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Wong LM, Pawlicki T. A systems theory-based safety assessment of pre-treatment patient-specific quality assurance for intensity-modulated treatments in a single-vendor environment. Radiother Oncol 2024; 201:110569. [PMID: 39362604 DOI: 10.1016/j.radonc.2024.110569] [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: 06/13/2024] [Revised: 08/28/2024] [Accepted: 09/27/2024] [Indexed: 10/05/2024]
Abstract
BACKGROUND AND PURPOSE While patient-specific quality assurance (PSQA) has been integral to intensity-modulated treatments, its value is debated. A systems approach to safety is essential for understanding complex systems like radiation oncology but is often overlooked in PSQA research. This study aims to elucidate PSQA's fundamental value and identify opportunities for enhancing safety in intensity-modulated treatments. MATERIALS AND METHODS First, causal scenarios that could lead to patient harm were identified using a prospective safety assessment technique developed for complex systems. Second, PSQA's ability to mitigate these scenarios was evaluated using standard stability and control principles. The analysis also included safeguards related to PSQA, such as daily linac QA, equipment commissioning, and equipment design. RESULTS Ten causal scenarios were identified, highlighting well-known issues like flawed algorithms, data corruption, and hardware errors. Mitigation is achieved through advanced dose calculation and optimization algorithms, software and data integration, and preconfigured beam data, which improve decision-making and system state determination. Modern linac control systems enhance all aspects of system stability and control. Commissioning, daily linac QA, and PSQA are effective in enhancing the determination of system states only when feedback is non-overlapping and unambiguous. CONCLUSION Given equipment improvement and related safeguards, the feedback generated from PSQA has diminished in value. To better complement other safeguards, PSQA should evolve to provide automated, unambiguous detection of any potential catastrophic treatment deviations prior to treatment. This evolution would allow physicists to focus on more critical aspects of patient care in radiation oncology.
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Affiliation(s)
- Lawrence M Wong
- Department of Radiation Medicine & Applied Sciences, University of California San Diego, 3855 Health Sciences Drive, La Jolla, CA 92093-0843, USA.
| | - Todd Pawlicki
- Department of Radiation Medicine & Applied Sciences, University of California San Diego, 3855 Health Sciences Drive, La Jolla, CA 92093-0843, USA.
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Iramina H, Tsuneda M, Okamoto H, Kadoya N, Mukumoto N, Toyota M, Fukunaga J, Fujita Y, Tohyama N, Onishi H, Nakamura M. Multi-institutional questionnaire-based survey on online adaptive radiotherapy performed using commercial systems in Japan in 2023. Radiol Phys Technol 2024; 17:581-595. [PMID: 39028438 DOI: 10.1007/s12194-024-00828-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 07/12/2024] [Accepted: 07/13/2024] [Indexed: 07/20/2024]
Abstract
In this study, we aimed to conduct a survey on the current clinical practice of, staffing for, commissioning of, and staff training for online adaptive radiotherapy (oART) in the institutions that installed commercial oART systems in Japan, and to share the information with institutions that will implement oART systems in future. A web-based questionnaire, containing 107 questions, was distributed to nine institutions in Japan. Data were collected from November to December 2023. Three institutions each with the MRIdian (ViewRay, Oakwood Village, OH, USA), Unity (Elekta AB, Stockholm, Sweden), and Ethos (Varian Medical Systems, Palo Alto, CA, USA) systems completed the questionnaire. One institution (MRIdian) had not performed oART by the response deadline. Each institution had installed only one oART system. Hypofractionation, and moderate hypofractionation or conventional fractionation were employed in the MRIdian/Unity and Ethos systems, respectively. The elapsed time for the oART process was faster with the Ethos than with the other systems. All institutions added additional staff for oART. Commissioning periods differed among the oART systems owing to provision of beam data from the vendors. Chambers used during commissioning measurements differed among the institutions. Institutional training was provided by all nine institutions. To the best of our knowledge, this was the first survey about oART performed using commercial systems in Japan. We believe that this study will provide useful information to institutions that installed, are installing, or are planning to install oART systems.
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Affiliation(s)
- Hiraku Iramina
- Adaptive Radiotherapy Working Group (ART-WG), QA/QC Committee, Japan Society of Medical Physics, Tokyo, Japan
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, 54 Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto-Shi, Kyoto, 606-8507, Japan
| | - Masato Tsuneda
- Adaptive Radiotherapy Working Group (ART-WG), QA/QC Committee, Japan Society of Medical Physics, Tokyo, Japan
- Department of Radiation Oncology, MR Linac ART Division, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba-Shi, Chiba, 260-8670, Japan
| | - Hiroyuki Okamoto
- Adaptive Radiotherapy Working Group (ART-WG), QA/QC Committee, Japan Society of Medical Physics, Tokyo, Japan
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-Ku, Tokyo, 104-0045, Japan
| | - Noriyuki Kadoya
- Adaptive Radiotherapy Working Group (ART-WG), QA/QC Committee, Japan Society of Medical Physics, Tokyo, Japan
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-Ku, Sendai-Shi, Miyagi, 980-8574, Japan
| | - Nobutaka Mukumoto
- Adaptive Radiotherapy Working Group (ART-WG), QA/QC Committee, Japan Society of Medical Physics, Tokyo, Japan
- Department of Radiation Oncology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka-Shi, Osaka, 545-8585, Japan
| | - Masahiko Toyota
- Adaptive Radiotherapy Working Group (ART-WG), QA/QC Committee, Japan Society of Medical Physics, Tokyo, Japan
- Division of Radiology, Department of Clinical Technology, Kagoshima University Hospital, 8-35-1 Sakuragaoka, Kagoshima-Shi, Kagoshima, 890-8520, Japan
| | - Junichi Fukunaga
- Adaptive Radiotherapy Working Group (ART-WG), QA/QC Committee, Japan Society of Medical Physics, Tokyo, Japan
- Division of Radiology, Department of Medical Technology, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-Ku, Fukuoka-Shi, Fukuoka, 812-8582, Japan
| | - Yukio Fujita
- Adaptive Radiotherapy Working Group (ART-WG), QA/QC Committee, Japan Society of Medical Physics, Tokyo, Japan
- Department of Radiation Oncology, MR Linac ART Division, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba-Shi, Chiba, 260-8670, Japan
- Department of Radiological Sciences, Komazawa University, 1-23-1 Komazawa, Setagaya-Ku, Tokyo, 154-8525, Japan
| | - Naoki Tohyama
- Department of Radiological Sciences, Komazawa University, 1-23-1 Komazawa, Setagaya-Ku, Tokyo, 154-8525, Japan
| | - Hiroshi Onishi
- Department of Radiology, University of Yamanashi, 1110 Shimokato, Chuo-Shi, Yamanashi, 409-3898, Japan
| | - Mitsuhiro Nakamura
- Adaptive Radiotherapy Working Group (ART-WG), QA/QC Committee, Japan Society of Medical Physics, Tokyo, Japan.
- Department of Advanced Medical Physics, Graduate School of Medicine, Kyoto University, 53 Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto-Shi, Kyoto, 606-8507, Japan.
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Chiou YR, Lin TC, Ji JH, Shiau AC, Huang CH, Liang JA. Large Pleural Metastases With Significant Inter-fractional Volume Reduction During Online Adaptive Radiotherapy: A Case Report With Dosimetry Comparison. Cureus 2024; 16:e68407. [PMID: 39360108 PMCID: PMC11445199 DOI: 10.7759/cureus.68407] [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] [Accepted: 08/30/2024] [Indexed: 10/04/2024] Open
Abstract
Online adaptive radiotherapy (oART) dose calculation relies on synthetic computed tomography (sCT), which notably influences anatomical changes. This study elucidates how sCT may respond to significant inter-fractional tumor volume reduction and its subsequent impact on dose distribution. In this case report, we exported sCT and cone-beam CT (CBCT) images from each treatment session. We retrospectively analyzed 20 adaptive and scheduled plans of a patient receiving oART for large pleural metastases with notable inter-fractional tumor regression. By overriding the CT number of the dissipated tumor volume with that of the lungs on each sCT, we recalculated each plan. We compared the dose distribution between the adaptive and scheduled plans. Percentage dose difference and 3D gamma analysis were employed to assess dose variability. Results of the dose analysis showed that, compared to the online (non-overridden) plans, the recalculated plans using overridden sCT demonstrated right-shifted dose-volume histogram curves for the targets and right lung, with a slight but statistically significant increase of no less than 1.5% in D mean and D max for the targets and right lung. The location of hotspots shifted in alignment with tumor shrinkage and beam arrangement. Both recalculated adaptive and scheduled plans achieved ideal GTV, CTV, and PTV coverage, with adaptive plans significantly reducing the dose and irradiated volume to the right lung. In conclusion, as the pleural tumor volume decreased, online plans slightly underestimated the dose distribution and shifted the location of hotspots, though this remained clinically acceptable. Importantly, adaptive plans significantly minimized the irradiated volume of the critical OAR (right lung) while ensuring optimal dose coverage of the target volume, demonstrating the potential of sCT and adaptive oART to enhance treatment precision and efficacy in dynamically changing tumor environments.
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Affiliation(s)
- Yu-Rou Chiou
- Department of Radiation Oncology, China Medical University Hospital, Taichung City, TWN
| | - Ting Chun Lin
- Department of Radiation Oncology, China Medical University Hospital, Taichung City, TWN
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung City, TWN
| | - Jin-Huei Ji
- Department of Radiation Oncology, China Medical University Hospital, Taichung City, TWN
| | - An-Cheng Shiau
- Department of Radiation Oncology, China Medical University Hospital, Taichung City, TWN
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, TWN
| | - Chi-Hsien Huang
- Department of Radiation Oncology, China Medical University Hospital, Taichung City, TWN
| | - Ji-An Liang
- Department of Radiation Oncology, China Medical University Hospital, Taichung City, TWN
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Wegener S, Exner F, Weick S, Stark S, Hutzel H, Lutyj P, Tamihardja J, Razinskas G. Prospective risk analysis of the online-adaptive artificial intelligence-driven workflow using the Ethos treatment system. Z Med Phys 2024; 34:384-396. [PMID: 36504142 PMCID: PMC11384068 DOI: 10.1016/j.zemedi.2022.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 10/20/2022] [Accepted: 11/14/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE The recently introduced Varian Ethos system allows adjusting radiotherapy treatment plans to anatomical changes on a daily basis. The system uses artificial intelligence to speed up the process of creating adapted plans, comes with its own software solutions and requires a substantially different workflow. A detailed analysis of possible risks of the associated workflow is presented. METHODS A prospective risk analysis of the adaptive workflow with the Ethos system was performed using Failure Modes and Effects Analysis (FMEA). An interprofessional team collected possible adverse events and evaluated their severity as well as their chance of occurrence and detectability. Measures to reduce the risks were discussed. RESULTS A total of 122 events were identified, and scored. Within the 20 events with the highest-ranked risks, the following were identified: Challenges due to the stand-alone software solution with very limited connectivity to the existing record and verify software and digital patient file, unfamiliarity with the new software and its limitations and the adaption process relying on results obtained by artificial intelligence. The risk analysis led to the implementation of additional quality assurance measures in the workflow. CONCLUSIONS The thorough analysis of the risks associated with the new treatment technique was the basis for designing details of the workflow. The analysis also revealed challenges to be addressed by both, the vendor and customers. On the vendor side, this includes improving communication between their different software solutions. On the customer side, this especially includes establishing validation strategies to monitor the results of the black box adaption process making use of artificial intelligence.
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Affiliation(s)
- Sonja Wegener
- University of Wuerzburg, Department of Radiation Oncology, Wuerzburg, Germany.
| | - Florian Exner
- University of Wuerzburg, Department of Radiation Oncology, Wuerzburg, Germany.
| | - Stefan Weick
- University of Wuerzburg, Department of Radiation Oncology, Wuerzburg, Germany.
| | - Silke Stark
- University of Wuerzburg, Department of Radiation Oncology, Wuerzburg, Germany.
| | - Heike Hutzel
- University of Wuerzburg, Department of Radiation Oncology, Wuerzburg, Germany.
| | - Paul Lutyj
- University of Wuerzburg, Department of Radiation Oncology, Wuerzburg, Germany.
| | - Jörg Tamihardja
- University of Wuerzburg, Department of Radiation Oncology, Wuerzburg, Germany.
| | - Gary Razinskas
- University of Wuerzburg, Department of Radiation Oncology, Wuerzburg, Germany.
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Jiang C, Ji T, Qiao Q. Application and progress of artificial intelligence in radiation therapy dose prediction. Clin Transl Radiat Oncol 2024; 47:100792. [PMID: 38779524 PMCID: PMC11109740 DOI: 10.1016/j.ctro.2024.100792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 05/07/2024] [Indexed: 05/25/2024] Open
Abstract
Radiation therapy (RT) nowadays is a main treatment modality of cancer. To ensure the therapeutic efficacy of patients, accurate dose distribution is often required, which is a time-consuming and labor-intensive process. In addition, due to the differences in knowledge and experience among participants and diverse institutions, the predicted dose are often inconsistent. In last several decades, artificial intelligence (AI) has been applied in various aspects of RT, several products have been implemented in clinical practice and confirmed superiority. In this paper, we will review the research of AI in dose prediction, focusing on the progress in deep learning (DL).
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Affiliation(s)
- Chen Jiang
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China
| | - Tianlong Ji
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China
| | - Qiao Qiao
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China
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Semeniuk O, Yu E, Rivard MJ. Current and Emerging Radiotherapy Options for Uveal Melanoma. Cancers (Basel) 2024; 16:1074. [PMID: 38473430 DOI: 10.3390/cancers16051074] [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: 01/21/2024] [Revised: 03/01/2024] [Accepted: 03/04/2024] [Indexed: 03/14/2024] Open
Abstract
What treatment options are there for patients having uveal melanoma? A randomized, prospective, multi-institutional clinical trial (COMS) showed no difference in survival between brachytherapy and enucleation for medium-sized lesions. With the obvious benefit of retaining the eye, brachytherapy has flourished and many different approaches have been developed such as low-dose-rate sources using alternate low-energy photon-emitting radionuclides, different plaque designs and seed-loading techniques, high-dose-rate brachytherapy sources and applicators, and low- and high-dose-rate beta-emitting sources and applicators. There also have been developments of other radiation modalities like external-beam radiotherapy using linear accelerators with high-energy photons, particle accelerators for protons, and gamma stereotactic radiosurgery. This article examines the dosimetric properties, targeting capabilities, and outcomes of these approaches. The several modalities examined herein have differing attributes and it may be that no single approach would be considered optimal for all patients and all lesion characteristics.
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Affiliation(s)
- Oleksii Semeniuk
- Department of Radiation Oncology, Warren Alpert Medical School, Brown University and Rhode Island Hospital, Providence, RI 02903, USA
| | - Esther Yu
- Department of Radiation Oncology, Warren Alpert Medical School, Brown University and Rhode Island Hospital, Providence, RI 02903, USA
| | - Mark J Rivard
- Department of Radiation Oncology, Warren Alpert Medical School, Brown University and Rhode Island Hospital, Providence, RI 02903, USA
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Callens D, Aerts K, Berkovic P, Vandewinckele L, Lambrecht M, Crijns W. Are offline ART decisions for NSCLC impacted by the type of dose calculation algorithm? Tech Innov Patient Support Radiat Oncol 2024; 29:100236. [PMID: 38313556 PMCID: PMC10835600 DOI: 10.1016/j.tipsro.2024.100236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 01/03/2024] [Accepted: 01/09/2024] [Indexed: 02/06/2024] Open
Abstract
Introduction Decisions for plan-adaptations may be impacted by a transitioning from one dose-calculation algorithm to another. This study examines the impact on dosimetric-triggered offline adaptation in LA-NSCLC in the context of a transition from superposition/convolution dose calculation algorithm (Type-B) to linear Boltzmann equation solver dose calculation algorithms (Type-C). Materials & Methods Two dosimetric-triggered offline adaptive treatment workflows are compared in a retrospective planning study on 30 LA-NSCLC patients. One workflow uses a Type-B dose calculation algorithm and the other uses Type-C. Treatment plans were re-calculated on the anatomy of a mid-treatment synthetic-CT utilizing the same algorithm utilized for pre-treatment planning. Assessment for plan-adaptation was evaluated through a decision model based on target coverage and OAR constraint violation. The impact of algorithm during treatment planning was controlled for by recalculating the Type-B plan with Type-C. Results In the Type-B approach, 13 patients required adaptation due to OAR-constraint violations, while 15 patients required adaptation in the Type-C approach. For 8 out of 30 cases, the decision to adapt was opposite in both approaches. None of the patients in our dataset encountered CTV-target underdosage that necessitated plan-adaptation. Upon recalculating the Type-B approach with the Type-C algorithm, it was shown that 10 of the original Type-B plans revealed clinically relevant dose reductions (≥3%) on the CTV in their original plans. This re-calculation identified 21 plans in total that required ART. Discussion In our study, nearly one-third of the cases would have a different decision for plan-adaption when utilizing Type-C instead of Type-B. There was no substantial increase in the total number of plan-adaptations for LA-NSCLC. However, Type-C is more sensitive to altered anatomy during treatment compared to Type-B. Recalculating Type-B plans with the Type-C algorithm revealed an increase from 13 to 21 cases triggering ART.
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Affiliation(s)
- Dylan Callens
- Laboratory of Experimental Radiotherapy, KU Leuven, Leuven, Belgium
- Department of Radiation Oncology, UZ Leuven, Leuven, Belgium
| | - Karel Aerts
- Laboratory of Experimental Radiotherapy, KU Leuven, Leuven, Belgium
| | - Patrick Berkovic
- Laboratory of Experimental Radiotherapy, KU Leuven, Leuven, Belgium
- Department of Radiation Oncology, UZ Leuven, Leuven, Belgium
| | - Liesbeth Vandewinckele
- Laboratory of Experimental Radiotherapy, KU Leuven, Leuven, Belgium
- Department of Radiation Oncology, UZ Leuven, Leuven, Belgium
| | - Maarten Lambrecht
- Laboratory of Experimental Radiotherapy, KU Leuven, Leuven, Belgium
- Department of Radiation Oncology, UZ Leuven, Leuven, Belgium
| | - Wouter Crijns
- Laboratory of Experimental Radiotherapy, KU Leuven, Leuven, Belgium
- Department of Radiation Oncology, UZ Leuven, Leuven, Belgium
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Naceur A, Bienvenue C, Romano P, Chilian C, Carrier JF. Extending deterministic transport capabilities for very-high and ultra-high energy electron beams. Sci Rep 2024; 14:2796. [PMID: 38307920 PMCID: PMC11226718 DOI: 10.1038/s41598-023-51143-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 12/31/2023] [Indexed: 02/04/2024] Open
Abstract
Focused Very-High Energy Electron (VHEE, 50-300 MeV) and Ultra-High Energy Electron (UHEE, > 300 MeV) beams can accurately target both large and deeply seated human tumors with high sparing properties, while avoiding the spatial requirements and cost of proton and heavy ion facilities. Advanced testing phases are underway at the CLEAR facilities at CERN (Switzerland), NLCTA at Stanford (USA), and SPARC at INFN (Italy), aiming to accelerate the transition to clinical application. Currently, Monte Carlo (MC) transport is the sole paradigm supporting preclinical trials and imminent clinical deployment. In this paper, we propose an alternative: the first extension of the nuclear-reactor deterministic chain NJOY-DRAGON for VHEE and UHEE applications. We have extended the Boltzmann-Fokker-Planck (BFP) multigroup formalism and validated it using standard radio-oncology benchmarks, complex assemblies with a wide range of atomic numbers, and comprehensive irradiation of the entire periodic table. We report that [Formula: see text] of water voxels exhibit a BFP-MC deviation below [Formula: see text] for electron energies under [Formula: see text]. Additionally, we demonstrate that at least [Formula: see text] of voxels of bone, lung, adipose tissue, muscle, soft tissue, tumor, steel, and aluminum meet the same criterion between [Formula: see text] and [Formula: see text]. For water, the thorax, and the breast intra-operative benchmark, typical average BFP-MC deviations of [Formula: see text] and [Formula: see text] were observed at [Formula: see text] and [Formula: see text], respectively. By irradiating the entire periodic table, we observed similar performance between lithium ([Formula: see text]) and cerium ([Formula: see text]). Deficiencies observed between praseodymium ([Formula: see text]) and einsteinium ([Formula: see text]) have been reported, analyzed, and quantified, offering critical insights for the ongoing development of the Evaluated Nuclear Data File mode in NJOY.
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Affiliation(s)
- Ahmed Naceur
- École Polytechnique, SLOWPOKE Nuclear Reactor Laboratory, Nuclear Engineering Institute, Montréal, H3T1J4, Canada.
- CRCHUM, Centre hospitalier de l'Université de Montréal, Montréal, H2L4M1, Canada.
| | - Charles Bienvenue
- École Polytechnique, Engineering Physics Department, Biomedical Engineering Institute, Montréal, H3T1J4, Canada
| | - Paul Romano
- Computational Science Division, Argonne National Laboratory, Lemont, IL, 60439, USA
| | - Cornelia Chilian
- École Polytechnique, SLOWPOKE Nuclear Reactor Laboratory, Nuclear Engineering Institute, Montréal, H3T1J4, Canada
| | - Jean-François Carrier
- Department of Physics, Université de Montréal, Montréal, H3T1J4, Canada
- CRCHUM, Centre hospitalier de l'Université de Montréal, Montréal, H2L4M1, Canada
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Akdeniz Y, Ispir B. Whole-brain radiotherapy with hippocampus sparing and simultaneous integrated boost to metastases: A plan quality comparison study between Ethos, HyperArc, VMAT and Tomotherapy. Med Dosim 2023; 49:185-191. [PMID: 38101995 DOI: 10.1016/j.meddos.2023.11.004] [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: 08/13/2023] [Accepted: 11/10/2023] [Indexed: 12/17/2023]
Abstract
This study provides a concise and structured overview of a dosimetric comparison study conducted to assess the feasibility and effectiveness of 4 advanced radiotherapy techniques in treating brain metastases with hippocampus sparing and simultaneous integrated boost (HS-WBRT+SIB). Eleven patients with brain metastases previously treated with radiotherapy were included in the study. Planning CT scans with 2 mm slice thickness and MR imaging were used for contouring and dose prescription. The bilateral hippocampus and other organs at risk (OARs) were automatically contoured, and hippocampal avoidance regions (HAR) were defined as a 7 mm 3D expansion around the hippocampus. Gross tumor volume for each metastasis (GTVmet) and planning target volume for metastases (PTVmet) were delineated. The whole-brain CTV (CTVWB) and planning target volume for whole brain (PTVWB) were defined accordingly. Treatment planning and optimization were conducted using state-of-the-art radiotherapy techniques: Ethos, HyperArc, VMAT, and Tomotherapy. Tomotherapy achieved the highest D98% for PTVmet, indicating the best metastasis coverage. HyperArc plans showed the highest D98% for PTVWB, suggesting superior whole-brain coverage. Tomotherapy demonstrated significantly lower D98%, D2%, and Dmean values for the hippocampus, indicating its superiority in sparing the hippocampus. VMAT resulted in the lowest D2% values for the eyes, optic nerves, brainstem, and hypophysis, showing the best sparing of these critical structures. Tomotherapy consistently achieved lower Dmean values for parotids, oral cavity, and lips compared to the other techniques. The dosimetric comparison revealed distinct strengths and weaknesses for each radiotherapy technique. Tomotherapy excelled in sparing the hippocampus, while VMAT showed promise in sparing OARs. HyperArc plans demonstrated the best overall whole-brain coverage. These findings should guide clinicians in selecting the most suitable technique based on patient characteristics and institutional resources.
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Affiliation(s)
- Yucel Akdeniz
- Radiation Oncology Department, Acıbadem Adana Hospital, Adana, Turkey.
| | - Burcin Ispir
- Radiation Oncology Department, Acıbadem Ataşehir Hospital, İstanbul, Turkey
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Liu Y, Yang B, Chen X, Zhu J, Ji G, Liu Y, Chen B, Lu N, Yi J, Wang S, Li Y, Dai J, Men K. Efficient segmentation using domain adaptation for MRI-guided and CBCT-guided online adaptive radiotherapy. Radiother Oncol 2023; 188:109871. [PMID: 37634767 DOI: 10.1016/j.radonc.2023.109871] [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: 04/09/2023] [Revised: 07/31/2023] [Accepted: 08/20/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Delineation of regions of interest (ROIs) is important for adaptive radiotherapy (ART) but it is also time consuming and labor intensive. AIM This study aims to develop efficient segmentation methods for magnetic resonance imaging-guided ART (MRIgART) and cone-beam computed tomography-guided ART (CBCTgART). MATERIALS AND METHODS MRIgART and CBCTgART studies enrolled 242 prostate cancer patients and 530 nasopharyngeal carcinoma patients, respectively. A public dataset of CBCT from 35 pancreatic cancer patients was adopted to test the framework. We designed two domain adaption methods to learn and adapt the features from planning computed tomography (pCT) to MRI or CBCT modalities. The pCT was transformed to synthetic MRI (sMRI) for MRIgART, while CBCT was transformed to synthetic CT (sCT) for CBCTgART. Generalized segmentation models were trained with large popular data in which the inputs were sMRI for MRIgART and pCT for CBCTgART. Finally, the personalized models for each patient were established by fine-tuning the generalized model with the contours on pCT of that patient. The proposed method was compared with deformable image registration (DIR), a regular deep learning (DL) model trained on the same modality (DL-regular), and a generalized model in our framework (DL-generalized). RESULTS The proposed method achieved better or comparable performance. For MRIgART of the prostate cancer patients, the mean dice similarity coefficient (DSC) of four ROIs was 87.2%, 83.75%, 85.36%, and 92.20% for the DIR, DL-regular, DL-generalized, and proposed method, respectively. For CBCTgART of the nasopharyngeal carcinoma patients, the mean DSC of two target volumes were 90.81% and 91.18%, 75.17% and 58.30%, for the DIR, DL-regular, DL-generalized, and the proposed method, respectively. For CBCTgART of the pancreatic cancer patients, the mean DSC of two ROIs were 61.94% and 61.44%, 63.94% and 81.56%, for the DIR, DL-regular, DL-generalized, and the proposed method, respectively. CONCLUSION The proposed method utilizing personalized modeling improved the segmentation accuracy of ART.
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Affiliation(s)
- Yuxiang Liu
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Bining Yang
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Xinyuan Chen
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Ji Zhu
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Guangqian Ji
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Yueping Liu
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Bo Chen
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Ningning Lu
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Junlin Yi
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Shulian Wang
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Yexiong Li
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Jianrong Dai
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China.
| | - Kuo Men
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China.
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11
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Morel A, Prunaretty J, Trauchessec D, Ailleres N, Fenoglietto P, Azria D. Comprehensive commissioning and quality assurance validation of Ethos™ therapy. Cancer Radiother 2023; 27:355-361. [PMID: 37085341 DOI: 10.1016/j.canrad.2022.10.001] [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: 09/22/2022] [Revised: 10/11/2022] [Accepted: 10/18/2022] [Indexed: 04/23/2023]
Abstract
PURPOSE Adaptive radiotherapy with the Ethos® therapy Varian system has been recently implemented at the Montpellier Cancer Institute, France. This article details the commissioning performed before the implementation of this new treatment planning system (TPS). MATERIAL AND METHODS To validate the golden beam data of the machine (Halcyon linear accelerator), percentage depth doses (PDD) and profiles were measured for several field sizes and at different depths with a microdiamond chamber. The final doses calculated for different plan types with the Ethos Acuros XB algorithm and the Halcyon Eclipse Analytic Anisotropic Algorithm were compared using the gamma index method. Lastly, for the patient quality assurance (QA) process, the patient treatment plan results obtained with the Mobius3D QA platform (Varian) were compared with the portal dosimetry results obtained with Epiqa (Epidos). RESULTS Minor differences were observed for the PDD and profile curves (mean difference of 0.2% and 2%, respectively). The χ index pass rate was above 98% for all measures using the 1%/1mm and 2%/2mm criteria for PDD and profile evaluations. The Ethos AXB algorithm was validated for every configuration (fixed fields, standard IMRT and VMAT fields, and clinical plans) with 2D/3D gamma index values>99%. Seventy-three 3-arcs-VMAT QA plans and 27 9-fields-IMRT QA plans were evaluated. Both showed excellent agreement with the TPS calculations (mean gamma pass rate higher than 99%). No difference was observed between IMRT and VMAT. CONCLUSION The beam delivery, the Ethos AXB algorithm, and the patient QA were comprehensively validated using independent tools.
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Affiliation(s)
- A Morel
- Institut du cancer de Montpellier (ICM), Montpellier, France
| | - J Prunaretty
- Institut du cancer de Montpellier (ICM), Montpellier, France.
| | - D Trauchessec
- Institut du cancer de Montpellier (ICM), Montpellier, France
| | - N Ailleres
- Institut du cancer de Montpellier (ICM), Montpellier, France
| | - P Fenoglietto
- Institut du cancer de Montpellier (ICM), Montpellier, France
| | - D Azria
- Institut du cancer de Montpellier (ICM), Montpellier, France
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12
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Saez J, Bar-Deroma R, Bogaert E, Cayez R, Chow T, Clark CH, Esposito M, Feygelman V, Monti AF, Garcia-Miguel J, Gershkevitsh E, Goossens J, Herrero C, Hussein M, Khamphan C, Kierkels RGJ, Lechner W, Lemire M, Nevelsky A, Nguyen D, Paganini L, Pasler M, Fernando Pérez Azorín J, Ramos Garcia LI, Russo S, Shakeshaft J, Vieillevigne L, Hernandez V. Universal evaluation of MLC models in treatment planning systems based on a common set of dynamic tests. Radiother Oncol 2023; 186:109775. [PMID: 37385376 DOI: 10.1016/j.radonc.2023.109775] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 06/19/2023] [Accepted: 06/23/2023] [Indexed: 07/01/2023]
Abstract
PURPOSE To demonstrate the feasibility of characterising MLCs and MLC models implemented in TPSs using a common set of dynamic beams. MATERIALS AND METHODS A set of tests containing synchronous (SG) and asynchronous sweeping gaps (aSG) was distributed among twenty-five participating centres. Doses were measured with a Farmer-type ion chamber and computed in TPSs, which provided a dosimetric characterisation of the leaf tip, tongue-and-groove, and MLC transmission of each MLC, as well as an assessment of the MLC model in each TPS. Five MLC types and four TPSs were evaluated, covering the most frequent combinations used in radiotherapy departments. RESULTS Measured differences within each MLC type were minimal, while large differences were found between MLC models implemented in clinical TPSs. This resulted in some concerning discrepancies, especially for the HD120 and Agility MLCs, for which differences between measured and calculated doses for some MLC-TPS combinations exceeded 10%. These large differences were particularly evident for small gap sizes (5 and 10 mm), as well as for larger gaps in the presence of tongue-and-groove effects. A much better agreement was found for the Millennium120 and Halcyon MLCs, differences being within ± 5% and ± 2.5%, respectively. CONCLUSIONS The feasibility of using a common set of tests to assess MLC models in TPSs was demonstrated. Measurements within MLC types were very similar, but TPS dose calculations showed large variations. Standardisation of the MLC configuration in TPSs is necessary. The proposed procedure can be readily applied in radiotherapy departments and can be a valuable tool in IMRT and credentialing audits.
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Affiliation(s)
- Jordi Saez
- Hospital Clínic de Barcelona, Department of Radiation Oncology, Barcelona, Spain.
| | - Raquel Bar-Deroma
- Rambam Health Care Campus, Department of Radiotherapy, Division of Oncology, Haifa, Israel
| | - Evelien Bogaert
- Ghent University Hospital and Ghent University, Department of Radiation Oncology, Ghent, Belgium
| | - Romain Cayez
- Oscar Lambret Center, Department of Medical Physics, Lille, France
| | - Tom Chow
- Juravinski Hospital and Cancer Centre at Hamilton Health Sciences, Department of Medical Physics, Ontario, Canada
| | - Catharine H Clark
- National Physical Laboratory, Metrology for Medical Physics Centre, London TW11 0PX, UK; Radiotherapy Physics, University College London Hospital, 250 Euston Rd, London NW1 2PG, UK; Dept Medical Physics and Bioengineering, University College London, Malet Place, London WC1 6BT, UK
| | - Marco Esposito
- AUSL Toscana Centro, Medical Physics Unit, Florence, Italy; The Abdus Salam International Center for Theoretical, Trieste, Italy
| | | | - Angelo F Monti
- ASST GOM Niguarda, Department of Medical Physics, Milano, Italy
| | - Julia Garcia-Miguel
- Consorci Sanitari de Terrassa, Department of Radiation Oncology, Terrassa, Spain
| | - Eduard Gershkevitsh
- North Estonia Medical Centre, Department of Medical Physics, Tallinn, Estonia
| | - Jo Goossens
- Iridium Netwerk, Department of Medical Physics, Antwerp, Belgium
| | - Carmen Herrero
- Centro Médico de Asturias-IMOMA, Department of Medical Physics, Oviedo, Spain
| | - Mohammad Hussein
- National Physical Laboratory, Metrology for Medical Physics Centre, London TW11 0PX, UK
| | - Catherine Khamphan
- Institut du Cancer - Avignon Provence, Department of Medical Physics, Avignon, France
| | - Roel G J Kierkels
- Radiotherapiegroep, Department of Medical Physics, Arnhem/Deventer, the Netherlands
| | - Wolfgang Lechner
- Medical University of Vienna, Department of Radiation Oncology, Vienna, Austria
| | - Matthieu Lemire
- CIUSSS de l'Est-de-l'Île-de-Montréal, Service de Radio-Physique, Montréal, Canada
| | - Alexander Nevelsky
- Rambam Health Care Campus, Department of Radiotherapy, Division of Oncology, Haifa, Israel
| | | | - Lucia Paganini
- Humanitas Clinical and Research Center, Radiotherapy and Radiosurgery Department, Rozzano, Italy
| | - Marlies Pasler
- Lake Constance Radiation Oncology Center, Department of Radiation Oncology, Singen, Friedrichshafen, Germany; Radiotherapy Hirslanden, St. Gallen, Switzerland
| | - José Fernando Pérez Azorín
- Medical Physics and Radiation Protection Department, Gurutzeta-Cruces University Hospital, Barakaldo, Spain; Biocruces Health Research Institute, Barakaldo, Spain
| | | | | | - John Shakeshaft
- Gold Coast University Hospital, ICON Cancer Centre, Gold Coast, Australia
| | - Laure Vieillevigne
- Institut Claudius Regaud-Institut Universitaire du Cancer de Toulouse, Department of Medical Physics, Toulouse, France
| | - Victor Hernandez
- Hospital Sant Joan de Reus, Department of Medical Physics, Reus, Spain; Universitat Rovira i Virgili, Tarragona, Spain
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Stanley DN, Harms J, Pogue JA, Belliveau J, Marcrom SR, McDonald AM, Dobelbower MC, Boggs DH, Soike MH, Fiveash JA, Popple RA, Cardenas CE. A roadmap for implementation of kV-CBCT online adaptive radiation therapy and initial first year experiences. J Appl Clin Med Phys 2023; 24:e13961. [PMID: 36920871 PMCID: PMC10338842 DOI: 10.1002/acm2.13961] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 01/12/2023] [Accepted: 02/23/2023] [Indexed: 03/16/2023] Open
Abstract
PURPOSE Online Adaptive Radiation Therapy (oART) follows a different treatment paradigm than conventional radiotherapy, and because of this, the resources, implementation, and workflows needed are unique. The purpose of this report is to outline our institution's experience establishing, organizing, and implementing an oART program using the Ethos therapy system. METHODS We include resources used, operational models utilized, program creation timelines, and our institutional experiences with the implementation and operation of an oART program. Additionally, we provide a detailed summary of our first year's clinical experience where we delivered over 1000 daily adaptive fractions. For all treatments, the different stages of online adaption, primary patient set-up, initial kV-CBCT acquisition, contouring review and edit of influencer structures, target review and edits, plan evaluation and selection, Mobius3D 2nd check and adaptive QA, 2nd kV-CBCT for positional verification, treatment delivery, and patient leaving the room, were analyzed. RESULTS We retrospectively analyzed data from 97 patients treated from August 2021-August 2022. One thousand six hundred seventy seven individual fractions were treated and analyzed, 632(38%) were non-adaptive and 1045(62%) were adaptive. Seventy four of the 97 patients (76%) were treated with standard fractionation and 23 (24%) received stereotactic treatments. For the adaptive treatments, the generated adaptive plan was selected in 92% of treatments. On average(±std), adaptive sessions took 34.52 ± 11.42 min from start to finish. The entire adaptive process (from start of contour generation to verification CBCT), performed by the physicist (and physician on select days), was 19.84 ± 8.21 min. CONCLUSION We present our institution's experience commissioning an oART program using the Ethos therapy system. It took us 12 months from project inception to the treatment of our first patient and 12 months to treat 1000 adaptive fractions. Retrospective analysis of delivered fractions showed that the average overall treatment time was approximately 35 min and the average time for the adaptive component of treatment was approximately 20 min.
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Affiliation(s)
- Dennis N. Stanley
- Department of Radiation OncologyUniversity of AlabamaBirminghamAlabamaUSA
| | - Joseph Harms
- Department of Radiation OncologyUniversity of AlabamaBirminghamAlabamaUSA
| | - Joel A. Pogue
- Department of Radiation OncologyUniversity of AlabamaBirminghamAlabamaUSA
| | - Jean‐Guy Belliveau
- Department of Radiation OncologyUniversity of AlabamaBirminghamAlabamaUSA
| | - Samuel R. Marcrom
- Department of Radiation OncologyUniversity of AlabamaBirminghamAlabamaUSA
| | - Andrew M. McDonald
- Department of Radiation OncologyUniversity of AlabamaBirminghamAlabamaUSA
| | | | - Drexell H. Boggs
- Department of Radiation OncologyUniversity of AlabamaBirminghamAlabamaUSA
| | - Michael H. Soike
- Department of Radiation OncologyUniversity of AlabamaBirminghamAlabamaUSA
| | - John A. Fiveash
- Department of Radiation OncologyUniversity of AlabamaBirminghamAlabamaUSA
| | - Richard A. Popple
- Department of Radiation OncologyUniversity of AlabamaBirminghamAlabamaUSA
| | - Carlos E. Cardenas
- Department of Radiation OncologyUniversity of AlabamaBirminghamAlabamaUSA
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Kisling K, Keiper TD, Branco D, Kim GG, Moore KL, Ray X. Clinical commissioning of an adaptive radiotherapy platform: Results and recommendations. J Appl Clin Med Phys 2022; 23:e13801. [PMID: 36316805 PMCID: PMC9797177 DOI: 10.1002/acm2.13801] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/31/2022] [Accepted: 09/09/2022] [Indexed: 12/29/2022] Open
Abstract
Online adaptive radiotherapy platforms present a unique challenge for commissioning as guidance is lacking and specialized adaptive equipment, such as deformable phantoms, are rare. We designed a novel adaptive commissioning process consisting of end-to-end tests using standard clinical resources. These tests were designed to simulate anatomical changes regularly observed at patient treatments. The test results will inform users of the magnitude of uncertainty from on-treatment changes during the adaptive workflow and the limitations of their systems. We implemented these tests for the cone-beam computed tomography (CT)-based Varian Ethos online adaptive platform. Many adaptive platforms perform online dose calculation on a synthetic CT (synCT). To assess the impact of the synCT generation and online dose calculation on dosimetric accuracy, we conducted end-to-end tests using commonly available equipment: a CIRS IMRT Thorax phantom, PinPoint ionization chamber, Gafchromic film, and bolus. Four clinical scenarios were evaluated: weight gain and weight loss were simulated by adding and removing bolus, internal target shifts were simulated by editing the CTV during the adaptive workflow to displace it, and changes in gas were simulated by removing and reinserting rods in varying phantom locations. The effect of overriding gas pockets during planning was also assessed. All point dose measurements agreed within 2.7% of the calculated dose, with one exception: a scenario simulating gas present in the planning CT, not overridden during planning, and dissipating at treatment. Relative film measurements passed gamma analysis (3%/3 mm criteria) for all scenarios. Our process validated the Ethos dose calculation for online adapted treatment plans. Based on our results, we made several recommendations for our clinical adaptive workflow. This commissioning process used commonly available equipment and, therefore, can be applied in other clinics for their respective online adaptive platforms.
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Affiliation(s)
- Kelly Kisling
- Department of Radiation Medicine and Applied SciencesUniversity of California San DiegoSan DiegoCaliforniaUSA
| | - Timothy D. Keiper
- Department of Radiation Medicine and Applied SciencesUniversity of California San DiegoSan DiegoCaliforniaUSA
| | - Daniela Branco
- Department of Radiation Medicine and Applied SciencesUniversity of California San DiegoSan DiegoCaliforniaUSA
| | - Grace Gwe‐Ya Kim
- Department of Radiation Medicine and Applied SciencesUniversity of California San DiegoSan DiegoCaliforniaUSA
| | - Kevin L Moore
- Department of Radiation Medicine and Applied SciencesUniversity of California San DiegoSan DiegoCaliforniaUSA
| | - Xenia Ray
- Department of Radiation Medicine and Applied SciencesUniversity of California San DiegoSan DiegoCaliforniaUSA
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15
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Byrne M, Archibald-Heeren B, Hu Y, Greer P, Luo S, Aland T. Assessment of semi-automated stereotactic treatment planning for online adaptive radiotherapy in ethos. Med Dosim 2022; 47:342-347. [PMID: 36127189 DOI: 10.1016/j.meddos.2022.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/04/2022] [Accepted: 08/22/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION The Ethos treatment planning system allows for the rapid generation of online adaptive treatment plans while the patient is on the treatment couch. One promising application of online adaptive radiotherapy is its use in stereotactic radiotherapy. The purpose of this study was to ensure the Ethos treatment planning system (TPS) can produce clinically acceptable stereotactic plans, that are non-inferior to those from the Eclipse TPS. METHOD Forty patients that received previous stereotactic radiotherapy treatment on a Halcyon, 20 of which were lung cases, and 20 that were brain cases, were replanned using the Ethos TPS. The generated IMRT and VMAT plans were compared to the clinical Eclipse VMAT plan. RESULTS This study found that the Ethos TPS can produce VMAT plans of equivalent quality (target coverage, conformity and OAR doses) to those from the Eclipse TPS for lung SBRT and brain SRT. The IMRT plans produced by the Ethos planning system were marginally inferior to Eclipse VMAT plans, with the differences likely primarily due to beam geometry rather than the optimization system. Ethos plans were generally more modulated than Eclipse plans. With careful selection of optimization structures and reduction in the body contour, VMAT plan generation time could be reduced by 87%. CONCLUSION Ethos can generate stereotactic VMAT plans that are equivalent to those from Eclipse in the timeframe required for online adaptive radiotherapy.
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Affiliation(s)
- Mikel Byrne
- Strategic Investment & Clinical Care, Icon Group, South Brisbane, QLD, Australia; University of Newcastle, Newcastle, NSW, Australia.
| | - Ben Archibald-Heeren
- Strategic Investment & Clinical Care, Icon Group, South Brisbane, QLD, Australia
| | - Yunfei Hu
- Strategic Investment & Clinical Care, Icon Group, South Brisbane, QLD, Australia
| | - Peter Greer
- University of Newcastle, Newcastle, NSW, Australia; Calvary Mater Newcastle Hospital, Newcastle, NSW, Australia
| | - Suhuai Luo
- University of Newcastle, Newcastle, NSW, Australia
| | - Trent Aland
- Strategic Investment & Clinical Care, Icon Group, South Brisbane, QLD, Australia
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16
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Price AT, Knutson NC, Kim T, Green OL. Commissioning a secondary dose calculation software for a 0.35 T MR-linac. J Appl Clin Med Phys 2022; 23:e13452. [PMID: 35166011 PMCID: PMC8906210 DOI: 10.1002/acm2.13452] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 08/09/2021] [Accepted: 08/28/2021] [Indexed: 11/09/2022] Open
Abstract
Secondary external dose calculations for a 0.35 T magnetic resonance image-guided radiation therapy (MRgRT) are needed within the radiation oncology community to follow safety standards set forth within the field. We evaluate the commercially available software, RadCalc, in its ability to accurately perform monitor unit dose calculations within a magnetic field. We also evaluate the potential effects of a 0.35 T magnetic field upon point dose calculations. Monitor unit calculations were evaluated with (wMag) and without (noMag) a magnetic field considerations in RadCalc for the ViewRay MRIdian. The magnetic field is indirectly accounted for by using asymmetric profiles for calculation. The introduction of double-stacked multi-leaf collimator leaves was also included in the monitor unit calculations and a single transmission value was determined. A suite of simple and complex geometries with a variety field arrangements were calculated for each method to demonstrate the effect of the 0.35 T magnetic field on monitor unit calculations. Finally, 25 patient-specific treatment plans were calculated using each method for comparison. All simple geometries calculated in RadCalc were within 2% of treatment planning system (TPS) values for both methods, except for a single noMag off-axis comparison. All complex muilt-leaf collimator (MLC) pattern calculations were within 5%. All complex phantom geometry calculations were within 5% except for a single field within a lung phantom at a distal point. For the patient calculations, the noMag method average percentage difference was 0.09 ± 2.5% and the wMag average percentage difference was 0.08 ± 2.5%. All results were within 5% for the wMag method. We performed monitor unit calculations for a 0.35 T MRgRT system using a commercially available secondary monitor unit dose calculation software and demonstrated minimal impact of the 0.35 T magnetic field on monitor unit dose calculations. This is the first investigation demonstrating successful calculations of dose using RadCalc in the low-field 0.35 T ViewRay MRIdian system.
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Affiliation(s)
- Alex T Price
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Nels C Knutson
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Taeho Kim
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Olga L Green
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
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Mao W, Riess J, Kim J, Vance S, Chetty IJ, Movsas B, Kretzler A. Evaluation of auto-contouring and dose distributions for online adaptive radiation therapy of patients with locally advanced lung cancers. Pract Radiat Oncol 2022; 12:e329-e338. [DOI: 10.1016/j.prro.2021.12.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/14/2021] [Accepted: 12/26/2021] [Indexed: 11/28/2022]
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18
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Pokharel S, Pacheco A, Tanner S. Assessment of efficacy in automated plan generation for Varian Ethos intelligent optimization engine. J Appl Clin Med Phys 2022; 23:e13539. [PMID: 35084090 PMCID: PMC8992949 DOI: 10.1002/acm2.13539] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 12/29/2021] [Accepted: 01/09/2022] [Indexed: 11/19/2022] Open
Abstract
Varian Ethos, a new treatment platform, is capable of automatically generating treatment plans for initial planning and for online, adaptive planning, using an intelligent optimization engine (IOE). The primary purpose of this study is to assess the efficacy of Varian Ethos IOE for auto‐planning and intercompare different treatment modalities within the Ethos treatment planning system (TPS). A total of 36 retrospective prostate and proximal seminal vesicles cases were selected for this study. The prescription dose was 50.4 Gy in 28 fractions to the proximal seminal vesicles, with a simultaneous integrated boost of 70 Gy to the prostate gland. Based on RT intent, three treatment plans were auto‐generated in the Ethos TPS and were exported to the Eclipse TPS for intercomparison with the Eclipse treatment plan. When normalized for the same planning target volume (PTV) coverage, Ethos plans Dmax% were 108.1 ± 1.2%, 108.4 ± 1.6%, and 109.6 ± 2.0%, for the 9‐field IMRT, 12‐field IMRT, and 2‐full arc VMAT plans, respectively. This compared well with Eclipse plan Dmax% values, which was 108.8 ± 1.4%. OAR indices were also evaluated for Ethos plans using Radiation Therapy Oncology Group report 0415 as a guide and were found to be comparable to each other and the Eclipse plans. While all Ethos plans were comparable, we found that, in general, the Ethos 12‐field IMRT plans met most of the dosimetric goals for treatment. Also, Ethos IOE consistently generated dosimetrically hotter VMAT plans versus IMRT plans. On average, Ethos TPS took 13 min to generate 2‐full arc VMAT plans, compared to 5 min for 12‐field IMRT plans. Varian Ethos TPS can generate multiple treatment plans in an efficient time frame and the quality of the plans could be deemed clinically acceptable when compared to manually generated treatment plans.
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Affiliation(s)
- Shyam Pokharel
- Department of Radiation Oncology, GenesisCare, Naples, Florida, USA.,Department of Radiation Oncology, Boca Raton Regional Hospital, Baptist Health South Florida, Lynn Cancer Institute, Boca Raton, Florida, USA
| | - Abilio Pacheco
- Department of Radiation Oncology, GenesisCare, Naples, Florida, USA
| | - Suzanne Tanner
- Department of Radiation Oncology, GenesisCare, Naples, Florida, USA
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Byrne M, Archibald-Heeren B, Hu Y, Teh A, Beserminji R, Cai E, Liu G, Yates A, Rijken J, Collett N, Aland T. Varian ethos online adaptive radiotherapy for prostate cancer: Early results of contouring accuracy, treatment plan quality, and treatment time. J Appl Clin Med Phys 2021; 23:e13479. [PMID: 34846098 PMCID: PMC8803282 DOI: 10.1002/acm2.13479] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 09/14/2021] [Accepted: 10/30/2021] [Indexed: 01/09/2023] Open
Abstract
The Varian Ethos system allows for online adaptive treatments through the utilization of artificial intelligence (AI) and deformable image registration which automates large parts of the anatomical contouring and plan optimization process. In this study, treatments of intact prostate and prostate bed, with and without nodes, were simulated for 182 online adaptive fractions, and then a further 184 clinical fractions were delivered on the Ethos system. Frequency and magnitude of contour edits were recorded, as well as a range of plan quality metrics. From the fractions analyzed, 11% of AI generated contours, known as influencer contours, required no change, and 81% required minor edits in any given fraction. The frequency of target and noninfluencer organs at risk (OAR) contour editing varied substantially between different targets and noninfluencer OARs, although across all targets 72% of cases required no edits. The adaptive plan was the preference in 95% of fractions. The adaptive plan met more goals than the scheduled plan in 78% of fractions, while in 15% of fractions the number of goals met was the same. The online adaptive recontouring and replanning process was carried out in 19 min on average. Significant improvements in dosimetry are possible with the Ethos online adaptive system in prostate radiotherapy.
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Affiliation(s)
- Mikel Byrne
- Icon Cancer Centre Wahroonga, Sydney Adventist Hospital, Wahroonga, New South Wales, Australia.,School of Information and Physical Sciences, University of Newcastle, Newcastle, New South Wales, Australia
| | - Ben Archibald-Heeren
- Icon Cancer Centre Wahroonga, Sydney Adventist Hospital, Wahroonga, New South Wales, Australia
| | - Yunfei Hu
- Icon Cancer Centre Gosford, Gosford, New South Wales, Australia
| | - Amy Teh
- Icon Cancer Centre Wahroonga, Sydney Adventist Hospital, Wahroonga, New South Wales, Australia
| | - Rhea Beserminji
- Icon Cancer Centre Wahroonga, Sydney Adventist Hospital, Wahroonga, New South Wales, Australia
| | - Emma Cai
- Icon Cancer Centre Wahroonga, Sydney Adventist Hospital, Wahroonga, New South Wales, Australia
| | - Guilin Liu
- Icon Cancer Centre Wahroonga, Sydney Adventist Hospital, Wahroonga, New South Wales, Australia
| | - Angela Yates
- Icon Cancer Centre Wahroonga, Sydney Adventist Hospital, Wahroonga, New South Wales, Australia
| | - James Rijken
- Icon Cancer Centre Windsor Gardens, Windsor Gardens, South Australia, Australia
| | - Nick Collett
- Icon Cancer Centre Wahroonga, Sydney Adventist Hospital, Wahroonga, New South Wales, Australia
| | - Trent Aland
- Icon Core Office, South Brisbane, Queensland, Australia
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20
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Boekhoff M, Defize I, Borggreve A, van Hillegersberg R, Kotte A, Lagendijk J, van Lier A, Ruurda J, Takahashi N, Mook S, Meijer G. An in-silico assessment of the dosimetric benefits of MR-guided radiotherapy for esophageal cancer patients. Radiother Oncol 2021; 162:76-84. [PMID: 34237345 DOI: 10.1016/j.radonc.2021.06.038] [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: 03/03/2021] [Revised: 06/17/2021] [Accepted: 06/26/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE To assess the dosimetric benefits of online MR-guided radiotherapy (MRgRT) for esophageal cancer patients and to assess how these benefits could be translated into a local boosting strategy to improve future outcomes. METHODS Twenty-nine patients were in-silico treated with both a MRgRT regimen and a conventional image guided radiotherapy (IGRT) regimen using dose warping techniques. Here, the inter and intrafractional changes that occur over the course of treatment (as derived from 5 MRI scans that were acquired weekly during treatment) were incorporated to assess the total accumulated dose for each regimen. RESULTS A significant reduction in dose to the organs-at-risk (OARs) was observed for all dose-volume-histogram (DVH) parameters for the MRgRT regimen without concessions to target coverage compared to the IGRT regimen. The mean lung dose was reduced by 28%, from 7.9 to 5.7 Gy respectively and V20Gy of the lungs was reduced by 55% (6.3-2.8%). A reduction of 24% was seen in mean heart dose (14.8-11.2 Gy), while the V25Gy of the heart was decreased by 53% (14.3-6.7%) and the V40Gy of the heart was decreased by 69% (3.9-1.2%). In addition, MRgRT dose escalation regimens with a boost up to 66% of the prescription dose to the primary tumor yielded approximately the same dose levels to the OARs as from the conventional IGRT regimen. CONCLUSION This study revealed that MRgRT for esophageal cancer has the potential to significantly reduce the dose to heart and lungs. In addition, online high precision targeting of the primary tumor opens new perspectives for local boosting strategies to improve outcome of the local management of this disease.
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Affiliation(s)
- Mick Boekhoff
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, The Netherlands.
| | - Ingmar Defize
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, The Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Alicia Borggreve
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, The Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht University, The Netherlands
| | | | - Alexis Kotte
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Jan Lagendijk
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Astrid van Lier
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Jelle Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Noriyoshi Takahashi
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, The Netherlands; Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Stella Mook
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Gert Meijer
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, The Netherlands.
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Hernandez V, Saez J, Angerud A, Cayez R, Khamphan C, Nguyen D, Vieillevigne L, Feygelman V. Dosimetric leaf gap and leaf trailing effect in a double-stacked multileaf collimator. Med Phys 2021; 48:3413-3424. [PMID: 33932237 DOI: 10.1002/mp.14914] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 04/02/2021] [Accepted: 04/23/2021] [Indexed: 01/21/2023] Open
Abstract
PURPOSE To investigate (i) the dosimetric leaf gap (DLG) and the effect of the "trailing distance" between leaves from different multileaf collimator (MLC) layers in Halcyon systems and (ii) the ability of the currently available treatment planning systems (TPSs) to approximate this effect. METHODS DICOM plans with transmission beams and sweeping gap tests were created in Python for measuring the DLG for each MLC layer independently and for both layers combined. In clinical Halcyon plans both MLC layers are interchangeably used and leaves from different layers are offset, thus forming a trailing pattern. To characterize the impact of such configuration, new tests called "trailing sweeping gaps" were designed and created where the leaves from one layer follow the leaves from the other layer at a fixed "trailing distance" t between the tips. Measurements were carried out on five Halcyons SX2 from different institutions and calculations from both the Eclipse and RayStation TPSs were compared with measurements. RESULTS The dose accumulated during a sweeping gap delivery progressively increased with the trailing distance t . We call this "the trailing effect." It is most pronounced for t between 0 and 5 mm, although some changes were obtained up to 20 mm. The dose variation was independent of the gap size. The measured DLG values also increased with t up to 20 mm, again with the steepest variation between 0 and 5 mm. Measured DLG values were negative at t = 0 (the leaves from both layers at the same position) but changed sign for t ≥ 1 mm, in line with the positive DLG sign usually observed with single-layer rounded-end MLCs. The Eclipse TPS does not explicitly model the leaf tip and, as a consequence, could not predict the dose reduction due to the trailing effect. This resulted in dose discrepancies up to +10% and -8% for the 5 mm sweeping gap and up to ±5% for the 10 mm one depending on the distance t . RayStation implements a simple model of the leaf tip that was able to approximate the trailing effect and improved the agreement with measured doses. In particular, with a prototype version of RayStation that assigned a higher transmission at the leaf tip the agreement with measured doses was within ±3% even for the 5 mm gap. The five Halcyon systems behaved very similarly but differences in the DLG around 0.2 mm were found across different treatment units and between MLC layers from the same system. The DLG for the proximal layer was consistently higher than for the distal layer, with differences ranging between 0.10 mm and 0.24 mm. CONCLUSIONS The trailing distance between the leaves from different layers substantially affected the doses delivered by sweeping gaps and the measured DLG values. Stacked MLCs introduce a new level of complexity in TPSs, which ideally need to implement an explicit model of the leaf tip in order to reproduce the trailing effect. Dynamic tests called "trailing sweeping gaps" were designed that are useful for characterizing and commissioning dual-layer MLC systems.
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Affiliation(s)
- Victor Hernandez
- Department of Medical Physics, Hospital Sant Joan de Reus, IISPV, 43204, Tarragona, Spain
| | - Jordi Saez
- Department of Radiation Oncology, Hospital Clínic de Barcelona, 08036, Barcelona, Spain
| | | | - Romain Cayez
- Department of Medical Physics, Oscar Lambret Center, 59000, Lille, France
| | - Catherine Khamphan
- Medical Physics Department, Institut Sainte-Catherine, 84000, Avignon, France
| | - Daniel Nguyen
- Centre de Radiothérapie de Mâcon, 71000, Mâcon, France
| | - Laure Vieillevigne
- Department of Medical Physics, Institut Claudius Regaud-Institut Universitaire du Cancer de Toulouse, 31059, Toulouse, France.,Centre de Recherche en Cancérologie de Toulouse UMR1037 INSERM, Université Toulouse 3-ERL5294 CNRS, Oncopole, 31037, Toulouse, France
| | - Vladimir Feygelman
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, 12902, Florida, USA
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