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Werner R, Szkitsak J, Sentker T, Madesta F, Schwarz A, Fernolendt S, Vornehm M, Gauer T, Bert C, Hofmann C. Comparison of intelligent 4D CT sequence scanning and conventional spiral 4D CT: a first comprehensive phantom study. Phys Med Biol 2021; 66. [PMID: 33171441 DOI: 10.1088/1361-6560/abc93a] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 11/10/2020] [Indexed: 11/11/2022]
Abstract
4D CT imaging is a cornerstone of 4D radiotherapy treatment. Clinical 4D CT data are, however, often affected by severe artifacts. The artifacts are mainly caused by breathing irregularity and retrospective correlation of breathing phase information and acquired projection data, which leads to insufficient projection data coverage to allow for proper reconstruction of 4D CT phase images. The recently introduced 4D CT approach i4DCT (intelligent 4D CT sequence scanning) aims to overcome this problem by breathing signal-driven tube control. The present motion phantom study describes the first in-depth evaluation of i4DCT in a real-world scenario. Twenty-eight 4D CT breathing curves of lung and liver tumor patients with pronounced breathing irregularity were selected to program the motion phantom. For every motion pattern, 4D CT imaging was performed with i4DCT and a conventional spiral 4D CT mode. For qualitative evaluation, the reconstructed 4D CT images were presented to clinical experts, who scored image quality. Further quantitative evaluation was based on established image intensity-based artifact metrics to measure (dis)similarity of neighboring image slices. In addition, beam-on and scan times of the scan modes were analyzed. The expert rating revealed a significantly higher image quality for the i4DCT data. The quantitative evaluation further supported the qualitative: While 20% of the slices of the conventional spiral 4D CT images were found to be artifact-affected, the corresponding fraction was only 4% for i4DCT. The beam-on time (surrogate of imaging dose) did not significantly differ between i4DCT and spiral 4D CT. Overall i4DCT scan times (time between first beam-on and last beam-on event, including scan breaks to compensate for breathing irregularity) were, on average, 53% longer compared to spiral CT. Thus, the results underline that i4DCT significantly improves 4D CT image quality compared to standard spiral CT scanning in the case of breathing irregularity during scanning.
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Affiliation(s)
- René Werner
- University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Juliane Szkitsak
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friederich-Alexander-Universität Erlangen-Nürnberg, 91504 Erlangen, Germany
| | - Thilo Sentker
- University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Frederic Madesta
- University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Annette Schwarz
- Friederich-Alexander-Universität Erlangen-Nürnberg, 91504 Erlangen, Germany.,Siemens Healthcare GmbH, Siemensstr. 3, 91301 Forchheim, Germany
| | - Susanne Fernolendt
- Friederich-Alexander-Universität Erlangen-Nürnberg, 91504 Erlangen, Germany.,Siemens Healthcare GmbH, Siemensstr. 3, 91301 Forchheim, Germany
| | - Marc Vornehm
- Friederich-Alexander-Universität Erlangen-Nürnberg, 91504 Erlangen, Germany.,Siemens Healthcare GmbH, Siemensstr. 3, 91301 Forchheim, Germany
| | - Tobias Gauer
- University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friederich-Alexander-Universität Erlangen-Nürnberg, 91504 Erlangen, Germany
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2
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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.
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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
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Werner R, Sentker T, Madesta F, Schwarz A, Vornehm M, Gauer T, Hofmann C. Intelligent 4D CT sequence scanning (i4DCT): First scanner prototype implementation and phantom measurements of automated breathing signal-guided 4D CT. Med Phys 2020; 47:2408-2412. [PMID: 32115724 DOI: 10.1002/mp.14106] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/05/2020] [Accepted: 02/20/2020] [Indexed: 11/05/2022] Open
Abstract
PURPOSE Four-dimensional (4D) computed tomography (CT) imaging is an essential part of current 4D radiotherapy treatment planning workflows, but clinical 4D CT images are often affected by artifacts. The artifacts are mainly caused by breathing irregularity during data acquisition, which leads to projection data coverage issues for currently available commercial 4D CT protocols. It was proposed to improve projection data coverage by online respiratory signal analysis and signal-guided CT tube control, but related work was always theoretical and presented as pure in silico studies. The present work demonstrates a first CT prototype implementation along with respective phantom measurements for the recently introduced intelligent 4D CT (i4DCT) sequence scanning concept (https://doi.org/10.1002/mp.13632). METHODS Intelligent 4D CT was implemented on the Siemens SOMATOM go platform. Four-dimensional CT measurements were performed using the CIRS motion phantom. Motion curves were programmed to systematically vary from regular to very irregular, covering typical irregular patterns that are known to result in image artifacts using standard 4D CT imaging protocols. Corresponding measurements were performed using i4DCT and routine spiral 4D CT with similar imaging parameters (e.g., mAs setting and gantry rotation time, retrospective ten-phase reconstruction) to allow for a direct comparison of the image data. RESULTS Following technological implementation of i4DCT on the clinical CT scanner platform, 4D CT motion artifacts were significantly reduced for all investigated levels of breathing irregularity when compared to routine spiral 4D CT scanning. CONCLUSIONS The present study confirms feasibility of fully automated respiratory signal-guided 4D CT scanning by means of a first implementation of i4DCT on a CT scanner. The measurements thereby support the conclusions of respective in silico studies and demonstrate that respiratory signal-guided 4D CT (here: i4DCT) is ready for integration into clinical CT scanners.
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Affiliation(s)
- René Werner
- Department of Computational Neuroscience, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany.,Center for Biomedical Artificial Intelligence (bAIome), University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Thilo Sentker
- Department of Computational Neuroscience, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany.,Department of Radiotherapy and Radio-Oncology, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Frederic Madesta
- Department of Computational Neuroscience, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Annette Schwarz
- Friedrich-Alexander-Universität Erlangen, 91504, Erlangen, Germany.,Siemens Healthcare GmbH, 91301, Forchheim, Germany
| | - Marc Vornehm
- Friedrich-Alexander-Universität Erlangen, 91504, Erlangen, Germany.,Siemens Healthcare GmbH, 91301, Forchheim, Germany
| | - Tobias Gauer
- Department of Radiotherapy and Radio-Oncology, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
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Werner R, Sentker T, Madesta F, Gauer T, Hofmann C. Intelligent 4D CT sequence scanning (i4DCT): Concept and performance evaluation. Med Phys 2019; 46:3462-3474. [DOI: 10.1002/mp.13632] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 04/30/2019] [Accepted: 05/22/2019] [Indexed: 12/20/2022] Open
Affiliation(s)
- René Werner
- Department of Computational Neuroscience University Medical Center Hamburg‐Eppendorf 20246Hamburg Germany
| | - Thilo Sentker
- Department of Computational Neuroscience University Medical Center Hamburg‐Eppendorf 20246Hamburg Germany
- Department of Radiotherapy and Radio‐Oncology University Medical Center Hamburg‐Eppendorf 20246Hamburg Germany
| | - Frederic Madesta
- Department of Computational Neuroscience University Medical Center Hamburg‐Eppendorf 20246Hamburg Germany
| | - Tobias Gauer
- Department of Radiotherapy and Radio‐Oncology University Medical Center Hamburg‐Eppendorf 20246Hamburg Germany
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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.
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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
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Is tumor volume reduction during radiotherapy prognostic relevant in patients with stage III non-small cell lung cancer? J Cancer Res Clin Oncol 2018; 144:1165-1171. [DOI: 10.1007/s00432-018-2640-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 04/03/2018] [Indexed: 12/26/2022]
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Mogadas N, Sothmann T, Knopp T, Gauer T, Petersen C, Werner R. Influence of deformable image registration on 4D dose simulation for extracranial SBRT: A multi-registration framework study. Radiother Oncol 2018; 127:225-232. [PMID: 29606523 DOI: 10.1016/j.radonc.2018.03.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 03/14/2018] [Accepted: 03/14/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE To evaluate the influence of deformable image registration approaches on correspondence model-based 4D dose simulation in extracranial SBRT by means of open source deformable image registration (DIR) frameworks. MATERIAL AND METHODS Established DIR algorithms of six different open source DIR frameworks were considered and registration accuracy evaluated using freely available 4D image data. Furthermore, correspondence models (regression-based correlation of external breathing signal measurements and internal structure motion field) were built and model accuracy evaluated. Finally, the DIR algorithms were applied for motion field estimation in radiotherapy planning 4D CT data of five lung and five liver lesion patients, correspondence model formation, and model-based 4D dose simulation. Deviations between the original, statically planned and the 4D-simulated VMAT dose distributions were analyzed and correlated to DIR accuracy differences. RESULTS Registration errors varied among the DIR approaches, with lower DIR accuracy translating into lower correspondence modeling accuracy. Yet, for lung metastases, indices of 4D-simulated dose distributions widely agreed, irrespective of DIR accuracy differences. In contrast, liver metastases 4D dose simulation results strongly vary for the different DIR approaches. CONCLUSIONS Especially in treatment areas with low image contrast (e.g. the liver), DIR-based 4D dose simulation results strongly depend on the applied DIR algorithm, drawing resulting dose simulations and indices questionable.
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Affiliation(s)
- Nik Mogadas
- Department of Computational Neuroscience, University Medical Center Hamburg-Eppendorf, Germany
| | - Thilo Sothmann
- Department of Computational Neuroscience, University Medical Center Hamburg-Eppendorf, Germany; Department of Radiotherapy and Radio-Oncology, University Medical Center Hamburg-Eppendorf, Germany.
| | - Tobias Knopp
- Section for Biomedical Imaging, University Medical Center Hamburg-Eppendorf, Germany
| | - Tobias Gauer
- Department of Radiotherapy and Radio-Oncology, University Medical Center Hamburg-Eppendorf, Germany
| | - Cordula Petersen
- Department of Radiotherapy and Radio-Oncology, University Medical Center Hamburg-Eppendorf, Germany
| | - René Werner
- Department of Computational Neuroscience, University Medical Center Hamburg-Eppendorf, Germany
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Prasetio H, Wölfelschneider J, Ziegler M, Serpa M, Witulla B, Bert C. Dose calculation and verification of the Vero gimbal tracking treatment delivery. Phys Med Biol 2018; 63:035043. [PMID: 29311415 DOI: 10.1088/1361-6560/aaa617] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The Vero linear accelerator delivers dynamic tumor tracking (DTT) treatment using a gimbal motion. However, the availability of treatment planning systems (TPS) to simulate DTT is limited. This study aims to implement and verify the gimbal tracking beam geometry in the dose calculation. Gimbal tracking was implemented by rotating the reference CT outside the TPS according to the ring, gantry, and gimbal tracking position obtained from the tracking log file. The dose was calculated using these rotated CTs. The geometric accuracy was verified by comparing calculated and measured film response using a ball bearing phantom. The dose was verified by comparing calculated 2D dose distributions and film measurements in a ball bearing and a homogeneous phantom using a gamma criterion of 2%/2 mm. The effect of implementing the gimbal tracking beam geometry in a 3D patient data dose calculation was evaluated using dose volume histograms (DVH). Geometrically, the gimbal tracking implementation accuracy was <0.94 mm. The isodose lines agreed with the film measurement. The largest dose difference of 9.4% was observed at maximum tilt positions with an isocenter and target separation of 17.51 mm. Dosimetrically, gamma passing rates were >98.4%. The introduction of the gimbal tracking beam geometry in the dose calculation shifted the DVH curves by 0.05%-1.26% for the phantom geometry and by 5.59% for the patient CT dataset. This study successfully demonstrates a method to incorporate the gimbal tracking beam geometry into dose calculations. By combining CT rotation and MU distribution according to the log file, the TPS was able to simulate the Vero tracking treatment dose delivery. The DVH analysis from the gimbal tracking dose calculation revealed changes in the dose distribution during gimbal DTT that are not visible with static dose calculations.
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Affiliation(s)
- H Prasetio
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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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.
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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
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Stera S, Balermpas P, Chan MKH, Huttenlocher S, Wurster S, Keller C, Imhoff D, Rades D, Dunst J, Rödel C, Hildebrandt G, Blanck O. Breathing-motion-compensated robotic guided stereotactic body radiation therapy : Patterns of failure analysis. Strahlenther Onkol 2017; 194:143-155. [PMID: 28875297 DOI: 10.1007/s00066-017-1204-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 08/16/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE We retrospectively evaluated the patterns of failure for robotic guided real-time breathing-motion-compensated (BMC) stereotactic body radiation therapy (SBRT) in the treatment of tumors in moving organs. PATIENTS AND METHODS Between 2011 and 2016, a total of 198 patients with 280 lung, liver, and abdominal tumors were treated with BMC-SBRT. The median gross tumor volume (GTV) was 12.3 cc (0.1-372.0 cc). Medians of mean GTV BEDα/β =10 Gy (BED = biological effective dose) was 148.5 Gy10 (31.5-233.3 Gy10) and prescribed planning target volume (PTV) BEDα/β =10 Gy was 89.7 Gy10 (28.8-151.2 Gy10), respectively. We analyzed overall survival (OS) and local control (LC) based on various factors, including BEDs with α/β ratios of 15 Gy (lung metastases), 21 Gy (primary lung tumors), and 27 Gy (liver metastases). RESULTS Median follow-up was 10.4 months (2.0-59.0 months). The 2‑year actuarial LC was 100 and 86.4% for primary early and advanced stage lung tumors, respectively, 100% for lung metastases, 82.2% for liver metastases, and 90% for extrapulmonary extrahepatic metastases. The 2‑year OS rate was 47.9% for all patients. In uni- and multivariate analysis, comparatively lower PTV prescription dose (equivalence of 3 × 12-13 Gy) and higher average GTV dose (equivalence of 3 × 18 Gy) to current practice were significantly associated with LC. For OS, Karnofsky performance score (100%), gender (female), and SBRT without simultaneous chemotherapy were significant prognostic factors. Grade 3 side effects were rare (0.5%). CONCLUSIONS Robotic guided BMC-SBRT can be considered a safe and effective treatment for solid tumors in moving organs. To reach sufficient local control rates, high average GTV doses are necessary. Further prospective studies are warranted to evaluate these points.
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Affiliation(s)
- Susanne Stera
- Department of Radiation Oncology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
| | - Panagiotis Balermpas
- Department of Radiation Oncology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.,Saphir Radiosurgery Center, Frankfurt, Germany
| | - Mark K H Chan
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | | | - Stefan Wurster
- Saphir Radiosurgery Center, Güstrow, Germany.,Department of Radiation Oncology, University Medicine Greifswald, Greifswald, Germany
| | - Christian Keller
- Department of Radiation Oncology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.,Saphir Radiosurgery Center, Frankfurt, Germany
| | - Detlef Imhoff
- Department of Radiation Oncology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Dirk Rades
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Jürgen Dunst
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany.,Department of Radiation Oncology, University Hospital Copenhagen, Copenhagen, Denmark
| | - Claus Rödel
- Department of Radiation Oncology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Guido Hildebrandt
- Department of Radiation Oncology, University Medicine Rostock, Rostock, Germany
| | - Oliver Blanck
- Saphir Radiosurgery Center, Frankfurt, Germany.,Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany.,Saphir Radiosurgery Center, Güstrow, Germany
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11
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Risk-adapted robotic stereotactic body radiation therapy for inoperable early-stage non-small-cell lung cancer. Strahlenther Onkol 2017; 194:91-97. [PMID: 28812120 DOI: 10.1007/s00066-017-1194-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 07/28/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE To evaluate efficacy and toxicity of stereotactic body radiation therapy (SBRT) with CyberKnife® (Accuray, Sunnyvale, CA, USA) in a selected cohort of primary, medically inoperable early-stage non-small cell lung cancer (NSCLC) patients. METHODS From 2012 to 2016, 106 patients (median age 74 years, range 50-94 years) with primary NSCLC were treated with SBRT using CyberKnife®. Histologic confirmation was available in 87 patients (82%). For mediastinal staging, 92 patients (87%) underwent 18F-fluorodeoxyglucose positron-emission tomography (18-FDG-PET) and/or endobronchial ultrasound (EBUS)-guided lymph node biopsy or mediastinoscopy. Tumor stage (UICC8, 2017) was IA/B (T1a-c, 1-3 cm) in 86 patients (81%) and IIA (T2a/b, 3-5 cm) in 20 patients (19%). Depending on tumor localization, three different fractionation schedules were used: 3 fractions of 17Gy, 5 fractions of 11Gy, or 8 fractions of 7.5 Gy. Tracking was based on fiducial implants in 13 patients (12%) and on image guidance without markers in 88%. RESULTS Median follow-up was 15 months (range 0.5-46 months). Acute side effects were mild (fatigue grade 1-2 in 20% and dyspnea grade 1-2 in 17%). Late effects were observed in 4 patients (4%): 3 patients developed pneumonitis requiring therapy (grade 2) and 1 patient suffered a rib fracture (grade 3). In total, 9/106 patients (8%) experienced a local recurrence, actuarial local control rates were 88% (95% confidence interval, CI, 80-96%) at 2 years and 77% (95%CI 56-98%) at 3 years. The median disease-free survival time was 27 months (95%CI 23-31 months). Overall survival was 77% (95%CI 65-85%) at 2 years and 56% (95%CI 39-73%) at 3 years. CONCLUSION CyberKnife® lung SBRT which allows for real-time tumor tracking and risk-adapted fractionation achieves satisfactory local control and low toxicity rates in inoperable early-stage primary lung cancer patients.
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12
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Park Y, Kim HJ, Chang AR. Predictors of chest wall toxicity after stereotactic ablative radiotherapy using real-time tumor tracking for lung tumors. Radiat Oncol 2017; 12:66. [PMID: 28381302 PMCID: PMC5382431 DOI: 10.1186/s13014-017-0803-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 03/26/2017] [Indexed: 12/20/2022] Open
Abstract
Background To evaluate the incidence of chest wall toxicity after lung stereotactic ablative radiotherapy (SABR) and identify risk factors for the development of rib fracture. Methods Thirty-nine patients with 49 lesions underwent SABR for primary or metastatic lung tumors using Cyberknife® with tumor tracking systems. Patient characteristics, treatment factors and variables obtained from dose-volume histograms (DVHs) were analyzed to find the association with chest wall toxicity. Four-dimensional (4D) dose calculations were done to investigate the effect of respiratory motion on dose to the ribs. Results After follow-up of median 26.7 months (range: 8.4 – 80.0), 8 patients (20.5%) experienced rib fractures and among these patients, three (37.5%) had chest wall pain at 2–3 months after SABR. Median time to rib fracture was 13.4 months (range: 8.0 – 38.5) and the 2-year actuarial risk of rib fracture was 12.2%. Dose to the 4.6 cc of the ribs (D4.6cc) and rib volume received 160 Gy or more (V160) were significant predictor for rib fracture. No significant differences between three-dimensional (3D) and 4D dose calculations were found. Conclusions Parameters from DVH are useful in predicting the risk of chest wall toxicity after SABR for lung tumors. Efforts should be made to reduce the risk of the rib fracture after lung SABR.
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Affiliation(s)
- Younghee Park
- Department of Radiation Oncology/CyberKnife Center, Soonchunhyang University Seoul Hospital, 59 Daesagwan-ro, Yongsan-gu, Seoul, 140-743, Republic of Korea
| | - Hee Jung Kim
- Department of Radiation Oncology/CyberKnife Center, Soonchunhyang University Seoul Hospital, 59 Daesagwan-ro, Yongsan-gu, Seoul, 140-743, Republic of Korea
| | - Ah Ram Chang
- Department of Radiation Oncology/CyberKnife Center, Soonchunhyang University Seoul Hospital, 59 Daesagwan-ro, Yongsan-gu, Seoul, 140-743, Republic of Korea.
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13
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Chan M, Grehn M, Cremers F, Siebert FA, Wurster S, Huttenlocher S, Dunst J, Hildebrandt G, Schweikard A, Rades D, Ernst F, Blanck O. Dosimetric Implications of Residual Tracking Errors During Robotic SBRT of Liver Metastases. Int J Radiat Oncol Biol Phys 2016; 97:839-848. [PMID: 28244421 DOI: 10.1016/j.ijrobp.2016.11.041] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 10/21/2016] [Accepted: 11/21/2016] [Indexed: 12/25/2022]
Abstract
PURPOSE Although the metric precision of robotic stereotactic body radiation therapy in the presence of breathing motion is widely known, we investigated the dosimetric implications of breathing phase-related residual tracking errors. METHODS AND MATERIALS In 24 patients (28 liver metastases) treated with the CyberKnife, we recorded the residual correlation, prediction, and rotational tracking errors from 90 fractions and binned them into 10 breathing phases. The average breathing phase errors were used to shift and rotate the clinical tumor volume (CTV) and planning target volume (PTV) for each phase to calculate a pseudo 4-dimensional error dose distribution for comparison with the original planned dose distribution. RESULTS The median systematic directional correlation, prediction, and absolute aggregate rotation errors were 0.3 mm (range, 0.1-1.3 mm), 0.01 mm (range, 0.00-0.05 mm), and 1.5° (range, 0.4°-2.7°), respectively. Dosimetrically, 44%, 81%, and 92% of all voxels differed by less than 1%, 3%, and 5% of the planned local dose, respectively. The median coverage reduction for the PTV was 1.1% (range in coverage difference, -7.8% to +0.8%), significantly depending on correlation (P=.026) and rotational (P=.005) error. With a 3-mm PTV margin, the median coverage change for the CTV was 0.0% (range, -1.0% to +5.4%), not significantly depending on any investigated parameter. In 42% of patients, the 3-mm margin did not fully compensate for the residual tracking errors, resulting in a CTV coverage reduction of 0.1% to 1.0%. CONCLUSIONS For liver tumors treated with robotic stereotactic body radiation therapy, a safety margin of 3 mm is not always sufficient to cover all residual tracking errors. Dosimetrically, this translates into only small CTV coverage reductions.
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Affiliation(s)
- Mark Chan
- Department for Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany; Tuen Mun Hospital, Hong Kong, China
| | - Melanie Grehn
- Department for Radiation Oncology, University Medical Center Schleswig-Holstein, Lübeck, Germany; Institute for Robotics and Cognitive Systems, University of Lübeck, Lübeck, Germany
| | - Florian Cremers
- Department for Radiation Oncology, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Frank-Andre Siebert
- Department for Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Stefan Wurster
- Saphir Radiosurgery Center Northern Germany, Güstrow, Germany; Department for Radiation Oncology, University Medicine Greifswald, Greifswald, Germany
| | | | - Jürgen Dunst
- Department for Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany; Department for Radiation Oncology, University Clinic Copenhagen, Copenhagen, Denmark
| | - Guido Hildebrandt
- Department for Radiation Oncology, University Medicine Rostock, Rostock, Germany
| | - Achim Schweikard
- Institute for Robotics and Cognitive Systems, University of Lübeck, Lübeck, Germany
| | - Dirk Rades
- Department for Radiation Oncology, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Floris Ernst
- Institute for Robotics and Cognitive Systems, University of Lübeck, Lübeck, Germany
| | - Oliver Blanck
- Department for Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany; Saphir Radiosurgery Center Northern Germany, Güstrow, Germany.
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14
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Blanck O, Ipsen S, Chan MK, Bauer R, Kerl M, Hunold P, Jacobi V, Bruder R, Schweikard A, Rades D, Vogl TJ, Kleine P, Bode F, Dunst J. Treatment Planning Considerations for Robotic Guided Cardiac Radiosurgery for Atrial Fibrillation. Cureus 2016; 8:e705. [PMID: 27588226 PMCID: PMC4999353 DOI: 10.7759/cureus.705] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Purpose Robotic guided stereotactic radiosurgery has recently been investigated for the treatment of atrial fibrillation (AF). Before moving into human treatments, multiple implications for treatment planning given a potential target tracking approach have to be considered. Materials & Methods Theoretical AF radiosurgery treatment plans for twenty-four patients were generated for baseline comparison. Eighteen patients were investigated under ideal tracking conditions, twelve patients under regional dose rate (RDR = applied dose over a certain time window) optimized conditions (beam delivery sequence sorting according to regional beam targeting), four patients under ultrasound tracking conditions (beam block of the ultrasound probe) and four patients with temporary single fiducial tracking conditions (differential surrogate-to-target respiratory and cardiac motion). Results With currently known guidelines on dose limitations of critical structures, treatment planning for AF radiosurgery with 25 Gy under ideal tracking conditions with a 3 mm safety margin may only be feasible in less than 40% of the patients due to the unfavorable esophagus and bronchial tree location relative to the left atrial antrum (target area). Beam delivery sequence sorting showed a large increase in RDR coverage (% of voxels having a larger dose rate for a given time window) of 10.8-92.4% (median, 38.0%) for a 40-50 min time window, which may be significant for non-malignant targets. For ultrasound tracking, blocking beams through the ultrasound probe was found to have no visible impact on plan quality given previous optimal ultrasound window estimation for the planning CT. For fiducial tracking in the right atrial septum, the differential motion may reduce target coverage by up to -24.9% which could be reduced to a median of -0.8% (maximum, -12.0%) by using 4D dose optimization. The cardiac motion was also found to have an impact on the dose distribution, at the anterior left atrial wall; however, the results need to be verified. Conclusion Robotic AF radiosurgery with 25 Gy may be feasible in a subgroup of patients under ideal tracking conditions. Ultrasound tracking was found to have the lowest impact on treatment planning and given its real-time imaging capability should be considered for AF robotic radiosurgery. Nevertheless, advanced treatment planning using RDR or 4D respiratory and cardiac dose optimization may be still advised despite using ideal tracking methods.
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Affiliation(s)
- Oliver Blanck
- Department for Radiation Oncology, University Medical Center Schleswig-Holstein, Campus Kiel, Germany ; Saphir Radiosurgery Center, Frankfurt and Güstrow, Germany
| | - Svenja Ipsen
- Robotics and Cognitive Systems, University of Lübeck
| | - Mark K Chan
- Department for Radiation Oncology, University Medical Center Schleswig-Holstein, Campus Kiel, Germany ; Department for Radiation Oncology, Tuen Mun Hospital, Hong Kong, Hong Kong
| | - Ralf Bauer
- Institute for Diagnostics and Interventional Radiology, University Clinic Frankfurt, Germany ; Department for Radiology and Nuclear Medicine, Kantonsspital St. Gallen, Switzerland
| | - Matthias Kerl
- Institute for Diagnostics and Interventional Radiology, University Clinic Frankfurt, Germany ; Radiology, Darmstadt, Germany
| | - Peter Hunold
- Clinic for Radiology and Nuclear Medicine, University Medical Center Schleswig-Holstein, Campus Lübeck, Germany
| | - Volkmar Jacobi
- Institute for Diagnostics and Interventional Radiology, University Clinic Frankfurt, Germany
| | - Ralf Bruder
- Institute for Robotics and Cognitive Systems, University of Lubeck
| | - Achim Schweikard
- Institute for Robotics and Cognitive Systems, University of Luebeck, Institute for Robotics and Cognitive Systems, University of Lubeck
| | - Dirk Rades
- Department for Radiation Oncology, University Medical Center Schleswig-Holstein, Campus Lübeck, Germany
| | - Thomas J Vogl
- Institute for Diagnostics and Interventional Radiology, University Clinic Frankfurt, Germany
| | - Peter Kleine
- Department for Thoracic, Cardiac and Thoracic Vascular Surgery, University Clinic Frankfurt, Germany
| | - Frank Bode
- Cardiology Department, Sana Clinic Oldenburg in Holstein
| | - Jürgen Dunst
- Department for Radiation Oncology, University Medical Center Schleswig-Holstein, Campus Kiel, Germany ; Department for Radiation Oncology, University Medical Center Copenhagen, Denmark
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Deep Inspiration Breath Hold-Based Radiation Therapy: A Clinical Review. Int J Radiat Oncol Biol Phys 2015; 94:478-92. [PMID: 26867877 DOI: 10.1016/j.ijrobp.2015.11.049] [Citation(s) in RCA: 159] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 11/03/2015] [Accepted: 11/29/2015] [Indexed: 01/06/2023]
Abstract
Several recent developments in linear accelerator-based radiation therapy (RT) such as fast multileaf collimators, accelerated intensity modulation paradigms like volumeric modulated arc therapy and flattening filter-free (FFF) high-dose-rate therapy have dramatically shortened the duration of treatment fractions. Deliverable photon dose distributions have approached physical complexity limits as a consequence of precise dose calculation algorithms and online 3-dimensional image guided patient positioning (image guided RT). Simultaneously, beam quality and treatment speed have continuously been improved in particle beam therapy, especially for scanned particle beams. Applying complex treatment plans with steep dose gradients requires strategies to mitigate and compensate for motion effects in general, particularly breathing motion. Intrafractional breathing-related motion results in uncertainties in dose delivery and thus in target coverage. As a consequence, generous margins have been used, which, in turn, increases exposure to organs at risk. Particle therapy, particularly with scanned beams, poses additional problems such as interplay effects and range uncertainties. Among advanced strategies to compensate breathing motion such as beam gating and tracking, deep inspiration breath hold (DIBH) gating is particularly advantageous in several respects, not only for hypofractionated, high single-dose stereotactic body RT of lung, liver, and upper abdominal lesions but also for normofractionated treatment of thoracic tumors such as lung cancer, mediastinal lymphomas, and breast cancer. This review provides an in-depth discussion of the rationale and technical implementation of DIBH gating for hypofractionated and normofractionated RT of intrathoracic and upper abdominal tumors in photon and proton RT.
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Cone-beam CT-guided radiotherapy in the management of lung cancer: Diagnostic and therapeutic value. Strahlenther Onkol 2015; 192:83-91. [PMID: 26630946 DOI: 10.1007/s00066-015-0927-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 11/18/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND Recent studies have demonstrated an increase in the necessity of adaptive planning over the course of lung cancer radiation therapy (RT) treatment. In this study, we evaluated intrathoracic changes detected by cone-beam CT (CBCT) in lung cancer patients during RT. METHODS AND MATERIALS A total of 71 lung cancer patients treated with fractionated CBCT-guided RT were evaluated. Intrathoracic changes and plan adaptation priority (AP) scores were compared between small cell lung cancer (SCLC, n = 13) and non-small cell lung cancer (NSCLC, n = 58) patients. RESULTS The median cumulative radiation dose administered was 54 Gy (range 30-72 Gy) and the median fraction dose was 1.8 Gy (range 1.8-3.0 Gy). All patients were subjected to a CBCT scan at least weekly (range 1-5/week). We observed intrathoracic changes in 83 % of the patients over the course of RT [58 % (41/71) regression, 17 % (12/71) progression, 20 % (14/71) atelectasis, 25 % (18/71) pleural effusion, 13 % (9/71) infiltrative changes, and 10 % (7/71) anatomical shift]. Nearly half, 45 % (32/71), of the patients had one intrathoracic soft tissue change, 22.5 % (16/71) had two, and three or more changes were observed in 15.5 % (11/71) of the patients. Plan modifications were performed in 60 % (43/71) of the patients. Visual volume reduction did correlate with the number of CBCT scans acquired (r = 0.313, p = 0.046) and with the timing of chemotherapy administration (r = 0.385, p = 0.013). CONCLUSION Weekly CBCT monitoring provides an adaptation advantage in patients with lung cancer. In this study, the monitoring allowed for plan adaptations due to tumor volume changes and to other anatomical changes.
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Kang KM, Jeong BK, Choi HS, Yoo SH, Hwang UJ, Lim YK, Jeong H. Combination effects of tissue heterogeneity and geometric targeting error in stereotactic body radiotherapy for lung cancer using CyberKnife. J Appl Clin Med Phys 2015; 16:193-204. [PMID: 26699300 PMCID: PMC5690167 DOI: 10.1120/jacmp.v16i5.5397] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 07/13/2015] [Accepted: 05/13/2015] [Indexed: 12/31/2022] Open
Abstract
We have investigated the combined effect of tissue heterogeneity and its variation associated with geometric error in stereotactic body radiotherapy (SBRT) for lung cancer. The treatment plans for eight lung cancer patients were calculated using effective path length (EPL) correction and Monte Carlo (MC) algorithms, with both having the same beam configuration for each patient. These two kinds of plans for individual patients were then subsequently recalculated with adding systematic and random geometric errors. In the ordinary treatment plans calculated with no geometric offset, the EPL calculations, compared with the MC calculations, largely overestimated the doses to PTV by ∼21%, whereas the overestimation were markedly lower in GTV by ∼12% due to relatively higher density of GTV than of PTV. When recalculating the plans for individual patients with assigning the systematic and random geometric errors, no significant changes in the relative dose distribution, except for overall shift, were observed in the EPL calculations, whereas largely altered in the MC calculations with a consistent increase in dose to GTV. Considering the better accuracy of MC than EPL algorithms, the present results demonstrated the strong coupling of tissue heterogeneity and geometric error, thereby emphasizing the essential need for simultaneous correction for tissue heterogeneity and geometric targeting error in SBRT of lung cancer. PACS numbers: 87.55.D, 87.55.kh, 87.53.Ly, 87.55.‐x
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Affiliation(s)
- Ki Mun Kang
- GyeongSang National University; Gyeongsang National University Hospital.
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