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Quetin S, Bahoric B, Maleki F, Enger SA. Deep learning for high-resolution dose prediction in high dose rate brachytherapy for breast cancer treatment. Phys Med Biol 2024; 69:105011. [PMID: 38604185 DOI: 10.1088/1361-6560/ad3dbd] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 04/11/2024] [Indexed: 04/13/2024]
Abstract
Objective.Monte Carlo (MC) simulations are the benchmark for accurate radiotherapy dose calculations, notably in patient-specific high dose rate brachytherapy (HDR BT), in cases where considering tissue heterogeneities is critical. However, the lengthy computational time limits the practical application of MC simulations. Prior research used deep learning (DL) for dose prediction as an alternative to MC simulations. While accurate dose predictions akin to MC were attained, graphics processing unit limitations constrained these predictions to large voxels of 3 mm × 3 mm × 3 mm. This study aimed to enable dose predictions as accurate as MC simulations in 1 mm × 1 mm × 1 mm voxels within a clinically acceptable timeframe.Approach.Computed tomography scans of 98 breast cancer patients treated with Iridium-192-based HDR BT were used: 70 for training, 14 for validation, and 14 for testing. A new cropping strategy based on the distance to the seed was devised to reduce the volume size, enabling efficient training of 3D DL models using 1 mm × 1 mm × 1 mm dose grids. Additionally, novel DL architecture with layer-level fusion were proposed to predict MC simulated dose to medium-in-medium (Dm,m). These architectures fuse information from TG-43 dose to water-in-water (Dw,w) with patient tissue composition at the layer-level. Different inputs describing patient body composition were investigated.Main results.The proposed approach demonstrated state-of-the-art performance, on par with the MCDm,mmaps, but 300 times faster. The mean absolute percent error for dosimetric indices between the MC and DL-predicted complete treatment plans was 0.17% ± 0.15% for the planning target volumeV100, 0.30% ± 0.32% for the skinD2cc, 0.82% ± 0.79% for the lungD2cc, 0.34% ± 0.29% for the chest wallD2ccand 1.08% ± 0.98% for the heartD2cc.Significance.Unlike the time-consuming MC simulations, the proposed novel strategy efficiently converts TG-43Dw,wmaps into preciseDm,mmaps at high resolution, enabling clinical integration.
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Affiliation(s)
- Sébastien Quetin
- Medical Physics Unit, Department of Oncology, McGill University, Montreal, QC, Canada
- Montreal Institute for Learning Algorithms, Mila, Montreal, QC, Canada
| | - Boris Bahoric
- Department of Radiation Oncology, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Farhad Maleki
- Department of Computer Science, University of Calgary, Calgary, AB, Canada
- Department of Diagnostic Radiology, McGill University, Montreal, QC, Canada
- Department of Radiology, University of Florida, Gainesville, FL, United States of America
| | - Shirin A Enger
- Medical Physics Unit, Department of Oncology, McGill University, Montreal, QC, Canada
- Montreal Institute for Learning Algorithms, Mila, Montreal, QC, Canada
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada
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Turkheimer LM, Petroni GR, Berger AC, Schroen AT, Brenin DR, Lazar M, Libby B, Janowski EM, Showalter TN, Showalter SL. Novel Form of Breast Intraoperative Radiation Therapy with CT-Guided High-Dose-Rate Brachytherapy: Interim Results of a Prospective Phase-II Clinical Trial. J Am Coll Surg 2024; 238:10-20. [PMID: 37870228 DOI: 10.1097/xcs.0000000000000869] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
BACKGROUND Precision breast intraoperative radiation therapy (PB-IORT) is a novel method of IORT that uses customized CT-based treatment plans and high-dose-rate (HDR) brachytherapy. We conducted a phase-II multi-institution trial to evaluate the efficacy of PB-IORT. STUDY DESIGN Between 2015 and 2022, 3 centers enrolled women aged 45 years and older with invasive or in situ carcinoma measuring 3 cm or smaller and N0 status (n = 358). Breast-conserving surgery was performed, and a multilumen balloon catheter was placed in the lumpectomy bed. CT images were used to create customized HDR brachytherapy plans that delivered 12.5 Gy to the tumor bed. The primary outcome assessed was the 5-year rate of index quadrant tumor recurrence. An interim analysis was conducted after one-third of eligible participants completed 5 years of follow-up. This trial is registered with clinicaltrials.gov (NCT02400658). RESULTS The cohort comprised 153 participants with a median age of 64 years and median follow-up time of 5.9 years. The estimated 5-year index quadrant tumor recurrence rate and overall survival were 5.08% (95% CI 2.23 to 9.68) and 95.1%, respectively. Locoregional (ipsilateral breast and axilla) and distant recurrence rates were each 1.96%. Seven deaths occurred during the first 5 years of follow-up, with only 1 attributable to breast cancer. Overall, 68.6% of patients experienced any adverse effects, and 4 cases of breast-related severe toxicities were observed. CONCLUSIONS This study presents the results of a planned interim analysis of a phase-II trial investigating PB-IORT and demonstrates the efficacy and safety of single-fraction, CT-based, HDR brachytherapy after breast-conserving surgery. These findings provide valuable insights into the use of PB-IORT as a treatment modality.
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Affiliation(s)
- Lena M Turkheimer
- From the Departments of Surgery (Turkheimer, Schroen, Brenin, SL Showalter), University of Virginia School of Medicine, Charlottesville, VA
| | - Gina R Petroni
- Division of Translational Research and Applied Statistics, Department of Public Health Sciences, University of Virginia Health System, Charlottesville, VA (Petroni)
| | - Adam C Berger
- Department of Surgery, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ (Berger)
| | - Anneke T Schroen
- From the Departments of Surgery (Turkheimer, Schroen, Brenin, SL Showalter), University of Virginia School of Medicine, Charlottesville, VA
| | - David R Brenin
- From the Departments of Surgery (Turkheimer, Schroen, Brenin, SL Showalter), University of Virginia School of Medicine, Charlottesville, VA
| | - Melissa Lazar
- Department of Surgery, Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, PA (Lazar)
| | - Bruce Libby
- Radiation Oncology, Moffitt Cancer Center, Tampa, FL (Libby)
| | - Einsley M Janowski
- Radiation Oncology (Janowski, TN Showalter), University of Virginia School of Medicine, Charlottesville, VA
| | - Timothy N Showalter
- Radiation Oncology (Janowski, TN Showalter), University of Virginia School of Medicine, Charlottesville, VA
| | - Shayna L Showalter
- From the Departments of Surgery (Turkheimer, Schroen, Brenin, SL Showalter), University of Virginia School of Medicine, Charlottesville, VA
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Ayala Alvarez DS, Watson PGF, Popovic M, Heng VJ, Evans MDC, Panet-Raymond V, Seuntjens J. Evaluation of Dosimetry Formalisms in Intraoperative Radiation Therapy of Glioblastoma. Int J Radiat Oncol Biol Phys 2023; 117:763-773. [PMID: 37150259 DOI: 10.1016/j.ijrobp.2023.04.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/21/2023] [Accepted: 04/29/2023] [Indexed: 05/09/2023]
Abstract
PURPOSE The intraoperative radiotherapy in newly diagnosed glioblastoma multiforme (INTRAGO) clinical trial assesses survival in patients with glioblastoma treated with intraoperative radiation therapy (IORT) using the INTRABEAM. Treatment planning for INTRABEAM relies on vendor-provided in-water depth dose curves obtained according to the TARGeted Intraoperative radioTherapy (TARGIT) dosimetry protocol. However, recent studies have shown discrepancies between the estimated TARGIT and delivered doses. This work evaluates the effect of the choice of dosimetry formalism on organs at risk (OAR) doses. METHODS AND MATERIALS A treatment planning framework for INTRABEAM was developed to retrospectively calculate the IORT dose in 8 INTRAGO patients. These patients received an IORT prescription dose of 20 to 30 Gy in addition to external beam radiation therapy. The IORT dose was obtained using (1) the TARGIT method; (2) the manufacturer's V4.0 method; (3) the CQ method, which uses an ionization chamber Monte Carlo (MC) calculated factor; (4) MC dose-to-water; and (5) MC dose-to-tissue. The IORT dose was converted to 2 Gy fractions equivalent dose. RESULTS According to the TARGIT method, the OAR dose constraints were respected in all cases. However, the other formalisms estimated a higher mean dose to OARs and revealed 1 case where the constraint for the brain stem was exceeded. The addition of the external beam radiation therapy and TARGIT IORT doses resulted in 10 cases of OARs exceeding the dose constraints. The more accurate MC calculation of dose-to-tissue led to the highest dosimetric differences, with 3, 3, 2, and 2 cases (out of 8) exceeding the dose constraint to the brain stem, optic chiasm, optic nerves, and lenses, respectively. Moreover, the mean cumulative dose to brain stem exceeded its constraint of 66 Gy with the MC dose-to-tissue method, which was not evident with the current INTRAGO clinical practice. CONCLUSIONS The current clinical approach of calculating the IORT dose with the TARGIT method may considerably underestimate doses to nearby OARs. In practice, OAR dose constraints may have been exceeded, as revealed by more accurate methods.
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Affiliation(s)
| | | | | | - Veng Jean Heng
- Department of Physics and Medical Physics Unit, McGill University, Montreal, QC, Canada
| | | | - Valerie Panet-Raymond
- Department of Radiation Oncology, McGill University Health Centre, Montreal, QC, Canada
| | - Jan Seuntjens
- Medical Physics Unit and; Princess Margaret Cancer Centre, Radiation Medicine Program, University Health Network, Toronto, ON, Canada
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Ward KA, Muller DA, Dutta SW, Malhi J, Sanders JC, Luminais CK, Millard TA, Showalter TN, Showalter SL, Janowski EM. Long-Term Adherence to Adjuvant Endocrine Therapy Following Various Radiotherapy Modalities in Early Stage Hormone Receptor Positive Breast Cancer. Clin Breast Cancer 2023; 23:369-377. [PMID: 36868913 DOI: 10.1016/j.clbc.2023.01.012] [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: 07/28/2022] [Revised: 12/24/2022] [Accepted: 01/25/2023] [Indexed: 02/04/2023]
Abstract
INTRODUCTION We compared the rates of long-term adjuvant endocrine therapy (AET) adherence after various radiation therapy (RT) modalities among patients with early stage breast cancer. MATERIALS AND METHODS Medical records from patients with stage 0, I, or IIA (tumors ≤3 cm), hormone receptor (HR) positive breast cancer that received adjuvant radiation therapy (RT) from 2013 to 2015 at a single institution were retrospectively reviewed. All patients received breast conserving surgery (BCS) followed by adjuvant RT via one of the following modalities: whole breast radiotherapy (WBI), partial breast irradiation (PBI) with either external beam radiation therapy (EBRT) or fractionated intracavitary high-dose rate (HDR) brachytherapy, or single fraction HDR-brachytherapy intraoperative-radiation therapy (IORT). RESULTS One hundred fourteen patients were reviewed. Thirty patients received WBI, 41 PBI, and 43 IORT with a median follow up of 64.2, 72.0, and 58.6 months, respectively. For the entire cohort, AET adherence was approximately 64% at 2 years and 56% at 5 years. Among patients in the IORT clinical trial, adherence to AET was approximately 51% at 2 years and 40% at 5 years. After controlling for additional factors, DCIS histology (vs invasive disease) and IORT (compared to other radiation modalities) were associated with decreased endocrine therapy adherence (P < 0.05). CONCLUSION DCIS histology and receipt of IORT were associated with lower rates of adherence to AET at 5 years. Our findings suggest that examination of the efficacy of RT interventions such as PBI and IORT in patients who do not receive AET is warranted.
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Affiliation(s)
- Kristin A Ward
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA.
| | - Donald A Muller
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA
| | - Sunil W Dutta
- Department of Radiation Oncology, Emory University, Atlanta, GA
| | - Jasmine Malhi
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA
| | - Jason C Sanders
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA
| | | | - Trish A Millard
- Department of Hematology/Oncology, University of Virginia, Charlottesville, VA
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA
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Shah C. Intraoperative radiation and electronic brachytherapy in Brachytherapy: A look back and forward. Brachytherapy 2023; 22:4-5. [PMID: 36725199 DOI: 10.1016/j.brachy.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 08/03/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH.
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6
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Intraoperative radiation therapy in the management of early stage breast cancer. Brachytherapy 2023; 22:47-52. [PMID: 36207243 DOI: 10.1016/j.brachy.2022.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 09/02/2022] [Indexed: 02/04/2023]
Abstract
Adjuvant radiotherapy (RT) following breast conserving surgery (BCS) is associated with an improvement in local control and a reduction in breast cancer mortality. While traditionally delivered with whole breast irradiation (WBI), novel approaches have looked to reduce the duration, target volume, and toxicity of adjuvant RT. One such approach is intraoperative radiation therapy (IORT), which delivers radiation at the time of surgery with 80-90% of patients not requiring additional WBI. The current review presents IORT techniques and outcomes from modern series evaluating IORT as monotherapy or as a tumor bed boost. Based on two randomized trials (TARGIT-A and ELIOT) with recent updates, concern regarding higher rates of local recurrence with IORT exist, whether using electrons or low-energy techniques. In contrast, data is promising regarding IORT used as a boost, with ongoing studies evaluating its role prospectively. With respect to toxicity, the data suggest IORT is associated with comparable to slightly lower rates of toxicity though there may be a higher risk of seroma requiring aspiration and fat necrosis with IORT. Given current data and guidelines, WBI or other partial breast techniques should remain the standard of care in early stage breast cancer patients, while IORT should not be utilized outside of prospective clinical trials at this time.
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Squeo GC, Lattimore CM, Simone NL, Suralik G, Dutta SW, Schad MD, Su L, Libby B, Janowski EM, Showalter SL, Lobo JM, Showalter TN. A comparative study using time-driven activity-based costing in single-fraction breast high-dose rate brachytherapy: An integrated brachytherapy suite vs. decentralized workflow. Brachytherapy 2022; 21:334-340. [PMID: 35125328 PMCID: PMC9149052 DOI: 10.1016/j.brachy.2021.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/06/2021] [Accepted: 12/07/2021] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Precision breast intraoperative radiation therapy (PB-IORT) is a novel approach to adjuvant radiation therapy for early-stage breast cancer performed as part of a phase II clinical trial at two institutions. One institution performs the entire procedure in an integrated brachytherapy suite which contains a CT-on-rails imaging unit and full anesthesia capabilities. At the other, breast conserving surgery and radiation therapy take place in two separate locations. Here, we utilize time-driven activity-based costing (TDABC) to compare these two models for the delivery of PB-IORT. METHODS Process maps were created to describe each step required to deliver PB-IORT at each institution, including personnel, equipment, and supplies. Time investment was estimated for each step. The capacity cost rate was determined for each resource, and total costs of care were then calculated by multiplying the capacity cost rates by the time estimate for the process step and adding any additional product costs. RESULTS PB-IORT costs less to deliver at a distributed facility, as is more commonly available, than an integrated brachytherapy suite ($3,262.22 vs. $3,996.01). The largest source of costs in both settings ($2,400) was consumable supplies, including the brachytherapy balloon applicator. The difference in costs for the two facility types was driven by personnel costs ($1,263.41 vs. $764.89). In the integrated facility, increased time required by radiation oncology nursing and the anesthesia attending translated to the greatest increases in cost. Equipment costs were also slightly higher in the integrated suite setting ($332.60 vs. $97.33). CONCLUSIONS The overall cost of care is higher when utilizing an integrated brachytherapy suite to deliver PB-IORT. This was primarily driven by additional personnel costs from nursing and anesthesia, although the greatest cost of delivery in both settings was the disposable brachytherapy applicator. These differences in cost must be balanced against the potential impact on patient experience with these approaches.
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Affiliation(s)
- Gabriella C Squeo
- Division of Breast and Melanoma Surgery, Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA
| | - Courtney M Lattimore
- Division of Breast and Melanoma Surgery, Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA
| | - Nicole L Simone
- Department of Radiation Oncology, Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, PA
| | - Greg Suralik
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | - Sunil W Dutta
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | - Michael D Schad
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | - Lucy Su
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | - Bruce Libby
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | - Einsley-Marie Janowski
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | - Shayna L Showalter
- Division of Breast and Melanoma Surgery, Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA
| | - Jennifer M Lobo
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA.
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Lattimore CM, Meneveau MO, Petroni GR, Varhegyi NE, Squeo GC, Showalter TN, Showalter SL. Effects of a novel form of intraoperative radiation therapy on quality of life among patients with early-stage breast cancer. Brachytherapy 2022; 21:325-333. [PMID: 35120862 PMCID: PMC9149037 DOI: 10.1016/j.brachy.2021.12.002] [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: 10/11/2021] [Revised: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE To investigate patient-perceived quality of life (QOL) among patients treated with a novel form of breast intraoperative radiation therapy (PB-IORT). METHODS AND MATERIALS Patients treated with PB-IORT as part of a phase II clinical trial from 2013 to 2020 were identified. Patients were given the European Organization for Research and Treatment of Cancer (EORTC) core 30-item Quality of Life Questionnaire (QLQ-C30) encompassing global health, functionality, and symptomatology at baseline, 1-month, 6-months, 12-months, and 24-months after PB-IORT. Scores were on a 100-point scale with change greater than 10 considered clinically significant. Scores at interval follow-up were compared to baseline using repeated measure modeling with an unstructured covariance matrix. RESULTS The cohort consisted of 303 patients, a majority of which were White (84.2%) with a median age of 64 years (IQR: 52, 76). One month after PB-IORT, a decline from baseline in physical (-2.5, 95% CI: -4.4 - -0.55, p = 0.01), role (-7.6, 95% CI: -11.7 - -3.5, p < 0.001), and social functioning (-3.0, 95% CI: -5.5 - -0.42, p = 0.02) were observed, which correlated with increased fatigue (8.4, 95% CI: 5.5-11.3, p < 0.001). At 6 months, nearly all QOL measures returned to baseline or improved. There were no statistically or clinically significant differences from baseline in overall global health. All functional and symptom scale differences were less than 10, indicating minimal clinical significance. CONCLUSIONS PB-IORT has minimal negative impact on QOL, further supporting this patient-centered treatment approach for early-stage breast cancer.
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Affiliation(s)
- Courtney M Lattimore
- Department of Surgery, University of Virginia Health System, Charlottesville, VA.
| | - Max O Meneveau
- Department of Surgery, University of Virginia Health System, Charlottesville, VA
| | - Gina R Petroni
- Division of Translational Research & Applied Statistics, Department of Public Health Sciences, University of Virginia Health System, Charlottesville, VA
| | - Nikole E Varhegyi
- Division of Translational Research & Applied Statistics, Department of Public Health Sciences, University of Virginia Health System, Charlottesville, VA
| | - Gabriella C Squeo
- Department of Surgery, University of Virginia Health System, Charlottesville, VA
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia Health System, VA 22908
| | - Shayna L Showalter
- Department of Surgery, University of Virginia Health System, Charlottesville, VA.
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Dickhoff LR, Vrancken Peeters MJ, Bosman PA, Alderliesten T. Therapeutic applications of radioactive sources: from image-guided brachytherapy to radio-guided surgical resection. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF... 2021; 65:190-201. [PMID: 34105339 DOI: 10.23736/s1824-4785.21.03370-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
It is well known nowadays that radioactivity can destroy the living cells it interacts with. It is therefore unsurprising that radioactive sources, such as iodine-125, were historically developed for treatment purposes within radiation oncology with the goal of damaging malignant cells. However, since then, new techniques have been invented that make creative use of the same radioactivity properties of these sources for medical applications. Here, we review two distinct kinds of therapeutic uses of radioactive sources with applications to prostate, cervical, and breast cancer: brachytherapy and radioactive seed localization. In brachytherapy (BT), the radioactive sources are used for internal radiation treatment. Current approaches make use of real-time image guidance, for instance by means of magnetic resonance imaging, ultrasound, computed tomography, and sometimes positron emission tomography, depending on clinical availability and cancer type. Such image-guided BT for prostate and cervical cancer presents a promising alternative and/or addition to external beam radiation treatments or surgical resections. Radioactive sources can also be used for radio-guided tumor localization during surgery, for which the example of iodine-125 seed use in breast cancer is given. Radioactive seed localization (RSL) is increasingly popular as an alternative tumor localization technique during breast cancer surgery. Advantages of applying RSL include added flexibility in the clinical scheduling logistics, an increase in tumor localization accuracy, and higher patient satisfaction; safety measures do however have to be employed. We exemplify the implementation of RSL in a clinic through experiences at the Netherlands Cancer Institute.
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Affiliation(s)
- Leah R Dickhoff
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands -
| | - Marie-Jeanne Vrancken Peeters
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.,Department of Surgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Peter A Bosman
- Life Sciences and Health group, Centrum Wiskunde & Informatica, Amsterdam, The Netherlands
| | - Tanja Alderliesten
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
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Unnikrishnan S, Brenin DR, Suralik G, Showalter TN, Shami V, Libby B, Watkins WT, Showalter SL, Zhao F, Govinahallisathyanarayana S, Hossack JA. Use of an ultrasound imaging device within the applicator to evaluate placement and support treatment planning for breast brachytherapy and intraoperative radiation therapy. Brachytherapy 2020; 20:200-206. [PMID: 33041231 DOI: 10.1016/j.brachy.2020.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/13/2020] [Accepted: 08/14/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE We evaluated the use of ultrasound imaging within a brachytherapy applicator as a method for applicator positioning, evaluation, and treatment planning in a series of in vitro, cadaver, and human studies. METHODS AND MATERIALS We evaluated the performance of a prototype system comprising a small ultrasound imaging catheter inserted within the lumen of a balloon brachytherapy catheter. We tested the device in an ultrasound phantom, in human breast tissue, and in an endoscopic ultrasound catheter in cadaveric breast tissue. We evaluated the visualization of adjacent tissue to consider future development of a similar system for use in brachytherapy and intraoperative radiation therapy. RESULTS Based on the ultrasound images obtained in an ultrasound phantom, cadaveric breast, and human participants, we observed that an ultrasound imaging catheter placed within the lumen of a brachytherapy applicator can effectively image adjacent tissue, ribs, and air voids, with appropriate quality to support clinical use. We observed high correlation in clinically useful information detected on ultrasound and comparative CT, with ultrasound spatial resolution near 1 mm (spatially variant). CONCLUSIONS The findings from our pilot work suggest that real-time ultrasound imaging, operated from within the applicator, is a promising technique for image guidance and treatment planning during brachytherapy and intraoperative radiation therapy. Further expansion of this technology for clinical use will require development of a cohesive system of components to suit specific clinical applications.
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Affiliation(s)
- S Unnikrishnan
- Department of Biomedical Engineering, School of Engineering, University of Virginia, Charlottesville, VA
| | - D R Brenin
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA
| | - G Suralik
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | - T N Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | - V Shami
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA
| | - B Libby
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | - W T Watkins
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | - S L Showalter
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA
| | - F Zhao
- Department of Biomedical Engineering, School of Engineering, University of Virginia, Charlottesville, VA
| | | | - J A Hossack
- Department of Biomedical Engineering, School of Engineering, University of Virginia, Charlottesville, VA.
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11
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Suralik G, Rudra S, Dutta SW, Yu J, Sanders JC, Schad MD, Janowski EM, Su L, Libby B, Showalter SL, Lobo JM, Showalter TN. Time-driven activity-based costing of a novel form of CT-guided high-dose-rate brachytherapy intraoperative radiation therapy compared with conventional breast intraoperative radiation therapy for early stage breast cancer. Brachytherapy 2020; 19:348-354. [PMID: 32229072 DOI: 10.1016/j.brachy.2020.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 02/04/2020] [Accepted: 02/04/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Intraoperative radiation therapy is an emerging option for adjuvant therapy for early stage breast cancer, although it is not currently considered standard of care in the United States. We applied time-driven activity-based costing to compare two alternative methods of breast intraoperative radiation therapy, including treatment similar to the techniques employed in the TARGIT-A clinical trial and a novel version with CT-guidance and high-dose-rate (HRD) brachytherapy. METHODS AND MATERIALS Process maps were created to describe the steps required to deliver intraoperative radiation therapy for early stage breast cancer at each institution. The components of intraoperative radiation therapy included personnel, equipment, and consumable supplies. The capacity cost rate was determined for each resource. Based on this, the delivery costs were calculated for each regimen. For comparison across centers, we did not account for indirect facilities costs and interinstitutional differences in personnel salaries. RESULTS The CT-guided, HRD form of intraoperative radiation therapy costs more to deliver ($4,126.21) than the conventional method studied in the TARGIT-A trial ($1,070.45). The cost of the brachytherapy balloon applicator ($2,750) was the primary driver of the estimated differences in costs. Consumable supplies were the largest contributor to the brachytherapy-based approach, whereas personnel costs were the largest contributor to costs of the standard form of intraoperative radiation therapy. CONCLUSIONS When compared with the more established method of intraoperative radiation therapy using a portable superficial photon unit, the delivery of treatment with CT guidance and HDR brachytherapy is associated with substantially higher costs. The excess costs are driven primarily by the cost of the disposable brachytherapy balloon applicator and, to a lesser extent, additional personnel costs. Future work should include evaluation of a less expensive brachytherapy applicator to increase the anticipated value of brachytherapy-based intraoperative radiation therapy.
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Affiliation(s)
- Greg Suralik
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | - Sonali Rudra
- Department of Radiation Medicine, Georgetown University School of Medicine, Washington, DC
| | - Sunil W Dutta
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | - Jialu Yu
- Department of Radiation Medicine, Georgetown University School of Medicine, Washington, DC
| | - Jason C Sanders
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | - Michael D Schad
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | - Einsley-Marie Janowski
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | - Lucy Su
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | - Bruce Libby
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | - Shayna L Showalter
- Division of Breast and Melanoma Surgery, Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA
| | - Jennifer M Lobo
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA.
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