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Tang Q, Mei C, Huang B, Huang R, Kang L, Chen A, lei N, Deng P, Ying S, Zhang P, Qin Y. Risk stratification of LA-NPC during chemoradiotherapy based on clinical classification and TVRR. Cancer Med 2024; 13:e7029. [PMID: 38396378 PMCID: PMC10891362 DOI: 10.1002/cam4.7029] [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: 11/15/2023] [Revised: 02/02/2024] [Accepted: 02/08/2024] [Indexed: 02/25/2024] Open
Abstract
PURPOSE To investigate the correlation between tumor volume reduction rate (TVRR) and prognosis in patients with diverse clinical types of nasopharyngeal carcinoma (NPC) undergoing chemoradiotherapy, thereby aptly categorizing risks and directing the personalized treatment of NPC. MATERIALS AND METHODS A total of 605 NPC patients with varying clinical types were enrolled in this study and subsequently segregated into six subgroups based on their clinical types and TVRR. To accentuate the efficacy of grouping, Groups 1-6 underwent clustered analysis of hazard atio (HR) values pertaining to progression-free survival (PFS), forming three risk clusters denoted as low, intermediate, and high. The log-rank test was employed to discern differences, and R 4.1.1 was utilized for cluster analysis. RESULTS According to survival rates, we classified the first (G2 and G4), second (G1 and G6), and third (G3 and G5) risk clusters as low-, intermediate-, and high-risk, respectively. When comparing risk stratification with the 8th edition of the TNM staging system, our classification exhibited superior predictive prognostic performance. Subgroup analysis of treatments for each risk cluster revealed that the PFS in the neoadjuvant chemotherapy (NACT) + concurrent chemoradiotherapy (CCRT) group surpassed that of the CCRT group significantly (p < 0.05). CONCLUSION The reliance on clinical types and TVRR facilitates risk stratification of NPC during chemoradiotherapy, providing a foundation for physicians to tailor therapeutic strategies. Moreover, the risk cluster delineated for NPC patients during the mid-term of chemoradiotherapy stands as an independent prognostic factor for progression-free survival (PFS), overall survival (OS), distantmetastasis-free survival (DMFS), and local recurrence-free (LRRFS) posttreatment. Additionally, individuals in the high-risk cluster are recommended to undergo adjuvant chemotherapy after CCRT.
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Affiliation(s)
- Qianlong Tang
- Department of OncologySichuan Mianyang 404 Hospital, First People's Hospital of MianyangMianyangChina
| | - Chaorong Mei
- Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region (Hospital.C.T.)ChengduChina
| | - Bei Huang
- Department of OncologyThird People's Hospital of MianyangMianyangChina
| | - Rui Huang
- Department of Radiation Oncology, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of MedicineUniversity of Electronic Science and Technology of China, Radiation Oncology Key Laboratory of Sichuan ProvinceChengduChina
| | - Le Kang
- Department of Hematology and OncologyAnyue County People's HospitalZiyangChina
| | - Ailin Chen
- West China Tianfu Hospital ,Sichuan UniversityChengduChina
| | - Na lei
- Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region (Hospital.C.T.)ChengduChina
| | - Pengcheng Deng
- Department of OncologyChengdu Qingbaijiang District People's HospitalChengduChina
| | - Shouyan Ying
- Department of OncologyYunnan Cancer HospitalKunmingChina
| | - Peng Zhang
- Department of Radiation Oncology, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of MedicineUniversity of Electronic Science and Technology of China, Radiation Oncology Key Laboratory of Sichuan ProvinceChengduChina
| | - Yuan Qin
- Department of Radiation Oncology, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of MedicineUniversity of Electronic Science and Technology of China, Radiation Oncology Key Laboratory of Sichuan ProvinceChengduChina
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Aliotta E, Hu YC, Zhang P, Lichtenwalner P, Caringi A, Allgood N, Tsai CJ, Zakeri K, Lee N, Zhang P, Cerviño L, Aristophanous M. Automated tracking of morphologic changes in weekly magnetic resonance imaging during head and neck radiotherapy. J Appl Clin Med Phys 2023:e13959. [PMID: 37147912 DOI: 10.1002/acm2.13959] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/15/2022] [Accepted: 02/20/2023] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND AND PURPOSE Anatomic changes during head and neck radiotherapy can impact dose delivery, necessitate adaptive replanning, and indicate patient-specific response to treatment. We have developed an automated system to track these changes through longitudinal MRI scans to aid identification and clinical intervention. The purpose of this article is to describe this tracking system and present results from an initial cohort of patients. MATERIALS AND METHODS The Automated Watchdog in Adaptive Radiotherapy Environment (AWARE) was developed to process longitudinal MRI data for radiotherapy patients. AWARE automatically identifies and collects weekly scans, propagates radiotherapy planning structures, computes structure changes over time, and reports important trends to the clinical team. AWARE also incorporates manual structure review and revision from clinical experts and dynamically updates tracking statistics when necessary. AWARE was applied to patients receiving weekly T2-weighted MRI scans during head and neck radiotherapy. Changes in nodal gross tumor volume (GTV) and parotid gland delineations were tracked over time to assess changes during treatment and identify early indicators of treatment response. RESULTS N = 91 patients were tracked and analyzed in this study. Nodal GTVs and parotids both shrunk considerably throughout treatment (-9.7 ± 7.7% and -3.7 ± 3.3% per week, respectively). Ipsilateral parotids shrunk significantly faster than contralateral (-4.3 ± 3.1% vs. -2.9 ± 3.3% per week, p = 0.005) and increased in distance from GTVs over time (+2.7 ± 7.2% per week, p < 1 × 10-5 ). Automatic structure propagations agreed well with manual revisions (Dice = 0.88 ± 0.09 for parotids and 0.80 ± 0.15 for GTVs), but for GTVs the agreement degraded 4-5 weeks after the start of treatment. Changes in GTV volume observed by AWARE as early as one week into treatment were predictive of large changes later in the course (AUC = 0.79). CONCLUSION AWARE automatically identified longitudinal changes in GTV and parotid volumes during radiotherapy. Results suggest that this system may be useful for identifying rapidly responding patients as early as one week into treatment.
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Affiliation(s)
- Eric Aliotta
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Yu-Chi Hu
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Peng Zhang
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Phillip Lichtenwalner
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Amanda Caringi
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Natasha Allgood
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - C Jillian Tsai
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kaveh Zakeri
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Nancy Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Pengpeng Zhang
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Laura Cerviño
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Michalis Aristophanous
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Gros SAA, Santhanam AP, Block AM, Emami B, Lee BH, Joyce C. Retrospective Clinical Evaluation of a Decision-Support Software for Adaptive Radiotherapy of Head and Neck Cancer Patients. Front Oncol 2022; 12:777793. [PMID: 35847951 PMCID: PMC9279735 DOI: 10.3389/fonc.2022.777793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 05/16/2022] [Indexed: 12/02/2022] Open
Abstract
Purpose This study aimed to evaluate the clinical need for an automated decision-support software platform for adaptive radiation therapy (ART) of head and neck cancer (HNC) patients. Methods We tested RTapp (SegAna), a new ART software platform for deciding when a treatment replan is needed, to investigate a set of 27 HNC patients’ data retrospectively. For each fraction, the software estimated key components of ART such as daily dose distribution and cumulative doses received by targets and organs at risk (OARs) from daily 3D imaging in real-time. RTapp also included a prediction algorithm that analyzed dosimetric parameter (DP) trends against user-specified thresholds to proactively trigger adaptive re-planning up to four fractions ahead. The DPs evaluated for ART were based on treatment planning dose constraints. Warning (V95<95%) and adaptation (V95<93%) thresholds were set for PTVs, while OAR adaptation dosimetric endpoints of +10% (DE10) were set for all Dmax and Dmean DPs. Any threshold violation at end of treatment (EOT) triggered a review of the DP trends to determine the threshold-crossing fraction Fx when the violations occurred. The prediction model accuracy was determined as the difference between calculated and predicted DP values with 95% confidence intervals (CI95). Results RTapp was able to address the needs of treatment adaptation. Specifically, we identified 18/27 studies (67%) for violating PTV coverage or parotid Dmean at EOT. Twelve PTVs had V95<95% (mean coverage decrease of −6.8 ± 2.9%) including six flagged for adaptation at median Fx= 6 (range, 1–16). Seventeen parotids were flagged for exceeding Dmean dose constraints with a median increase of +2.60 Gy (range, 0.99–6.31 Gy) at EOT, including nine with DP>DE10. The differences between predicted and calculated PTV V95 and parotid Dmean was up to 7.6% (mean ± CI95, −2.7 ± 4.1%) and 5 Gy (mean ± CI95, 0.3 ± 1.6 Gy), respectively. The most accurate predictions were obtained closest to the threshold-crossing fraction. For parotids, the results showed that Fx ranged between fractions 1 and 23, with a lack of specific trend demonstrating that the need for treatment adaptation may be verified for every fraction. Conclusion Integrated in an ART clinical workflow, RTapp aids in predicting whether specific treatment would require adaptation up to four fractions ahead of time.
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Affiliation(s)
- Sebastien A. A. Gros
- Loyola University Chicago, Loyola University Medical Center, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL, United States
- *Correspondence: Sebastien A. A. Gros,
| | - Anand P. Santhanam
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Alec M. Block
- Loyola University Chicago, Loyola University Medical Center, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL, United States
| | - Bahman Emami
- Loyola University Chicago, Loyola University Medical Center, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL, United States
| | - Brian H. Lee
- Loyola University Chicago, Loyola University Medical Center, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL, United States
| | - Cara Joyce
- Department of Public Health, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, United States
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Evaluation and risk factors of volume and dose differences of selected structures in patients with head and neck cancer treated on Helical TomoTherapy by using Deformable Image Registration tool. POLISH JOURNAL OF MEDICAL PHYSICS AND ENGINEERING 2022. [DOI: 10.2478/pjmpe-2022-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Abstract
Introduction: The aim of this study was the evaluation of volume and dose differences in selected structures in patients with head and neck cancer during treatment on Helical TomoTherapy (HT) using a commercially available deformable image registration (DIR) tool. We attempted to identify anatomical and clinical predictive factors for significant volume changes probability.
Material and methods: According to our institutional protocol, we retrospectively evaluated the group of 20 H&N cancer patients treated with HT who received Adaptive Radiotherapy (ART) due to soft tissue alterations spotted on daily MVCT. We compared volumes on initial computed tomography (iCT) and replanning computed tomography (rCT) for clinical target volumes (CTV) – CTV1 (the primary tumor) and CTV2 (metastatic lymph nodes), parotid glands (PG) and body contour (B-body). To estimate the planned and delivered dose discrepancy, the dose from the original plan was registered and deformed to create a simulation of dose distribution on rCT (DIR-rCT).
Results: The decision to replan was made at the 4th week of RT (N = 6; 30%). The average volume reduction in parotid right PG[R] and left PG[L] was 4.37 cc (18.9%) (p < 0.001) and 3.77 cc (16.8%) (p = 0.004), respectively. In N = 13/20 cases, the delivered dose was greater than the planned dose for PG[R] of mean 3 Gy (p < 0.001), and in N = 6/20 patients for PG[L] the mean of 3.6 Gy (p = 0.031). Multivariate regression analysis showed a very strong predictor explaining 88% (R2 = 0.88) and 83% (R2 = 0.83) of the variance based on the mean dose of iPG[R] and iPG[L] (p < 0.001), respectively. No statistically significant correlation between volume changes and risk factors was found.
Conclusions: Dosimetric changes to the target demonstrated the validity of replanning. A DIR tool can be successfully used for dose deformation and ART qualification, significantly reducing the workload of radiotherapy centers. In addition, the mean dose for PG was a significant predictor that may indicate the need for a replan.
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Does Tumor Volume Have a Prognostic Role in Oropharyngeal Squamous Cell Carcinoma? A Systematic Review and Meta-Analysis. Cancers (Basel) 2022; 14:cancers14102465. [PMID: 35626068 PMCID: PMC9139846 DOI: 10.3390/cancers14102465] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 05/08/2022] [Accepted: 05/15/2022] [Indexed: 12/17/2022] Open
Abstract
The aim of this study was to assess the prognostic value of tumor volume in oropharyngeal squamous cell carcinoma (OPSCC). The study was performed according to the PRISMA guidelines. A total of 1417 patients with a median age of 59.3 years (IQR 57.5−60) were included. The combined Hazard Ratios (HRs) for overall survival (OS) were 1.02 (95% CI, 0.99−1.05; p = 0.21) for primary tumor volume (pTV) and 1.01 (95% CI, 1.00−1.02; p = 0.15) for nodal tumor volume (nTV). Regarding locoregional control (LRC), the pooled HRs were 1.07 (95% CI, 0.99−1.17; p = 0.10) for pTV and 1.02 (95% CI, 1.01−1.03; p < 0.05) for nTV. Finally, the pooled HRs for disease-free survival (DFS) were 1.01 (95% CI, 1.00−1.03; p < 0.05) for pTV and 1.02 (95% CI, 1.01−1.03; p < 0.05) for nTV. In conclusion, pTV and nTV seem not to behave as reliable prognostic factors in OPSCC.
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Bak B, Skrobala A, Adamska A, Kazmierska J, Jozefacka N, Piotrowski T, Malicki J. Criteria for Verification and Replanning Based on the Adaptive Radiotherapy Protocol "Best for Adaptive Radiotherapy" in Head and Neck Cancer. Life (Basel) 2022; 12:722. [PMID: 35629389 PMCID: PMC9144703 DOI: 10.3390/life12050722] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 11/17/2022] Open
Abstract
No clear criteria have yet been established to guide decision-making for patient selection and the optimal timing of adaptive radiotherapy (ART) based on image-guided radiotherapy (IGRT). We have developed a novel protocol—the Best for Adaptive Radiotherapy (B-ART) protocol—to guide patient selection for ART. The aim of the present study is to describe this protocol, to evaluate its validity in patients with head and neck (HN) cancer, and to identify the anatomical and clinical predictors of the need for replanning. We retrospectively evaluated 82 patients with HN cancer who underwent helical tomotherapy (HT) and subsequently required replanning due to soft tissue changes upon daily MVCT. Under the proposed criteria, patients with anatomical changes >3 mm on three to four consecutive scans are candidates for ART. We compared the volumes on the initial CT scan (iCT) and the replanning CT (rCT) scan for the clinical target volumes (CTV1, referring to primary tumor or tumor bed and CTV2, metastatic lymph nodes) and for the parotid glands (PG) and body contour (B-body). The patients were stratified by primary tumor localization, clinical stage, and treatment scheme. The main reasons for replanning were: (1) a planning target volume (PTV) outside the body contour (n = 70; 85.4%), (2) PG shrinkage (n = 69; 84.1%), (3) B-body deviations (n = 69; 84.1%), and (4) setup deviations (n = 40; 48.8%). The replanning decision was made, on average, during the fourth week of treatment (n = 47; 57.3%). The mean reductions in the size of the right and left PG volumes were 6.31 cc (20.9%) and 5.98 cc (20.5%), respectively (p < 0.001). The reduction in PG volume was ≥30% in 30 patients (36.6%). The volume reduction in all of the anatomical structures was statistically significant. Four variables—advanced stage disease (T3−T4), chemoradiation, increased weight loss, and oropharyngeal localization—were significantly associated with the need for ART. The B-ART protocol provides clear criteria to eliminate random errors, and to allow for an early response to relevant changes in target volumes.
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Affiliation(s)
- Bartosz Bak
- Department of Electroradiology, Poznan University of Medical Science, 61-866 Poznan, Poland; (A.S.); (J.K.); (T.P.); (J.M.)
- Department of Radiotherapy II, Greater Poland Cancer Centre, 61-866 Poznan, Poland
| | - Agnieszka Skrobala
- Department of Electroradiology, Poznan University of Medical Science, 61-866 Poznan, Poland; (A.S.); (J.K.); (T.P.); (J.M.)
- Department of Medical Physics, Greater Poland Cancer Centre, 61-866 Poznan, Poland
| | - Anna Adamska
- Department and Radiotherapy Ward I, Greater Poland Cancer Centre, 61-866 Poznan, Poland;
| | - Joanna Kazmierska
- Department of Electroradiology, Poznan University of Medical Science, 61-866 Poznan, Poland; (A.S.); (J.K.); (T.P.); (J.M.)
- Department of Radiotherapy II, Greater Poland Cancer Centre, 61-866 Poznan, Poland
| | - Natalia Jozefacka
- Institute of Psychology, Pedagogical University in Krakow, 30-084 Krakow, Poland;
| | - Tomasz Piotrowski
- Department of Electroradiology, Poznan University of Medical Science, 61-866 Poznan, Poland; (A.S.); (J.K.); (T.P.); (J.M.)
- Department of Medical Physics, Greater Poland Cancer Centre, 61-866 Poznan, Poland
| | - Julian Malicki
- Department of Electroradiology, Poznan University of Medical Science, 61-866 Poznan, Poland; (A.S.); (J.K.); (T.P.); (J.M.)
- Department of Medical Physics, Greater Poland Cancer Centre, 61-866 Poznan, Poland
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Ebrahimi S, Lim GJ. A reinforcement learning approach for finding optimal policy of adaptive radiation therapy considering uncertain tumor biological response. Artif Intell Med 2021; 121:102193. [PMID: 34763808 DOI: 10.1016/j.artmed.2021.102193] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 08/25/2021] [Accepted: 10/05/2021] [Indexed: 12/01/2022]
Abstract
Recent studies have shown that a tumor's biological response to radiation varies over time and has a dynamic nature. Dynamic biological features of tumor cells underscore the importance of using fractionation and adapting the treatment plan to tumor volume changes in radiation therapy treatment. Adaptive radiation therapy (ART) is an iterative process to adjust the dose of radiation in response to potential changes during the treatment. One of the key challenges in ART is how to determine the optimal timing of adaptations corresponding to tumor response to radiation. This paper aims to develop an automated treatment planning framework incorporating the biological uncertainties to find the optimal adaptation points to achieve a more effective treatment plan. First, a dynamic tumor-response model is proposed to predict weekly tumor volume regression during the period of radiation therapy treatment based on biological factors. Second, a Reinforcement Learning (RL) framework is developed to find the optimal adaptation points for ART considering the uncertainty in biological factors with the goal of achieving maximum final tumor control while minimizing or maintaining the toxicity level of the organs at risk (OARs) per the decision-maker's preference. Third, a beamlet intensity optimization model is solved using the predicted tumor volume at each adaptation point. The performance of the proposed RT treatment planning framework is tested using a clinical non-small cell lung cancer (NSCLC) case. The results are compared with the conventional fractionation schedule (i.e., equal dose fractionation) as a reference plan. The results show that the proposed approach performed well in achieving a robust optimal ART treatment plan under high uncertainty in the biological parameters. The ART plan outperformed the reference plan by increasing the mean biological effective dose (BED) value of the tumor by 2.01%, while maintaining the OAR BED within +0.5% and reducing the variability, in terms of the interquartile range (IQR) of tumor BED, by 25%.
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Affiliation(s)
- Saba Ebrahimi
- Department of Industrial Engineering, University of Houston, 4800 Calhoun Road, Houston, TX 77204, United States of America.
| | - Gino J Lim
- Department of Industrial Engineering, University of Houston, 4800 Calhoun Road, Houston, TX 77204, United States of America.
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Bak B, Skrobala A, Adamska A, Malicki J. What information can we gain from performing adaptive radiotherapy of head and neck cancer patients from the past 10 years? Cancer Radiother 2021; 26:502-516. [PMID: 34772603 DOI: 10.1016/j.canrad.2021.08.019] [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: 06/22/2021] [Revised: 08/06/2021] [Accepted: 08/12/2021] [Indexed: 01/10/2023]
Abstract
The aim of the review was to present the current literature status about replanning regarding anatomical and dosimetric changes in the target and OARs in the head and neck region during radiotherapy, to discuss and to analyze factors influencing the decision for adaptive radiotherapy of head and neck cancer patients. Significant progress has been made in head and neck patients' evaluation and qualification for adapted radiotherapy over the past ten years. Many factors leading to anatomical and dosimetric changes during treatment have been identified. Based on the literature, the most common factors triggering re-plan are weight loss, tumor and nodal changes, and parotid glands shrinkage. The fluctuations in dose distribution in the clinical area are significant predictive factors for patients' quality of life and the possibility of recovery. It has been shown that re-planning influence clinical outcomes: local control, disease free survival and overall survival. Regarding literature studies, it seems that adaptive radiotherapy would be the most beneficial for tumors of immense volume or those in the nearest proximity of the OARs. All researchers agree that the timing of re-planning is a crucial challenge, and there are still no clear consensus guidelines for time or criteria of re-planning. Nowadays, thanks to significant technological progress, the decision is mostly made based on observation and supported with IGRT verification. Although further research is still needed, adaptive strategies are evolving and now became the state of the art of modern radiotherapy.
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Affiliation(s)
- B Bak
- Radiotherapy Department II, Greater Poland Cancer Center, Poznan, Poland; Department of Electroradiology, University of Medical Science, Poznan, Poland.
| | - A Skrobala
- Department of Electroradiology, University of Medical Science, Poznan, Poland; Department of Medical Physics, Greater Poland Cancer Center, Poznan, Poland
| | - A Adamska
- Radiotherapy Ward I and Department I, Greater Poland Cancer Center, Poznan, Poland
| | - J Malicki
- Department of Electroradiology, University of Medical Science, Poznan, Poland
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Yoon HG, Ahn YC, Oh D, Noh JM, Park SG, Nam H, Ju SG, Kwon D, Park S. Early Clinical Outcomes of Intensity Modulated Radiation Therapy/Intensity Modulated Proton Therapy Combination in Comparison with Intensity Modulated Radiation Therapy Alone in Oropharynx Cancer Patients. Cancers (Basel) 2021; 13:cancers13071549. [PMID: 33801766 PMCID: PMC8037748 DOI: 10.3390/cancers13071549] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/18/2021] [Accepted: 03/24/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Intensity-modulated proton therapy (IMPT) is expected to reduce toxicity more effectively than intensity-modulated radiation therapy (IMRT) in treating oropharynx cancer (OPC) patients. Because of long waiting before starting IMPT, authors began IMRT first and then determined whether to continue IMRT or to switch into IMPT at time of adaptive re-plan, based on the rival plan comparison in 148 OPC patients. Early clinical outcomes were analyzed and compared between IMRT alone and IMRT/IMPT combination groups through propensity score matching method. We found that, with comparable oncologic outcomes, more favorable acute toxicity profiles (mucositis and need for analgesic use) were achieved following IMRT/IMPT combination than IMRT alone. Abstract Purpose: To report the early clinical outcomes of combining intensity-modulated radiation therapy (IMRT) and intensity-modulated proton therapy (IMPT) in comparison with IMRT alone in treating oropharynx cancer (OPC) patients. Materials and Methods: The medical records of 148 OPC patients who underwent definitive radiotherapy (RT) with concurrent systemic therapy, from January 2016 till December 2019 at Samsung Medical Center, were retrospectively reviewed. During the 5.5 weeks’ RT course, the initial 16 (or 18) fractions were delivered by IMRT in all patients, and the subsequent 12 (or 10) fractions were either by IMRT in 81 patients (IMRT only) or by IMPT in 67 (IMRT/IMPT combination), respectively, based on comparison of adaptive re-plan profiles and availability of equipment. Propensity-score matching (PSM) was done on 76 patients (38 from each group) for comparative analyses. Results: With the median follow-up of 24.7 months, there was no significant difference in overall survival and progression free survival between groups, both before and after PSM. Before PSM, the IMRT/IMPT combination group experienced grade ≥ 3 acute toxicities less frequently: mucositis in 37.0% and 13.4% (p < 0.001); and analgesic quantification algorithm (AQA) in 37.0% and 19.4% (p = 0.019), respectively. The same trends were observed after PSM: mucositis in 39.5% and 15.8% (p = 0.021); and AQA in 47.4% and 21.1% (p = 0.016), respectively. In multivariate logistic regression, grade ≥ 3 mucositis was significantly less frequent in the IMRT/IMPT combination group, both before and after PSM (p = 0.027 and 0.024, respectively). AQA score ≥ 3 was also less frequent in the IMRT/IMPT combination group, both before and after PSM (p = 0.085 and 0.018, respectively). Conclusions: In treating the OPC patients, with comparable early oncologic outcomes, more favorable acute toxicity profiles were achieved following IMRT/IMPT combination than IMRT alone.
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Affiliation(s)
- Han Gyul Yoon
- Samsung Medical Center, Department of Radiation Oncology, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (H.G.Y.); (D.O.); (J.M.N.); (S.G.J.); (D.K.); (S.P.)
| | - Yong Chan Ahn
- Samsung Medical Center, Department of Radiation Oncology, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (H.G.Y.); (D.O.); (J.M.N.); (S.G.J.); (D.K.); (S.P.)
- Correspondence:
| | - Dongryul Oh
- Samsung Medical Center, Department of Radiation Oncology, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (H.G.Y.); (D.O.); (J.M.N.); (S.G.J.); (D.K.); (S.P.)
| | - Jae Myoung Noh
- Samsung Medical Center, Department of Radiation Oncology, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (H.G.Y.); (D.O.); (J.M.N.); (S.G.J.); (D.K.); (S.P.)
| | - Seung Gyu Park
- Keimyung University Dongsan Medical Center, Department of Radiation Oncology, Keimyung University School of Medicine, Daegu 42601, Korea;
| | - Heerim Nam
- Department of Radiation Oncology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul 03181, Korea;
| | - Sang Gyu Ju
- Samsung Medical Center, Department of Radiation Oncology, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (H.G.Y.); (D.O.); (J.M.N.); (S.G.J.); (D.K.); (S.P.)
| | - Dongyeol Kwon
- Samsung Medical Center, Department of Radiation Oncology, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (H.G.Y.); (D.O.); (J.M.N.); (S.G.J.); (D.K.); (S.P.)
| | - Seyjoon Park
- Samsung Medical Center, Department of Radiation Oncology, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (H.G.Y.); (D.O.); (J.M.N.); (S.G.J.); (D.K.); (S.P.)
- Yonsei Cancer Center, Department of Radiation Oncology, Yonsei University College of Medicine, Seoul 03722, Korea
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10
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Figen M, Çolpan Öksüz D, Duman E, Prestwich R, Dyker K, Cardale K, Ramasamy S, Murray P, Şen M. Radiotherapy for Head and Neck Cancer: Evaluation of Triggered Adaptive Replanning in Routine Practice. Front Oncol 2020; 10:579917. [PMID: 33282734 PMCID: PMC7690320 DOI: 10.3389/fonc.2020.579917] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 10/13/2020] [Indexed: 12/30/2022] Open
Abstract
Purpose and Objective A proportion of patients receiving radiotherapy for head and neck squamous cell carcinoma (HNSCC) require ad hoc treatment re-planning. The aim of this retrospective study is to analyze the patients who required ad hoc re-planning and to identify factors, which may predict need for re-planning. Materials and Methods A single center evaluation of all patients receiving radical or adjuvant (chemo)radiotherapy (CRT) for HNSCC between January and December 2016 was undertaken. Patients who underwent ad hoc re-planning during the treatment were identified in electronic records. Reasons for re-planning were categorized as: weight loss, tumor shrinkage, changes in patient position and immobilization-related factors. Potential trigger factors for adaptive radiotherapy such as patient characteristics, primary tumor site, stage, concomitant chemotherapy, weight loss ratios, radical/adjuvant treatment, and nutritional interventions were investigated. Results 31/290 (10.6%) HNSCC patients who underwent radical/adjuvant radiotherapy required re-planning. The adaptive radiotherapy (ART) was performed at a mean fraction of 15. The most common documented reasons for re-planning were tumor shrinkage (35.5%) and weight loss (35.5%). Among the patient/tumor/treatment factors, nasopharyngeal primary site (p = 0.013) and use of concurrent chemotherapy with radiotherapy (p = 0.034) were found to be significantly correlated with the need for re-planning. Conclusion Effective on-treatment verification schedules and close follow up of patients especially with NPC primary and/or treated with concurrent chemoradiotherapy are crucial to identify patients requiring ART. We suggest an individualized triggered approach to ART rather than scheduled strategies as it is likely to be more feasible in terms of utilization of workload and resources.
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Affiliation(s)
- Metin Figen
- Department of Radiation Oncology Şişli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Didem Çolpan Öksüz
- Department of Radiation Oncology, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Evrim Duman
- Department of Radiation Oncology Antalya Training and Research Hospital, Antalya, Turkey
| | - Robin Prestwich
- Department of Clinical Oncology, Leeds Cancer Center, St. James's Institute of Oncology, Leeds, United Kingdom
| | - Karen Dyker
- Department of Clinical Oncology, Leeds Cancer Center, St. James's Institute of Oncology, Leeds, United Kingdom
| | - Kate Cardale
- Department of Clinical Oncology, Leeds Cancer Center, St. James's Institute of Oncology, Leeds, United Kingdom
| | - Satiavani Ramasamy
- Department of Clinical Oncology, Leeds Cancer Center, St. James's Institute of Oncology, Leeds, United Kingdom
| | - Patrick Murray
- Department of Clinical Oncology, Leeds Cancer Center, St. James's Institute of Oncology, Leeds, United Kingdom
| | - Mehmet Şen
- Department of Clinical Oncology, Leeds Cancer Center, St. James's Institute of Oncology, Leeds, United Kingdom
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11
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Yang H, Liu Y, Zhang R, Ye Y, Chen Q, Qin Q, Huang L, Li X, Cai R, Tang H, Jiang W. Prognostic value of the tumor volume reduction rate after neoadjuvant chemotherapy in patients with locoregional advanced nasopharyngeal carcinoma. Oral Oncol 2020; 110:104897. [PMID: 32679404 DOI: 10.1016/j.oraloncology.2020.104897] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 06/06/2020] [Accepted: 07/04/2020] [Indexed: 01/03/2023]
Abstract
PURPOSE Aim of this study was to evaluate the prognostic value of the tumor volume reduction rate (TVRR) of neoadjuvant chemotherapy (NACT) in patients with locoregional advanced nasopharyngeal carcinoma (NPC). METHODS We collected the clinical data of 263 patients with locoregional advanced NPC receiving NACT and subsequent radiotherapy from two hospitals: a training cohort (n = 130) was obtained from one hospital and a validation cohort was obtained the other hospital (n = 133). By follow-up and calculating the TVRR of all patients, the prognostic value of the TVRR was analyzed though a univariate and multivariate Cox regression model. A cut-off point of the TVRR relating to survival was explored by means of the Youden index, and the prognostic value of the TNM stage plus TVRR was measured by creating receiver operating characteristic (ROC) curves. RESULTS 12.6%, a cut-off point of TVRR, was found to best predict DFS. Patients with a TVRR > 12.6% had better DFS (hazard ratio, 0.160, 95% confidence interval 0.072-0.354; P < 0.001), LRRFS (0.064, 0.013-0.310; 0.001) and DMFS (0.274, 0.106-0.711; 0.008) than patients with a TVRR ≤ 12.6%. The TVRR was a significant independent prognostic factor for OS, DFS, LRRFS and DMFS. Combining the TVRR and TNM stage enhanced the ability to predict DFS and LRRFS. CONCLUSIONS The TVRR of NACT is an independent prognostic factor for patients with locoregional advanced NPC receiving radiotherapy. Adding the TVRR to the original TNM staging system improves the prognostic value for locoregional advanced NPC.
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Affiliation(s)
- Huiyun Yang
- Department of Radiation Oncology, Guilin Medical University Affiliated Hospital, Guilin 541001, PR China
| | - Yuanyuan Liu
- Department of Radiation Oncology, Wuzhou Red Cross Hospital, Wuzhou 543002, PR China
| | - Rongjun Zhang
- Department of Radiation Oncology, Guilin Medical University Affiliated Hospital, Guilin 541001, PR China
| | - Yaomin Ye
- Department of Radiation Oncology, Guilin Medical University Affiliated Hospital, Guilin 541001, PR China
| | - Qiuqiu Chen
- Department of Radiation Oncology, Guilin Medical University Affiliated Hospital, Guilin 541001, PR China
| | - Qinghua Qin
- Department of Radiation Oncology, Guilin Medical University Affiliated Hospital, Guilin 541001, PR China
| | - Liying Huang
- Department of Radiation Oncology, Guilin Medical University Affiliated Hospital, Guilin 541001, PR China
| | - Xi Li
- Department of Radiation Oncology, Guilin Medical University Affiliated Hospital, Guilin 541001, PR China
| | - Rui Cai
- Department of Radiation Oncology, Guilin Medical University Affiliated Hospital, Guilin 541001, PR China
| | - Huaying Tang
- Department of Radiation Oncology, Guilin Medical University Affiliated Hospital, Guilin 541001, PR China
| | - Wei Jiang
- Department of Radiation Oncology, Guilin Medical University Affiliated Hospital, Guilin 541001, PR China; Department of Oncology, People's Hospital of Gongcheng Yao Autonomous County, Guilin 542500, PR China.
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12
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Treatment margins in radiotherapy for liver tumors visualized as T2*-hypointense areas on SPIO-enhanced MRI at 9.4 T. MAGNETIC RESONANCE MATERIALS IN PHYSICS BIOLOGY AND MEDICINE 2020; 33:701-712. [PMID: 32130567 DOI: 10.1007/s10334-020-00838-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/31/2020] [Accepted: 02/17/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To investigate whether a SPIO-labeling technique could enable MR visualization of the treatment margin after X-irradiation at a single dose of 30 Gy. MATERIALS AND METHODS Fifteen rats bearing N1-S1 hepatoma in either the left (group 1) or right (group 2) liver lobe were examined. Four hours after systemic SPIO administration, the left lobe was selectively irradiated at 30 Gy. Liver T2* maps were acquired 7 days later using a 9.4 T scanner. The livers were excised and examined histologically. RESULTS The irradiated area showed T2*-weighted hypointensity with significantly shorter T2* values than those in the non-irradiated area (p < 0.001). Tumors in group 1 completely disappeared, whereas tumors in group 2 had grown outside the T2*-weighted hypointensity by up to ~ 2.3 times that at baseline. Group 1 showed significantly higher probability of tumor regression than group 2 (p = 0.048). Histologically, iron deposition was heavier in irradiated areas than in non-irradiated areas. DISCUSSION Even at a single dose of 30 Gy, which is a slightly higher dose than can be used clinically in stereotactic body radiotherapy, MR visualization of the treatment margin was achieved, because tumors showed significant growth outside the T2*-hypointense areas. In contrast, tumors disappeared inside the T2*-hypointense areas.
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13
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Belfatto A, Jereczek-Fossa BA, Baroni G, Cerveri P. Model-Supported Radiotherapy Personalization: In silico Test of Hyper- and Hypo-Fractionation Effects. Front Physiol 2018; 9:1445. [PMID: 30374310 PMCID: PMC6197078 DOI: 10.3389/fphys.2018.01445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 09/24/2018] [Indexed: 12/25/2022] Open
Abstract
The need for radiotherapy personalization is now widely recognized, however, it would require considerations not only on the probability of control and survival of the tumor, but also on the possible toxic effects, on the quality of the expected life and the economic efficiency of the treatment. In this paper, we propose a simulation tool that can be integrated into a decision support system that allows selection of the most suitable irradiation regimen. We used a macroscale mathematical model, which includes active and necrotic tumor dynamics and the role of oxygenation to simulate the effects of different hypo-/hyper-fractional regimens using retrospective data of seven virtual patients from as many cervical cancer patients used for its training in a previous study. The results confirmed the heterogeneous response across the patients as a function of treatment regimen and suggested the tumor growth rate as a main factor in the final tumor regression. In addition to the maximum regression, another criterion was suggested to select the most suitable regimen (minimum number of fractions to achieve a regression of 80%) minimizing the toxicity and maximizing the cost-effectiveness ratio. Despite the lack of direct validation, the simulation results are in agreement with the literature findings that suggest the need for hypo-fractionated regimens in case of aggressive tumor phenotypes. Finally, the paper suggests a possible exploitation of the model within a tool to support clinical decisions.
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Affiliation(s)
- Antonella Belfatto
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy,Division of Radiotherapy, European Institute of Oncology, Milan, Italy
| | - Guido Baroni
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Pietro Cerveri
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy,*Correspondence: Pietro Cerveri,
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14
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Kabarriti R, Brodin NP, Lundgren G, Ohri N, Tomé WA, Kalnicki S, Garg MK. Early Response Assessment on Mid-treatment Computed Tomography Predicts for Locoregional Recurrence in Oropharyngeal Cancer Patients Treated With Definitive Radiation Therapy. Int J Radiat Oncol Biol Phys 2018; 102:1036-1045. [PMID: 29779936 DOI: 10.1016/j.ijrobp.2018.03.059] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 03/19/2018] [Accepted: 03/29/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE To evaluate whether a response assessment using mid-treatment computed tomography (CT) scans during definitive radiation therapy (RT) for oropharyngeal head and neck cancer can predict for locoregional recurrence (LRR). METHODS AND MATERIALS Head and neck cancer patients who receive RT at our institution undergo CT repeat scans at the 15th fraction, with treatment replanning in the case of an inadequate dose to gross disease or an increased dose to organs at risk. A retrospective cohort analysis was performed of 96 consecutive patients with oropharyngeal cancer treated from 2007 to 2015 with mid-treatment repeat CT scans available. The primary disease volume and involved lymph node volume were delineated on the pre- and mid-treatment CT scans. Univariable and multivariable Cox proportional hazards regression analyses were used to evaluate the efficacy of the mid-treatment reduction in tumor volume as a predictor of LRR. Risk stratification was performed by dichotomizing the patients into high- and low-risk groups according to the mid-treatment response and p16 status and smoking history. RESULTS With a median follow-up of 34 months, 14 patients experienced LRR. The median reduction in the total tumor volume was 18.7% (interquartile range 8.4%-30.9%). A reduction in total tumor volume greater than the median was an independent predictor of LRR (hazard ratio 0.22, 95% confidence interval 0.05-0.89; P = .020). The reduction in primary tumor volume was an even stronger predictor of LRR (hazard ratio 0.11, 95% confidence interval 0.02-0.57; P = .002). Stratifying patients into a high-risk group for those with a reduction in the total tumor volume at mid-treatment at or less than the median, p16 negative status, and smoking status of >10 pack-years and a low-risk group for those without these factors, we found a clear separation in Kaplan-Meier curves, with actuarial 3-year locoregional control, progression-free survival, and overall survival rates for the high-risk patients of 45.7%, 38.2%, and 71.8% compared with 90.7%, 70.6%, and 89.8% for low-risk patients, respectively (P ≤ .021 for all). CONCLUSIONS Our results have shown that the treatment response from an early assessment using mid-treatment CT scans is an independent predictor of LRR and can be used to effectively distinguish high- and low-risk patients, allowing for risk-adaptive treatment stratification at the midway point.
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Affiliation(s)
- Rafi Kabarriti
- Department of Radiation Oncology, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, New York
| | - N Patrik Brodin
- Department of Radiation Oncology, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, New York; Institute for Onco-Physics, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, New York
| | - George Lundgren
- Department of Radiation Oncology, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, New York
| | - Nitin Ohri
- Department of Radiation Oncology, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, New York
| | - Wolfgang A Tomé
- Department of Radiation Oncology, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, New York; Institute for Onco-Physics, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, New York
| | - Shalom Kalnicki
- Department of Radiation Oncology, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, New York
| | - Madhur K Garg
- Department of Radiation Oncology, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, New York.
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15
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Lee YH, Song JH, Choi HS, Jeong H, Kang KM, Kang JH, Woo SH, Park JJ, Kim JP, Jeong BK. Using primary tumor volumetry to predict treatment outcome for patients with oropharyngeal cancer who were treated with definitive chemoradiotherapy. Asia Pac J Clin Oncol 2017; 14:e21-e28. [DOI: 10.1111/ajco.12704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 04/18/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Yun Hee Lee
- Department of Radiation Oncology; Gyeongsang National University School of medicine and Gyeongsang National University Hospital; Jinju Republic of Korea
- Institute of Health Sciences; Gyeongsang National University; Jinju Republic of Korea
| | - Jin Ho Song
- Institute of Health Sciences; Gyeongsang National University; Jinju Republic of Korea
- Department of Radiation Oncology; Gyeongsang National University School of medicine and Gyeongsang National University Changwon Hospital; Changwon Republic of Korea
| | - Hoon-Sik Choi
- Department of Radiation Oncology; Gyeongsang National University School of medicine and Gyeongsang National University Hospital; Jinju Republic of Korea
| | - Hojin Jeong
- Department of Radiation Oncology; Gyeongsang National University School of medicine and Gyeongsang National University Hospital; Jinju Republic of Korea
- Institute of Health Sciences; Gyeongsang National University; Jinju Republic of Korea
| | - Ki Mun Kang
- Department of Radiation Oncology; Gyeongsang National University School of medicine and Gyeongsang National University Hospital; Jinju Republic of Korea
- Institute of Health Sciences; Gyeongsang National University; Jinju Republic of Korea
| | - Jung Hun Kang
- Institute of Health Sciences; Gyeongsang National University; Jinju Republic of Korea
- Department of Internal Medicine; Gyeongsang National University School of medicine and Gyeongsang National University Hospital; Jinju Republic of Korea
| | - Seung Hoon Woo
- Institute of Health Sciences; Gyeongsang National University; Jinju Republic of Korea
- Department of Otorhinolaryngology; Gyeongsang National University School of medicine and Gyeongsang National University Hospital; Jinju Republic of Korea
| | - Jung Je Park
- Institute of Health Sciences; Gyeongsang National University; Jinju Republic of Korea
- Department of Otorhinolaryngology; Gyeongsang National University School of medicine and Gyeongsang National University Hospital; Jinju Republic of Korea
| | - Jin Pyeong Kim
- Institute of Health Sciences; Gyeongsang National University; Jinju Republic of Korea
- Department of Otorhinolaryngology; Gyeongsang National University School of medicine and Gyeongsang National University Hospital; Jinju Republic of Korea
| | - Bae Kwon Jeong
- Department of Radiation Oncology; Gyeongsang National University School of medicine and Gyeongsang National University Hospital; Jinju Republic of Korea
- Institute of Health Sciences; Gyeongsang National University; Jinju Republic of Korea
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16
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Gros SA, Xu W, Roeske JC, Choi M, Emami B, Surucu M. A novel surrogate to identify anatomical changes during radiotherapy of head and neck cancer patients. Med Phys 2017; 44:924-934. [DOI: 10.1002/mp.12067] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 10/31/2016] [Accepted: 12/14/2016] [Indexed: 11/09/2022] Open
Affiliation(s)
- Sébastien A.A. Gros
- Department of Radiation Oncology; Loyola University Medical Center; Maywood IL 60153 USA
| | - William Xu
- Department of Radiation Oncology; Loyola University Medical Center; Maywood IL 60153 USA
| | - John C. Roeske
- Department of Radiation Oncology; Loyola University Medical Center; Maywood IL 60153 USA
| | - Mehe Choi
- Department of Radiation Oncology; Loyola University Medical Center; Maywood IL 60153 USA
| | - Bahman Emami
- Department of Radiation Oncology; Loyola University Medical Center; Maywood IL 60153 USA
| | - Murat Surucu
- Department of Radiation Oncology; Loyola University Medical Center; Maywood IL 60153 USA
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17
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Study of diffusion weighted MRI as a predictive biomarker of response during radiotherapy for high and intermediate risk squamous cell cancer of the oropharynx: The MeRInO study. Clin Transl Radiat Oncol 2017; 2:13-18. [PMID: 29657994 PMCID: PMC5893522 DOI: 10.1016/j.ctro.2016.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 12/06/2016] [Accepted: 12/13/2016] [Indexed: 11/22/2022] Open
Abstract
Introduction and background A significant proportion of patients with intermediate and high risk squamous cell cancer of the oropharynx (OPSCC) continue to relapse locally despite radical chemoradiotherapy (CRT). The toxicity of the current combination of intensified dose per fraction radiotherapy and platinum based chemotherapy limits further uniform intensification. If a predictive biomarker for outcomes from CRT can be identified during treatment then individualised and adaptive treatment strategies may be employed. Methods/design The MeRInO study is a prospective observational imaging study of patients with intermediate and high risk, locally advanced OPSCC receiving radical RT or concurrent CRT Patients undergo diffusion weighted MRI prior to treatment (MRI_1) and during the third week of RT (MRI_2). Apparent diffusion coefficient (ADC) measurements will be made on each scan for previously specified target lesions (primary and lymph nodes) and change in ADC calculated. Patients will be followed up and disease status for each target lesion noted. The primary aim of the MeRInO study is to determine the threshold change in ADC from baseline to week 3 of RT that may identify the sub-group of non-responders during treatment. Discussion The use of DW-MRI as a predictive biomarker during RT for SCC H&N is in its infancy but studies to date have found that response to treatment may indeed be predicted by comparison of DW-MRI carried out before and during treatment. However, previous studies have included all sub-sites and biological sub-types. Establishing ADC thresholds that predict for local failure is an essential step towards using DW-MRI to improve the therapeutic ratio in treating SCC H&N. This would be done most robustly in a specific H&N sub-site and in sub-types with similar biological behaviour. The MeRInO study will help establish these thresholds in OPSCC.
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18
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Surucu M, Shah KK, Roeske JC, Choi M, Small W, Emami B. Adaptive Radiotherapy for Head and Neck Cancer. Technol Cancer Res Treat 2016; 16:218-223. [PMID: 27502958 DOI: 10.1177/1533034616662165] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To investigate the effects of adaptive radiotherapy on dosimetric, clinical, and toxicity outcomes for patients with head and neck cancer undergoing chemoradiotherapy with intensity-modulated radiotherapy. METHODS Fifty-one patients with advanced head and neck cancer underwent definitive chemoradiotherapy with the original plan optimized to deliver 70.2 Gy. All patients were resimulated at a median dose of 37.8 Gy (range, 27.0-48.6 Gy) due to changes in tumor volume and/or patient weight loss (>15% from baseline). Thirty-four patients underwent adaptive replanning for their boost planning (21.6 Gy). The dosimetric effects of the adaptive plan were compared to the original plan and the original plan copied on rescan computed tomography. Acute and late toxicities and tumor local control were assessed. Gross tumor volume reduction rate was calculated. RESULTS With adaptive replanning, the maximum dose to the spinal cord, brain stem, mean ipsilateral, and contralateral parotid had a median reduction of -4.5%, -3.0%, -6.2%, and -2.5%, respectively (median of 34 patients). Median gross tumor volume and boost planning target volume coverage improved by 0.8% and 0.5%, respectively. With a median follow-up time of 17.6 months, median disease-free survival and overall survival was 14.8 and 21.1 months, respectively. Median tumor volume reduction rate was 35.2%. For patients with tumor volume reduction rate ≤35.2%, median disease-free survival was 8.7 months, whereas it was 16.9 months for tumor volume reduction rate >35.2%. Four patients had residual disease after chemoradiotherapy, whereas 64.7% (20 of 34) of patients achieved locoregional control. CONCLUSION Implementation of adaptive radiotherapy in head and neck cancer offers benefits including improvement in tumor coverage and decrease in dose to organs at risk. The tumor volume reduction rate during treatment was significantly correlated with disease-free survival and overall survival.
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Affiliation(s)
- Murat Surucu
- 1 Department of Radiation Oncology, Loyola University Medical Center, Maywood, IL, USA
| | - Karan K Shah
- 1 Department of Radiation Oncology, Loyola University Medical Center, Maywood, IL, USA
| | - John C Roeske
- 1 Department of Radiation Oncology, Loyola University Medical Center, Maywood, IL, USA
| | - Mehee Choi
- 1 Department of Radiation Oncology, Loyola University Medical Center, Maywood, IL, USA
| | - William Small
- 1 Department of Radiation Oncology, Loyola University Medical Center, Maywood, IL, USA
| | - Bahman Emami
- 1 Department of Radiation Oncology, Loyola University Medical Center, Maywood, IL, USA
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Replanning Criteria and Timing Definition for Parotid Protection-Based Adaptive Radiation Therapy in Nasopharyngeal Carcinoma. BIOMED RESEARCH INTERNATIONAL 2015; 2015:476383. [PMID: 26793717 PMCID: PMC4697077 DOI: 10.1155/2015/476383] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 11/30/2015] [Indexed: 11/30/2022]
Abstract
The goal of this study was to evaluate real-time volumetric and dosimetric changes of the parotid gland so as to determine replanning criteria and timing for parotid protection-based adaptive radiation therapy in nasopharyngeal carcinoma. Fifty NPC patients were treated with helical tomotherapy; volumetric and dosimetric (Dmean, V1, and D50) changes of the parotid gland at the 1st, 6th, 11th, 16th, 21st, 26th, 31st, and 33rd fractions were evaluated. The clinical parameters affecting these changes were studied by analyses of variance methods for repeated measures. Factors influencing the actual parotid dose were analyzed by a multivariate logistic regression model. The cut-off values predicting parotid overdose were developed from receiver operating characteristic curves and judged by combining them with a diagnostic test consistency check. The median absolute value and percentage of parotid volume reduction were 19.51 cm3 and 35%, respectively. The interweekly parotid volume varied significantly (p < 0.05). The parotid Dmean, V1, and D50 increased by 22.13%, 39.42%, and 48.45%, respectively. The actual parotid dose increased by an average of 11.38% at the end of radiation therapy. Initial parotid volume, initial parotid Dmean, and weight loss rate are valuable indicators for parotid protection-based replanning.
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20
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Ding Y, Hazle JD, Mohamed ASR, Frank SJ, Hobbs BP, Colen RR, Gunn GB, Wang J, Kalpathy-Cramer J, Garden AS, Lai SY, Rosenthal DI, Fuller CD. Intravoxel incoherent motion imaging kinetics during chemoradiotherapy for human papillomavirus-associated squamous cell carcinoma of the oropharynx: preliminary results from a prospective pilot study. NMR IN BIOMEDICINE 2015; 28:1645-54. [PMID: 26451969 PMCID: PMC4715635 DOI: 10.1002/nbm.3412] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 08/24/2015] [Accepted: 08/25/2015] [Indexed: 05/02/2023]
Abstract
This study aims to identify the temporal kinetics of intravoxel incoherent motion (IVIM) MRI in patients with human papillomavirus-associated (HPV+) oropharyngeal squamous cell carcinoma. Patients were enrolled under an Institutional Review Board (IRB)-approved protocol as part of an ongoing prospective clinical trial. All patients underwent two MRI studies: a baseline scan before chemoradiotherapy and a mid-treatment scan 3-4 weeks after treatment initiation. Parametric maps representing pure diffusion coefficient (D), pseudo-diffusion coefficient (D*), perfusion fraction (f) and apparent diffusion coefficient (ADC) were generated. The Mann-Whitney U-test was used to assess the temporal variation of IVIM metrics. Bayesian quadratic discriminant analysis (QDA) was used to evaluate the extent to which mid-treatment changes in IVIM metrics could be combined to predict sites that would achieve complete response (CR) in multivariate analysis. Thirty-one patients were included in the final analysis with 59 lesions. Pretreatment ADC and D values of the CR lesions (n = 19) were significantly lower than those of non-CR lesions (n = 33). Mid-treatment ADC, D and f values were significantly higher (p < 0.0001) than pretreatment values for all lesions. Each increase in normalized ΔADC of size 0.1 yielded a 1.45-fold increase in the odds of CR (p < 0.0003), each increase in normalized ΔD of size 0.1 yielded a 1.53-fold increase in the odds of CR (p < 0.0002), and each unit increase in Δf yielded a 2.29-fold increase in the odds of CR (p < 0.02). Combined ΔD and ΔADC were integrated into a multivariate prediction model and attained an AUC of 0.87 (95% confidence interval: 0.79, 0.96), as well as a sensitivity of 0.63, specificity of 0.85 and accuracy of 0.78, under leave-one-out cross-validation. In conclusion, IVIM is feasible and potentially useful in the prediction and assessment of the early response of HPV+ oropharyngeal squamous cell carcinoma to chemoradiotherapy.
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Affiliation(s)
- Yao Ding
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Imaging physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - John D. Hazle
- Department of Imaging physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Abdallah S. R. Mohamed
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Clinical Oncology and Nuclear Medicine, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Steven J. Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Brian P. Hobbs
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rivka R. Colen
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - G. Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jihong Wang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jayashree Kalpathy-Cramer
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital/Division of Health Sciences & Technology, Massachusetts Institute of Technology, Charlestown, MA, USA
| | - Adam S. Garden
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Stephen Y. Lai
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David I. Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Clifton D. Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- The University of Texas Graduate School of Biomedical Sciences, Houston, TX, USA
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21
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Thomson DJ, Teo BKK, Ong A, Ang KW, Kirk M, Ahn PH, Lukens JN, Swisher-McClure S, Liptrot T, Solberg TD, Slevin NJ, Lin A. The Impact of Anatomic Change on Pencil Beam Scanning in the Treatment of Oropharynx Cancer. Int J Part Ther 2015. [DOI: 10.14338/ijpt-15-00002.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- David J. Thomson
- The Christie NHS Foundation Trust, Manchester, United Kingdom
- University of Manchester, Institute of Cancer Sciences, Manchester, United Kingdom
| | - Boon-Keng Kevin Teo
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Ashley Ong
- National Cancer Centre Singapore, Singapore
| | | | - Maura Kirk
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter H. Ahn
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - John N. Lukens
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Tom Liptrot
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Timothy D. Solberg
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Nick J. Slevin
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Alexander Lin
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
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22
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Lee H, Ahn YC, Oh D, Nam H, Noh JM, Park SY. Tumor Volume Reduction Rate during Adaptive Radiation Therapy as a Prognosticator for Nasopharyngeal Cancer. Cancer Res Treat 2015; 48:537-45. [PMID: 26194371 PMCID: PMC4843740 DOI: 10.4143/crt.2015.081] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 06/09/2015] [Indexed: 11/21/2022] Open
Abstract
Purpose The purpose of this study is to evaluate the prognostic significance of the tumor volume reduction rate (TVRR) measured during adaptive definitive radiation therapy (RT) for nasopharyngeal cancer (NPC). Materials and Methods We reviewed the RT records of 159 NPC patients treated with definitive RT with or without concurrent chemotherapy between January 2006 and February 2013. Adaptive re-planning was performed in all patients at the third week of RT. The pre- and mid-RT gross tumor volumes (GTVs) of the primary tumor and the metastatic lymph nodes were measured and analyzed for prognostic implications. Results After a median follow-up period of 41.5 months (range, 11.2 to 91.8 months) for survivors, there were 43 treatment failures. The overall survival and progression-free survival (PFS) rates at 5 years were 89.6% and 69.7%, respectively. The mean pre-RT GTV, mid-RT GTV, and TVRR were 45.9 cm3 (range, 1.5 to 185.3 cm3), 26.7 cm3 (1.0 to 113.8 cm3), and –41.9% (range, –87% to 78%), respectively. Patients without recurrence had higher TVRR than those with recurrence (44.3% in the no recurrence group vs. 34.0% in the recurrence group, p=0.004), and those with TVRR > 35% achieved a significantly higher rate of PFS at 5 years (79.2% in TVRR > 35% vs. 53.2% in TVRR ≤ 35%; p < 0.001). In multivariate analysis, TVRR was a significant factor affecting PFS (hazard ratio, 2.877; 95% confidence interval, 1.555 to 5.326; p=0.001). Conclusion TVRR proved to be a significant prognostic factor in NPC patients treated with definitive RT, and could be used as a potential indicator for early therapeutic modification during the RT course.
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Affiliation(s)
- Hyebin Lee
- Department of Radiation Oncology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Chan Ahn
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dongryul Oh
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Heerim Nam
- Department of Radiation Oncology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Myoung Noh
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Su Yeon Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Bio-medical Science, Korea University, Seoul, Korea
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23
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Surucu M, Shah KK, Mescioglu I, Roeske JC, Small W, Choi M, Emami B. Decision Trees Predicting Tumor Shrinkage for Head and Neck Cancer: Implications for Adaptive Radiotherapy. Technol Cancer Res Treat 2015; 15:139-45. [PMID: 25731804 DOI: 10.1177/1533034615572638] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 01/22/2015] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE To develop decision trees predicting for tumor volume reduction in patients with head and neck (H&N) cancer using pretreatment clinical and pathological parameters. METHODS Forty-eight patients treated with definitive concurrent chemoradiotherapy for squamous cell carcinoma of the nasopharynx, oropharynx, oral cavity, or hypopharynx were retrospectively analyzed. These patients were rescanned at a median dose of 37.8 Gy and replanned to account for anatomical changes. The percentages of gross tumor volume (GTV) change from initial to rescan computed tomography (CT; %GTVΔ) were calculated. Two decision trees were generated to correlate %GTVΔ in primary and nodal volumes with 14 characteristics including age, gender, Karnofsky performance status (KPS), site, human papilloma virus (HPV) status, tumor grade, primary tumor growth pattern (endophytic/exophytic), tumor/nodal/group stages, chemotherapy regimen, and primary, nodal, and total GTV volumes in the initial CT scan. The C4.5 Decision Tree induction algorithm was implemented. RESULTS The median %GTVΔ for primary, nodal, and total GTVs was 26.8%, 43.0%, and 31.2%, respectively. Type of chemotherapy, age, primary tumor growth pattern, site, KPS, and HPV status were the most predictive parameters for primary %GTVΔ decision tree, whereas for nodal %GTVΔ, KPS, site, age, primary tumor growth pattern, initial primary GTV, and total GTV volumes were predictive. Both decision trees had an accuracy of 88%. CONCLUSIONS There can be significant changes in primary and nodal tumor volumes during the course of H&N chemoradiotherapy. Considering the proposed decision trees, radiation oncologists can select patients predicted to have high %GTVΔ, who would theoretically gain the most benefit from adaptive radiotherapy, in order to better use limited clinical resources.
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Affiliation(s)
- Murat Surucu
- Department of Radiation Oncology, Loyola University Chicago, Maywood, IL, USA
| | - Karan K Shah
- Department of Radiation Oncology, Loyola University Chicago, Maywood, IL, USA
| | - Ibrahim Mescioglu
- Department of Management Information Systems, Lewis University, Romeoville, IL, USA
| | - John C Roeske
- Department of Radiation Oncology, Loyola University Chicago, Maywood, IL, USA
| | - William Small
- Department of Radiation Oncology, Loyola University Chicago, Maywood, IL, USA
| | - Mehee Choi
- Department of Radiation Oncology, Loyola University Chicago, Maywood, IL, USA
| | - Bahman Emami
- Department of Radiation Oncology, Loyola University Chicago, Maywood, IL, USA
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24
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Yock AD, Rao A, Dong L, Beadle BM, Garden AS, Kudchadker RJ, Court LE. Predicting oropharyngeal tumor volume throughout the course of radiation therapy from pretreatment computed tomography data using general linear models. Med Phys 2014; 41:051705. [PMID: 24784371 DOI: 10.1118/1.4870437] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE The purpose of this work was to develop and evaluate the accuracy of several predictive models of variation in tumor volume throughout the course of radiation therapy. METHODS Nineteen patients with oropharyngeal cancers were imaged daily with CT-on-rails for image-guided alignment per an institutional protocol. The daily volumes of 35 tumors in these 19 patients were determined and used to generate (1) a linear model in which tumor volume changed at a constant rate, (2) a general linear model that utilized the power fit relationship between the daily and initial tumor volumes, and (3) a functional general linear model that identified and exploited the primary modes of variation between time series describing the changing tumor volumes. Primary and nodal tumor volumes were examined separately. The accuracy of these models in predicting daily tumor volumes were compared with those of static and linear reference models using leave-one-out cross-validation. RESULTS In predicting the daily volume of primary tumors, the general linear model and the functional general linear model were more accurate than the static reference model by 9.9% (range: -11.6%-23.8%) and 14.6% (range: -7.3%-27.5%), respectively, and were more accurate than the linear reference model by 14.2% (range: -6.8%-40.3%) and 13.1% (range: -1.5%-52.5%), respectively. In predicting the daily volume of nodal tumors, only the 14.4% (range: -11.1%-20.5%) improvement in accuracy of the functional general linear model compared to the static reference model was statistically significant. CONCLUSIONS A general linear model and a functional general linear model trained on data from a small population of patients can predict the primary tumor volume throughout the course of radiation therapy with greater accuracy than standard reference models. These more accurate models may increase the prognostic value of information about the tumor garnered from pretreatment computed tomography images and facilitate improved treatment management.
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Affiliation(s)
- Adam D Yock
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030 and The Graduate School of Biomedical Sciences, The University of Texas Health Science Center at Houston, Houston, Texas 77030
| | - Arvind Rao
- Department of Bioinformatics and Computational Biology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030 and the Graduate School of Biomedical Sciences, the University of Texas Health Science Center at Houston, Houston, Texas 77030
| | - Lei Dong
- Scripps Proton Therapy Center, San Diego, California 92121 and The Graduate School of Biomedical Sciences, The University of Texas Health Science Center at Houston, Houston, Texas 77030
| | - Beth M Beadle
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030
| | - Adam S Garden
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030
| | - Rajat J Kudchadker
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030 and The Graduate School of Biomedical Sciences, The University of Texas Health Science Center at Houston, Houston, Texas 77030
| | - Laurence E Court
- Department of Radiation Physics and Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030 and The Graduate School of Biomedical Sciences, The University of Texas Health Science Center at Houston, Houston, Texas 77030
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