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Lombardo J, Castillo E, Castillo R, Miller R, Jones B, Miften M, Kavanagh B, Dicker A, Boyle C, Leiby B, Banks J, Simone NL, Movsas B, Grills I, Guerrero T, Rusthoven CG, Vinogradskiy Y. Prospective Trial of Functional Lung Avoidance Radiation Therapy for Lung Cancer: Quality of Life Report. Int J Radiat Oncol Biol Phys 2024; 120:593-602. [PMID: 38614278 PMCID: PMC11381170 DOI: 10.1016/j.ijrobp.2024.03.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 03/26/2024] [Accepted: 03/29/2024] [Indexed: 04/15/2024]
Abstract
PURPOSE A novel form of lung function imaging has been developed that uses 4-dimensional computed tomography (4DCT) data to generate lung ventilation images (4DCT-ventilation). Functional avoidance uses 4DCT-ventilation to reduce doses to functional lung with the aim of reducing pulmonary side effects. A phase 2, multicenter 4DCT-ventilation functional avoidance clinical trial was completed. The purpose of this work was to quantify changes in patient-reported outcomes (PROs) for patients treated with functional avoidance and determine which metrics are predictive of PRO changes. MATERIALS AND METHODS Patients with locally advanced lung cancer receiving curative-intent radiation therapy were accrued. Each patient had a 4DCT-ventilation image generated using 4DCT data and image processing. PRO instruments included the Functional Assessment of Cancer Therapy-Lung (FACT-L) questionnaire administered pretreatment; at the end of treatment; and at 3, 6, and 12 months posttreatment. Using the FACT-Trial Outcome Index and the FACT-Lung Cancer Subscale results, the percentage of clinically meaningful declines (CMDs) were determined. A linear mixed-effects model was used to determine which patient, clinical, dose, and dose-function metrics were predictive of PRO decline. RESULTS Of the 59 patients who completed baseline PRO surveys. 83% had non-small cell lung cancer, with 75% having stage 3 disease. The median dose was 60 Gy in 30 fractions. CMD FACT-Trial Outcome Index decline was 46.3%, 38.5%, and 26.8%, at 3, 6, and 12 months, respectively. CMD FACT-Lung Cancer Subscale decline was 33.3%, 33.3%, and 29.3%, at 3, 6, and 12 months, respectively. Although an increase in most dose and dose-function parameters was associated with a modest decline in PROs, none of the results were significant (all P > .053). CONCLUSIONS The current work presents an innovative combination of use of functional avoidance and PRO assessment and is the first report of PROs for patients treated with prospective 4DCT-ventilation functional avoidance. Approximately 30% of patients had clinically significant decline in PROs at 12 months posttreatment. The study provides additional data on outcomes with 4DCT-ventilation functional avoidance.
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Affiliation(s)
- Joseph Lombardo
- Thomas Jefferson University, Radiation Oncology, Philadelphia, Pennsylvania
| | - Edward Castillo
- UT Austin, Department of Biomedical Engineering, Austin, Texas
| | - Richard Castillo
- Emory University School of Medicine, Radiation Oncology, Atlanta, Georgia
| | - Ryan Miller
- Thomas Jefferson University, Radiation Oncology, Philadelphia, Pennsylvania
| | - Bernard Jones
- University of Colorado, Radiation Oncology, Denver, Colorado
| | - Moyed Miften
- University of Colorado, Radiation Oncology, Denver, Colorado
| | - Brian Kavanagh
- University of Colorado, Radiation Oncology, Denver, Colorado
| | - Adam Dicker
- Thomas Jefferson University, Radiation Oncology, Philadelphia, Pennsylvania
| | - Cullen Boyle
- Thomas Jefferson University, Radiation Oncology, Philadelphia, Pennsylvania
| | - Benjamin Leiby
- Thomas Jefferson University, Department of Pharmacology, Physiology, and Cancer Biology, Philadelphia, Pennsylvania
| | - Joshua Banks
- Thomas Jefferson University, Department of Pharmacology, Physiology, and Cancer Biology, Philadelphia, Pennsylvania
| | - Nicole L Simone
- Thomas Jefferson University, Radiation Oncology, Philadelphia, Pennsylvania
| | - Benjamin Movsas
- Henry Ford Cancer Institute, Radiation Oncology, Detroit, Michigan
| | - Inga Grills
- Beaumont Health, Radiation Oncology, Royal Oak, Michigan
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Midroni J, Salunkhe R, Liu Z, Chow R, Boldt G, Palma D, Hoover D, Vinogradskiy Y, Raman S. Incorporation of Functional Lung Imaging Into Radiation Therapy Planning in Patients With Lung Cancer: A Systematic Review and Meta-Analysis. Int J Radiat Oncol Biol Phys 2024; 120:370-408. [PMID: 38631538 DOI: 10.1016/j.ijrobp.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 03/27/2024] [Accepted: 04/02/2024] [Indexed: 04/19/2024]
Abstract
Our purpose was to provide an understanding of current functional lung imaging (FLI) techniques and their potential to improve dosimetry and outcomes for patients with lung cancer receiving radiation therapy (RT). Excerpta Medica dataBASE (EMBASE), PubMed, and Cochrane Library were searched from 1990 until April 2023. Articles were included if they reported on FLI in one of: techniques, incorporation into RT planning for lung cancer, or quantification of RT-related outcomes for patients with lung cancer. Studies involving all RT modalities, including stereotactic body RT and particle therapy, were included. Meta-analyses were conducted to investigate differences in dose-function parameters between anatomic and functional RT planning techniques, as well as to investigate correlations of dose-function parameters with grade 2+ radiation pneumonitis (RP). One hundred seventy-eight studies were included in the narrative synthesis. We report on FLI modalities, dose-response quantification, functional lung (FL) definitions, FL avoidance techniques, and correlations between FL irradiation and toxicity. Meta-analysis results show that FL avoidance planning gives statistically significant absolute reductions of 3.22% to the fraction of well-ventilated lung receiving 20 Gy or more, 3.52% to the fraction of well-perfused lung receiving 20 Gy or more, 1.3 Gy to the mean dose to the well-ventilated lung, and 2.41 Gy to the mean dose to the well-perfused lung. Increases in the threshold value for defining FL are associated with decreases in functional parameters. For intensity modulated RT and volumetric modulated arc therapy, avoidance planning results in a 13% rate of grade 2+ RP, which is reduced compared with results from conventional planning cohorts. A trend of increased predictive ability for grade 2+ RP was seen in models using FL information but was not statistically significant. FLI shows promise as a method to spare FL during thoracic RT, but interventional trials related to FL avoidance planning are sparse. Such trials are critical to understanding the effect of FL avoidance planning on toxicity reduction and patient outcomes.
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Affiliation(s)
- Julie Midroni
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; Radiation Medicine Program, Princess Margaret Cancer Center, Toronto, Canada
| | - Rohan Salunkhe
- Radiation Medicine Program, Princess Margaret Cancer Center, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Zhihui Liu
- Biostatistics, Princess Margaret Cancer Center, Toronto, Canada
| | - Ronald Chow
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; Radiation Medicine Program, Princess Margaret Cancer Center, Toronto, Canada; London Regional Cancer Program, London Health Sciences Centre, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - Gabriel Boldt
- London Regional Cancer Program, London Health Sciences Centre, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - David Palma
- London Regional Cancer Program, London Health Sciences Centre, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada; Ontario Institute for Cancer Research, Toronto, Canada
| | - Douglas Hoover
- London Regional Cancer Program, London Health Sciences Centre, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - Yevgeniy Vinogradskiy
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, United States of America; Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, United States of America
| | - Srinivas Raman
- Radiation Medicine Program, Princess Margaret Cancer Center, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada.
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Bi S, Yuan Q, Dai Z, Sun X, Wan Sohaimi WFB, Bin Yusoff AL. Advances in CT-based lung function imaging for thoracic radiotherapy. Front Oncol 2024; 14:1414337. [PMID: 39286020 PMCID: PMC11403405 DOI: 10.3389/fonc.2024.1414337] [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: 04/08/2024] [Accepted: 08/14/2024] [Indexed: 09/19/2024] Open
Abstract
The objective of this review is to examine the potential benefits and challenges of CT-based lung function imaging in radiotherapy over recent decades. This includes reviewing background information, defining related concepts, classifying and reviewing existing studies, and proposing directions for further investigation. The lung function imaging techniques reviewed herein encompass CT-based methods, specifically utilizing phase-resolved four-dimensional CT (4D-CT) or end-inspiratory and end-expiratory CT scans, to delineate distinct functional regions within the lungs. These methods extract crucial functional parameters, including lung volume and ventilation distribution, pivotal for assessing and characterizing the functional capacity of the lungs. CT-based lung ventilation imaging offers numerous advantages, notably in the realm of thoracic radiotherapy. By utilizing routine CT scans, additional radiation exposure and financial burdens on patients can be avoided. This imaging technique also enables the identification of different functional areas of the lung, which is crucial for minimizing radiation exposure to healthy lung tissue and predicting and detecting lung injury during treatment. In conclusion, CT-based lung function imaging holds significant promise for improving the effectiveness and safety of thoracic radiotherapy. Nevertheless, challenges persist, necessitating further research to address limitations and optimize clinical utilization. Overall, this review highlights the importance of CT-based lung function imaging as a valuable tool in radiotherapy planning and lung injury monitoring.
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Affiliation(s)
- Suyan Bi
- School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Qingqing Yuan
- National Cancer Center/National Clinical Research Center for Cancer/ Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Zhitao Dai
- National Cancer Center/National Clinical Research Center for Cancer/ Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Xingru Sun
- Huizhou Third People's Hospital, Guangzhou Medical University, Huizhou, Guangdong, China
| | - Wan Fatihah Binti Wan Sohaimi
- Department of Nuclear Medicine Radiotherapy and Oncology, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Ahmad Lutfi Bin Yusoff
- Department of Nuclear Medicine Radiotherapy and Oncology, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
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Baschnagel AM, Flakus MJ, Wallat EM, Wuschner AE, Chappell RJ, Bayliss RA, Kimple RJ, Christensen GE, Reinhardt JM, Bassetti MF, Bayouth JE. A Phase 2 Randomized Clinical Trial Evaluating 4-Dimensional Computed Tomography Ventilation-Based Functional Lung Avoidance Radiation Therapy for Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2024; 119:1393-1402. [PMID: 38387810 DOI: 10.1016/j.ijrobp.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/10/2024] [Accepted: 02/08/2024] [Indexed: 02/24/2024]
Abstract
PURPOSE To determine whether 4-dimensional computed tomography (4DCT) ventilation-based functional lung avoidance radiation therapy preserves pulmonary function compared with standard radiation therapy for non-small cell lung cancer (NSCLC). METHODS AND MATERIALS This single center, randomized, phase 2 trial enrolled patients with NSCLC receiving curative intent radiation therapy with either stereotactic body radiation therapy or conventionally fractionated radiation therapy between 2016 and 2022. Patients were randomized 1:1 to standard of care radiation therapy or functional lung avoidance radiation therapy. The primary endpoint was the change in Jacobian-based ventilation as measured on 4DCT from baseline to 3 months postradiation. Secondary endpoints included changes in volume of high- and low-ventilating lung, pulmonary toxicity, and changes in pulmonary function tests (PFTs). RESULTS A total of 122 patients were randomized and 116 were available for analysis. Median follow up was 29.9 months. Functional avoidance plans significantly (P < .05) reduced dose to high-functioning lung without compromising target coverage or organs at risk constraints. When analyzing all patients, there was no difference in the amount of lung showing a reduction in ventilation from baseline to 3 months between the 2 arms (1.91% vs 1.87%; P = .90). Overall grade ≥2 and grade ≥3 pulmonary toxicities for all patients were 24.1% and 8.6%, respectively. There was no significant difference in pulmonary toxicity or changes in PFTs between the 2 study arms. In the conventionally fractionated cohort, there was a lower rate of grade ≥2 pneumonitis (8.2% vs 32.3%; P = .049) and less of a decline in change in forced expiratory volume in 1 second (-3 vs -5; P = .042) and forced vital capacity (1.5 vs -6; P = .005) at 3 months, favoring the functional avoidance arm. CONCLUSIONS There was no difference in posttreatment ventilation as measured by 4DCT between the arms. In the cohort of patients treated with conventionally fractionated radiation therapy with functional lung avoidance, there was reduced pulmonary toxicity, and less decline in PFTs suggesting a clinical benefit in patients with locally advanced NSCLC.
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Affiliation(s)
- Andrew M Baschnagel
- Department of Human Oncology, University of Wisconsin Hospital and Clinics, Madison, Wisconsin.
| | - Mattison J Flakus
- Department of Medical Physics, University of Wisconsin-Madison, Madison, Wisconsin
| | - Eric M Wallat
- Department of Medical Physics, University of Wisconsin-Madison, Madison, Wisconsin
| | - Antonia E Wuschner
- Department of Medical Physics, University of Wisconsin-Madison, Madison, Wisconsin
| | - Richard J Chappell
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin
| | - R Adam Bayliss
- Department of Human Oncology, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Randall J Kimple
- Department of Human Oncology, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Gary E Christensen
- Department of Electrical and Computer Engineering, University of Iowa, Iowa City, Iowa; Department of Radiation Oncology, University of Iowa, Iowa City, Iowa
| | - Joseph M Reinhardt
- Roy J. Carver Department of Biomedical Engineering, University of Iowa, Iowa City, Iowa
| | - Michael F Bassetti
- Department of Human Oncology, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - John E Bayouth
- Department of Radiation Medicine, Oregon Health & Science University, Portland, Oregon.
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Hou Z, Kong Y, Wu J, Gu J, Liu J, Gao S, Yin Y, Zhang L, Han Y, Zhu J, Li S. A deep learning model for translating CT to ventilation imaging: analysis of accuracy and impact on functional avoidance radiotherapy planning. Jpn J Radiol 2024; 42:765-776. [PMID: 38536558 DOI: 10.1007/s11604-024-01550-2] [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: 12/13/2023] [Accepted: 02/19/2024] [Indexed: 07/03/2024]
Abstract
PURPOSE Radiotherapy planning incorporating functional lung images has the potential to reduce pulmonary toxicity. Free-breathing 4DCT-derived ventilation image (CTVI) may help quantify lung function. This study introduces a novel deep-learning model directly translating planning CT images into CTVI. We investigated the accuracy of generated images and the impact on functional avoidance planning. MATERIALS AND METHODS Paired planning CT and 4DCT scans from 48 patients with NSCLC were randomized to training (n = 41) and testing (n = 7) data sets. The ventilation maps were generated from 4DCT using a Jacobian-based algorithm to provide ground truth labels (CTVI4DCT). A 3D U-Net-based model was trained to map CT to synthetic CTVI (CTVISyn) and validated using fivefold cross-validation. The highest-performing model was applied to the testing set. Spearman's correlation (rs) and Dice similarity coefficient (DSC) determined voxel-wise and functional-wise concordance between CTVI4DCT and CTVISyn. Three plans were designed per patient in the testing set: one clinical plan without CTVI and two functional avoidance plans combined with CTVI4DCT or CTVISyn, aimed at sparing high-functional lungs defined as the top 50% of the percentile ventilation ranges. Dose-volume (DVH) parameters regarding the planning target volume (PTV) and organs at risk (OARs) were recorded. Radiation pneumonitis (RP) risk was estimated using a dose-function (DFH)-based normal tissue complication probability (NTCP) model. RESULTS CTVISyn showed a mean rs value of 0.65 ± 0.04 compared to CTVI4DCT. Mean DSC values over the top 50% and 60% of ventilation ranges were 0.41 ± 0.07 and 0.52 ± 0.10, respectively. In the test set (n = 7), all patients' RP-risk benefited from CTVI4DCT-guided plans (Riskmean_4DCT_vs_Clinical: 29.24% vs. 49.12%, P = 0.016), and six patients benefited from CTVISyn-guided plans (Riskmean_Syn_vs_Clinical: 31.13% vs. 49.12%, P = 0.022). There were no significant differences in DVH and DFH metrics between CTVISyn and CTVI4DCT-guided plan (P > 0.05). CONCLUSION Using deep-learning techniques, CTVISyn generated from planning CT exhibited a moderate-to-high correlation with CTVI4DCT. The CTVISyn-guided plans were comparable to the CTVI4DCT-guided plans, effectively reducing pulmonary toxicity in patients while maintaining acceptable plan quality. Further prospective trials are needed to validate these findings.
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Affiliation(s)
- Zhen Hou
- The Comprehensive Cancer Centre of Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210000, Jiangsu, China
| | - Youyong Kong
- School of Computer Science and Engineering, Southeast University, Nanjing, 210000, Jiangsu, China
- Centre de Recherche en Information, BioMdicale Sino-Franais, Nanjing, China
- Centre de Recherche en Information, BioMdicale Sino-Franais, 35000, Rennes, France
| | - Junxian Wu
- School of Computer Science and Engineering, Southeast University, Nanjing, 210000, Jiangsu, China
| | - Jiabing Gu
- School of Computer Science and Engineering, Southeast University, Nanjing, 210000, Jiangsu, China
| | - Juan Liu
- The Comprehensive Cancer Centre of Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210000, Jiangsu, China
| | - Shanbao Gao
- The Comprehensive Cancer Centre of Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210000, Jiangsu, China
| | - Yicai Yin
- The Comprehensive Cancer Centre of Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210000, Jiangsu, China
| | - Ling Zhang
- The Comprehensive Cancer Centre of Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210000, Jiangsu, China
| | - Yongchao Han
- The Comprehensive Cancer Centre of Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210000, Jiangsu, China
| | - Jian Zhu
- Department of Radiation Oncology Physics and Technology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250000, Shandong, China.
- Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250000, Shandong, China.
- Centre de Recherche en Information, BioMdicale Sino-Franais, Nanjing, China.
- Centre de Recherche en Information, BioMdicale Sino-Franais, 35000, Rennes, France.
| | - Shuangshuang Li
- The Comprehensive Cancer Centre of Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210000, Jiangsu, China.
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Zhou PX, Zhang SX. Functional lung imaging in thoracic tumor radiotherapy: Application and progress. Front Oncol 2022; 12:908345. [PMID: 36212454 PMCID: PMC9544588 DOI: 10.3389/fonc.2022.908345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 08/17/2022] [Indexed: 12/12/2022] Open
Abstract
Radiotherapy plays an irreplaceable and unique role in treating thoracic tumors, but the occurrence of radiation-induced lung injury has limited the increase in tumor target doses and has influenced patients' quality of life. However, the introduction of functional lung imaging has been incorporating functional lungs into radiotherapy planning. The design of the functional lung protection plan, while meeting the target dose requirements and dose limitations of the organs at risk (OARs), minimizes the radiation dose to the functional lung, thus reducing the occurrence of radiation-induced lung injury. In this manuscript, we mainly reviewed the lung ventilation or/and perfusion functional imaging modalities, application, and progress, as well as the results based on the functional lung protection planning in thoracic tumors. In addition, we also discussed the problems that should be explored and further studied in the practical application based on functional lung radiotherapy planning.
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Affiliation(s)
- Pi-Xiao Zhou
- Radiotherapy Center, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, China
- Department of Oncology, The First People's Hospital of Changde City, Changde, China
| | - Shu-Xu Zhang
- Radiotherapy Center, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, China
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