1
|
Choi B, Beltran CJ, Yoo SK, Kwon NH, Kim JS, Park JC. The InterVision Framework: An Enhanced Fine-Tuning Deep Learning Strategy for Auto-Segmentation in Head and Neck. J Pers Med 2024; 14:979. [PMID: 39338233 PMCID: PMC11432789 DOI: 10.3390/jpm14090979] [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: 07/22/2024] [Revised: 08/13/2024] [Accepted: 09/10/2024] [Indexed: 09/30/2024] Open
Abstract
Adaptive radiotherapy (ART) workflows are increasingly adopted to achieve dose escalation and tissue sparing under dynamic anatomical conditions. However, recontouring and time constraints hinder the implementation of real-time ART workflows. Various auto-segmentation methods, including deformable image registration, atlas-based segmentation, and deep learning-based segmentation (DLS), have been developed to address these challenges. Despite the potential of DLS methods, clinical implementation remains difficult due to the need for large, high-quality datasets to ensure model generalizability. This study introduces an InterVision framework for segmentation. The InterVision framework can interpolate or create intermediate visuals between existing images to generate specific patient characteristics. The InterVision model is trained in two steps: (1) generating a general model using the dataset, and (2) tuning the general model using the dataset generated from the InterVision framework. The InterVision framework generates intermediate images between existing patient image slides using deformable vectors, effectively capturing unique patient characteristics. By creating a more comprehensive dataset that reflects these individual characteristics, the InterVision model demonstrates the ability to produce more accurate contours compared to general models. Models are evaluated using the volumetric dice similarity coefficient (VDSC) and the Hausdorff distance 95% (HD95%) for 18 structures in 20 test patients. As a result, the Dice score was 0.81 ± 0.05 for the general model, 0.82 ± 0.04 for the general fine-tuning model, and 0.85 ± 0.03 for the InterVision model. The Hausdorff distance was 3.06 ± 1.13 for the general model, 2.81 ± 0.77 for the general fine-tuning model, and 2.52 ± 0.50 for the InterVision model. The InterVision model showed the best performance compared to the general model. The InterVision framework presents a versatile approach adaptable to various tasks where prior information is accessible, such as in ART settings. This capability is particularly valuable for accurately predicting complex organs and targets that pose challenges for traditional deep learning algorithms.
Collapse
Affiliation(s)
- Byongsu Choi
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA; (B.C.); (C.J.B.); (J.C.P.)
- Yonsei Cancer Center, Department of Radiation Oncology, Yonsei Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (S.K.Y.); (N.H.K.)
- Medical Physics and Biomedical Engineering Lab (MPBEL), Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Chris J. Beltran
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA; (B.C.); (C.J.B.); (J.C.P.)
| | - Sang Kyun Yoo
- Yonsei Cancer Center, Department of Radiation Oncology, Yonsei Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (S.K.Y.); (N.H.K.)
- Medical Physics and Biomedical Engineering Lab (MPBEL), Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Na Hye Kwon
- Yonsei Cancer Center, Department of Radiation Oncology, Yonsei Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (S.K.Y.); (N.H.K.)
- Medical Physics and Biomedical Engineering Lab (MPBEL), Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Jin Sung Kim
- Yonsei Cancer Center, Department of Radiation Oncology, Yonsei Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (S.K.Y.); (N.H.K.)
- Medical Physics and Biomedical Engineering Lab (MPBEL), Yonsei University College of Medicine, Seoul 03722, Republic of Korea
- OncoSoft Inc., Seoul 03776, Republic of Korea
| | - Justin Chunjoo Park
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA; (B.C.); (C.J.B.); (J.C.P.)
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Wang Y, Hu Y, Chen S, Deng H, Wen Z, He Y, Zhang H, Zhou P, Pang H. Improved automatic segmentation of brain metastasis gross tumor volume in computed tomography images for radiotherapy: a position attention module for U-Net architecture. Quant Imaging Med Surg 2024; 14:4475-4489. [PMID: 39022229 PMCID: PMC11250326 DOI: 10.21037/qims-23-1627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 04/26/2024] [Indexed: 07/20/2024]
Abstract
Background Brain metastases present significant challenges in radiotherapy due to the need for precise tumor delineation. Traditional methods often lack the efficiency and accuracy required for optimal treatment planning. This paper proposes an improved U-Net model that uses a position attention module (PAM) for automated segmentation of gross tumor volumes (GTVs) in computed tomography (CT) simulation images of patients with brain metastases to improve the efficiency and accuracy of radiotherapy planning and segmentation. Methods We retrospectively collected CT simulation imaging datasets of patients with brain metastases from two centers, which were designated as the training and external validation datasets. The U-Net architecture was enhanced by incorporating a PAM into the transition layer, which improved the automated segmentation capability of the U-Net model. With cross-entropy loss employed as the loss function, the samples from the training dataset underwent training. The model's segmentation performance on the external validation dataset was assessed using metrics including the Dice similarity coefficient (DSC), intersection over union (IoU), accuracy, sensitivity, specificity, Matthews correlation coefficient (MCC), and Hausdorff distance (HD). Results The proposed automated segmentation model demonstrated promising performance on the external validation dataset, achieving a DSC of 0.753±0.172. In terms of evaluation metrics (including the DSC, IoU, accuracy, sensitivity, MCC, and HD), the model outperformed the standard U-Net, which had a DSC of 0.691±0.142. The proposed model produced segmentation results that were closer to the ground truth and could reveal more detailed features of brain metastases. Conclusions The PAM-improved U-Net model offers considerable advantages in the automated segmentation of the GTV in CT simulation images for patients with brain metastases. Its superior performance in comparison with the standard U-Net model supports its potential for streamlining and improving the accuracy of radiotherapy. With its ability to produce segmentation results consistent with the ground truth, the proposed model holds promise for clinical adoption and provides a reference for radiation oncologists to make more informed GTV segmentation decisions.
Collapse
Affiliation(s)
- Yiren Wang
- School of Nursing, Southwest Medical University, Luzhou, China
- Wound Healing Basic Research and Clinical Application Key Laboratory of Luzhou, School of Nursing, Southwest Medical University, Luzhou, China
| | - Yiheng Hu
- Department of Medical Imaging, Southwest Medical University, Luzhou, China
| | - Shouying Chen
- School of Nursing, Southwest Medical University, Luzhou, China
- Wound Healing Basic Research and Clinical Application Key Laboratory of Luzhou, School of Nursing, Southwest Medical University, Luzhou, China
| | - Hairui Deng
- School of Nursing, Southwest Medical University, Luzhou, China
- Wound Healing Basic Research and Clinical Application Key Laboratory of Luzhou, School of Nursing, Southwest Medical University, Luzhou, China
| | - Zhongjian Wen
- School of Nursing, Southwest Medical University, Luzhou, China
- Wound Healing Basic Research and Clinical Application Key Laboratory of Luzhou, School of Nursing, Southwest Medical University, Luzhou, China
| | - Yongcheng He
- Department of Pharmacy, Sichuan Agricultural University, Chengdu, China
| | - Huaiwen Zhang
- Department of Radiotherapy, Jiangxi Cancer Hospital, The Second Affiliated Hospital of Nanchang Medical College, Jiangxi Clinical Research Center for Cancer, Nanchang, China
| | - Ping Zhou
- Wound Healing Basic Research and Clinical Application Key Laboratory of Luzhou, School of Nursing, Southwest Medical University, Luzhou, China
- Department of Nursing, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Haowen Pang
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| |
Collapse
|
4
|
Bopp MHA, Grote A, Gjorgjevski M, Pojskic M, Saß B, Nimsky C. Enabling Navigation and Augmented Reality in the Sitting Position in Posterior Fossa Surgery Using Intraoperative Ultrasound. Cancers (Basel) 2024; 16:1985. [PMID: 38893106 PMCID: PMC11171013 DOI: 10.3390/cancers16111985] [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: 04/03/2024] [Revised: 05/09/2024] [Accepted: 05/21/2024] [Indexed: 06/21/2024] Open
Abstract
Despite its broad use in cranial and spinal surgery, navigation support and microscope-based augmented reality (AR) have not yet found their way into posterior fossa surgery in the sitting position. While this position offers surgical benefits, navigation accuracy and thereof the use of navigation itself seems limited. Intraoperative ultrasound (iUS) can be applied at any time during surgery, delivering real-time images that can be used for accuracy verification and navigation updates. Within this study, its applicability in the sitting position was assessed. Data from 15 patients with lesions within the posterior fossa who underwent magnetic resonance imaging (MRI)-based navigation-supported surgery in the sitting position were retrospectively analyzed using the standard reference array and new rigid image-based MRI-iUS co-registration. The navigation accuracy was evaluated based on the spatial overlap of the outlined lesions and the distance between the corresponding landmarks in both data sets, respectively. Image-based co-registration significantly improved (p < 0.001) the spatial overlap of the outlined lesion (0.42 ± 0.30 vs. 0.65 ± 0.23) and significantly reduced (p < 0.001) the distance between the corresponding landmarks (8.69 ± 6.23 mm vs. 3.19 ± 2.73 mm), allowing for the sufficient use of navigation and AR support. Navigated iUS can therefore serve as an easy-to-use tool to enable navigation support for posterior fossa surgery in the sitting position.
Collapse
Affiliation(s)
- Miriam H. A. Bopp
- Department of Neurosurgery, University of Marburg, Baldingerstrasse, 35043 Marburg, Germany; (A.G.); (M.G.); (M.P.); (B.S.); (C.N.)
- Center for Mind, Brain and Behavior (CMBB), 35043 Marburg, Germany
| | - Alexander Grote
- Department of Neurosurgery, University of Marburg, Baldingerstrasse, 35043 Marburg, Germany; (A.G.); (M.G.); (M.P.); (B.S.); (C.N.)
| | - Marko Gjorgjevski
- Department of Neurosurgery, University of Marburg, Baldingerstrasse, 35043 Marburg, Germany; (A.G.); (M.G.); (M.P.); (B.S.); (C.N.)
| | - Mirza Pojskic
- Department of Neurosurgery, University of Marburg, Baldingerstrasse, 35043 Marburg, Germany; (A.G.); (M.G.); (M.P.); (B.S.); (C.N.)
| | - Benjamin Saß
- Department of Neurosurgery, University of Marburg, Baldingerstrasse, 35043 Marburg, Germany; (A.G.); (M.G.); (M.P.); (B.S.); (C.N.)
| | - Christopher Nimsky
- Department of Neurosurgery, University of Marburg, Baldingerstrasse, 35043 Marburg, Germany; (A.G.); (M.G.); (M.P.); (B.S.); (C.N.)
- Center for Mind, Brain and Behavior (CMBB), 35043 Marburg, Germany
| |
Collapse
|
5
|
Uehara T, Nishimura Y, Ishikawa K, Inada M, Matsumoto K, Doi H, Monzen H, Matsuo Y. Cone-beam computed tomography-guided online adaptive radiotherapy for pharyngeal cancer with whole neck irradiation: dose-volume histogram analysis between adapted and scheduled plans. JOURNAL OF RADIATION RESEARCH 2024; 65:223-230. [PMID: 38264828 PMCID: PMC10959439 DOI: 10.1093/jrr/rrad103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/24/2023] [Indexed: 01/25/2024]
Abstract
The present study aimed to evaluate whether an adapted plan with Ethos™ could be used for pharyngeal cancer. Ten patients with pharyngeal cancer who underwent chemoradiotherapy with available daily cone-beam computed tomography (CBCT) data were included. Simulated treatments were generated on the Ethos™ treatment emulator using CBCTs every four to five fractions for two plans: adapted and scheduled. The simulated treatments were divided into three groups: early (first-second week), middle (third-fourth week), and late (fifth-seventh week) periods. Dose-volume histogram parameters were compared for each period between the adapted and scheduled plans in terms of the planning target volume (PTV) (D98%, D95%, D50% and D2%), spinal cord (Dmax and D1cc), brainstem (Dmax) and ipsilateral and contralateral parotid glands (Dmedian and Dmean). The PTV D98%, D95% and D2% of the adapted plan were significantly higher than those of the scheduled plans in all periods, except for D98% in the late period. The adapted plan significantly reduced the spinal cord Dmax and D1cc compared with the scheduled plan in all periods. Ipsilateral and contralateral parotid glands Dmean of the adapted plan were lower than those of scheduled plan in the late period. In conclusion, the present study revealed that the adapted plans could maintain PTV coverage while reducing the doses to organs at risk in each period compared with scheduled plans.
Collapse
Affiliation(s)
- Takuya Uehara
- Department of Radiation Oncology, Kindai University Faculty of Medicine, Osaka 589-8511, Japan
- Department of Radiation Oncology, Yamatotakada Municipal Hospital, Nara 635-8501, Japan
| | - Yasumasa Nishimura
- Department of Radiation Oncology, Kindai University Faculty of Medicine, Osaka 589-8511, Japan
- Radiation Therapy Center, Fuchu Hospital, Osaka 594-0076, Japan
| | - Kazuki Ishikawa
- Department of Radiation Oncology, Kindai University Faculty of Medicine, Osaka 589-8511, Japan
- Department of Radiation Oncology, Nara Prefecture General Medical Center, Nara 630-8581, Japan
| | - Masahiro Inada
- Department of Radiation Oncology, Kindai University Faculty of Medicine, Osaka 589-8511, Japan
| | - Kenji Matsumoto
- Department of Medical Physics, Graduate School of Medical Sciences, Kindai University, Osaka 589-8511, Japan
| | - Hiroshi Doi
- Department of Radiation Oncology, Kindai University Faculty of Medicine, Osaka 589-8511, Japan
| | - Hajime Monzen
- Department of Medical Physics, Graduate School of Medical Sciences, Kindai University, Osaka 589-8511, Japan
| | - Yukinori Matsuo
- Department of Radiation Oncology, Kindai University Faculty of Medicine, Osaka 589-8511, Japan
| |
Collapse
|
6
|
Roberfroid B, Lee JA, Geets X, Sterpin E, Barragán-Montero AM. DIVE-ART: A tool to guide clinicians towards dosimetrically informed volume editions of automatically segmented volumes in adaptive radiation therapy. Radiother Oncol 2024; 192:110108. [PMID: 38272315 DOI: 10.1016/j.radonc.2024.110108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 01/17/2024] [Accepted: 01/17/2024] [Indexed: 01/27/2024]
Affiliation(s)
- Benjamin Roberfroid
- Université catholique de Louvain - Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), Brussels, Belgium.
| | - John A Lee
- Université catholique de Louvain - Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), Brussels, Belgium
| | - Xavier Geets
- Université catholique de Louvain - Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), Brussels, Belgium; Cliniques universitaires Saint-Luc, Department of Radiation Oncology, Brussels, Belgium
| | - Edmond Sterpin
- Université catholique de Louvain - Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), Brussels, Belgium; KU Leuven - Department of Oncology, Laboratory of Experimental Radiotherapy, Leuven, Belgium; Particle Therapy Interuniversity Center Leuven - PARTICLE, Leuven, Belgium
| | - Ana M Barragán-Montero
- Université catholique de Louvain - Center of Molecular Imaging, Radiotherapy and Oncology (MIRO), Brussels, Belgium
| |
Collapse
|
7
|
Zhuang T, Parsons D, Desai N, Gibbard G, Keilty D, Lin MH, Cai B, Nguyen D, Chiu T, Godley A, Pompos A, Jiang S. Simulation and pre-planning omitted radiotherapy (SPORT): a feasibility study for prostate cancer. Biomed Phys Eng Express 2024; 10:025019. [PMID: 38241733 DOI: 10.1088/2057-1976/ad20aa] [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: 08/27/2023] [Accepted: 01/19/2024] [Indexed: 01/21/2024]
Abstract
This study explored the feasibility of on-couch intensity modulated radiotherapy (IMRT) planning for prostate cancer (PCa) on a cone-beam CT (CBCT)-based online adaptive RT platform without an individualized pre-treatment plan and contours. Ten patients with PCa previously treated with image-guided IMRT (60 Gy/20 fractions) were selected. In contrast to the routine online adaptive RT workflow, a novel approach was employed in which the same preplan that was optimized on one reference patient was adapted to generate individual on-couch/initial plans for the other nine test patients using Ethos emulator. Simulation CTs of the test patients were used as simulated online CBCT (sCBCT) for emulation. Quality assessments were conducted on synthetic CTs (sCT). Dosimetric comparisons were performed between on-couch plans, on-couch plans recomputed on the sCBCT and individually optimized plans for test patients. The median value of mean absolute difference between sCT and sCBCT was 74.7 HU (range 69.5-91.5 HU). The average CTV/PTV coverage by prescription dose was 100.0%/94.7%, and normal tissue constraints were met for the nine test patients in on-couch plans on sCT. Recalculating on-couch plans on the sCBCT showed about 0.7% reduction of PTV coverage and a 0.6% increasing of hotspot, and the dose difference of the OARs was negligible (<0.5 Gy). Hence, initial IMRT plans for new patients can be generated by adapting a reference patient's preplan with online contours, which had similar qualities to the conventional approach of individually optimized plan on the simulation CT. Further study is needed to identify selection criteria for patient anatomy most amenable to this workflow.
Collapse
Affiliation(s)
- Tingliang Zhuang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, United States of America
| | - David Parsons
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, United States of America
| | - Neil Desai
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, United States of America
| | - Grant Gibbard
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, United States of America
| | - Dana Keilty
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, United States of America
| | - Mu-Han Lin
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, United States of America
| | - Bin Cai
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, United States of America
| | - Dan Nguyen
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, United States of America
| | - Tsuicheng Chiu
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, United States of America
| | - Andrew Godley
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, United States of America
| | - Arnold Pompos
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, United States of America
| | - Steve Jiang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, United States of America
| |
Collapse
|
8
|
Galand A, Prunaretty J, Mir N, Morel A, Bourgier C, Aillères N, Azria D, Fenoglietto P. Feasibility study of adaptive radiotherapy with Ethos for breast cancer. Front Oncol 2023; 13:1274082. [PMID: 38023141 PMCID: PMC10679322 DOI: 10.3389/fonc.2023.1274082] [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: 08/07/2023] [Accepted: 10/26/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose The aim of this study was to assess the feasibility of online adaptive radiotherapy with Ethos for breast cancer. Materials and methods This retrospective study included 20 breast cancer patients previously treated with TrueBeam. All had undergone breast surgery for different indications (right/left, lumpectomy/mastectomy) and were evenly divided between these four cases, with five extended cone beam computed tomography (CBCT) scans per patient. The dataset was used in an Ethos emulator to test the full adaptive workflow. The contours generated by artificial intelligence (AI) for the influencers (left and right breasts and lungs, heart) and elastic or rigid propagation for the target volumes (internal mammary chain (IMC) and clavicular lymph nodes (CLNs)) were compared to the initial contours delineated by the physician using two metrics: Dice similarity coefficient (DICE) and Hausdorff 95% distance (HD95). The repeatability of influencer generation was investigated. The times taken by the emulator to generate contours, optimize plans, and calculate doses were recorded. The quality of the scheduled and adapted plans generated by Ethos was assessed using planning target volume (PTV) coverage, homogeneity indices (HIs), and doses to organs at risk (OARs) via dose-volume histogram (DVH) metrics. Quality assurance (QA) of the treatment plans was performed using an independent portal dosimetry tool (EpiQA) and gamma index. Results On average, the DICE for the influencers was greater than 0.9. Contours resulting from rigid propagation had a higher DICE and a lower HD95 than those resulting from elastic deformation but remained below the values obtained for the influencers: DICE values were 0.79 ± 0.11 and 0.46 ± 0.17 for the CLN and IMC, respectively. Regarding the repeatability of the influencer segmentation, the DICE was close to 1, and the mean HD95 was strictly less than 0.15 mm. The mean time was 73 ± 4 s for contour generation per AI and 80 ± 9 s for propagations. The average time was 53 ± 3 s for dose calculation and 125 ± 9 s for plan optimization. A dosimetric comparison of scheduled and adapted plans showed a significant difference in PTV coverage: dose received by 95% of the volume (D95%) values were higher and closer to the prescribed doses for adapted plans. Doses to organs at risk were similar. The average gamma index for quality assurance of adapted plans was 99.93 ± 0.38 for a 3%/3mm criterion. Conclusion This study comprehensively evaluated the Ethos® adaptive workflow for breast cancer and its potential technical limitations. Although the results demonstrated the high accuracy of AI segmentation and the superiority of adapted plans in terms of target volume coverage, a medical assessment is still required.
Collapse
Affiliation(s)
| | - Jessica Prunaretty
- Radiotherapy Department, Montpellier Regional Cancer Institute, Montpellier, France
| | | | | | | | | | | | | |
Collapse
|
9
|
Chen Y, Gensheimer MF, Bagshaw HP, Butler S, Yu L, Zhou Y, Shen L, Kovalchuk N, Surucu M, Chang DT, Xing L, Han B. Patient-Specific Auto-segmentation on Daily kVCT Images for Adaptive Radiation Therapy. Int J Radiat Oncol Biol Phys 2023; 117:505-514. [PMID: 37141982 DOI: 10.1016/j.ijrobp.2023.04.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 04/18/2023] [Accepted: 04/25/2023] [Indexed: 05/06/2023]
Abstract
PURPOSE This study explored deep-learning-based patient-specific auto-segmentation using transfer learning on daily RefleXion kilovoltage computed tomography (kVCT) images to facilitate adaptive radiation therapy, based on data from the first group of patients treated with the innovative RefleXion system. METHODS AND MATERIALS For head and neck (HaN) and pelvic cancers, a deep convolutional segmentation network was initially trained on a population data set that contained 67 and 56 patient cases, respectively. Then the pretrained population network was adapted to the specific RefleXion patient by fine-tuning the network weights with a transfer learning method. For each of the 6 collected RefleXion HaN cases and 4 pelvic cases, initial planning computed tomography (CT) scans and 5 to 26 sets of daily kVCT images were used for the patient-specific learning and evaluation separately. The performance of the patient-specific network was compared with the population network and the clinical rigid registration method and evaluated by the Dice similarity coefficient (DSC) with manual contours being the reference. The corresponding dosimetric effects resulting from different auto-segmentation and registration methods were also investigated. RESULTS The proposed patient-specific network achieved mean DSC results of 0.88 for 3 HaN organs at risk (OARs) of interest and 0.90 for 8 pelvic target and OARs, outperforming the population network (0.70 and 0.63) and the registration method (0.72 and 0.72). The DSC of the patient-specific network gradually increased with the increment of longitudinal training cases and approached saturation with more than 6 training cases. Compared with using the registration contour, the target and OAR mean doses and dose-volume histograms obtained using the patient-specific auto-segmentation were closer to the results using the manual contour. CONCLUSIONS Auto-segmentation of RefleXion kVCT images based on the patient-specific transfer learning could achieve higher accuracy, outperforming a common population network and clinical registration-based method. This approach shows promise in improving dose evaluation accuracy in RefleXion adaptive radiation therapy.
Collapse
Affiliation(s)
- Yizheng Chen
- Department of Radiation Oncology, Stanford University, Stanford, California
| | | | - Hilary P Bagshaw
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Santino Butler
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Lequan Yu
- Department of Statistics and Actuarial Science, The University of Hong Kong, Hong Kong, China
| | - Yuyin Zhou
- Department of Computer Science and Engineering, University of California Santa Cruz, Santa Cruz, California
| | - Liyue Shen
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
| | - Nataliya Kovalchuk
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Murat Surucu
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Daniel T Chang
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Lei Xing
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Bin Han
- Department of Radiation Oncology, Stanford University, Stanford, California.
| |
Collapse
|
10
|
Liu H, Schaal D, Curry H, Clark R, Magliari A, Kupelian P, Khuntia D, Beriwal S. Review of cone beam computed tomography based online adaptive radiotherapy: current trend and future direction. Radiat Oncol 2023; 18:144. [PMID: 37660057 PMCID: PMC10475190 DOI: 10.1186/s13014-023-02340-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 08/25/2023] [Indexed: 09/04/2023] Open
Abstract
Adaptive radiotherapy (ART) was introduced in the late 1990s to improve the accuracy and efficiency of therapy and minimize radiation-induced toxicities. ART combines multiple tools for imaging, assessing the need for adaptation, treatment planning, quality assurance, and has been utilized to monitor inter- or intra-fraction anatomical variations of the target and organs-at-risk (OARs). Ethos™ (Varian Medical Systems, Palo Alto, CA), a cone beam computed tomography (CBCT) based radiotherapy treatment system that uses artificial intelligence (AI) and machine learning to perform ART, was introduced in 2020. Since then, numerous studies have been done to examine the potential benefits of Ethos™ CBCT-guided ART compared to non-adaptive radiotherapy. This review will explore the current trends of Ethos™, including improved CBCT image quality, a feasible clinical workflow, daily automated contouring and treatment planning, and motion management. Nevertheless, evidence of clinical improvements with the use of Ethos™ are limited and is currently under investigation via clinical trials.
Collapse
Affiliation(s)
- Hefei Liu
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, USA
- Varian Medical Systems Inc, Palo Alto, CA, USA
| | | | | | - Ryan Clark
- Varian Medical Systems Inc, Palo Alto, CA, USA
| | | | | | | | - Sushil Beriwal
- Varian Medical Systems Inc, Palo Alto, CA, USA.
- Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA.
| |
Collapse
|
11
|
Pogue JA, Cardenas CE, Cao Y, Popple RA, Soike M, Boggs DH, Stanley DN, Harms J. Leveraging intelligent optimization for automated, cardiac-sparing accelerated partial breast treatment planning. Front Oncol 2023; 13:1130119. [PMID: 36845685 PMCID: PMC9950631 DOI: 10.3389/fonc.2023.1130119] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 02/02/2023] [Indexed: 02/12/2023] Open
Abstract
Background Accelerated partial breast irradiation (APBI) yields similar rates of recurrence and cosmetic outcomes as compared to whole breast radiation therapy (RT) when patients and treatment techniques are appropriately selected. APBI combined with stereotactic body radiation therapy (SBRT) is a promising technique for precisely delivering high levels of radiation while avoiding uninvolved breast tissue. Here we investigate the feasibility of automatically generating high quality APBI plans in the Ethos adaptive workspace with a specific emphasis on sparing the heart. Methods Nine patients (10 target volumes) were utilized to iteratively tune an Ethos APBI planning template for automatic plan generation. Twenty patients previously treated on a TrueBeam Edge accelerator were then automatically replanned using this template without manual intervention or reoptimization. The unbiased validation cohort Ethos plans were benchmarked via adherence to planning objectives, a comparison of DVH and quality indices against the clinical Edge plans, and qualitative reviews by two board-certified radiation oncologists. Results 85% (17/20) of automated validation cohort plans met all planning objectives; three plans did not achieve the contralateral lung V1.5Gy objective, but all other objectives were achieved. Compared to the Eclipse generated plans, the proposed Ethos template generated plans with greater evaluation planning target volume (PTV_Eval) V100% coverage (p = 0.01), significantly decreased heart V1.5Gy (p< 0.001), and increased contralateral breast V5Gy, skin D0.01cc, and RTOG conformity index (p = 0.03, p = 0.03, and p = 0.01, respectively). However, only the reduction in heart dose was significant after correcting for multiple testing. Physicist-selected plans were deemed clinically acceptable without modification for 75% and 90% of plans by physicians A and B, respectively. Physicians A and B scored at least one automatically generated plan as clinically acceptable for 100% and 95% of planning intents, respectively. Conclusions Standard left- and right-sided planning templates automatically generated APBI plans of comparable quality to manually generated plans treated on a stereotactic linear accelerator, with a significant reduction in heart dose compared to Eclipse generated plans. The methods presented in this work elucidate an approach for generating automated, cardiac-sparing APBI treatment plans for daily adaptive RT with high efficiency.
Collapse
Affiliation(s)
- Joel A. Pogue
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
| | | | | | | | | | | | | | | |
Collapse
|
12
|
Henke LE, Fischer-Valuck BW, Rudra S, Wan L, Samson PS, Srivastava A, Gabani P, Roach MC, Zoberi I, Laugeman E, Mutic S, Robinson CG, Hugo GD, Cai B, Kim H. Prospective imaging comparison of anatomic delineation with rapid kV cone beam CT on a novel ring gantry radiotherapy device. Radiother Oncol 2023; 178:109428. [PMID: 36455686 DOI: 10.1016/j.radonc.2022.11.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 11/22/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION A kV imager coupled to a novel, ring-gantry radiotherapy system offers improved on-board kV-cone-beam computed tomography (CBCT) acquisition time (17-40 seconds) and image quality, which may improve CT radiotherapy image-guidance and enable online adaptive radiotherapy. We evaluated whether inter-observer contour variability over various anatomic structures was non-inferior using a novel ring gantry kV-CBCT (RG-CBCT) imager as compared to diagnostic-quality simulation CT (simCT). MATERIALS/METHODS Seven patients undergoing radiotherapy were imaged with the RG-CBCT system at breath hold (BH) and/or free breathing (FB) for various disease sites on a prospective imaging study. Anatomy was independently contoured by seven radiation oncologists on: 1. SimCT 2. Standard C-arm kV-CBCT (CA-CBCT), and 3. Novel RG-CBCT at FB and BH. Inter-observer contour variability was evaluated by computing simultaneous truth and performance level estimation (STAPLE) consensus contours, then computing average symmetric surface distance (ASSD) and Dice similarity coefficient (DSC) between individual raters and consensus contours for comparison across image types. RESULTS Across 7 patients, 18 organs-at-risk (OARs) were evaluated on 27 image sets. Both BH and FB RG-CBCT were non-inferior to simCT for inter-observer delineation variability across all OARs and patients by ASSD analysis (p < 0.001), whereas CA-CBCT was not (p = 0.923). RG-CBCT (FB and BH) also remained non-inferior for abdomen and breast subsites compared to simCT on ASSD analysis (p < 0.025). On DSC comparison, neither RG-CBCT nor CA-CBCT were non-inferior to simCT for all sites (p > 0.025). CONCLUSIONS Inter-observer ability to delineate OARs using novel RG-CBCT images was non-inferior to simCT by the ASSD criterion but not DSC criterion.
Collapse
Affiliation(s)
- Lauren E Henke
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Benjamin W Fischer-Valuck
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Soumon Rudra
- Department of Radiation Oncology, Emory University, Atlanta, GA, United States
| | - Leping Wan
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Pamela S Samson
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Amar Srivastava
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Prashant Gabani
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | | | - Imran Zoberi
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Eric Laugeman
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Sasa Mutic
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States; Varian Medical Systems, Palo Alto, California, USA
| | - Clifford G Robinson
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Geoffrey D Hugo
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Bin Cai
- Department of Radiation Oncology, University of Texas Southwestern School of Medicine, Dallas, TX, United States
| | - Hyun Kim
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States.
| |
Collapse
|