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Aleong AM, Berlin A, Borg J, Helou J, Beiki-Ardakani A, Rink A, Raman S, Chung P, Weersink RA. Rapid multi-catheter segmentation for magnetic resonance image-guided catheter-based interventions. Med Phys 2024; 51:5361-5373. [PMID: 38713919 DOI: 10.1002/mp.17117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 04/02/2024] [Accepted: 04/18/2024] [Indexed: 05/09/2024] Open
Abstract
BACKGROUND Magnetic resonance imaging (MRI) is the gold standard for delineating cancerous lesions in soft tissue. Catheter-based interventions require the accurate placement of multiple long, flexible catheters at the target site. The manual segmentation of catheters in MR images is a challenging and time-consuming task. There is a need for automated catheter segmentation to improve the efficiency of MR-guided procedures. PURPOSE To develop and assess a machine learning algorithm for the detection of multiple catheters in magnetic resonance images used during catheter-based interventions. METHODS In this work, a 3D U-Net was trained to retrospectively segment catheters in scans acquired during clinical MR-guided high dose rate (HDR) prostate brachytherapy cases. To assess confidence in segmentation, multiple AI models were trained. On clinical test cases, average segmentation results were used to plan the brachytherapy delivery. Dosimetric parameters were compared to the original clinical plan. Data was obtained from 35 patients who underwent HDR prostate brachytherapy for focal disease with a total of 214 image volumes. 185 image volumes from 30 patients were used for training using a five-fold cross validation split to divide the data for training and validation. To generate confidence measures of segmentation accuracy, five trained models were generated. The remaining five patients (29 volumes) were used to test the performance of the trained model by comparison to manual segmentations of three independent observers and assessment of dosimetric impact on the final clinical brachytherapy plans. RESULTS The network successfully identified 95% of catheters in the test set at a rate of 0.89 s per volume. The multi-model method identified the small number of cases where AI segmentation of individual catheters was poor, flagging the need for user input. AI-based segmentation performed as well as segmentations by independent observers. Plan dosimetry using AI-segmented catheters was comparable to the original plan. CONCLUSION The vast majority of catheters were accurately identified by AI segmentation, with minimal impact on plan outcomes. The use of multiple AI models provided confidence in the segmentation accuracy and identified catheter segmentations that required further manual assessment. Real-time AI catheter segmentation can be used during MR-guided insertions to assess deflections and for rapid planning of prostate brachytherapy.
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Affiliation(s)
- Amanda M Aleong
- Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Alejandro Berlin
- Department of Radiation Medicine, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Jette Borg
- Department of Radiation Medicine, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Joelle Helou
- Department of Radiation Medicine, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Akbar Beiki-Ardakani
- Department of Radiation Medicine, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Alexandra Rink
- Department of Radiation Medicine, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Srinivas Raman
- Department of Radiation Medicine, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Peter Chung
- Department of Radiation Medicine, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Robert A Weersink
- Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
- Department of Radiation Medicine, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
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Eidex Z, Ding Y, Wang J, Abouei E, Qiu RLJ, Liu T, Wang T, Yang X. Deep learning in MRI-guided radiation therapy: A systematic review. J Appl Clin Med Phys 2024; 25:e14155. [PMID: 37712893 PMCID: PMC10860468 DOI: 10.1002/acm2.14155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/10/2023] [Accepted: 08/21/2023] [Indexed: 09/16/2023] Open
Abstract
Recent advances in MRI-guided radiation therapy (MRgRT) and deep learning techniques encourage fully adaptive radiation therapy (ART), real-time MRI monitoring, and the MRI-only treatment planning workflow. Given the rapid growth and emergence of new state-of-the-art methods in these fields, we systematically review 197 studies written on or before December 31, 2022, and categorize the studies into the areas of image segmentation, image synthesis, radiomics, and real time MRI. Building from the underlying deep learning methods, we discuss their clinical importance and current challenges in facilitating small tumor segmentation, accurate x-ray attenuation information from MRI, tumor characterization and prognosis, and tumor motion tracking. In particular, we highlight the recent trends in deep learning such as the emergence of multi-modal, visual transformer, and diffusion models.
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Affiliation(s)
- Zach Eidex
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
- School of Mechanical EngineeringGeorgia Institute of TechnologyAtlantaGeorgiaUSA
| | - Yifu Ding
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Jing Wang
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Elham Abouei
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Richard L. J. Qiu
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Tian Liu
- Department of Radiation OncologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Tonghe Wang
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Xiaofeng Yang
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
- School of Mechanical EngineeringGeorgia Institute of TechnologyAtlantaGeorgiaUSA
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Sanmamed N, Adleman J, Berlin A, Borg J, Lao B, Weersink R, Simeonov A, Rink A, Beiki-Ardakani A, Menard C, Chung P, Helou J. Acute toxicity and health-related quality of life outcomes of localized prostate cancer patients treated with magnetic resonance imaging-guided high-dose-rate brachytherapy: A prospective phase II trial. Brachytherapy 2023; 22:58-65. [PMID: 36414526 DOI: 10.1016/j.brachy.2022.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/18/2022] [Accepted: 08/28/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE To report acute toxicity and health-related quality of life (HRQoL) outcomes of a phase II clinical trial of magnetic resonance imaging (MRI)-guided prostate high-dose-rate brachytherapy (HDR-BT) combined with external beam radiotherapy. METHODS AND MATERIALS Patients with intermediate- and high-risk prostate cancer (PCa) were eligible. Treatment consisted of a single 15 Gy MRI-guided HDR-BT followed by external beam radiotherapy (37.5-46 Gy depending on their risk category). Dosimetry, toxicity and HRQoL outcomes were collected prospectively at baseline, 1 and 3 months using Common Terminology Criteria for Adverse Events Version 4.0 and the expanded PCa index composite, respectively. General linear mixed modeling was conducted to assess the changes in expanded PCa index composite domain scores over time. A minimally important difference was defined as a deterioration of HRQoL scores at 3 months compared to baseline ≥ 0.5 standard deviation. A p value ≤ 0.05 was considered statistically significant. RESULTS Sixty-one patients were included. Acute grade (G)2 urinary toxicity was observed in 18 (30%) patients while 1 (2%) patient had G3 toxicity, and none had G4 toxicity. Two patients had an acute urinary retention. G2 gastrointestinal toxicity was reported by 5 (8%) patients with no G3-4. Compared to baseline, urinary HRQoL scores significantly declined at 1 month (p < 0.001) but recovered at 3 months (p > 0.05). Bowel (p < 0.001) and sexual (p < 0.001) domain scores showed a significant decline over the 3-month follow-up period. At 3 months, 44%, 49% and 57% of patients reported a minimally important difference respectively in the urinary bowel and sexual domains. CONCLUSION MRI-guided HDR-BT boost is a safe and well tolerated treatment of intermediate- and high-risk PCa in the acute setting. A longer follow-up and a comparison to ultrasound-based HDR-BT are needed to assess the potential benefit of MRI-guided prostate HDR-BT.
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Affiliation(s)
- Noelia Sanmamed
- Department of Radiation Oncology, Hospital Clinico San Carlos, Madrid, Spain; Investigation institute, Clinico San Carlos Hospital, Madrid, Spain
| | - Jenna Adleman
- Department of Radiation Oncology, Lakeridge Health, Oshawa, ON, Canada
| | - Alejandro Berlin
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; TECHNA Institute, University of Toronto, Toronto, ON, Canada
| | - Jette Borg
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Bernadeth Lao
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Robert Weersink
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Anna Simeonov
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Alex Rink
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Akbar Beiki-Ardakani
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Cynthia Menard
- TECHNA Institute, University of Toronto, Toronto, ON, Canada; Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Peter Chung
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Joelle Helou
- Department of Radiation Oncology, Lakeridge Health, Oshawa, ON, Canada; Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada.
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Prisciandaro J, Zoberi JE, Cohen G, Kim Y, Johnson P, Paulson E, Song W, Hwang KP, Erickson B, Beriwal S, Kirisits C, Mourtada F. AAPM Task Group Report 303 endorsed by the ABS: MRI Implementation in HDR Brachytherapy-Considerations from Simulation to Treatment. Med Phys 2022; 49:e983-e1023. [PMID: 35662032 DOI: 10.1002/mp.15713] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 04/11/2022] [Accepted: 05/05/2022] [Indexed: 11/05/2022] Open
Abstract
The Task Group (TG) on Magnetic Resonance Imaging (MRI) Implementation in High Dose Rate (HDR) Brachytherapy - Considerations from Simulation to Treatment, TG 303, was constituted by the American Association of Physicists in Medicine's (AAPM's) Science Council under the direction of the Therapy Physics Committee, the Brachytherapy Subcommittee, and the Working Group on Brachytherapy Clinical Applications. The TG was charged with developing recommendations for commissioning, clinical implementation, and on-going quality assurance (QA). Additionally, the TG was charged with describing HDR brachytherapy (BT) workflows and evaluating practical consideration that arise when implementing MR imaging. For brevity, the report is focused on the treatment of gynecologic and prostate cancer. The TG report provides an introduction and rationale for MRI implementation in BT, a review of previous publications on topics including available applicators, clinical trials, previously published BT related TG reports, and new image guided recommendations beyond CT based practices. The report describes MRI protocols and methodologies, including recommendations for the clinical implementation and logical considerations for MR imaging for HDR BT. Given the evolution from prescriptive to risk-based QA,1 an example of a risk-based analysis using MRI-based, prostate HDR BT is presented. In summary, the TG report is intended to provide clear and comprehensive guidelines and recommendations for commissioning, clinical implementation, and QA for MRI-based HDR BT that may be utilized by the medical physics community to streamline this process. This report is endorsed by the American Brachytherapy Society (ABS). This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | | | - Gil'ad Cohen
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | - Perry Johnson
- University of Florida Health Proton Therapy Institute, Jacksonville, FL
| | | | | | - Ken-Pin Hwang
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Sushil Beriwal
- Allegheny Health Network Cancer Institute, Pittsburgh, PA
| | | | - Firas Mourtada
- Sidney Kimmel Cancer Center at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Kong VC, Dang J, Li W, Navarro I, Padayachee J, Malkov V, Winter J, Raman S, Berlin A, Catton C, Warde P, Chung P. Dosimetric comparison of MR-guided adaptive IMRT versus 3DOF-VMAT for prostate stereotactic radiotherapy. Tech Innov Patient Support Radiat Oncol 2022; 21:64-70. [PMID: 35252598 PMCID: PMC8892164 DOI: 10.1016/j.tipsro.2022.02.003] [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: 11/29/2021] [Revised: 01/13/2022] [Accepted: 02/09/2022] [Indexed: 11/15/2022] Open
Abstract
Prostate SBRT are treated using MR-guided adaptive IMRT (A-IMRT) and VMAT based on translation correction (3DOF-VMAT) at our institution. Comparison of reference and delivered dose between adaptive-IMRT and 3DOF-VMAT to assess the effect of interfractional motion. Despite large interfractional changes, prostate received clinically acceptable dose with a margin of 5 mm through either A-IMRT or 3DOF-VMAT. A-IMRT was more superior than 3DOF-VMAT in sparing the rectum in the high dose region; no difference between the two systems was observed for bladder.
Introduction Methods & Materials Results Conclusions
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Affiliation(s)
- Vickie C. Kong
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
- Corresponding author at: Princess Margaret Cancer Centre, 610 University Avenue, Toronto, Ontario M5G 2M9, Canada.
| | - Jennifer Dang
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - Winnie Li
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Inmaculada Navarro
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Jerusha Padayachee
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Victor Malkov
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Jeff Winter
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Srinivas Raman
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Alejandro Berlin
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Charles Catton
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Padraig Warde
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Peter Chung
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
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Lakosi F, Antal G, Pall J, Farkas A, Jenei T, Nagy D, Liptak J, Sipocz I, Pytel A, Csima M, Gulyban A, Toller G. HDR brachytherapy boost using MR-only workflow for intermediate- and high-risk prostate cancer: 8-year results of a pilot study. Brachytherapy 2021; 20:576-583. [PMID: 33478906 DOI: 10.1016/j.brachy.2020.12.003] [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: 10/05/2020] [Revised: 12/05/2020] [Accepted: 12/09/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE To report 8-year clinical outcome with high-dose-rate brachytherapy (HDRBT) boost using MRI-only workflow for intermediate (IR) and high-risk (HR) prostate cancer (PC) patients. METHODS AND MATERIALS Fifty-two patients were treated with 46-60 Gy of 3D conformal radiotherapy preceded and/or followed by a single dose of 8-10 Gy MRI-guided HDRBT. Interventions were performed in a 0.35 T MRI scanner. Trajectory planning, navigation, contouring, catheter reconstruction, and dose calculation were exclusively based on MRI images. Biochemical relapse-free- (BRFS), local relapse-free- (LRFS), distant metastasis-free- (DMFS), cancer-specific-(CCS) and overall survival (OS) were analyzed. Late morbidity was scored using the Common Terminology Criteria for Adverse Events (CTCAE 4.0) combined with RTOG (Radiation Therapy Oncology Group) scale for urinary toxicity and rectal urgency (RU) determined by Yeoh. RESULTS Median follow-up time was 107 (range: 19-143) months. The 8-year actuarial rates of BRFS, LRFS, DMFS, CSS and OS were 85.7%, 97%, 97.6%, and 77.6%, respectively. There were no Gr.3 GI side effects. The 8-year actuarial rate of Gr.2 proctitis was 4%. The 8-year cumulative incidence of Gr.3 GU side effects was 8%, including two urinary stenoses (5%) and one cystitis (3%). EPIC urinary and bowel scores did not change significantly over time. CONCLUSIONS MRI-only HDR-BT boost with moderate dose escalation provides excellent 8-year disease control with a favorable toxicity profile for IRPC and HRPC patients. Our results support the clinical importance of MRI across the BT workflow.
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Affiliation(s)
- Ferenc Lakosi
- Somogy County Kaposi Mór Teaching Hospital, Dr. József Baka Center, Department of Radiation Oncology, Kaposvár, Hungary.
| | - Gergely Antal
- Somogy County Kaposi Mór Teaching Hospital, Dr. József Baka Center, Department of Radiation Oncology, Kaposvár, Hungary
| | - Janos Pall
- Somogy County Kaposi Mór Teaching Hospital, Dr. József Baka Center, Department of Radiation Oncology, Kaposvár, Hungary; Department of Radiation Oncology, Csolnoky Ferenc Hospital, Veszprém, Hungary
| | - Andrea Farkas
- Somogy County Kaposi Mór Teaching Hospital, Dr. József Baka Center, Department of Radiation Oncology, Kaposvár, Hungary
| | - Tibor Jenei
- Somogy County Kaposi Mór Teaching Hospital, Department of Urology, Kaposvár, Hungary
| | - Denes Nagy
- Somogy County Kaposi Mór Teaching Hospital, Department of Urology, Kaposvár, Hungary
| | - Jozsef Liptak
- Kanizsai Dorottya Hospital, Department of Urology, Nagykanizsa, Hungary
| | - Istvan Sipocz
- Petz Aladár County Teaching Hospital, Department of Radiation Oncology, Győr, Hungary
| | - Akos Pytel
- Pécs University, Department of Urology, Pecs, Hungary
| | - Melinda Csima
- Faculty of Pedagogy, Szent István University, Kaposvár Campus, Kaposvár, Hungary
| | - Akos Gulyban
- Medical Physics Department, Institut Jules Bordet, Bruxelles, Belgium
| | - Gabor Toller
- Somogy County Kaposi Mór Teaching Hospital, Dr. József Baka Center, Department of Radiation Oncology, Kaposvár, Hungary
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Dai X, Lei Y, Zhang Y, Qiu RLJ, Wang T, Dresser SA, Curran WJ, Patel P, Liu T, Yang X. Automatic multi-catheter detection using deeply supervised convolutional neural network in MRI-guided HDR prostate brachytherapy. Med Phys 2020; 47:4115-4124. [PMID: 32484573 DOI: 10.1002/mp.14307] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/19/2020] [Accepted: 05/24/2020] [Indexed: 12/19/2022] Open
Abstract
PURPOSE High-dose-rate (HDR) brachytherapy is an established technique to be used as monotherapy option or focal boost in conjunction with external beam radiation therapy (EBRT) for treating prostate cancer. Radiation source path reconstruction is a critical procedure in HDR treatment planning. Manually identifying the source path is labor intensive and time inefficient. In recent years, magnetic resonance imaging (MRI) has become a valuable imaging modality for image-guided HDR prostate brachytherapy due to its superb soft-tissue contrast for target delineation and normal tissue contouring. The purpose of this study is to investigate a deep-learning-based method to automatically reconstruct multiple catheters in MRI for prostate cancer HDR brachytherapy treatment planning. METHODS Attention gated U-Net incorporated with total variation (TV) regularization model was developed for multi-catheter segmentation in MRI. The attention gates were used to improve the accuracy of identifying small catheter points, while TV regularization was adopted to encode the natural spatial continuity of catheters into the model. The model was trained using the binary catheter annotation images offered by experienced physicists as ground truth paired with original MRI images. After the network was trained, MR images of a new prostate cancer patient receiving HDR brachytherapy were fed into the model to predict the locations and shapes of all the catheters. Quantitative assessments of our proposed method were based on catheter shaft and tip errors compared to the ground truth. RESULTS Our method detected 299 catheters from 20 patients receiving HDR prostate brachytherapy with a catheter tip error of 0.37 ± 1.68 mm and a catheter shaft error of 0.93 ± 0.50 mm. For detection of catheter tips, our method resulted in 87% of the catheter tips within an error of less than ± 2.0 mm, and more than 71% of the tips can be localized within an absolute error of no >1.0 mm. For catheter shaft localization, 97% of catheters were detected with an error of <2.0 mm, while 63% were within 1.0 mm. CONCLUSIONS In this study, we proposed a novel multi-catheter detection method to precisely localize the tips and shafts of catheters in three-dimensional MRI images of HDR prostate brachytherapy. It paves the way for elevating the quality and outcome of MRI-guided HDR prostate brachytherapy.
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Affiliation(s)
- Xianjin Dai
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30332, USA
| | - Yang Lei
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30332, USA
| | - Yupei Zhang
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30332, USA
| | - Richard L J Qiu
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30332, USA
| | - Tonghe Wang
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30332, USA
| | - Sean A Dresser
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30332, USA
| | - Walter J Curran
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30332, USA
| | - Pretesh Patel
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30332, USA
| | - Tian Liu
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30332, USA
| | - Xiaofeng Yang
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30332, USA
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Tumor-targeted dose escalation for localized prostate cancer using MR-guided HDR brachytherapy (HDR) or integrated VMAT (IB-VMAT) boost: Dosimetry, toxicity and health related quality of life. Radiother Oncol 2020; 149:240-245. [PMID: 32447033 DOI: 10.1016/j.radonc.2020.05.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 12/20/2022]
Abstract
PURPOSE To report dosimetry, preliminary toxicity and health-related quality of life (HRQoL) outcomes of tumor-targeted dose-escalation delivered by integrated boost volumetric arc therapy (IB-VMAT) or MR-guided HDR brachytherapy (HDR) boost for prostate cancer. MATERIALS AND METHODS Patients diagnosed with localized prostate cancer, with at least 1 identifiable intraprostatic lesion on multiparametric MRI (mpMRI) were enrolled in a prospective non-randomized phase II study. All patients received VMAT to the prostate alone (76 Gy in 38 fractions) plus a GTV boost: IB-VMAT (95 Gy in 38 fractions) or MR-guided HDR (10 Gy single fraction). GTV was delineated on mpMRI and deformably registered to planning CT scans. Comparative dosimetry using EQD2 assuming α/β 3 Gy was performed. Toxicity and health-related quality of life data (HRQoL) data were collected using CTCAE v.4.0, International Prostate Symptom Score (IPSS) and the Expanded Prostate Index Composite (EPIC). RESULTS Forty patients received IB-VMAT and 40 HDR boost. Organs at risk and target minimal doses were comparable between the two arms. HDR achieved higher mean and maximal tumor doses (p < 0.05). Median follow-up was 31 months (range 25-48); Acute grade G2 genitourinary (GU) toxicity was 30% and 37.5% in IB-VMAT and HDR boost, while gastrointestinal (GI) toxicity was 7.5% and 10%, respectively. Three patients developed acute G3 events, two GU toxicity (one IB-VMAT and one HDR boost) and one GI (IB-VMAT). Late G2 GU toxicity was 25% and 17.5% in the IB-VMAT and HDR boost arm and G2 GI was 5% and 7.5%, respectively. Two patients, both on the IB-VMAT arm, developed late G3 toxicity: one GI and one GU. No statistically significant difference was found in HRQoL between radiotherapy techniques (p > 0.2). Urinary and bowel HRQoL domains in both groups declined significantly by week 6 of treatment in both arms (p < 0.05) and recovered baseline scores at 6 months. CONCLUSION Intraprostatic tumor dose escalation using IB-VMAT or MR-guided HDR boost achieved comparable OAR dosimetry, toxicity and HRQOL outcomes, but higher mean and maximal tumor dose were achieved with the HDR technique. Further follow-up will determine long-term outcomes including disease control.
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10
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Dose to the bladder neck in MRI-guided high-dose-rate prostate brachytherapy: Impact on acute urinary toxicity and health-related quality of life. Brachytherapy 2019; 18:477-483. [DOI: 10.1016/j.brachy.2019.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 01/28/2019] [Accepted: 02/11/2019] [Indexed: 12/16/2022]
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The Role of Magnetic Resonance Imaging in Brachytherapy. Clin Oncol (R Coll Radiol) 2018; 30:728-736. [DOI: 10.1016/j.clon.2018.07.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 07/14/2018] [Accepted: 07/16/2018] [Indexed: 11/19/2022]
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Phase I study of dose escalation to dominant intraprostatic lesions using high-dose-rate brachytherapy. J Contemp Brachytherapy 2018; 10:193-201. [PMID: 30038638 PMCID: PMC6052382 DOI: 10.5114/jcb.2018.76881] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 05/18/2018] [Indexed: 01/02/2023] Open
Abstract
Purpose Radiation dose escalation for prostate cancer improves biochemical control but is limited by toxicity. Magnetic resonance spectroscopic imaging (MRSI) can define dominant intraprostatic lesions (DIL). This phase I study evaluated dose escalation to MRSI-defined DIL using high-dose-rate (HDR) brachytherapy. Material and methods Enrollment was closed early due to low accrual. Ten patients with prostate cancer (T2a-3b, Gleason 6-9, PSA < 20) underwent pre-treatment MRSI, and eight patients had one to three DIL identified. The eight enrolled patients received external beam radiation therapy to 45 Gy and HDR brachytherapy boost to the prostate of 19 Gy in 2 fractions. MRSI images were registered to planning CT images and DIL dose-escalated up to 150% of prescription dose while maintaining normal tissue constraints. The primary endpoint was genitourinary (GU) toxicity. Results The median total DIL volume was 1.31 ml (range, 0.67-6.33 ml). Median DIL boost was 130% of prescription dose (range, 110-150%). Median urethra V120 was 0.15 ml (range, 0-0.4 ml) and median rectum V75 was 0.74 ml (range, 0.1-1.0 ml). Three patients had acute grade 2 GU toxicity, and two patients had late grade 2 GU toxicity. No patients had grade 2 or higher gastrointestinal toxicity, and no grade 3 or higher toxicities were noted. There were no biochemical failures with median follow-up of 4.9 years (range, 2-8.5 years). Conclusions Dose escalation to MRSI-defined DIL is feasible. Toxicity was low but incompletely assessed due to limited patients’ enrollment.
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13
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Blanchard P, Graff-Cailleaud P, Bossi A. [Prostate brachytherapy: New techniques, new indications]. Cancer Radiother 2018; 22:352-358. [PMID: 29858134 DOI: 10.1016/j.canrad.2017.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 11/11/2017] [Accepted: 11/27/2017] [Indexed: 01/01/2023]
Abstract
Prostate brachytherapy has been for a long time one of the standard treatments for low risk prostate cancer, with high rates of biochemical control and low levels of urinary and sexual late toxicity compared to other available techniques, namely external beam radiotherapy and radical prostatectomy. The aim of this article is to review the recent innovations of prostate brachytherapy, which suggest a bright future for the technique. We will discuss the extension of indications of permanent implant brachytherapy to favorable intermediate-risk patients, the use of novel isotopes such as Palladium 103 and Cesium 131, and the benefit of brachytherapy as a boost following external beam radiotherapy for intermediate and high-risk patients. We will also discuss the rise of high dose rate brachytherapy, as a boost or monotherapy, the increasing use of MRI for patient selection and treatment planning, as well as the development of brachytherapy as a means of focal therapy.
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Affiliation(s)
- P Blanchard
- Département de radiothérapie, Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif, France; Inserm unité 1018, Oncostat, CESP, 16, avenue Paul-Vaillant-Couturier, 94807 Villejuif cedex, France.
| | - P Graff-Cailleaud
- Département de radiothérapie, institut universitaire du cancer de Toulouse - Oncopole, avenue Hubert-Curien, 31100 Toulouse, France
| | - A Bossi
- Département de radiothérapie, Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif, France
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14
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Dutta SW, Bauer-Nilsen K, Sanders JC, Trifiletti DM, Libby B, Lash DH, Lain M, Christodoulou D, Hodge C, Showalter TN. Time-driven activity-based cost comparison of prostate cancer brachytherapy and intensity-modulated radiation therapy. Brachytherapy 2018. [DOI: 10.1016/j.brachy.2018.01.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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15
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Dutta SW, Alonso CE, Libby B, Showalter TN. Prostate cancer high dose-rate brachytherapy: review of evidence and current perspectives. Expert Rev Med Devices 2017; 15:71-79. [PMID: 29251165 DOI: 10.1080/17434440.2018.1419058] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Patients with intermediate to high risk disease (prostate specific antigen (PSA) ≥ 10, Gleason score ≥ 7, or clinical stage ≥ T2b) suffer from poorer long-term biochemical control (freedom from an increasing prostate specific antigen level) when treated with external beam radiation (EBRT) alone. In order to improve biochemical control while limiting long-term complications, brachytherapy has been incorporated into radiotherapy treatment, either alone or in combination with EBRT. AREAS COVERED Current literature regarding the use of high dose-rate (HDR) brachytherapy for localized prostate cancer, including as a boost and monotherapy. The efficacy and toxicities of various approaches are evaluated including comparisons to low dose-rate (LDR) brachytherapy. EXPERT COMMENTARY Prostate HDR brachytherapy has higher conformality than EBRT, potentially improving the therapeutic ratio by allowing higher doses per fraction to tumor cells. The improved biochemical control shown in trials have resulted in EBRT plus brachytherapy to be included as a standard treatment option supported by the NCCN and ASCO guidance documents for intermediate to high risk prostate cancer.
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Affiliation(s)
- Sunil W Dutta
- a Department of Radiation Oncology , University of Virginia School of Medicine , Charlottesville , VA , USA
| | - Clayton E Alonso
- a Department of Radiation Oncology , University of Virginia School of Medicine , Charlottesville , VA , USA
| | - Bruce Libby
- a Department of Radiation Oncology , University of Virginia School of Medicine , Charlottesville , VA , USA
| | - Timothy N Showalter
- a Department of Radiation Oncology , University of Virginia School of Medicine , Charlottesville , VA , USA
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Lakosi F, Antal G, Pall J, Miovecz A, Nagy D, Jenei T, Csima M, Gulyban A, Vandulek C, Repa I, Hadjiev J, Toller G. Clinical outcome in prostate cancer treated with magnetic resonance imaging-guided high-dose-rate brachytherapy combined with external beam radiotherapy. Acta Oncol 2017; 56:1647-1651. [PMID: 28840771 DOI: 10.1080/0284186x.2017.1349333] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Ferenc Lakosi
- Institute of Diagnostic Imaging and Radiation Oncology, Health Center, Kaposvar University, Kaposvar, Hungary
| | - Gergely Antal
- Institute of Diagnostic Imaging and Radiation Oncology, Health Center, Kaposvar University, Kaposvar, Hungary
| | - Janos Pall
- Institute of Diagnostic Imaging and Radiation Oncology, Health Center, Kaposvar University, Kaposvar, Hungary
- Department of Radiation Oncology, Cholnoky Ferenc Hospital, Veszprem, Hungary
| | - Adam Miovecz
- Institute of Diagnostic Imaging and Radiation Oncology, Health Center, Kaposvar University, Kaposvar, Hungary
| | - Denes Nagy
- Department of Urology, Somogy County Kaposi Mor Teaching Hospital, Kaposvar, Hungary
| | - Tibor Jenei
- Department of Urology, Somogy County Kaposi Mor Teaching Hospital, Kaposvar, Hungary
| | - Melinda Csima
- Faculty of Pedagogy, Kaposvar University, Kaposvar, Hungary
| | - Akos Gulyban
- Department of Radiation Oncology, University Hospital of Liège, Liège, Belgium
| | - Csaba Vandulek
- Institute of Diagnostic Imaging and Radiation Oncology, Health Center, Kaposvar University, Kaposvar, Hungary
- Doctoral School of Health, Faculty of Health Sciences, University of Pecs, Pecs, Hungary
| | - Imre Repa
- Institute of Diagnostic Imaging and Radiation Oncology, Health Center, Kaposvar University, Kaposvar, Hungary
| | - Janaki Hadjiev
- Institute of Diagnostic Imaging and Radiation Oncology, Health Center, Kaposvar University, Kaposvar, Hungary
| | - Gabor Toller
- Institute of Diagnostic Imaging and Radiation Oncology, Health Center, Kaposvar University, Kaposvar, Hungary
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17
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Rink A, Borg J, Simeonov A, O'Leary G, Helou J, Ménard C, Chung P, Jaffray DA, Berlin A. Dosimetric impact of intrafraction changes in MR-guided high-dose-rate (HDR) brachytherapy for prostate cancer. Brachytherapy 2017; 17:59-67. [PMID: 28764881 DOI: 10.1016/j.brachy.2017.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 05/03/2017] [Accepted: 06/06/2017] [Indexed: 11/17/2022]
Abstract
PURPOSE To assess changes in implant and treatment volumes through the course of a prostate high-dose-rate brachytherapy procedure and their impact on plan quality metrics. METHODS AND MATERIALS Sixteen MRI-guided high-dose-rate procedures included a post-treatment MR (ptMR) immediately after treatment delivery (135 min between MR scans). Target and organs at risk (OARs) were contoured, and catheters were reconstructed. The delivered treatment plan was applied to the ptMR image set. Volumes and dosimetric parameters in the ptMR were evaluated and compared with the delivered plan using a paired two-tailed t-test with p < 0.05 considered statistically significant. RESULTS An average increase of 8.9% in prostate volume was observed for whole-gland treatments, resulting in reduction in coverage for both prostate and planning target volume, reflected in decreased V100 (mean 3.3% and 4.6%, respectively, p < 0.05), and D90 (mean 7.1% and 7.6%, respectively, of prescription dose, p < 0.05). There was no significant change in doses to OARs. For partial-gland treatments, there was an increase in planning target volume (9.1%), resulting in reduced coverage and D90 (mean 3.6% and 12.4%, respectively, p < 0.05). A decrease in D0.5cc for bladder (3%, p < 0.05) was observed, with no significant changes in dose to other OARs. CONCLUSIONS Volumetric changes were observed during the time between planning MR and ptMR. Nonetheless, treatment plans for both whole- and partial-gland therapies remained clinically acceptable. These results apply to clinical settings in which patients remain in the same position and under anesthesia during the entire treatment process.
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Affiliation(s)
- Alexandra Rink
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada; TECHNA Institute, Toronto, Canada.
| | - Jette Borg
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Anna Simeonov
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Gerald O'Leary
- Department of Anesthesia, University of Toronto, Toronto, Canada; University Health Network, Toronto, Canada
| | - Joelle Helou
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Cynthia Ménard
- TECHNA Institute, Toronto, Canada; University of Montreal Hospital Research Center (CRCHUM), Montreal, Canada
| | - Peter Chung
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - David A Jaffray
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada; TECHNA Institute, Toronto, Canada; University Health Network, Toronto, Canada; Department of Medical Biophysics, University of Toronto, Toronto, Canada
| | - Alejandro Berlin
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada.
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18
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Hrinivich WT, Hoover DA, Surry K, Edirisinghe C, Velker V, Bauman G, D'Souza D, Fenster A, Wong E. Accuracy and variability of high-dose-rate prostate brachytherapy needle tip localization using live two-dimensional and sagittally reconstructed three-dimensional ultrasound. Brachytherapy 2017; 16:1035-1043. [PMID: 28764882 DOI: 10.1016/j.brachy.2017.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 05/29/2017] [Accepted: 06/20/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE To measure the accuracy and variability of manual high-dose-rate (HDR) prostate brachytherapy (BT) needle tip localization using sagittally reconstructed three-dimensional (3D) transrectal ultrasound (TRUS) augmented with live two-dimensional (2D) sagittal TRUS. METHODS AND MATERIALS Ten prostate cancer patients underwent HDR-BT during which the sagittally assisted sagittally reconstructed (SASR) segmentation technique was completed in parallel with commercially available sagittally assisted axially reconstructed (SAAR) TRUS for comparison. The SASR technique makes use of live 2D ultrasound intraoperatively and allows needle tip updates using the final 3D image in the absence of image artifacts. These updates were repeated offline twice by two separate users. Needle end-length measurements were used to calculate insertion depth errors (IDEs) for each technique. RESULTS Images of 147 needles were analyzed. For the SASR technique, both users were confident in tip positions on the final 3D image within 3 mm for 52% of needles, so these tip positions were updated. For the remaining 48% of needles, the tip positions from the live 2D images were used. This SASR technique enabled the localization of all needles with IDEs within ±3 mm for 84% of needles and IDE range of [-6.2 mm, 5.9 mm], compared with 57% and [-8.1 mm, 7.7 mm] when using the commercially available SAAR technique. CONCLUSIONS The SASR technique mitigates the impact of 3D TRUS image artifacts on HDR-BT needle tip localization by incorporating live 2D sagittal TRUS intraoperatively and provides a statistically significant reduction in IDE variance compared with the routine SAAR technique.
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Affiliation(s)
- William Thomas Hrinivich
- Department of Medical Biophysics, Western University, London, ON, Canada; Robarts Imaging Research Lab, Western University, London, ON, Canada.
| | - Douglas A Hoover
- Department of Medical Biophysics, Western University, London, ON, Canada; Department of Oncology, Western University, London, ON, Canada; London Regional Cancer Program, London, ON, Canada
| | - Kathleen Surry
- Department of Medical Biophysics, Western University, London, ON, Canada; Department of Oncology, Western University, London, ON, Canada; London Regional Cancer Program, London, ON, Canada
| | | | - Vikram Velker
- Department of Oncology, Western University, London, ON, Canada; London Regional Cancer Program, London, ON, Canada
| | - Glenn Bauman
- Department of Oncology, Western University, London, ON, Canada; London Regional Cancer Program, London, ON, Canada
| | - David D'Souza
- Department of Oncology, Western University, London, ON, Canada; London Regional Cancer Program, London, ON, Canada
| | - Aaron Fenster
- Department of Medical Biophysics, Western University, London, ON, Canada; Department of Oncology, Western University, London, ON, Canada; Department of Physics and Astronomy, Western University, London, ON, Canada; Robarts Imaging Research Lab, Western University, London, ON, Canada
| | - Eugene Wong
- Department of Medical Biophysics, Western University, London, ON, Canada; Department of Oncology, Western University, London, ON, Canada; Department of Physics and Astronomy, Western University, London, ON, Canada; London Regional Cancer Program, London, ON, Canada
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19
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Brachytherapy patient safety events in an academic radiation medicine program. Brachytherapy 2017; 17:16-23. [PMID: 28757402 DOI: 10.1016/j.brachy.2017.06.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 04/26/2017] [Accepted: 06/22/2017] [Indexed: 12/17/2022]
Abstract
PURPOSE To describe the incidence and type of brachytherapy patient safety events over 10 years in an academic brachytherapy program. METHODS AND MATERIALS Brachytherapy patient safety events reported between January 2007 and August 2016 were retrieved from the incident reporting system and reclassified using the recently developed National System for Incident Reporting in Radiation Treatment taxonomy. A multi-incident analysis was conducted to identify common themes and key learning points. RESULTS During the study period, 3095 patients received 4967 brachytherapy fractions. An additional 179 patients had MR-guided prostate biopsies without treatment as part of an interventional research program. A total of 94 brachytherapy- or biopsy-related safety events (incidents, near misses, or programmatic hazards) were identified, corresponding to a rate of 2.8% of brachytherapy patients, 1.7% of brachytherapy fractions, and 3.4% of patients undergoing MR-guided prostate biopsy. Fifty-one (54%) events were classified as actual incidents, 29 (31%) as near misses, and 14 (15%) as programmatic hazards. Two events were associated with moderate acute medical harm or dosimetric severity, and two were associated with high dosimetric severity. Multi-incident analysis identified five high-risk activities or clinical scenarios as follows: (1) uncommon, low-volume or newly implemented brachytherapy procedures, (2) real-time MR-guided brachytherapy or biopsy procedures, (3) use of in-house devices or software, (4) manual data entry, and (5) patient scheduling and handoffs. CONCLUSIONS Brachytherapy is a safe treatment and associated with a low rate of patient safety events. Effective incident management is a key element of continuous quality improvement and patient safety in brachytherapy.
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20
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Wang J, Tanderup K, Cunha A, Damato AL, Cohen GN, Kudchadker RJ, Mourtada F. Magnetic resonance imaging basics for the prostate brachytherapist. Brachytherapy 2017; 16:715-727. [PMID: 28396178 DOI: 10.1016/j.brachy.2017.03.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 02/23/2017] [Accepted: 03/04/2017] [Indexed: 11/27/2022]
Abstract
Magnetic resonance imaging (MRI) is increasingly being used in radiation therapy, and integration of MRI into brachytherapy in particular is becoming more common. We present here a systematic review of the basic physics and technical aspects of incorporating MRI into prostate brachytherapy. Terminology and MRI system components are reviewed along with typical work flows in prostate high-dose-rate and low-dose-rate brachytherapy. In general, the brachytherapy workflow consists of five key components: diagnosis, implantation, treatment planning (scan + plan), implant verification, and delivery. MRI integration is discussed for diagnosis; treatment planning; and MRI-guided brachytherapy implants, in which MRI is used to guide the physical insertion of the brachytherapy applicator or needles. Considerations and challenges for establishing an MRI brachytherapy program are also discussed.
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Affiliation(s)
- Jihong Wang
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Adam Cunha
- Department of Radiation Oncology, University of California-San Francisco, CA
| | - Antonio L Damato
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Gil'ad N Cohen
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Rajat J Kudchadker
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Firas Mourtada
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, TX; Department of Radiation Oncology, Helen F. Graham Cancer Center, Newark, DE; Department of Radiation Oncology, Bodine Cancer Center, Thomas Jefferson University, Philadelphia, PA.
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21
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Hrinivich WT, Hoover DA, Surry K, Edirisinghe C, Montreuil J, D'Souza D, Fenster A, Wong E. Simultaneous automatic segmentation of multiple needles using 3D ultrasound for high-dose-rate prostate brachytherapy. Med Phys 2017; 44:1234-1245. [PMID: 28160517 DOI: 10.1002/mp.12148] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 01/10/2017] [Accepted: 01/29/2017] [Indexed: 12/31/2022] Open
Abstract
PURPOSE Sagittally reconstructed 3D (SR3D) ultrasound imaging shows promise for improved needle localization for high-dose-rate prostate brachytherapy (HDR-BT); however, needles must be manually segmented intraoperatively while the patient is anesthetized to create a treatment plan. The purpose of this article was to describe and validate an automatic needle segmentation algorithm designed for HDR-BT, specifically capable of simultaneously segmenting all needles in an HDR-BT implant using a single SR3D image with ~5 mm interneedle spacing. MATERIALS AND METHODS The segmentation algorithm involves regularized feature point classification and line trajectory identification based on the randomized 3D Hough transform modified to handle multiple straight needles in a single image simultaneously. Needle tips are identified based on peaks in the derivative of the signal intensity profile along the needle trajectory. For algorithm validation, 12 prostate cancer patients underwent HDR-BT during which SR3D images were acquired with all needles in place. Needles present in each of the 12 images were segmented manually, providing a gold standard for comparison, and using the algorithm. Tip errors were assessed in terms of the 3D Euclidean distance between needle tips, and trajectory error was assessed in terms of 2D distance in the axial plane and angular deviation between trajectories. RESULTS In total, 190 needles were investigated. Mean execution time of the algorithm was 11.0 s per patient, or 0.7 s per needle. The algorithm identified 82% and 85% of needle tips with 3D errors ≤3 mm and ≤5 mm, respectively, 91% of needle trajectories with 2D errors in the axial plane ≤3 mm, and 83% of needle trajectories with angular errors ≤3°. The largest tip error component was in the needle insertion direction. CONCLUSIONS Previous work has indicated HDR-BT needles may be manually segmented using SR3D images with insertion depth errors ≤3 mm and ≤5 mm for 83% and 92% of needles, respectively. The algorithm shows promise for reducing the time required for the segmentation of straight HDR-BT needles, and future work involves improving needle tip localization performance through improved image quality and modeling curvilinear trajectories.
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Affiliation(s)
- William Thomas Hrinivich
- Department of Medical Biophysics, University of Western Ontario, London, Ontario, N6A 5C1, Canada.,Imaging Research Laboratories, Robarts Research Institute, University of Western Ontario, London, Ontario, N6A 5K8, Canada
| | - Douglas A Hoover
- Department of Medical Biophysics, University of Western Ontario, London, Ontario, N6A 5C1, Canada.,Department of Oncology, University of Western Ontario, London, Ontario, N6A 4L6, Canada.,London Regional Cancer Program, London, Ontario, N6A 5W9, Canada
| | - Kathleen Surry
- Department of Medical Biophysics, University of Western Ontario, London, Ontario, N6A 5C1, Canada.,Department of Oncology, University of Western Ontario, London, Ontario, N6A 4L6, Canada.,London Regional Cancer Program, London, Ontario, N6A 5W9, Canada
| | - Chandima Edirisinghe
- Imaging Research Laboratories, Robarts Research Institute, University of Western Ontario, London, Ontario, N6A 5K8, Canada
| | - Jacques Montreuil
- Imaging Research Laboratories, Robarts Research Institute, University of Western Ontario, London, Ontario, N6A 5K8, Canada
| | - David D'Souza
- Department of Oncology, University of Western Ontario, London, Ontario, N6A 4L6, Canada.,London Regional Cancer Program, London, Ontario, N6A 5W9, Canada
| | - Aaron Fenster
- Department of Medical Biophysics, University of Western Ontario, London, Ontario, N6A 5C1, Canada.,Imaging Research Laboratories, Robarts Research Institute, University of Western Ontario, London, Ontario, N6A 5K8, Canada.,Department of Oncology, University of Western Ontario, London, Ontario, N6A 4L6, Canada.,Department of Physics and Astronomy, University of Western Ontario, London, Ontario, N6A 3K7, Canada
| | - Eugene Wong
- Department of Medical Biophysics, University of Western Ontario, London, Ontario, N6A 5C1, Canada.,Department of Oncology, University of Western Ontario, London, Ontario, N6A 4L6, Canada.,London Regional Cancer Program, London, Ontario, N6A 5W9, Canada.,Department of Physics and Astronomy, University of Western Ontario, London, Ontario, N6A 3K7, Canada
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22
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Thaker NG, Orio PF, Potters L. Defining the value of magnetic resonance imaging in prostate brachytherapy using time-driven activity-based costing. Brachytherapy 2017; 16:665-671. [PMID: 28187994 DOI: 10.1016/j.brachy.2016.11.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 11/29/2016] [Accepted: 11/29/2016] [Indexed: 10/20/2022]
Abstract
Magnetic resonance imaging (MRI) simulation and planning for prostate brachytherapy (PBT) may deliver potential clinical benefits but at an unknown cost to the provider and healthcare system. Time-driven activity-based costing (TDABC) is an innovative bottom-up costing tool in healthcare that can be used to measure the actual consumption of resources required over the full cycle of care. TDABC analysis was conducted to compare patient-level costs for an MRI-based versus traditional PBT workflow. TDABC cost was only 1% higher for the MRI-based workflow, and utilization of MRI allowed for cost shifting from other imaging modalities, such as CT and ultrasound, to MRI during the PBT process. Future initiatives will be required to follow the costs of care over longer periods of time to determine if improvements in outcomes and toxicities with an MRI-based approach lead to lower resource utilization and spending over the long-term. Understanding provider costs will become important as healthcare reform transitions to value-based purchasing and other alternative payment models.
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Affiliation(s)
- Nikhil G Thaker
- Department of Radiation Oncology, Arizona Oncology, The US Oncology Network, Tucson, AZ.
| | - Peter F Orio
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Milford Regional Medical Center, Boston, MA
| | - Louis Potters
- Department of Radiation Medicine at North Shore-LIJ Health System, New Hyde Park, NY
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23
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Ménard C, Pambrun JF, Kadoury S. The utilization of magnetic resonance imaging in the operating room. Brachytherapy 2017; 16:754-760. [PMID: 28139421 DOI: 10.1016/j.brachy.2016.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 12/12/2016] [Accepted: 12/12/2016] [Indexed: 11/26/2022]
Abstract
Online image guidance in the operating room using ultrasound imaging led to the resurgence of prostate brachytherapy in the 1980s. Here we describe the evolution of integrating MRI technology in the brachytherapy suite or operating room. Given the complexity, cost, and inherent safety issues associated with MRI system integration, first steps focused on the computational integration of images rather than systems. This approach has broad appeal given minimal infrastructure costs and efficiencies comparable with standard care workflows. However, many concerns remain regarding accuracy of registration through the course of a brachytherapy procedure. In selected academic institutions, MRI systems have been integrated in or near the brachytherapy suite in varied configurations to improve the precision and quality of treatments. Navigation toolsets specifically adapted to prostate brachytherapy are in development and are reviewed.
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Affiliation(s)
- C Ménard
- University of Montréal Hospital Research Centre (CRCHUM), Montréal, QC, Canada; TECHNA Institute, University of Toronto, Toronto, ON, Canada; Princess Margaret Cancer Center, Toronto, ON, Canada.
| | - J-F Pambrun
- University of Montréal Hospital Research Centre (CRCHUM), Montréal, QC, Canada; École polytechnique de Montréal, Montréal, QC, Canada
| | - S Kadoury
- University of Montréal Hospital Research Centre (CRCHUM), Montréal, QC, Canada; École polytechnique de Montréal, Montréal, QC, Canada
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24
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Clinical use of magnetic resonance imaging across the prostate brachytherapy workflow. Brachytherapy 2017; 16:734-742. [PMID: 28153700 DOI: 10.1016/j.brachy.2016.11.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 11/08/2016] [Accepted: 11/29/2016] [Indexed: 11/21/2022]
Abstract
MRI produces better soft tissue contrast than does ultrasonography or computed tomography for visualizing male pelvic anatomy and prostate cancer. Better visualization of the tumor and organs at risk could allow better conformation of the dose to the target volumes while at the same time minimizing the dose to critical structures and the associated toxicity. Although the use of MRI for prostate brachytherapy would theoretically result in an improved therapeutic ratio, its implementation been slow, mostly because of technical challenges. In this review, we describe the potential role of MRI at different steps in the treatment workflow for prostate brachytherapy: for patient selection, treatment planning, in the operating room, or for postimplant assessment. We further present the current clinical experience with MRI-guided prostate brachytherapy, both for permanent seed implantation and high-dose-rate brachytherapy.
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Tanderup K, Ménard C, Polgar C, Lindegaard JC, Kirisits C, Pötter R. Advancements in brachytherapy. Adv Drug Deliv Rev 2017; 109:15-25. [PMID: 27637454 DOI: 10.1016/j.addr.2016.09.002] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Revised: 06/14/2016] [Accepted: 09/05/2016] [Indexed: 11/17/2022]
Abstract
Brachytherapy is a radiotherapy modality associated with a highly focal dose distribution. Brachytherapy treats the cancer tissue from the inside, and the radiation does not travel through healthy tissue to reach the target as with external beam radiotherapy techniques. The nature of brachytherapy makes it attractive for boosting limited size target volumes to very high doses while sparing normal tissues. Significant developments over the last decades have increased the use of 3D image guided procedures with the utilization of CT, MRI, US and PET. This has taken brachytherapy to a new level in terms of controlling dose and demonstrating excellent clinical outcome. Interests in focal, hypofractionated and adaptive treatments are increasing, and brachytherapy has significant potential to develop further in these directions with current and new treatment indications.
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Affiliation(s)
- Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark.
| | - Cynthia Ménard
- Centre Hospitalier de l'Université de Montréal, Montréal and Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Csaba Polgar
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary
| | | | - Christian Kirisits
- Department of Radiotherapy, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Richard Pötter
- Department of Radiotherapy, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
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26
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Soni PD, Berlin A, Venkatesan AM, McLaughlin PW. Magnetic resonance imaging-guided functional anatomy approach to prostate brachytherapy. Brachytherapy 2016; 16:698-714. [PMID: 28040380 DOI: 10.1016/j.brachy.2016.11.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 11/17/2016] [Accepted: 11/18/2016] [Indexed: 01/18/2023]
Abstract
PURPOSE To provide an MRI based functional anatomy guide to prostate brachytherapy. METHODS AND MATERIALS We performed a narrative review of periprostatic functional anatomy and the significance of this anatomy in prostate brachytherapy treatment planning. RESULTS MRI has improved delineation of gross tumor and critical periprostatic structures that have been implicated in toxicity. Furthermore, MRI has revealed the significant anatomic variants and the dynamic nature of these structures that can have significant implications for treatment planning and dosimetry. CONCLUSIONS The MRI-based functional anatomy approach to prostate brachytherapy takes into account extent of disease, its relation to the patient's individual anatomy, and functional baseline to optimize the therapeutic ratio of prostate cancer treatment.
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Affiliation(s)
- Payal D Soni
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Alejandro Berlin
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Aradhana M Venkatesan
- Section of Abdominal Imaging, Department of Diagnostic Radiology, MD Anderson Cancer Center, Houston, TX
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Hosni A, Carlone M, Rink A, Ménard C, Chung P, Berlin A. Dosimetric feasibility of ablative dose escalated focal monotherapy with MRI-guided high-dose-rate (HDR) brachytherapy for prostate cancer. Radiother Oncol 2016; 122:103-108. [PMID: 27916416 DOI: 10.1016/j.radonc.2016.11.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 11/04/2016] [Accepted: 11/10/2016] [Indexed: 12/13/2022]
Abstract
PURPOSE To determine the dosimetric feasibility of dose-escalated MRI-guided high-dose-rate brachytherapy (HDR-BT) focal monotherapy for prostate cancer (PCa). METHODS In all patients, GTV was defined with mpMRI, and deformably registered onto post-catheter insertion planning MRI. PTV included the GTV plus 9mm craniocaudal and 5mm in every other direction. In discovery-cohort, plans were obtained for each PTV independently aiming to deliver ⩾16.5Gy/fraction (two fraction schedule) while respecting predefined organs-at-risk (OAR) constraints or halted when achieved equivalent single-dose plan (24Gy). Dosimetric results of original and focal HDR-BT plans were evaluated to develop a planning protocol for the validation-cohort. RESULTS In discovery-cohort (20-patients, 32-GTVs): PTV D95% ⩾16.5Gy could not be reached in a single plan (3%) and was accomplished (range 16.5-23.8Gy) in 15 GTVs (47%). Single-dose schedule was feasible in 16 (50%) plans. In the validation-cohort (10-patients, 10-GTVs, two separate implants each): plans met acceptable and ideal criteria in 100% and 43-100% respectively. Migration to single-dose treatment schedule was feasible in 7 implants (35%), without relaxing OAR's constraints or increasing the dose (D100% and D35%) to mpMRI-normal prostate (p>0.05). CONCLUSION Focal ablative dose-escalated radiation is feasible with the proposed protocol. Prospective studies are warranted to determine the clinical outcomes.
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Affiliation(s)
- Ali Hosni
- Radiation Medicine Program, Princess Margaret Cancer Centre - University Health Network, Department of Radiation Oncology, University of Toronto, Canada
| | - Marco Carlone
- Radiation Medicine Program, Princess Margaret Cancer Centre - University Health Network, Department of Radiation Oncology, University of Toronto, Canada
| | - Alexandra Rink
- Radiation Medicine Program, Princess Margaret Cancer Centre - University Health Network, Department of Radiation Oncology, University of Toronto, Canada
| | - Cynthia Ménard
- Département de radio-oncologie, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Canada
| | - Peter Chung
- Radiation Medicine Program, Princess Margaret Cancer Centre - University Health Network, Department of Radiation Oncology, University of Toronto, Canada
| | - Alejandro Berlin
- Radiation Medicine Program, Princess Margaret Cancer Centre - University Health Network, Department of Radiation Oncology, University of Toronto, Canada.
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