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Polizzi M, Weiss E, Jan N, Ricco A, Kim S, Urdaneta A, Rosu‐Bubulac M. Rectal deformation management with IGRT in prostate radiotherapy: Can it be managed with rigid alignment alone? J Appl Clin Med Phys 2024; 25:e14241. [PMID: 38193605 PMCID: PMC11005986 DOI: 10.1002/acm2.14241] [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: 02/01/2023] [Revised: 10/15/2023] [Accepted: 10/25/2023] [Indexed: 01/10/2024] Open
Abstract
PURPOSE It is challenging to achieve appropriate target coverage of the prostate with Image Guided Radiation Therapy (IGRT) while simultaneously constraining rectal doses within planned values when there is significant variability in rectal filling and shape. We investigated if rectum planning goals can be fulfilled using rigid CBCT-based on-board alignment to account for interfraction rectal deformations. METHODS Delivered rectal doses corresponding to prostate alignment ("PR") and anterior rectum alignment ("AR") for 239 daily treatments from 13 patients are reported. Rectal doses were estimated by rigidly mapping the planned dose on the daily CT derived from the daily CBCT according to respective alignment shifts. Rectum V95% (rV95%) was used for analyses. RESULTS Compared to "PR", "AR" alignment increased rV95% for an average of 34.4% across all patients. rV95% (cc) averaged over all fractions was significant from planning values for 10/13 patients for "PR" and for 9/13 for "AR". 3/13 patients had reproducible anatomy. Of patients with non-reproducible anatomy, three had dosimetrically more favorable, while seven had less favorable anatomies. Most shift differences (82.3%) between the "PR" and "AR" alignments larger than 2 mm resulted in rV95% changes larger than 2 cc. Most shift differences (82.2%) of 2 mm or less between the "PR" and "AR" alignments resulted in rV95% changes less than 2 cc. The average percentage of fractions among patients in which anterior or posterior shifts for "AR" and "PR" alignment was larger than the PTV margins was 9.1% (0.0%-37.5%) and 1.3% (0%-10%). CONCLUSION Rectal deformation and subsequent inconsistent interfraction separation between prostate and rectal wall translate into anatomical changes that cannot always be mitigated with rigid alignment. If systematic differences exist due to a non-reproducible planning anatomy, attempts to restore the planned rectal doses through anterior rectum alignment produce rather small improvements and may result in unacceptable target underdosage.
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Affiliation(s)
- Mitchell Polizzi
- Department of Radiation OncologyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Elisabeth Weiss
- Department of Radiation OncologyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Nuzhat Jan
- Department of Radiation OncologyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Anthony Ricco
- Department of Radiation OncologyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Siyong Kim
- Department of Radiation OncologyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Alfredo Urdaneta
- Department of Radiation OncologyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Mihaela Rosu‐Bubulac
- Department of Radiation OncologyVirginia Commonwealth UniversityRichmondVirginiaUSA
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Li Kuan Ong A, Knight K, Panettieri V, Dimmock M, Kit Loong Tuan J, Qi Tan H, Wright C. Predictors for late genitourinary toxicity in men receiving radiotherapy for high-risk prostate cancer using planned and accumulated dose. Phys Imaging Radiat Oncol 2023; 25:100421. [PMID: 36817981 PMCID: PMC9932727 DOI: 10.1016/j.phro.2023.100421] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 02/05/2023] Open
Abstract
Background and purpose Significant deviations between bladder dose planned (DP) and dose accumulated (DA) have been reported in patients receiving radiotherapy for prostate cancer. This study aimed to construct multivariate analysis (MVA) models to predict the risk of late genitourinary (GU) toxicity with clinical and DP or DA as dose-volume (DV) variables. Materials and methods Bladder DA obtained from 150 patients were compared with DP. MVA models were built from significant clinical and DV variables (p < 0.05) at univariate analysis. Previously developed dose-based-region-of-interest (DB-ROI) metrics using expanded ring structures from the prostate were included. Goodness-of-fit test and calibration plots were generated to determine model performance. Internal validation was accomplished using Bootstrapping. Results Intermediate-high DA (V30-65 Gy and DB-ROI-20-50 mm) for bladder increased compared to DP. However, at the very high dose region, DA (D0.003 cc, V75 Gy, and DB-ROI-5-10 mm) were significantly lower. In MVA, single variable models were generated with odds ratio (OR) < 1. DB-ROI-50 mm was predictive of Grade ≥ 1 GU toxicity for DA and DP (DA and DP; OR: 0.96, p: 0.04) and achieved an area under the receiver operating curve (AUC) of > 0.6. Prostate volume (OR: 0.87, p: 0.01) was significant in predicting Grade 2 GU toxicity with a high AUC of 0.81. Conclusions Higher DA (V30-65 Gy) received by the bladder were not translated to higher late GU toxicity. DB-ROIs demonstrated higher predictive power than standard DV metrics in associating Grade ≥ 1 toxicity. Smaller prostate volumes have a minor protective effect on late Grade 2 GU toxicity.
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Affiliation(s)
- Ashley Li Kuan Ong
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore,Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia,Corresponding author at: Division of Radiation Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore 169610, Singapore
| | - Kellie Knight
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia
| | - Vanessa Panettieri
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia,Central Clinical School, Monash University, Melbourne, VIC, Australia,Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Mathew Dimmock
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia,School of Allied Health Professions, Keele University, Staffordshire, UK
| | | | - Hong Qi Tan
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - Caroline Wright
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia
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Ong ALK, Knight K, Panettieri V, Dimmock M, Tuan JKL, Tan HQ, Wright C. Predictive modelling for late rectal and urinary toxicities after prostate radiotherapy using planned and delivered dose. Front Oncol 2022; 12:1084311. [PMID: 36591496 PMCID: PMC9800591 DOI: 10.3389/fonc.2022.1084311] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 11/30/2022] [Indexed: 12/23/2022] Open
Abstract
Background and purpose Normal tissue complication probability (NTCP) parameters derived from traditional 3D plans may not be ideal in defining toxicity outcomes for modern radiotherapy techniques. This study aimed to derive parameters of the Lyman-Kutcher-Burman (LKB) NTCP model using prospectively scored clinical data for late gastrointestinal (GI) and genitourinary (GU) toxicities for high-risk prostate cancer patients treated using volumetric-modulated-arc-therapy (VMAT). Dose-volume-histograms (DVH) extracted from planned (DP) and accumulated dose (DA) were used. Material and methods DP and DA obtained from the DVH of 150 prostate cancer patients with pelvic-lymph-nodes irradiation treated using VMAT were used to generate LKB-NTCP parameters using maximum likelihood estimations. Defined GI and GU toxicities were recorded up to 3-years post RT follow-up. Model performance was measured using Hosmer-Lemeshow goodness of fit test and the mean area under the receiver operating characteristics curve (AUC). Bootstrapping method was used for internal validation. Results For mild-severe (Grade ≥1) GI toxicity, the model generated similar parameters based on DA and DP DVH data (DA-D50:71.6 Gy vs DP-D50:73.4; DA-m:0.17 vs DP-m:0.19 and DA/P-n 0.04). The 95% CI for DA-D50 was narrower and achieved an AUC of >0.6. For moderate-severe (Grade ≥2) GI toxicity, DA-D50 parameter was higher and had a narrower 95% CI (DA-D50:77.9 Gy, 95% CI:76.4-79.6 Gy vs DP-D50:74.6, 95% CI:69.1-85.4 Gy) with good model performance (AUC>0.7). For Grade ≥1 late GU toxicity, D50 and n parameters for DA and DP were similar (DA-D50: 58.8 Gy vs DP-D50: 59.5 Gy; DA-n: 0.21 vs DP-n: 0.19) with a low AUC of<0.6. For Grade ≥2 late GU toxicity, similar NTCP parameters were attained from DA and DP DVH data (DA-D50:81.7 Gy vs DP-D50:81.9 Gy; DA-n:0.12 vs DP-n:0.14) with an acceptable AUCs of >0.6. Conclusions The achieved NTCP parameters using modern RT techniques and accounting for organ motion differs from QUANTEC reported parameters. DA-D50 of 77.9 Gy for GI and DA/DP-D50 of 81.7-81.9 Gy for GU demonstrated good predictability in determining the risk of Grade ≥2 toxicities especially for GI derived D50 and are recommended to incorporate as part of the DV planning constraints to guide dose escalation strategies while minimising the risk of toxicity.
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Affiliation(s)
- Ashley Li Kuan Ong
- Division of Radiation Oncology, National Cancer Centre, Singapore, Singapore,Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia,*Correspondence: Ashley Li Kuan Ong,
| | - Kellie Knight
- Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia
| | - Vanessa Panettieri
- Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia,Alfred Health Radiation Oncology, Alfred Hospital, Melbourne, VIC, Australia
| | - Mathew Dimmock
- Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia,School of Allied Health Professions, Keele University, Staffordshire, United Kingdom
| | | | - Hong Qi Tan
- Division of Radiation Oncology, National Cancer Centre, Singapore, Singapore
| | - Caroline Wright
- Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia
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Brink A, Stewart K, Hargrave C. Evaluation of dose accumulation methods and workflows utilising cone beam computed tomography images. J Med Radiat Sci 2022; 70 Suppl 2:26-36. [PMID: 36168134 PMCID: PMC10122928 DOI: 10.1002/jmrs.622] [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: 02/09/2022] [Accepted: 09/13/2022] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Various adaptive radiation therapy (ART) methods have emerged, with little consensus amongst the literature as to which is most appropriate. This study aimed to compare dose mapping (DM) versus Monte Carlo recalculation (MCR), using cone beam computed tomography (CBCT) images when utilised in automated ART dose accumulation workflows in the MIM Maestro software package. METHODS The treatment plans for 38 cancer patients (19 prostate and 19 head and neck cases) were used to perform DM or MCR retrospectively upon CBCTs acquired during treatment, which were then deformably registered to the planning CT (DR-pCT) to facilitate dose accumulation. Dose-volume and region-of-interest data were extracted for the planning target volumes and organs at risk. Intraclass correlation (ICC) values and Bland-Altman plots were utilised to compare DM versus MCR doses on the CBCT images as well as CBCT versus DR-pCT doses. RESULTS When comparing DM and MCR on CBCTs, the differences across dose level mean dose differences were mostly within a ±5% level of agreement based on the Bland-Altman plots, with over 67% of ICC values over 0.9 and indicative of good correlation. When these distributions were deformed back to the planning CT, the agreement was reduced considerably, with larger differences (exceeding ±5%) resulting from workflow-related issues. CONCLUSION The results emphasise the need to consider and make adaptations to minimise the effect of workflows on algorithm performance. Manual user intervention, refined departmental protocols and further developments to the MIM Maestro software will enhance the use of this tool.
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Affiliation(s)
- Amelia Brink
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Radiation Oncology, Royal Brisbane and Women's Hospital (RBWH), Metro North Health Service District, Herston, Queensland, Australia
| | - Kate Stewart
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Radiation Oncology, Royal Brisbane and Women's Hospital (RBWH), Metro North Health Service District, Herston, Queensland, Australia
| | - Catriona Hargrave
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia.,Radiation Oncology PAH - Raymond Terrace Campus, Division of Cancer Services, Metro South Health Service District, South Brisbane, Queensland, Australia
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Ong A, Knight K, Panettieri V, Dimmock M, Tuan JKL, Tan HQ, Master Z, Wright C. Application of an automated dose accumulation workflow in high-risk prostate cancer - validation and dose-volume analysis between planned and delivered dose. Med Dosim 2021; 47:92-97. [PMID: 34740517 DOI: 10.1016/j.meddos.2021.09.004] [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: 05/21/2021] [Revised: 07/28/2021] [Accepted: 09/09/2021] [Indexed: 10/19/2022]
Abstract
Inter-fraction organ variations cause deviations between planned and delivered doses in patients receiving radiotherapy for prostate cancer. This study compared planned (DP) vs accumulated doses (DA) obtained from daily cone-beam computed tomography (CBCT) scans in high-risk- prostate cancer with pelvic lymph nodes irradiation. An intensity-based deformable image registration algorithm used to estimate contours for DA was validated using geometrical agreement between radiation oncologist's and deformable image registration algorithm propagated contours. Spearman rank correlations (rs) between geometric measures and changes in organ volumes were evaluated for 20 cases. Dose-volume (DV) differences between DA and DP were compared (Wilcoxon rank test, p < 0.05). A novel region-of-interest (ROI) method was developed and mean doses were analyzed. Geometrical measures for the prostate and organ-at-risk contours were within clinically acceptable criteria. Inter-group mean (± SD) CBCT volumes for the rectum were larger compared to planning CT (pCT) (51.1 ± 11.3 cm3vs 46.6 ± 16.1 cm3), and were moderately correlated with variations in pCT volumes, rs = 0.663, p < 0.01. Mean rectum DV for DA was higher at V30-40 Gy and lower at V70-75 Gy, p < 0.05. Mean bladder CBCT volumes were smaller compared to pCT (198.8 ± 55 cm3vs 211.5 ± 89.1 cm3), and was moderately correlated with pCT volumes, rs = 0.789, p < 0.01. Bladder DA was higher at V30-65 Gy and lower at V70-75 Gy (p < 0.05). For the ROI method, rectum and bladder DA were lower at 5 to 10 mm (p < 0.01) as compared to DP, whilst bladder DA was higher than DP at 20 to 50 mm (p < 0.01). Generated DA demonstrated significant differences in organ-at-risk doses as compared to DP. A well-constructed workflow incorporating a ROI DV-extraction method has been validated in terms of efficiency and accuracy designed for seamless integration in the clinic to guide future plan adaptation.
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Affiliation(s)
- Ashley Ong
- National Cancer Centre Singapore, Division of Radiation Oncology, Singapore; Monash University, Department of Medical Imaging and Radiation Sciences, Clayton, Australia.
| | - Kellie Knight
- Monash University, Department of Medical Imaging and Radiation Sciences, Clayton, Australia
| | - Vanessa Panettieri
- Monash University, Department of Medical Imaging and Radiation Sciences, Clayton, Australia; Alfred Hospital, Alfred Health Radiation Oncology, Melbourne, Australia
| | - Mathew Dimmock
- Monash University, Department of Medical Imaging and Radiation Sciences, Clayton, Australia
| | | | - Hong Qi Tan
- National Cancer Centre Singapore, Division of Radiation Oncology, Singapore
| | - Zubin Master
- National Cancer Centre Singapore, Division of Radiation Oncology, Singapore
| | - Caroline Wright
- Monash University, Department of Medical Imaging and Radiation Sciences, Clayton, Australia
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Tamihardja J, Cirsi S, Kessler P, Razinskas G, Exner F, Richter A, Polat B, Flentje M. Cone beam CT-based dose accumulation and analysis of delivered dose to the dominant intraprostatic lesion in primary radiotherapy of prostate cancer. Radiat Oncol 2021; 16:205. [PMID: 34702305 PMCID: PMC8549146 DOI: 10.1186/s13014-021-01933-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 10/19/2021] [Indexed: 12/02/2022] Open
Abstract
Background Evaluation of delivered dose to the dominant intraprostatic lesion (DIL) for moderately hypofractionated radiotherapy of prostate cancer by cone beam computed tomography (CBCT)-based dose accumulation and target coverage analysis. Methods Twenty-three patients with localized prostate cancer treated with moderately hypofractionated prostate radiotherapy with simultaneous integrated boost (SIB) between December 2016 and February 2020 were retrospectively analyzed. Included patients were required to have an identifiable DIL on bi-parametric planning magnetic resonance imaging (MRI). After import into the RayStation treatment planning system and application of a step-wise density override, the fractional doses were computed on each CBCT and were consecutively mapped onto the planning CT via a deformation vector field derived from deformable image registration. Fractional doses were accumulated for all CBCTs and interpolated for missing CBCTs, resulting in the delivered dose for PTVDIL, PTVBoost, PTV, and the organs at risk. The location of the index lesions was recorded according to the sector map of the Prostate Imaging Reporting and Data System (PIRADS) Version 2.1. Target coverage of the index lesions was evaluated and stratified for location. Results In total, 338 CBCTs were available for analysis. Dose accumulation target coverage of PTVDIL, PTVBoost, and PTV was excellent and no cases of underdosage in DMean, D95%, D02%, and D98% could be detected. Delivered rectum DMean did not significantly differ from the planned dose. Bladder mean DMean was higher than planned with 19.4 ± 7.4 Gy versus 18.8 ± 7.5 Gy, p < 0.001. The penile bulb showed a decreased delivered mean DMean with 29.1 ± 14.0 Gy versus 29.8 ± 14.4 Gy, p < 0.001. Dorsal DILs, defined as DILs in the posterior medial peripheral zone of the prostate, showed a significantly lower delivered dose with a mean DMean difference of 2.2 Gy (95% CI 1.3–3.1 Gy, p < 0.001) compared to ventral lesions. Conclusions CBCT-based dose accumulation showed an adequate delivered dose to the dominant intraprostatic lesion and organs at risk within planning limits. Cautious evaluation of the target coverage for index lesions adjacent to the rectum is warranted to avoid underdosage.
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Affiliation(s)
- Jörg Tamihardja
- Department of Radiation Oncology, University of Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany.
| | - Sinan Cirsi
- Department of Radiation Oncology, University of Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
| | - Patrick Kessler
- Department of Radiation Oncology, University of Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
| | - Gary Razinskas
- Department of Radiation Oncology, University of Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
| | - Florian Exner
- Department of Radiation Oncology, University of Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
| | - Anne Richter
- Department of Radiation Oncology, University of Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
| | - Bülent Polat
- Department of Radiation Oncology, University of Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
| | - Michael Flentje
- Department of Radiation Oncology, University of Wuerzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
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