang Y. CBCT-Based Dose Monitoring and Adaptive Planning Triggers in Head and Neck PBS Proton Therapy. Cancers (Basel) 2023; 15:3881. [PMID: 37568697 PMCID: PMC10417147 DOI: 10.3390/cancers15153881] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/13/2023] Open
Abstract
PURPOSE To investigate the feasibility of using cone-beam computed tomography (CBCT)-derived synthetic CTs to monitor the daily dose and trigger a plan review for adaptive proton therapy (APT) in head and neck cancer (HNC) patients. METHODS For 84 HNC patients treated with proton pencil-beam scanning (PBS), same-day CBCT and verification CT (vfCT) pairs were retrospectively collected. The ground truth CT (gtCT) was created by deforming the vfCT to the same-day CBCT, and it was then used as a dosimetric baseline and for establishing plan review trigger recommendations. Two different synthetic CT algorithms were tested; the corrected CBCT (corrCBCT) was created using an iterative image correction method and the virtual CT (virtCT) was created by deforming the planning CT to the CBCT, followed by a low-density masking process. Clinical treatment plans were recalculated on the image sets for evaluation. RESULTS Plan review trigger criteria for adaptive therapy were established after closely reviewing the cohort data. Compared to the vfCT, the corrCBCT and virtCT reliably produced dosimetric data more similar to the gtCT. The average discrepancy in D99 for high-risk clinical target volumes (CTV) was 1.1%, 0.7%, and 0.4% and for standard-risk CTVs was 1.8%, 0.5%, and 0.5% for the vfCT, corrCBCT, and virtCT, respectively. CONCLUSION Streamlined APT has been achieved with the proposed plan review criteria and CBCT-based synthetic CT workflow.
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Affiliation(s)
- Keaton Reiners
- University of Florida Health Proton Therapy Institute, Jacksonville, FL 32206, USA; (K.R.); (R.D.); (C.B.); (P.J.)
- Medical Physics Graduate Program, University of Florida College of Medicine, Gainesville, FL 32610, USA
| | - Roi Dagan
- University of Florida Health Proton Therapy Institute, Jacksonville, FL 32206, USA; (K.R.); (R.D.); (C.B.); (P.J.)
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL 32610, USA
| | - Adam Holtzman
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA;
| | - Curtis Bryant
- University of Florida Health Proton Therapy Institute, Jacksonville, FL 32206, USA; (K.R.); (R.D.); (C.B.); (P.J.)
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL 32610, USA
| | | | - Rasmus Nilsson
- RaySearch Laboratories, SE-103 65 Stockholm, Sweden; (S.A.); (R.N.)
| | - Liu Hong
- Ion Beam Applications S.A., 1348 Louvain-la-Neuve, Belgium;
| | - Perry Johnson
- University of Florida Health Proton Therapy Institute, Jacksonville, FL 32206, USA; (K.R.); (R.D.); (C.B.); (P.J.)
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL 32610, USA
| | - Yawei Zhang
- University of Florida Health Proton Therapy Institute, Jacksonville, FL 32206, USA; (K.R.); (R.D.); (C.B.); (P.J.)
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL 32610, USA
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Lalonde A, Bobić M, Sharp GC, Chamseddine I, Winey B, Paganetti H. Evaluating the effect of setup uncertainty reduction and adaptation to geometric changes on normal tissue complication probability using online adaptive head and neck intensity modulated proton therapy. Phys Med Biol 2023; 68:115018. [PMID: 37164020 PMCID: PMC10351361 DOI: 10.1088/1361-6560/acd433] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 05/03/2023] [Accepted: 05/10/2023] [Indexed: 05/12/2023]
Abstract
Objective. To evaluate the impact of setup uncertainty reduction (SUR) and adaptation to geometrical changes (AGC) on normal tissue complication probability (NTCP) when using online adaptive head and neck intensity modulated proton therapy (IMPT).Approach.A cohort of ten retrospective head and neck cancer patients with daily scatter corrected cone-beam CT (CBCT) was studied. For each patient, two IMPT treatment plans were created: one with a 3 mm setup uncertainty robustness setting and one with no explicit setup robustness. Both plans were recalculated on the daily CBCT considering three scenarios: the robust plan without adaptation, the non-robust plan without adaptation and the non-robust plan with daily online adaptation. Online-adaptation was simulated using an in-house developed workflow based on GPU-accelerated Monte Carlo dose calculation and partial spot-intensity re-optimization. Dose distributions associated with each scenario were accumulated on the planning CT, where NTCP models for six toxicities were applied. NTCP values from each scenario were intercompared to quantify the reduction in toxicity risk induced by SUR alone, AGC alone and SUR and AGC combined. Finally, a decision tree was implemented to assess the clinical significance of the toxicity reduction associated with each mechanism.Main results. For most patients, clinically meaningful NTCP reductions were only achieved when SUR and AGC were performed together. In these conditions, total reductions in NTCP of up to 30.48 pp were obtained, with noticeable NTCP reductions for aspiration, dysphagia and xerostomia (mean reductions of 8.25, 5.42 and 5.12 pp respectively). While SUR had a generally larger impact than AGC on NTCP reductions, SUR alone did not induce clinically meaningful toxicity reductions in any patient, compared to only one for AGC alone.SignificanceOnline adaptive head and neck proton therapy can only yield clinically significant reductions in the risk of long-term side effects when combining the benefits of SUR and AGC.
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Affiliation(s)
- Arthur Lalonde
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Mislav Bobić
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
- ETH Zürich, Zürich, Switzerland
| | - Gregory C Sharp
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Ibrahim Chamseddine
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Brian Winey
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
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Huiskes M, Astreinidou E, Kong W, Breedveld S, Heijmen B, Rasch C. Dosimetric impact of adaptive proton therapy in head and neck cancer - A review. Clin Transl Radiat Oncol 2023; 39:100598. [PMID: 36860581 PMCID: PMC9969246 DOI: 10.1016/j.ctro.2023.100598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/10/2023] [Accepted: 02/12/2023] [Indexed: 02/18/2023] Open
Abstract
Background Intensity Modulated Proton Therapy (IMPT) in head and neck cancer (HNC) is susceptible to anatomical changes and patient set-up inaccuracies during the radiotherapy course, which can cause discrepancies between planned and delivered dose. The discrepancies can be counteracted by adaptive replanning strategies. This article reviews the observed dosimetric impact of adaptive proton therapy (APT) and the timing to perform a plan adaptation in IMPT in HNC. Methods A literature search of articles published in PubMed/MEDLINE, EMBASE and Web of Science from January 2010 to March 2022 was performed. Among a total of 59 records assessed for possible eligibility, ten articles were included in this review. Results Included studies reported on target coverage deterioration in IMPT plans during the RT course, which was recovered with the application of an APT approach. All APT plans showed an average improved target coverage for the high- and low-dose targets as compared to the accumulated dose on the planned plans. Dose improvements up to 2.5 Gy (3.5 %) and up to 4.0 Gy (7.1 %) in the D98 of the high- and low dose targets were observed with APT. Doses to the organs at risk (OARs) remained equal or decreased slightly after APT was applied. In the included studies, APT was largely performed once, which resulted in the largest target coverage improvement, but eventual additional APT improved the target coverage further. There is no data showing what is the most appropriate timing for APT. Conclusion APT during IMPT for HNC patients improves target coverage. The largest improvement in target coverage was found with a single adaptive intervention, and an eventual second or more frequent APT application improved the target coverage further. Doses to the OARs remained equal or decreased slightly after applying APT. The most optimal timing for APT is yet to be determined.
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Affiliation(s)
- Merle Huiskes
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands,Corresponding author at: Department of Radiation Oncology, Leiden University Medical Centre, Albinusdreef 2, P.O. Box 9600, Postal zone K1-P, 2300 RC Leiden, the Netherlands.
| | - Eleftheria Astreinidou
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Wens Kong
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, the Netherlands
| | - Sebastiaan Breedveld
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, the Netherlands
| | - Ben Heijmen
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, the Netherlands
| | - Coen Rasch
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands,HollandPTC, Delft, the Netherlands
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Miyazaki K, Fujii Y, Yamada T, Kanehira T, Miyamoto N, Matsuura T, Yasuda K, Uchinami Y, Otsuka M, Aoyama H, Takao S. Deformed dose restoration to account for tumor deformation and position changes for adaptive proton therapy. Med Phys 2023; 50:675-687. [PMID: 36502527 DOI: 10.1002/mp.16149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/10/2022] [Accepted: 11/25/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Online adaptation during intensity-modulated proton therapy (IMPT) can minimize the effect of inter-fractional anatomical changes, but remains challenging because of the complex workflow. One approach for fast and automated online IMPT adaptation is dose restoration, which restores the initial dose distribution on the updated anatomy. However, this method may fail in cases where tumor deformation or position changes occur. PURPOSE To develop a fast and robust IMPT online adaptation method named "deformed dose restoration (DDR)" that can adjust for inter-fractional tumor deformation and position changes. METHODS The DDR method comprises two steps: (1) calculation of the deformed dose distribution, and (2) restoration of the deformed dose distribution. First, the deformable image registration (DIR) between the initial clinical target volume (CTV) and the new CTV were performed to calculate the vector field. To ensure robustness for setup and range uncertainty and the ability to restore the deformed dose distribution, an expanded CTV-based registration to maintain the dose gradient outside the CTV was developed. The deformed dose distribution was obtained by applying the vector field to the initial dose distribution. Then, the voxel-by-voxel dose difference optimization was performed to calculate beam parameters that restore the deformed dose distribution on the updated anatomy. The optimization function was the sum of total dose differences and dose differences of each field to restore the initial dose overlap of each field. This method only requires target contouring, which eliminates the need for organs at risk (OARs) contouring. Six clinical cases wherein the tumor deformation and/or position changed on repeated CTs were selected. DDR feasibility was evaluated by comparing the results with those from three other strategies, namely, not adapted (continuing the initial plan), adapted by previous dose restoration, and fully optimized. RESULTS In all cases, continuing the initial plan was largely distorted on the repeated CTs and the dose-volume histogram (DVH) metrics for the target were reduced due to the tumor deformation or position changes. On the other hand, DDR improved DVH metrics for the target to the same level as the initial dose distribution. Dose increase was seen for some OARs because tumor growth had reduced the relative distance between CTVs and OARs. Robustness evaluation for setup and range uncertainty (3 mm/3.5%) showed that deviation in DVH-bandwidth for CTV D95% from the initial plan was 0.4% ± 0.5% (Mean ± S.D.) for DDR. The calculation time was 8.1 ± 6.4 min. CONCLUSIONS An online adaptation algorithm was developed that improved the treatment quality for inter-fractional anatomical changes and retained robustness for intra-fractional setup and range uncertainty. The main advantage of this method is that it only requires target contouring alone and saves the time for OARs contouring. The fast and robust adaptation method for tumor deformation and position changes described here can reduce the need for offline adaptation and improve treatment efficiency.
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Affiliation(s)
- Koichi Miyazaki
- Graduate School of Biomedical Science and Engineering, Hokkaido University, Sapporo, Hokkaido, Japan.,Department of Medical Physics, Hokkaido University Hospital, Sapporo, Hokkaido, Japan.,Research and Development Group, Hitachi Ltd, Hitachi, Ibaraki, Japan
| | - Yusuke Fujii
- Research and Development Group, Hitachi Ltd, Hitachi, Ibaraki, Japan
| | - Takahiro Yamada
- Research and Development Group, Hitachi Ltd, Hitachi, Ibaraki, Japan
| | - Takahiro Kanehira
- Department of Medical Physics, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Naoki Miyamoto
- Department of Medical Physics, Hokkaido University Hospital, Sapporo, Hokkaido, Japan.,Division of Quantum Science and Engineering, Faculty of Engineering, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Taeko Matsuura
- Department of Medical Physics, Hokkaido University Hospital, Sapporo, Hokkaido, Japan.,Division of Quantum Science and Engineering, Faculty of Engineering, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Koichi Yasuda
- Department of Radiation Oncology, Faculty of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Yusuke Uchinami
- Department of Radiation Oncology, Faculty of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Manami Otsuka
- Department of Radiation Oncology, Faculty of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Hidefumi Aoyama
- Department of Radiation Oncology, Faculty of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Seishin Takao
- Department of Medical Physics, Hokkaido University Hospital, Sapporo, Hokkaido, Japan.,Division of Quantum Science and Engineering, Faculty of Engineering, Hokkaido University, Sapporo, Hokkaido, Japan.,Global Center for Biomedical Science and Engineering, Faculty of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
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8
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Zhang Y, Alshaikhi J, Amos RA, Tan W, Anaya VM, Pang Y, Royle G, Bär E. Pre-treatment analysis of non-rigid variations can assist robust intensity-modulated proton therapy plan selection for head and neck patients. Med Phys 2022; 49:7683-7693. [PMID: 36083223 PMCID: PMC10092578 DOI: 10.1002/mp.15971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 08/13/2022] [Accepted: 08/27/2022] [Indexed: 12/27/2022] Open
Abstract
PURPOSE To incorporate small non-rigid variations of head and neck patients into the robust evaluation of intensity-modulated proton therapy (IMPT) for the selection of robust treatment plans. METHODS A cohort of 20 nasopharynx cancer patients with weekly kilovoltage CT (kVCT) and 15 oropharynx cancer patients with weekly cone-beam CT (CBCT) were retrospectively included. Anatomical variations between week 0/week 1 of treatment were acquired using deformable image registration (DIR) for all 35 patients and then applied to the planning CT of four patients who have kVCT scanned each week to simulate potential small non-rigid variations (sNRVs). The robust evaluations were conducted on IMPT plans with: (1) different number of beam fields from 3-field to 5-field; (2) different beam angles. The robust evaluation before treatment, including the sNRVs and setup uncertainty, referred to as sNRV+R evaluation was compared with the conventional evaluation (without sNRVs) in terms of robustness consistency with the gold standard evaluation based on weekly CT. RESULTS Among four patients (490 scenarios), we observed a maximum difference in the sNRV+R evaluation to the nominal dose of: 9.37% dose degradation on D95 of clinical target volumes (CTVs), increase in mean dose (D mean $_{\text{mean}}$ ) of parotid 11.87 Gy, increase in max dose (D max $_{\text{max}}$ ) of brainstem 20.82 Gy. In contrast, in conventional evaluation, we observed a maximum difference to the nominal dose of: 7.58% dose degradation on D95 of the CTVs, increase in parotid D mean $_{\text{mean}}$ by 4.88 Gy, increase in brainstem D max $_{\text{max}}$ by 13.5 Gy. In the measurement of the robustness ranking consistency with the gold standard evaluation, the sNRV+R evaluation was better or equal to the conventional evaluation in 77% of cases, particularly, better on spinal cord, parotid glands, and low-risk CTV. CONCLUSION This study demonstrated the additional dose discrepancy that sNRVs can make. The inclusion of sNRVs can be beneficial to robust evaluation, providing information on clinical uncertainties additional to the conventional rigid isocenter shift.
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Affiliation(s)
- Ying Zhang
- Department of Medical Physics and Biomedical Engineering, University College London, Gower Street, London, UK
| | - Jailan Alshaikhi
- Saudi Proton Therapy Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Richard A Amos
- Department of Medical Physics and Biomedical Engineering, University College London, Gower Street, London, UK
| | - Wenyong Tan
- Department of Oncology, Shenzhen Hospital of Southern Medical University Shenzhen, Guangdong, China
| | - Virginia Marin Anaya
- University College London Hospitals NHS Foundation Trust, Radiotherapy Physics, London, UK
| | - Yaru Pang
- Department of Medical Physics and Biomedical Engineering, University College London, Gower Street, London, UK
| | - Gary Royle
- Department of Medical Physics and Biomedical Engineering, University College London, Gower Street, London, UK
| | - Esther Bär
- Department of Medical Physics and Biomedical Engineering, University College London, Gower Street, London, UK.,University College London Hospitals NHS Foundation Trust, Radiotherapy Physics, London, UK
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9
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Zhao L, Liu G, Li X, Ding X. An evolutionary optimization algorithm for proton arc therapy. Phys Med Biol 2022; 67. [DOI: 10.1088/1361-6560/ac8411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 07/25/2022] [Indexed: 11/12/2022]
Abstract
Abstract
Objective. Proton arc plan normally contains thousands of spot numbers and hundreds of energy layers. A recent study reported that the beam delivery time (BDT) is proportional to the spot numbers. Thus, it is critical to find an optimal plan with a fast delivery speed while maintaining a good plan quality. Thus, we developed a novel evolutionary algorithm to directly search for the optimal spot sparsity solution to balance plan quality and BDT. Approach. The planning platform included a plan quality objective, a generator, and a selector. The generator is based on trust-region-reflective solver. A selector was designed to filter or add the spot according to the expected spot number, based on the user’s input of BDT. The generator and selector are used alternatively to optimize a spot sparsity solution. Three clinical cases’ CT and structure datasets, e.g. brain, lung, and liver cancer, were used for testing purposes. A series of user-defined BDTs from 15 to 250 s were used as direct inputs. The relationship between the plan’s cost function value and BDT was evaluated in these three cases. Main results. The evolutionary algorithm could optimize a proton arc plan based on clinical user input BDT directly. The plan quality remains optimal in the brain, lung, and liver cases until the BDT was shorter than 25 s, 50 s and 100 s, respectively. The plan quality degraded as the input delivery time became too short, indicating that the plan lacked enough spot or degree of freedom. Significance. This is the first proton arc planning framework to directly optimize plan quality with the BDT as an input for the new generation of proton therapy systems. This work paved the roadmap for implementing such new technology in a routine clinic and provided a planning platform to explore the trade-off between the BDT and plan quality.
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10
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Nuyts S, Bollen H, Ng SP, Corry J, Eisbruch A, Mendenhall WM, Smee R, Strojan P, Ng WT, Ferlito A. Proton Therapy for Squamous Cell Carcinoma of the Head and Neck: Early Clinical Experience and Current Challenges. Cancers (Basel) 2022; 14:cancers14112587. [PMID: 35681568 PMCID: PMC9179360 DOI: 10.3390/cancers14112587] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 05/18/2022] [Accepted: 05/20/2022] [Indexed: 11/19/2022] Open
Abstract
Simple Summary Proton therapy is a promising type of radiation therapy used to destroy tumor cells. It has the potential to further improve the outcomes for patients with head and neck cancer since it allows to minimize the radiation dose to vital structures around the tumor, leading to less toxicity. This paper describes the current experience worldwide with proton therapy in head and neck cancer. Abstract Proton therapy (PT) is a promising development in radiation oncology, with the potential to further improve outcomes for patients with squamous cell carcinoma of the head and neck (HNSCC). By utilizing the finite range of protons, healthy tissue can be spared from beam exit doses that would otherwise be irradiated with photon-based treatments. Current evidence on PT for HNSCC is limited to comparative dosimetric analyses and retrospective single-institution series. As a consequence, the recognized indications for the reimbursement of PT remain scarce in most countries. Nevertheless, approximately 100 PT centers are in operation worldwide, and initial experiences for HNSCC are being reported. This review aims to summarize the results of the early clinical experience with PT for HNSCC and the challenges that are currently faced.
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Affiliation(s)
- Sandra Nuyts
- Laboratory of Experimental Radiotherapy, Department of Oncology, Katholieke Universiteit Leuven, 3000 Leuven, Belgium;
- Department of Oncology, Leuven Cancer Institute, Universitair Ziekenhuis Leuven, 3000 Leuven, Belgium
- Correspondence:
| | - Heleen Bollen
- Laboratory of Experimental Radiotherapy, Department of Oncology, Katholieke Universiteit Leuven, 3000 Leuven, Belgium;
- Department of Oncology, Leuven Cancer Institute, Universitair Ziekenhuis Leuven, 3000 Leuven, Belgium
| | - Sweet Ping Ng
- Department of Radiation Oncology, Austin Health, The University of Melbourne, Melbourne, VIC 3000, Australia;
| | - June Corry
- Division of Medicine, Department of Radiation Oncology, St. Vincent’s Hospital, The University of Melbourne, Melbourne, VIC 3000, Australia;
| | - Avraham Eisbruch
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI 48109, USA;
| | - William M Mendenhall
- Department of Radiation Oncology, College of Medicine, University of Florida, Gainesville, FL 32209, USA;
| | - Robert Smee
- Department of Radiation Oncology, The Prince of Wales Cancer Centre, Sydney, NSW 2031, Australia;
| | - Primoz Strojan
- Department of Radiation Oncology, Institute of Oncology, University of Ljubljana, 1000 Ljubljana, Slovenia;
| | - Wai Tong Ng
- Department of Clinical Oncology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China;
| | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group, 35125 Padua, Italy;
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11
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Zhang Y, McGowan Holloway S, Zoë Wilson M, Alshaikhi J, Tan W, Royle G, Bär E. DIR-based models to predict weekly anatomical changes in head and neck cancer proton therapy. Phys Med Biol 2022; 67:095001. [PMID: 35316795 PMCID: PMC10437002 DOI: 10.1088/1361-6560/ac5fe2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 03/17/2022] [Accepted: 03/22/2022] [Indexed: 11/12/2022]
Abstract
Objective. We proposed two anatomical models for head and neck patients to predict anatomical changes during the course of radiotherapy.Approach. Deformable image registration was used to build two anatomical models: (1) the average model (AM) simulated systematic progressive changes across the patient cohort; (2) the refined individual model (RIM) used a patient's CT images acquired during treatment to update the prediction for each individual patient. Planning CTs and weekly CTs were used from 20 nasopharynx patients. This dataset included 15 training patients and 5 test patients. For each test patient, a spot scanning proton plan was created. Models were evaluated using CT number differences, contours, proton spot location deviations and dose distributions.Main results. If no model was used, the CT number difference between the planning CT and the repeat CT at week 6 of treatment was on average 128.9 Hounsfield Units (HU) over the test population. This can be reduced to 115.5 HU using the AM, and to 110.5 HU using the RIM3(RIM, updated at week (3). When the predicted contours from the models were used, the average mean surface distance of parotid glands can be reduced from 1.98 (no model) to 1.16 mm (AM) and 1.19 mm (RIM3) at week 6. Using the proton spot range, the average anatomical uncertainty over the test population reduced from 4.47 ± 1.23 (no model) to 2.41 ± 1.12 mm (AM), and 1.89 ± 0.96 mm (RIM3). Based on the gamma analysis, the average gamma index over the test patients was improved from 93.87 ± 2.48 % (no model) to 96.16 ± 1.84% (RIM3) at week 6.Significance. The AM and the RIM both demonstrated the ability to predict anatomical changes during the treatment. The RIM can gradually refine the prediction of anatomical changes based on the AM. The proton beam spots provided an accurate and effective way for uncertainty evaluation.
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Affiliation(s)
- Ying Zhang
- Department of Medical Physics and Biomedical Engineering, University College London, Gower Street, London WC1E 6BT, United Kingdom
| | - Stacey McGowan Holloway
- CRUK RadNet Glasgow, University of Glasgow, Beatson West of Scotland Cancer Centre, Radiotherapy Physics, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
| | - Megan Zoë Wilson
- Department of Medical Physics and Biomedical Engineering, University College London, Gower Street, London WC1E 6BT, United Kingdom
| | - Jailan Alshaikhi
- Saudi Proton Therapy Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Wenyong Tan
- Department of Oncology, Shenzhen Hospital of Southern Medical University Shenzhen 518101, People's Republic of China
| | - Gary Royle
- Department of Medical Physics and Biomedical Engineering, University College London, Gower Street, London WC1E 6BT, United Kingdom
| | - Esther Bär
- Department of Medical Physics and Biomedical Engineering, University College London, Gower Street, London WC1E 6BT, United Kingdom
- University College London Hospitals NHS Foundation Trust, Radiotherapy Physics, 250 Euston Road, London NW1 2PG, United Kingdom
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12
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Stanforth A, Lin L, Beitler JJ, Janopaul-Naylor JR, Chang CW, Press RH, Patel SA, Zhao J, Eaton B, Schreibmann EE, Jung J, Bohannon D, Liu T, Yang X, McDonald MW, Zhou J. Onboard cone-beam CT-based replan evaluation for head and neck proton therapy. J Appl Clin Med Phys 2022; 23:e13550. [PMID: 35128788 PMCID: PMC9121026 DOI: 10.1002/acm2.13550] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 12/08/2021] [Accepted: 01/20/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Quality assurance computed tomography (QACT) is the current clinical practice in proton therapy to evaluate the needs for replan. QACT could falsely indicate replan because of setup issues that would be solved on the treatment machine. Deforming the treatment planning CT (TPCT) to the pretreatment CBCT may eliminate this issue. We investigated the performance of replan evaluation based on deformed TPCT (TPCTdir) for proton head and neck (H&N) therapy. Methods and materials Twenty‐eight H&N datasets along with pretreatment CBCT and QACT were used to validate the method. The changes in body volume were analyzed between the no‐replan and replan groups. The dose on the TPCTdir, the deformed QACT (QACTdir), and the QACT were calculated by applying the clinical plans to these image sets. Dosimetric parameters’ changes, including ΔD95, ΔDmean, and ΔD1 for the clinical target volumes (CTVs) were calculated. Receiver operating characteristic curves for replan evaluation based on ΔD95 on QACT and TPCTdir were calculated, using ΔD95 on QACTdir as the reference. A threshold for replan based on ΔD95 on TPCTdir is proposed. The specificities for the proposed method were calculated. Results The changes in the body contour were 95.8 ± 83.8 cc versus 305.0 ± 235.0 cc (p < 0.01) for the no‐replan and replan groups, respectively. The ΔD95, ΔDmean, and ΔD1 are all comparable for all the evaluations. The differences between TPCTdir and QACTdir evaluations were 0.30% ± 0.86%, 0.00 ± 0.22 Gy, and −0.17 ± 0.61 Gy for CTV ΔD95, ΔDmean, and ΔD1, respectively. The corresponding differences between the QACT and QACTdir were 0.12% ± 1.1%, 0.02 ± 0.32 Gy, and −0.01 ± 0.71 Gy. CTV ΔD95 > 2.6% in TPCTdir was chosen as the threshold to trigger QACT/replan. The corresponding specificity was 94% and 98% for the clinical practice and the proposed method, respectively. Conclusions The replan evaluation based on TPCTdir provides better specificity than that based on the QACT.
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Affiliation(s)
- Alexander Stanforth
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Liyong Lin
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Jonathan J Beitler
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - James R Janopaul-Naylor
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Chih-Wei Chang
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Robert H Press
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA.,New York Proton Center, New York, New York, USA
| | - Sagar A Patel
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Jennifer Zhao
- Department of Pre-Medicine, Cornell University, New York, New York, USA
| | - Bree Eaton
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Eduard E Schreibmann
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - James Jung
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Duncan Bohannon
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA.,Medical Physics Program, Georgia institute of Technology, Atlanta, Georgia, USA
| | - Tian Liu
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Xiaofeng Yang
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Mark W McDonald
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Jun Zhou
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
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13
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Scandurra D, Meijer T, Free J, van den Hoek J, Kelder L, Oldehinkel E, Steenbakkers R, Both S, Langendijk J. Evaluation of robustly optimised intensity modulated proton therapy for nasopharyngeal carcinoma. Radiother Oncol 2022; 168:221-228. [DOI: 10.1016/j.radonc.2022.01.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 01/31/2022] [Accepted: 01/31/2022] [Indexed: 02/08/2023]
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14
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Paganetti H, Botas P, Sharp GC, Winey B. Adaptive proton therapy. Phys Med Biol 2021; 66:10.1088/1361-6560/ac344f. [PMID: 34710858 PMCID: PMC8628198 DOI: 10.1088/1361-6560/ac344f] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/28/2021] [Indexed: 12/25/2022]
Abstract
Radiation therapy treatments are typically planned based on a single image set, assuming that the patient's anatomy and its position relative to the delivery system remains constant during the course of treatment. Similarly, the prescription dose assumes constant biological dose-response over the treatment course. However, variations can and do occur on multiple time scales. For treatment sites with significant intra-fractional motion, geometric changes happen over seconds or minutes, while biological considerations change over days or weeks. At an intermediate timescale, geometric changes occur between daily treatment fractions. Adaptive radiation therapy is applied to consider changes in patient anatomy during the course of fractionated treatment delivery. While traditionally adaptation has been done off-line with replanning based on new CT images, online treatment adaptation based on on-board imaging has gained momentum in recent years due to advanced imaging techniques combined with treatment delivery systems. Adaptation is particularly important in proton therapy where small changes in patient anatomy can lead to significant dose perturbations due to the dose conformality and finite range of proton beams. This review summarizes the current state-of-the-art of on-line adaptive proton therapy and identifies areas requiring further research.
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Affiliation(s)
- Harald Paganetti
- Department of Radiation Oncology, Physics Division, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Pablo Botas
- Department of Radiation Oncology, Physics Division, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Foundation 29 of February, Pozuelo de Alarcón, Madrid, Spain
| | - Gregory C Sharp
- Department of Radiation Oncology, Physics Division, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Brian Winey
- Department of Radiation Oncology, Physics Division, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
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15
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Adaptive radiation therapy: When, how and what are the benefits that literature provides? Cancer Radiother 2021; 26:622-636. [PMID: 34688548 DOI: 10.1016/j.canrad.2021.08.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 08/21/2021] [Accepted: 08/24/2021] [Indexed: 11/21/2022]
Abstract
PURPOSE To identify from the current literature when is the right time to replan and to assign thresholds for the optimum process of replanning. Nowadays, adaptive radiotherapy (ART) for head and neck cancer plays an exceptional role consisting of an evaluation procedure of the prominent anatomical and dosimetric variations. By performing complex radiotherapy methods, the credibility of the therapeutic result is crucial. Image guided radiotherapy (IGRT) was developed to ensure locoregional control and thus changes that might occur during radiotherapy be dealt with. MATERIALS AND METHODS An electronic research of articles published in PubMed/MEDLINE and Science Direct databases from January 2004 to October 2020 was performed. Among a total of 127 studies assessed for eligibility, 85 articles were ultimately retained for the review. RESULTS The most noticeable changes have been reported in the middle fraction of the treatment. Therefore, the suggested optimal time to replan is between the third and the fourth week. Anatomical deviations>1cm in the external contour, average weight loss>10%, violation in the dose coverage of the targets>5%, and violation in the dose of the peripherals were some of the thresholds that are currently used, and which lead to replanning. CONCLUSION ART may decrease toxicity and improve local-control. Whether it is beneficial or not, depends ultimately on each patient. However, more investigation of the changes should be performed in future prospective studies to obtain more accurate results.
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16
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Nenoff L, Matter M, Charmillot M, Krier S, Uher K, Weber DC, Lomax AJ, Albertini F. Experimental validation of daily adaptive proton therapy. Phys Med Biol 2021; 66. [PMID: 34587589 DOI: 10.1088/1361-6560/ac2b84] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 09/29/2021] [Indexed: 11/12/2022]
Abstract
Anatomical changes during proton therapy require rapid treatment plan adaption to mitigate the associated dosimetric impact. This in turn requires a highly efficient workflow that minimizes the time between imaging and delivery. At the Paul Scherrer Institute, we have developed an online adaptive workflow, which is specifically designed for treatments in the skull-base/cranium, with the focus set on simplicity and minimizing changes to the conventional workflow. The dosimetric and timing performance of this daily adaptive proton therapy (DAPT) workflow has been experimentally investigated using an in-house developed DAPT software and specifically developed anthropomorphic phantom. After a standard treatment preparation, which includes the generation of a template plan, the treatment can then be adapted each day, based on daily imaging acquired on an in-room CT. The template structures are then rigidly propagated to this CT and the daily plan is fully re-optimized using the same field arrangement, DVH constraints and optimization settings of the template plan. After a dedicated plan QA, the daily plan is delivered. To minimize the time between imaging and delivery, clinically integrated software for efficient execution of all online adaption steps, as well as tools for comprehensive and automated QA checks, have been developed. Film measurements of an end-to-end validation of a multi-fraction DAPT treatment showed high agreement to the calculated doses. Gamma pass rates with a 3%/3 mm criteria were >92% when comparing the measured dose to the template plan. Additionally, a gamma pass rate >99% was found comparing measurements to the Monte Carlo dose of the daily plans reconstructed from the logfile, accumulated over the delivered fractions. With this, we experimentally demonstrate that the described adaptive workflow can be delivered accurately in a timescale similar to a standard delivery.
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Affiliation(s)
- Lena Nenoff
- Paul Scherrer Institute, Center for Proton Therapy, Switzerland.,Department of Physics, ETH Zurich, Switzerland
| | - Michael Matter
- Paul Scherrer Institute, Center for Proton Therapy, Switzerland.,Department of Physics, ETH Zurich, Switzerland
| | | | - Serge Krier
- Department of Physics, ETH Zurich, Switzerland
| | - Klara Uher
- Department of Physics, ETH Zurich, Switzerland
| | - Damien Charles Weber
- Paul Scherrer Institute, Center for Proton Therapy, Switzerland.,Department of Radiation Oncology, University Hospital Zurich, Switzerland.,Department of Radiation Oncology, University Hospital Bern, Switzerland
| | - Antony John Lomax
- Paul Scherrer Institute, Center for Proton Therapy, Switzerland.,Department of Physics, ETH Zurich, Switzerland
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17
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Vidal M, Moignier C, Patriarca A, Sotiropoulos M, Schneider T, De Marzi L. Future technological developments in proton therapy - A predicted technological breakthrough. Cancer Radiother 2021; 25:554-564. [PMID: 34272182 DOI: 10.1016/j.canrad.2021.06.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 06/18/2021] [Indexed: 12/13/2022]
Abstract
In the current spectrum of cancer treatments, despite high costs, a lack of robust evidence based on clinical outcomes or technical and radiobiological uncertainties, particle therapy and in particular proton therapy (PT) is rapidly growing. Despite proton therapy being more than fifty years old (first proposed by Wilson in 1946) and more than 220,000 patients having been treated with in 2020, many technological challenges remain and numerous new technical developments that must be integrated into existing systems. This article presents an overview of on-going technical developments and innovations that we felt were most important today, as well as those that have the potential to significantly shape the future of proton therapy. Indeed, efforts have been done continuously to improve the efficiency of a PT system, in terms of cost, technology and delivery technics, and a number of different developments pursued in the accelerator field will first be presented. Significant developments are also underway in terms of transport and spatial resolution achievable with pencil beam scanning, or conformation of the dose to the target: we will therefore discuss beam focusing and collimation issues which are important parameters for the development of these techniques, as well as proton arc therapy. State of the art and alternative approaches to adaptive PT and the future of adaptive PT will finally be reviewed. Through these overviews, we will finally see how advances in these different areas will allow the potential for robust dose shaping in proton therapy to be maximised, probably foreshadowing a future era of maturity for the PT technique.
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Affiliation(s)
- M Vidal
- Centre Antoine-Lacassagne, Fédération Claude Lalanne, 227, avenue de la Lanterne, 06200 Nice, France
| | - C Moignier
- Centre François Baclesse, Department of Medical Physics, Centre de protonthérapie de Normandie, 14000 Caen, France
| | - A Patriarca
- Institut Curie, PSL Research University, Radiation oncology department, Centre de protonthérapie d'Orsay, Campus universitaire, bâtiment 101, 91898 Orsay, France
| | - M Sotiropoulos
- Institut Curie, Université PSL, CNRS UMR3347, Inserm U1021, Signalisation radiobiologie et cancer, 91400 Orsay, France
| | - T Schneider
- Institut Curie, Université PSL, CNRS UMR3347, Inserm U1021, Signalisation radiobiologie et cancer, 91400 Orsay, France
| | - L De Marzi
- Institut Curie, PSL Research University, Radiation oncology department, Centre de protonthérapie d'Orsay, Campus universitaire, bâtiment 101, 91898 Orsay, France; Institut Curie, PSL Research University, University Paris Saclay, Inserm LITO, Campus universitaire, 91898 Orsay, France.
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18
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Lalonde A, Bobić M, Winey B, Verburg J, Sharp GC, Paganetti H. Anatomic changes in head and neck intensity-modulated proton therapy: Comparison between robust optimization and online adaptation. Radiother Oncol 2021; 159:39-47. [PMID: 33741469 PMCID: PMC8205952 DOI: 10.1016/j.radonc.2021.03.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 03/08/2021] [Accepted: 03/08/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND/PURPOSE Setup variations and anatomical changes can severely affect the quality of head and neck intensity-modulated proton therapy (IMPT) treatments. The impact of these changes can be alleviated by increasing the plan's robustness a priori, or by adapting the plan online. This work compares these approaches in the context of head and neck IMPT. MATERIALS/METHODS A representative cohort of 10 head and neck squamous cell carcinoma (HNSCC) patients with daily cone-beam computed tomography (CBCT) was evaluated. For each patient, three IMPT plans were created: 1- a classical robust optimization (cRO) plan optimized on the planning CT, 2- an anatomical robust optimization (aRO) plan additionally including the two first daily CBCTs and 3- a plan optimized without robustness constraints, but online-adapted (OA) daily, using a constrained spot intensity re-optimization technique only. RESULTS The cumulative dose following OA fulfilled the clinical objective of both the high-risk and low-risk clinical target volumes (CTV) coverage in all 10 patients, compared to 8 for aRO and 4 for cRO. aRO did not significantly increase the dose to most organs at risk compared to cRO, although the integral dose was higher. OA significantly reduced the integral dose to healthy tissues compared to both robust methods, while providing equivalent or superior target coverage. CONCLUSION Using a simple spot intensity re-optimization, daily OA can achieve superior target coverage and lower dose to organs at risk than robust optimization methods.
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Affiliation(s)
- Arthur Lalonde
- Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, USA.
| | - Mislav Bobić
- Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, USA; ETH Zürich, Zürich, Switzerland
| | - Brian Winey
- Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, USA
| | - Joost Verburg
- Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, USA
| | - Gregory C Sharp
- Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, USA
| | - Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, USA
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19
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Bobić M, Lalonde A, Sharp GC, Grassberger C, Verburg JM, Winey BA, Lomax AJ, Paganetti H. Comparison of weekly and daily online adaptation for head and neck intensity-modulated proton therapy. Phys Med Biol 2021; 66. [PMID: 33503592 DOI: 10.1088/1361-6560/abe050] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 01/27/2021] [Indexed: 12/11/2022]
Abstract
The high conformality of intensity-modulated proton therapy (IMPT) dose distributions causes treatment plans to be sensitive to geometrical changes during the course of a fractionated treatment. This can be addressed using adaptive proton therapy (APT). One important question in APT is the frequency of adaptations performed during a fractionated treatment, which is related to the question whether plan adaptation has to be done online or offline. The purpose of this work is to investigate the impact of weekly and daily online IMPT plan adaptation on the treatment quality for head and neck patients. A cohort of ten head and neck patients with daily acquired cone-beam CT (CBCT) images was evaluated retrospectively. Dose tracking of the IMPT treatment was performed for three scenarios: base plan with no adaptation (BP), weekly online adaptation (OAW), and daily online adaptation (OAD). Both adaptation schemes used an in-house developed online APT workflow, performing Monte Carlo (MC) dose calculations on scatter-corrected CBCTs. IMPT plan adaptation was achieved by only tuning the weights of a subset of beamlets, based on deformable image registration from the planning CT to each CBCT. Although OADmitigated random delivery errors more effectively than OAWon a fraction per fraction basis, both OAWand OADachieved the clinical goals for all ten patients, while BP failed for six cases. In the high-risk CTV, accumulated values of D98%ranged between 97.15% and 99.73% of the prescription dose for OAD, with a median of 98.07%. For OAW, values between 95.02% and 99.26% were obtained, with a median of 97.61% of the prescription dose. Otherwise, the dose to most organs at risk was similar for all three scenarios. Globally, our results suggest that OAWcould be used as an alternative approach to OADfor most patients in order to reduce the clinical workload.
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Affiliation(s)
- Mislav Bobić
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, UNITED STATES
| | - Arthur Lalonde
- Radiation-Oncology, Massachusetts General Hospital, Boston, Massachusetts, 02114-2696, UNITED STATES
| | - Gregory C Sharp
- Dept of Radiation Oncology, Massachusetts General Hospital, 100 Blossom Street, Cox Building, 302, Boston, MA 02114, USA, Boston, UNITED STATES
| | | | - Joost M Verburg
- Department of Radiation Oncology, Harvard Medical School, Massachussets General Hospital, Francis H Burr Proton Therapy Center, 30 Fruit Street, Boston, 02114, UNITED STATES
| | - Brian A Winey
- Department of Radiation Oncology, Harvard Medical School, FH Burr Proton Therapy Center, 55 Fruit St, Boston, Massachusetts, 02114, UNITED STATES
| | - Antony John Lomax
- Department of Radiation Medicine, Paul Scherrer Institute, CH-5232 Villigen PSI, Villigen, SWITZERLAND
| | - Harald Paganetti
- Northeast Proton Therapy Centre, Massachusetts General Hospital, 30 Fruit Street, Boston, MA 02114, USA, Boston, Massachusetts, 02114, UNITED STATES
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Deiter N, Chu F, Lenards N, Hunzeker A, Lang K, Mundy D. Evaluation of replanning in intensity-modulated proton therapy for oropharyngeal cancer: Factors influencing plan robustness. Med Dosim 2020; 45:384-392. [PMID: 32660887 DOI: 10.1016/j.meddos.2020.06.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 05/07/2020] [Accepted: 06/03/2020] [Indexed: 12/01/2022]
Abstract
The head and neck (H&N) region is frequently replanned during intensity-modulated proton therapy (IMPT), but replanning disrupts clinical workflow and presents additional burden on patients. The purpose of this study was to establish a standard treatment planning approach to minimize H&N replanning by identifying a correlation between dosimetric variables and replan frequency. In a retrospective study of 27 bilateral oropharyngeal cancer patients treated with IMPT at a single institution, cases were evaluated using Fisher's exact tests and logistic regression for a significant relationship between replan frequency and the following variables: beam number, clinical target volume (CTV) coverage, presence of dental fillings, and robustness. The reason and timing for replan initiation, and patient immobilization was also recorded to identify trends. Results suggested that beam number, CTV coverage, presence of dental fillings, and the initial robustness curve on the high-dose CTV did not individually contribute to replanning frequency. Setup variation in the soft tissue of the neck was the most prominent reason for replanning. A lack of correlation between the number of replans and the studied dosimetric variables highlights the necessity of verification CT and adaptive replanning in IMPT of H&N cancer. Departments may therefore benefit from a methodical replan workflow. One development showing potential to enhance clinical replan processes is machine learning-based automatic adaptive replanning.
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Affiliation(s)
- Noelle Deiter
- Medical Dosimetry Program, University of Wisconsin, La Crosse, WI, USA
| | - Felicia Chu
- Medical Dosimetry Program, University of Wisconsin, La Crosse, WI, USA.
| | - Nishele Lenards
- Medical Dosimetry Program, University of Wisconsin, La Crosse, WI, USA
| | - Ashley Hunzeker
- Medical Dosimetry Program, University of Wisconsin, La Crosse, WI, USA
| | - Karen Lang
- Medical Dosimetry Program, University of Wisconsin, La Crosse, WI, USA
| | - Daniel Mundy
- Medical Dosimetry Program, University of Wisconsin, La Crosse, WI, USA
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Nenoff L, Matter M, Jarhall AG, Winterhalter C, Gorgisyan J, Josipovic M, Persson GF, Munck af Rosenschold P, Weber DC, Lomax AJ, Albertini F. Daily Adaptive Proton Therapy: Is it Appropriate to Use Analytical Dose Calculations for Plan Adaption? Int J Radiat Oncol Biol Phys 2020; 107:747-755. [DOI: 10.1016/j.ijrobp.2020.03.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 02/26/2020] [Accepted: 03/27/2020] [Indexed: 12/25/2022]
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22
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Nenoff L, Ribeiro CO, Matter M, Hafner L, Josipovic M, Langendijk JA, Persson GF, Walser M, Weber DC, Lomax AJ, Knopf AC, Albertini F, Zhang Y. Deformable image registration uncertainty for inter-fractional dose accumulation of lung cancer proton therapy. Radiother Oncol 2020; 147:178-185. [DOI: 10.1016/j.radonc.2020.04.046] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 04/22/2020] [Accepted: 04/25/2020] [Indexed: 12/25/2022]
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23
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Nenoff L, Matter M, Hedlund Lindmar J, Weber DC, Lomax AJ, Albertini F. Daily adaptive proton therapy - the key to innovative planning approaches for paranasal cancer treatments. Acta Oncol 2019; 58:1423-1428. [PMID: 31364904 DOI: 10.1080/0284186x.2019.1641217] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background: For proton therapy of paranasal tumors, field directions avoiding volumes that might change during therapy are typically used. If the plan is optimized on the daily anatomy using daily adapted proton therapy (DAPT) however, field directions crossing the nasal cavities might be feasible. In this study, we investigated the effectiveness of DAPT for enabling narrow-field treatment approaches. Material and methods: For five paranasal tumor patients, representing a wide patient spectrum, anatomically robust 4-field-star and narrow-field plans were calculated and their robustness to anatomical and setup uncertainties was compared with and without DAPT. Based on the nominal planning CTs, per patient up to 125 simulated CTs (simCTs) with different nasal cavity fillings were created and random translations and rotations due to patient setup uncertainties were further simulated. Plans were recalculated or re-optimized on all error scenarios, representing non-adapted and DAPT fractions, respectively. From these, 100 possible treatments (60 GyRBE, 30 fx) were simulated and changes in integral dose, target and organs at risk (OARs) doses evaluated. Results: In comparison to the 4-field-star approach, the use of narrow-fields reduced integral dose between 29% and 56%. If OARs did not overlap with the target, OAR doses were also reduced. Finally, the significantly reduced target coverage in non-adapted treatments (mean V95 reductions of up to 34%) could be almost fully restored with DAPT in all cases (differences <1%). Conclusions: DAPT was found to be not only an effective way to increase plan robustness to anatomical and positional uncertainties, but also opened the possibility to use improved and more conformal field arrangements.
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Affiliation(s)
- Lena Nenoff
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
- Department of Physics, ETH Zurich, Zurich, Switzerland
| | - Michael Matter
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
- Department of Physics, ETH Zurich, Zurich, Switzerland
| | - Johanna Hedlund Lindmar
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
- Department of Physics, ETH Zurich, Zurich, Switzerland
| | - Damien Charles Weber
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
- Department of Radiation Oncology, University Hospital Bern, Bern, Switzerland
| | - Antony John Lomax
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
- Department of Physics, ETH Zurich, Zurich, Switzerland
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Lester-Coll NH, Margalit DN. Modeling the Potential Benefits of Proton Therapy for Patients With Oropharyngeal Head and Neck Cancer. Int J Radiat Oncol Biol Phys 2019; 104:563-566. [DOI: 10.1016/j.ijrobp.2019.03.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/24/2019] [Accepted: 03/26/2019] [Indexed: 12/25/2022]
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25
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Soisson E, Guerrieri P, Balasubramanian S, Ahamad A, Moran JM, Joiner MC, Dominello M, Burmeister J. Three discipline collaborative radiation therapy special debate: All head and neck cancer patients with intact tumors/nodes should have scheduled adaptive replanning performed at least once during the course of radiotherapy. J Appl Clin Med Phys 2019; 20:7-11. [PMID: 30983132 PMCID: PMC6523017 DOI: 10.1002/acm2.12587] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 03/28/2019] [Accepted: 03/28/2019] [Indexed: 11/07/2022] Open
Affiliation(s)
- Emilie Soisson
- Department of RadiologyUniversity of VermontBurlingtonVTUSA
- Medical Physics UnitMcGill UniversityMontrealQCCanada
| | | | | | - Anesa Ahamad
- Department of Radiation OncologyUniversity of Miami Miller School of MedicineSylvester Comprehensive Cancer CenterMiamiFLUSA
| | - Jean M. Moran
- Department of Radiation OncologyUniversity of MichiganAnn ArborMIUSA
| | - Michael C. Joiner
- Department of OncologyWayne State University School of MedicineDetroitMIUSA
| | - Michael Dominello
- Department of OncologyWayne State University School of MedicineDetroitMIUSA
| | - Jay Burmeister
- Department of OncologyWayne State University School of MedicineDetroitMIUSA
- Gershenson Radiation Oncology CenterBarbara Ann Karmanos Cancer InstituteDetroitMIUSA
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Cubillos-Mesías M, Troost EG, Lohaus F, Agolli L, Rehm M, Richter C, Stützer K. Including anatomical variations in robust optimization for head and neck proton therapy can reduce the need of adaptation. Radiother Oncol 2019; 131:127-134. [DOI: 10.1016/j.radonc.2018.12.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 10/29/2018] [Accepted: 12/05/2018] [Indexed: 10/27/2022]
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Charters EK, Bogaardt H, Freeman-Sanderson AL, Ballard KJ. Systematic review and meta-analysis of the impact of dosimetry to dysphagia and aspiration related structures. Head Neck 2019; 41:1984-1998. [PMID: 30680831 DOI: 10.1002/hed.25631] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 10/21/2018] [Accepted: 12/14/2018] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Technological advances in radiotherapy have allowed investigations into new methods to spare healthy tissue in those treated for head and neck cancer. This systematic review with meta-analysis demonstrates the effect that radiation has on swallowing. METHODS Selection and analysis of studies examining the effect of radiation to swallowing structures. A fixed effects meta-analysis calculated the pooled proportions for select outcomes of dysphagia, common across many studies. RESULTS The majority of the papers found a correlation between radiation dose to the swallowing structures and dysphagia, however a meta-analysis found the studies carried a significant degree of heterogeneity. The appraisal demonstrates the need for large-scale studies using a randomized design and instrumental dysphagia assessments. CONCLUSIONS Radiation dose to dysphagia and aspiration structures is correlated with incidence of dysphagia and aspiration. The variables in this population contribute to the heterogeneity within and cross studies and future studies should consider controlling for this.
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Affiliation(s)
| | - Hans Bogaardt
- Faculty of Health Sciences, The University of Sydney, Sydney, Australia
| | | | - Kirrie J Ballard
- Faculty of Health Sciences, The University of Sydney, Sydney, Australia
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28
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Busch K, Muren LP, Thörnqvist S, Andersen AG, Pedersen J, Dong L, Petersen JBB. On-line dose-guidance to account for inter-fractional motion during proton therapy. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2018; 9:7-13. [PMID: 33458420 PMCID: PMC7807653 DOI: 10.1016/j.phro.2018.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 11/26/2018] [Indexed: 11/13/2022]
Abstract
Background and purpose Proton therapy (PT) of extra-cranial tumour sites is challenged by density changes caused by inter-fractional organ motion. In this study we investigate on-line dose-guided PT (DGPT) to account inter-fractional target motion, exemplified by internal motion in the pelvis. Materials and methods On-line DGPT involved re-calculating dose distributions with the isocenter shifted up to 15 mm from the position corresponding to conventional soft-tissue based image-guided PT (IGPT). The method was applied to patient models with simulated prostate/seminal vesicle target motion of ±3, ±5 and ±10 mm along the three cardinal axes. Treatment plans were created using either two lateral (gantry angles of 90°/270°) or two lateral oblique fields (gantry angles of 35°/325°). Target coverage and normal tissue doses from DGPT were compared to both soft-tissue and bony anatomy based IGPT. Results DGPT improved the dose distributions relative to soft-tissue based IGPT for 39 of 90 simulation scenarios using lateral fields and for 50 of 90 scenarios using lateral oblique fields. The greatest benefits of DGPT were seen for large motion, e.g. a median target coverage improvement of 13% was found for 10 mm anterior motion with lateral fields. DGPT also improved the dose distribution in comparison to bony anatomy IGPT in all cases. The best strategy was often to move the fields back towards the original target position prior to the simulated target motion. Conclusion DGPT has the potential to better account for large inter-fractional organ motion in the pelvis than IGPT.
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Affiliation(s)
- Kia Busch
- Department of Medical Physics, Aarhus University Hospital/Aarhus University, Aarhus, Denmark
| | - Ludvig P Muren
- Department of Medical Physics, Aarhus University Hospital/Aarhus University, Aarhus, Denmark
| | - Sara Thörnqvist
- Department of Physics and Technology, University of Bergen, Norway.,Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Andreas G Andersen
- Department of Medical Physics, Aarhus University Hospital/Aarhus University, Aarhus, Denmark
| | - Jesper Pedersen
- Department of Medical Physics, Aarhus University Hospital/Aarhus University, Aarhus, Denmark
| | - Lei Dong
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, USA
| | - Jørgen B B Petersen
- Department of Medical Physics, Aarhus University Hospital/Aarhus University, Aarhus, Denmark
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29
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Botas P, Kim J, Winey B, Paganetti H. Online adaption approaches for intensity modulated proton therapy for head and neck patients based on cone beam CTs and Monte Carlo simulations. ACTA ACUST UNITED AC 2018; 64:015004. [DOI: 10.1088/1361-6560/aaf30b] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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30
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Intensity modulated proton therapy (IMPT) - The future of IMRT for head and neck cancer. Oral Oncol 2018; 88:66-74. [PMID: 30616799 DOI: 10.1016/j.oraloncology.2018.11.015] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 11/11/2018] [Accepted: 11/12/2018] [Indexed: 12/13/2022]
Abstract
Radiation therapy plays an integral role in the management of head and neck cancers (HNCs). While most HNC patients have historically been treated with photon-based radiation techniques such as intensity modulated radiation therapy (IMRT), there is a growing awareness of the potential clinical benefits of proton therapy over IMRT in the definitive, postoperative and reirradiation settings given the unique physical properties of protons. Intensity modulated proton therapy (IMPT), also known as "pencil beam proton therapy," is a sophisticated mode of proton therapy that is analogous to IMRT and an active area of investigation in cancer care. Multifield optimization IMPT allows for high quality plans that can target superficially located HNCs as well as large neck volumes while significantly reducing integral doses. Several dosimetric studies have demonstrated the superiority of IMPT over IMRT to improve dose sparing of nearby organs such as the larynx, salivary glands, and esophagus. Evidence of the clinical translation of these dosimetric advantages has been demonstrated with documented toxicity reductions (such as decreased feeding tube dependency) after IMPT for patients with HNCs. While there are relative challenges to IMPT planning that exist today such as particle range uncertainties and high sensitivity to anatomical changes, ongoing investigations in image-guidance techniques and robust optimization methods are promising. A systematic approach towards utilizing IMPT and additional prospective studies are necessary in order to more accurately estimate the clinical benefit of IMPT over IMRT and passive proton therapy on a case-by-case basis for patients with sub-site specific HNCs.
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31
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Kurz C, Süss P, Arnsmeyer C, Haehnle J, Teichert K, Landry G, Hofmaier J, Exner F, Hille L, Kamp F, Thieke C, Ganswindt U, Valentini C, Hölscher T, Troost E, Krause M, Belka C, Küfer KH, Parodi K, Richter C. Dose-guided patient positioning in proton radiotherapy using multicriteria-optimization. Z Med Phys 2018; 29:216-228. [PMID: 30409729 DOI: 10.1016/j.zemedi.2018.10.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 10/01/2018] [Accepted: 10/15/2018] [Indexed: 12/25/2022]
Abstract
Proton radiotherapy (PT) requires accurate target alignment before each treatment fraction, ideally utilizing 3D in-room X-ray computed tomography (CT) imaging. Typically, the optimal patient position is determined based on anatomical landmarks or implanted markers. In the presence of non-rigid anatomical changes, however, the planning scenario cannot be exactly reproduced and positioning should rather aim at finding the optimal position in terms of the actually applied dose. In this work, dose-guided patient alignment, implemented as multicriterial optimization (MCO) problem, was investigated in the scope of intensity-modulated and double-scattered PT (IMPT and DSPT) for the first time. A method for automatically determining the optimal patient position with respect to pre-defined clinical goals was implemented. Linear dose interpolation was used to access a continuous space of potential patient shifts. Fourteen head and neck (H&N) and eight prostate cancer patients with up to five repeated CTs were included. Dose interpolation accuracy was evaluated and the potential dosimetric advantages of dose-guided over bony-anatomy-based patient alignment investigated by comparison of clinically relevant target and organ-at-risk (OAR) dose-volume histogram (DVH) parameters. Dose interpolation was found sufficiently accurate with average pass-rates of 90% and 99% for an exemplary H&N and prostate patient, respectively, using a 2% dose-difference criterion. Compared to bony-anatomy-based alignment, the main impact of automated MCO-based dose-guided positioning was a reduced dose to the serial OARs (spinal cord and brain stem) for the H&N cohort. For the prostate cohort, under-dosage of the target structures could be efficiently diminished. Limitations of dose-guided positioning were mainly found in reducing target over-dosage due to weight loss for H&N patients, which might require adaptation of the treatment plan. Since labor-intense online quality-assurance is not required for dose-guided patient positioning, it might, nevertheless, be considered an interesting alternative to full online re-planning for initially mitigating the effects of anatomical changes.
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Affiliation(s)
- Christopher Kurz
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany; Department of Medical Physics, Faculty of Physics, Ludwig-Maximilians-Universität München, Am Coulombwall 1, 85748 Garching bei München, Germany.
| | - Philipp Süss
- Fraunhofer Institute for Industrial Mathematics (ITWM), Fraunhofer-Platz 1, 67663 Kaiserslautern, 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
| | - Jonas Haehnle
- Fraunhofer Institute for Industrial Mathematics (ITWM), Fraunhofer-Platz 1, 67663 Kaiserslautern, Germany
| | - Katrin Teichert
- Fraunhofer Institute for Industrial Mathematics (ITWM), Fraunhofer-Platz 1, 67663 Kaiserslautern, Germany
| | - Guillaume Landry
- Department of Medical Physics, Faculty of Physics, Ludwig-Maximilians-Universität München, Am Coulombwall 1, 85748 Garching bei München, Germany
| | - Jan Hofmaier
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Florian Exner
- 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
| | - Lucas Hille
- Department of Medical Physics, Faculty of Physics, Ludwig-Maximilians-Universität München, Am Coulombwall 1, 85748 Garching bei München, Germany
| | - Florian Kamp
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Christian Thieke
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Ute Ganswindt
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Chiara Valentini
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307 Dresden, Germany
| | - Tobias Hölscher
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307 Dresden, Germany
| | - Esther Troost
- 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; German Cancer Consortium (DKTK) partner site Dresden, Germany and German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Bautzner Landstr. 400, 01328 Dresden, Germany; National Center for Tumor Diseases (NCT), partner site Dresden, Germany
| | - Mechthild Krause
- 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; German Cancer Consortium (DKTK) partner site Dresden, Germany and German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Bautzner Landstr. 400, 01328 Dresden, Germany; National Center for Tumor Diseases (NCT), partner site Dresden, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany; German Cancer Consortium (DKTK) partner site Munich, Germany and German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Karl-Heinz Küfer
- Fraunhofer Institute for Industrial Mathematics (ITWM), Fraunhofer-Platz 1, 67663 Kaiserslautern, Germany
| | - Katia Parodi
- Department of Medical Physics, Faculty of Physics, Ludwig-Maximilians-Universität München, Am Coulombwall 1, 85748 Garching bei München, 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; 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, 69120 Heidelberg, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Bautzner Landstr. 400, 01328 Dresden, Germany
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Cristaudo A, Hickman M, Fong C, Sanghera P, Hartley A. Assessing Novel Drugs and Radiation Technology in the Chemoradiation of Oropharyngeal Cancer. MEDICINES (BASEL, SWITZERLAND) 2018; 5:E65. [PMID: 29954154 PMCID: PMC6163293 DOI: 10.3390/medicines5030065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 06/21/2018] [Accepted: 06/25/2018] [Indexed: 01/21/2023]
Abstract
Integrating immunotherapy, proton therapy and biological dose escalation into the definitive chemoradiation of oropharyngeal cancer poses several challenges. Reliable and reproducible data must be obtained in a timely fashion. However, despite recent international radiotherapy contouring guidelines, controversy persists as to the applicability of such guidelines to all cases. Similarly, a lack of consensus exists concerning both the definition of the organ at risk for oral mucositis and the most appropriate endpoint to measure for this critical toxicity. Finally, the correlation between early markers of efficacy such as complete response on PET CT following treatment and subsequent survival needs elucidation for biological subsets of oropharyngeal cancer.
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Affiliation(s)
- Agostino Cristaudo
- Department of Radiation Oncology, University of Pisa, 56100 Pisa PI, Italy.
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, Birmingham B15 2TH, UK.
| | - Mitchell Hickman
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, Birmingham B15 2TH, UK.
| | - Charles Fong
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, Birmingham B15 2TH, UK.
| | - Paul Sanghera
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, Birmingham B15 2TH, UK.
| | - Andrew Hartley
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, Birmingham B15 2TH, UK.
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