1
|
Paronetto C, den Toom W, Milder MTW, van Norden Y, Baak R, Heijmen BJM, Méndez Romero A. Inter- and intrafraction dose variations in robotic stereotactic body radiation therapy (SBRT) for perihilar cholangiocarcinoma in the prospective phase I STRONG trial. Front Oncol 2023; 13:1114737. [PMID: 36969072 PMCID: PMC10032458 DOI: 10.3389/fonc.2023.1114737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/20/2023] [Indexed: 03/11/2023] Open
Abstract
Using fiducial-marker-based robotic respiratory tumor tracking, we treated perihilar cholangiocarcinoma patients in the STRONG trial with 15 daily fractions of 4 Gy. For each of the included patients, in-room diagnostic-quality repeat CTs (rCT) were acquired pre- and post-dose delivery in 6 treatment fractions to analyze inter- and intrafraction dose variations. Planning CTs (pCTs) and rCTs were acquired in expiration breath-hold. Analogous to treatment, spine and fiducials were used to register rCTs with pCTs. In each rCT, all OARs were contoured, and the target was rigidly copied from the pCT based on grey values. The rCTs acquired were used to calculate the doses to be delivered through the treatment-unit settings. On average, target doses in rCTs and pCTs were similar. However, due to target displacements relative to the fiducials in rCTs, 10% of the rCTs showed PTV coverage losses of >10%. Although target coverages had been planned below desired values in order to protect OARs, many pre-rCTs contained OAR constraint violations: 44.4% for the 6 major constraints. Most OAR dose differences between pre- and post-rCTs were not statistically significant. The dose deviations observed in repeat CTs represent opportunities for more advanced adaptive approaches to enhancing SBRT treatment quality.
Collapse
Affiliation(s)
- Chiara Paronetto
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Radiotherapy, Istituto Oncologico Veneto (IOV), Padova, Italy
- *Correspondence: Chiara Paronetto, ,
| | - Wilhelm den Toom
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Maaike T. W. Milder
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Yvette van Norden
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Rogier Baak
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Ben J. M. Heijmen
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Alejandra Méndez Romero
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| |
Collapse
|
2
|
Rong Y, Ding X, Daly ME. Hypofractionation and SABR: 25 years of evolution in medical physics and a glimpse of the future. Med Phys 2023. [PMID: 36756953 DOI: 10.1002/mp.16270] [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: 12/13/2022] [Revised: 12/13/2022] [Accepted: 01/30/2023] [Indexed: 02/10/2023] Open
Abstract
As we were invited to write an article for celebrating the 50th Anniversary of Medical Physics journal, on something historically significant, commemorative, and exciting happening in the past decades, the first idea came to our mind is the fascinating radiotherapy paradigm shift from conventional fractionation to hypofractionation and stereotactic ablative radiotherapy (SABR). It is historically and clinically significant since as we all know this RT treatment revolution not only reduces treatment duration for patients, but also improves tumor control and cancer treatment outcomes. It is also commemorative and exciting for us medical physicists since the technology development in medical physics has been the main driver for the success of this treatment regimen which requires high precision and accuracy throughout the entire treatment planning and delivery. This article provides an overview of the technological development and clinical trials evolvement in the past 25 years for hypofractionation and SABR, with an outlook to the future improvement.
Collapse
Affiliation(s)
- Yi Rong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Xuanfeng Ding
- Department of Radiation Oncology, Corewell Health, William Beaumont University Hospital, Royal Oak, Michigan, USA
| | - Megan E Daly
- Department of Radiation Oncology, University of California Davis Comprehensive Cancer Center, Sacramento, California, USA
| |
Collapse
|
3
|
Ibrahim MK, Bashar BS, Al-Nabi NRA, Ismail MM. Robot-assisted for medical surgery: A literature review. AIP CONFERENCE PROCEEDINGS 2023. [DOI: 10.1063/5.0119586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
|
4
|
Ogawa A, Nakamura M, Iramina H, Yoshimura M, Mizowaki T. Potential utility of cone-beam CT-guided adaptive radiotherapy under end-exhalation breath-hold conditions for pancreatic cancer. J Appl Clin Med Phys 2022; 24:e13827. [PMID: 36316795 PMCID: PMC9924116 DOI: 10.1002/acm2.13827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/15/2022] [Accepted: 10/07/2022] [Indexed: 02/14/2023] Open
Abstract
PURPOSE The purpose of this study was to demonstrate the potential utility of cone-beam computed tomography (CBCT)-guided online adaptive radiotherapy (ART) under end-exhalation breath-hold (EE-BH) conditions for pancreatic cancer (PC). METHODS Eleven PC patients who underwent 15-fraction volumetric-modulated arc therapy under EE-BH conditions were included. Planning CT images and daily 165 CBCT images were imported into a dedicated treatment planning system. The prescription dose was set to 48 Gy in 15 fractions. The reference plan was automatically generated along with predefined clinical goals. After segmentation was completed on CBCT images, two different plans were generated: One was an adapted (ADP) plan in which re-optimization was performed on the anatomy of the day, and the other was a scheduled (SCH) plan, which was the same as the reference plan. The dose distributions calculated using the synthetic CT created from both planning CT and CBCT were compared between the two plans. Independent calculation-based quality assurance was also performed for the ADP plans, with a gamma passing rate of 3%/3 mm. RESULTS All clinical goals were successfully achieved during the reference plan generation. Of the 165 sessions, gross tumor volume D98% and clinical target volume D98% were higher in 100 (60.1%) and 122 (74.0%) ADP fractions. In each fraction, the V3 Gy < 1 cm3 of the stomach and duodenum was violated in 47 (28.5%) and 48 (29.1%), respectively, of the SCH fractions, whereas no violations were observed in the ADP fractions. There were statistically significant differences in the dose-volume indices between the SCH and ADP fractions (p < 0.05). The gamma passing rates were above 95% in all ADP fractions. CONCLUSIONS The CBCT-guided online ART under EE-BH conditions successfully reduced the dose to the stomach and duodenum while maintaining target coverage.
Collapse
Affiliation(s)
- Ayaka Ogawa
- Department of Radiation Oncology and Image‐Applied TherapyGraduate School of MedicineKyoto UniversityKyotoJapan
| | - Mitsuhiro Nakamura
- Department of Radiation Oncology and Image‐Applied TherapyGraduate School of MedicineKyoto UniversityKyotoJapan,Division of Medical PhysicsDepartment of Information Technology and Medical EngineeringHuman Health SciencesGraduate School of MedicineKyoto UniversityKyotoJapan
| | - Hiraku Iramina
- Department of Radiation Oncology and Image‐Applied TherapyGraduate School of MedicineKyoto UniversityKyotoJapan
| | - Michio Yoshimura
- Department of Radiation Oncology and Image‐Applied TherapyGraduate School of MedicineKyoto UniversityKyotoJapan
| | - Takashi Mizowaki
- Department of Radiation Oncology and Image‐Applied TherapyGraduate School of MedicineKyoto UniversityKyotoJapan
| |
Collapse
|
5
|
Gong W, Yao Y, Ni J, Jiang H, Jia L, Xiong W, Zhang W, He S, Wei Z, Zhou J. Deep learning-based low-dose CT for adaptive radiotherapy of abdominal and pelvic tumors. Front Oncol 2022; 12:968537. [PMID: 36059630 PMCID: PMC9436420 DOI: 10.3389/fonc.2022.968537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 07/28/2022] [Indexed: 11/15/2022] Open
Abstract
The shape and position of abdominal and pelvic organs change greatly during radiotherapy, so image-guided radiation therapy (IGRT) is urgently needed. The world’s first integrated CT-linac platform, equipped with fan beam CT (FBCT), can provide a diagnostic-quality FBCT for achieve adaptive radiotherapy (ART). However, CT scans will bring the risk of excessive scanning radiation dose. Reducing the tube current of the FBCT system can reduce the scanning dose, but it will lead to serious noise and artifacts in the reconstructed images. In this study, we proposed a deep learning method, Content-Noise Cycle-Consistent Generative Adversarial Network (CNCycle-GAN), to improve the image quality and CT value accuracy of low-dose FBCT images to meet the requirements of adaptive radiotherapy. We selected 76 patients with abdominal and pelvic tumors who received radiation therapy. The patients received one low-dose CT scan and one normal-dose CT scan in IGRT mode during different fractions of radiotherapy. The normal dose CT images (NDCT) and low dose CT images (LDCT) of 70 patients were used for network training, and the remaining 6 patients were used to validate the performance of the network. The quality of low-dose CT images after network restoration (RCT) were evaluated in three aspects: image quality, automatic delineation performance and dose calculation accuracy. Taking NDCT images as a reference, RCT images reduced MAE from 34.34 ± 5.91 to 20.25 ± 4.27, PSNR increased from 34.08 ± 1.49 to 37.23 ± 2.63, and SSIM increased from 0.92 ± 0.08 to 0.94 ± 0.07. The P value is less than 0.01 of the above performance indicators indicated that the difference were statistically significant. The Dice similarity coefficients (DCS) between the automatic delineation results of organs at risk such as bladder, femoral heads, and rectum on RCT and the results of manual delineation by doctors both reached 0.98. In terms of dose calculation accuracy, compared with the automatic planning based on LDCT, the difference in dose distribution between the automatic planning based on RCT and the automatic planning based on NDCT were smaller. Therefore, based on the integrated CT-linac platform, combined with deep learning technology, it provides clinical feasibility for the realization of low-dose FBCT adaptive radiotherapy for abdominal and pelvic tumors.
Collapse
Affiliation(s)
- Wei Gong
- Department of Radiation Oncology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yiming Yao
- Department of Radiation Oncology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jie Ni
- Department of Radiation Oncology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hua Jiang
- Department of Radiation Oncology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Lecheng Jia
- Real Time Laboratory, Shenzhen United Imaging Research Institute of Innovative Medical Equipment, Shenzhen, China
| | - Weiqi Xiong
- Radiotherapy Business Unit, Shanghai United Imaging Healthcare Co., Ltd., Shanghai, China
| | - Wei Zhang
- Radiotherapy Business Unit, Shanghai United Imaging Healthcare Co., Ltd., Shanghai, China
| | - Shumeng He
- IRT Laboratory, United Imaging Research Institute of Intelligent Imaging, Beijing, China
| | - Ziquan Wei
- Real Time Laboratory, Shenzhen United Imaging Research Institute of Innovative Medical Equipment, Shenzhen, China
- *Correspondence: Ziquan Wei, ; Juying Zhou,
| | - Juying Zhou
- Department of Radiation Oncology, First Affiliated Hospital of Soochow University, Suzhou, China
- *Correspondence: Ziquan Wei, ; Juying Zhou,
| |
Collapse
|
6
|
Milder MT, Magallon-Baro A, den Toom W, de Klerck E, Luthart L, Nuyttens JJ, Hoogeman MS. Technical feasibility of online adaptive stereotactic treatments in the abdomen on a robotic radiosurgery system. Phys Imaging Radiat Oncol 2022; 23:103-108. [PMID: 35928600 PMCID: PMC9344339 DOI: 10.1016/j.phro.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Maaike T.W. Milder
- Corresponding author at: Department of Radiation Oncology, Erasmus MC – Cancer Institute, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands.
| | | | | | | | | | | | | |
Collapse
|
7
|
Magallon-Baro A, Milder MTW, Granton PV, den Toom W, Nuyttens JJ, Hoogeman MS. Impact of Using Unedited CT-Based DIR-Propagated Autocontours on Online ART for Pancreatic SBRT. Front Oncol 2022; 12:910792. [PMID: 35756687 PMCID: PMC9213731 DOI: 10.3389/fonc.2022.910792] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/19/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose To determine the dosimetric impact of using unedited autocontours in daily plan adaptation of patients with locally advanced pancreatic cancer (LAPC) treated with stereotactic body radiotherapy using tumor tracking. Materials and Methods The study included 98 daily CT scans of 35 LAPC patients. All scans were manually contoured (MAN), and included the PTV and main organs-at-risk (OAR): stomach, duodenum and bowel. Precision and MIM deformable image registration (DIR) methods followed by contour propagation were used to generate autocontour sets on the daily CT scans. Autocontours remained unedited, and were compared to MAN on the whole organs and at 3, 1 and 0.5 cm from the PTV. Manual and autocontoured OAR were used to generate daily plans using the VOLO™ optimizer, and were compared to non-adapted plans. Resulting planned doses were compared based on PTV coverage and OAR dose-constraints. Results Overall, both algorithms reported a high agreement between unclipped MAN and autocontours, but showed worse results when being evaluated on the clipped structures at 1 cm and 0.5 cm from the PTV. Replanning with unedited autocontours resulted in better OAR sparing than non-adapted plans for 95% and 84% plans optimized using Precision and MIM autocontours, respectively, and obeyed OAR constraints in 64% and 56% of replans. Conclusion For the majority of fractions, manual correction of autocontours could be avoided or be limited to the region closest to the PTV. This practice could further reduce the overall timings of adaptive radiotherapy workflows for patients with LAPC.
Collapse
Affiliation(s)
- Alba Magallon-Baro
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Maaike T W Milder
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Patrick V Granton
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Wilhelm den Toom
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Joost J Nuyttens
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Mischa S Hoogeman
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| |
Collapse
|
8
|
Jing S, Jiang C, Ji X, Qiu X, Li J, Sun X, Zhu X. Study on Motion Management of Pancreatic Cancer Treated by CyberKnife. Front Oncol 2021; 11:767832. [PMID: 34926273 PMCID: PMC8674533 DOI: 10.3389/fonc.2021.767832] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/08/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose We investigated the movement characteristics of pancreas and the clinical accuracy of tracking pancreas with the Synchrony Respiratory Tracking System (SRTS) during the CyberKnife treatment. These data provide a clinical data basis for the expansion margins of pancreatic tumor target. Methods and Materials Forty-two patients with pancreatic cancer treated by CyberKnife were retrospectively studied. The pancreatic displacement calculated from the x-ray images collected during the time interval between two consecutive movements constituted a data set. Results The total mean motion amplitudes and standard deviations of pancreatic tumors in SI, LR, AP, and radial directions were 3.66 ± 1.71 mm, 0.97 ± 0.62 mm, 1.52 ± 1.02 mm, and 1.36 ± 0.49 mm, respectively. The overall mean correlation errors and standard deviations were 0.82 ± 0.46 mm, 0.47 ± 0.33 mm, 0.41 ± 0.24 mm, and 0.98 ± 0.37 mm, respectively. The overall mean prediction errors and standard deviations were 0.57 ± 0.14 mm, 0.62 ± 0.28 mm, 0.39 ± 0.17 mm, and 1.58 ± 0.36 mm, respectively. The correlation errors and prediction errors of pancreatic tumors at different anatomical positions in SI, LR, and AP directions were statistically significant (p < 0.05). Conclusions The tumor motion amplitude, the tumor location, and the treatment time are the main factors affecting the tracking accuracy. The pancreatic tumors at different anatomical locations should be treated differently to ensure sufficient dose coverage of the pancreatic target area.
Collapse
Affiliation(s)
- Shenghua Jing
- Department of Radiation Oncology, East Region Military Command General Hospital, Nanjing, China
| | - Changchen Jiang
- Department of Radiation Oncology, East Region Military Command General Hospital, Nanjing, China
| | - Xiaoqin Ji
- Department of Radiation Oncology, East Region Military Command General Hospital, Nanjing, China
| | - Xiangnan Qiu
- Department of Radiation Oncology, East Region Military Command General Hospital, Nanjing, China
| | - Jing Li
- Department of Radiation Oncology, East Region Military Command General Hospital, Nanjing, China
| | - Xiangdong Sun
- Department of Radiation Oncology, East Region Military Command General Hospital, Nanjing, China
| | - Xixu Zhu
- Department of Radiation Oncology, East Region Military Command General Hospital, Nanjing, China
| |
Collapse
|
9
|
Lam BQ, Srivastava R, Morvant J, Shankar S, Srivastava RK. Association of Diabetes Mellitus and Alcohol Abuse with Cancer: Molecular Mechanisms and Clinical Significance. Cells 2021; 10:cells10113077. [PMID: 34831299 PMCID: PMC8620339 DOI: 10.3390/cells10113077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/28/2021] [Accepted: 11/06/2021] [Indexed: 12/12/2022] Open
Abstract
Diabetes mellitus (DM), one of the metabolic diseases which is characterized by sustained hyperglycemia, is a life-threatening disease. The global prevalence of DM is on the rise, mainly in low- and middle-income countries. Diabetes is a major cause of blindness, heart attacks, kidney failure, stroke, and lower limb amputation. Type 2 diabetes mellitus (T2DM) is a form of diabetes that is characterized by high blood sugar and insulin resistance. T2DM can be prevented or delayed by a healthy diet, regular physical activity, maintaining normal body weight, and avoiding alcohol and tobacco use. Ethanol and its metabolites can cause differentiation defects in stem cells and promote inflammatory injury and carcinogenesis in several tissues. Recent studies have suggested that diabetes can be treated, and its consequences can be avoided or delayed with proper management. DM has a greater risk for several cancers, such as breast, colorectal, endometrial, pancreatic, gallbladder, renal, and liver cancer. The incidence of cancer is significantly higher in patients with DM than in those without DM. In addition to DM, alcohol abuse is also a risk factor for many cancers. We present a review of the recent studies investigating the association of both DM and alcohol abuse with cancer incidence.
Collapse
Affiliation(s)
- Bao Q. Lam
- Stanley S. Scott Cancer Center, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA; (B.Q.L.); (S.S.)
| | - Rashmi Srivastava
- Department of Pharmacology, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA;
| | - Jason Morvant
- Department of Surgery, Ochsner Health System, 120 Ochsner Boulevard, Gretna, LA 70056, USA;
- A.B. Freeman School of Business, Tulane University, New Orleans, LA 70118, USA
| | - Sharmila Shankar
- Stanley S. Scott Cancer Center, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA; (B.Q.L.); (S.S.)
- Department of Genetics, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA
- John W. Deming Department of Medicine, School of Medicine, Tulane University, New Orleans, LA 70112, USA
- Southeast Louisiana Veterans Health Care System, New Orleans, LA 70119, USA
| | - Rakesh K. Srivastava
- Stanley S. Scott Cancer Center, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA; (B.Q.L.); (S.S.)
- A.B. Freeman School of Business, Tulane University, New Orleans, LA 70118, USA
- Department of Genetics, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA
- Correspondence:
| |
Collapse
|
10
|
Kord M, Kluge A, Kufeld M, Kalinauskaite G, Loebel F, Stromberger C, Budach V, Gebauer B, Acker G, Senger C. Risks and Benefits of Fiducial Marker Placement in Tumor Lesions for Robotic Radiosurgery: Technical Outcomes of 357 Implantations. Cancers (Basel) 2021; 13:cancers13194838. [PMID: 34638321 PMCID: PMC8508340 DOI: 10.3390/cancers13194838] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/19/2021] [Accepted: 09/22/2021] [Indexed: 12/15/2022] Open
Abstract
Simple Summary Robotic radiosurgery (RRS) allows for the accurate treatment of primary tumors or metastases with high single doses. However, organ motion during or between fractions can lead to imprecise irradiation. We sought to evaluate the risks and advantages of fiducial marker (FM) implantation regarding clinical complications, marker migration, and motion amplitude. Complications were most common in Synchrony®-tracked lesions affected by respiratory motion, particularly lung lesions. Pneumothoraces and pulmonary bleeding were the most common complications. An increased complication rate was associated with concomitant biopsy sampling and FM implantation. Most FM migration observed in this study occurred after CT-guided placements and clinical FM insertions. The largest motion amplitudes were observed in hepatic and lower lung lobe lesions. This study highlights the benefits of marker implantation, especially in lesions with a large motion amplitude, including hepatic lesions and lesions of the lower lobe of the lung located >100.0 mm from the spine. Abstract Fiducial markers (FM) inserted into tumors increase the precision of irradiation during robotic radiosurgery (RRS). This retrospective study evaluated the clinical complications, marker migration, and motion amplitude of FM implantations by analyzing 288 cancer patients (58% men; 63.1 ± 13.0 years) who underwent 357 FM implantations prior to RRS with CyberKnife, between 2011 and 2019. Complications were classified according to the Society of Interventional Radiology (SIR) guidelines. The radial motion amplitude was calculated for tumors that moved with respiration. A total of 725 gold FM was inserted. SIR-rated complications occurred in 17.9% of all procedures. Most complications (32.0%, 62/194 implantations) were observed in Synchrony®-tracked lesions affected by respiratory motion, particularly in pulmonary lesions (46.9% 52/111 implantations). Concurrent biopsy sampling was associated with a higher complication rate (p = 0.001). FM migration occurred in 3.6% after CT-guided and clinical FM implantations. The largest motion amplitudes were observed in hepatic (20.5 ± 11.0 mm) and lower lung lobe (15.4 ± 10.5 mm) lesions. This study increases the awareness of the risks of FM placement, especially in thoracic lesions affected by respiratory motion. Considering the maximum motion amplitude, FM placement remains essential in hepatic and lower lung lobe lesions located >100.0 mm from the spine.
Collapse
Affiliation(s)
- Melina Kord
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (A.K.); (G.K.); (C.S.); (V.B.)
- Charité CyberKnife Center, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (F.L.); (G.A.)
| | - Anne Kluge
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (A.K.); (G.K.); (C.S.); (V.B.)
- Charité CyberKnife Center, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (F.L.); (G.A.)
| | - Markus Kufeld
- Charité CyberKnife Center, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (F.L.); (G.A.)
| | - Goda Kalinauskaite
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (A.K.); (G.K.); (C.S.); (V.B.)
- Charité CyberKnife Center, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (F.L.); (G.A.)
| | - Franziska Loebel
- Charité CyberKnife Center, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (F.L.); (G.A.)
- Department of Neurosurgery, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany
| | - Carmen Stromberger
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (A.K.); (G.K.); (C.S.); (V.B.)
- Charité CyberKnife Center, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (F.L.); (G.A.)
| | - Volker Budach
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (A.K.); (G.K.); (C.S.); (V.B.)
- Charité CyberKnife Center, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (F.L.); (G.A.)
| | - Bernhard Gebauer
- Department of Radiology, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany;
| | - Gueliz Acker
- Charité CyberKnife Center, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (F.L.); (G.A.)
- Department of Neurosurgery, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health at Charité Universitätsmedizin Berlin, BIH Acadamy, Clinician Scientist Program, Charitéplatz 1, 10117 Berlin, Germany
| | - Carolin Senger
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (A.K.); (G.K.); (C.S.); (V.B.)
- Charité CyberKnife Center, Augustenburger Platz 1, 13353 Berlin, Germany; (M.K.); (F.L.); (G.A.)
- Correspondence: ; Tel.: +49-30-450-557221
| |
Collapse
|
11
|
Magallon-Baro A, Milder MTW, Granton PV, Nuyttens JJ, Hoogeman MS. Comparison of Daily Online Plan Adaptation Strategies for a Cohort of Pancreatic Cancer Patients Treated with SBRT. Int J Radiat Oncol Biol Phys 2021; 111:208-219. [PMID: 33811976 DOI: 10.1016/j.ijrobp.2021.03.050] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 03/01/2021] [Accepted: 03/26/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To study the trade-offs of three online strategies to adapt treatment plans of patients with locally advanced pancreatic carcinoma (LAPC) treated using the CyberKnife with tumor tracking. METHODS AND MATERIALS A total of 35 planning computed tomography scans and 98 daily in-room computed tomography scans were collected from 35 patients with LAPC. Planned dose distributions, optimized with VOLO, were evaluated on manually contoured daily anatomies to collect daily doses. Three strategies were tested to adapt treatment plans: (1) unrestricted full replanning using a patient-specific plan template, (2) time-restricted replanning on organs at risk (OARs) within 3 cm from the planning target volume (PTV) structure, and (3) dose realignment optimization to stay within OAR constraints. Dose distributions resulting from each plan adaptation strategy were dosimetrically compared by means of gross tumor volume (GTV), PTV coverage, and OAR tolerances. RESULTS Planned doses did not result in dose-constraint violations for 28 of 98 daily anatomies. None of the suggested plan adaptation strategies improved planned doses significantly for this subset. For 70 of the 98 reported violations, the median (interquartile range) PTV coverage of the planned dose was 84% (76% to 86%). After plan adaptation, unrestricted replanning achieved clinically acceptable plans in 93% of these fractions, time-restricted replanning in 90%, and dose realignment in 74%, at median computational times of 8.5, 3, and 0.5 minutes. Over all 98 fractions, PTV coverage was reduced: -1% (-3% to 1%), -2% (-5% to 0%), and -2% (-8% to 0%) after each strategy, respectively. In 3 of 70 fractions, none of the suggested strategies achieved clinically acceptable OAR dose volumes. CONCLUSIONS Unrestricted replanning was the most time-consuming method but reached the highest number of successfully adapted plans. Time-restricted replanning and dose realignment resulted in a high number of plans within dose constraints. Depending on the resources available, an adaptive strategy can be selected for each patient to address the specific anatomic challenges on the treatment day. The increase in the complexity of the strategy corresponds with an increasing number of successfully adapted plans.
Collapse
Affiliation(s)
- Alba Magallon-Baro
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands.
| | - Maaike T W Milder
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Patrick V Granton
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Joost J Nuyttens
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Mischa S Hoogeman
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
12
|
Hoekstra N, Habraken S, Swaak-Kragten A, Pignol JP, Hoogeman M. Fiducial marker motion relative to the tumor bed has a significant impact on PTV margins in partial breast irradiation. Radiother Oncol 2021; 163:1-6. [PMID: 34329655 DOI: 10.1016/j.radonc.2021.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/28/2021] [Accepted: 07/19/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION With the introduction of accelerated partial breast irradiation (APBI) and the trend of reducing the number of fractions, the geometric accuracy of treatment delivery becomes critical. APBI patient setup is often based on fiducials, as the seroma is frequently not visible on pretreatment imaging. We assessed the motion of fiducials relative to the tumor bed between planning CT and treatment, and calculated margins to compensate for this motion. METHODS A cohort of seventy patients treated with APBI on a Cyberknife was included. Planning and in-room pretreatment CT scans were registered on the tumor bed. Residual motion of the centers of mass of surgical clips and interstitial gold markers was calculated. We calculated the margins required per desired percentage of patients with 100% CTV coverage, and the systematic and random errors for fiducial motion. RESULTS For a single fraction treatment, a margin of 1.8 mm would ensure 100% CTV coverage in 90% of patients when using surgical clips for patient set-up. When using interstitial markers, the margin should be 2.2 mm. The systematic and random errors were 0.46 mm for surgical clip motion and 0.60 mm for interstitial marker motion. No clinical factors were found predictive for fiducial motion. CONCLUSIONS Fiducial motion relative to the tumor bed between planning CT and APBI treatment is non-negligible and should be included in the PTV margin calculation to prevent geographical miss. Systematic and random errors of fiducial motion were combined with other geometric uncertainties to calculate comprehensive PTV margins for different treatment techniques.
Collapse
Affiliation(s)
- Nienke Hoekstra
- Erasmus MC Cancer Institute, Department of Radiation Oncology, Rotterdam, The Netherlands.
| | - Steven Habraken
- Erasmus MC Cancer Institute, Department of Radiation Oncology, Rotterdam, The Netherlands
| | | | | | - Mischa Hoogeman
- Erasmus MC Cancer Institute, Department of Radiation Oncology, Rotterdam, The Netherlands
| |
Collapse
|
13
|
Giżyńska MK, Rossi L, den Toom W, Milder MTW, de Vries KC, Nuyttens J, Heijmen BJM. Largely reduced OAR doses, and planning and delivery times for challenging robotic SBRT cases, obtained with a novel optimizer. J Appl Clin Med Phys 2021; 22:35-47. [PMID: 33475227 PMCID: PMC7984474 DOI: 10.1002/acm2.13172] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 12/21/2020] [Accepted: 12/25/2020] [Indexed: 11/12/2022] Open
Abstract
Recently, VOLO™ was introduced as a new optimizer for CyberKnife® planning. In this study, we investigated possibilities to improve treatment plans for MLC-based prostate SBRT with enhanced peripheral zone dose while sparing the urethra, and central lung tumors, compared to existing Sequential Optimization (SO). The primary focus was on reducing OAR doses. For 25 prostate and 25 lung patients treated with SO plans, replanning with VOLO™ was performed with the same planning constraints. For equal PTV coverage, almost all OAR plan parameters were improved with VOLO™. For prostate patients, mean rectum and bladder doses were reduced by 34.2% (P < 0.001) and 23.5% (P < 0.001), with reductions in D0.03cc of 3.9%, 11.0% and 3.1% for rectum, mucosa and bladder (all P ≤ 0.01). Urethra D5% and D10% were 3.8% and 3.0% lower (P ≤ 0.002). For lung patients, esophagus, main bronchus, trachea, and spinal cord D0.03cc was reduced by 18.9%, 11.1%, 16.1%, and 13.2%, respectively (all P ≤ 0.01). Apart from the dosimetric advantages of VOLO™ planning, average reductions in MU, numbers of beams and nodes for prostate/lung were 48.7/32.8%, 26.5/7.9% and 13.4/7.9%, respectively (P ≤ 0.003). VOLO™ also resulted in reduced delivery times with mean/max reductions of: 27/43% (prostate) and 15/41% (lung), P < 0.001. Planning times reduced from 6 h to 1.1 h and from 3 h to 1.7 h for prostate and lung, respectively. The new VOLO™ planning was highly superior to SO planning in terms of dosimetric plan quality, and planning and delivery times.
Collapse
Affiliation(s)
- Marta K Giżyńska
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Dr.Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands
| | - Linda Rossi
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Dr.Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands
| | - Wilhelm den Toom
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Dr.Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands
| | - Maaike T W Milder
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Dr.Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands
| | - Kim C de Vries
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Dr.Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands
| | - Joost Nuyttens
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Dr.Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands
| | - Ben J M Heijmen
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Dr.Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands
| |
Collapse
|
14
|
Loi M, Magallon-Baro A, Suker M, Van Eijck C, Hoogeman M, Nuyttens JJ. Daily dose to organs at risk predicts acute toxicity in pancreatic stereotactic radiotherapy. Acta Oncol 2020; 59:944-948. [PMID: 32207351 DOI: 10.1080/0284186x.2020.1742931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Mauro Loi
- Department of Radiotherapy, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Alba Magallon-Baro
- Department of Radiotherapy, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Mustafa Suker
- Department of Surgery, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Casper Van Eijck
- Department of Surgery, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Mischa Hoogeman
- Department of Radiotherapy, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Joost J. Nuyttens
- Department of Radiotherapy, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| |
Collapse
|
15
|
Grégoire V, Guckenberger M, Haustermans K, Lagendijk JJW, Ménard C, Pötter R, Slotman BJ, Tanderup K, Thorwarth D, van Herk M, Zips D. Image guidance in radiation therapy for better cure of cancer. Mol Oncol 2020; 14:1470-1491. [PMID: 32536001 PMCID: PMC7332209 DOI: 10.1002/1878-0261.12751] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 06/08/2020] [Accepted: 06/08/2020] [Indexed: 12/11/2022] Open
Abstract
The key goal and main challenge of radiation therapy is the elimination of tumors without any concurring damages of the surrounding healthy tissues and organs. Radiation doses required to achieve sufficient cancer-cell kill exceed in most clinical situations the dose that can be tolerated by the healthy tissues, especially when large parts of the affected organ are irradiated. High-precision radiation oncology aims at optimizing tumor coverage, while sparing normal tissues. Medical imaging during the preparation phase, as well as in the treatment room for localization of the tumor and directing the beam, referred to as image-guided radiotherapy (IGRT), is the cornerstone of precision radiation oncology. Sophisticated high-resolution real-time IGRT using X-rays, computer tomography, magnetic resonance imaging, or ultrasound, enables delivery of high radiation doses to tumors without significant damage of healthy organs. IGRT is the most convincing success story of radiation oncology over the last decades, and it remains a major driving force of innovation, contributing to the development of personalized oncology, for example, through the use of real-time imaging biomarkers for individualized dose delivery.
Collapse
Affiliation(s)
- Vincent Grégoire
- Department of Radiation OncologyLéon Bérard Cancer CenterLyonFrance
| | - Matthias Guckenberger
- Department for Radiation OncologyUniversity Hospital ZurichUniversity of ZurichSwitzerland
| | - Karin Haustermans
- Department of Radiation OncologyLeuven Cancer InstituteUniversity Hospital GasthuisbergLeuvenBelgium
| | | | | | - Richard Pötter
- Department of Radiation OncologyMedical UniversityGeneral Hospital of ViennaAustria
| | - Ben J. Slotman
- Department of Radiation OncologyAmsterdam University Medical CentersThe Netherlands
| | - Kari Tanderup
- Department of OncologyAarhus University HospitalDenmark
| | - Daniela Thorwarth
- Section for Biomedical PhysicsDepartment of Radiation OncologyUniversity of TübingenGermany
| | - Marcel van Herk
- Department of Biomedical Engineering and PhysicsCancer Center AmsterdamAmsterdam UMCUniversity of AmsterdamThe Netherlands
- Institute of Cancer SciencesUniversity of ManchesterUK
- Department of Radiotherapy Related ResearchThe Christie NHS Foundation TrustManchesterUK
| | - Daniel Zips
- Department of Radiation OncologyUniversity of TübingenGermany
| |
Collapse
|
16
|
Zaffino P, Moccia S, De Momi E, Spadea MF. A Review on Advances in Intra-operative Imaging for Surgery and Therapy: Imagining the Operating Room of the Future. Ann Biomed Eng 2020; 48:2171-2191. [PMID: 32601951 DOI: 10.1007/s10439-020-02553-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 06/17/2020] [Indexed: 12/19/2022]
Abstract
With the advent of Minimally Invasive Surgery (MIS), intra-operative imaging has become crucial for surgery and therapy guidance, allowing to partially compensate for the lack of information typical of MIS. This paper reviews the advancements in both classical (i.e. ultrasounds, X-ray, optical coherence tomography and magnetic resonance imaging) and more recent (i.e. multispectral, photoacoustic and Raman imaging) intra-operative imaging modalities. Each imaging modality was analyzed, focusing on benefits and disadvantages in terms of compatibility with the operating room, costs, acquisition time and image characteristics. Tables are included to summarize this information. New generation of hybrid surgical room and algorithms for real time/in room image processing were also investigated. Each imaging modality has its own (site- and procedure-specific) peculiarities in terms of spatial and temporal resolution, field of view and contrasted tissues. Besides the benefits that each technique offers for guidance, considerations about operators and patient risk, costs, and extra time required for surgical procedures have to be considered. The current trend is to equip surgical rooms with multimodal imaging systems, so as to integrate multiple information for real-time data extraction and computer-assisted processing. The future of surgery is to enhance surgeons eye to minimize intra- and after-surgery adverse events and provide surgeons with all possible support to objectify and optimize the care-delivery process.
Collapse
Affiliation(s)
- Paolo Zaffino
- Department of Experimental and Clinical Medicine, Universitá della Magna Graecia, Catanzaro, Italy
| | - Sara Moccia
- Department of Information Engineering (DII), Universitá Politecnica delle Marche, via Brecce Bianche, 12, 60131, Ancona, AN, Italy.
| | - Elena De Momi
- Department of Electronics, Information and Bioengineering (DEIB), Politecnico di Milano, Piazza Leonardo da Vinci, 32, 20133, Milano, MI, Italy
| | - Maria Francesca Spadea
- Department of Experimental and Clinical Medicine, Universitá della Magna Graecia, Catanzaro, Italy
| |
Collapse
|
17
|
Schmitt D, Blanck O, Gauer T, Fix MK, Brunner TB, Fleckenstein J, Loutfi-Krauss B, Manser P, Werner R, Wilhelm ML, Baus WW, Moustakis C. Technological quality requirements for stereotactic radiotherapy : Expert review group consensus from the DGMP Working Group for Physics and Technology in Stereotactic Radiotherapy. Strahlenther Onkol 2020; 196:421-443. [PMID: 32211939 PMCID: PMC7182540 DOI: 10.1007/s00066-020-01583-2] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 01/13/2020] [Indexed: 12/25/2022]
Abstract
This review details and discusses the technological quality requirements to ensure the desired quality for stereotactic radiotherapy using photon external beam radiotherapy as defined by the DEGRO Working Group Radiosurgery and Stereotactic Radiotherapy and the DGMP Working Group for Physics and Technology in Stereotactic Radiotherapy. The covered aspects of this review are 1) imaging for target volume definition, 2) patient positioning and target volume localization, 3) motion management, 4) collimation of the irradiation and beam directions, 5) dose calculation, 6) treatment unit accuracy, and 7) dedicated quality assurance measures. For each part, an expert review for current state-of-the-art techniques and their particular technological quality requirement to reach the necessary accuracy for stereotactic radiotherapy divided into intracranial stereotactic radiosurgery in one single fraction (SRS), intracranial fractionated stereotactic radiotherapy (FSRT), and extracranial stereotactic body radiotherapy (SBRT) is presented. All recommendations and suggestions for all mentioned aspects of stereotactic radiotherapy are formulated and related uncertainties and potential sources of error discussed. Additionally, further research and development needs in terms of insufficient data and unsolved problems for stereotactic radiotherapy are identified, which will serve as a basis for the future assignments of the DGMP Working Group for Physics and Technology in Stereotactic Radiotherapy. The review was group peer-reviewed, and consensus was obtained through multiple working group meetings.
Collapse
Affiliation(s)
- Daniela Schmitt
- Klinik für Radioonkologie und Strahlentherapie, National Center for Radiation Research in Oncology (NCRO), Heidelberger Institut für Radioonkologie (HIRO), Universitätsklinikum Heidelberg, Heidelberg, Germany.
| | - Oliver Blanck
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Tobias Gauer
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Michael K Fix
- Abteilung für Medizinische Strahlenphysik und Universitätsklinik für Radio-Onkologie, Inselspital-Universitätsspital Bern, Universität Bern, Bern, Switzerland
| | - Thomas B Brunner
- Universitätsklinik für Strahlentherapie, Universitätsklinikum Magdeburg, Magdeburg, Germany
| | - Jens Fleckenstein
- Klinik für Strahlentherapie und Radioonkologie, Universitätsmedizin Mannheim, Universität Heidelberg, Mannheim, Germany
| | - Britta Loutfi-Krauss
- Klinik für Strahlentherapie und Onkologie, Universitätsklinikum Frankfurt, Frankfurt am Main, Germany
| | - Peter Manser
- Abteilung für Medizinische Strahlenphysik und Universitätsklinik für Radio-Onkologie, Inselspital-Universitätsspital Bern, Universität Bern, Bern, Switzerland
| | - Rene Werner
- Institut für Computational Neuroscience, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Maria-Lisa Wilhelm
- Klinik für Strahlentherapie, Universitätsmedizin Rostock, Rostock, Germany
| | - Wolfgang W Baus
- Klinik für Radioonkologie, CyberKnife- und Strahlentherapie, Universitätsklinikum Köln, Cologne, Germany
| | - Christos Moustakis
- Klinik für Strahlentherapie-Radioonkologie, Universitätsklinikum Münster, Münster, Germany
| |
Collapse
|
18
|
Albertini F, Matter M, Nenoff L, Zhang Y, Lomax A. Online daily adaptive proton therapy. Br J Radiol 2020; 93:20190594. [PMID: 31647313 PMCID: PMC7066958 DOI: 10.1259/bjr.20190594] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 10/15/2019] [Accepted: 10/22/2019] [Indexed: 12/11/2022] Open
Abstract
It is recognized that the use of a single plan calculated on an image acquired some time before the treatment is generally insufficient to accurately represent the daily dose to the target and to the organs at risk. This is particularly true for protons, due to the physical finite range. Although this characteristic enables the generation of steep dose gradients, which is essential for highly conformal radiotherapy, it also tightens the dependency of the delivered dose to the range accuracy. In particular, the use of an outdated patient anatomy is one of the most significant sources of range inaccuracy, thus affecting the quality of the planned dose distribution. A plan should be ideally adapted as soon as anatomical variations occur, ideally online. In this review, we describe in detail the different steps of the adaptive workflow and discuss the challenges and corresponding state-of-the art developments in particular for an online adaptive strategy.
Collapse
Affiliation(s)
| | | | | | - Ye Zhang
- Paul Scherrer Institute, Center for Proton Therapy, Switzerland
| | | |
Collapse
|
19
|
Pezzulla D, Loi M, Suker M, van Eijck C, Nuyttens J. Two cases of Hemosuccus pancreaticus after stereotactic radiotherapy to the pancreas: A case study. Cancer Radiother 2020; 24:60-63. [PMID: 31980360 DOI: 10.1016/j.canrad.2019.09.003] [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: 08/16/2019] [Revised: 09/07/2019] [Accepted: 09/10/2019] [Indexed: 10/25/2022]
Abstract
Hemosuccus Pancreaticus (HP) is a very rare upper gastro-intestinal haemorrhagic event whose causes can be aneurismal lesions, acute and chronic pancreatic inflammatory conditions, and pancreatic masses. We present 2 cases of patients who underwent stereotactic radiotherapy for pancreatic lesions who manifested signs of HP after treatment. Two male patients were diagnosed with an inoperable locally advanced pancreatic cancer and underwent 8 cycles of chemotherapy followed by stereotactic radiotherapy to the pancreatic lesion delivering 40Gy in 8 fractions. The first patient complained of melena and had a necrotic tumoural mass with a new aneurysmal bulge 3 months after the SBRT. A stent was placed in the aneurysmal lesion, however, a few days later, the bleeding occurred again and the patient died. The other patient had local tumour progression 12 months after SBRT with a pancreatic mass eroding the near vessels. He developed a fast and massive bleeding. HP may occur after SBRT. Inflammation of the tumour mass can lead to erosion of the vessels with subsequent bleeding. The radiotherapy treatment may have contributed to the HP genesis. The treatment is complex and consists of the placement of a stent or surgery.
Collapse
Affiliation(s)
- D Pezzulla
- Department of Radiation Oncology, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy.
| | - M Loi
- Radiotherapy Departement Hopital Tenon, Paris, France
| | - M Suker
- Department of Surgery, Erasmus MC University Medical Centre, Groene Hilledijk 301, Rotterdam, Netherlands
| | - C van Eijck
- Department of Surgery, Erasmus MC University Medical Centre, Groene Hilledijk 301, Rotterdam, Netherlands
| | - J Nuyttens
- Department of Radiotherapy, Erasmus MC cancer Centre, Groene Hilledijk 301, Rotterdam, Netherlands
| |
Collapse
|
20
|
Qiao Y, Jagt T, Hoogeman M, Lelieveldt BPF, Staring M. Evaluation of an Open Source Registration Package for Automatic Contour Propagation in Online Adaptive Intensity-Modulated Proton Therapy of Prostate Cancer. Front Oncol 2019; 9:1297. [PMID: 31828037 PMCID: PMC6890846 DOI: 10.3389/fonc.2019.01297] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 11/08/2019] [Indexed: 12/17/2022] Open
Abstract
Objective: Our goal was to investigate the performance of an open source deformable image registration package, elastix, for fast and robust contour propagation in the context of online-adaptive intensity-modulated proton therapy (IMPT) for prostate cancer. Methods: A planning and 7–10 repeat CT scans were available of 18 prostate cancer patients. Automatic contour propagation of repeat CT scans was performed using elastix and compared with manual delineations in terms of geometric accuracy and runtime. Dosimetric accuracy was quantified by generating IMPT plans using the propagated contours expanded with a 2 mm (prostate) and 3.5 mm margin (seminal vesicles and lymph nodes) and calculating dosimetric coverage based on the manual delineation. A coverage of V95% ≥ 98% (at least 98% of the target volumes receive at least 95% of the prescribed dose) was considered clinically acceptable. Results: Contour propagation runtime varied between 3 and 30 s for different registration settings. For the fastest setting, 83 in 93 (89.2%), 73 in 93 (78.5%), and 91 in 93 (97.9%) registrations yielded clinically acceptable dosimetric coverage of the prostate, seminal vesicles, and lymph nodes, respectively. For the prostate, seminal vesicles, and lymph nodes the Dice Similarity Coefficient (DSC) was 0.87 ± 0.05, 0.63 ± 0.18, and 0.89 ± 0.03 and the mean surface distance (MSD) was 1.4 ± 0.5 mm, 2.0 ± 1.2 mm, and 1.5 ± 0.4 mm, respectively. Conclusion: With a dosimetric success rate of 78.5–97.9%, this software may facilitate online adaptive IMPT of prostate cancer using a fast, free and open implementation.
Collapse
Affiliation(s)
- Yuchuan Qiao
- The Division of Image Processing, Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Thyrza Jagt
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Mischa Hoogeman
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Boudewijn P. F. Lelieveldt
- The Division of Image Processing, Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
- Intelligent Systems Department, Faculty of EEMCS, Delft University of Technology, Delft, Netherlands
| | - Marius Staring
- The Division of Image Processing, Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
- Intelligent Systems Department, Faculty of EEMCS, Delft University of Technology, Delft, Netherlands
- Department of Radiotherapy, Leiden University Medical Center, Leiden, Netherlands
- *Correspondence: Marius Staring
| |
Collapse
|
21
|
Magallon-Baro A, Granton PV, Milder MTW, Loi M, Zolnay AG, Nuyttens JJ, Hoogeman MS. A model-based patient selection tool to identify who may be at risk of exceeding dose tolerances during pancreatic SBRT. Radiother Oncol 2019; 141:116-122. [PMID: 31606227 DOI: 10.1016/j.radonc.2019.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 09/04/2019] [Accepted: 09/19/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Locally advanced pancreatic cancer (LAPC) patients are prone to experience daily anatomical variations, which can lead to additional doses in organs-at-risk (OAR) during SBRT. A patient selection tool was developed to identify who may be at risk of exceeding dose tolerances, by quantifying the dosimetric impact of daily variations using an OAR motion model. MATERIALS AND METHODS The study included 133 CT scans from 35 LAPC patients. By following a leave-one-out approach, an OAR motion model trained with the remaining 34 subjects variations was used to simulate organ deformations on the left-out patient planning CT anatomy. Dose-volume histograms obtained from planned doses sampled on simulated organs resulted in the probability of exceeding OAR dose-constraints due to anatomical variations. Simulated probabilities were clustered with a threshold per organ according to clinical observations. If the prediction of at least one OAR was above the established thresholds, the patient was classified as being at risk. RESULTS Clinically, in 20/35 patients at least one OAR exceeded dose-constraints in the daily CTs. The model-based prediction had an accuracy of 89%, 71%, 91% in estimating the risk of exceeding dose tolerances for the duodenum, stomach and bowel, respectively. By combining the three predictions, our approach resulted in a correct patient classification for 29/35 patients (83%) when compared with clinical observations. CONCLUSIONS Our model-based patient selection tool is able to predict who might be at risk of exceeding dose-constraints during SBRT. It is a promising tool to tailor LAPC treatments, e.g. by employing online adaptive SBRT; and hence, to minimize toxicity of patients being at risk.
Collapse
Affiliation(s)
- Alba Magallon-Baro
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, The Netherlands.
| | - Patrick V Granton
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, The Netherlands
| | - Maaike T W Milder
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, The Netherlands
| | - Mauro Loi
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, The Netherlands
| | - Andras G Zolnay
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, The Netherlands
| | - Joost J Nuyttens
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, The Netherlands
| | - Mischa S Hoogeman
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, The Netherlands
| |
Collapse
|
22
|
Magallon-Baro A, Loi M, Milder MT, Granton PV, Zolnay AG, Nuyttens JJ, Hoogeman MS. Modeling daily changes in organ-at-risk anatomy in a cohort of pancreatic cancer patients. Radiother Oncol 2019; 134:127-134. [DOI: 10.1016/j.radonc.2019.01.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 01/10/2019] [Accepted: 01/22/2019] [Indexed: 11/15/2022]
|
23
|
Loi M, Magallon-Baro A, Suker M, van Eijck C, Sharma A, Hoogeman M, Nuyttens J. Pancreatic cancer treated with SBRT: Effect of anatomical interfraction variations on dose to organs at risk. Radiother Oncol 2019; 134:67-73. [PMID: 31005226 DOI: 10.1016/j.radonc.2019.01.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 01/14/2019] [Accepted: 01/17/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND PURPOSE Interfraction shape and position variations of organs at risk (OARs) may increase uncertainty in dose delivery during stereotactic body radiotherapy (SBRT), potentially leading to overirradiation or concessions in planned tumor dose and/or coverage to prevent clinical constraints violation. The aim of our study was to quantitatively analyze the impact of anatomical interfraction variations on dose to OARs in pancreatic cancer (PC) treated by SBRT using a CyberKnife with integrated CT-on-rails. MATERIALS AND METHODS Thirty-five PC patients treated with SBRT (40 Gy/5 fractions) underwent a CT-scan in treatment position before each of the first three fractions using the CT-on-rails system. OARs (stomach, duodenum, bowel) were manually delineated and concatenated to one structure (Gastro-Intestinal Organ, GIO). To overlay the planned dose distribution, fiducial-based alignment of the fraction CT with the planning CT was performed. Planned DVH parameters of the OAR were compared to the parameters calculated in the fractions CTs. RESULTS Compared to the treatment plan, the median V35, D2, D5, D10 and Dmax of the fraction CTs in the GIO was increased by 1.0 (IQR: 0.2-2.6), 4.4% (0.4-10.8), 2.3% (0.2-7.5), 3.3% (-0.4 to 7.1), and 12.0% (5.0-18.9) respectively. Median increase was statistically significant for all parameters in GIO and for V35 in all critical structures at Wilcoxon test. CONCLUSIONS Anatomical interfraction variations increase OAR dose during SBRT for pancreatic cancer daily imaging using integrated CT/CyberKnife may allow to implement strategies to reduce the risk of OAR overirradiation during pancreatic SBRT.
Collapse
Affiliation(s)
- Mauro Loi
- Department of Radiotherapy, Erasmus MC University Medical Centre, Rotterdam, the Netherlands.
| | - Alba Magallon-Baro
- Department of Radiotherapy, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Mustafa Suker
- Department of Surgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Casper van Eijck
- Department of Surgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Aman Sharma
- Department of Radiotherapy, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Mischa Hoogeman
- Department of Radiotherapy, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Joost Nuyttens
- Department of Radiotherapy, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| |
Collapse
|
24
|
Baumann R, Chan MKH, Pyschny F, Stera S, Malzkuhn B, Wurster S, Huttenlocher S, Szücs M, Imhoff D, Keller C, Balermpas P, Rades D, Rödel C, Dunst J, Hildebrandt G, Blanck O. Clinical Results of Mean GTV Dose Optimized Robotic-Guided Stereotactic Body Radiation Therapy for Lung Tumors. Front Oncol 2018; 8:171. [PMID: 29868486 PMCID: PMC5966546 DOI: 10.3389/fonc.2018.00171] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 05/01/2018] [Indexed: 12/24/2022] Open
Abstract
Introduction We retrospectively evaluated the efficacy and toxicity of gross tumor volume (GTV) mean dose optimized stereotactic body radiation therapy (SBRT) for primary and secondary lung tumors with and without robotic real-time motion compensation. Materials and methods Between 2011 and 2017, 208 patients were treated with SBRT for 111 primary lung tumors and 163 lung metastases with a median GTV of 8.2 cc (0.3–174.0 cc). Monte Carlo dose optimization was performed prioritizing GTV mean dose at the potential cost of planning target volume (PTV) coverage reduction while adhering to safe normal tissue constraints. The median GTV mean biological effective dose (BED)10 was 162.0 Gy10 (34.2–253.6 Gy10) and the prescribed PTV BED10 ranged 23.6–151.2 Gy10 (median, 100.8 Gy10). Motion compensation was realized through direct tracking (44.9%), fiducial tracking (4.4%), and internal target volume (ITV) concepts with small (≤5 mm, 33.2%) or large (>5 mm, 17.5%) motion. The local control (LC), progression-free survival (PFS), overall survival (OS), and toxicity were analyzed. Results Median follow-up was 14.5 months (1–72 months). The 2-year actuarial LC, PFS, and OS rates were 93.1, 43.2, and 62.4%, and the median PFS and OS were 18.0 and 39.8 months, respectively. In univariate analysis, prior local irradiation (hazard ratio (HR) 0.18, confidence interval (CI) 0.05–0.63, p = 0.01), GTV/PTV (HR 1.01–1.02, CI 1.01–1.04, p < 0.02), and PTV prescription, mean GTV, and maximum plan BED10 (HR 0.97–0.99, CI 0.96–0.99, p < 0.01) were predictive for LC while the tracking method was not (p = 0.97). For PFS and OS, multivariate analysis showed Karnofsky Index (p < 0.01) and tumor stage (p ≤ 0.02) to be significant factors for outcome prediction. Late radiation pneumonitis or chronic rip fractures grade 1–2 were observed in 5.3% of the patients. Grade ≥3 side effects did not occur. Conclusion Robotic SBRT is a safe and effective treatment for lung tumors. Reducing the PTV prescription and keeping high GTV mean doses allowed the reduction of toxicity while maintaining high local tumor control. The use of real-time motion compensation is strongly advised, however, well-performed ITV motion compensation may be used alternatively when direct tracking is not feasible.
Collapse
Affiliation(s)
- Rene Baumann
- Department of Radiation Oncology, Universitätsklinikum Schleswig-Holstein, Kiel, Germany.,Saphir Radiochirurgie Zentrum Frankfurt und Norddeutschland, Güstrow, Germany
| | - Mark K H Chan
- Department of Radiation Oncology, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Florian Pyschny
- Department of Radiation Oncology, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Susanne Stera
- Department of Radiation Oncology, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - Bettina Malzkuhn
- Department of Radiation Oncology, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Stefan Wurster
- Saphir Radiochirurgie Zentrum Frankfurt und Norddeutschland, Güstrow, Germany.,Department of Radiation Oncology, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Stefan Huttenlocher
- Saphir Radiochirurgie Zentrum Frankfurt und Norddeutschland, Güstrow, Germany
| | - Marcella Szücs
- Department of Radiation Oncology, Universitätsmedizin Rostock, Rostock, Germany
| | - Detlef Imhoff
- Department of Radiation Oncology, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - Christian Keller
- Saphir Radiochirurgie Zentrum Frankfurt und Norddeutschland, Güstrow, Germany.,Department of Radiation Oncology, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - Panagiotis Balermpas
- Saphir Radiochirurgie Zentrum Frankfurt und Norddeutschland, Güstrow, Germany.,Department of Radiation Oncology, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - Dirk Rades
- Department of Radiation Oncology, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Claus Rödel
- Department of Radiation Oncology, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - Jürgen Dunst
- Department of Radiation Oncology, Universitätsklinikum Schleswig-Holstein, Kiel, Germany.,Department of Radiation Oncology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Guido Hildebrandt
- Department of Radiation Oncology, Universitätsmedizin Rostock, Rostock, Germany
| | - Oliver Blanck
- Department of Radiation Oncology, Universitätsklinikum Schleswig-Holstein, Kiel, Germany.,Saphir Radiochirurgie Zentrum Frankfurt und Norddeutschland, Güstrow, Germany
| |
Collapse
|
25
|
Koay EJ, Hall W, Park PC, Erickson B, Herman JM. The role of imaging in the clinical practice of radiation oncology for pancreatic cancer. Abdom Radiol (NY) 2018; 43:393-403. [PMID: 29110053 PMCID: PMC5832555 DOI: 10.1007/s00261-017-1373-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Advances in technology have enabled the delivery of high doses of radiation therapy for pancreatic ductal adenocarcinoma (PDAC) with low rates of toxicity. Although the role of radiation for pancreatic cancer continues to evolve, encouraging results with newer techniques indicate that radiation may benefit selected patient populations. Imaging has been central to the modern successes of radiation therapy for PDAC. Here, we review the role of diagnostic imaging, imaging-based planning, and image guidance in radiation oncology practice for PDAC.
Collapse
Affiliation(s)
- Eugene J Koay
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, MS 97, Houston, TX, 77030, USA.
| | - William Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Madison, WI, USA
| | - Peter C Park
- Department of Radiation Physics, MD Anderson Cancer Center, Houston, TX, USA
| | - Beth Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Madison, WI, USA
| | - Joseph M Herman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, MS 97, Houston, TX, 77030, USA
| |
Collapse
|
26
|
Karava K, Ehrbar S, Riesterer O, Roesch J, Glatz S, Klöck S, Guckenberger M, Tanadini-Lang S. Potential dosimetric benefits of adaptive tumor tracking over the internal target volume concept for stereotactic body radiation therapy of pancreatic cancer. Radiat Oncol 2017; 12:175. [PMID: 29121945 PMCID: PMC5680781 DOI: 10.1186/s13014-017-0906-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 10/30/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Radiotherapy for pancreatic cancer has two major challenges: (I) the tumor is adjacent to several critical organs and, (II) the mobility of both, the tumor and its surrounding organs at risk (OARs). A treatment planning study simulating stereotactic body radiation therapy (SBRT) for pancreatic tumors with both the internal target volume (ITV) concept and the tumor tracking approach was performed. The two respiratory motion-management techniques were compared in terms of doses to the target volume and organs at risk. METHODS AND MATERIALS Two volumetric-modulated arc therapy (VMAT) treatment plans (5 × 5 Gy) were created for each of the 12 previously treated pancreatic cancer patients, one using the ITV concept and one the tumor tracking approach. To better evaluate the overall dose delivered to the moving tumor volume, 4D dose calculations were performed on four-dimensional computed tomography (4DCT) scans. The resulting planning target volume (PTV) size for each technique was analyzed. Target and OAR dose parameters were reported and analyzed for both 3D and 4D dose calculation. RESULTS Tumor motion ranged from 1.3 to 11.2 mm. Tracking led to a reduction of PTV size (max. 39.2%) accompanied with significant better tumor coverage (p<0.05, paired Wilcoxon signed rank test) both in 3D and 4D dose calculations and improved organ at risk sparing. Especially for duodenum, stomach and liver, the mean dose was significantly reduced (p<0.05) with tracking for 3D and 4D dose calculations. CONCLUSIONS By using an adaptive tumor tracking approach for respiratory-induced pancreatic motion management, a significant reduction in PTV size can be achieved, which subsequently facilitates treatment planning, and improves organ dose sparing. The dosimetric benefit of tumor tracking is organ and patient-specific.
Collapse
Affiliation(s)
- Konstantina Karava
- Department of Radiation Oncology, University Hospital Zurich (USZ), Rämistrasse 100, Zurich, 8091, Switzerland. .,University of Zurich, Rämistrasse 71, Zurich, 8006, Switzerland.
| | - Stefanie Ehrbar
- Department of Radiation Oncology, University Hospital Zurich (USZ), Rämistrasse 100, Zurich, 8091, Switzerland.,University of Zurich, Rämistrasse 71, Zurich, 8006, Switzerland
| | - Oliver Riesterer
- Department of Radiation Oncology, University Hospital Zurich (USZ), Rämistrasse 100, Zurich, 8091, Switzerland.,University of Zurich, Rämistrasse 71, Zurich, 8006, Switzerland
| | - Johannes Roesch
- Department of Radiation Oncology, University Hospital Zurich (USZ), Rämistrasse 100, Zurich, 8091, Switzerland.,University of Zurich, Rämistrasse 71, Zurich, 8006, Switzerland
| | - Stefan Glatz
- Department of Radiation Oncology, University Hospital Zurich (USZ), Rämistrasse 100, Zurich, 8091, Switzerland.,University of Zurich, Rämistrasse 71, Zurich, 8006, Switzerland
| | - Stephan Klöck
- Department of Radiation Oncology, University Hospital Zurich (USZ), Rämistrasse 100, Zurich, 8091, Switzerland.,University of Zurich, Rämistrasse 71, Zurich, 8006, Switzerland
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich (USZ), Rämistrasse 100, Zurich, 8091, Switzerland.,University of Zurich, Rämistrasse 71, Zurich, 8006, Switzerland
| | - Stephanie Tanadini-Lang
- Department of Radiation Oncology, University Hospital Zurich (USZ), Rämistrasse 100, Zurich, 8091, Switzerland.,University of Zurich, Rämistrasse 71, Zurich, 8006, Switzerland
| |
Collapse
|